Development and pilot testing of PROACTIVE: A pediatric onco-critical care capacity and quality assessment tool for resource-limited settings

Abstract

Background: Nearly 90% children with cancer reside in low- and middle-income countries, which face multiple challenges delivering high-quality pediatric onco-critical care (POCC). We recently identified POCC quality and capacity indicators for PROACTIVE (PediatRic Oncology cApaCity assessment Tool for IntensiVe carE), a tool that evaluates strengths and limitations in POCC services. This study describes pilot testing of PROACTIVE, development of center-specific reports, and identification of common POCC challenges.

Methods: The original 119 consensus-derived PROACTIVE indicators were converted into 182 questions divided between 2 electronic surveys for intensivists and oncologists managing critically ill pediatric cancer patients. Alpha-testing was conducted to confirm face-validity with four pediatric intensivists. Eleven centers representing diverse geographic regions, income levels, and POCC services conducted beta-testing to evaluate usability, feasibility, and applicability of PROACTIVE. Centers' responses were scored and indicators with mean scores ≤75% in availability/performance were classified as common POCC challenges.

Results: Alpha-testing ensured face-validity and beta-testing demonstrated feasibility and usability of PROACTIVE (October 2020-June 2021). Twenty-two surveys (response rate 99.4%) were used to develop center-specific reports. Adjustments to PROACTIVE were made based on focus group feedback and surveys, resulting in 200 questions. Aggregated data across centers identified common POCC challenges: (1) lack of pediatric intensivists, (2) absence of abstinence and withdrawal symptoms monitoring, (3) shortage of supportive care resources, and (4) limited POCC training for physicians and nurses.

Conclusions: PROACTIVE is a feasible and contextually appropriate tool to help clinicians and organizations identify challenges in POCC services across a wide range of resource-levels. Widespread use of PROACTIVE can help prioritize and develop tailored interventions to strengthen POCC services and outcomes globally.

Keywords: critical care medicine; global health; health quality of care; pediatric cancer; quality improvement.

FIGURE 1

Stages in the development and pilot testing of PROACTIVE. The diagram details the process in the development and validation of the PROACTIVE tool in 7 stages: 1) Operationalization of Indicators, 2) Alpha‐testing, 3) Beta‐testing, 4) Data Analysis, 5) Development of PROACTIVE reports, 6) Identification of Common POCC challenges, and 7) Revised PROACTIVE tool.

FIGURE 2

Number of questions per stage. An initial set of 119 consensus‐derived quality and capacity POCC indicators were operationalized into 159 questions; these questions plus 17 oncology questions were subjected to alpha‐testing (176 questions). A total of 182 questions were then included for beta‐testing (164 PICU and 55 oncology questions, with 37 questions included in both surveys), resulting in a final PROACTIVE tool containing 200 questions (148 PICU and 52 oncology questions) to assess POCC services.

FIGURE 3

Aggregated data per domain. The centers' average performance per domain is represented in this figure. Centers are ranked by country income level, from low‐ (A) to high‐income level (K), with 2 centers (yellow) not having a designated PICU area. Overall, centers with no PICUs scored inferiorly in most domains independently of their country income level. The National Context obtained the lowest mean score (58%) across the 11 centers, while the Facility/Local context and the Medication/Equipment domains received the highest scores (84%). Abbreviations: L‐LMIC, Low‐ and Low‐Middle Income Countries; UM‐HIC, Upper‐Middle and High‐Income Countries; ICU, Intensive Care Unit.