Kate Gooding

OP09 For whom and in what circumstances does the use of patient reported outcome measures (PROMs) improve patient care? A realist synthesis

Background It is suggested that the use of patient reported outcome measure (PROMs) can enhance patients’ consultations with clinicians and improve clinical management. However, existing systematic reviews have found it difficult to reach firm conclusions about the impact of PROMs feedback on the process and outcomes of patient care, largely due to the heterogeneity and complexity of the intervention itself and the wide range of indicators used to assess its impact. This suggests a lack of consensus or even clarity about how this interventions is expected to work. Methods We conducted a realist synthesis to explore the contexts in which and processes through which PROMs enable patients to share concerns with clinicians and change clinicians’ communication practices within the consultation. We identified the ideas and assumptions (program theories) underlying how PROMs use was intended to work and developed an overall model to act as a framework for the review. Electronic databases were searched and backwards and forward citation tracking were carried out on key systematic reviews. We selected papers relevant to testing our theories and 36 papers were included. Results PROMs completion prompts patients to engage in self-reflection and identify then prioritise issues of importance to them. Whether PROMs supported or constrained patients in sharing issues with clinicians depended on the structure of the PROM and existing clinician-patient relationship. Patients valued PROMs but preferred to share information with clinicians when they had established a trusting relationship with them. Clinicians preferred to develop rapport through their verbal interactions with patients. Clinicians perceived standardised PROMs constrained their relationship with patients and were difficult to incorporate into the flow of consultations. Clinicians avoided using them or adapted the PROM, which may compromise their validity. Individualised PROMs supported consultations by allowing patients to ‘tell their story’ but were less useful as an outcome measure to measure change over time. Discussion It is the process of PROMs completion which helps patients to reflect on their health and raise issues with clinicians. The structure of the PROM was a key determinant of the extent to which the use of PROMs supported or constrained the clinician-patient relationship. PROMs may support the care of individual patients through acting as a ‘conversation opener’ rather than as a standardised, quantified summary of patients’ problems.

How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis

BackgroundIn this paper, we report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. We tested two overarching programme theories: (1) PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians and (2) PROMs scores raise clinicians’ awareness of patients’ problems and prompts discussion and action. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes.ResultsPROMs completion prompts patients to reflect on their health and gives them permission to raise issues with clinicians. However, clinicians found standardised PROMs completion during patient assessments sometimes constrained rather than supported communication. In response, clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships. Individualised PROMs supported dialogue by enabling the patient to tell their story. In oncology, PROMs completion outside of the consultation enabled clinicians to identify problematic symptoms when the PROM acted as a substitute rather than addition to the clinical encounter and when the PROM focused on symptoms and side effects, rather than health related quality of life (HRQoL). Patients did not always feel it was appropriate to discuss emotional, functional or HRQoL issues with doctors and doctors did not perceive this was within their remit.ConclusionsThis paper makes two important contributions to the literature. First, our findings show that PROMs completion is not a neutral act of information retrieval but can change how patients think about their condition. Second, our findings reveal that the ways in which clinicians use PROMs is shaped by their relationships with patients and professional roles and boundaries. Future research should examine how PROMs completion and feedback shapes and is influenced by the process of building relationships with patients, rather than just their impact on information exchange and decision making.