Journal of Physiotherapy 63 (2017) 1–3
Journal of
PHYSIOTHERAPY
journal homepage: www.elsevier.com/locate/jphys
Editorial
The changing landscape of patient outcome assessment
Ilana N Ackerman
Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
[2_TD$IF]Over the past three decades, there has been a major shift
towards capturing patient-centred healthcare outcomes.1 By
definition, patient-reported outcome measures (PROMs) are
designed to capture the patient’s own perspective of their
wellbeing or quality of life, although patients may not have
necessarily been involved in the development of the instrument.2
While PROMs have traditionally been perceived as an optional
add-on in some areas of physiotherapy practice (to complement
‘more objective’ measures of treatment outcomes), their use is
more firmly entrenched in other areas of practice such as
musculoskeletal and cardiorespiratory physiotherapy. Valid and
reliable PROMs are now available across a range of constructs that
are relevant to physiotherapy (such as pain, health-related quality
of life, physical activity, dyspnoea, fatigue, dizziness, balance and
urinary urgency). While some instruments require licensing
arrangements, others are freely available for physiotherapists to
use in clinical and research settings.
Routine use of PROMs can support clinical practice and
healthcare delivery in a number of ways.1,3–5 At the clinician
level, PROMs can be used: to monitor short- and longer-term
improvement or deterioration; to communicate progress to
patients; and as a motivational tool to promote engagement with
treatment and self-management strategies. PROMs can also be
used to support clinical decision-making and quantitatively report
the outcomes of treatment to referrers and health funders. At a
healthcare system level, there is now significant appetite for
utilising PROMs to evaluate and improve the quality of care, and to
guide healthcare funding and resource allocation decisions.
Value-based healthcare and patient-reported outcome
measures
There is currently an international buzz around PROMs and
their potential role in facilitating ‘value-based healthcare’. Coined
by Michael Porter of Harvard Business School, value-based
healthcare aims to deliver the best possible outcomes for patients,
while minimising costs.6 As this concept centres on improving
patient outcomes and providing high-quality care more efficiently, it requires mechanisms for longitudinal data collection and
reporting outcomes back to clinicians and/or healthcare organisations. The International Consortium for Health Outcomes
Measurement (ICHOM) is a USA-based, non-profit organisation
that was established to promote a transition towards value-based
healthcare. Since 2012, ICHOM has developed standardised
outcome measurement sets (termed ‘Standard Sets’) for a range
of high-burden health conditions (such as coronary artery disease,
stroke and low back pain), as highlighted by the Global Burden of
Disease Study. The organisation is now promoting and supporting
the uptake of these measurement sets in clinical practice
internationally. The Standard Sets incorporate existing PROM
instruments and new measurement items, and are designed to
cover outcomes that are important to patients, clinicians and health
funders. Reference guides and data dictionaries can be accessed
from ICHOM’s website (www.ichom.org/medical-conditions). Each
Standard Set is developed by an international working group
comprising expert clinicians, clinical registry leaders, researchers,
and patient representatives. Physiotherapists have been strong
contributors to the development and refinement of Standard Sets
relevant to our fields of practice, contributing both clinical and
outcomes measurement expertise.7–9 As the Standard Sets cover
the full cycle of patient care (including non-surgical and surgical
management), they can be used across different healthcare
settings, including primary care, acute hospital, and rehabilitation
settings. Twenty Standard Sets have now been published,
including for health conditions commonly managed by physiotherapists such as hip and knee osteoarthritis, low back pain,
Box 1. Available ICHOM Standard Sets.
Cancer
Advanced prostate cancer
Breast cancer
Colorectal cancer
Localised prostate cancer
Lung cancer
Cardiovascular
Coronary artery disease
Heart failure
Stroke
Congenital abnormalities
Cleft lip and palate
Craniofacial microsomia
Maternal and neonatal health
Pregnancy and childbirth
Mental and behavioural disorders
Depression and anxiety
Musculoskeletal
Hip and knee osteoarthritis
Low back pain
Neurological
Dementia
Parkinson’s disease
Primary and preventive care
Older person
Sensory organs
Cataracts
Macular degeneration
Urogenital
Overactive bladder
http://dx.doi.org/10.1016/j.jphys.2016.11.003
1836-9553/ß 2016 Australian Physiotherapy Association. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
2
Editorial
Parkinson’s disease, stroke and overactive bladder (Box 1). A
further 10 Standard Sets are currently in development (including
Standard Sets for adult overall health, paediatric overall health,
and inflammatory arthritis) and should be available in 2017. Internationally, a large number of prominent organisations (including state and federal government agencies, hospitals,
healthcare networks, and private health insurers[3_TD$IF]) have now
partnered with ICHOM, commonly to support the local implementation of Standard Sets or to prioritise the development of
new Standard Sets.
