The utilization of patient-reported outcome measures (PROMs) has been driven by a growing interest in understanding patients’ perceptions of their physical and psychosocial health and outcomes of treatment. Although most agree with this general direction, the institutional uptake of PROMs at the point of care is highly variable, with a range of logistical, cultural, and clinical barriers to adoption. Nevertheless, PROMs may be useful in evaluating health-related outcomes from the individual’s perspective across a variety of conditions within musculoskeletal medicine.
Orthopaedic surgeons have a strong grasp of the natural history of bone and joint diseases, as well as the associated risks and benefits of various treatment options, but they often are “in the dark” when it comes to defining the physical limitations and psychosocial effects faced by individuals following interventions. Failing to assess self-reported aspects of health and quality of life at the point of care may leave surgeons in the awkward position of trying to forecast future outcomes. On the other hand, routine use of PROMs provides objective and comparable patient-focused assessments that may help derive patient outcomes more effectively with validated metrics rather than guesswork.
Utilizing PROMs creates several advantages for surgeons and patients. For one, the measures permit more detailed discussions of potential benefits of interventions based on comparisons of baseline scores to expected follow-up scores observed in previous patients. With such benchmarks in hand, clinicians can quantify an “expectation” of improvement over the recovery trajectory and match what is measured with what is typically seen. In the case of total knee arthroplasty (TKA), a clinician might say, “An artificial knee rarely feels like a totally normal knee, but this is what you could expect to achieve based on the scores you’ve provided. …” We can help patients get away from the assumption that interventions such as TKA are a panacea and work toward an approach where the right treatment is made for the right patient at the right time. Furthermore, by systematically using patient-reported measures of pain and function, we can determine the effectiveness of a given treatment in the wider population.
This article seeks to share the authors’ experiences bringing PROMs into the daily practice of musculoskeletal care of patients and populations.
The history of PROMs
Slowly rising to prominence as supplements to clinician-based outcome measurements, modern PROMs evolved from the Nottingham Health Profile, a subjective health status survey introduced in 1980. That inaugural PROM eventually engendered the Short Form 36. Generic health instruments eventually gave rise to questionnaires geared toward certain populations, including disease-specific scores such as the Harris Hip Score.
Although initially reliant on pencil and paper, PROMs are now calibrated for digital administration, with the added functionality of mandating responses and eliminating any ambiguity in handwritten and circled responses. However, an important advance in digitizing tools lies in computer-adaptive PROMs. Such tools are based on item response theory and allow a large bank of questions to be condensed without losing any resolution (as opposed to fixed-scale PROMs) in pinpointing patient status. A subsequent question presented to a patient is informed by prior responses, thereby providing more tailored measurement that dramatically reduces the patient burden and time required for survey completion. Developing more practical measures that are easier and quicker to complete, while being as precise if not more precise, aims to support the widespread adoption of PROMs in daily practice.
Advantages of PROMs
Adoption of PROMs in health sciences research has been somewhat expected because of the growing interest in patient-centered care, but the power of PROMs in clinical practice is relatively underappreciated. The measures can be deployed in real time to convey more complete pictures of patients’ conditions. For most conditions, surgeons should consider combinations of relevant PROMs—a general health survey and a region- or condition-specific survey may strengthen a clinician’s view of both health-related quality of life and specific limitations of a particular patient. General health questionnaires relate to overall well-being (e.g., the health-related quality of life assessment). A common condition-specific measure used in lower-extremity orthopaedics is the Knee Injury and Osteoarthritis Outcome Score, which contains questions about pain and ability to perform activities of daily life with respect to a single knee joint. Global and region- and condition-specific measures provide detailed snapshots of patient health. Such insights may otherwise take much more time during a visit, generating information that is unusable or of limited use. When obtained prior to a visit, PROM data may provide indicators of a patient’s primary concerns before a provider sets foot in a clinic room, therefore helping to guide conversation and yielding greater insights into the patient’s preferences, needs, and values.
