The routine use of patient reported outcome measures in healthcare settingsBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c186 (Published 18 January 2010) Cite this as: BMJ 2010;340:c186
All rapid responses
The paper by Dawson and colleagues1 provides an interesting overview
of the routine use of patient reported outcome measures (PROMs) in health
care, with a check-list of issues to be considered by those embarking on a
The authors make two statements that do not appear to us to be highly
evidence-based. We are not aware of any empirical work that can support
the claim that the systematic use of PROMs improves patient outcomes. In
fact the empirical papers and reviews of routine use of PROMs in clinical
practice suggest that outcomes are not improved.2 3 A firmer research base
is required, to establish the costs and benefits associated with routine
measurement of PROMs, before the further roll-out of such initiatives.
The second strong statement by Dawson and colleagues1 is that
‘clinicians are very positive about the usefulness of collecting PROMs’. A
major PROMs initiative undertaken in Vancouver and Richmond, British
Columbia, and reported in Wright and colleagues,4 sought to determine the
feasibility of routine evaluation of indications for and outcomes of
elective surgery. They collected PROM data before and after surgery from
5313 patients (across five hospitals) who underwent one of six elective
procedures (e.g. cataract replacement, hysterectomy). A total of 138
surgeons participated and were asked at the end of the study whether the
PROMs initiative was worthwhile and whether they wished to continue
receiving routine reports on patients’ outcomes.4 The authors indicate
that ‘Most surgeons were not enthusiastic about this type of evaluation.’
Perhaps surgeons in the UK are a different breed to those in British
Columbia but it might be wrong to assume universal support for PROM-type
work from all stakeholders, especially those whose performance might be
‘judged’ using such data.5
This brings us to the main point of our letter. Before embarking on
the routine collection of PROMs data, as encouraged by Dawson and
colleagues,1 we encourage researchers to spend some time understanding the
problem they wish to address and consider whether routine PROM data will
help to address it. Don’t start with the solution! There is the potential
to squander considerable resource on such data collection activity; Browne
and colleagues6 estimate the cost to be £6.50 per patient.
We are, however, supporters of PROMs initiatives and see routine PROM
data as potentially being useful to address questions posed by four
different stakeholders in the health care system: the patient, the
clinician, the manager/policy maker and the researcher. For example:
The patient who has undergone surgery asks: Is my recovery
post-surgery similar to that of other patients or should I be worried?
The surgeon asks: Which of my patients are experiencing on-
going health problems and might benefit from early clinical review?
The health sector manager asks: Which are the high
performing surgical teams and what lessons can they offer to other groups?
The health service researcher asks: How variable are
surgical health outcomes and what are the main drivers of such variation?
We challenge Dawson and colleagues1 claim that routine collection of
PROMs data in clinical cohorts can be used to assess the impact of health
care interventions on patient outcomes and to guide resource allocation.
Such questions require data (and more than just PROMs) from well
controlled comparative studies rather than data from clinical cohorts.
And so our message to would-be PROMs researchers is to proceed in a
considered and thoughtful manner, understanding the questions you want to
answer and building in rigorous evaluation work to generate research
evidence on the value-for-money of PROMs initiatives.
Stirling Bryan, PhD
Professor, School of Population & Public Health, University of British
Director, Centre for Clinical Epidemiology & Evaluation, Vancouver
Coastal Health Research Institute
Jennifer Davis, MSc
PhD Candidate, University of British Columbia
Centre for Clinical Epidemiology & Evaluation
1. Dawson J, Doll H, Fitzpatrick R, Jenkinson C, Carr AJ. The routine
use of patient reported outcome measures in healthcare settings. BMJ
2. Marshall S, Haywood K, Fitzpatrick R. Impact of patient-reported
outcome measures on routine practice: a structured review. J Eval Clin
3. Valderas JM, Kotzeva A, Espallargues M, Guyatt G, Ferrans CE,
Halyard MY, et al. The impact of measuring patient-reported outcomes in
clinical practice: a systematic review of the literature. Qual Life Res
4. Wright CJ, Chambers GK, Robens-Paradise Y. Evaluation of
indications for and outcomes of elective surgery. CMAJ 2002;167(5):461-6.
5. Bellan L. Evaluating elective surgery. CMAJ 2003;168(4):397-8;
author reply 398-400.
6. Browne J, Jamieson E, Lewsey J, van der Meulen J, Black N, Cairns
J. Patient Reported Outcome Measures(PROMs) in Elective Surgery – Report
to the Department of Health: London School of Hygiene & Tropical
Competing interests: No competing interests
Patient Reported Outcome Measures are a step forwards, but many
patients feel unable to express their true thoughts and feelings, even
some time after treatment has ended, for fear of possible reprisals
(whether or not unfounded).
Patient narratives, on the other hand, are often written by people
who desperately want their story to be acknowledged so that other patients
will not suffer as they did.
As a patient, I felt too intimidated to speak out and far too
indebted to those who were saving my life even to mention the lack of
toilet facilities, let alone things that should not have happened.
The patient narrative that offers an insight into thoughts and
feelings, warts and all, is surely a valuable resource. If clinicians and
others really want to get inside a patient's skin, perhaps such books (or
more of them) should be on the essential reading list for all medical
students and included in the requirements for Continuing Medical
author, Nothing Personal, disturbing undercurrents in cancer care, Radcliffe Publishing, winner,
Medical Journalists' Association Open Book Award 2009
Competing interests: No competing interests