Measuring change in Musculoskeletal Physiotherapy Outpatient Services - Using the EQ5D-5L
The introduction of patient reported outcome measures (PROMs) in 2009 signaled a
significant change of emphasis in the need to measure the impact of health care
interventions from the patient perspective.(1) Health care is costly and accounts for a large
proportion of government spending and it is imperative that this money is used wisely. The
current economic climate has brought into sharp focus the need to demonstrate the cost
effectiveness of any health care services, including physiotherapy. The introduction of the
'any willing provider' procurement model
(2)
which aims to improve patient choice, the further
increases the pressure on services to demonstrate their quality and cost effectiveness if they
are to successfully negotiate service provision.
In the recently published King's Fund report 'Getting the most out of PROMS'
(3)
the EQ-5D,
a generic outcome measure, is promoted as a useful instrument in the assessing health
change. Given the potential power of the EQ-5D data to produce both simple and complex
cost effectiveness information and the support from this leading and influential academic
institution it was decided the EQ-5D would be examined in relation to MSK outpatient
services.
The need to measure
Measuring the impact of interventions will demonstrate the quality and effectiveness of the
service and provide data for use in economic evaluation . The use of outcome measures are
known to empower the patient by enhancing communication and enabling greater
involvement in the care they receive (4). As a profession, physiotherapy will be able to identify
high quality practice and equally poor or unnecessary practice . Accumulating a body of
information will underpin the development of standards by which services can be monitored
and improved. Changes in practice or services can also be evaluated once standardised
tools are systematically used. Commissioners will require evidence of the effectiveness and
efficiency of physiotherapy services. This will go beyond the process issues of numbers of
patients seen and waiting times and will require patient reported outcomes of intervention.(1)
The availability of simple, clearly presented and relevant information will be invaluable in
supporting negotiations between purchasers and providers in health.
Why use EQ-5D-5L?
The EQ-5D is a standardised measure of health status which aims,
'….to provide a simple generic measure of health for clinical and economic appraisal'
(EuroQol Group 2010.)
EQ-5D data is used to calculate quality of life adjusted years (QALY), the unit of
measurement used by the National Institute of Clinical Excellence (NICE) to assess the
value of health outcomes.
The EQ-5D-5L is a development of the original EQ-5D (sometimes known as the EQ-5D-3L)
The EQ-5D-5L gives greater choice of response and it is anticipated that it will be more
sensitive to changes in health state than the original. It is possible to describe 3127 different
health states using the EQ-5D-5L.
The EQ-5D-5L comprises two parts, the descriptive system which has five dimensions with
questions
relating
to
mobility,
self-care,
usual
activities,
pain/discomfort
and
anxiety/depression. There are five responses for each question ranging from 'I have no
problems….' to 'I am unable to…'. The response to each of the five dimensions is assigned a
number 1 to 5 with '1' representing no problem through to '5' representing the most severe
problem. The five responses represent a 'health state'. This health state is then converted
via a pre-constructed table into a weighted score. It is this figure which is used in economic
evaluation.
The second part asks the patient to assess their health 'today' on a visual analogue scale of
0-100. The VAS is important when undertaking research but is not essential in routine
clinical outcome measurement.
The EQ-5D-5L measure is non-contentious, easy to read and understand and takes
approximately two minutes to complete.
Despite its apparent simplicity the EQ-5D-5L is capable of producing information at a patient
level or as a profile of patient or healthy populations (5).
See the EuroQol website for full details of administration and scoring www.euroqol.org
Using the EQ-5D-5L
It is important to adhere to a standard procedure when collecting and analyzing of 5L. It is
recommended that:

Patients should be encouraged to complete the measure unassisted where possible.
Assistance may be required where there are problems with reading, a lack of
understanding or visual disturbance.

Services should complete only the descriptive system of the EQ-5D-5L. (The VAS
should be used where valuation studies are undertaken)

Data should be collected at baseline (prior to the first treatment) and on discharge.
Discharge is the easiest time point to collect outcome data and will achieve more
complete data sets. However where possible patients should be asked to complete
the tool again at three months from baseline. This will enhance the possibility for
benchmarking against changes in practice, in and across services.

Data should not to be collected continually but at set time points in the year and
include either all conditions or targeted conditions depending on need for data.

Further details on the EQ-5D administration can be found on the EuroQol website
www.euroqol.org
Service Experience of the EQ-5D
In a recent scoping exercise undertaken by the CSP eleven services were identified as
having experience of using the EQ-5D-3L to measure the impact of intervention in their
services. Services currently using it were initially attracted by its simplicity and brevity and, in
general, find it acceptable to both patients and staff.
Although there are only a small number of MSK services currently using the EQ-5D they
have revealed some positive issues. The paper by Sephton et al
(6)
demonstrated sensitivity
to change of the EQ-5D-3L in their preliminary evaluation of a primary care MSK clinical
assessment service. This was a welcome finding as it the sensitivity to change which has led
people to question the appropriateness of the EQ-5D-3L in MSK physiotherapy. Dorset
County Hospital NHS Foundation Trust Physiotherapy department have been using the EQ5D-3L since 2009 and found that it helped to identify yellow flags - not something that has
been recognised previously. Currently Dorset are using the data from the EQ-5D-3L to
inform their in-service training and to highlight further training needs. They are also in a
strong position to support purchaser / provider negotiations when they are required to do so.
Challenges to implementation
The simplicity of the EQ-5D questions and scoring system tend to make physiotherapists
sceptical about its potential sensitivity to change and have dismissed it as unsuitable for
measuring intervention. Implementation will require further education and knowledge of the
measure before physiotherapists will begin to reap the benefits of the data it can provide.
Data management, analysis and interpretation are hurdles which need to be faced. There is
great variation in the level and type of support given to services. Those without
organisational support have been resourceful in developing systems to deal with these
issues. The use of software packages such as Excel, have been employed by physiotherapy
staff, to enable the use of the EQ-5D data. EuroQol are continuing with the development of
a web-based version.
The EuroQol website www.euroqol.org provides detailed guidance and support for those
wishing to use the measure.
The CSP are currently exploring with the EuroQol Group, the possibility of providing
members with a software package which will support data input and analysis and the
necessary licensing arrangement.
Conclusion
As a minimum the EQ-5D-5L should be used to assess musculoskeletal disorder services. It
is quick and easy to use and is capable of providing information for the patient, the
physiotherapy profession, the purchaser and the provider. It is a measurement tool which
has a sound academic base and currently has the backing of the highly influential and
independent organisation the King's Fund.
The EQ-5D-5L has many positive attributes but it recommended by the EuroQol Group that
where more detailed patient level information is required a disease specific outcome
measure should also be used.
References
(1) Department of Health. Guidance of the routine Collection of patient Reported Outcome
Measures (PROMs) . 2007.
(2) Department of Health. 'Procurement guide for commissioners of NHS funded services'.
2010.
(3) Devlin NJ, Appleby J. Getting the most out of PROMS. 2010.
(4) Jette DU, Halbert J, Iverson C, Miceli E, Shah P. Use of Standardized Outcome
Measures in Physical Therapist Practice: Perceptions and Applications. Phys Ther 2009
02;89(2):125-135.
(5) Szende A, 'Oppe M, Devlin N. 'EQ-5D value sets: inventory, comparative review and user
guide' . 2006;2.
(6) Sephton R, Hough E, Roberts SA, Oldham J. Evaluation of a primary care
musculoskeletal clinical assessment service: a preliminary study. Physiotherapy 2010
12;96(4):296-302.