Musculoskeletal medicine often ignores fundamental facets of health and well-being, such as mental and emotional health; PROMs can efficiently screen for symptoms of anxiety and depression. This can be quite helpful for orthopaedic surgeons, especially in high-volume and demanding practices, who are looking to achieve thorough consultations encompassing those aspects without investing extensive time performing full psychosocial evaluations. The latter is rarely feasible nor entirely necessary. A simple panel of validated instruments with published positive screen cutoffs (e.g., ≥ 3 on the Patient Health Questionnaire) can serve this purpose.
Another advantage with the routine use of objective PROMs lies in their ability to serve as metrics of quality-of-life benefits when evaluating interventions. PROMs used in this way provide an alternative approach to assessing the value of treatments, such as joint injections, where the evidence may be equivocal. The opportunity to do so is somewhat rare in medicine, outside of oncological risk-benefit ratios offered to patients considering chemotherapy. Thresholds such as the minimum clinically important difference (MCID), calculated either by an anchor- (reliant on an anchor question as a proxy landmark) or distribution-based (typically a half standard deviation for the population mean) method, represent specific cutoffs for meaningful benefit. Analysis of patients achieving and not achieving MCID, based on preoperatively available characteristics, will eventually allow for predictions of benefit after interventions such as surgery.
Shared decision-making (SDM) is another area where PROMs are advantageous. SDM is defined as a process of transferring relevant aspects of an intervention with expert communication skills, enabling clinicians and patients to work together in arriving at informed decisions aligned with the needs and preferences of patients. Orthopaedic surgeons may convey this concept by stating in clear terms: “I need to share with you my expertise about your condition and available options, including what we can and cannot expect to achieve, along with the risks and benefits of treatment(s), while you need to share with me your expertise on ‘being you,’ and conveying your needs and preferences so we can come to the right decision for you together.”
Although SDM is the primary goal and patient preference is the most important factor, thresholds of meaningful improvement based on PROMs promise to enhance discussions and move us toward judging interventions based on their value.
Benchmarking PROMs for better understanding
In the next logical iteration, condition-specific registries collating PROMs from multiple centers and regions will contribute to societal understanding of populations under care. Findings from the expanding amount of PROM data points in registries should help clinicians place scores in context of similar patients (i.e., determining age-matched norms and quartile ranges). When a clinician gets the “Doc, how bad is it?” question, PROM population benchmarks may provide substrates for intelligent comparisons. This context is especially important when considering elective and “preference-sensitive” treatments, as patients and physicians are continually looking for better inputs in order to make the most appropriate decisions among a suite of viable options. The International Consortium for Health Outcomes Measurement’s standard sets offer some guidance on what should be measured for a particular condition, helping standardize the capture of PROMs and enabling comparisons across populations experiencing specific conditions.
As we move toward measuring our success and performance on outcomes that matter to patients, rather than relying solely on process metrics as surrogates for quality care, both patients and surgeons will benefit from widespread adoption of objective measures of pain and function.
Demonstrable improvement in quality of life as reported from a patient’s own perspective should be the goal, and consistently delivering it should be the yardstick for all providers. PROMs represent powerful assessment tools, and we advocate incorporating them routinely into the process of assessing patients’ conditions, discussing the potential benefits of treatments, and measuring the outcomes of care provided.
Meredith L. Grogan Moore, BS, is a 2018–2019 value-based care fellow in the Department of Surgery and Perioperative Care at Dell Medical School at the University of Texas at Austin.
Prakash Jayakumar, MBBS, DPhil, is an orthopaedic surgeon with a background in outcome measurement, high-value health care, human-centered design, and consulting in medical technologies. He is an assistant professor of surgery and perioperative care and director of clinical research and outcome measurement at Dell Medical School at the University of Texas at Austin.
Karl Koenig, MD, MS, is the medical director of the Musculoskeletal Institute and associate professor in the Department of Surgery and Perioperative Care at the University of Texas at Austin. He is the director of the Joseph M. Abell Arthroplasty and Value-based Health Care Delivery Fellowship and leads the initiative to improve access to musculoskeletal care for the residents of Austin and beyond.
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- International Consortium for Health Outcomes Measurement: Standard Sets. Available at: https://www.ichom.org/standard-sets/. Accessed August 20, 2019.