Electronic Patient-Reported Outcome Collection Systems in Orthopaedic Clinical Practice

The advantages, disadvantages, threats, and opportunities of electronic patient-reported outcome systems in cancer: A systematic review

Objective

Electronic patient-reported outcome (ePRO) systems hold promise for revolutionizing communication between cancer patients and healthcare providers across various care settings. This systematic review explores the multifaceted landscape of ePROs in cancer care, encompassing their advantages, disadvantages, potential risks, and opportunities for improvement.

Methods

In our systematic review, we conducted a rigorous search in Scopus, Web of Science, and PubMed, employing comprehensive medical subject heading terms for ePRO and cancer, with no date limitations up to 2024. Studies were critically appraised and thematically analyzed based on inclusion and exclusion criteria, including considerations of advantages, disadvantages, opportunities, and threats.

Findings

Analyzing 85 articles revealed 69 themes categorized into four key areas. Advantages (n = 14) were dominated by themes like "improved quality of life and care." Disadvantages (n = 26) included "limited access and technical issues." Security concerns and lack of technical skills were prominent threats (n = 10). Opportunities (n = 19) highlighted advancements in symptom management and potential solutions for technical challenges.

Conclusion

This review emphasizes the crucial role of continuous exploration, integration, and innovation in ePRO systems for optimizing patient outcomes in cancer care. Beyond traditional clinical settings, ePROs hold promise for applications in survivorship, palliative care, and remote monitoring. By addressing existing limitations and capitalizing on opportunities, ePROs can empower patients, enhance communication, and ultimately improve care delivery across the entire cancer care spectrum.

Disconnected: Electronic Patient-Reported Outcome Measure Collection In Orthopaedic Patients at an Urban Safety-Net Hospital

INTRODUCTION

Collection of patient-reported outcome measures (PROMs) in orthopaedic patients at safety-net hospitals is challenging. The purpose of this study was to evaluate the success of electronic PROM (E-PROM) collection in this setting.

METHODS

A retrospective review identified 207 consecutive orthopaedic patients undergoing 77 elective arthroplasty procedures and 130 trauma procedures. E-PROMs were collected through automated e-mails from an online patient engagement platform (PatientIQ) at 2 weeks, 6 weeks, and 3 months postoperatively. Patients with trauma received the percentage of normal Single Assessment Numerical Evaluation (SANE) and Patient-Reported Outcomes Measurement Information System-Physical Function (PROMIS-PF). Arthroplasty patients received the Hip/Knee SANE, Hip/Knee Disability and Osteoarthritis Outcome Score-Joint Replacement (HOOS Jr/KOOS Jr), PROMIS Global Physical Health (PROMIS-G-PH), and Veterans RAND 12-Item (VR-12) Health Survey.

RESULTS

Compared with patients with trauma, arthroplasty patients were older (median difference 18.0 years; 95% confidence interval [CI] 12.0-22.0; P < 0.0001), more likely to be Hispanic/Black (proportional difference 16.9%; CI 2.8-30.3%; P = 0.02), more likely to have noncommercial or no insurance (proportional difference 34.0%; CI 23.2-43.0%; P < 0.001), and did not differ in Area Deprivation Index or E-PROM completion at each time point. E-PROMs were completed at 2 weeks, 6 weeks, and 3 months by 25.1% (52 of 207), 24.6% (51 of 207), and 21.7% (45 of 207) of all patients, respectively. Trauma and arthroplasty patients had a similar rate of partial E-PROM completion. Patients who completed 3-month E-PROMs were less likely to be Hispanic/Black (PD -16.4%; CI -31.0 to -0.2%; P < 0.04); less likely to have noncommercial/no insurance (PD -20.0%; CI -35.5 to -4.5%; P = 0.01); and did not differ in age, sex, Area Deprivation Index, or procedure type.

DISCUSSION

The low collection rate of E-PROMs from orthopaedic patients at safety-net hospitals should be weighed against their costs. E-PROM collection may exacerbate disparities in PROM collection among certain patient populations.

LEVEL OF EVIDENCE

Diagnostic Level III.

