A case for ePAQ-PF


A summary of potential applications and benefits of using ePAQ-PF in women’s health

Updated: January 2016


Introduction


ePAQ (electronic Personal Assessment Questionnaire) is a validated, web-based clinical assessment system, specifically designed to provide detailed, reliable and meaningful self-reported symptoms & quality of life data from women with pelvic floor disorders.1,2,3,4 Although primarily designed as a clinical assessment tool to support patient assessment, ePAQ is also recognised by NICE and the British Society of Urogynaecology (BSUG) as a responsive & meaningful patient reported outcome measure (PROM).11,12,13 ePAQ enables the delivery of virtual clinics and provides valuable outcomes data for activities including audit, service evaluation, revalidation, appraisal and research.14-22 ePAQ has a number of potential applications and benefits to clinicians, providers and patients, which are summarised below.


ePAQ Applications


  1. Appraisal, revalidation & accreditation
  2. Efficiency
  3. Multi-Disciplinary Team (MDT)
  4. Specialist Clinics
  5. Virtual Clinics
  6. References

1. Appraisal, revalidation & accreditation


Units & individual clinicians are increasingly required to provide outcomes data in order to evaluate the quality and efficiency of services provided. This is now a key element in the accreditation of specialist units in urogynaecology.33 Experience in the UK has demonstrated the benefit of using ePAQ in this context; Providing embedded meaningful outcomes measurement in routine clinical practice.

The final item in all ePAQ questionnaires asks patients whether they are willing to allow their data to be used confidentially in appropriately registered research, audit and service evaluation projects: 95% of women who use ePAQ-PF agree to this, thereby enabling in-depth quality assessments of services, based on accurate & meaningful patient reported outcomes data. A growing number of peer reviewed publications have utilised these data effectively (see below).

Clinicians require outcomes data relating to their own practice for the purposes of appraisal and revalidation. Routine measurement of outcome using ePAQ, readily lends itself to this process. In addition, the inclusion of ‘Friends and Family’ and ‘Global rating of outcome’ scales within ePAQ, also supports such activity. Free text items relating to patients’ goals, concerns, questions and comments, further enrich the dataset with qualitative data, enabling & encouraging patient self-expression & engagement.


2. Efficiency


ePAQ serves as an adjunct to traditional clinical consultation, presenting a patient’s symptom profile & associated quality of life impact graphically. The instrument is reliable & responsive to change; its use has been validated in a number of studies since its inception in 2003. ePAQ has been shown to have high patient acceptability & value, with low burden. It improves discussion rates of intimate issues and the evaluation of sensitive conditions & problems. ePAQ is completed by patients prior to appointments; patient care may thus be more efficient, informed, focussed & effective.9,10

ePAQ-PF can improve efficiency: Saving clinic time, both in virtual (telephone) and outpatient clinics. New outpatient appointments may be up to ten minutes shorter, thereby allowing more new appointments to be provided. Virtual clinic consultations are approximately 50% shorter than face to face attendances.30

The use of paper-based questionnaires in order to monitor outcomes, is not itself without significant cost implications, previously estimated at £7 per patient episode. In a unit seeing 500 new patients / year, this would carry an implementation cost of 500 x £7 = £3,500 per annum. Paper questionnaires are less useful & more costly to deploy in clinical practice; lacking the instantaneous data analysis and storage afforded by ePAQ.11, 16, 17, 18, 19, 31

NICE Guidelines state that urodynamic investigation may not be required prior to surgery in a significant number of women with stress urinary incontinence. ePAQ provides an objective, patient-based assessment of stress incontinence and overactive bladder, which enables informed clinical decision making, including the use or non-use of urodynamics in this context. University of York (YHEC) metrics suggest that reduced requirement for urodynamic investigation due to improved diagnostics provided by ePAQ: Assuming trusts undertake 400 Urodynamic tests per year (2007‐'08 national tariff cost = £176) and use of ePAQ removes this requirement in 20% of cases (i.e. 80 patients per year) this would provide a potential saving of £176 x 80 = £14,080 per Trust, per annum.32


3. Multidisciplinary Team (MDT)


ePAQ-PF provides a central element and basis for case discussions held in regular MDT meetings. The documented objective views of the patient themselves provided by ePAQ summary & detailed reports are routinely presented, particularly when discussing patients with complex, chronic or recurrent conditions. In the Sheffield Urogynaecology MDT, up to 10 cases are presented and discussed weekly; Management decisions for all patients can be based on objective & detailed assessments, including the free text items such as BMI data and ‘Personal Goals’, which are of value when discussing patients with colleagues in an MDT or similar setting.5


4. Specialist Clinics


ePAQ-PF has been used extensively in perineal trauma & OASI clinics, where it is particularly valuable in monitoring outcomes and identifying issues such as faecal incontinence, vaginal capacity and sexual function, as well as using free text items relating to patients’ personal concerns and questions.

