Patient-reported outcome measures

In this present study, a selection of patient-reported outcome measures from the baseline and 1-year follow-up questionnaire package was used in papers I, II and III.

Nijmegen Continuity Questionnaire-Norwegian version

In 2007, Uijen et al. developed and tested the Nijmegen Continuity Questionnaire (NCQ) [108]. The NCQ is a patient-rated instrument measuring personal, team and cross-boundary continuity of care [108,138,157]. Hence, these aspects of continuity cover informational, relational and management continuity described by Reid et al.

[112]. According to a psychometric evaluation, the NCQ has been identified as a valid and reliable generic instrument measuring patient-experienced care continuity as a multi-dimensional concept to be utilised regardless of diagnosis, multi-morbidity or settings [138]. The NCQ has previously been used for chronic illness [123], heart failure [158] and chronic obstructive pulmonary diseases [124].

The NCQ comprises 28 positively formulated items divided into seven subscales [108,138]:

• Personal continuity: ‘the GP knows me’ (five items)

• Personal continuity: ‘the GP shows commitment’ (three items)

• Personal continuity: ‘the care provider knows me’ (five items)

• Personal continuity: ‘the care provider shows commitment’ (three items)

• Team continuity: ‘collaboration between care providers within the team’ (four items)

• Team continuity: ‘collaboration within the hospital or outpatient department’

(four items)

• Cross-boundary continuity: ‘collaboration between GP and specialist’ (four items)

The original Dutch version of the NCQ was translated into Norwegian in 2014 [159].

According to the recommended guidelines by Beaton et al [154], the original Dutch version of the NCQ was translated using a forward and backward translation process [154], and the research group included linguistic and health care professionals from the Netherlands and Norway.

The Norwegian version of the NCQ (NCQ-N) was included in the 1-year follow-up questionnaire (Appendix 6) and used in Papers II and III. For the purpose of this study, the NCQ-N included in the one-year follow-up questionnaire package was adapted to be utilised in a rehabilitation setting. Consequently, Papers II and III employed two subscales for personal continuity, now reading: ‘the most important health care provider in the rehabilitation centre knows me’ and ‘the most important health care provider in the rehabilitation centre shows commitment’. Furthermore, it included one subscale regarding team continuity: ‘collaboration between health care professionals working in the rehabilitation centre’, and one subscale regarding cross-boundary continuity: ‘collaboration between the rehabilitation centres and GPs in the

municipality’. The NCQ-N uses a five-point Likert scale ranging from one (strongly disagree) to five (strongly agree), with an additional option to answer, ‘don’t know’.

The NCQ can be accessed online: (https://ars.els-cdn.com/content/image/1-s2.0-S0895435611000928-mmc1.pdf).

World Health Organisation Disability Assessment Schedule- version 2.0 In 1988, the WHO published the original Disability Assessment Schedule

(WHO/DAS), which primarily assessed functioning of psychiatric inpatients. A beta version of the generic assessment instrument WHODAS II was issued in 1999 [100].

WHODAS II provided a cross-cultural and standardised method for measuring activity limitations and restrictions concerning participation in community activities, and was based on the WHO Psychiatric Disability Assessment Schedule [100].

The WHO developed the WHODAS version 2.0 (WHODAS 2.0) using the activity and participation domains from the ICF to measure disability and to identify the effectiveness of health interventions [101]. The instrument was cross-culturally tested in 19 countries worldwide and was found to perform well in terms of psychometric properties across widely different cultures, populations and diseases [101]. The manual for measuring health and disability through the use of WHODAS 2.0 was published in 2010 [160]. Currently, WHODAS 2.0 constitutes a leading standardised measure of disability across cultures worldwide [100]. Furthermore, WHODAS 2.0 has previously been used to evaluate disability in rehabilitation settings [160-163] and chronic care [164].

