1 Introduction

The need for arthroplasty surgery by patients is more subjective than objective. Patient reported outcome measures (PROMs) are an ideal way to objectively assess the pre-operative and post-operative condition of the patient with the efficacy of the intervention being indirectly documented.¹ Although useful, they come with their own set of challenges like choosing the right PROM, lack of standardization and readability which can impact the score.²

Although literature is awash with studies on PROM in orthopedics, there is paucity of information regarding the perception about PROM and its usage among arthroplasty surgeons from a developing country like India. Previous studies have shown North America and Europe having the most widespread usage of PROM in orthopedics.³ Lack of time and usage barriers in their institutes were cited as the most common reasons for not using PROM in North America and Europe.³ These reasons may or may not be same in a developing country where the standard of healthcare is vastly different from the developed world.⁴ The aim of this study is to describe the usage of PROM, its use or lack of use, barriers in using it and its future prospect among the arthroplasty surgeons from a developing country like India.

2 Methods

An online survey was conducted by emailing an anonymous questionnaire to orthopaedic surgeons who have been performing or assisting in arthroplasty and arthroscopy. The study was cross-sectional in design based on a single response from all surgeons. The questionnaire was designed by five independent orthopaedic surgeons after exploring all the literature regarding the use of PROMs in joint surgeries in PubMed/MEDLINE, EMBASE, and Google scholar using the keywords “PROs”, “PROMs”, “survey”, “arthroplasty”, “arthroscopy”, “joint replacement”, “sports injury”, “orthopaedics”. Of the five surgeons who prepared the questionnaire, three belonged to a public run teaching institutes of national importance and two belonged to private sector hospitals. The articles were thoroughly reviewed to note the utility, limitations, and barriers in using PROMs. The surveys conducted in different regions on the same or related topics were also reviewed to form the final questionnaire.

3 Results

The pilot study among the 10 surgeons showed good comprehensibility. The mean Flesch reading ease score was 91 ± 4.3. None of the questions underwent any change after the pilot study. The mean time to answer the questionnaire was 6.2 ± 0.9 min. There were no missing responses in the pilot study.

The mean age of the 87 surgeons participating in this study was 38.6 ± 4.7 years. The majority of the surgeons were aged between 30 and 40 years (39.7%) (Table 1). A total of 42.9% of respondent surgeons were working in an academic institution, 35.7% in a government medical college, 9.5% in corporate hospitals, 7.1% in private owned medical colleges, and 4.8% surgeons were working in a standalone clinic of their own. The majority of respondents (35.4%) were having a work experience of 10–15 years in the field of orthopaedics. Among the total respondents, 73.6% (64 out of 87) surgeons were familiar with one or more of the existing PROMs (Table 2). Only 2.4% of these surgeons were using PROMs for daily clinical purposes and 14.9% were using them for research purposes. Surprisingly, a total of 62.1% of surgeons had used PROMs for both clinical as well as research purposes at some point. PROMs were being used for a duration of 1–3 years by 35.7% of participants, less than 1 year by 26.4%, and more than 3 years by 17.2% of participants. Although the majority of the PROMs were being filled at the clinic (66.7%), 11.5% of PROMs were online based and custom-built methods of collecting PROMs were being used by 4.6% of participants. The Visual Analog Scale (VAS) was used for assessing the pain by 47.1% of surgeons. The Harris Hip Score (HHS) was used for assessing functional assessment of hip pathologies by 11.3% of surgeons. The most commonly used knee functional score was Oxford Knee Score (33.4%), followed by WOMAC score (21.7%), and Knee Society Score (20.9%) in descending order. The forgotten joint score was being used by 5.6% of surgeons and 15.1% of surgeons were using the Short Form 12 score for quality of life assessment.

The majority of the surgeons agreed that the PROMs can be a useful tool to identify a patient in need of a procedure (57.1%) and help the surgeon set a baseline functional status (59.1%) or prioritize the clinical problems to be addressed (61.9%) (Table 3). Most of the participants had a strong agreement about PROM's ability to facilitate doctor-patient communications (42.9%) and agree with the fact that it can also increase patient engagement in treatment plans (57.1%). Another advantage of PROM can be predicting the potential benefits from the planned treatment according to 59.5% of surgeons. A total of 42.9% of surgeons agreed that legal aspects of the practice can also be benefited if the surgeon is documenting a proper PROM.

