Scaling and Spreading Electronic Capture of Patient-Reported Outcomes Leveraging a National Surgical Quality Improvement Program

On an individual patient basis, patient-reported outcome measures (PROMs) can enhance patient-clinician communication, identify problematic symptoms and treatment priorities, and facilitate shared decision making. In the aggregate, PROMs can also catalyze quality and performance improvement and as such, are increasingly incorporated into healthcare policy, global hospital rankings, and value-based healthcare initiatives across various conditions, particularly surgery. Current measures of surgical quality emphasize processes, adverse events, and resource use, which are necessary to track, but do not provide a complete picture of the recovery, symptoms, and outcomes patients experience. PROMs provide important information about patients who do not experience complications. However, the implementation of PROMs for surgical quality improvement remains restricted to single centers and has not been routinely ingrained into quality improvement thinking.

The purpose of this study was to evaluate the feasibility of scaling and spreading a technology-enabled PROM implementation across the United States using the ACS NSQIP, a clinical registry that collects patient characteristics, perioperative details, and postoperative adverse events occurring within 30 days for quality improvement purposes. The intent was to learn from the implementation process to obtain generalizable knowledge and to understand how PROMs can identify quality improvement opportunities in patients undergoing surgery, specifically ambulatory surgery.

The specific aims of the research were as follows:

• Demonstrate feasibility for widespread adoption of the routine, technology-enabled capture of PROMs from surgical patients to at least 30 ACS NSQIP hospitals for quality improvement.
• Identify and understand common (program-wide) and unique (institutional) best practices to spread the technology-enabled PROM implementation.
• Explore the potential of identifying quality improvement gaps with aggregated PROMs.

Hospitals in the US participating in the NSQIP were recruited on a rolling basis to participate in the implementation project conducted between February 2020 and April 2023. The study's enrollment grew from a pilot project with 11 sites in 2020 to including up to 65 hospitals at the end of the project. PROMs were collected via the ACS NSQIP patient-reported outcome platform, an electronic, encrypted, HIPAA-compliant platform. During the study period, the 65 participating hospitals collected four Patient-Reported Outcomes Measurement Information System (PROMIS) measures (Global-10, Pain Interference 4a, Fatigue 4a, Physical Function 4a) and two measures of shared decision making (CollaboRATE and SDM-Q-9).

At the project end, the median hospital-level collection rate was 40.7 percent. The highest increases in collection rates occurred when both email and text messaging were used, communications to patients were personalized with their surgeon’s and hospital’s information, and the number of reminders increased from two to five. Adjusting for patient- and case-mix, patients who experienced postoperative morbidity, compared to those without, had significantly worse physical function, fatigue, pain interference, and mental quality of life.

The findings underscore the significance of PROMs in providing a comprehensive view of surgical outcomes from the patient's perspective. The study's success in improving response rates and integrating PROMs into the ACS NSQIP signifies a meaningful advance in patient-centered surgical care. The study is the first in the nation to implement PROMs effectively on such a scale for surgical quality improvement. Continued work is ongoing to incorporate baseline and longitudinal measurements as well as the incorporation of condition-specific PROMs. This work sets the stage for future quality measurement development and accelerates value-based healthcare transformation.