Benchmarking patient outcomes
At the healthcare system level, there are many examples of
existing and upcoming initiatives that use routine PROMs
collection (including the ICHOM Standard Sets) to monitor
patient care and enable benchmarking of outcomes between
organisations. Perhaps the most well known example of routine
PROMs collection comes from the United Kingdom. In 2009, the
National Health Service (NHS) introduced mandatory preoperative and postoperative collection of PROMs for patients undergoing hip or knee replacement, hernia repair, and varicose vein
surgery. Annual data releases available via the NHS website report
average health-related quality of life scores and average health
gains for these procedures by healthcare organisation.10[4_TD$IF] People
considering joint replacement surgery can also access the
interactive ‘My NHS’ online portal,11 which provides a simple
interpretation of average health-related quality of life scores and
condition-specific scores for each organisation (for example, ‘as
expected’, ‘better than expected, ‘among the best’, or ‘worse than
expected’), providing greater transparency around surgical outcomes and supporting patients and their families to make
decisions about future care.
In Australia, the Victorian Department of Health and Human
Services will soon pilot the ongoing collection of data from PROMs
in public hospitals for conditions including hip and knee
osteoarthritis, heart failure, and prostate cancer, with the relevant
ICHOM Standard Sets being considered for data collection.12[5_TD$IF] It is
anticipated that these PROMs data will be used for performance
monitoring and informing future health policy.12 Other Australian
state health agencies have also introduced programs to systematically capture PROMs data in integrated care programs for people
with chronic conditions.13 The New South Wales Agency for
Clinical Innovation’s ‘Patient Reported Measures’ program is
currently being piloted at 10 proof-of-concept sites, and a wider
rollout to all health services is planned with consideration of
factors affecting scalability and sustainability. The collected
PROMs data are being used to provide real-time feedback to
clinicians to support patient management, and to generate
aggregate reports for service managers to support quality
monitoring and service improvement. Within this program,
physiotherapists have been involved in advisory and governance
capacities, and are further involved in data collection in
physiotherapist-led musculoskeletal clinics.
The ICHOM Standard Sets have also been designed to facilitate
benchmarking of healthcare outcomes between healthcare
settings, states and countries. The ICHOM Global Health Outcomes Benchmarking Program (GLOBE) was established in
2015 to compare international outcomes from joint replacement
surgery over an 18-month period. Our research team is currently
evaluating the feasibility of implementing the ICHOM Standard
Set for Hip and Knee Osteoarthritis in public and private hospital
settings in Melbourne, Australia, and has been invited to
participate in this exciting global initiative involving 10 healthcare organisations from Australia, Netherlands, Portugal,
Sweden, and the USA. Ramsay Health Care, a multi-national
private hospital group, is also undertaking benchmarking
programs to evaluate patient outcomes after treatment of low
back pain and other selected conditions, using the ICHOM
Standard Sets.
Using patient-reported outcome measures to guide healthcare
funding
There is growing interest from governments and other funders
of healthcare services in moving to value-based payment models,
as opposed to the fee-for-service or activity-based structures that
exist in many jurisdictions. Under these new payment models,
PROMs are being used to align funding for healthcare procedures
(particularly for costly, high-volume surgical procedures) with
demonstrated value or performance. Specific examples of this
approach come from Sweden and the USA. In 2013, value-based
reimbursement models were introduced in Sweden for spinal
surgery, with small performance-based payments (representing
approximately 10% of the base payment for an episode of care)
linked to improvements in patient-reported pain scores that are
compared with national registry outcomes data.14 In 2016, the
Comprehensive Care for Joint Replacement model15 was introduced in 67 geographical areas of the USA, comprising approximately 800 acute hospitals. Administered by the Centers for
Medicare and Medicaid Services, the 5-year Comprehensive Care
for Joint Replacement model provides bundle payments16 for hip
and knee replacement surgery based on quality indicators. As part
of this model, hospitals are asked to submit PROMs data collected
prior to and at 1 year after surgery. Scores on these PROMs will be
used, in conjunction with complication rates and other quality
indicators, to assign a quality composite score to each hospital.
