Abstract
Background
Precisely defining the different applications of patient-reported outcome measures (PROs) in clinical practice can be difficult. This is because the intervention is complex and varies amongst different studies in terms of the type of PRO used, how the PRO is fed back, and to whom it is fed back.
Methods
A theory-driven approach is used to describe six different applications of PROs in clinical practice. The evidence for the impact of these applications on the process and outcomes of care are summarised. Possible explanations for the limited impact of PROs on patient management are then discussed and directions for future research are highlighted.
Results
The applications of PROs in clinical practice include screening tools, monitoring tools, as a method of promoting patient-centred care, as a decision aid, as a method of facilitating communication amongst multidisciplinary teams (MDTs), and as a means of monitoring the quality of patient care. Evidence from randomised controlled trials suggests that the use of PROs in clinical practice is valuable in improving the discussion and detection of HRQoL problems but has less of an impact on how clinicians manage patient problems or on subsequent patient outcomes. Many of the reasons for this may lie in the ways in which PROs fit (or do not fit) into the routine ways in which patients and clinicians communicate with each other, how clinicians make decisions, and how healthcare as a whole is organised.
Conclusions
Future research needs to identify ways in with PROs can be better incorporated into the routine care of patients by combining qualitative and quantitative methods and adopting appropriate trial designs.
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References
Valderas, J. M., Kotzeva, A., Espallargues, M., Guyatt, G., Ferrans, C. E., Halyard, M. Y., et al. (2008). The impact of measuring patient-reported outcomes in clinical practice: A systematic review of the literature. Quality of Life Research, 17(2), 179–193. doi:10.1007/s11136-007-9295-0.
Marshall, S., Haywood, K. L., & Fitzpatrick, R. (2006). Impact of patient-reported outcome measures on routine practice: A structured review. Journal of Evaluation in Clinical Practice, 12(5), 559–568. doi:10.1111/j.1365-2753.2006.00650.x. Review 46 refs.
Campbell, M., Fitzpatrick, R., Haines, A., Kinmonth, A. L., Sandercock, P., Spiegelhalter, D., et al. (2000). Framework for design and evaluation of complex interventions to improve health. British Medical Journal (Clinical Research Ed.), 321(7262), 694–696. doi:10.1136/bmj.321.7262.694.
Greenhalgh, J., Long, A. F., & Flynn, R. (2005). The use of patient-reported outcome measures in routine clinical practice: Lack of impact or lack of theory? Social Science & Medicine, 60(4), 833–843. doi:10.1016/j.socscimed.2004.06.022.
Pawson, R. (2002). Does Megan’s law work: A theory-driven systematic review. Report No. 8.
Weiss, C. H. (1995). Nothing as practical as a good theory: Exploring theory-based evaluation for comprehensive community initiatives for children and families. In J. P. Connell (Ed.), New approaches to evaluating community initiatives: Concepts, methods and contexts. Washington, DC: Aspen Institute.
Connell, J. P., & Kubisch, A. C. (1995). Applying a theory of change approach to the evaluation of comprehensive community initiatives: Progress, prospects and problems. In J. P. Connell (Ed.), New approaches to evaluating community initiatives. Washington, DC: Aspen Institute.
Gilbody, S., Whitty, P., Grimshaw, J., & Thomas, R. (2003). Educational and organizational interventions to improve the management of depression in primary care: A systematic review. Journal of American Medical Association, 289(23), 3145–3151. doi:10.1001/jama.289.23.3145.
Gilbody, S. M., Whitty, P. M., Grimshaw, J. M., & Thomas, R. E. (2003). Improving the detection and management of depression in primary care. Quality & Safety in Health Care, 12(2), 149–155. doi:10.1136/qhc.12.2.149.
Dowrick, C. (1995). Does testing for depression influence diagnosis or management by general practitioners? Family Practice, 12(4), 461–465. doi:10.1093/fampra/12.4.461.