Devolving patient care to specialist nurse-led clinics, either in primary or secondary care, provides the opportunity for efficiency and effective use of resources, whilst maintaining high standards and continuity of care. Selected patients, such as those undergoing routine surgery for prolapse or incontinence may be followed up in these clinics, supported by ePAQ, to enable quality control and monitoring of outcomes. Women undergoing Botox injection for OAB may be similarly managed in this way, with access to consultant led care for repeat Botox injection, supported by evidence-based, protocol driven pathways of care.

Joint clinics involving colorectal and urology are supported by ePAQ, which is routinely used for women attending these clinics with functional pelvic floor disorders. The use of a standardised assessment tool and outcome measure in this context enables collaborative working and helps to identify key areas for focus and prioritisation. The system also provides the opportunity for evaluating new services and practices, such as Sacral Nerve Stimulation, Botox and pharmacotherapy.16, 20, 21


5. Virtual Clinics


In the context of the Virtual Clinic, ePAQ-PF supports telephone consultation for selected new & follow-up patients resulting in triage to the most appropriate service, investigation, treatment or discharge to primary care, thereby reducing the number of hospital appointments, associated travel & time for patients and reducing clinic costs and consultation times for providers. This service has been found to be highly acceptable to patients, particularly following surgical intervention such as incontinence or prolapse surgery, or Botox treatment for overactive bladder. In Sheffield, where virtual clinic follow up is routinely offered to women undergoing routine prolapse surgery, 75% choose virtual clinic follow-up (ePAQ + telephone consultation) in preference to outpatient department attendance. The cost savings of Virtual Clinics is £28 per patient. Based on 300 such prolapse procedures being carried out per year & 75% of patients being suitable for virtual follow-up (i.e. 225) this equates to a maximum of £6,300 per annum.28, 29, 30