A strong agreement was observed among most of the surgeons (54.8%) regarding the benefits of PROM in the assessment of the patients from home during the postoperative period (Table 3). Most of the surgeons agreed that the PROM can help in monitoring the response to treatment (54.1%), assess the satisfaction of the patient (54.8%), help in monitoring the quality of healthcare (57.1%), and help to detect any complications (47.6%). However, a neutral response was observed from most of the surgeons (45.2%) regarding the role of PROMs in assessing a surgeon's performance.

Only 25.9% of surgeons had an adequate understanding of the function, benefits, and drawbacks of PROMs, while the majority of them (57.1%) were neutral about their knowledge regarding the same (Table 4). However, a total of 66.7% of surgeons agreed that PROMs can be a valuable addition to the management plan, and 64.3% of surgeons believed that PROMs are a transparent way to assess patient outcomes. Although very few of the surgeons (19% agreed, 20.5% strongly agreed) agreed that their patients can accurately and honestly report their health status by PROMs, a large proportion of surgeons disagreed on the same (21.4% agreed, 16.6% strongly disagreed). The majority of the respondents (50%) believed that PROMs are the best way to report outcomes of a procedure while publishing research.

Among the barriers against using PROMs, time constraint was agreed upon by most of the surgeons (59.5%) (Table 5). A large proportion of respondents agreed that PROMs interpretation can be difficult for patients due to the language barrier (14.3% strongly agree, 42.9% agree) as well as the IQ barrier (5.8% strongly agree, 36.7% agree). However, there was an equivocal response among surgeons regarding the difficulty in interpretation of PROMs by a healthcare worker (7.1% strongly agree, 31% agree, 4.8% strongly disagree, and 21.4% disagree). In addition, 26.2% of respondents strongly agreed and 35.7% of respondents agreed that PROMs may be too subjective. The lack of infrastructure was reported as a barrier to incorporating PROM into their practice by many surgeons (11.9% strongly agree, 35.7% agree). Lastly, 64.3% of surgeons were willing to incorporate the PROMs into their daily practice if the barriers are overcome and 14.3% of surgeons were in doubt if they would be able to incorporate the PROMs or not.

4 Discussion

The measure of outcomes in healthcare can be subjective or objective and PROMs are objective tools to measure health outcome. The development, validation and testing of PROMs have become an integral part of modern medicine. PROMs are validated questionnaires filled by the patients during the treatment phase to assess the outcomes objectively. They usually comprise various sections on general, physical and mental health as well as on quality of life. It can also be focussed on a particular disease or particular joint of the body. Healthcare values have been defined as a balance between costs and health outcomes and hence this need to focus on PROMs in the last few years.⁵

India currently lacks any study or objective data regarding the use of PROMs among the arthroplasty and arthroscopy surgeons. The aim of this study is to describe the usage of PROM, its use or lack of use, barriers in using it and its future prospect among the arthroplasty surgeons from a developing country like India. This study showed numerous interesting facts. A few worth mentioning about are.a)62.1% of surgeons had used PROMs for both clinical as well as research purposes at some pointb)majority of the PROMs were being filled at the clinic (66.7%)c)facilitate doctor-patient communications (42.9%)d)42.9% of surgeons agreed that legal aspects of the practice can also be benefited if the surgeon is documenting a proper PROMe)help in monitoring the response to treatment (54.1%)f)help in monitoring the quality of healthcare (57.1%)g)25.9% of surgeons had an adequate understanding of the function, benefits, and drawbacks of PROMsh)Among the barriers against using PROMs, time constraint was agreed upon by most of the surgeons (59.5%)i)64.3% of surgeons were willing to incorporate the PROMs into their daily practice if the barriers are overcome

The field of practice has been seen to influence the usage of PROMs, e.g., orthopedics has more validated PROMs than maxillofacial surgery thus leading to more orthopedicians being aware of and using PROMs rather than maxillofacial surgeons.^3,6 This is proved in this study where 62.1% of arthroplasty surgeons had used PROM at one point or the other, either for clinical or research purposes. The increased familiarity may be due to increasing number of post graduate residency seats in the country and PROM being used in some form or other to assess outcomes in the dissertation of the residents. Also, many reputed publications and journals now insist on standardized and validated PROMs to assess outcomes objectively in submitted manuscripts. Apart from these, with growing litigation in the urban centers of the country, these tools are handy as evidence in the court of law. Furthermore, many researchers have undertaken to translate and validate the regional versions of many tools for which would lead to its widespread use in India even in patients not literate in English.

