Quality improvement in an outpatient department for subacute low back pain patients: prospective surveillance by outcome and performance measures in a health technology assessment perspective

Abstract

Study design: Prospective cohort study.

Objectives: To develop clinical indicators and standards in an outpatients' department for sub acute low back pain patients.

Summary of background data: A systematic quantitative surveillance to assess quality of care was implemented using outcome and performance measures. These measures were developed within the framework of Health Technology Assessment, which comprises the areas of healthcare technology, patient, organization, and economy.

Methods: A multidisciplinary project group defined 1) clinical indicators in terms of outcome and performance measures and 2) the corresponding standards using the available evidence from literature. Observed outcomes were compared with the standards. Associations between process and outcome measures were investigated.

Results: A total of 300 patients were included consecutively. In relation to technology, the standards for the field of application were fulfilled (e.g., not too many patients were x-rayed). With respect to effectiveness, the observed rate of patients reaching a 50% cutoff point of improvement of pain and function did not fulfill the standards. In relation to patient aspects, the standards of, for example, proper understanding of patient education and satisfaction, were fulfilled. In relation to organization, nearly one third of the patients were referred later to the department than the recommended 24 weeks. This refer variable showed an association to a reduced chance of scoring "better" or "much better" in "patients global assessment." The chance was reduced by 50% if patients were referred later than 12 weeks after onset of pain. In relation to economy, the cost of gaining a quality adjusted life-year by a course in the department was considerably lower than by comparison with total hip arthroplasty.

Conclusions: Surveillance by clinical indicators in relation to the four areas of health technology assessment provides quantitative information that is meaningful for various stakeholders on important aspects of the quality of care (including consumers), provides a basis for quality improvement, and provides data for analysis of possible important relationships between structure, process, and outcome.