Patient-reported outcome measures in orthopaedics

In Denmark, there is increasing emphasis on incorporating patient perspectives in health policy through patient-reported outcome measures (PROMs) [1, 2]. Orthopaedic departments spearhead using PROMs to enhance patient care, quality evaluation and research [3, 4]. Patient completion of PROMs and clinician feedback improve communication, care processes, patient involvement [5] and health outcomes [3]. Various PROM tools in orthopaedics primarily support clinical research [3].

The Patient Activity Treatment Outcome Scale (PATOS) is a newly developed PROM aiming to advance patient involvement in clinical practice [6]. PATOS was developed for orthopaedic surgery and has potential in planning hip or knee arthroplasty in patients diagnosed with osteoarthritis in the hip or knee (see Table 1) [7]. This study aimed to investigate how using PATOS as part of a PROM battery for surgeons (see Table 2) influences patient involvement and healthcare decisions in orthopaedic surgical outpatient settings, specifically for patients considered for hip or knee arthroplasty. In this study, patient involvement was defined as “the relationship between patients and healthcare providers as they work together to promote and support active patient and public involvement in health and healthcare and to strengthen their influence on healthcare decisions” [8, 9]. Henceforth, PROMS refers to the specific PROM battery investigated.

Methods

A qualitative research design inspired by Braun and Clarke [10] with semi-structured interviews was adopted to investigate participants’ experiences with PATOS. PATOS was created as an electronic PROM to be used in stages. Preoperatively, patients identify daily activity issues related to self-care, work and hobbies (see Table 2). Postoperatively, patients repeat scores at three and six months for outcome evaluation. In December 2021, PATOS was introduced at one orthopaedic surgery department at a public Danish hospital to increase patient involvement and underpin preoperative patient–surgeon discussions and post-operative outcome assessment during consultations at the orthopaedic outpatient clinics [11]. For visual representations of the patient interface and the surgeon interface, see the Supplementary Material. PATOS was introduced as an addition to the departments’ existing PROMs in an electronic database that has been used since 2017. This was facilitated by the last author and included an information meeting with the surgeons during which PATOS was presented and demonstrated.

Participants were patients and orthopaedic surgeons purposively sampled [10] from the clinic where PATOS was introduced. The participating patients were diagnosed with knee or hip osteoarthritis and scheduled for either knee or hip arthroplasty at the orthopaedic surgical department. The sample size was determined to generate rigour and nuanced answers to the research question [10]. The first author developed a semi-structured, open-ended interview guide including prompts and probes inspired by Braun and Clarke to explore the aim (Supplementary Material). The guide was reviewed and revised by the author group until a consensus on appropriate contents had been reached. Interviews were conducted 11 months after the introduction of PATOS at the department. All surgeons in the department were informed about the study at a meeting and invited to participate via email. Patients were approached during their scheduled consultations at the department and invited to participate by a clinical nurse. In total, 19 patients and nine surgeons were included in interviews, see Table 3. The participants (all male) comprised all the surgeons employed at the department. Five patients declined to participate for lack of time; none dropped out. Interviews were conducted from 16 February 2022 to 17 March 2022. The interviews lasted 8-28 minutes. All interviews were conducted in person by the last author (a female senior clinical advisor, registered nurse, PhD) with whom none of the participants were acquainted. Interviews were audio-recorded on a digital voice recorder and transcribed verbatim. The participants were anonymised using codes. The first author inductively analysed the interview transcripts using Braun and Clarke’s reflexive thematic analysis. This involved familiarisation with data, initial semantic and latent code generation, including interpretation of underlying meanings, theme identification, theme review and definition/naming of themes [12]. The analyses underwent critical revision by the co-authors until a consensus had been reached. NVivo software was used for the analysis, organising data, coding it into themes and extracting citations.

The study was reported according to the Consolidated Criteria for Reporting Qualitative Research guideline [13]. Participants provided informed consent, and the study was conducted in compliance with the Declaration of Helsinki [14]. ChatGPT 4 assisted in translating Danish citations into English for Table 4. The first author confirmed the accuracy of the intended meaning.

Trial registration: not relevant.

Results

Four themes emerged from the analysis: 1) Patient involvement is key, 2) Questionnaire load, 3) Meaningful home-based completion of questionnaires, and 4) PROMs were not used in the decision-making process. In the following, references carrying an S-ID are surgeon quotes, whereas P-IDs are patient quotes.

Patient involvement is key

Both patients and surgeons emphasised that patient involvement was key to developing a trustful relationship between surgeon and patient. Surgeons found that involvement is crucial (S-ID28, Table 4) because the patient’s expectations of potential surgery should align with the expected satisfactory outcome.

Patients had expectations of involvement as surgery involved their bodies, and they felt that surgery was a major decision. However, following their conversation, most patients trusted that the surgeon had the specialist knowledge needed to decide about surgery. Patients associated patient involvement with experiences of being listened to, seen and treated as human beings during the consultation.

The patients did not expect the surgeon to talk about their PROMs, even though they were introduced as an initiative to increase patient involvement in healthcare decisions related to potential surgery. Surgeons did not consider PROMs as a tool to increase patient involvement as they verbally asked patients some of the same questions. Surgeons preferred to ask about aspects such as pain during in-person patient interactions. This approach led some patients to question their need to complete the questionnaires. Thus, actions to foster patient involvement in the relationship overruled the application and potential of PROMs known from the literature, such as systematic assessment of patients.

