Debate
Article
An
introduction
to
patient-reported
outcome
measures
(PROMs)
in
physiotherapy
D.G.
Kyte
a,b,
M.
Calvert
b,
P.J.
van
der
Wees
c,
R.
ten
Hove
d,
S.
Tolan
d,
J.C.
Hill
e,∗aSchoolofSport,Exercise&Rehabilitation,UniversityofBirmingham,Birmingham,UK bPrimaryCareandClinicalSciences,UniversityofBirmingham,Birmingham,UK
cRadboudUniversityMedicalCentre,ScientificInstituteforQualityofHealthcare,Nijmegen,TheNetherlands dCharteredSocietyofPhysiotherapy,UK
eArthritisResearchUKPrimaryCareCentre,PrimaryCareSciences,KeeleUniversity,Stoke-on-Trent,UK
Abstract
Theuseofpatient-reportedoutcomemeasures(PROMs)issettoriseinphysiotherapy.PROMsprovideadditional‘patient-centred’data whichisuniqueincapturingthepatient’sownopinionontheimpactoftheirdiseaseordisorder,anditstreatment,ontheirlife.Thus,PROMs areincreasinglyusedbyclinicianstoguideroutinepatientcare,orforthepurposesofaudit,andarealreadyfirmlyembeddedinclinical research.ThisarticleseekstosummarisethekeyaspectsofPROMuseforphysiotherapists,bothinroutineclinicalpracticeandintheresearch setting,andhighlightsrecentdevelopmentsinthefield.Genericandcondition-specificPROMsaredefinedandexamplesofcommonlyused measuresareprovided.TheselectionofappropriatePROMs,andtheireffectiveuseintheclinicalandresearchsettingsisdiscussed.Finally, existingbarrierstoPROMuseinpracticeareidentifiedandrecentphysiotherapyPROMinitiatives,ledby theRoyalDutchSocietyfor PhysicalTherapyareexplored.
©2014TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/
licenses/by-nc-nd/4.0/).
Keywords:Physiotherapy;Patient-reportedoutcomes;Patient-reportedoutcomemeasures;PROMs;Clinicalpractice;Physiotherapyresearch
Introduction
Patient-reportedoutcomemeasures(PROMs)havebeen
collected in the NHS since 2009 and look set to
pro-foundly change the face of modern healthcare delivery
[1]. PROMs are increasingly used by clinicians to guide
and audit routine care, and are already firmly
embed-ded in clinical research. These important patient-centred
measuresare likely to havea growing impact on
physio-therapists, in the UK and internationally. Patient-reported outcome research findings will increasingly guide policy makersandcliniciansinprovidingevidence-basedtreatment.
∗Correspondingauthor.Tel.:+4401782733900;fax:+4401782733911. E-mailaddress:j.hill@keele.ac.uk(J.C.Hill).
In addition, theroutine clinical useof PROMsmayallow physiotherapiststomoreeffectivelytracktreatmentimpact, thusaidingthedevelopmentofoptimalmanagement strate-gies.Indeed,theCharteredSocietyofPhysiotherapy(CSP) activelyencouragessuchanapproach,stating: ‘Physiothera-pistsmustbeabletodemonstratemeasurableimprovements in the clinical outcomes of their patients as part of daily practice.’[2]. The use of PROMs to measure health sta-tus in routine practice has some distinct advantages over traditional research-based outcome measures, as theymay directlyfacilitatechange behaviourfor patients,clinicians,
managersandpolicymakers.WidespreadadoptionofPROMs
acrossphysiotherapyisthereforesomethingforthe profes-siontoembraceasithasthepotentialtoempowerpatients, supportclinicaldecision-makinganddriveforwardquality improvement.
http://dx.doi.org/10.1016/j.physio.2014.11.003
0031-9406/©2014TheAuthors.PublishedbyElsevierLtd.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/ licenses/by-nc-nd/4.0/).
