PROMs or PPMs?

Patient reported outcome measures1 (PROMs) have been in use since about the 1960s. PROMs generally take the form of questionnaires – which patients complete – and may relate to specific health conditions, such as diabetes, hypertension or musculoskeletal conditions, or they may relate to more generic health outcomes. But is a PROM consistent with the Aims of Healthcare?

PROMs pre-date the introduction of the Triple Aim2 of Healthcare and its updated Quadruple Aim3 (and the emergent Quintuple Aim4, adding the dimension of health equity). The Triple Aim first named “patient experience” as a measurable, along with “outcome” as dimensions to be tracked. The Quadruple Aim added provider wellbeing to the model.

One detailed systematic review examined the evidence for provider burnout negatively impacting patient outcomes and noted that previous studies had failed to find links between provider burnout and independent clinical outcomes5. However, I’m of the view that provider wellbeing should be part of a model of healthcare for its own ends, rather than simply serving clinical outcomes. Whether or not the wellbeing of a provider affects a clinical outcome is less important than honouring the wellbeing of providers! (One possible explanation for this result could be that providers are adept at “soldiering on” and continuing to provide support for good outcomes, even to their own detriment.)

But with so much of the focus on outcomes, is it possible that there is an element which is being missed? Outcomes describe exactly that – the results, or “the ends” if you prefer. Many everyday outcomes are clinical indicators relevant to clinicians – for example HbA1c, numerical measures of blood pressure or blood cholesterol; gait speed, the timed-get-up-and-go-test6 and many more. Most outcome measures have been designed by clinicians and researchers to measure outcomes important to clinicians or researchers. A useful review of available PROMs has been compiled by the Australian Commission on Safety and Quality in Health Care7.

If “patient experience” is truly a focus of the Aims of Healthcare, then it’s not sufficient to measure the patient perspective of an outcome valued by the clinician. The focus must turn to “patient priority” – what really matters to, is important to and is valued by the patient.

Focusing on patient priority as a measurable requires the clinician to perform some translation work. Firstly, it requires inviting the patient to describe and share what matters to them in their health. This will almost always be an expression of the patient’s values in some way. For example, a patient may describe wanting to get up and down from the floor to play with grandchildren or wanting to have enough stamina for all day walking while travelling, or wanting to outlive the threat of a chronic disease which runs in the family, or desiring to live independently, rather than in an assisted-living facility. These are patient-chosen priorities which will certainly be more achievable when certain clinical outcomes are satisfied. Importantly though, the clinical outcomes are serving the patient priorities.

This is not just semantics. In a cluster RCT conducted in 20148, local communities in Québec, Canada were organised into intervention groups (involving patients in setting priorities) and control groups (deciding outcomes with no patient involvement). The results showed that priorities decided with patients were more aligned to factors such as access to primary care, support for self-care, participation by the patient in clinical decision making, and partnership with community organisations, whereas those priorities established solely by professionals tended to focus on the technical quality of single disease management.

The principle of “patient priority” is not novel and has been appearing in the literature since the 1970s. In fact, in a nursing text published in 1976, the author asserted that: “if the patient’s priorities seem inappropriate to the nurse, the nurse and the patient should work out this conflict and arrive at a solution that is acceptable to the patient first and to the nurse second.”9 A Google Ngram search reveals the sharp rise in appearances of this phrase in books since about 1990. Yet much of what currently constitutes “patient-centred” care still fails to place patient priorities at the heart of treatment.

A shift to a more patient-priority focused health care system would then require a shift from well-established PROMs1 to novel measures (Patient Priority Measures – PPMs) which seek to understand the extent to which patient goals, preferences and priorities have been met. We have some way to travel here.

So, what does this all mean for Lifestyle Medicine? This is maybe not the best question to ask here. Instead, we might ask “What does lifestyle medicine mean for patient priorities?” A Lifestyle Medicine approach is inherently aligned with the notion of patient priorities. With its mantra of “add years to your life and life to your years”, the focus on what might matter to the patient is clear. Lifestyle Medicine clinicians and providers can be leaders in the implementation of a patient-priority approach. They can routinely ask patients “What matters to you here?” when discussing healthcare and then consider how to translate common PROMs and outcomes into the patient’s own personally meaningful priorities.