Operationalizing PROMs at the Musculoskeletal Practice and Policy Levels

There continues to be growing interest in patient-reported outcome measures (PROMs), especially as value-based healthcare initiatives gain more traction. Although it is well-established that PROMs can be useful in clinical research, how to operationalize PROMs in clinical care and policy initiatives remains a "work in progress." Following the design of a comprehensive PROM administration and routine collection system, orthopaedic surgeons and their patients can reap the benefits of PROMs in practice through improved shared clinical decision-making discussions at the individual patient level and closer symptom monitoring on a large scale, with improved resource allocation at the population health level. Although certain government and payer incentives exist to collect PROMs at present, it is reasonable to assume that future policy initiatives will begin to use the actual PROM scores to assess clinical outcomes. Orthopaedic surgeons with interest in this area should prioritize their involvement in policy discussion to ensure PROMs are being used appropriately in novel payment models and policy endeavors so that they are both evaluated and compensated fairly. Specifically, orthopaedic surgeons can help ensure appropriate risk adjustment of patients when this is being done. Undoubtedly, PROMs will only become a larger part of musculoskeletal care moving forward.

Compliance with Electronic Patient Reported Outcome Measure System Data Collection Is 51% Two-years After Shoulder Arthroscopy

Objective

To determine patient compliance in completing electronic patient-reported outcome measures (PROMs) following arthroscopic shoulder surgery and identify risk factors for noncompliance.

Methods

A retrospective review of compliance data was performed for patients who underwent arthroscopic shoulder surgery by a single surgeon in a private practice setting from June 2017 to June 2019. All patients were enrolled in Surgical Outcomes System (Arthrex) as a part of routine clinical care, and outcome reporting was integrated into our practice electronic medical record. Patient compliance with PROMs was calculated at preoperative, three-month, 6-month, 1-year, and 2-year follow-up time points. Compliance was defined as a complete patient response to each assigned outcome module in the database over time. Logistic regression for compliance at the one-year timepoint was performed to assess for factors associated with survey compliance.

Results

Compliance with PROMs was highest preoperatively (91.1%) and decreased at each subsequent time point. The largest decrease in compliance with PROMs occurred between the preoperative and 3-month follow-up time points. Compliance was 58% at 1 year and 51% at 2 years after surgery. Overall, 36% of patients were compliant at all individual time points. There were no significant predictors of compliance with regard to age, sex, race, ethnicity, or procedure.

Conclusions

Patient compliance with PROMs decreased over time with the lowest percentage of patients completing electronic surveys at the traditional 2-year follow-up for shoulder arthroscopy. In this study, basic demographic factors were not predictive of patient compliance with PROMs.

Clinical Relevance

PROMs are commonly collected after arthroscopic shoulder surgery; however, low patient compliance may affect their utility in research and clinical practice.

New Computerized Elbow and Forearm Clinical Scores

Background  Current elbow clinical scores are scarce with limited comparability between them. None of them are computerized yet. There is no forearm clinical score assessing all anatomical components of forearm disorders such as the Essex-Lopresti injuries. The aims of this paper were to present new computerized elbow and forearm clinical scores. Methods  These new computerized elbow and forearm clinical scores include four clinical criteria: pain, function, active range of motion and muscle strength. To each criterion is given a numerical value among 5 grades. The weight of each criterion is equivalent so that patient's and physician's related scores are equally balanced. Results  Clinical scores components are automatically included into diamond-shape graphs and tables that can be directly exported into PowerPoint presentations for demonstration and comparison purposes. Discussion  These user-friendly updatable clinical elbow and forearm scores are based on four classic clinical criteria, pain, function, motion, and strength that are expressed into grades. They were designed to evaluate any osteoarticular elbow or forearm disorder regardless of the etiology. These scores are open since they may be modified in future versions.

Is the Promise of PROMs Being Realized? Implementation Experience in a Large Orthopedic Practice

Patient-reported outcome measures (PROMs), increasingly used for research and quality measurement, are lauded for their potential to improve patient-centered care, both through aggregate reporting and when integrated into clinical practice. However, there are few published studies of the resultant use of PROMs in clinical practice. This case study describes the implementation and use of PROMS in a Midwestern multispecialty medical group orthopedic practice among patients undergoing total knee and hip surgery. Specifically, rates of PROMs use by care teams are tracked over time once made available in the electronic health record. During this time, the orthopedics department achieved a patient PROMS survey response rate of 68% at baseline, 58% 3 months post-surgery, and 55% 12 months post-surgery. However, these data were only accessed by the care teams for fewer than 1% of associated clinical encounters. This suggests that making PROMs available for care team review in the electronic health record, even when coupled with relatively high response rates from patients and departmental leadership support is not enough to encourage integration of PROMs into clinical care for patients. Additional effort is required to identify barriers to PROMs use in clinical care and to test methods to enhance use.

Collection and Utilization of Patient-Reported Outcome Measures in a Colorectal Surgery Clinic

INTRODUCTION

The routine collection of patient-reported outcome measures (PROMs) promises to improve patient care. However, in colorectal surgery, PROMs are uncommonly collected outside of clinical research studies and rarely used in clinical care. We designed and implemented a quality improvement project with the goals of routinely collecting PROMs and increasing the frequency that PROMs are utilized by colorectal surgeons in clinical practice.