Mazonson, P. D., Mathias, S. D., Fifer, S. K., Buesching, D. P., Malek, P., & Patrick, D. L. (1996). The mental health patient profile: Does it change primary care physicians’ practice patterns? The Journal of the American Board of Family Practice, 9(5), 336–345.
Rubenstein, L. V., McCoy, J. M., Cope, D. W., Barrett, P. A., Hirsch, S. H., Messer, K. S., et al. (1995). Improving patient quality of life with feedback to physicians about functional status. Journal of General Internal Medicine, 10(11), 607–614. doi:10.1007/BF02602744.
Rubenstein, L. V., Calkins, D. R., Young, R. T., Cleary, P. D., Fink, A., Kosecoff, J., et al. (1989). Improving patient function: A randomized trial of functional disability screening. Annals of Internal Medicine, 111(10), 836–842.
Marks, J., Goldberg, D., & Hillier, V. F. (1979). Determinants of the ability of general practitioners to detect psychiatric illness. Psychological Medicine, 9, 337–353.
Freeling, P., Rao, B. M., Paykel, E. S., Sireling, L. I., & Burton, R. H. (1985). Unrecognised depression in general practice. British Medical Journal (Clinical Research Ed.), 290(6485), 1880–1883.
Schor, E. L., Lerner, D. J., & Malspeis, S. (1995). Physicians’ assessment of functional health status and well-being. The patient’s perspective. Archives of Internal Medicine, 155(3), 309–314. doi:10.1001/archinte.155.3.309.
Howard, K. I., Moras, K., Bril, l. P. L., Martinovich, Z., & Lutz, W. (1996). Evaluation of psychotherapy. Efficacy, effectiveness, and patient progress. The American Psychologist, 51(10), 1059–1064. doi:10.1037/0003-066X.51.10.1059.
Miller, S. D., Duncan, B. L., & Hubble, M. A. (2007). Beyond integration: The triumph of outcome over process in clinical practice. Psychotherapy in Australia, 10(2), 2–19.
Lambert, M. J., Hansen, N. B., & Finch, A. E. (2001). Patient-focused research: Using patient outcome data to enhance treatment effects. Journal of Consulting Clinical Psychology, 69(2), 159–172. doi:10.1037/0022-006X.69.2.159.
Slade, M. (2002). Routine outcome assessment in mental health services. Psychological Medicine, 32(8), 1339–1343. doi:10.1017/S0033291701004974.
Long, A. F., & Fairfield, G. (1996). Confusion of levels in monitoring outcomes and/or process. Lancet, 347, 1572. doi:10.1016/S0140-6736(96)91072-7.
Asay, T. P., Lambert, M. J., Gregersen, A. T., & Goates, M. K. (2002). Using patient-focused research in evaluating treatment outcome in private practice. Journal of Clinical Psychology, 58(10), 1213–1225. doi:10.1002/jclp.10107.
Department of Health. (2004). Patient and public involvement in health: The evidence for policy implementation. A summary of the results of the Health in Partnership programme. London: DoH.
Stewart, M. (2001). Towards a global definition of patient-centred care. British Medical Journal (Clinical Research Ed.), 322(7284), 444–445. doi:10.1136/bmj.322.7284.444.
Roter, D. (2000). The enduring and evolving nature of the patient-physician relationship. Patient Education and Counseling, 39(1), 5–15. doi:10.1016/S0738-3991(99)00086-5.
Charles, C., Gafni, A., & Whelan, T. (1997). Shared decision-making in the medical encounter: What does it mean? (or it takes at least two to tango). Social Science & Medicine, 44(5), 681–692. doi:10.1016/S0277-9536(96)00221-3.
Higginson, I. J., & Carr, A. J. (2001). Measuring quality of life: Using quality of life measures in the clinical setting. British Medical Journal (Clinical Research Ed.), 322(7297), 1297–1300. doi:10.1136/bmj.322.7297.1297.
