Surgeon Perceptions of the Integration of Patient-Reported Outcome Measures into Clinical Practice

How Can the Use of Patient-Reported Outcomes Data by Orthopaedic Surgeons Be Improved? A National Qualitative Study

BACKGROUND

Routine collection of patient-reported outcome measures (PROMs) is increasing within orthopaedic settings. Although PROMs have the potential to aid orthopaedic surgeons in clinical decision-making, surgeon engagement with and use of these data is limited. Identifying and addressing the facilitators and barriers to the use of PROMs data by orthopaedic surgeons may increase their usage in routine clinical practice.

QUESTIONS/PURPOSES

In a qualitative study, we asked: (1) What are the barriers to the use of PROMs data by orthopaedic surgeons? (2) What are the facilitators to the use of PROMs data by orthopaedic surgeons? (3) How can orthopaedic surgeons' uptake of and engagement with PROMs data in clinical practice be enhanced?

METHODS

A descriptive qualitative study design was undertaken by enrolling 20 orthopaedic surgeon participants (18 of whom were men). The surgeons were purposively sampled from a carefully curated matrix developed from the research team's professional contacts. This sampling database comprised surgeons performing arthroplasty and endeavored to span a range of demographic and professional characteristics including practice setting (metropolitan and regional Australia, private and public hospitals), clinical experience (< 10 years to 30+ years), and surgeon age (30 to 39 years to 70 to 79 years). In total, 28 orthopaedic surgeons were invited to participate, of which 25 were determined to be eligible. Following established qualitative methods, surgeon recruitment, data collection, and data analysis occurred concurrently. Specifically, invitations to participate were sent to potentially eligible surgeons in successive batches, with ongoing consideration of diversity in sample characteristics. The interviewer determined that thematic saturation had occurred after analyzing the final four interviews, which revealed repetitive themes and no new insights, leading to the cessation of recruitment after 20 interviews. Individual semistructured interviews explored participants' perceptions of factors that support and hinder the use of orthopaedic PROMs data in clinical practice. Surgeons' views on enhancing the utilization of PROMS data were also sought, including opportunities for improving electronic PROMs reporting systems, using a national registry platform as an exemplar. To enhance methodological rigor and reduce researcher bias, five randomly selected, deidentified interview transcripts were independently reviewed by two researchers to ensure consistency in coding and theme development. A combined deductive and inductive approach was then used for data analysis, enabling the categorization of themes into barriers, enablers, and opportunities for improving PROMs use by orthopaedic surgeons.

RESULTS

Key barrier themes impacting orthopaedic surgeons' use of PROMs data included time constraints and a lack of awareness or understanding of PROMs and how these data could be used. Key facilitator themes included better availability of PROMs-specific reports, including reporting within hospital-level audits and providing opportunities for surgeon participation in PROMs research activities to improve familiarization with PROMs data. To increase the use of PROMs data in clinical practice, participants suggested the development and delivery of multiple PROMs education options (for example, seminars and written materials such as email communications with practical examples of PROMs use in clinical practice) for orthopaedic surgeons, continuing education incentives for using PROMs data (for continuing professional development points for reviewing individual PROMs reports), and modern technology solutions (including portable options of PROMs systems) to improve ease of access.

CONCLUSION

Despite the widespread availability of PROMs data, an incomplete understanding of how to interpret and utilize the data effectively could be addressed if surgeons are provided with supportive educational tools. We will conduct further research to facilitate the development of these tools through codesign methods with surgeons, with careful consideration of the time limitations that impact surgeons' abilities to access and utilize PROMs data.

CLINICAL RELEVANCE

Targeted educational tools, codeveloped with orthopaedic surgeons, could help realize the potential of PROMs data to support shared decision-making and patient care.

Factors that impact the implementation of patient reported outcomes in routine clinical care for peripheral artery disease from the patient perspective

PURPOSE

Patient reported outcome measures (PROMs) are well-suited for the longitudinal assessment of quality of life, including depression and physical limitations associated with peripheral artery disease (PAD) that are not routinely assessed in clinical care. This study was designed to gain the patient perspective to facilitate implementation of PROMs into clinical practice for PAD management.

METHODS

Twenty-three patients with PAD at a single vascular surgery clinic were enrolled for a qualitative interview, July-December 2022. Patients completed PROMIS Physical Function and Depression assessments before undergoing semi-structured interviews. Two researchers used an inductive thematic analysis to analyze emergent themes from transcribed interviews.

RESULTS

The average age of participants was 69.5 ± 8.2 years; 91% were Caucasian, and 39% were female. Qualitative interviews revealed three implementation-related themes: (1) patient preferences on the timing and type of PROMs collected, (2) PROMs applications in outpatient PAD care, including discussions with their physician, and (3) the clinical value of PROMs. Overall, patients with PAD prefer PROMs related to quality of life and physical function over other domains. Patients appreciate the convenience to complete PROMs before their appointment. Patients would like to verbally discuss meaningful score changes with their providers without the use of graphical aids. Most patients believe PROMs are valuable in their clinical care if their physician reviews the results and the PROM questions apply to their disease symptoms.

CONCLUSIONS

Patient preferences inform future successful implementations and will improve patient completion rates for the collection and clinical use of PROMs in PAD clinical care.

A systematic review of qualitative studies examining barriers and facilitators to orthopaedic surgeon engagement with patient-reported outcome measures data

BACKGROUND

Orthopaedic surgeon engagement with patient-reported outcome measures (PROMs) data has not been comprehensively evaluated, despite increasing uptake of orthopaedic PROMs programmes globally. The aim of this review was to systematically identify, appraise and synthesise qualitative evidence on barriers and facilitators to orthopaedic surgeons' engagement with PROMs data and their use of these data to support clinical practice.