METHODS

This mixed-methods, quality improvement project was conducted in the colorectal surgery clinic of a tertiary academic medical center. Patients were administered up to five PROMs before each appointment. PROM completion rates were measured. Additionally, we performed two educational interventions to increase utilization of our electronic health record's PROM dashboard by colorectal surgeons. Utilization rates and attitudes toward the PROM dashboard were measured.

RESULTS

Overall, patients completed 3600 of 3977 (90.9%) administered PROMs during the study period. At baseline, colorectal surgeons reviewed 6.7% of completed PROMs. After two educational interventions, this increased to 39.3% (P = 0.004). Colorectal surgeons also felt that the PROM dashboard was easier to use. Barriers to greater PROM dashboard utilization included poor user interface/user experience and a perceived lack of knowledge, time, and relevance.

CONCLUSIONS

The collection of PROMs in colorectal surgery clinics is feasible and can result in high PROM completion rates. Educational interventions can improve the utilization of PROMs by colorectal surgeons in clinical practice. Our experience collecting PROMs through this quality improvement initiative can serve as a template for other colorectal surgery clinics interested in collecting and utilizing data from PROMs.

Capturing patient-reported outcomes: paper versus electronic survey administration

Objective: To compare the capture rates and costs of paper patient-reported outcomes (pPRO) administered in-clinic and electronic PROs (ePRO) collected through emails and texts. Design: Retrospective review. Setting: Level 1 trauma center. Patients/Participants: The pPRO program enrolled 2164 patients for postsurgical follow-up in 4 fracture types: ankle, distal radius, proximal humerus, and implant removal from 2012 to 2017. The ePRO program enrolled 3096 patients in 13 fracture types from 2018 to 2020. Among the patients enrolled in the ePRO program, 1296 patients were matched to the 4 original fracture types and time points. Main Outcome Measures: PRO capture rates in 4 fracture types by matched time point and estimated cost of each program per enrolled patient. Results: At first follow-up, pPRO provided a higher capture rate than ePRO for 3 of 4 fracture types except for implant removal (P < 0.05). However, at 6-month and 1-year follow-ups, ePRO demonstrated statistically significant higher capture rates when compared with pPRO for all applicable modules (P < 0.05). The average cost for the pPRO program was $171 per patient versus $56 per patient in the ePRO program. Patients were 1.19 times more likely to complete ePRO compared with pPRO (P = 0.007) after controlling for age, sex, fracture type, and time point. Conclusion: The electronic PRO service has improved long-term capture rates compared with paper PROs, while minimizing cost. A combined program that includes both in-clinic and out of clinic effort may be the ideal model for collection of PROs. Level of Evidence: Level 3.

How Do PROMIS Scores Correspond to Common Physical Abilities?

BACKGROUND

The Patient-Report Outcomes Measurement Information System (PROMIS) is increasingly used as a general-purpose tool for measuring orthopaedic surgery outcomes. This set of questionnaires is efficient, precise, and correlates well with specialty-specific measures, but impactful implementation of patient-specific data, especially at the point of care, remains a challenge. Although clinicians may have substantial experience with established patient-reported outcome measures in their fields, PROMIS is relatively new, and the real-life meaning of PROMIS numerical summary scores may be unknown to many orthopaedic surgeons.

QUESTIONS/PURPOSES

We aimed to (1) identify a small subset of important items in the PROMIS Physical Function (PF) item bank that are answered by many patients with orthopaedic conditions and (2) graphically display characteristic responses to these items across the physical function spectrum in order to translate PROMIS numerical scores into physical ability levels using clinically relevant, familiar terms.

