The routine use of patient reported outcome measures in healthcare settings
The routine use of patient reported outcome measures in healthcare settings
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DOI：
10.1136/bmj.c186
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发表时间：
2010-01-18
影响因子：
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通讯作者：
Carr, Andrew J.
中科院分区：
文献类型：
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作者：
Dawson, Jill;Doll, Helen;Carr, Andrew J.
使用患者报告的结果测量似乎很简单；然而，一些陷阱等待着专业知识有限的临床医生。Jill Dawson及其同事为热衷于在当地使用患者报告结果测量的个人提供了指南。Patient Reported Response(PROMS)是标准化的、有效的问卷，由患者填写，以衡量他们对自己的功能状态和健康状况的看法。许多此类措施最初是在临床试验的背景下评估治疗效果的，1但现在被更广泛地用于评估患者对护理结果的看法。这种基于结果的PROM定义有别于用来衡量患者护理过程体验的问卷。PROM旨在衡量患者对其一般健康状况的看法(“一般”健康状况)，或他们对其与特定疾病或状况有关的健康状况的看法。例如，简表36(SF-36)健康调查2是一种通用问卷，通过使用与八大幸福领域(或“领域”)有关的36个问题来评估自我感知的健康状况。具体情况问卷的例子包括帕金森病问卷(PDQ-39)，3评估帕金森病患者的生活质量；视觉功能问卷(VF-14)，4使用14个问题来衡量受白内障影响的视觉功能的各个方面；牛津髋关节评分，5，使用12个问题来评估髋关节疼痛和功能与髋关节置换手术的结果。患者通过对个人问题的回答对自己的健康进行评级来完成毕业典礼。这些反应根据患者报告的难度或严重程度进行评分(例如，从0到4)。当对胎动进行分析时，结合个人评分来产生一个总体分数，以代表潜在的现象或“结构”，如“感觉到的疼痛水平”或焦虑。PROMS的分析倾向于集中于患者病情或其一般健康相关生活质量发生的变化的量，如干预后PROM评分的变化。到目前为止，PROM已被用于临床试验、(67)国家审计、(8)和关节置换登记(9)(10)和其他情况。(11)然而，PROM的常规使用在地方一级的卫生保健中已变得普遍。(12)PROM在审计和登记方面的应用也迅速增长，(12 13 14 15 16)事实上，在髋关节和膝关节置换、腹股沟疝气修补和静脉曲张手术等特定领域，自2009年4月以来，整个NHS都引入了PROM的常规收集，以衡量和改善临床质量。(17)政府主导的此类倡议可能会鼓励在国家和地方层面更广泛地使用PROM。最近NHS范围内的PROM倡议的指导方针中提供了收集PROM基准数据的具体指导，(18)随后的数据收集和处理由私人承包商进行。然而，本文针对的是那些热衷于在地方一级使用PROM的个人，他们的研究经验或获得相关研究方法的专业知识和建议的机会有限，他们可能不知道一些陷阱可能会破坏他们最终产生有用、有意义的数据的目标。此外，在临床管理和质量保证方面应用PROMS的已发表的例子很少(19)，这种应用形式在很大程度上没有评估。使用PROM对常规练习产生影响的证据也很缺乏。
The use of patient reported outcome measures might seem to be quite straightforward; however, a number of pitfalls await clinicians with limited expertise. Jill Dawson and colleagues provide a guide for individuals keen to use patient reported outcome measures at a local levelPatient reported outcome measures (PROMs) are standardised, validated questionnaires that are completed by patients to measure their perceptions of their own functional status and wellbeing. Many such measures were originally designed for assessing treatment effectiveness in the context of clinical trials, 1 but are now used more widely to assess patient perspectives of care outcomes. This outcomes based definition of PROMs distinguishes them from questionnaires used to measure patients' experience of the care process.PROMs are designed to measure either patients' perceptions of their general health ("generic" health status) or their perceptions of their health in relation to specific diseases or conditions. The short form 36 (SF-36) health survey, 2 for example, is a generic questionnaire that assesses self perceived health status by using 36 questions relating to eight broad areas (or "domains") of wellbeing. Examples of condition specific questionnaires include the Parkinson's disease questionnaire (PDQ-39), 3 which assesses quality of life in patients with Parkinson's disease; the visual function questionnaire (VF-14), 4 which uses 14 questions to measure various aspects of visual function affected by cataracts; and the Oxford hip score, 5 which uses 12 questions to assess hip pain and function in relation to outcomes of hip replacement surgery.Patients complete PROMs by rating their health in response to individual questions. These responses are scored (from 0 to 4, for example) according to the level of difficulty or severity reported by the patient. When PROMs are analysed, the individual ratings are combined to produce an overall score to represent an underlying phenomenon or "construct," such as " perceived level of pain" or anxiety. The analysis of PROMs tends to focus on the amount of change that has occurred in the patients' condition or their general health related quality of life, as represented by a change in PROM score following an intervention.To date, PROMs have been used in clinical trials,(6 7) national audits,(8) and registers for joint replacement(9) (10) and other conditions.(11) However, the routine use of PROMs has become widespread in heath care at a local level.(12) Interest is also rapidly growing in the application of PROMs in the context of audit and "registers," to inform individual care and manage the performance of healthcare providers.(12 13 14 15 16) Indeed, in the specific areas of hip and knee replacement, inguinal hernia repair, and varicose vein surgery, the routine collection of PROMs has, since April 2009, been introduced throughout the NHS to measure and improve clinical quality.(17) Government led initiatives such as this are likely to encourage more widespread use of PROMs at both a national and a local level.Specific guidance on methods for collecting baseline PROM data are provided in guidelines for the recent NHS-wide PROMs initiative,(18) in which subsequent data collection and handling are undertaken by private contractors. This article, however, is aimed at individuals who are keen to use PROMs at a local level, who may have limited research experience or access to expertise and advice on relevant research methods, and who may be unaware of a number of pitfalls that could undermine their aim of ultimately producing useful, meaningful data. In addition, there are very few published examples of the application of PROMs in the context of clinical governance and quality assurance,(19) with this form of application being largely unevaluated. Evidence of the impact of using PROMs on routine practice is also lacking.