Three different versions of WHODAS 2.0 exist: a 36-item version, a 12-item version and a 12+24-item version. In addition, three modes of administration are available:

self-administration, interview, and proxy—a third-party view of functioning taken from, for instance, family member or caretakers [160]. In this study, WHODAS 2.0 was included in a larger questionnaire package. WHODAS 2.0 was completed by the patient, and measured the level of disability in the past 28 days of filling in the questionnaire. The 36-item version was employed, including six activity and participation domains [100]:

• Cognition – ‘understanding and communicating’ (six items)

• Mobility – ‘moving and getting around’(five items)

• Self-care – ‘hygiene, dressing, eating and being alone’ (four items)

• Getting along – ‘interacting with other people’ (five items)

• Life activities – ‘domestic responsibilities, leisure, work and school’ (eight items = four items related to household and four items related to work)

• Participation – ‘joining in community activities’ (eight items)

Responses to each item were ascertained on a five-point Likert scale ranging from one (none) to five (extreme or cannot do). Domain scores are transformed within a range between zero (no disability) and 100 (full disability). In accordance with the

WHODAS 2.0 manual, four items of the ‘Life activity’ domain were omitted if no work relations were reported by the respondents [165]. The WHODAS 2.0 global score was calculated using either 36 or 32 items, depending on work-related

participation. The global score ranges from zero (best/no disability) to 100 (worst/full disability). The WHODAS 2.0 domain and global scores were calculated using complex scoring in accordance with the WHODAS 2.0 manual [165]. Permission to use the WHODAS 2.0 in the present study was granted by the WHO.

EuroQol EQ-VAS

The EuroQol five-dimension descriptive system (EQ-5D) was developed by an interdisciplinary five-country EuroQol group from 1987 to 1991 [166-169]. The three-level EQ-5D was introduced in 1990 and consisted of five dimensions: mobility, self-care, usual activities, pain or discomfort and anxiety or depression. An elaborated version—the five-level EQ-5D—was developed after extensive research and was introduced in 2005 [167]. The EQ-5D describes a generic self-report instrument measuring health status across disease areas, comprising a five-domain questionnaire and a visual analogue scale (EQ-VAS) [166,167,170-172]. The EQ-VAS offers information concerning the patient-rated health state at the time they fill in the questionnaire [167]. Furthermore, the EQ-VAS measures the patients’ overall health ranging from zero (‘worst imaginable health state’) to 100 (‘best imaginable health state’) [167].

The EQ-5D constitutes a validated instrument [173,174] and has been employed in various settings, such as rehabilitation [162,175,176], primary care [177] and chronic care [178,179]. The five-level EQ-5D has also been included in a core set of outcome measures for rehabilitation in Norway [180]. The EuroQol group granted permission to use this instrument in the present study.

PasOpp

In 2003 the Patient Experiences Questionnaire (PEQ) was developed as part of RESKVA (RESultat & KVAlitet=results and quality) to be used among inpatients in somatic hospitals in secondary health [181]. The PEQ has been used to measure patient experiences of a hospital stay in Norway [181]. The PasOpp (Pasient-Opplevelser=patient experiences) replaced RESKVA in a later development of the questionnaire in 2009 [182].

The Norwegian Institute of Public Health (Folkehelseinstituttet) developed the patient-reported PasOpp survey for capturing patient experiences of a stay in private

rehabilitation centres in secondary health care. The PasOpp survey aimed to develop a validated method for measuring patient experiences of a rehabilitation stay regardless of diagnosis groups [183]. PasOpp was tested in 2008 and has since been used nationally by collaborating private rehabilitation centres in secondary health care as a quality assurance measure [183].

In the current study only five questions concerning the patient-experienced benefit of the rehabilitation stay, including overall rehabilitation benefits, physical health benefits, mental health benefits, activity of daily living (ADL) benefits, and social participation were retrieved and utilised from the PasOpp survey [156]. Responses were measured on a five-point Likert scale ranging from one (not at all) to five (to a great extent) with an additional option of ‘not applicable’. The PasOpp questionnaire can be accessed online:

(https://www.fhi.no/globalassets/dokumenterfiler/rapporter/2009-og-eldre/pasopp_sporreskjema_rehab_nasjonal.pdf)