METHODS

In a cross-sectional study, 97,852 PROMIS PF assessments completed by 37,517 patients with orthopaedic conditions presenting to a tertiary-care academic institution were pooled and descriptively analyzed. Between 2017 and 2020, we evaluated 75,354 patients for outpatient orthopaedic care. Of these, 67% (50,578) were eligible for inclusion because they completed a PROMIS version 2.0 physical function assessment; 17% (12,720) were excluded because they lacked information in the database on individual item responses, and another < 1% (341) were excluded because the assessment standard error was greater than 0.32, leaving 50% of the patients (37,517) for analysis. The PROMIS PF is scored on a 0-point to 100-point scale, with a population mean of 50 and SD of 10. Anchor-based minimum clinically important differences have been found to be 8 to 10 points in a foot and ankle population, 7 to 8 points in a spine population, and approximately 4 points in a hand surgery population. The most efficient and precise means of administering the PROMIS PF is as a computerized adaptive test (CAT), whereby an algorithm intelligently tailors each follow-up question based on responses to previous questions, requiring only a few targeted questions to generate an accurate result. In this study, the mean PROMIS PF score was 41 ± 9. The questions most frequently used by the PROMIS CAT software were identified (defined in this study as any question administered to > 0.1% of the cohort). To understand the ability levels of patients based on their individual scores, patients were grouped into score categories: < 18, 20 ± 2, 25 ± 2, 30 ± 2, 35 ± 2, 40 ± 2, 45 ± 2, 50 ± 2, 55 ± 2, 60 ± 2, and > 62. For each score category, the relative frequency of each possible response (ranging from "cannot do" to "without any difficulty") was determined for each question. The distribution of responses given by each score group for each question was graphically displayed to generate an intuitive map linking PROMIS scores to patient ability levels (with ability levels represented by how patients responded to the PROMIS items).

RESULTS

Twenty-eight items from the 165-question item bank were used frequently (that is, administered to more than 0.1% of the cohort) by the PROMIS CAT software. The top four items constituted 63% of all items. These top four items asked about the patient's ability to perform 2 hours of physical labor, yard work, household chores, and walking more than 1 mile. Graphical displays of responses to the top 28 and top four items revealed how PROMIS scores correspond to patient ability levels. Patients with a score of 40 most frequently responded that they experienced "some difficulty" with physical labor, yard work, household chores, and walking more than 1 mile, compared with "little" or "no" difficulty for patients with a score of 50 and "cannot do" for patients with a score of 30.

CONCLUSION

We provided a visual key linking PROMIS numerical scores to physical ability levels using clinically relevant, familiar terms. Future studies might investigate whether using similar graphical displays as a patient education tool enhances patient-provider communication and improves the patient experience.

CLINICAL RELEVANCE

The visual explanation of PROMIS scores provided by this study may help new users of the PROMIS understand the instrument, feel empowered to incorporate it into their practices, and use it as a tool for counseling patients about their scores.

Cohort profile: the St Vincent's Melbourne Arthroplasty Outcomes (SMART) Registry, a pragmatic prospective database defining outcomes in total hip and knee replacement patients

PURPOSE

The St Vincent's Melbourne Arthroplasty Outcomes (SMART) Registry is an institutional clinical registry housed at a tertiary referral hospital in Australia. The SMART Registry is a pragmatic prospective database, which was established to capture a broad range of longitudinal clinical and patient-reported outcome data to facilitate collaborative research that will improve policy and practice relevant to arthroplasty surgery for people with advanced arthritis of the hip or knee. The purpose of this cohort profile paper is to describe the rationale for the SMART Registry's creation, its methods, baseline data and future plans for the Registry. A full compilation of the data is provided as a reference point for future collaborators.

PARTICIPANTS

The SMART Registry cohort comprises over 13 000 consecutive arthroplasty procedures in more than 10 000 patients who underwent their procedure at St Vincent's Hospital Melbourne, since January 1998. Participant recruitment, data collection and follow-up is ongoing and currently includes up to 20 years follow-up data.

FINDINGS TO DATE

SMART Registry data are used for clinical audit and feedback, as well as for a broad range of research including epidemiological studies, predictive statistical modelling and health economic evaluations. At the time of writing, there were 46 publications from SMART Registry data, with contributions from more than 67 coauthors.

FUTURE PLANS

With the recent linking of the SMART Registry with Medicare Benefits Schedule and Pharmaceutical Benefits Scheme data through the Australian Institute of Health and Welfare, research into prescribing patterns and health system utilisation is currently underway. The SMART Registry is also being updated with the Clavien-Dindo classification of surgical complications.

Meaningful Clinical Applications of Patient-Reported Outcome Measures in Orthopaedics

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Patient-reported outcome measures (PROMs) comprise valuable data, when combined with traditional clinical information, for patient-centered health outcome assessment.

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While PROMs form the foundation of orthopaedic clinical research, they are invaluable tools for clinical care.

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PROMs play a critical role in shared decision-making with patients, as they are quantitative measures of patient health (function, pain, and satisfaction).

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PROMs should be incorporated into routine postoperative care for effective clinical monitoring and understanding of the response to surgery.

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PROMs can be additionally utilized for meaningful clinical research, predictive analytics, and value-based care delivery pathways.

What Factors Are Associated with Patient-reported Outcome Measure Questionnaire Completion for an Electronic Shoulder Arthroplasty Registry?

