Patient-reported Outcome Measures Play a Role in the Evaluation and Management of Trauma Patients

Editor’s note: This article is part of an ongoing “PROMs in Practice” series presented by the AAOS Patient-reported Outcome Measures (PROMs) Workgroup. Each month, a workgroup member will address the impact of PROMs on their subspecialty, patient care, the future of musculoskeletal healthcare, and more.

Among orthopaedic surgeons, there is a trend toward becoming specialists instead of generalists. In contradistinction, orthopaedic trauma surgeons work on many or all areas of the body.

When the only tool available is a hammer, each specialty sees the problem as a nail. For example, a trend has arisen in proximal humeral fracture treatment in the elderly. Shoulder surgeons see the fracture and treat it with reverse shoulder arthroplasty. Younger trauma surgeons treat these fractures with locked plating technology. Older surgeons usually treat it with nonoperative management.

For young patients with femoral neck fractures, despite a very high complication rate, trauma surgeons treat such fractures with open reduction–internal fixation, whereas arthroplasty surgeons may treat the same fractures with total hip arthroplasty. Outcomes from these different approaches may be similar from a clinical standpoint, but the optimal individual PROM scores for recovery from these injuries are currently unknown.

PROMs can be utilized to facilitate changes in practice to improve outcomes. Consider the example of tibial shaft fractures. Historically, tibial shaft fractures were treated with a variety of nonoperative approaches (e.g., casting, bracing) and operative care (e.g., plating, external fixation, intramedullary nailing). Based on a matched-pair analysis, tibial shaft fracture outcomes were improved with intramedullary nailing instead of the traditional casting methods. This produced a clear improvement in patient satisfaction, with fewer office visits and quicker time to union, as well as improved PROMs, with greater knee and ankle scores and 36-item Short-form Survey outcomes. In contrast, some areas of orthopaedic trauma struggle to achieve a consensus in care and integrate the use of PROMs, for example proximal humeral fractures in the elderly and femoral neck fractures in the young.

In order to better deliver high-quality musculoskeletal care and advance musculoskeletal health, PROMs will be required to help navigate shared decision making and clinically relevant outcomes such as pain, activities of daily living, mental health, and overall quality of life.

Benefits and barriers
Obtaining accurate and validated PROMs improves a physician’s ability to provide and drive shared decision making. It also engages both the patient and the family.

Because patients with limited English proficiency are not well represented in most PROMs, which are administered primarily in English, technology-based interventions with non-English options are an opportunity for improved participation. Offering PROMs in languages other than English may improve patients’ perception and management of their health. Because orthopaedic trauma surgeons have occasionally been misperceived as cold-hearted technicians—“bone broke, need fix”—PROMs are a way to help patients feel that they are at the center of their care.

In many areas of orthopaedic surgery, a patient presents in an office setting electively with either a chronic condition or an acute event precipitating an orthopaedic consultation. The patient can spend time with the orthopaedic clinician, ask questions, have an exam, and then formulate a plan of action using shared decision making. In orthopaedic trauma, an acute event usually precipitates the patient-surgeon relationship. The relationship usually begins in the emergency department, trauma bay, or hospital. The exam is limited and is secondary to a fracture, pain, and often opioids. Therefore, no or limited preinjury evaluation and/or measurement can be reliably obtained. The shared decision plan is also more hurried and sometimes circumscribed because of the acute event, pain, and hospital environment.

Sometimes a straight bone does not always translate into a perfect outcome, and sometimes a bent bone (malunion) does not generate a poor outcome. Function can be more important than form or alignment. For example, with most humeral shaft fractures, when patients are educated and shared decision making is conducted based on baseline PROMs, some patients may avoid surgery. Many studies have confirmed that nonoperative treatment of humeral shaft fractures leads to improved PROMs with time. In the case of a nonanatomically aligned humeral shaft, with transient atrophy, stiff shoulder, and limited transient activities of daily living, at the time of maximum medical improvement, the PROMs results of operative and nonoperative care may be similar given time and appropriate therapy.

Impact of care teams and health disparities
Most orthopaedic PROMs relate to a certain procedure, injury, or condition. Many orthopaedic trauma patients, especially polytrauma patients, have more than one injury or condition. Furthermore, other bodily injuries, such as head injuries, are common. Many care teams are involved with orthopaedic trauma patient care, which can create barriers in allocating the responsibility and implementation of PROMs. Confounding variables may obscure or affect the ability to obtain a reliable and standardized measurement.

In addition, orthopaedic trauma patients can have different outcomes based on geographic disparities. Socioeconomic factors in rural and low-income patients represent another barrier to reliably obtaining PROMs. Because most PROMs are tested and standardized in white, wealthy communities, people with limited English proficiency and underserved communities may require further analysis and testing. Family or social deprivation can negatively affect fracture healing and PROM scores. Future use and research on PROMs in these environments and populations need to be performed.

PROMs are here to stay. Integrating these measures into clinical work algorithms and settings will be variable at first. A clinical team is required to create the most appropriate and simplest PROM questionnaire, and computer specialists will be required to provide the best platforms and help communicate data. Because of barriers to patient data collection, clinicians and healthcare systems can be negative and cynical about their use. However, clinically relevant outcomes, especially pain and function, can be obtained remotely and enable longitudinal follow-up without office visits.

Orthopaedic trauma patients have unique challenges (e.g., lack of baseline measures) and offer unique opportunities for implementation of these measurement tools. PROMs should be used to generate patient education and enhance shared decision making. In the end, PROMs will facilitate improved patient outcomes.

The AAOS PROMs Workgroup understands these healthcare challenges and is creating new resources to equip AAOS members with best practices and tools to evaluate patient care outcomes and use PROMs for performance measure programs. With diverse input, orthopaedic surgeons can facilitate PROMs utilization.

Resources developed by the PROMs Workgroup will be announced to AAOS membership as they are released and can be found at aaos.org/proms. For more information or to get involved, email proms@aaos.org.

Clifford B. Jones, MD, FAAOS, FACS, is a professor of orthopaedic surgery at Creighton University Medical School and chair of the Department of Orthopaedic Surgery at Dignity Health in Phoenix, Ariz. Dr. Jones is a member of the AAOS Education Committee and PROMs Workgroup.

Lauren M. Shapiro, MD, MS, FAAOS, is an assistant professor of orthopaedic hand and upper-extremity surgery at the University of California, San Francisco; affiliate faculty at the Philip R. Lee Institute for Health Policy Studies; and co-chair of the AAOS PROMs Workgroup.

Richard F. Seiden, LD, is a public member of the PROMs Workgroup and serves as chair of the Public Advisory Board to the AAOS Registry Program. He is a retired healthcare transactional attorney and serves on several nonprofit health-related boards and panels.

Kurt Spindler, MD, FAAOS, is the director of research and outcomes at Cleveland Clinic in Florida; professor of surgery at the Cleveland Clinic Lerner College of Medicine, Cleveland Clinic; and co-chair of the AAOS PROMs Workgroup.

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