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Year : 2021  |  Volume : 36  |  Issue : 3  |  Page : 45-47

Incorporating clinician-assessed and patient-reported outcome measures in routine orthopedic practice

Department of Orthopaedics, Apex Trauma Centre, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India

Date of Submission26-Nov-2021
Date of Acceptance29-Nov-2021
Date of Web Publication22-Dec-2021

Correspondence Address:
Kumar Keshav
Flat-B-506, Arsha Sumangalam, GH-13C, Sector-14, Vrindavan Yojna, Lucknow 226014, Uttar Pradesh.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jbjd.jbjd_19_21

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How to cite this article:
Keshav K. Incorporating clinician-assessed and patient-reported outcome measures in routine orthopedic practice. J Bone Joint Dis 2021;36:45-7

How to cite this URL:
Keshav K. Incorporating clinician-assessed and patient-reported outcome measures in routine orthopedic practice. J Bone Joint Dis [serial online] 2021 [cited 2022 May 25];36:45-7. Available from: http://www.jbjd.in/text.asp?2021/36/3/45/333204

During coronavirus disease-2019 (COVID-19) pandemic after the second wave in India was over and before routine clinical services had resumed, I tried to compile the data of patients whom I had operated at my tertiary care hospital. It was like a sort of self-realization exercise for me as I found that for most of the patients, I did not have the complete data. Although I had the X-rays and most of the other details of the patient, there was specifically one parameter that made my records incomplete––clinical outcome measures. It is not uncommon to see that when a patient comes for follow-up in the clinic, we usually advise the radiological investigations like X-rays and evaluate the functional outcome in just a gross manner. More often, we just check the range of movements of joints near a fracture and ambulatory status of the patient in lower limb fractures and presence of pain and tenderness at the site of injury/pathology. Very rarely do we check for stability, alignment, and all other parameters. Even if we look for them, we shy away from properly quantifying and documenting it. In our clinical practice, we have often witnessed that the patient is not fully satisfied, even though as surgeons we are confident to have done our job quite well. There comes the importance of patient-reported outcome measures. Over the past decade, we have seen the transformation of clinician/surgeon-centric outcome measures to patient-centric ones.[1],[2],[3]

In simple words, an outcome measure is a tool that can be used to assess the clinical condition of a patient or the impact of an intervention.[1],[3],[4] Traditionally, outcomes have been assessed by specific clinical parameters such as radiographic findings, range of movements, or rate of complications and were thus assessed by clinicians themselves.[2] Clinician-assessed outcome measures (CAOMs) are based on clinical examination and assessment of the patient by the surgeon himself or by any other medical professional in the hospital.[1],[2] One requires specialized professional training to evaluate a patient’s health status. CAOMs can also be used to define end points that can be interpreted as treatment benefits or failures of medical interventions. They are more liable to be influenced by human choices, judgment, or motivation.[2],[4] Unlike just a random gross clinical examination, these measures are more complete, comprehensive, reliable, valid, responsive, and have minimal flooring and ceiling effects.[1],[2],[3],[5],[6] They are a way of objectifying the clinical status of the patient and thus help in the assessment of the same patient over time and compare across different modes of interventions.[3],[4] It contains various parameters and different weights may be assigned to individual elements. Of course, it is a bit more time-consuming. There are several scoring systems with regard to specific anatomic regions, for example, Harris Hip Score for hip, Mayo Elbow Performance score for elbow, and Constant Shoulder score for shoulder.[2],[3],[4] If we look at these, they are mainly looking at absence of pain, functional capacity, alignment of the limb, stability of the joints, and activities of daily living.[1],[2],[5] CAOMs cannot be used by the patients themselves. They require a trained health-care professional for it to be assessed and reported.[2],[4],[5],[6]

On the contrary, patient-reported outcome measures (PROMs) relate to patient’s own evaluation of their problems. A patient-reported outcome (PRO) is “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” (FDA 2009). PROMs are instruments for measuring the PROs.[5] Their use has increased dramatically in the last two decades.[6] In the present-day world of consumerism, we cannot deny that the patients are like consumers and we surgeons and clinicians are like care providers.[7],[8],[9] What matters in the end is the satisfaction level of consumers, which can best be assessed by PROMs. PROMs can either be generic like Short-Form-36 (SF-36)[10] or region/disease specific like Oxford Knee and Hip scores.[11] They are important for several reasons. First, they help in shared decision-making with the patients which will in turn reduce patient dissatisfaction and protect the surgeons from medicolegal point of view. Second, it improves the value of health-care delivery. Health-care value from economic standpoint is the improvement in quality and outcomes (numerator) divided by the cost of treatment (denominator). As the patient is the focal point of health-care delivery, his/her own assessment of his/her condition will increase the numerator and thus the value of healthcare delivery. Third, postoperative care and monitoring gets streamlined. Fourth, it paves the way for meaningful clinical research, especially when data are aggregated on a large scale. Lastly, it helps us to assess the efficacy of a particular treatment.[6],[12],[13]