Questionnaire load

The integration of PATOS with other PROMs made it difficult for surgeons and patients to exclusively discuss PATOS during the interviews. Most surgeons stated that they always read PROMs before seeing their patients, while some stated that they had stopped reading PROMs as they were too lengthy. However, following their conversation, most patients trusted that the surgeon had the specialist knowledge to decide about surgery.

Patients mentioned the high number of questions (P-ID1, Table 4). They doubted whether they had answered the questions correctly as some questions seemed similar but were phrased differently. Patients took between 15 and 45 minutes to complete the PROMs, making it difficult for them to stay focused. Patients stated that it would be helpful to consider the repetition of contents in the PROM battery (see Table 1). Patients completed PROMs as part of the information needed for the hospital trajectory and research.

Surgeons agreed that PROMs might be relevant for both patients and surgeons by providing valuable data to inform quality work and research. However, PROMs should not lead to patient questionnaire overload, and some surgeons stated that more knowledge about the current PROM package is needed to clarify which PROMs should be used and how.

Meaningful home-based completion of patient-reported outcome measures

Most patients completed the PROMs at home. Patients who could not complete PROMs at home were asked to do so when arriving at the hospital for their consultation. Patients conveyed that completing the PROMs at home prompted them to reflect on their situation, priorities and goals concerning potential hip or knee arthroplasty. The questions helped them raise awareness of their current situation and realise that surgery may not fulfil their wishes for future daily activity abilities.

Surgeons stated that PROMs supported their consultations as patients who had completed them at home seemed clearer about their situation when attending their consultation (S-ID24, Table 4). The interviews revealed that completing extensive PROMs with numerous questions required a quiet context conducive to concentration for PROMs to be perceived as meaningful to patients.

Patient-reported outcome measures were not used in the decision-making process

According to patients and surgeons, although PROMs were available, they were rarely used. Few surgeons used PROMs to clarify patient expectations, whereas most preferred a more traditional conversation with patients. Surgeons stated that their assessment relied on objective information such as patient X-rays and a physical examination in the decision-making process and aimed to determine if a patient was a candidate for surgery (S-ID25, Table 4). Patient preferences were considered to form part of a dialogue, including information on the process, risks related to surgery and what to expect in terms of physical ability. Patients did not experience PROMs being used for decision-making as their self-reported measures were not verbalised during the conversation. Patients trusted the opinions of the surgeons in terms of their X-rays and how/if the condition of their hip or knee could be improved by an arthroplasty.

Discussion

This study identified four themes relating to patients’ and surgeons’ experiences with PATOS as part of PROMs and their influence on patient involvement and healthcare decisions. First, patients and surgeons agreed that patient involvement is key for a good consultation. Second, the interviews uncovered that the PROMs applied were cumbersome for patients to complete and for surgeons to apply. Third, PROMs positively affected patients who completed them at home, and surgeons found that these patients were better prepared for consultations. Fourth, patients and surgeons did not use PROMs to guide healthcare decisions. Minor themes not discussed in this paper are variations in patient satisfaction with consultations and the impact of PROMs on treatment adherence. Exploring these may potentially offer insights into how PROMs are best integrated into clinical practice.

A review from 2017 found that PROMs may potentially yield insights into orthopaedics and that PROMs will advance the field in a way that can contribute to science, improve patient care and save resources [3]. Our study has shed light on complexities related to using PROMs in routine orthopaedic clinical practice as the PROMs in this study failed to foster patient involvement or change procedures during healthcare decisions. According to the literature, clinicians’ engagement with PROMs is of major importance and may be influenced by how clinicians are involved, introduced to and trained in the application and communication of PROMs [15-19]. In the orthopaedic department, introducing PATOS as part of a PROM battery was an initial step, which was not based on a theory-driven implementation strategy. This may explain the lack of adoption and why the results did not support the existing literature on the benefits of implementing PROMs in clinical care. Moreover, the results highlight pitfalls and quality indicators associated with PROMs [18]. They suggest that the PROMs might be too extensive, posing a barrier to practical implementation in clinical settings. This was evident in our study, particularly the importance of evaluating the length and purpose of the PROMs. Based on the insights from our qualitative study, the clinical use of PROMS was unclear based on the PROMs completed for the clinical databases, and the potential benefits of enhanced patient care through PROMs have yet to be fully realised.

This study's strengths include an in-depth qualitative approach and a large, diverse participant group. However, participants struggled to distinguish PATOS from the PROMs battery, making their experiences more reflective of the overall battery. Despite this, PATOS, alongside the full battery, helped patients prepare for consultations. A significant limitation is the lack of evidence on PATOS's development, testing or validation, despite claims of its validation [6], with no transparent quality criteria or methods [20].

Conclusions

This study investigated the experiences of patients and surgeons with PATOS as part of a PROM battery in the context of an orthopaedic surgical outpatient setting. The study results revealed that the integration of PATOS with other PROMs made it difficult to investigate PATOS exclusively because the clinical use of PROMS was unclear based on the PROMS completed for the clinical databases. Encouraging the home-based completion of PROMs helped patients reflect on their situations, priorities and goals relating to potential hip or knee arthroplasty, leading to better-prepared discussions with surgeons. However, the study raises concerns about the extensive nature of the applied PROM battery, which may constitute a barrier to clinical application. The results emphasise the importance of refining PROMs for orthopaedic practice and further investigate how PROMs may support orthopaedic clinical practice.