Rothwell, P. M., McDowell, Z., Wong, C. K., & Dorman, P. J. (1997). Doctors and patients don’t agree: Cross sectional study of patients’ and doctors’ perceptions and assessments of disability in multiple sclerosis. British Medical Journal, 314, 1580–1583.
Long, A. F., & Greenhalgh, J. (1997). Addressing the user’s desired outcomes within routine clinical practice. Journal of Irish College Physicians Surgeons, 26(4), 292–296.
Stimson, G. V. (1974). Obeying doctor’s orders: A view from the other side. Social Science & Medicine, 8(2), 97–104. doi:10.1016/0037-7856(74)90039-0.
Lacy, N. L., Paulman, A., Reuter, M. D., & Lovejoy, B. (2004). Why we don’t come: Patient perceptions on no-shows. Annals of Family Medicine, 2(6), 541–545. doi:10.1370/afm.123.
Ling, B. S., Klein, W. M., & Dang, Q. (2006). Relationship of communication and information measures to colorectal cancer screening utilization: Results from HINTS. Journal of Health Communication, 11(Suppl 1), 181–190. doi:10.1080/10810730600639190.
O’Connor, A. (2001). Using patient decision aids to promote evidence-based decision making. ACP Journal of Club, 135(1), A11–A12.
Sawka, C. A., Goel, V., Mahut, C. A., Taylor, G. A., Thiel, E. C., O’Connor, A. M., et al. (1998). Development of a patient decision aid for choice of surgical treatment for breast cancer. Health Expect, 1(1), 23–36. doi:10.1046/j.1369-6513.1998.00003.x.
O’Connor, A. M. (2007). Using decision aids to help patients navigate the “grey zone” of medical decision making. Canadian Medical Association Journal, 176(11), 1597–1598. doi:10.1503/cmaj.070490.
Elwyn, G., O’Connor, A., Stacey, D., Volk, R., Edwards, A., Coulter, A., et al. (2006). Developing a quality criteria framework for patient decision aids: Online international Delphi consensus process. British Medical Journal (Clinical Research Ed.), 333(7565), 417. doi:10.1136/bmj.38926.629329.AE.
Feldman-Stewart, D., Brundage, M. D., Van, M. L., & Svenson, O. (2004). Patient-focussed decision-making in early-stage prostate cancer: Insights from a cognitively based decision aid. Health Expect, 7(2), 126–141. doi:10.1111/j.1369-7625.2004.00271.x.
Feldman-Stewart, D., Brundage, M. D., Hayter, C., Groome, P., Nickel, J. C., Downes, H., et al. (2000). What questions do patients with curable prostate cancer want answered? Medical Decision Making, 20(1), 7–19. doi:10.1177/0272989X0002000102.
Brundage, M., Leis, A., Bezjak, A., Feldman-Stewart, D., Degner, L., Velji, K., et al. (2003). Cancer patients’ preferences for communicating clinical trial quality of life information: A qualitative study. Quality of Life Research, 12(4), 395–404. doi:10.1023/A:1023404731041.
Brundage, M., Feldman-Stewart, D., Leis, A., Bezjak, A., Degner, L., Velji, K., et al. (2005). Communicating quality of life information to cancer patients: A study of six presentation formats. Journal of Clinical Oncology, 23(28), 6949–6956. doi:10.1200/JCO.2005.12.514.
Brundage, M., Feldman-Stewart, D., Leis, A., Bezjak, A., & Pater, J. L. (2006). Patients’ judgements about the value of quality of life information when considering lung cancer (NSCLC) treatment options. International Society for Quality of Life Research meeting abstracts. The QLR Journal A-68, Abstract no. 1810.
Payne, M. (2000). Teamwork in multiprofessional care. Basingstoke: Macmillan.
Davis, R. M., Wagner, E. G., & Groves, T. (2000). Advances in managing chronic disease: research, performance measurement and quality improvement are key. British Medical Journal, 320, 525–526. doi:10.1136/bmj.320.7234.525.