ThisarticleseekstosummarisethekeyaspectsofPROM useforphysiotherapists,bothinroutineclinicalpracticeand intheresearchsetting,andhighlightsrecentdevelopmentsin thefield.
WhatarePROMs?
Patient-reportedoutcomesmeasures(PROMs)aredefined as:‘... anyreportofthestatusofapatient’shealthcondition thatcomesdirectlyfromthepatient,withoutinterpretation ofthepatient’sresponsebyaclinicianor anyoneelse.’[3].
PROM information can be gathered using paper-based or
electronicquestionnaires.Theiruseinclinicalpracticehelps to ensure the patient ‘voice’ is present in all aspects of care,whichis essential toensuretherapeutic management remains patient-centred[4].PROMs capturepatient’sown opinionsontheimpactoftheircondition,anditstreatment, ontheirlife.Questionnairesarethereforeusuallydesigned tofocusononeormorespecificelementsofapatient’s
well-being.SomePROMsspecificallymeasureacombinationof
physical, mentalandsocial aspects,collectively known as health-relatedqualityoflife(HRQL),whileothersevaluate single dimensions of health, for example, physical activ-ity[5].The specific questions within aPROM (known as ‘items’) are usually grouped together to form appropriate sub-categories,or‘domains’.Forexample,severalquestions
regarding ambulation may be grouped within the domain
‘mobility’.Patient’sanswersinthesesub-categoriesprovide individualdomainscores,whichareoftencombinedto gen-erateanoverallPROMscore.Scoringmethodsvarybetween PROMs,however,soitisimportanttocarefullycheckeach instrument’sinstructions.
PROMscanbebroadlycategorisedas eithergenericor condition-specificinstruments[6]:thisdistinctionis impor-tant.GenericPROMsmeasurethewellbeingofalltypesof patients, regardless of their illness or disorder. Thus,they areparticularlyusefulforcomparingoutcomesatthegroup, or aggregatelevel.Forexample, theEQ-5D [7]is a
com-mongenericPROMrecommendedbytheCSPasastandard
measureforout-patientMSKphysiotherapypractice[2].Its consistentuseacross therapyserviceswill allowlocaland nationalcomparisonswithotherprovidersandwiththe gen-eralpopulation.
GenericPROMsmaynotalwaysprovideasufficientlevel ofdetailorresponsivenessformeasuringchangeinasingle patientovertime,however.Inthisinstance,physiotherapists should also considerutilising a condition-specific PROM. Thesemeasuresfocusonaparticulardiseaseordisorderand addressthemostrelevantconcernsforatargetpopulation;an exampleistheNeckDisabilityIndex[8].Condition-specific PROMstendtobemoreresponsivetosubtlechangesinthe patient’scondition,andarethereforebettersuitedto measur-ingoutcomesattheindividuallevel.
Athirdcategory ofPROMswhichhasgainedattention inresearchandpractice,areindividualisedinstrumentssuch
as the Patient Generated Index[9],Patient Specific Func-tionScale[10]ortheMYMOP[11].Individualisedmeasures examinepatients’owndefinitionofhealthrelatedqualityof lifeandchallengetheprevailingapproachofpre-definition of the outcomes being measured byresearchers and clini-cians.Theirparticularvalueisforgoalsettingandmonitoring progressatahighly individual level,whichtendstomake themmoresensitivetochangethanconventionalmeasures. However,policymakerstendnottofavourtheuseof indivi-dualisedinstrumentsinisolation,theyarethereforetypically usedincombinationwithothertypesofPROMs.
CommonPROMsinphysiotherapyresearchand
routinepractice
PROMs are increasingly collected in physiotherapy
research, usually as secondaryoutcomes inclinical trials,
often accompanying a more objective ‘clinical’ primary
outcome. Recent examples includethe ‘mirror therapyfor patientswithseverearmparesisafterstroke’trial[12],which usedagenericPROMtomeasureindependenceinactivities of dailyliving (the Barthel Index),alongside a condition-specific measure of quality of life in stroke patients (the StrokeImpactScale).Thesesecondaryoutcomeswere
col-lected alongside a primary outcome, measured using an
objectivephysicaltest(theFugl–MeyerAssessment),which evaluatedfunctionalupperlimbrecovery.Thisuseofboth objectiveandpatient-reportedtrialoutcomesisnowcommon andensuresthattrialsbettercaptureinformationregarding aspects of recoverythat are important topatients. Further examplesarepresentedinTable1.
