PROMs (Patient-Reported Outcome Measures)

Many healthcare systems now require documentation of a completed PROM before pre-authorization for partial and total knee replacements. This means that patients who do not have a Patient-Reported Outcome Measure on file for insurance review could have their surgery denied or significantly delayed. The same documentation applies to hemi and total hip replacements.

Patients at Florida Orthopaedic Institute are already completing PROMs as part of a convenient online check-in process ahead of office visits. They are sent out via text and email for patients who are scheduled for surgery.

Florida Orthopaedic Institute is leading the way in orthopaedic surgery and helping patients seamlessly navigate insurance industry changes.

ABOUT PATIENT-REPORTED OUTCOME MEASURES

What are PROMs?

PROMs are questions that patients answer that tell their healthcare provider how an injury affects their lives. Since an injury can affect a person in many ways, these questions cover several topics (general and disease-specific physical health, mental health, social activities, etc.).

What makes PROMs different from other questions or scores that a doctor might ask?

Instead of the doctor asking the patient questions or scoring them, Patient-Reported Outcome Measures are asked directly to the patient, typically before seeing the doctor. Their scores have been shown to be better at predicting how a patient will recover after treatment or surgery. It also allows the doctor to monitor how a patient is doing over time more accurately.

Why did FOI introduce Patient-Reported Outcome Measures into the practice?

Patient-Reported Outcome Measures are part of a movement called ‘patient-centered care’. Patients do better when more information is collected about how they experience the injury and when they are more involved in their own care.

For example, if you hurt your knee, your doctor might look at your range of motion (“How far can you move your lower leg?”) as part of the evaluation of how hurt your knee is. But the range of motion in a knee does not necessarily fully capture how difficult it is for you to take a walk, climb stairs, or bend down to pick something up when you are at home. PROMs capture this information.

With FOI’s knee-injury specific PROM (KOOS JR – Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement), patients answer questions about these kinds of activities and get a score from 0-100%. The score summarizes exactly how badly the injured knee affects their life and ability to do what they want to do. Some patients have reported that answering these questions also made it easier to talk to their doctor about specific activities that are difficult.

How do patients fill out PROMs?

When patients register, they are typically sent an email or text message to complete their paperwork prior to their appointment. PROMs are automatically included in that same packet. Patients who have not completed theirs before they arrive can complete them on a tablet during check-in.

MORE ABOUT PROMS

Patient-Reported Outcome Measures (PROMs) were initially used in clinical research as a standardized way of comparing outcomes among patients enrolled in research studies. But over the last ten years or so, physicians started using PROMs clinically. This means they began collecting the information from patients to track health and progress and predict outcomes like reoperations.

Before this, physicians and other healthcare providers filled out the assessments during or after office visits. Responses were based on how they thought the patient was doing, rather than asking the patient directly.

We have learned that PROMs are often better at predicting what will happen in the future for a patient than the questionnaires completed by physicians. PROMs also tend to give more accurate views of a patient’s recovery and make it easier to see health changes.

It is important to remember there are no ‘right’ or ‘wrong’ answers to these questions. Honest answers help both you and your provider understand how your injury impacts your life and helps to monitor your recovery if you undergo surgery.

Florida Orthopaedic Institute now collects several different PROMs. Some are filled out by every patient, while others are specific to an injury. Read below to learn about the different PROMs we collect and what they measure.

ALL PATIENTS:

PROMIS GLOBAL 10

PROMIS Global 10 is a 10-question global health assessment. This means that it looks at your health across several different areas:

• Your overall quality of life.
• Physical health/activities.
• Mental health.
• Social activities/relationships.
• General fatigue.
• Pain levels.

Your injury can affect you in many different ways. Through recent discoveries in science, we have learned that things like your mental health and social support network can affect your physical recovery (the mind-body connection).

Scoring: Your responses are scored and converted to something called a ‘t-score.’ Higher scores mean better global health. A t-score of 50 is considered “average” for the population. A score of less than 30 means your global health is considered significantly lower than average. A score of more than 70 means your global health is considered significantly better than average.

PROMIS PHYSICAL FUNCTION CAT:

PROMIS Physical Function CAT is a computer-adaptive test (CAT) that assesses overall physical functioning. With a CAT form the questionnaire changes based on how you answer questions – beginning with the very first question. Although there are 121 questions in the pool, you will only have to answer 4-5 to give an equally accurate score! We believe that this type of testing is the wave of the future because it drastically shortens the amount of paperwork that patients have to complete.

Scoring: This is scored the same way as the PROMIS Global 10. Your raw score is converted to a ‘t-score,’ and a higher score means better physical functioning. A t-score of 50 is considered “average” for the population. A score less than 30 means your physical health is considered significantly lower than average. A score more than 70 means your physical health is considered significantly better than average.

