The panel advocated the inclusion of a metrics component for all TLC interventions and emphasized the selection of assessment instruments that are culturally sensitive and validated in the population. Data obtained by recording indicators before and after implementation can not only measure effectiveness of the intervention but also provide feedback to help patients and providers understand the utility of the intervention and offer reinforcement of progress.
Assessment methods may be qualitative or quantitative and focus on processes or outcomes. Outcome indicators need to be selected and measured reliably and validly to determine impact. They must be appropriate and sensitive to the changes generated by the intervention. The outcomes selected can be those that the intervention was designed to change as well as unintended, negative outcomes.
Measurement approaches and tools should be compatible with the characteristics of the target population for which they are used. This is of particular importance in hypertension management because of the high proportion of patients who are from minority groups, are elderly, and have comorbidities. Strickland et al72
reported that a large proportion of psychometric tools used in nursing research had not been adequately designed and tested for use in ethnic and racial minorities ().
Laying the Groundwork for Effective Reporting of Metrics
Many questionnaires and scales are not designed for use in the elderly or persons who are not well educated. Long and burdensome measurement tools may be too time consuming or impractical for use in clinical settings or with individuals who are ill or frail.73–75
The reliability and validity of outcome assessments can be compromised when assessment approaches are used in a patient population or setting for which they are not compatible, and inappropriate conclusions can be drawn from the data about the effectiveness of hypertension programs. An example of an assessment instrument that has been to be shown to be reliable and valid in African Americans76
is the 12-item version of the Medical Outcomes Study 36-item Short Form Health Survey (SF-36).77
This instrument is also less cumbersome than the original version in assessing mental and physical health status.
Timing of measurement is crucial. Baseline measures of the selected outcome should be obtained. Follow-up assessments should be conducted at appropriate intervals so that change in the outcome due to the intervention can be documented. Therefore, assessment tools need to be highly sensitive to changes in outcome variables that measure the impact of interventions designed to control BP.
Assessment opportunities comprise: 1) patient attitudes and outcomes, 2) provider activities, and 3) aspects of the practice setting. Beyond the health center or clinic, assessments can be conducted across a community or within the larger health care system to which an individual belongs, such as an employer’s health system or managed care organization (MCO).
Some health systems are well organized in assessing the impact of interventions. In MCOs or Veterans Affairs medical centers, for example, data can be captured on clinical outcomes as well as resource use, physician and staff workflow, sustainability, and cost to the system and patient. Combined with the patient’s self-report of outcome and satisfaction, information from electronic health records and claims data can result in a comprehensive assessment of the relative cost and benefit of an intervention. In less-integrated settings, Health Insurance Portability and Accountability Act issues and irreconcilable databases can make the collection of such information impossible.