Clinical Question

Are patient-reported outcome measures (PROMs) effective at improving patient-reported health outcomes and processes of care for patients and health care professionals?

Evidence-Based Answer

PROMs (e.g., CAGE questionnaire, Generalized Anxiety Disorder 7-item questionnaire) completed by patients (or other individuals pertinent to the patient) improve diagnosis and documentation of relevant health information in the patient's chart, such as accurate coding, severity of disease, and relevant changes with treatment related to the PROM (relative risk [RR] = 1.73; 95% CI, 1.44 to 2.08). PROMs also improve communication with health care professionals, as perceived by the patient, including discussion about side effects of treatment and other areas of concern (standardized mean difference [SMD] = 0.36; 95% CI, 0.21 to 0.52). The use of PROMs improves quality of life (SMD = 0.15; 95% CI, 0.05 to 0.26) and disease control (RR = 1.25; 95% CI, 1.10 to 1.41). However, PROMs seem to have little to no effect on a patient's general health perception, social functioning, or pain.¹ (Strength of Recommendation: B, inconsistent or limited-quality patient-oriented evidence.)

Practice Pointers

Patient experience and understanding of their individualized health care are essential in providing meaningful and positive patient care. PROMs are tools that measure patient-reported outcomes, allowing a patient to report on their general health, quality of life, or functional status. PROMs can be disease-specific to screen for and monitor specific medical conditions (e.g., Patient Health Questionnaire-9), or they can monitor overall health (e.g., 36-item Short-Form Health Survey).² Patient input is often overlooked when discussing diagnoses and providing treatment plans.¹ Contextual factors, such as the type of encounter (e.g., routine visit vs. motivational interviewing) or a patient's behavior toward the physician, affect a patient's willingness or ability to accept and adhere to treatment. These contextual factors also affect a physician's willingness or ability to act on the feedback provided. Improving the processes of communication, such as allowing patients more flexibility in bringing up concerns, can ultimately lead to improved shared decision-making while providing holistic patient care.¹

This Cochrane review sought to determine whether patient care improves when patients provide feedback using PROMs.¹ The review included 116 randomized controlled trials and cluster randomized controlled trials (N = 49,785) from high-income countries, with a mean follow-up of one month to two years. These studies were conducted in ambulatory outpatient settings. Primary outcomes included quality of life, general health perception, symptoms, and functioning. Many of these outcomes were assessed using a multitude of scoring systems to encompass a broad spectrum of illnesses (e.g., monitoring asthma symptoms vs. self-reported pain for chronic pain syndrome). Adverse effects were also evaluated, such as distress related to completing the PROM. Secondary outcomes included communication with health care professionals and health services and resources offered to and used by the patient. Excluded studies did not use feedback from PROMs as part of their intervention.

Implementing PROMs improved diagnosis and documentation, as well as communication between health care professionals and patients. When PROM feedback was provided, health care professionals were more likely to document a relevant diagnosis in the patient's medical chart for either the PROM (e.g., asthma severity determined using an asthma severity app on a smartphone) or for patient concerns if nonspecific PROMs were used (RR = 1.73; 95% CI, 1.44 to 2.08). Health care professional communication scores, as perceived by patients, also improved when PROMs were implemented (SMD = 0.36; 95% CI, 0.21 to 0.52). Disease control—specifically the condition that the PROM was designed to monitor—improved with PROM use, albeit only marginally (i.e., symptoms improved in mood, anxiety disorders, or depression, or the patient decreased the number of alcoholic drinks consumed; RR = 1.25; 95% CI, 1.10 to 1.41).

Among primary outcomes, very little improvement occurred in quality of life (SMD = 0.15; 95% CI, 0.05 to 0.26). PROMs had a small positive effect on patient-reported mental functioning (SMD = 0.16; 95% CI, 0.06 to 0.27), little to no effect on patient-reported physical functioning (SMD = −0.10; 95% CI, −0.30 to 0.10), and no effect on social functioning. It was not always clear how these parameters were defined in the individual studies.

Patient perceptions of their own health did not improve with the use of PROMs, although patients in the intervention groups reported better health perceptions than those in the control groups. The certainty of the evidence was low because of the risk of bias from the intervention design and small number of studies available.

This Cochrane review supports only generalized conclusions of the overall impact of patient-reported feedback to health care professionals. Many of the studies that were analyzed defined and measured each outcome so uniquely that direct, accurate comparison of the effects was difficult. Furthermore, many studies had a high risk of bias. These studies did not seem to take measures to ensure inclusion of special populations, and the results did not account for potential inequities related to socioeconomic status, ethnicity, or race.¹

The National Institutes of Health funds the Patient-Reported Outcomes Measurement Information System (PROMIS) to be implemented into electronic health record software,³ with the goal of making health care more patient centered by emphasizing the importance of understanding the implications of PROMs.⁴ Overall, this Cochrane review demonstrates that the use of PROMs in clinical practice can improve some aspects of health care and gives patients a critical voice.

The practice recommendations in this activity are available at https://www.cochrane.org/CD011589.

The opinions and assertions expressed herein are those of the authors and do not reflect the official policy or position of the U.S. Army or the Department of Defense.