Abstract
BackgroundIn this paper, we report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. We tested two overarching programme theories: (1) PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians and (2) PROMs scores raise clinicians’ awareness of patients’ problems and prompts discussion and action. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes.ResultsPROMs completion prompts patients to reflect on their health and gives them permission to raise issues with clinicians. However, clinicians found standardised PROMs completion during patient assessments sometimes constrained rather than supported communication. In response, clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships. Individualised PROMs supported dialogue by enabling the patient to tell their story. In oncology, PROMs completion outside of the consultation enabled clinicians to identify problematic symptoms when the PROM acted as a substitute rather than addition to the clinical encounter and when the PROM focused on symptoms and side effects, rather than health related quality of life (HRQoL). Patients did not always feel it was appropriate to discuss emotional, functional or HRQoL issues with doctors and doctors did not perceive this was within their remit.ConclusionsThis paper makes two important contributions to the literature. First, our findings show that PROMs completion is not a neutral act of information retrieval but can change how patients think about their condition. Second, our findings reveal that the ways in which clinicians use PROMs is shaped by their relationships with patients and professional roles and boundaries. Future research should examine how PROMs completion and feedback shapes and is influenced by the process of building relationships with patients, rather than just their impact on information exchange and decision making.
Highlights
The clinician-patient relationship has been an enduring focus of research across many disciplines and has received considerable attention from policy makers internationally
We report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measure (PROM) support patient-clinician communication and subsequent care processes and outcomes in clinical care
Clinicians used a number of strategies to manage the process of completing a PROM in a way that preserved their relationship with patients. These included completing the PROM alongside patients[26], delaying the use of standardised PROMs to assess patients’ needs during their interactions with patients until they perceived a relationship had been sufficiently built [86], avoiding using them at all [81] or omitting or changing items to avoid upsetting patients [80]. Clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships
Summary
The clinician-patient relationship has been an enduring focus of research across many disciplines and has received considerable attention from policy makers internationally. There are many quantitative systematic reviews of PROMs feedback in the care of individual patients but they have struggled to draw definitive conclusions about its impact [8,9,10,11,12]. One pattern evident in quantitative reviews is that PROMs feedback has a greater impact on clinician-patient communication, the provision of advice or counselling and the detection of problems than on patient management and subsequent patient outcomes. Reviews have included qualitative studies of clinician and patient experiences of using PROMs to synthesise evidence on their implementation and use [14,15,16] While these reviews provide a useful summary of barriers and facilitators, they do not explain why barriers in one context may be facilitators in another [15] nor the mechanisms through which these barriers or facilitators work. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes
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