Patient Reported Outcome Measures

Written by: Dr Amanda Cormack – created: 15 March 2023; last modified: 15 March 2023

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“"The consequences of our actions are always so complicated, so diverse, that predicting the future is a very difficult business indeed."”

—Albus Dumbledore

In musculoskeletal medicine, patient-reported outcome measures (PROMs) are critical for assessing the impact of treatments on patients' health status. PROMs are particularly useful in this field due to the subjective nature of chronic pain, psychosocial aspects, and disability measures. However, the practicalities of implementing PROMs in clinical settings remain challenging. This article aims to provide a comprehensive overview of PROMs for musculoskeletal medicine doctors and discuss their relevance, practicalities, and issues.

Outcome Measures and the Backdrop for the Current Conundrum

Outcome Measures and the Backdrop for the Current Conundrum

The term "outcome measure" refers to quantifiable aspects of a patient's health status used to assess the benefits of a treatment. In recent years, this term has increasingly been used to describe self-administered questionnaires. These questionnaires aim to measure the change in a patient's status over time, focusing on aspects that are important to the patient.

The 'Outcomes Movement'

The 'Outcomes Movement' has led to the creation of numerous PROMs. However, few have been validated, and even fewer are suitable for use outside of research settings. There is also a lack of consensus on which PROMs to use.

Furthermore, the collection of PROMs can be paper-based or electronic, and may involve static testing (answering every question) or computerized adaptive testing. Electronic data collection, through clinical research and PROM software or patient apps, can facilitate integration into clinical practice and workflow.

Relevance of PROMs in Musculoskeletal Care

PROMs are essential in musculoskeletal medicine for various reasons:

1. Patients: High relevance due to the subjective nature of chronic pain, psychosocial aspects, and disability measures.
2. Practice: Important for audit, communication, quality, and proof of efficacy.
3. Research: Powerful tools when used appropriately, such as in determining the Minimal Clinically Important Change (or Difference).

Despite their importance, numerous challenges hinder the adoption of PROMs in clinical practice. These challenges include cost, concerns about the relevance to patient care, time-consuming processes, bias from practitioners against reporting subjective findings, and resistance to change.

What Makes a Fantastic PROM?

A fantastic PROM should be:

• Useful for the target population (disease/region-specific vs. quality of life, constructs, or function)
• Time-efficient
• Patient-friendly (easy to understand and not offensive)
• Cost-effective (low royalties, paper/printing costs)
• Easy to score and interpret
• Reliable (predictable and repeatable)
• Valid for the condition (measures what it proposes to measure)
• Responsive to change (detects clinically important change over time)

Choosing PROMs

Selecting an appropriate PROM can be challenging. The following steps provide a guide to find the best PROM for your needs:

1. Look for a Core Outcome Set: A minimal set of outcome measures recommended for clinical trials.
2. Check for Systematic Reviews of PROMs: Consult the COSMIN database for PROMs with good properties (validity, reliability, responsiveness, and interpretability).
3. Conduct Your Own Systematic Review: If no systematic review is available, perform your own using COSMIN guidance.
4. Perform Original Measurement/Psychometric Research: If no studies have tested the validity, reliability, and responsiveness for a given set of PROMs for a condition, you could conduct your own research.
5. Develop a New PROM: As a last resort, develop a new PROM instrument and test it, though this is not recommended due to the rigorous process involved and the abundance of existing PROMs.

The Problem with PROMs

Despite their usefulness, there are several issues associated with PROMs:

• Most PROMs have poor or unknown evidence for their properties, necessitating caution when using them.
• Additional rigorous research is needed to validate many PROMs.
• There is an overabundance of PROMs, making selection difficult.
• A small selection of PROMs have been deemed good, but overall consensus is lacking.

When used appropriately, outcome measurement can lead to a better understanding of disease and disability, improved evaluation of treatments, and enhanced patient care in the long term.

Conclusion

In musculoskeletal medicine, PROMs play a critical role in understanding patients' health status and the impact of treatments. While there are challenges in implementing PROMs in clinical settings, such as cost, time, and resistance to change, their benefits in improving patient care and informing clinical decision-making cannot be overstated.

Selecting the right PROMs for your practice can be a complex process, but by following the steps outlined in this article and considering factors such as validity, reliability, and responsiveness, you can make an informed choice that benefits both your patients and your practice.

“"We must all face the choice between what is right and what is easy."”

—The Goblet of Fire

Literature Review

Literature Review

Reviews from the last 7 years: review articles, free review articles, systematic reviews, meta-analyses, NCBI Bookshelf

Articles from all years: PubMed search, Google Scholar search.

TRIP Database: clinical publications about evidence-based medicine.

Other Wikis: Radiopaedia, Wikipedia Search, Wikipedia I Feel Lucky, Orthobullets,