Currently, submission of PROMs data by hospitals is on a voluntary
basis.17 In subsequent years, however, submission of these data
will be mandatory and quality composite scores will be tied to
financial incentives (additional reward payments) and disincentives (potential partial repayments to Medicare).15 In the United
Kingdom there is also provision for primary care trusts (organisations that purchase healthcare from the NHS on behalf of their
communities) to make incentive payments to healthcare organisations, based on performance demonstrated by PROMs data.18
Practical considerations for physiotherapists
While a detailed exposition of the practicalities of PROMs
implementation is beyond the scope of this paper, there are
several key points to be raised. Firstly, the routine capture of
PROMs in clinical settings requires planning around appropriate
instrument selection, assessment intervals, information technology (IT), staffing requirements, and data management and
storage. Physiotherapists can seek guidance on these aspects
from outcome measurement experts and PROMs implementation
consultants. Considerable thought should also be given to how the
data will be utilised. If the data will be used for benchmarking
purposes, adequate case-mix data (for example demographic, comorbidity and intervention data) must be collected alongside
PROMs to enable risk adjustment and fair comparisons.19[6_TD$IF]
Processes for identifying, communicating and managing suboptimal outcomes will also need to be considered. Local ethics and/or
governance approvals may also be required, depending on the
overarching purpose of PROMs collection and any reporting or
dissemination plans. Investment may also be needed (potentially
in IT infrastructure and technical support, as well as administrative and clinical staff training) to establish data capture methods
that can be integrated with existing workflows and that maximise
data completeness and accuracy. Finally, to be worthwhile,
PROMs data must be made available in formats that are
meaningful, with raw item or instrument scores providing little
value in isolation. Interactive reports or graphs (for example,
graphs that track actual versus expected recovery)5 can provide
tangible information for clinicians at the point of care, but may
require specialised software and analysis. Clinicians and healthcare organisations will likely have different needs with regard to
data presentation, so platforms that enable outcomes reporting at
specific levels (patient, clinician and/or organisation levels) may
be needed.
Editorial
In conclusion, there is growing international momentum around
using PROMs to drive improvements in quality of care, and to achieve
better value for patients and funders of healthcare. Physiotherapists
have made (and can continue to make) valuable contributions in this
space through: identifying and using PROMs that adequately capture
the outcomes of our care; taking lead roles in implementation
initiatives; and actively engaging in dialogue about the merit of
PROMs in guiding healthcare funding and resource allocation
decisions. There is certainly scope to improve how we systematically
capture and report outcomes from physiotherapy treatments and
multidisciplinary team care, and also how we monitor patients with
complex chronic conditions over time. Demonstrated interest in
PROMs at the health funder level underscores the need for
physiotherapists to be on the front foot when it comes to the
changing landscape of patient outcome assessment.
Ethics approval: N/A
Source(s) of support: Nil.
Acknowledgements: Nil.
Competing interests: Ilana Ackerman was a Working Group
member for the ICHOM Standard Set for Hip and Knee Osteoarthritis, is a collaborator on the ICHOM Global Health Outcomes
Benchmarking Program (GLOBE), and has received competitive
research funds to evaluate the implementation of the ICHOM
Standard Set for Hip and Knee Osteoarthritis in hospital settings.
Provenance: Not invited. Peer reviewed[7_TD$IF].
3
Correspondence: Ilana Ackerman, Monash University, Melbourne, Australia. Email: [email protected].
References
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
Nelson EC, et al. BMJ. 2015;350:g7818.
Wiering B, et al. Health Expect. 2016. http://dx.doi.org/10.1111/hex.12442.
Dawson J, et al. BMJ. 2010;340:c186.
Black N. BMJ. 2013;346:f167.
Baumhauer JF, et al. Clin Orthop Rel Res. 2016;474:1375–1378.
Porter ME. N Engl J Med. 2010;363:2477–2481.
Clement RC, et al. Acta Orthop. 2015;86:523–533.
Salinas J, et al. Stroke. 2015. http://dx.doi.org/10.1161/strokeaha.115.010898.
Rolfson O, et al. Arthritis Care Res. 2016. http://dx.doi.org/10.1002/acr.22868.
NHS Digital. Patient Reported Outcome Measures (PROMs). http://digital.nhs.uk/
proms [Accessed 28/09/16].
National Health Service. My NHS. https://www.nhs.uk/Service-Search/
performance/search [Accessed 28/09/16].
Department of Health and Human Services. Collecting Patient Reported Outcomes
Measures in Victoria Consultation Paper September 2016. Melbourne: State Government of Victoria; 2016.
New South Wales Agency for Clinical Innovation. Patient Reported Measures.
https://www.aci.health.nsw.gov.au/resources/integrated-care/aci/
patient-reported-measures [Accessed 28/09/16].
Porter ME, Marks CM. OrthoChoice: Bundled Payments in the County of Stockholm (C).
Boston: Harvard Business School; 2014.
Centers for Medicare & Medicaid Services. Comprehensive Care for Joint Replacement Model. https://innovation.cms.gov/initiatives/CJR [Accessed 28/09/16].
Mechanic RE. N Engl J Med. 2015;373:1291–1293.
Lyman S, et al. J Arthroplasty. 2016;31:1144–1147.
Devlin NJ, Appleby J. Getting the most out of PROMs. Putting health outcomes at the
heart of NHS decision-making. London: The King’s Fund; 2010.
Fehring TK. J Arthroplasty. 2016;31:1148–1150.