It has been noted that there are various logistical and perceptual barriers to widespread PROM use in orthopedics practice.⁷ Logistical barriers are examples like time constraints and accessing PROMs in the electronic records while perceptual barriers are the understanding capability of the patient and surgeons concerns regarding the validity of the PROM tool. Surgeons usually believe speaking directly to patients is of much greater benefit than using PROMs in assessing outcomes.^3,7–9 For widespread incorporation of PROM into clinical care, well designed PROM with good psychometric properties is the need of the hour and from the patient's perspective, these tools should enhance patient-doctor communication rather than curtailing them. Substantial investment in terms of resources and time have to be done by researchers, surgeons and patients for making PROM more widespread.

Predicting patient benefit from arthroplasty has also been seen as one of the top current use by a previous study.¹⁰ There is a need to increase usage among the surgical care team as well as to complete all the surveys among the patients within the required time frame for PROMs to become an effective prognostic tool.¹¹ Successful incorporation PROM have been reported by institutes in the Western world and this would require apart from the apparent stakeholders, involvement of regulatory agencies and professional societies like Indian Orthopedic Association (IOA), state chapters of IOA, Indian Society of Hip and Knee Surgeons and Indian Arthroplasty Association.¹²

Similarly, before embarking on a widespread use, the limitations of use of PROM should also be borne in mind. Choosing the correct tool which is validated for the specific population is crucial. The history of the tools should also be noted because many had been developed for research purposes and its extrapolation to routine clinical use may be controversial. Data collection is another aspect which needs to be thought into. On site feedback collection is a popular method but patients may not be in an ideal physical or mental state to give correct and true responses and they also may be concerned about the quality of care they might receive post such feedback. Post-contact information collection may lead to low response rates. All the patients might not be well fluent in the language of the validated tool which places the need for translated and validated versions for its widespread use.

This cross-sectional study is the first study assessing and analysing the use of PROM among Indian arthroplasty surgeons. The research was led by researchers from a variety of workplaces such as academic institutions of national repute as well as well-known private hospitals. This would have taken care of the opinion of the public sector and private sector surgeons equally. The researchers are from different parts of the country implying widespread dissemination of the questionnaire and fairly generalised response analysis. The small sample size may be a limiting factor for a huge country like India but nevertheless, the findings of this study would let us analyse more about PROMs and how to put into use more effectively and on a widespread way, both for clinical and research purposes.

5 Conclusion

Though a fairly large number of surgeons were aware of PROMs, the surgeons regularly using it for clinical or research purpose is low. Majority of the surgeons did not have adequate understanding of the function, benefits, and drawbacks of PROMs. Time constraint was the major barrier restricting its widespread use. Involvement of regulatory and professional societies as well as substantial investment in manpower, money and time is required for making the use of PROMs regular.

Funding/sponsorship

This research did not receive any specific grant from funding agencies in the public, commercial or not-for-profit sectors.

Informed consent (patient/guardian), mandatory only for case reports/clinical images

NA.

Institutional ethical committee approval (for all human studies)

Obtained 2022-28-IND-02 (AIIMS Deoghar).

Authors contribution

a) Dr Souvik Paul – Methodology, Formal analysis, Data Curation

b) Dr Sitanshu Barik - Methodology, Formal analysis, Data Curation, Writing - Original Draft, Writing - Review & Editing.

c) Dr Vikash Raj – Conceptualization, Supervision, Project administration, Writing - Review & Editing.

d) Dr Manish Raj - Conceptualization, Supervision, Project administration, Writing - Review & Editing.

e) Dr Roop Bhushan Kalia - Conceptualization, Supervision, Project administration, Writing - Review & Editing.

f) Dr Tarun Goyal - Conceptualization, Supervision, Project administration, Writing - Review & Editing.

g) Dr Manit Arora - Conceptualization, Supervision, Project administration, Writing - Review & Editing.

h) Dr Muhammed Nazeer - Conceptualization, Supervision, Project administration, Writing - Review & Editing.