Clinical Review

Implementing Patient-Reported Outcome Measures in Your Practice: Pearls and Pitfalls

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Patient-reported outcome measures (PROMs) are an important component of health outcomes assessment. Preoperative and postoperative measurement of patient-reported pain, functionality, and quality of life offers many benefits to orthopedic surgeons in all practice settings. PROM data are used in research and have many other applications. Providers can use PROM data to measure the individual or institutional recovery trajectory for any surgical procedure, and patients can actively engage in their recovery after a procedure by learning about its expected outcomes.

Although PROMs have many benefits and applications, implementation has its challenges. There are issues regarding PROM selection, longitudinal data collection with high compliance, and integration of PROMs into clinical care. In this article, we discuss the challenges associated with implementing PROMs in an orthopedic surgery practice and review the literature for best practices in PROM selection, patient follow-up, and novel ways to use PROM data.


 

References

Take-Home Points

  • Systematic use of PROMs allows physicians to review data on pain, physical function, and psychological status to aid in clinical decision-making and best practices.
  • PROMs should include both general outcome measures (VAS, SF-36, or EQ-5D) and reliable, valid, and responsive disease specific measures.
  • PROM questionnaires should collect pertinent information while limiting the length to maximize patient compliance and reliability.
  • PROMIS has been developed to standardize questionnaires, but generality for specific orthopedic procedures may result in less effective measures.
  • PROMs can also be used for predictive modeling, which has the potential to help develop more cost-effective care and predict expected outcomes and recovery trajectories for individual patients.

Owing to their unique ability to recognize patients as stakeholders in their own healthcare, patient-reported outcome measures (PROMs) are becoming increasingly popular in the assessment of medical and surgical outcomes. 1 PROMs are an outcome measures subset in which patients complete questionnaires about their perceptions of their overall health status and specific health limitations. By systematically using PROMs before and after a clearly defined episode of care, clinicians can collect data on perceived pain level, physical function, and psychological status and use the data to validate use of surgical procedures and shape clinical decisions about best practices. 2-4 Although mortality and morbidity rates and other traditional measures are valuable in assessing outcomes, they do not represent or communicate the larger impact of an episode of care. As many orthopedic procedures are elective, and some are low-risk, the evaluation of changes in quality of life and self-reported functional improvement is an important addition to morbidity and mortality rates in capturing the true impact of a surgical procedure and recovery. The patient’s preoperative and postoperative perspectives on his or her health status have become important as well; our healthcare system has been placing more emphasis on patient-centered quality care. 2,5

Although PROMs have many benefits, implementation in an orthopedic surgery practice has its challenges. With so many PROMs available, selecting those that fit the patient population for a specialized orthopedic surgery practice can be difficult. In addition, although PROM data are essential for research and for measuring individual or institutional recovery trajectories for surgical procedures, in a busy practice getting patients to provide these data can be difficult.

PROMs are heavily used for outcomes assessment in the orthopedics literature, but there are few resources for orthopedic surgeons who want to implement PROMs in their practices. In this article, we review the literature on the challenges of effectively implementing PROMs in an orthopedic surgery practice.

PROM Selection Considerations

PROMs can be categorized as either generic or disease-specific, 4 but together they are used to adequately capture the impact, both broad and local, of an orthopedic condition.

Generic Outcome Measures

Generic outcome measures apply to a range of subspecialties or anatomical regions, allowing for evaluation of a patient’s overall health or quality of life. The most widely accepted measure of pain is the visual analog scale (VAS). The VAS for pain quantifies the level of pain a patient experiences at a given time on a graphic sliding scale from 0 (no pain) to 10 (worst possible pain). The VAS is used in clinical evaluation of pain and in reported outcomes literature. 6,7

Many generic PROMs assess mental health status in addition to physical limitations. Poor preoperative mental health status has been recognized as a predictor of worse outcomes across a variety of orthopedic procedures. 8,9 Therefore, to assess the overall influence of an orthopedic condition, it is important to include at least 1 generic PROM that assesses mental health status before and after an episode of care. Generic PROMs commonly used in orthopedic surgery include the 36-Item Short Form Health Survey (SF-36), the shorter SF-12, the Veterans RAND 12-Item Health Survey (VR-12), the World Health Organization Disability Assessment Schedule (WHODAS), the European Quality of Life-5 Dimensions (EQ-5D) index, and the 10-item Patient-Reported Outcomes Measurement Information System Global Health (PROMIS-10) scale. 10-14

Some generic outcome measures (eg, the EQ-5D index) offer the “utility” calculation, which represents a preference for a patient’s desired health status. Such utilities allow for a measurement of quality of life, represented by quality-adjusted life years (QALY), which is a standardized measure of disease burden. Calculated QALY from measures such as the EQ-5D can be used in cost-effectiveness analyses of surgical interventions and have been used to validate use of procedures, particularly in arthroplasty. 15-17

Disease-Specific Outcome Measures

Likewise, there is a range of disease-specific PROMs validated for use in orthopedic surgery, and providers select

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