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 Table of Contents  
CONTINUING PROFESSIONAL EDUCATION
Year : 2019  |  Volume : 13  |  Issue : 2  |  Page : 73-83

Importance and usage of patient-reported outcome measures in clinical physiotherapy practice


Deputy Manager, Physiotherapy Trainer, Health Care at Home India Pvt Ltd, Noida, Uttar Pradesh, India

Date of Submission27-Feb-2019
Date of Acceptance01-Jun-2019
Date of Web Publication07-Oct-2019

Correspondence Address:
Dr. Gaurav Shori
Health Care at Home India Pvt. Ltd, D8 Sector 3 Noida, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/PJIAP.PJIAP_7_19

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  Abstract 


Interest in patient-related outcome information is a prerequisite for patient-centered care, which has increasingly been recognized as an ethical imperative in modern health care. Patient-reported outcomes assess aspects of a patient's health status coming directly from the patient. Patient-reported outcome measures (PROMs) intent to profoundly change the face of modern health-care delivery. PROMs are increasingly used by clinicians to guide and audit routine care and are already firmly embedded in clinical research. These important patient-centered measures are likely to have a growing impact on physiotherapists all over the world. Patient-reported outcome research findings will increasingly guide policymakers and clinicians in providing evidence-based treatment. In addition, the routine clinical use of PROMs may allow physiotherapists to more effectively track treatment impact, thus aiding the development of optimal management strategies. The Chartered Society of Physiotherapy encourages as well as promotes at every level that physiotherapists must demonstrate measurable improvements in the clinical outcomes of their patients as part of daily practice. The use of PROMs to measure health status in routine practice has some distinct advantages over the traditional research-based outcome measures, as they may directly facilitate change behavior for patients, clinicians, managers, and policymakers. Widespread adoption of PROMs across physiotherapy is, therefore, something for the profession to embrace as it has the potential to empower patients, support clinical decision-making, and drive forward quality improvement. Thus, this article aim towards highlighting the importance and usage of PROMs in clinical physiotherapy practice.

Keywords: Clinical physiotherapy practice, health care, patient-reported outcome measures


How to cite this article:
Shori G. Importance and usage of patient-reported outcome measures in clinical physiotherapy practice. Physiother - J Indian Assoc Physiother 2019;13:73-83

How to cite this URL:
Shori G. Importance and usage of patient-reported outcome measures in clinical physiotherapy practice. Physiother - J Indian Assoc Physiother [serial online] 2019 [cited 2020 May 28];13:73-83. Available from: http://www.pjiap.org/text.asp?2019/13/2/73/274290




  What is Patient-Reported Outcome Measure? Top


Patient-reported outcomes measures (PROMs) are defined as “any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else.”[1],[2] PROMs' information can be gathered using paper-based or electronic questionnaires. Their use in clinical practice helps to ensure the patient “voice” in all aspects of care, which is essential to ensure that therapeutic management remains patient centered.[3] PROMs capture patient's own opinions on the impact of their condition, and its treatment, on their life. Questionnaires are, therefore, usually designed to focus on one or more specific elements of a patient's well-being. Some PROMs specifically measure a combination of physical, mental, and social aspects, and are collectively known as health-related quality of life tools, while others evaluate single dimensions of health; for example, physical activity.[4] The specific questions within a PROM (known as “items”) are usually grouped together to form appropriate subcategories, or domains. Patients' answers in these subcategories provide individual domain scores, which are often combined to generate an overall PROM score.

PROMs can be broadly categorized as either generic or condition-specific instruments.[5] Generic PROMs measure the well-being of all types of patients, regardless of their illness or disorder. Thus, they are particularly useful for comparing outcomes at the group, or aggregate level. For example, the EQ-5D[6] is a common generic PROM recommended by the Chartered Society of Physiotherapy as a standard measure for outpatient MSK physiotherapy practice. Its consistent use across therapy services will allow local and national comparisons with other providers and with the general population. Generic PROMs may not always provide enough level of detail or responsiveness for measuring change in a single patient over time.

On the other hand, condition-specific measures focus on a disease or disorder and address the most relevant concerns for a target population; an example is the Neck Disability Index.[7] Condition-specific PROMs tend to be more responsive to subtle changes in the patient's condition and are therefore better suited to measuring outcomes at the individual level. A third category of PROMs which has gained attention in research and practice includes individualized instruments such as the patient-generated index[8] and patient-specific function scale.[9] Individualized measures examine patients' own definition of health-related quality of life and challenge the prevailing approach of predefinition of the outcomes being measured by researchers and clinicians. Their value is for goal setting and monitoring progress at a strongly individual level, which tends to make them more sensitive to change than the conventional measures. However, policymakers tend not to favor these types of PROMs being used in isolation and they are therefore typically used in combination with other types of PROMs.