The incorporation of both the measures––CAOMs and PROMs––in routine clinical practice is an arduous task in itself, especially in setups having scarcity of manpower. With the increasing adoption of Electronic Medical Record Systems (EMRS) especially in corporate hospitals, which have CAOMs and PROMs as a part of software, these are becoming less bothersome to complete. Those hospitals and clinics, which are not so fortunate to have EMRS, can make use of several free software and websites which can be used to hasten the process of evaluation.[14] CAOM can be completed by the surgeons themselves during routine follow-ups by taking proper history and doing methodical clinical evaluation of the patients as per the selected scoring system.[1],[2] We need to document them in the clinical record book of the patients. This will help in temporal evaluation of a clinical condition after a conservative or surgical management. With regular use of CAOMs, the duration in which it can be completed goes on decreasing. On the contrary, PROs are rather difficult to administer. This becomes more challenging in our country because many of our patients are illiterate or even if they are literate, and are generally unable to fully comprehend the questions properly. Most of the scores are in English. However, some of them have been published and validated in regional languages by the creator of scores themselves.[2],[15] For those which are not available, we may need to translate and validate them in local languages. We may even create our own new scores based on the requirements and expectations of patients in our country. To enable collection of PROM data from the common masses, it can be done either via online mode or in-office by allied health professionals like nursing staff or data entry operators. In-office setting can be a part of normal workflow in outpatient clinics where these professionals/staff can ask specific questions regarding how the patients perceive their pain and functional status. This can be done before the patient reaches the clinician’s chamber for consultation and the collected PROM can be made available to the clinician before patient consultation.[1],[4],[16]

Finally, I would like to point out that we need to have the complete data of all patients routinely to avoid selective reporting of patients and for our data to have some real impact. Basically, a paradigm shift is required to make it a part of routine orthopedic practice. The impact that authentic clinical outcome data can create is still underrated by the orthopedic community of the country. There are several regions, especially in tier-two and tier-three cities where the epidemiology of orthopedic care is entirely different and we can get great insights from them. Understanding the importance of both CAOMs and PROMs and willingness to gather them preoperatively (before intervention) and in every follow-up is something that we should strive for. This will not only help the individual orthopedic surgeons to reflect upon the surgical/interventional procedures that they do but can also be a basis for creating newer patient-centric guidelines and treatment strategies in future.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Ayers DC, Bozic KJ. The importance of outcome measurement in orthopaedics. Clin Orthop Relat Res 2013;471:3409-11.  Back to cited text no. 1
Nisar S, Pandit H. Outcome measures in trauma and orthopaedics: A guide to evaluating your practice. Orthopaedics and Trauma 2021;35:260-6.  Back to cited text no. 2
Smith PG, Morrow RH, Ross DA, editors. Field Trials of Health Interventions: A Toolbox. 3rd ed. Oxford: Oxford University Press; 2015.  Back to cited text no. 3
Darwich A, Schüttler V, Obertacke U, Jawhar A. Outcome measures to evaluate upper and lower extremity: Which scores are valid? Z Orthop Unfall 2020;158:90-103.  Back to cited text no. 4
Powers JH 3rd, Patrick DL, Walton MK, Marquis P, Cano S, Hobart J, et al. Clinician-reported outcome assessments of treatment benefit: Report of the ISPOR clinical outcome assessment emerging good practices task force. Value Health 2017;20: 2-14.  Back to cited text no. 5
Makhni EC. Meaningful clinical applications of patient-reported outcome measures in orthopaedics. J Bone Joint Surg Am 2021;103:84-91.  Back to cited text no. 6
Sanders C, Egger M, Donovan J, Tallon D, Frankel S. Reporting on quality of life in randomised controlled trials: Bibliographic study. BMJ 1998;317:1191-4.  Back to cited text no. 7
Makhni EC, Baumhauer JF, Ayers D, Bozic KJ. Patient-reported outcome measures: How and why they are collected. Instr Course Lect 2019;68:675-80.  Back to cited text no. 8
Gagnier JJ. Patient reported outcomes in orthopaedics. J Orthop Res 2017;35:2098-108.  Back to cited text no. 9
Stewart M. The medical outcomes study 36-item short-form health survey (SF-36). Aust J Physiother 2007;53:208.  Back to cited text no. 10
Dawson J, Fitzpatrick R, Murray D, Carr A. Questionnaire on the perceptions of patients about total knee replacement. J Bone Joint Surg Br 1998;80:63-9.  Back to cited text no. 11
Brook EM, Glerum KM, Higgins LD, Matzkin EG. Implementing patient-reported outcome measures in your practice: Pearls and pitfalls. Am J Orthop (Belle Mead NJ) 2017;46: 273-8.  Back to cited text no. 12
Meadows KA. Patient-reported outcome measures: An overview. Br J Community Nurs 2011;16:146-51.  Back to cited text no. 13
Orthopaedic Scores. Available from: http://www.orthopaedicscore.com. [Last accessed on 2021 Nov 23].  Back to cited text no. 14
Oxford University Innovation Click to Licence Portal. Available from: https://process.innovation.ox.ac.uk/clinical/p/oks/questionnaire/1. [Last accessed on 2021 Nov 23].  Back to cited text no. 15
Ayers DC, Zheng H, Franklin PD. Integrating patient-reported outcomes into orthopaedic clinical practice: Proof of concept from Force-TJR. Clin Orthop Relat Res 2013;471:3419-25.  Back to cited text no. 16


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