METHODS

Six databases (MEDLINE, EMBASE, COCHRANE CENTRAL, PSYCINFO, CINAHL and EMCARE) were searched from January 2000-March 2024 to identify potentially eligible qualitative studies. Established systematic review methods were used for screening and data extraction, applying PRISMA guidelines. Quality assessment was undertaken using the Joanna Briggs Institute tool for qualitative research.

RESULTS

Eight studies were eligible for inclusion; of these, five studies were qualitative and three studies were mixed-method designs incorporating a qualitative component. Three studies were specific to orthopaedic surgeons and the remaining five studies comprised of mixed samples of health professionals including orthopaedic surgeons. Only one study was classified as being of high methodological quality. Key barrier themes for orthopaedic surgeons were logistical issues, difficulty interpreting and understanding PROMs, and scepticism of the value of PROMs in clinical care. Key enabler themes included improvements to PROMs infrastructure, surgeon education around the potential value, uses and interpretation of PROMs data, aggregate reporting of PROMs data and early involvement of surgeons in the planning and development of PROM systems.

CONCLUSION

While these studies highlight some practical considerations and opportunities that can be addressed through clinician education, there is little high-quality evidence on factors that influence orthopaedic surgeon engagement with PROMs data. Robust qualitative research is needed to better inform tailored support and assist surgeons in integrating PROMs data within orthopaedic care.

Surgically-relevant quality of life thresholds for the Short Inflammatory Bowel Disease Questionnaire in Crohn's disease

BACKGROUND

Despite growing interest in patient-reported outcome measures to track the progression of Crohn's disease, frameworks to apply these questionnaires in the preoperative setting are lacking. Using the Short Inflammatory Bowel Disease Questionnaire (sIBDQ), this study aimed to describe the interpretable quality of life thresholds and examine potential associations with future bowel resection in Crohn's disease.

METHODS

Adult patients with Crohn's disease completing an sIBDQ at a clinic visit between 2020 and 2022 were eligible. A stoplight framework was adopted for sIBDQ scores, including a "Resection Red" zone suggesting poor quality of life that may benefit from discussions about surgery as well as a "Nonoperative Green" zone. Thresholds were identified with both anchor- and distribution-based methods using receiver operating characteristic curve analysis and subgroup percentile scores, respectively. To quantify associations between sIBDQ scores and subsequent bowel resection, multivariable logistic regression models were fit with covariates of age, sex assigned at birth, body mass index, medications, disease pattern and location, resection history, and the Harvey Bradshaw Index. The incremental discriminatory value of the sIBDQ beyond clinical factors was assessed through the area under the receiver operating characteristics curve (AUC) with an internal validation through bootstrap resampling.

RESULTS

Of the 2003 included patients, 102 underwent Crohn's-related bowel resection. The sIBDQ Nonoperative Green zone threshold ranged from 61 to 64 and the Resection Red zone from 36 to 38. When adjusting for clinical covariates, a worse sIBDQ score was associated with greater odds of subsequent 90-day bowel resection when considered as a 1-point (odds ratio [OR] [95% CI], 1.05 [1.03-1.07]) or 5-point change (OR [95% CI], 1.27 [1.14-1.41]). Inclusion of the sIBDQ modestly improved discriminative performance (AUC [95% CI], 0.85 [0.85-0.86]) relative to models that included only demographics (0.57 [0.57-0.58]) or demographics with clinical covariates (0.83 [0.83-0.84]).

CONCLUSION

In the decision-making process for bowel resection, disease-specific patient-reported outcome measures may be useful to identify patients with Crohn's disease with poor quality of life and promote a shared understanding of personalized burden.

Understanding providers' perspectives using patient-reported outcomes in a pain management setting: a pilot study

Aim: This pilot study evaluated an electronic patient-reported outcomes collection system in pain management to understand providers' experiences using the data, and how it affects their patient interaction and guides their clinical decision-making. Materials & methods: Using stratified convenience sampling, nine semi-structured interviews were conducted with consented pain physicians. The transcribed, de-identified interviews were coded and analyzed. Results: Although most physicians utilized patient reported outcomes (PROs), one-third reported no significant change in their practice since implementation and 56% stated it does not influence their treatment recommendations. Conclusion: Despite the importance of measuring the impact of chronic pain on quality of life, there are significant limitations to the real-world use of PRO that may limit the patient's assessment and care.

Barriers and facilitators to measuring patient reported outcomes in an academic breast cancer clinic: An application of the RE-AIM framework

BACKGROUND

Patient reported outcome measures (PROMs) are important for patient-centered, value-based care; however, implementation into surgical practice remains limited. We aimed to demonstrate feasibility of measuring PROMs in an academic breast cancer clinic.

METHODS

We conducted a pilot study implementing the patient-reported outcome measure BREAST-Q among patients with Stage 0-III breast cancer at a single institution from 06/2019-03/2023 using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework. Barriers and facilitators were characterized. Survey completion was assessed pre-operatively and up to 12 months post-operatively.

RESULTS

Barriers included limited time and lack of incorporation into the electronic medical record. Facilitators included utilizing trained team members and an automated workflow. Among eligible patients, 74% completed BREAST-Q at 2-weeks post-operatively and 55% at 12 months post-operatively.

CONCLUSIONS

We describe the implementation of a PROM using the RE-AIM framework, highlighting facilitators and barriers that may assist others in collecting patient-reported outcome data.