TheuseofPROMsinroutineUKphysiotherapypractice islesswellestablished,butisincreasingaspartofthewider qualityimprovementagendadrivenbythecommissionersof services [13]. Physiotherapy providers are therefore being asked tousePROMstoevidencethequalityof theircare, alongside othermetrics such as safety andpatient experi-ence data.Significantly the CSPincluded PROMsintheir 2012‘AnyQualifiedProvider’(AQP)nationalspecification formusculoskeletalphysiotherapy[14].Sincethentheuseof
PROMshasbeenextendedforwidermonitoringby
commis-sionersandalsoasacontractrequirementformanyprivate sectorhealthinsurers.TheCSPhasthuspromotedtheuseof
theEuroQolEQ-5DPROM[7]asaroutinegenericpatient
reportedoutcomemeasurewithextensivetakeupbytheUK profession.Morerecently,thesocietyhasstartedto encour-ageacombinedapproach:advocatingroutinecollectionofa
generic PROMalongside botha condition-specificPROM
and a patient-reported experience measure. The CSP has
also been workingwithits professionalnetworks tomake
recommendations for routine PROMcollection relatingto
particularconditionsorpathwaysofcare.Tohelpfacilitate consistencyandbestpracticeinPROMdatacollection,the CSPhasrecentlysetupahealthinformaticsteamtoprovide
Table1
PROMsinselectedrecentphysiotherapytrials.
Study Subject PROMs
BrovoldT,SkeltonDA,BerglandA.Olderadults recentlydischargedfromthehospital:effect ofaerobicintervalexerciseonhealth-related qualityoflife,physicalfitness,andphysical activity.JAmGeriatrSoc2013;61:1580–5
Theeffectofaerobicintervalexerciseon health-relatedqualityoflife,physicalfitness, andphysicalactivityinolderadultsrecently dischargedfromthehospital
Medicaloutcomesstudy36-itemshortform survey(SF-36)a,c
Physicalactivityscalefortheelderly (PASE)b,d
CrossJL,ElenderF,BartonG,ClarkA, ShepstoneL,BlythA,etal.Evaluationofthe effectivenessofmanualchestphysiotherapy techniquesonqualityoflifeatsixmonths postexacerbationofCOPD(MATREX):a randomisedcontrolledequivalencetrial.BMC PulmMed2012;12:33
Effectivenessofmanualchestphysiotherapy techniquesonqualityoflifeatsixmonths postexacerbationofCOPD
SaintGeorgesrespiratoryquestionnairea,d
Cuesta-VargasAI,Gonzalez-SanchezM, Casuso-HolgadoMJ.Effectonhealth-related qualityoflifeofamultimodalphysiotherapy programinpatientswithchronic
musculoskeletaldisorders.HealthQualLife Outcomes2013;11:19
Effectonhealth-relatedqualityoflifeofa multimodalphysiotherapyprogrammein patientswithchronicmusculoskeletal disorders
Shortform-12healthsurvey(SF-12)a,c EuroQoL-5Db,c
Visualanaloguescale(VAS)b,c
KjekenI,BoI,RonningenA,SpadaC, MowinckelP,HagenKB,etal.Athree-week multidisciplinaryin-patientrehabilitation programmehadpositivelong-termeffectsin patientswithankylosingspondylitis: randomizedcontrolledtrial.JRehabilMed: OffJUEMSEurBoardPhysRehabilMed 2013;45:260–7
