Many surgeons do not use patient-reported outcome measures in spine care

Patient-reported outcome measures are the most widely accepted means of measuring outcomes following spine procedures

Almost one third of spine surgeons do not routinely use patient-reported outcome measures (PROMs). This was the result presented by Asdrubal Falavigna (Department of Neurosurgery, Caxias do Sul University, Caxias do Sul, Brazil) at the Global Spine Congress (1–5 May, Singapore), for which he and his colleagues received the prize for Best Paper.

The investigators set out to determine the worldwide use of PROMs, and to assess the current status of knowledge and barriers to the routine use of a registry on a global scale. An electronic questionnaire was created by the study authors to evaluate demographic features of participants, familiarity with PROMs instruments, perception regarding the usefulness of PROMs in spine care, and barriers to implementing PROMs and clinical registries in routine practice. An e-mail request to participate in the survey was sent to members of AOSpine with a cover letter explaining the study objectives, with a link to Survey Monkey.

A total of 1,632 AOSpine members from Latin America, Europe, the Asia Pacific, North America and the Middle East answered the PROMs questionnaire.

Falavigna and colleagues found that 31.9% of respondents did not routinely use any of the PROMs, and 28.3% of spine surgeons were not familiar with the generic health-related quality of life questionnaire.

Speaking to Spinal News International of these results, Falavigna discloses: “In general, the participants strongly agree, [by] greater than four points, that PROMs are useful to evaluate treatment outcomes, compare results between centres, and monitor the impact of the disease. The residence or fellowship programs had a positive influence on the use of the PROs in each region.

“Different lifestyles, training, economic burden, and cultures influenced the use of PROMs.

“The present study agrees with the literature because the most important barriers for the physicians were lack of time to apply the questionnaires (57%), lack of staff to assist in data collection (72%), and lack of structure in the service to carry out data collection (60%).”

The study also found that the routine use of questionnaires was more frequent in North America and Europe, and less common in Latin America and the Middle East (p<0.001). In fact, being a spine surgeon in Europe (adjusted OR 1.90, 95% CI 1.46-2.46, P<0.001) and North America (adjusted OR 1.61, 95% CI 1.10-2.38, P 1⁄4 0.015) was found to have a positive indication for using PROMs. When accounting for this geographic disparity, 39% of survey respondents claimed that the lack of an electronic database was an important barrier, and most of these physicians were from Latin America, the Middle East, or the Asia Pacific region.

Working at an academic centre was also an independent predictor for PROM use (adjusted OR 2.39, 95% CI 1.93–2.96, P<0.001).

The benefits of patient-reported outcome measures

PROMs are the most widely accepted means of measuring outcomes following spine procedures, according to the study authors. Outcome assessments made using PRO instruments help spine surgeons to better manage their patients and monitor treatment progress.

Falavigna explains to Spinal News International: “In patients with spinal disorders, the main objective of treatment is to improve health-related quality of life by reducing pain and disability. In this sense, the best measurement of treatment quality should be the patient’s opinion regarding the results using patient-reported outcome measures (PROMs). PROMs has the potential to narrow the gap between the clinician’s and the patient’s view of clinical reality and help tailor treatment plans to meet the patient’s preferences and needs. In recent decades, several generic and disease-specific patient-reported outcome instruments have been developed and validated for the clinical and functional evaluation of spinal treatment outcomes. Patient-reported outcome instruments provide results as numerical scores, making it easier to detect the changes between the pre- and postoperative periods.”

Falavigna lists the benefits of PROMs as allowing physicians to:

  • Assess outcomes from the patients’ perspective
  • Select patients for whom surgery is appropriate
  • Evaluate the burden of disease
  • Monitor treatment outcomes
  • Facilitate patient-physician communication
  • Allow results of treatments to be compared between different centres
  • Measure treatment quality for health economic analyses in spine care
  • Promote feedback regarding their performance, benchmarking and quality improvement

Barriers to using patient-reported outcome measures

“In order to actively involve the treating physician, it is necessary to recognise and overcome the barriers to the implementation of clinical registries,” the investigators write.

These barriers to the full implementation of clinical registries differ in different regions of the world. In the Middle East, Latin America, and the Asia Pacific region, a lack of an electronic database is the most significant barrier to utilising PROMs.

According to the study authors, the main barriers to the full implementation of PROMs in health care appear to be lack of knowledge regarding their importance, an absence of physician reimbursement for the extra work, minimal financial support for clinical research in this area, the costs of implementation, and the capacity to administer the instruments.

However, there are some strategies that could be implemented to make PROMs more widely used. Falavigna explains, “Some strategies based on education in research (symposium, books, webinars, e-learning, post-graduation program training) and technical support have been conducted to increase the number and improve the quality of comparative-effectiveness research in spine care.

“Besides the need for implementation of clinical registry studies to assess the effectiveness of spine care in these countries, these efforts were also motivated by the low rate of scientific publications among Latin American spine surgeons in the last decade. Prospective patients for the clinical registry who are undergoing elective spine surgery for lumbar degenerative diseases are enrolled in a clinical registry by the Caxias do Sul University Spine Surgery Group. Preoperative and follow-up data (30 days, six months, and annually) are collected including demographics, PROMs, radiologic results, and costs. All data are collected and managed with a database specifically built for this registry.

“Another strategy to support the use of PROMs in routine clinical care is to integrate them into routine workflow, something that could happen if they were mandatory in a given institution.”

Alternatives to using PROMs include clinical evaluation by surgeons and radiological measurements of the spine alignment.


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