Associations between quality of health care and clinical outcomes in patients with rheumatic and musculoskeletal diseases: a rehabilitation cohort study

Anne-Lene Sand-Svartrud, Gunnhild Berdal, Maryam Azimi, Ingvild Bø, Turid Nygaard Dager, Siv Grødal Eppeland, Guro Ohldieck Fredheim, Anne Sirnes Hagland, Åse Klokkeide, Anita Dyb Linge, Joseph Sexton, Kjetil Tennebø, Helene Lindtvedt Valaas, Kristin Mjøsund, Hanne Dagfinrud, Ingvild Kjeken, Anne-Lene Sand-Svartrud, Gunnhild Berdal, Maryam Azimi, Ingvild Bø, Turid Nygaard Dager, Siv Grødal Eppeland, Guro Ohldieck Fredheim, Anne Sirnes Hagland, Åse Klokkeide, Anita Dyb Linge, Joseph Sexton, Kjetil Tennebø, Helene Lindtvedt Valaas, Kristin Mjøsund, Hanne Dagfinrud, Ingvild Kjeken

Abstract

Background: The quality of provided health care may be an important source of variation in rehabilitation outcomes, increasing the interest in associations between quality indicators (QIs) and improved patient outcomes. Therefore, we examined the associations between the quality of rehabilitation processes and subsequent clinical outcomes among patients with rheumatic and musculoskeletal diseases (RMDs).

Methods: In this multicentre prospective cohort study, adults with RMDs undergoing multidisciplinary rehabilitation at eight participating centres reported the quality of rehabilitation after 2 months and outcomes after 2, 7, and 12 months. We measured perceived quality of rehabilitation by 11 process indicators that cover the domains of initial assessments, patient participation and individual goal-setting, and individual follow-up and coordination across levels of health care. The patients responded "yes" or "no" to each indicator. Scores were calculated as pass rates (PRs) from 0 to 100% (best score). Clinical outcomes were goal attainment (Patient-Specific Functional Scale), physical function (30 s sit-to-stand test), and health-related quality of life (EuroQoL 5D-5L). Associations between patient-reported quality of care and each outcome measure at 7 months was analysed by linear mixed models.

Results: A total of 293 patients were enrolled in this study (mean age 52 years, 76% female). Primary diagnoses were inflammatory rheumatic disease (64%), fibromyalgia syndrome (18%), unspecific neck, shoulder, or low back pain (8%), connective tissue disease (6%), and osteoarthritis (4%). The overall median PR for the process indicators was 73% (range 11-100%). The PR was lowest (median 40%) for individual follow-up and coordination across levels of care. The mixed model analyses showed that higher PRs for the process indicators were not associated with improved goal attainment or improved physical function or improved health-related quality of life.

Conclusions: The quality of rehabilitation processes was not associated with important clinical outcomes. An implication of this is that measuring only the outcome dimension of quality may result in incomplete evaluation and monitoring of the quality of care, and we suggest using information from both the structure, process, and outcome dimensions to draw inferences about the quality, and plan future quality initiatives in the field of complex rehabilitation.

Trial registration: The study is part of the larger BRIDGE trial (ClinicalTrials.gov NCT03102814 ).

Keywords: Health services research; Musculoskeletal disease; Quality indicators; Quality of health care; Rehabilitation.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2022. The Author(s).

Figures

Fig. 1
Fig. 1
Patient-reported quality of rehabilitation. Pass rates for single process indicators (P01-P11), reported by 293 participants in the BRIDGE trial. P01-P02 (light grey): initial assessments (group A). P03-P06 (grey): individual goal-setting through the rehabilitation process (group B). P07-P11 (dark grey): individual follow-up and coordination across levels of care (group C)
Fig. 2
Fig. 2
Distribution of change scores between 7 months and baseline for each clinical outcome in the BRIDGE trial. Positive values indicate improvements during the time period. PSFS: Patient-Specific Functional Scale, mean performance score for all reported goals; PSFSA1: Patient-Specific Functional Scale, the performance score for the first reported goal only; 30secSTS: 30-s sit-to-stand test; EQ5D-index: EuroQoL 5D-5L index value; EQ5D-vas: EuroQoL 5D-5L visual analogue scale
Fig. 3
Fig. 3
Change in outcome by summary pass rate quartile for the process indicators. A positive change score indicates improvements between baseline and 7 months. Pass rates in the highest quartile indicate highest fulfilment of the process indicators (best quality). PSFSA1: Patient-Specific Functional Scale, the performance score for the first reported goal only; 30secSTS: 30-s sit-to-stand test; EQ5D-index: EuroQoL 5D-5L index value; EQ5D-vas: EuroQoL 5D-5L visual analogue scale

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