SVS Performance Committee members Mounir Haurani, MD, and Jose Almeida, MD, weigh up the importance of patient-reported outcomes (PROs) and how they can be effectively deployed in practice.
MH: Patient-reported outcomes (PROs) are direct reports from the patient of their health condition, health behavior or experience with healthcare, and are not subject to interpretation by the clinician or anyone but the patient. PRO measures (PROMs) are the tools that are used to evaluate PROs.
JA: But PROs measure outcomes that aren’t relevant and we do not have many vascular disease-specific PROMs!
MH: While clinicians and other stakeholders may value traditionally measured outcomes, those often do not reflect the patient experience of healthcare. PROs provide an unadulterated assessment of the patient’s perception of their own health status. Importantly, a properly developed, validated PRO will address issues that are important to the patient.
PROMs fall into two major categories: health-related quality of life (HRQOL) and satisfaction. Most people are familiar with the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS), which is a satisfaction survey that includes topics like cleanliness and quietness of the hospital environment. I agree; those aren’t particularly relevant to vascular surgery; but, in fact, there are a number of vascular specific PROMs, such as the VascuQOL and the Peripheral Artery Questionnaire (PAQ) that can be used to assess treatment for peripheral arterial disease (PAD).
JA: Maybe you’ve convinced me that PROs have some value but collecting them sounds like just more paperwork in an endless battle against increased bureaucracy that detracts from patient care. Health and wellness task forces cite increased paperwork as a source of physician burnout. Post-op edema is clearly a real and debilitating problem that needs to be managed. Patients communicate this effectively with their voices when in the exam room. PROMs just add an additional barrier to personalized care—in that they make calculators and protocols tantamount to direct communication.
MH: There are ways that we can streamline the collection of PROs, such as the use of tablets that integrate with the electronic medical record (EMR) patients can fill out. Moving forward, the Centers for Medicare & Medicaid Services (CMS) will expect PROs to be measured and will use the results as performance standards for reimbursement. In order to provide the best care possible for our patients, and satisfy CMS requirements, it is important for us as vascular surgeons to be part of developing more vascular disease-specific PROMs, as well as developing recommendations for efficiently and effectively integrating PROs into our practices. PROs will not replace quality listening, and thorough history and physical examinations. When a PRO is incorporated properly, we can use it to augment listening to and examining the patient.
How do I use PROs effectively?
MH: PROs can be used as a mechanism to quantify and discuss issues important to patients. Using standardized, validated PROMs can allow us to have a common language when speaking with all stakeholders. Having reliable data on how the patient perceives their recovery to be progressing and their ability to resume their normal activities can help us better understand the barriers they face in returning to normal.
JA: I still think that the most important postoperative outcomes are our traditional measures like mortality and patency. Without achieving success in those traditional measures, the other issues that PROs address become irrelevant.
MH: I agree that PROs do not replace our traditional outcome measures. However, we can use PROs to improve the shared decision-making process. The difference between informed consent and shared decision-making is taking the patient’s goals into account when deciding on a treatment option. While the first question on the mind of most patients with an aortic aneurysm is, “What is my likelihood of surviving the surgery?”, the next question is often related to the recovery process. When we quantify patients’ HRQOL during the recovery process, we can use that information to help us objectively advise patients about their recovery process.
JA: The addition of PRO data will not fundamentally change the decision-making interaction between a doctor and an individual patient in a meaningful way. We do not know whether having this information ahead of time will better inform or instead confuse patients. Patients rely on and trust their surgeon’s experience.
MH: In general, I’ve found that most patients are grateful for more information. And PROs can be used on an individual level. For example, a great way of utilizing a PRO in your daily practice is by using it to measure change in HRQOL before and after an intervention. Sometimes it can be difficult for patients to remember how much disability they had before their operation for thoracic outlet syndrome. By using a PROM, you can quantify progress over time.