PROMs: This is where the patient’s perspective counts when measuring quality.
PROMs: This is where the patient’s perspective counts when measuring quality.
An x-ray says a lot – but not everything. For example, it does not tell you how functional the patient really is in everyday life after an operation. Or how he feels about it. It is precisely these aspects that so-called Patient Reported Outcome Measures, or PROMs for short, can measure.
There are various quality measurement systems in medicine. All contribute in their own way to providing patients, hospitals and doctors with important information. A specific form of patient surveys are so-called PROMs (Patient Reported Outcome Measures). Their results capture the patient’s subjective perspective on his or her illness and treatment, which is not covered by a clinical measure, but is just as important for the patient. Markus P. Arnold, attending physician at the Birshof Clinic and knee specialist in the LEONARDO group practice in Münchenstein, Basel, and Nicole Vogel, who is a research associate in charge of PROMs evaluations, will tell us more about this topic. They have been using this measurement method for over two years in patients who have received a knee prosthesis.
Why are Patient Reported Outcome Measures (PROMs) needed in addition to existing quality measurement systems?
Prof. Dr. med. Markus P. Arnold: I think PROMs are the only way to find out how the patient really feels. After all, the treatment is all about solving the problem. For example, the patient says after the operation that he is still not able to walk down the stairs well, which he has to do several times a day. So it’s of no use to him if I, as an orthopaedic surgeon, tell him: “But the replacement is perfectly fitted”. PROMs measure functional capability and quality of life from the patient’s perspective, which is hardly ever used in other measurements.
Nicole Vogel: It’s the only way I can measure knee function and quality of life as the patient experiences it himself. PROMs include questionnaires that ask step by step and at defined intervals how the patient is doing. They are standardized and therefore comparable with other study results.
What distinguishes PROMs from other quality measurement systems?
Prof. Dr. med. Markus P. Arnold: Other systems measure, for example, mobility, stability or whether the leg is straight or crooked, i.e. geometric objective parameters without the subjective patient focus. PROMs are not about how well the prosthesis fits, but how the patient feels. In other words, whether I have really helped the patient and not how satisfied I am with the X-ray image. The patient doesn’t really care, especially if he still has pain or poor function. PROMs surveys reveal just such discrepancies.
Nicole Vogel: And I experience this subjective feeling and its development by repeatedly asking the same questions at certain intervals. Questions that are very concrete, for example how well stairs or kneeling down works. In this way I can follow and compare the development.
How is such a questionnaire created or how do you get it?
Nicole Vogel: There is already a wealth of existing questionnaires. These are standardised so that you can also compare yourself with others. There are general questionnaires or very specific ones for a joint, then again different ones depending on the disease. It makes a difference whether someone has a meniscus problem or receives a prosthesis, for example. From these questionnaires you have to choose which one or which one to use. On the one hand, this way you can see which one fits best. On the other hand, it also tells you how often the questionnaire has already been used, so that you can compare yourself with others.
Prof. Dr. med. Markus P. Arnold: Depending on the spectrum you want to cover, you choose. So you don’t have to reinvent the survey, but use the existing pool. The questionnaires we use are already years or decades old. Such questionnaires are created, for example, when doctors help develop prostheses, and are validated by scientific committees according to standardized processes and then published. You can also see in the specialist literature which questionnaires are used again and again or even newly for which questions, and which ones are becoming established.
And are you satisfied with your questionnaire selection?
Prof. Dr. med. Markus P. Arnold: Yes, but we can and do refine it further. We implant classic and custom-made prostheses. Some of the questionnaires we have used so far are not specific enough to detect a difference. We will refine them with an additional questionnaire that goes into more detail, especially with regard to sports activities. This also takes into account the fact that today’s 70-year-olds are more active than 20 years ago. The demands of older patients have also changed: They no longer want to be able to get up out of the chair easily with a prosthesis, but perhaps also to be able to play some tennis. This leads to additional questions, which may help us to find measurable differences between the different types of prosthesis. Of course, it can always be refined and evaluated further. But you have to start somewhere. And now we already have results of 200 patients from 2 ½ years in our database.
And what do these results say?
Prof. Dr. med. Markus P. Arnold: Something very beautiful. They contradict the general opinion, which is spread at congresses, lectures etc., that 20 to 30 % of the patients are dissatisfied with a knee prosthesis. This is what you tell the patients, but it does not have to be that way. According to our results, we are definitely doing things differently. Currently, 85 % of patients are satisfied or very satisfied with the results one year after the operation, 10 % are neutral, 5 % dissatisfied or very dissatisfied (status July 2019 ).
How well do patients respond to the PROMs questionnaire?