References & links


  1. Computer interviewing in urogynaecology: concept, development and psychometric testing of an electronic pelvic floor assessment questionnaire in primary and secondary care. Radley SC, Jones GL, Tanguy EA, Stevens VG, Nelson C, Mathers NJ. BJOG. 2006 Feb;113(2):231-8.
  2. Electronic pelvic floor symptoms assessment: tests of data quality of ePAQ-PF. Int Urogyn J Pelvic Floor Dysfunct; 2008.
  3. Quality of life measurement & electronic assessment in Urogynaecology. Radley SC, Dua A. The Obstetrician & Gynaecologist; Oct 2011; 13: 219 – 223
  4. Responsiveness of ePAQ - Pelvic Floor. Jones et al. Int Urogyn J Pelvic Floor Dysfunct; 2008
  5. Int Urogynecol J. 2015 Aug;26(8):1221-7. Multidisciplinary team meetings in urogynaecology. Gopinath D, Jha S.
  6. Electronic pelvic floor assessment questionnaire: a systematic review. McCooty S, Latthe P. Br J Nurs. 2014 Oct 9;23 Suppl 18:S32-7. doi: 10.12968/bjon.2014.23.Sup18.S32.
  7. Understanding women’s experiences of electronic interviewing during the clinical episode in urogynaecology: A qualitative study. Anupreet Dua, Georgina Jones, Hilary Wood, Herjit Sidhu: International Urogynecology Journal. 2013
  8. Development of an instrument to measure face validity, feasibility and utility of patient questionnaire use during health care: the QQ-10. Moores KL, Jones GL, Radley SC. Int J Qual Health Care. Aug 2012
  9. Patient experience of an electronic questionnaire in clinical practice. Jha S, Radley S, Toozs-Hobson Farkas A, Jones G. Int J Pelvic floor Dysfunct. 2007. Suppl1 244.
  10. Increasing Discussion Rates of Incontinence in Primary Care: A Randomized Controlled Trial. Sophia Miryam Schussler-Fiorenza Rose, Ronald E. Gangnon, Betty Chewning, Arnold Wald. Journal of Women’s Health. Volume 24, Number 11, 2015
  11. NICE Audit Support Tool. ePAQ as an outcome measure for mesh repair of prolapse. www.nice.org.uk/nicemedia/pdf/IPG267AuditSupport.doc
  12. British Society of Urogynaecology; National Surgical Database. https://nww.bsug.nhs.uk/bsug/
  13. RCOG: Scientific Advisory Paper on PROMs in women’s health http://www.rcog.org.uk/files/rcog-corp/SAC31PROM.pdf
  14. Effect of anticholinergics on the overactive bladder and bowel domain of the electronic personal assessment questionnaire (ePAQ). Bulchandani S, Toozs-Hobson P, Parsons M, McCooty S, Perkins K, Latthe P.
  15. The personal impact of pelvic floor symptoms and their relationship to age. Dua A, Radley S, Jones G, Farkas A. Int Urogynecol J. 2014
  16. Bowel dysfunction after total abdominal hysterectomy for benign conditions: a prospective longitudinal study. Lashen H, Jones GL, Duru C, Pitsillides C, Radley S, Jacques RM, McAlindon M. Eur J Gastroenterol Hepatol. 2013
  17. Does sacral nerve stimulation improve global pelvic function in women? Jadav AM, Wadhawan H, Jones GL, Wheldon LW, Radley SC, Brown SR. Colorectal Dis. 2013
  18. The Effect of Prolapse Repair on Sexual Function in Women. Dua A, Jha S, Farkas A, Radley S. J Sex Med. (Feb 2012).
  19. Impact of posterior repair on anorectal function. Dua et al. International Urogynaecology Journal; 2011
  20. Impact of TVT on Sexual function. Jha S, Radley SC, Farkas AG, Jones GL. Int Urogyn J Pelvic Floor Dysfunct; 2008.
  21. YUAG Poster 2013 : Prospective outcomes of Sacral neuromodulation for the treatment of Overactive Bladders pre, post and after 1 year, using electronic Patient Assessment Questionnaire (ePAQR). Vyas L, Gulamhussein A, Simmons R, Reid S. Royal Hallamshire Hospital, Dept. of Urology Research, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
  22. Poster: EAU Milan, 2013 Affect on bowel symptoms in patients having sacral neuromodulation for detrusor overactivity. A. Gulamhusein, J. Fielding, R. Simmons, S.V. Reid. Poster no: 777. Royal Hallamshire Hospital, Dept. of Urology Research, Sheffield Teaching Hospitals NHS Foundation Trust
  23. NHS Innovation catalogue (page 51) https://innovault.innovation.nhs.uk/dl/cv_content/61462
  24. NHS Digital 1st (High Impact Innovations). http://system.improvement.nhs.uk/ImprovementSystem/ViewDocument.aspx?path=Diagnostics%2FNational%2FWebsite%2FPublications%2FCaseForChange_120807.pdf.
  25. NHS Pre Operative Screening Solutions Factsheet http://www.networks.nhs.uk/nhs-networks/qipp-digital-technology-and-vision/documents/Factsheet-20on-20Preoperative-20Screening-1.pdf/at_download/file
  26. NICE: Audit Support: Surgical repair of vaginal wall prolapse using mesh (page 5) www.nice.org.uk/nicemedia/pdf/IPG267AuditSupport.doc
  27. Regional Innovation www.networks.nhs.uk/.../East_Midlands_Inovation_Report_2010_final.pdf www.yh-hitap.org/epaq.asp
  28. Yorkshire Post (Virtual Clinics) www.yorkshirepost.co.uk/news/around-yorkshire/local-stories/treatment_without_the_blushes_at_virtual_clinic_1_2560277
  29. https://clinicaltrials.gov/ct2/show/NCT02176330
  30. The Virtual Urogynaecology Clinic: Patient experience and economic evaluation. IUGA 2008 (Abstract) Paper submitted for publication 2015
  31. Browne et al. Patient Reported Outcome Measures (PROMs) in elective surgery: Report to the Department of Health. London School of Hygiene and Tropical Medicine. December 2007.
  32. NICE guideline [CG171] Urinary incontinence: The management of urinary incontinence in women. September 2013
  33. Accreditation of Units: Standards for Service Provision in Urogynaecology Units: http://bsug.org.uk/accreditation-of-units.php