  Selecting an “appropriate” Patient-Reported Outcomes Measure Top


When searching for an appropriate PROM, it is important first to ask the following questions: (a) “what clinician wants to measure?”; (b) “what is the rationale for assessment?”; and (c) “at what level will the measurement take place (group or individual)?” For clinicians wanting to benchmark the performance of their service, it is also increasingly important to ask (d) “what PROMs are recommended and being used by others?” The first question will help determine which health domain (s) should be utilized, for example, pain, mobility, and social functioning. Consideration should also be given to capture the most relevant health domains for the target population. The second, third, and fourth questions will aid the selection of the appropriate tool. For instance, to measure differences in pain between patient groups in a trial, in a way that would be easily generalizable to the population, a generic PROM may be most appropriate.[5] If, on the other hand, one wished to measure the same changes in a single patient with knee pain, to inform decisions about ongoing treatment, a sensitive condition-specific measure may be the best option.[10] Of course, it may be appropriate and optimal to use a generic, a condition-specific PROM, and/or a patient-generated scale in combination.[11] The final selection of PROM should be done with a clear understanding of the ultimate purpose of outcome measurement in the given context, to ensure that the right tool is selected for the job.

PROMs should also be selected based on the strength of their measurement properties (i.e., reliability, validity, and responsiveness), which should be established in the population of interest, and on other key aspects including acceptability and interpretability. Reliability encompasses test–retest reliability, or the degree to which results are replicated over time in stable patients; internal consistency, how well items that are grouped in a domain correlate; and in interviewer-administered PROMs, inter-rater reliability, i.e., agreement between two independent interviewers. Validity encompasses content validity, or the degree to which the PROM evaluates all important aspects of the disease/disorder; construct validity, whether behavior of the measure is consistent with hypotheses regarding: (a) probable relationships with other instruments, and/or (b) performance of the tool in different subgroups; and criterion validity, i.e., correlation with a “gold standard.”[12] Some measures are better than others in their ability to discriminate between individuals with different levels of severity at a single point in time, and some are better than others in their responsiveness, which is their ability to detect change within individuals over time. Measures must also be easily interpretable, i.e., the meaning of differences in PROM score should be clearly understood.[13]

A number of resources are available to aid the selection of validated PROMs. The Patient-Reported Outcome and Quality of life Instruments Database (www.proqolid.org)[14] can be searched for specific instruments (e.g., “Neck Disability Index”), or disease/disorder (e.g., “osteoarthritis”), or domain (e.g., “pain”). The International Society for Quality of Life Research has published recommendations on the agreed minimum measurement property standards for PROMs.[15] Finally, the Consensus-based Standards for the selection of health Measurement Instruments group have produced a critical appraisal checklist (available at www.cosmin.nl) for the evaluation of PROM measurement properties.[16]


  Utilizing Patient-Reported Outcome Measures in Clinical Physiotherapy Practice Top


PROMs can assist physiotherapists in their clinical reasoning process for diagnosis and treatment, with a specific focus on the patient's perspective. Involving the patient in this way can also help stimulate self-management.[17] PROMs can also be used by the physiotherapist, in concert with the patient, to identify the major problems in functioning and activities in daily living. Thus, PROMs can assist in establishing treatment objectives and monitor treatment results. It is also essential to be aware of the PROMs' minimal clinically important difference, defined as: the smallest difference in PROM domain score which patients may perceive to be beneficial and which is “significant enough to change patient management,”[18] and the minimal detectable change, which is defined as the minimal change that falls outside the measurement error in the score of an instrument used to measure a symptom.


  Barriers to Patient-Reported Outcome Measure Use Top


Clinicians widely recognize the potential use of PROMs for improving the process of care by enhancing communication, patient education, shared decision-making, and monitoring response to treatment. However, several barriers to the use of PROMs have been identified, which could lessen their usefulness in informing important health-care decisions. Literature suggests practical barriers including the absence of a PROM collection infrastructure and the additional staff burden from PROM measurement that was “disruptive to normal work duties,”[19],[20] the absence of effective PROM-specific organizational and peer support, and a lack of knowledge and confidence about using outcome measures.[21]

Several studies have identified the added value of PROMs in improving the communication between clinicians and patients and for detecting health problems that would otherwise have gone unnoticed.[22] However, the effectiveness of PROMs' feedback on patient outcomes shows that the impact of such interventions is variable.[19],[22]


  Common Patient-Reported Outcome Measures in Musculoskeletal and Neurological Physiotherapy Top


Musculoskeletal

Refer [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9].
Table 1: Pain

Click here to view
Table 2: Back pain

Click here to view
Table 3: Neck pain

Click here to view
Table 4: Shoulder pain

Click here to view
Table 5: Upper-extremity physical function

Click here to view
Table 6: Hip dysfunctions

Click here to view
Table 7: Knee dysfunctions

Click here to view
Table 8: Foot and ankle dysfunctions

Click here to view
Table 9: Lower-extremity physical function

Click here to view


Neurological

Refer [Table 10], [Table 11], [Table 12], [Table 13], [Table 14].
Table 10: Level of consciousness

Click here to view
Table 11: Tone

Click here to view
Table 12: Motor assessment

Click here to view
Table 13: Balance

Click here to view
Table 14: Activities of daily living

Click here to view




Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



[88]



 
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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9], [Table 10], [Table 11], [Table 12], [Table 13], [Table 14]



 

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