BACKGROUND

There has been an increase in the use of electronic systems to collect patient-reported outcome measures. There is limited data on the added value of electronic reporting on increasing patient response proportions and little knowledge of which patients are more likely to respond.

QUESTIONS/PURPOSES

(1) What proportion of patients completed patient-reported outcome questionnaires at baseline and at 1 year and 2 years of follow-up after shoulder arthroplasty, and what methods did they use to complete these questionnaires (either automated or manual data collection)? (2) What factors were associated with questionnaire completion?

METHODS

Our shoulder arthroplasty registry from a high-volume, tertiary care center implemented an electronic platform to collect patient-reported outcomes. A total of 2128 patients underwent shoulder arthroplasty between 2016 and 2019. Patients without an email address on file were excluded; 90% (1907 of 2128) of patients were included in the study. The population was 50% women (954 of 1907) with a mean age of 67 ± 9 years. A query was performed to determine whether patients completed questionnaires by either automated or manual data collection at baseline and 1 year and 2 years of follow-up after shoulder arthroplasty. In a logistic regression analysis, patient factors (such as demographics, education, and living arrangements) were evaluated for their association with whether patients completed these questionnaires.

RESULTS

The proportion of questionnaire completion at baseline, 1 year, and 2 years were 72% (1369 of 1907), 47% (456 of 972), and 33% (128 of 393), respectively. Of the patients who completed their questionnaires, 63% (868 of 1369) did so through automated emails at baseline, 84% (381 of 456) did so at 1 year, and 81% (103 of 128) did so at 2 years. The remainder completed their questionnaires through manual data collection with a research assistant: 37% (501 of 1369) at baseline, 16% (75 of 456) at 1 year, and 19% (25 of 128) at 2 years. After controlling for potentially confounding variables like patient demographics, college education, and living arrangements, women were less likely to complete baseline questionnaires than men (odds ratio 0.78 [95% confidence interval 0.62 to 0.99]; p = 0.04), and white patients (OR 1.6 [95% CI 1.05 to 2.44]; p = 0.03) were more likely than nonwhite patients to have complete baseline questionnaires. At 2 years of follow-up, patients with a college education (OR 2.06 [95% CI 1.14 to 3.71]; p = 0.02), those who lived alone (OR 2.11 [95% CI 1.13 to 3.94]; p = 0.02), and those who had higher baseline Shoulder Activity Scale scores (OR 1.05 [95% CI 1.00 to 1.11]; p = 0.04) were more likely to have complete questionnaires than those without a college education, those who lived with other people, and those with lower SAS scores, respectively.

CONCLUSION

The challenges of adopting an online platform include low follow-up proportions and the need for manual assistance by a research assistant to increase patient completion of questionnaires.

CLINICAL RELEVANCE

The knowledge of which patient characteristics are associated with a higher likelihood of completing questionnaires has implications for targeted follow-up or representative sampling of the population in a registry. Populations that are less likely to respond may require more effort to reach to prevent exacerbating health outcome disparities. Random sampling with upweighting of hard-to-reach populations may also provide a solution to achieve a representative population of patients undergoing shoulder arthroplasty.

Validation of Remote Collection of Patient-Reported Outcomes Using Patients' Smartphones

Backgroud

The purpose of this study was to examine the between-mode equivalence and the relative efficiency of the 2 available modes of patient-reported outcome (PRO) data collection: a web-enabled touch screen tablet and a smartphone in a sample of patients who underwent foot and ankle orthopedic surgery.

Methods

A total of 136 patients who visited the clinic after foot/ankle surgery participated in the study. All patients completed the PRO questionnaire set using tablets at the hospital. After 24 hours of completing the first PRO questionnaire, the patients completed the same PRO questionnaire at home using their personal smartphones. The outcomes were statistically compared, and the patients' preferences were surveyed.

Results

The intraclass correlation coefficients for comparing the results of PRO measurements between the 2 modes were 0.970 for the visual analog scale, 0.952 for the Foot Function Index, 0.959 for the foot and ankle outcome scale, and 0.957 for the patient's satisfaction. Sixty-eight participants (58.6%) responded that they were able to answer the questionnaires with more honesty at home using their smartphones. Regarding the mode, 60 participants (48.1%) responded that they have no preference between the devices.

Conclusions

The results of this study showed the equivalence of the 2 modes of PRO data collection: web-enabled touch screen tablets and smartphones. Smartphones may be the preferred mode of PRO measurement, due to their easy accessibility, increased privacy, and the patients' increased honesty in answering questionnaires.