Long-termeffectsofathree-week multidisciplinaryin-patientrehabilitation programmeforpatientswithankylosing spondylitis
BathAnkylosingSpondylitisDisease ActivityScale(BASDAI)a,d
BathAnkylosingSpondylitisFunctional Index(BASFI)a,d
Medicaloutcomesstudy36-itemshortform survey(SF-36)b,c
KromerTO,deBieRA,BastiaenenCH. Physiotherapyinpatientswithclinicalsigns ofshoulderimpingementsyndrome:a randomizedcontrolledtrial.JRehabilMed: OffJUEMSEurBoardPhysRehabilMed 2013;45:488–97
Physiotherapyinpatientswithclinicalsigns ofshoulderimpingementsyndrome
Shoulderpainanddisabilityindexa,d
Patient’sglobalimpressionofchangea,c
Weeklypainscoreb,c
Genericpatient-specificscaleb,c Patients’satisfactionwithtreatmentb,c RutaD,GarrattAM,LengM,RussellIT,
MacDonaldLM.Anewapproachtothe measurementofqualityoflife:thepatient generatedindex.MedCare32;1109–26
Mirrortherapyforpatientswithseverearm paresisafterstroke
Barthelindexb,c Stokeimpactscaleb,d
vanNimwegenM,SpeelmanAD,OvereemS, vandeWarrenburgBP,SmuldersK,Dontje ML,etal.Promotionofphysicalactivityand fitnessinsedentarypatientswithParkinson’s disease:randomisedcontrolledtrial.BMJ 2013;346:f576
Promotionofphysicalactivityandfitnessin sedentarypatientswithParkinson’sdisease
LASAphysicalactivityquestionnaire (LAPAQ)a,c
Activitydiaryb,c
Parkinson’sdiseasequestionnaire (PDQ-39)b,d
Abbreviations:PROMs,patient-reportedoutcomemeasures.
a Primaryoutcome. b Secondaryoutcome. c Genericmeasure.
d Condition-specificmeasure.
leadershipinthisrapidlychangingenvironmentandfurther informationisavailableatwww.csp.org.uk/proms.
Selectingan‘appropriate’PROM
WhensearchingforanappropriatePROM,itisfirst impor-tanttoaskthe followingquestions:(a)‘whatdoI wantto measure?’;(b) ‘whatistherationalefor assessment?’;and (c)‘atwhatlevelwillthemeasurementtakeplace(groupor individual)?’Forclinicians wantingtobenchmarkthe per-formanceoftheirserviceitisalsoincreasinglyimportantto
ask(d)‘whatPROMsarerecommendedandbeingusedby
others?’Thefirstquestionwillhelpdeterminewhichhealth domain(s)shouldbeutilised,e.g.,pain,mobility,social func-tioning,etc.Considerationshouldalsobegiventocapturing themostrelevant healthdomainsforthetargetpopulation. Thesecond,thirdandfourthquestionswillaidselectionof theappropriatetool.Forinstance,tomeasuredifferencesin painbetweenpatientgroupsinatrial,inawaythatwouldbe easilygeneralisabletothepopulation,agenericPROMmay be mostappropriate[6].If,onthe otherhand,onewished tomeasurethesamechangesinasinglepatientwithknee pain,inordertoinformdecisionsaboutongoingtreatment,a
sensitivecondition-specificmeasuremaybethebestoption
[15].Ofcourse,itmaybeappropriateandoptimaltousea generic,andcondition-specificPROMand/orapatient gener-atedscaleincombination[16].Whateverthefinalselection,it shouldbeunderpinnedwithaclearunderstandingofthe ulti-matepurposeofoutcomemeasurementinthegivencontext, toensuretherighttoolisselectedforthejob.
