THE USE OF PATIENT REPORTED OUTCOME MEASURES BY PRIMARY MEDICAL PROVIDERS IN THE PEDIATRIC SPORTS POPULATION
Authors: Aberdeen Jamila N. , Burnett Rebecca K. Frank , Stewart Heather F. , Greenberg Elliot 
Published: March 2019

Background:

Patient reported outcome measures (PROs) allow medical providers to assess functional limitations, track progress, and evaluate outcomes. Although progress has been made developing and validating PROs, much of this work has been done within the adult population, and only a limited number of pediatric specific PROs exist. The use of PROs within pediatric orthopedics remains unstudied. The purposes of this study are to evaluate the current use of PROs within pediatric sports medicine and determine how the information from PROs is used for treatment decisions.

Methods:

An online email survey was sent to members of the Pediatric Research in Sports Medicine Society (PRiSM) using REDCap™. The survey was developed and pilot tested by 4 physical therapists and 3 orthopedic surgeons. The final survey consisted of 24 multiple choice questions, designed to garner information relative to provider use of PROs. Some questions allowed free text for answers not previously-defined. The survey took 3-5 minutes to complete and was open for an 8 week period. Although PRiSM is a multi-disciplinary society, only data from primary medical providers (PMPs -orthopedic surgeons, sports medicine primary care physicians, nurse practitioners, physician assistants) was utilized. Descriptive statistics and frequency tallies were used to analyze the data.

Results:

Seventy-two surveys were used for analysis; a response rate of 45% given total membership. The sample distribution can be seen in Table 1. The use of PROs was reported by 57% (n=41) of PMPs. PROs administration occurred at post-operative encounters (83%, n=34), new patient visits (73%, n=30), pre-op visits 44% (n=18), when there is a change in status/new injury 27% (n=11), and every visit 12% (n=5). The majority of information from PROs was used for research (85%, n=35), assess response to treatment (51%), inform clinical prognosis (37%) and guide clinical decisions (32%). There were no PMPs that reported distributing PROs to satisfy insurance requirements. PRO use was reported at the highest frequency for knee (98%, n=40) and shoulder (68%, n=28) injuries. There was variability in specific PRO selection with 80%, 56% and 34% using the Pedi-IKDC, IKDC, and KOOS, respectively. For the shoulder, the DASH and QuickDASH garnered the highest use (32% each) however variability in scale selection persisted with 24% using “other” scales, including activity and fear avoidance scales. PRO use for the hip (41%), ankle (39%), back (20%) and neck (17%) were reported less frequently. (Figure 3 details scale specifics). Nearly half the sample (46%) reported using affective domain or quality of life scales like the Pedi-Fabs (24%) and ACL-RSI (17%) and PROMIS (12%). Interestingly, 43% (n=31/41) of the sample indicated they do not use PROs, with 39% of these respondents citing inadequate time as the primary barrier to use, 23% were unsure of which measure to use and 16% did not find them useful or relevant. Additional barriers are presented in Figure 4.

Conclusions:

Only 57% of PMPs are using PROs within their practice. The information from PROs is largely used to perform research and demonstrate the effectiveness of treatment. Interestingly, no one used PROs to satisfy insurance requirements. Within all body regions, there is little consistency in scale selection. A large number of respondents indicated that PROs for hip, ankle and spine were “not applicable” to their practice, making generalization of this data difficult. Although it cannot be determined why there was such a low percentage of PRO use for these body regions, the authors feel this may be related to a small volume of patients seen with diagnoses of these regions among our sample or perceptions that no existing scale is useful for this population. It was surprising that over 40% of the sample did not use PROs in their practice. Among those respondents, inadequate time for administration and indecision regarding which measure to use, were indicated as the greatest barriers to use.

Clinical Relevance:

Healthcare policy within the United States is undergoing a transformation towards a value-based system, under which PROs will be heavily relied upon to demonstrate effectiveness of treatment and help determine reimbursement; this transition has already occurred in adults/the Medicare system. Our results show that although 85% of PMPs use PROs for research purposes, the use of PROs in the clinical setting is low. Given the changing payment model and increased emphasis on patient-centered care, our results highlight the importance of integrating PROs into clinical practice and support the need for ongoing research related to the validation research and scale development as many of the scales have not been evaluated in pediatrics.

Tables and Figures:

[Table: see text][Figure: see text][Figure: see text][Figure: see text]