Heruti, R. J., & Ohry, A. (1995). The rehabilitation team. American Journal of Physical Medicine & Rehabilitation, 74(6), 466–468. doi:10.1097/00002060-199511000-00017.
van Bennekom, C. A., Jelles, F., & Lankhorst, G. J. (1995). Rehabilitation activities profile: The ICIDH as a framework for a problem-oriented assessment method in rehabilitation medicine. Disability and Rehabilitation, 17(3–4), 169–175.
Law, M., Polatajko, H., Pollock, N., McColl, M. A., Carswell, A., Baptiste, S., et al. (1994). Pilot testing of the Canadian occupational performance measure: Clinical and measurement issues. Canadian Journal of Occupational Therapy, 61(4), 191–197.
Callahan, M. B. (2001). Using quality of life measurement to enhance interdisciplinary collaboration. Advances in Renal Replacement Therapy, 8(2), 148–151. doi:10.1053/jarr.2001.24248.
Verhoef, J., Toussaint, P. J., Vliet Vlieland, T. P., & Zwetsloot-Schonk, J. H. (2004). The impact of structuring multidisciplinary team conferences mediated by ICT in the treatment of patients with rheumatic diseases. Studies in Health Technology and Informatics, 103, 183–190.
Verhoef, J., Toussaint, P. J., Zwetsloot-Schonk, J. H., Breedveld, F. C., Putter, H., & Vlieland, T. P. M. V. (2007). Effectiveness of the introduction of an international classification of functioning, disability and health-based rehabilitation tool in multidisciplinary team care in patients with rheumatoid arthritis. Arthritis and Rheumatism, 57(2), 240–248. doi:10.1002/art.22539.
Beckerman, H., Roelofsen, E., Knol, D., & Lankhorst, G. (2004). The value of the rehabilitation activities profile (RAP) as a quality sub-system in rehabilitation medicine. Disability and Rehabilitation, 26(7), 387–400. doi:10.1080/09638280410001662941.
Wressle, E., Lindstrand, J., Neher, M., Marcusson, J., & Henriksson, C. (2003). The Canadian occupational performance measure as an outcome measure and team tool in a day treatment programme. Disability and Rehabilitation, 25(10), 497–506. doi:10.1080/0963828031000090560.
Ellwood, P. M. (1998). Shattuck lecture—outcomes management. A technology of patient experience. New England Journal of Medicine, 318, 1549–1556.
Wennberg, J. E., Barry, M. J., Fowler, F. J., & Mulley, A. (1993). Outcomes research, PORTs, and health care reform. Annals of New York Academy of Sciences, 703, 52–62. doi:10.1111/j.1749-6632.1993.tb26335.x.
Gilbody, S. M., House, A. O., & Sheldon, T. A. (2002). Outcomes research in mental health. Systematic review. The British Journal of Psychiatry, 181, 8–16. doi:10.1192/bjp.181.1.8.
Department of Health. (2008). High quality care for all: NHS next stage review final report. London: Department of Health.
Appleby, J., & Devlin, N. (2004). Measuring success in the NHS: Using patient assessed health outcomes to manage performance of healthcare providers. London: Dr. Foster Ethics Committee.
Gompertz, P., Pound, P., Briffa, J., & Ebrahim, S. (1995). How useful are non-random comparisons of outcomes and quality of care in purchasing hospital stroke services. Age and Ageing, 24(2), 127–141. doi:10.1093/ageing/24.2.137.
Lilford, R. J., Brown, C. A., & Nicholl, J. (2007). Use of process measures to monitor the quality of clinical practice. British Medical Journal (Clinical Research Ed.), 335(7621), 648–650. doi:10.1136/bmj.39317.641296.AD.
Davies, H. T. O., & Combie, I. K. (1997). Interpreting health outcomes. Journal of Evaluation in Clinical Practice, 3(3), 187–199. doi:10.1046/j.1365-2753.1997.00003.x.