PROMsshouldalsobeselectedbasedonthestrengthof their measurement properties (i.e., reliability, validity and responsiveness),whichshould be established inthe popu-lation of interest, andalso on otherkey aspects including acceptability and interpretability.Reliability encompasses: test-retestreliability,orthedegreetowhichresultsare repli-catedovertimeinstablepatients;internalconsistency,how wellitemsthataregroupedinaparticulardomaincorrelate; and,inintervieweradministeredPROMs,inter-rater reliabil-ity, i.e., agreement between two independent interviewers
[17].Validity encompasses:content validity,or the degree towhichthe PROMevaluatesallimportant aspectsof the disease/disorder;constructvalidity,whetherbehaviourofthe measureisconsistentwithhypothesesregarding:(a)probable relationshipswithotherinstrumentsand/or(b)performance ofthetoolindifferentsubgroups;andcriterionvalidity,i.e., correlationwitha‘goldstandard’[17].Somemeasuresare betterthanothersintheirabilitytodiscriminatebetween indi-vidualswithdifferentlevels ofseverityatasinglepointin time,andsomearebetterthanothersintheirresponsiveness, whichistheirabilitytodetectchangewithinindividualsover time[17].PROMsshouldalsobeacceptabletotheirtarget population,bothinterms of the questions asked(e.g., are theyappropriatelyworded?)andtheiroverallpatientburden (e.g.,isthecompletiontimeforthePROMagreeable?)[15]. Measuresmustalsobeeasilyinterpretable,i.e.,themeaning ofdifferencesinPROMscoreshouldbeclearlyunderstood
[18].
There are anumber of resources available to aid both
location and selection of validated PROMs. The
Patient-ReportedOutcomeandQualityoflifeInstrumentsDatabase
(PROQOLID;www.proqolid.org)[19]canbe searchedfor
specificinstruments(e.g.,‘NeckDisabilityIndex’)orby dis-ease/disorder(e.g.,‘osteoarthritis’),ordomain(e.g.,‘pain’).
The International Society for Quality of Life Research
(ISOQOL) has published recommendations on the agreed
minimum measurement property standards for PROMs
[20].Finally,theCOnsensus-basedStandardsforthe
selec-tionofhealthMeasurementINstruments(COSMIN)group
have produced a critical appraisal checklist (available at
www.cosmin.nl)for theevaluationofPROMmeasurement properties[17,18,21].
UsingPROMsinresearch
Beforecommencingaresearchstudy,oneshouldensure thateachPROMisvalidatedinthepopulationunderstudy, typicallyinalongitudinalorcross-sectionalstudyoraspart
ofaclinicaltrial[5,22].Ifnot,avalidationprocesswillneed to be factored into the design of the project (see Coyne etal.[22]fordetails).Asmentionedabove,theinstrument
should possess adequate measurement properties,
respon-siveness,acceptabilityandinterpretability.Inaddition,itis vitaltoincludecomprehensivedetailssurroundingthe col-lectionof PROMdatainthe studyprotocol,thiswillhelp maximisethequalityofthedata,andisespeciallyimportant
wherePROMassessmentmighttakeplaceacrossmultiple
research sites [23]. In particular, plansfor the prevention
of missing PROM data (either individual items or whole
questionnaires)shouldberoutinelyincludedasthiscanbea commonproblem[24].Localguidelinesregardingthe inclu-sionofPROMinformationinprotocolsareavailable[25]and internationalconsensusguidelinesareindevelopment[26].
Finally,aCONSORT(ConsolidatedStandardsofReporting
Trials)PROchecklisthasbeendevelopedtoassistresearchers inreportingpatient-reportedoutcometrialresults[27].
UsingPROMsinclinicalpractice
PROMscanassist physiotherapistsintheir clinical rea-soningprocessfordiagnosis andtreatment,withaspecific focusonthepatient’sperspective.Involvingthepatientinthis waycanalsohelpstimulateself-management[28].PROMs canalsobeusedbythephysiotherapist,inconcertwiththe patient, to identify the main problems in functioning and activitiesindailyliving.Thus,PROMscanassistin estab-lishing treatment objectivesandmonitor treatment results.