SINGLE ASSESSMENT NUMERIC EVALUATION (SANE)

Single Assessment Numeric Evaluation (SANE) is given to all patients who are only injured on one side (called unilateral). Patients who have the same joint injured on both sides (bilateral) do not complete this form.

This form contains only two questions and asks you to rate your affected and unaffected side on a scale of 0-100. Although it sounds too simple, the early results show that asking these two questions might be as predictive as asking a panel of 8-9 questions. At Florida Orthopaedic Institute, we are very interested in finding the shortest forms possible for our patients. We are looking at whether the SANE might be used in place of other longer measures. Stay tuned for our findings!

PROMS BY INJURY AREA:

NECK INJURY/DISEASE: NECK DISABILITY INDEX (NDI)

Neck Disability Index (NDI) is a 10-question form that asks various questions about how your neck injury affects you. This includes:

• Pain.
• Being able to take care of yourself (washing, dressing, etc.).
• Reading.
• Concentration.
• Work.
• Sleep.
• Driving.
• Fun activities.

Scoring: Your score will range from 0-100% and is interpreted as a % of disability. 0% is no disability at all, and 100% is a total disability. Here is the complete breakdown of the scores:

0-8% – No Disability

10-28% – Mild Disability

30-48% – Moderate Disability

50-64% – Severe Disability

70-100% – Complete Disability

Your physician may also use this information to help decide when to try conservative (non-surgical) therapies versus surgery.

SHOULDER INJURY/DISEASE: AMERICAN SHOULDER AND ELBOW SURGEONS SHOULDER ASSESSMENT FORM (ASES)

American Shoulder and Elbow Surgeons Shoulder Assessment Form (ASES) is a 17-question form that asks you questions about how your shoulder injury affects your life in three primary areas:

• Pain.
• Instability.
• Activities of daily living (meaning, the normal things you need to be able to do every day).

Scoring: Your overall shoulder health score will range from 0-100. 100 is the best possible score, and 0 is the worst possible score. There are no other established scoring categories for the ASES.

ELBOW, WRIST, HAND INJURY/DISEASE: QUICK- DISABILITIES OF THE ARM, SHOULDER, AND HAND FORM (QUICK-DASH)

The main form has 11 questions that ask you questions about how your elbow/wrist/hand injury affects your life. There are two additional small sets of questions that are sometimes asked:

• A work module (questions specific to work activities-4 questions).
• Sports/performing arts module (questions specific to your ability to do those activities-4 questions).

Scoring: Your overall elbow/wrist/hand score will range from 0-100 and is interpreted as % disability. A score of 0% is the best possible health, and a score of 100% is the worst possible health.

LOWER BACK INJURY/DISEASE: OSWESTRY DISABILITY INDEX (ODI)

Oswestry Disability Index (ODI) is a 10-question form that asks questions about how your lower back injury affects your life.

Scoring: Your overall lower back score will range from 0-100 and is interpreted as % disability. A score of 0% would be the best possible health, and a score of 100% would be the worst possible health. The following is the complete breakdown of the score categories:

0-20%: Minimal Disability

21-40%: Moderate Disability

41-60%: Severe Disability

61-80%: Crippling disability

81-100%: Bed-bound

Like the Neck Disability Index, the ODI will also sometimes be used to help your provider decide whether to focus on conservative or surgical treatments.

HIP INJURY/DISEASE: HIP DISABILITY AND OSTEOARTHRITIS OUTCOME SCORE- JUNIOR (SHORT FORM) (HOOS, JR)

Hip Disability and Osteoarthritis Outcome Score is a 6-question form that asks about different activities that can be affected by hip injury/disease.

Scoring: Your HOOS, Jr score will range from 0-100 and represents % of hip health. A score of 0% means the worst possible hip health, and a score of 100% is the best possible hip health.

KNEE INJURY/DISEASE: KNEE INJURY AND OSTEOARTHRITIS OUTCOME SCORE – JUNIOR (SHORT FORM) (KOOS, JR)

Knee injury and Osteoarthritis Outcome Score is a 7-question form that asks you about different activities that are affected by your knee injury/disease.

Scoring: Your KOOS, Jr score will range from 0-100 and represents % knee health. A score of 0% means the worst possible knee health, and a score of 100% is the best possible knee health.

FOOT INJURY/DISEASE: FOOT AND ANKLE ABILITY MEASURE (FAAM)

Foot and Ankle Ability Measure is a 21-question form that asks you about different activities that are affected by your foot or ankle injury/disease. While most of the other PROMs are less than ten questions, why are 21 needed to assess the foot/ankle? The foot and ankle contain a large number of bones (19 in the foot, 7 in the ankle) that all have to work in harmony to give you normal motion. This means that your foot and ankle can be injured in a lot of different ways.

If you complete the FAAM, you’ll notice that it asks questions that may seem similar but need information about different parts of your foot/ankle’s functionality. For instance, going up stairs is different than going down stairs. Depending on your injury, you might be able to do one but not the other!