Browne, J., Jamieson, L., Lewsey, J., van der, M. J., Copley, L., & Black, N. (2008). Case-mix & patients’ reports of outcome in independent sector treatment centres: Comparison with NHS providers. BMC Health Services Research, 8, 78. doi:10.1186/1472-6963-8-78.
McColl, A., Rodrick, P., Gabbay, J., & Ferris, G. (1998). What do health authorities think of population based health outcome indicators? Quality in Health Care, 7, 90–97.
Espallargues, M., Valderas, J. M., & Alonso, J. (2000). Provision of feedback on perceived health status to health care professionals: A systematic review of its impact. Medical Care, 38(2), 175–186. doi:10.1097/00005650-200002000-00007.
Greenhalgh, J., & Meadows, K. (1999). The effectiveness of the use of patient-based measures of health in routine practice in improving the process and outcomes of patient care: A literature review. Journal of Evaluation in Clinical Practice, 5(4), 401–416. doi:10.1046/j.1365-2753.1999.00209.x.
Moore, J. T., Silimperi, D. R., & Bobula, J. A. (1978). Recognition of depression by family medicine residents: The impact of screening. The Journal of Family Medicine, 7, 509–513.
Velikova, G., Booth, L., Smith, A. B., Brown, P., Lynch, P., Brown, J. M., et al. (2004). Measuring quality of life in routine oncology practice improves communication and patient well being—a randomized controlled trial. Journal of Clinical Oncology, 22(4), 714–724. doi:10.1200/JCO.2004.06.078.
Lambert, M. J., Harmon, C., Slade, K., Whipple, J. L., & Hawkins, E. J. (2005). Providing feedback to psychotherapists on their patients’ progress: Clinical results and practice suggestions. Journal of Clinical Psychology, 61(2), 165–174. doi:10.1002/jclp.20113.
O’Connor, A. M. (2007). Decision aids for people facing health treatment or screening decisions. Cochrane Database of Systematic Reviews (Online: Update Software), 4.
Bekker, H. L., Thornton, J. G., Airey, M., Connelly, J., Hewison, J., Robinson, M., et al. (1999). Informed decision making: an annotated bibliography and systematic review. Health Technology Assessment, 3(1), 1–156.
Valderas, J. M., Rue, M., Guyatt, G., & Alonso, J. (2005). The impact of the VF-14 index, a perceived visual function measure, in the routine management of cataract patients. Quality of Life Research, 14, 1743–1753. doi:10.1007/s11136-005-1745-y.
Detmar, S. B., Muller, M. J., Schornagel, J. H., Wever, L. D., & Aaronson, N. K. (2002). Health related quality of life assessments and patient-physician communication. Journal of American Medical Association, 288(23), 3027–3034. doi:10.1001/jama.288.23.3027.
Gilbody, S. M., House, A. O., & Sheldon, T. A. (2001). Routinely administered questionnaires for depression and anxiety: Systematic review. British Medical Journal (Clinical Research Ed.), 322(7283), 406–409. doi:10.1136/bmj.322.7283.406.
Wasson, J., Hays, R., Rubenstein, L., Nelson, E., Leaning, J., Johnson, D., et al. (1992). The short-term effect of patient health status assessment in a health maintenance organization. Quality of Life Research, 1(2), 99–106. doi:10.1007/BF00439717.
Kazis, L., Callahan, L., Meenan, R., & Pincus, T. (1990). Health status reports in the care of patient with rheumatoid arthritis. Journal of Clinical Epidemiology, 43(11), 1243–1253. doi:10.1016/0895-4356(90)90025-K.
Saitz, R., Horton, N. J., Sullivan, L. M., Moskowitz, M. A., & Samet, J. H. (2003). Addressing alcohol problems in primary care: A cluster randomized, controlled trial of a systems intervention. The screening and intervention in primary care (SIP) study. Annals of Internal Medicine, 138(5), 372–382.