WhenusingPROMsformonitoringpurposes,however,
phy-siotherapistsshouldbeawarequestionnairedatawilllikely incorporate a degreeof measurementerror at the individ-ual patientlevel. Therefore it is important tobe aware of
the PROMs Minimal Clinically Important Change Score
(MCID),definedasthesmallestdifferenceinPROMdomain scorewhichpatientsmayperceivetobebeneficialandwhich is‘significantenoughtochangepatientmanagement’[29]. ThosePROMsthathavebeendevelopedforuseatthegroup level inresearchsettings(especiallygenerictools)maybe less reliableat the individual patient level [30],therefore,
PROMmeasurementshouldalwaysbeusedasanadjunctto
clinicaljudgement.
BarrierstoPROMuse
ClinicianswidelyrecognisethepotentialuseofPROMs
for improving the process of care by enhancing
commu-nication, patient education, shared-decision making and
monitoring response to treatment. However, several barri-erstotheuseofPROMshavebeenidentified,whichcould lessen their usefulness in informing important healthcare decisions.Boyceandcolleague’s[31]reviewof qualitative studies investigating the experiences of healthcare profes-sionalsusingPROMsidentifiedpracticalbarriersincluding:
the absence of a PROM collection infrastructure and the
additionalstaffburdenfromPROMmeasurementthatwas
‘disruptivetonormalworkduties’[32].Similarly,a system-aticreviewundertakenbyalliedhealthprofessionals,outlined
a number of potential obstacles to routine outcome
mea-surement,including:theabsenceofeffectivePROM-specific organisational and peer-support; and a lack of knowledge andconfidenceaboutusing outcomemeasures[33].These findingshighlighttheimportanceofhavingefficientPROM collectionsystems,aswellastrainingstaffinvolvedin imple-mentingtheprocess.
SeveralstudieshaveidentifiedtheaddedvalueofPROMs
in improving the communication between clinicians and
patientsandfordetectinghealthproblemsthatwould other-wisehavegoneunnoticed[34].However,systematicreviews thatassesstheeffectivenessofPROMsfeedbackon
patient-outcomes show that the impact of such interventions is
variable[34,35].Effectivenessappearstoberelatedtothe functionof thePROM, withthehighest impactassociated
withtheuseof PROMsas managementtoolsinoutpatient
settingsfor aspecialisedpatientpopulation;whilethe evi-denceforuseofgenericPROMswaslessconclusive [35]. Thisresearchhighlightsthe importance of havinga target populationinmind,withcleargoalsinplace,toensureroutine PROMcollectiondeliversthemaximumbenefitfor patient care.
TheuseofPROMsforbenchmarking
PROMs data have been introduced for service
evalua-tion and commissioning of care in several countries. The
National HealthService (NHS)inEngland introducedthe
routinecollectionofPROMsdatain2009,usingtheEQ-5D asgeneric questionnairealongsideothercondition-specific questionnairestocollectdatabefore andafter elective sur-gicalproceduresincludingtotalhipandkneereplacements
[36].IntheNetherlands,PROMsdataarebeingcollectedby purchasersofcareforaccountabilitypurposesincombination withpatientexperience measures[37].Whileinternational case studies illustrate the use of PROM data in clinical practicesettingsandimplementationathealthsystemlevel
for performance measurement, these efforts have not yet
demonstratedthefeasibilityofintegratingtheuseofPROMs onawidescale[38].
TheuseofPROMsatgrouplevelforqualityimprovement orperformancemeasurementhasreceivedlittleattentionin the literature. A recent systematic review found only one studythatassessedpeer-comparisonfeedbackforimproving patientfunctionalstatus,andfoundnostatisticaldifferences betweeninterventionandcontrolgroups[35].The
effective-ness of public reporting of PROMsdata has also not yet
beenstudied.However,indirectevidencefor the effective-nessof publicreportingofperformancemeasuressuggests thatqualityimprovementactivitiesofhealthcarepractitioners increasebasedonpublicreportcards[39,40].