Nicole Vogel: Very well. We ask all patients who receive a classic or custom-made knee prosthesis from us whether they would like to participate. About 80 % participate and about 95 % of them are still participating after one year. The patients receive a questionnaire before the operation, after 4 months, after one year and then annually until five years after the operation. Although it is an effort for the patients, most of them like it because it makes them feel they are being taken seriously.
What kind of questions should a patient who takes part in such a survey expect?
Nicole Vogel: Very concrete questions about everyday situations: For example, whether the patient has pain when climbing stairs, can get into the car without any problems or can put on the stockings. Further questions about quality of life: Does he have to change his life because of the pain? Can he look after himself?
Prof. Dr. med. Markus P. Arnold: From the answers, for example, whether the patient has pain when climbing stairs, can get into the car without problems or can put on the stockings. Further questions on quality of life: Does he have to change his life because of the pain? Can he look after himself?
Bei dieser 63-jährigen Patientin zeigt sich, wie sich insbesondere ihre Möglichkeiten für Sport und Freizeitaktivitäten nach der Operation gesteigert haben.
Dieser 68-jährige Patient verbesserte sich in allen Teilbereichen deutlich. Erfreulicherweise scheint er seine Prothese im Alltag kaum wahrzunehmen, sprich «vergessen» zu haben.
Bei dieser 69-jährigen Patientin war die Ausgangslage gemäss eigenem Empfinden nicht ganz so einschränkend. Sie konnte sich dennoch in allen Teilbereichen verbessern und vor allem ihre Lebensqualität steigern.
Auch diese 80-jährige Patientin hat deutlich von der Operation profitiert. Ihre Lebensqualität hat sich beachtlich gesteigert. Zudem denkt sie im Alltag deutlich weniger an ihr Knie als zuvor.
Anhand von solchen Diagrammen lässt sich mit PROMs veranschaulichen, wie sich der allgemeine Gesundheitszustand des Patienten entwickelt.
Diese Messung zeigt die Zufriedenheit aller Patienten, die an der Befragung teilgenommen haben per Juli 2019. Das Bild zeigt erfreulich viele zufriedene Patienten (entgegen der verbreiteten Annahme, dass 20 bis 30% mit einer Knieprothese generell unzufrieden sind).
What conclusions do you draw from the collected data?
Nicole Vogel: The data is enormous and there are many exciting aspects which I will continue to evaluate. With the ongoing results, there may be something that stands out again that we want to pursue further. The evaluation possibilities are enormous and we are constantly analyzing and deciding what we want to focus on.
Prof. Dr. med. Markus P. Arnold: One idea is to compare the results of patients with the first custom-made prostheses with those who were operated on later. This is the only way we can really find out whether the system has a learning curve.
The methodology of our knee prostheses, especially the custom-made ones, does not change much because of the measurement, since the results are fortunately very good. So we have the luxury problem that all our patients (with standard and custom-made prostheses) are very satisfied. We need even more time for a larger number of cases and more specific questionnaires to be able to find out specific details. The first step, however, was to find out whether this innovative method is really good or at least as good as the standard version. If the results were bad, I would have to draw the consequences and change something or leave it alone.
Another major advantage is that we can more precisely define patient satisfaction or dissatisfaction.
Please explain this in more detail.
Nicole Vogel: In the case of dissatisfied patients, we look in detail at what the problem is. What can the patient do and what not? Is it possible to deal with it more specifically in the treatment? It is not simply a “not good” or “good”, but we look in detail at what the problem is. Later we can filter out whether there is a difference between dissatisfied and satisfied patients based on the answers. Perhaps limited flexion is more of a problem? Or is it that men differ from women or slim patients from the more corpulent ones? Such points can be extracted and evaluated later.
Prof. Dr. med. Markus P. Arnold: This then also results in feedback for us again, because certain patterns may arise: If I have patient X in front of me and I already know that I will never satisfy him regarding expectation Y, then I have to tell him that. In everyday life we are always confronted with individual cases. And suddenly patterns and answers emerge on the basis of such measurements. Is it really difficult to help a corpulent woman with knock-knees with a prosthesis? Is it possible to pay attention to special aspects in certain cases? Perhaps we can find factors that constitute a high risk of dissatisfaction. This way we know that we cannot make such patients happy with our treatment or that we may have to change something. By collecting data, we move from the individual case to an overview of what we are doing.
Markus P. Arnold, MD,PhD is a specialist in orthopaedic surgery and traumatology of the musculoskeletal system and holds a certificate of competence in sports medicine (SGSM). He works as an attending physician at the Birshof Clinic and as a knee specialist in the LEONARDO group practice in Münchenstein, Basel.
Nicole Vogel is a research assistant in the group practice LEONARDO in Münchenstein. In particular, she is responsible for the collection and evaluation of Patient Reported Outcome Measures (PROMs), a type of quality measurement that focuses on the patient perspective.