Murray, E., Davis, H., See Tai, S., Coulter, A., Gray, A., & Haines, A. (2001). Randomised controlled trial of sn interactive multimedia decision aid on benign prostatic hypertrophy in primary care. British Medical Journal, 323, 1–6. doi:10.1136/bmj.323.7303.1.
Mathias, S. D., Fifer, S. K., Mazonson, P. D., Lubeck, D. P., Buesching, D. P., & Patrick, D. L. (1994). Necessary but not sufficient: The effect of screening and feedback on outcomes of primary care patients with untreated anxiety. Journal of General Internal Medicine, 9(11), 606–615. doi:10.1007/BF02600303.
Magruder-Habib, K., Zung, W. W. K., & Feussner, J. R. (1990). Improving physicians’ recognition and treatment of depression in general medical care. Results from a randomized clinical trial. Medical Care, 28, 239–250. doi:10.1097/00005650-199003000-00004.
Donaldson, M. S. (2008). Taking PROs and patient-centred care seriously: Incremental and disruptive ideas for incorporating PROs in oncology practice. Quality of Life Research. doi:10.1007/s11136-008-9414-6.
Ahles, T. A., Wasson, J. H., Seville, J. L., Johnson, D. J., Cole, B. F., Hanscom, B., et al. (2006). A controlled trial of methods for managing pain in primary care patients with or without co-occurring psychosocial problems. Annals of Family Medicine, 4(4), 341–350. doi:10.1370/afm.527.
Detmar, S. B., Muller, M. J., Wever, L. D., Schornagel, J. H., & Aaronson, N. K. (2001). The patient-physician relationship. Patient-physician communication during outpatient palliative treatment visits: An observational study. Journal of American Medical Association, 285(10), 1351–1357. doi:10.1001/jama.285.10.1351.
Detmar, S. B., Aaronson, N. K., Wever, L. D., Muller, M. J., & Schornagel, J. H. (2000). How are you feeling? Who wants to know? Patients’ and oncologists’ preferences for discussing health related quality of life issues. Journal of Clinical Oncology, 18(18), 3295–3301.
Detmar, S. B., Muller, M. J., Schornagel, J. H., Wever, L. D., & Aaronson, N. K. (2002). Role of health-related quality of life in palliative chemotherapy treatment decisions. Journal of Clinical Oncology, 20(4), 1056–1062. doi:10.1200/JCO.20.4.1056.
Gilbody, S. M., House, A. O., & Sheldon, T. A. (2002). Psychiatrists in the UK do not use outcomes measures. National survey. The British Journal of Psychiatry, 180, 101–103. doi:10.1192/bjp.180.2.101.
McKevitt, C., & Wolfe, C. (2002). Quality of life: what, how, why? Quality in aging-policy. Practice and Research, 3(1), 13–19.
Greenhalgh, J., Flynn, R., Long, A. F., & Tyson, S. (2008). Tacit and encoded knowledge in the use of standardised outcome measures in multidisciplinary team decision making: A case study of in-patient neurorehabilitation. Social Science & Medicine, 67, 183–194. doi:10.1016/j.socscimed.2008.03.006.
Greenhalgh, J., Abhyankar, P., McCluskey, S., Takeurchi, E., & Velikova, G. (2008). How do doctors and patients talk about QoL data in consultations? International Society for Quality of Life Research meeting abstracts. The QLR Journal A-16. Abstract no. 1348.
Fayers, P. M. (2008). Evaluating the effectiveness of using PROs in clinical practice: a role for cluster-randomised trials. Quality of Life Research. doi:10.1007/s11136-008-9391-9.
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Greenhalgh, J. The applications of PROs in clinical practice: what are they, do they work, and why?. Qual Life Res 18, 115–123 (2009). https://doi.org/10.1007/s11136-008-9430-6
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DOI: https://doi.org/10.1007/s11136-008-9430-6