Abstract
PurposePatient-reported outcome and experience measures (PROMs/PREMs) are well established in research for many health conditions, but barriers persist for implementing them in routine care. Implementation science (IS) offers a potential way forward, but its application has been limited for PROMs/PREMs.MethodsWe compare similarities and differences for widely used IS frameworks and their applicability for implementing PROMs/PREMs through case studies. Three case studies implemented PROMs: (1) pain clinics in Canada; (2) oncology clinics in Australia; and (3) pediatric/adult clinics for chronic conditions in the Netherlands. The fourth case study is planning PREMs implementation in Canadian primary care clinics. We compare case studies on barriers, enablers, implementation strategies, and evaluation.ResultsCase studies used IS frameworks to systematize barriers, to develop implementation strategies for clinics, and to evaluate implementation effectiveness. Across case studies, consistent PROM/PREM implementation barriers were technology, uncertainty about how or why to use PROMs/PREMs, and competing demands from established clinical workflows. Enabling factors in clinics were context specific. Implementation support strategies changed during pre-implementation, implementation, and post-implementation stages. Evaluation approaches were inconsistent across case studies, and thus, we present example evaluation metrics specific to PROMs/PREMs.ConclusionMultilevel IS frameworks are necessary for PROM/PREM implementation given the complexity. In cross-study comparisons, barriers to PROM/PREM implementation were consistent across patient populations and care settings, but enablers were context specific, suggesting the need for tailored implementation strategies based on clinic resources. Theoretically guided studies are needed to clarify how, why, and in what circumstances IS principles lead to successful PROM/PREM integration and sustainability.
Highlights
Patient-reported outcome and experience measures (PROMs/PREMs) are well established in research for many health conditions [1, 2], but barriers persist for implementing them in routine care
The case study in an integrated chronic pain care network [30] combined Consolidated Framework for Implementation Research (CFIR) with the Theoretical Domains Framework (TDF) [36,37,38] to identify barriers and enablers for implementing PROMs
Bold and italic font show the important distinction between evaluating perceptions of the innovation (PROMs/PREMs) vs. evaluating implementation strategies ePROM electronic patient-reported outcome measure, AACTTaction, actor, context, target, time framework, StaRi standards for reporting implementation studies guidelines, FRAME framework for reporting adaptations and modifications-enhanced, Cost of Implementing New Strategies” (COINS) Cost of Implementing New Strategies (COINS) scale psychometric properties) in the subdomain “characteristics of the innovation,” suggesting modifications to CFIR or additional frameworks may be needed to capture PROM/ PREM nuances
Summary
Patient-reported outcome and experience measures (PROMs/PREMs) are well established in research for many health conditions [1, 2], but barriers persist for implementing them in routine care. The case study in an integrated chronic pain care network [30] combined CFIR with the Theoretical Domains Framework (TDF) [36,37,38] to identify barriers and enablers for implementing PROMs. TDF is grounded in a psychology perspective on behavior change at the clinician level. The case study implementing PREMs in primary care clinics [43] combined CFIR with the Knowledge to Action (KTA) model [43, 44] and Normalization Process Theory (NPT) [45, 46]. During pre-implementation, case studies engaged stakeholders and clinic leaders, and assessed barriers, enablers, PROM/PREM needs, and workflow. They engaged clinic teams to develop tailored implementation strategies. An alternative is to assess contextual factors with stakeholder interviews
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