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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/).

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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

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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

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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:

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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

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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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