The use of PROMsdata for performancemeasurement
providesuniquemethodologicalchallenges.First,thePROM itselfshould bevalidandreliablefor measuringtreatment results at patient level. Second, the performance measure
as derived fromthe PROM data shouldbe valid and
reli-abletoidentify practicevariationandqualityofhealthcare providers.Third,datashouldbereportedandpresentedinan unambiguousmannertosupportcommissionersandpatients
inmakinginformedchoices[41–43].Advanced
methodol-ogyisneededtoenhanceinterpretationofdataincomparing the qualityofproviders toinformpatientsandpurchasers. Basedonemergingevidence,guidanceandresearchefforts toimprovetheinterpretabilityofpatient-reportedoutcomes is likelyto enhancedecision-makingand the impactfrom usingPROMsinpractice.
PROMs:recentdirections
TheRoyalDutchSocietyforPhysicalTherapy(KNGF)
hasestablishedanationalfour-yearprogrammetostimulate the useof PROMsinclinical practice andprovide perfor-mancemeasurement.InaseriesofpilotprojectsPROMsare beingtestedfortheiraddedvalueinsupporting physiother-apistsandpatientsindecision-making.Anationaldatabase hasbeenestablishedforaggregatingdataatthegrouplevel tomeasuretheresultsandqualityofphysiotherapyservices. Datawillbefedbacktophysiotherapistsforquality improve-ment purposes, andthe validity and reliabilityof datafor developing performancemeasureswill betested.The cur-rentfocusoftheprogrammeistheuseofPROMsinprimary care practice for five mainpatient groups(low backpain, neckpain,hipandkneeproblems,andshouldercomplaints). PROMswillalsobetestedforseveralchronicconditionssuch asperipheralarterydisease.
In the UK, ideas for a similar programme are still in theirinfancybutarebeingdiscussedwithintheCSP. Under-pinningresearch isrequiredtodevelop methodstoenable futurebenchmarkingofphysiotherapyservicesusingPROM dataandtheprovisionofnationalnormativePROMchange scores.Atpresent,datadescribingthevariabilityofclinical outcomes andcostsamongphysiotherapyservices is lack-ing.Toenablefuturefaircomparisons,methodsarerequired toenablethe standardisationof PROMsinformationusing appropriateadjustmentforlocalcase-mix(e.g.,deprivation, ageandethnicity)andtoensurePROMsdataisableto iden-tifyvariabilityinperformance.
Conclusion
Within UK physiotherapy, PROMs are making a rapid
transitionfromtheirtraditionalhomewithinresearchto real-lifebusyclinicalpractice. Themaindriverfor thischange
appears to be the political context and the demands of
provide.Thereareseveralkeymessagesforphysiotherapists wishingtoutilisePROMs.Forclinicians,itisimportantthat PROMsare selected carefully, toensure theyrealise their potentialinplayingadirectroleinassistingclinical reason-ing,managementandshareddecision-making. Itiscrucial that the tool capturesthe aspectsof health that matterthe mosttothepatientpopulationforwhichtheyareintended. Formanagerstherearekeymessagestoensurethesuccessful integration of PROMs into practice, including the impor-tanceofaddressingbarrierssuchasknowledgedeficitsand
alack of confidence inusing PROMs; andalso
overcom-ingthecomplexityof establishingacultureof routinedata collection. Finally, for leaders of the profession we high-lighttheurgentneedtoensurethatappropriateorganisational andpeer-supportonthistopicis available,whichincludes caseexamplesofbestpractice,alongsideclearguidanceon the choice of PROMs for different conditions relevant to physiotherapypractice.Wealsocallforgreater fundingof theunderpinningresearchrequiredtoenablefuture
bench-markingandperformancecomparisons.
Ethicalapproval:Notapplicable.
Funding: D.K. is supported by a National Institute for
HealthResearch(NIHR)SchoolforPrimaryCareResearch
(SPCR)fundedPh.D.studentship.J.H.hasbeensupported
todevelop and validate anew musculoskeletal PROM by
theNationalInstituteforHealthResearchUKResearchfor
PatientBenefitProgramme(PB-PG-0909-20283).Noother
funding sources reported.The funders had no role in the decisiontopublish,orpreparationofthemanuscript.
Conflictofinterest:Nonetodeclare.
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