The routine use of patient reported outcome measures in healthcare settings

The use of patient reported outcome measures might seem to be quite straightforward; however, a number of pitfalls await clinicians with limited expertise. Jill Dawson and colleagues provide a guide for individuals keen to use patient reported outcome measures at a local level Patient reported outcome measures (PROMs) are standardised, validated questionnaires that are completed by patients to measure their perceptions of their own functional status and wellbeing. Many such measures were originally designed for assessing treatment effectiveness in the context of clinical trials, 1 but are now used more widely to assess patient perspectives of care outcomes. This outcomes based definition of PROMs distinguishes them from questionnaires used to measure patients' experience of the care process. PROMs are designed to measure either patients' perceptions of their general health ("generic" health status) or their perceptions of their health in relation to specific diseases or conditions. The short form 36 (SF-36) health survey, 2 for example, is a generic questionnaire that assesses self perceived health status by using 36 questions relating to eight broad areas (or "domains") of wellbeing. Examples of condition specific questionnaires include the Parkinson's disease questionnaire (PDQ-39), 3 which assesses quality of life in patients with Parkinson's disease; the visual function questionnaire (VF-14), 4 which uses 14 questions to measure various aspects of visual function affected by cataracts; and the Oxford hip score, 5 which uses 12 questions to assess hip pain and function in relation to outcomes of hip replacement surgery. Patients complete PROMs by rating their health in response to individual questions. These responses are scored (from 0 to 4, for example) according to the level of difficulty or severity reported by the patient. When PROMs are analysed, the individual ratings are combined to produce an overall score to represent an underlying phenomenon or "construct," such as " perceived level of pain" or anxiety. The analysis of PROMs tends to focus on the amount of change that has occurred in the patients' condition or their general health related quality of life, as represented by a change in PROM score following an intervention. To date, PROMs have been used in clinical trials,(6 7) national audits,(8) and registers for joint replacement(9) (10) and other conditions.(11) However, the routine use of PROMs has become widespread in heath care at a local level.(12) Interest is also rapidly growing in the application of PROMs in the context of audit and "registers," to inform individual care and manage the performance of healthcare providers.(12 13 14 15 16) Indeed, in the specific areas of hip and knee replacement, inguinal hernia repair, and varicose vein surgery, the routine collection of PROMs has, since April 2009, been introduced throughout the NHS to measure and improve clinical quality.(17) Government led initiatives such as this are likely to encourage more widespread use of PROMs at both a national and a local level. Specific guidance on methods for collecting baseline PROM data are provided in guidelines for the recent NHS-wide PROMs initiative,(18) in which subsequent data collection and handling are undertaken by private contractors. This article, however, is aimed at individuals who are keen to use PROMs at a local level, who may have limited research experience or access to expertise and advice on relevant research methods, and who may be unaware of a number of pitfalls that could undermine their aim of ultimately producing useful, meaningful data. In addition, there are very few published examples of the application of PROMs in the context of clinical governance and quality assurance,(19) with this form of application being largely unevaluated. Evidence of the impact of using PROMs on routine practice is also lacking.