• ACL
• Sporting injuries

Clinicians’ first exposure to clinical testing are clinician-applied standard tests. Physiotherapists assess joint range of motion, physicians measure blood pressure or take blood for laboratory testing. These provide essential information and do not require the patient to contribute their perspective.

In addition to clinical features that lend themselves to be measured in such a manner, many factors that characterise a patient's health status cannot be observed, measured with a device, or analysed with even the most sophisticated imaging methods. How a patient feels and performs remains largely impenetrable to devices. Instruments that reflect the patient's perspective about their health status have the collective title of Patient Reported Outcome Measures (PROMs).1 The appetite for routine use of PROMs reflects the idea that a properly queried patient represents a critical complement of information about health.

PROMs commonly used in sports medicine include the Western Ontario Shoulder Instability Index (WOSI)2 for shoulder instability, the Knee injury and Osteoarthritis Outcome Score (KOOS)3 for knee complaints, and the Victorian Institute of Sport Assessment (VISA) scales for tendinopathies.4 In this first of two educational pieces related to PROMs we provide an overview for the reader who has not considered PROMs formally before. We recommend the reader consult Davidson and Keatings's5 review for complementary material.

There are three primary contexts in which PROMs are used: (1) clinical practice and (2) clinical research and (3) healthcare policy. Conceptually PROMs can be viewed either as a ‘tool for evaluation’ or as a ‘mechanism for improvement’. The most widespread use of PROMs has been for measurement to inform evaluation (ie, clinical research).

Without PROMs, health service accounting (is a service, such as an operation, useful?) focuses on production of healthcare (ie, the number of surgeries performed, wait times). This method does not capture the patient experience—ideally, the patient benefit. If it were routine practice for sports medicine patients to have their outcomes measured (ie, PROMs such as the KOOS after anterior cruciate ligament (ACL) reconstruction), it would provide a measure of what ‘health’ the operation or clinical treatment had provided. We see three distinct categories where patients, clinicians, health sector managers, policymakers, and researchers would benefit from having summary PROMs information of patients’ perceived health status over time.

1. Clinical practice settings: individual clinics and clinics in a franchise

2. Practically, the following resources must exist for successful PROMs implementation. The outcome scores and results from the PROMs completed by each patient would need to be available in real time. Clinicians who are reviewing these data will need to be informed about interpretation relating to patient outcomes and subsequent treatment decisions (not unlike seeing blood test results and knowing norms). Implementing PROMs in clinical practice settings will enable quality improvement initiatives detailed below:

   1. Patients empowered to interpret a relevant PROM (eg, KOOS after ACL surgery) could readily monitor their health profile over time and compare themselves with their peers. By better understanding their experience, these patients may be more actively engaged in striving for health outcomes like full rehabilitation.

   2. PROMs can help clinicians quickly identify which of their patients experience improved or deteriorated health outcomes over time. This will highlight any consistent patient complaints, which would suggest refinements to care pathways. Ideally a PROM could contribute to a return to play assessment.

3. Clinical research:

   1. Two Cochrane systematic reviews use PROMs to evaluate the effectiveness of two surgical interventions in a sports and exercise medicine setting.6 ,7 One RCT used a condition specific and a generic PROM (ie, the KOOS and SF-36) to track patient outcomes over a two year time horizon.8 Inclusion of PROMs in clinical trials will enable important clinical questions to be answered. One example could be deciding whether structured rehabilitation plus early ACL reconstruction with structured rehabilitation with the option of later ACL reconstruction if needed.3

4. Healthcare policy:

   1. PROMs allow health sector managers to identify ‘outlier’ practitioners or clinics—those that are associated with superior and inferior health outcomes. This provides opportunities for efficiency gains through learning from the high-performing centres.

   2. Policymakers could make use of these data to assess overall health sector productivity. If sports medicine/rehabilitation processes are demonstrating improvements in PROMs, this could be used as part of an argument for increasing access to such an intervention. An example could be the use of physiotherapists in the emergency department setting—an idea that is becoming popular in certain jurisdictions but may be more palatable for policy.

As a prelude to our discussion of PROMs in sports medicine, consider the value of monitoring ACL reconstruction outcomes nationally by PROMs. To an extent, this is occurring in Scandinavia with the ACL registries. In the second piece, we specifically examine the advancing the application of PROMs in sports and exercise medicine.