Key points
- PROMs help personalise care and manage expectations
- Patient engagement is the biggest challenge
- PROMs provide valuable insights but should not be used alone
- Patients are increasingly interested in their own health data
- Publishing PROMs data requires careful interpretation
Introduction
Mr Dennis Kosuge is an orthopaedic surgeon specialising in hip and knee surgery. He works across both NHS (The Princess Alexandra Hospital NHS Trust) and private ( Rivers Hospital , Ramsay Healthcare) settings, covering the West Essex and East Hertfordshire region.
His interest in hip and knee surgery developed early during his training, inspired by mentors in the field. This quickly led to a broader interest in how outcomes are measured.
Why the interest in PROMs
PROMs (Patient-Reported Outcome Measures) have been part of Mr Kosuge’s clinical thinking for over 20 years. As he explained, they allow clinicians to provide more individualised answers, recognising that “every surgeon probably has some subtle differences in their practices.”
PROMs help move conversations beyond generic success rates. They enable clinicians to explain how outcomes may vary depending on a patient’s starting point, condition and circumstances. For example, patients with poorer pre-operative scores often achieve lower post-operative scores than those starting from a higher baseline. Sharing this helps set realistic expectations and supports informed consent.
PROMs also provide insight that traditional measures can miss. While revision rates, such as those captured by the National Joint Registry (NJR), are important, they do not provide a complete picture. As he noted, PROMs “paint that picture a little better.”
However, increased transparency also brings greater scrutiny. PROMs make variation in outcomes more visible at an individual clinician or departmental level. For example, surgical practices made up predominantly of complicated pathologies or patients with significant comorbidities are factors that will affect PROMs outcomes. For this reason, these factors must be considered alongside other measures, including registry data and patient satisfaction data, to build a balanced view of performance.
Embedding PROMs into practice: software and process
Mr Kosuge currently uses a PROMs system which allows him to register patients and distribute questionnaires via email. While email access was once a barrier, particularly among older patients, this is now less of an issue as patients in their 70s and 80s become more comfortable using digital tools.
The greater challenge is engagement. While pre-operative questionnaires can be built into routine pathways, post-operative completion depends on patients staying engaged throughout their recovery. He has found that introducing PROMs early helps normalise the process, with some of his patients continuing to complete PROMs up to 10 years post-procedure. However, he emphasised that “the first year is most important” in understanding whether an operation has made a meaningful difference from the patients’ perspective. Longer term PROMs analysis is useful for studying longevity of joint replacements and for identifying potential problems at an earlier stage.
Looking ahead, integrating PROMs into patient portals, particularly within the NHS, could help make completion part of routine care. Similarly, he highlighted practical considerations in system design. Ease of use and accessibility are likely more important than complex functionality.
Reminders are another important factor in improving response rates. This means not just one-off prompts, but follow-up reminders – and where possible, human interaction. As he suggested, if “someone is on the phone actually doing the questionnaire with you […] most patients, as long as they’ve got 5–10 minutes, would not mind.”
How PROMs are communicated to patients
PROMs can be framed in ways that resonate with patients:
Monitoring individual recovery
- Patients are encouraged to see PROMs as a way of tracking their own progress: “It’s one way of monitoring their recovery so that they feel some ownership.”
Improving care for future patients
- Through participation, patients help clinicians better understand outcomes and refine treatment.
Supporting wider research and improvement
- PROMs data collection and aggregation lead to sector-wide learning.
This positions PROMs as beneficial not only to individual patients but also to the healthcare system as a whole.
How are PROMs used in practice?
PROMs are typically used alongside other clinical follow-up methods, such as imaging, to build a fuller picture of patient recovery. They can highlight issues that may otherwise go unnoticed. For example, a declining trend in PROMs scores may prompt further investigation even where other clinical measures appear normal.
However, PROMs are not always straightforward to interpret. Patients can respond based on their overall health rather than the single condition of interest. For example, back pain may influence responses about hip function. While clear instructions can help, it can be difficult for patients to compartmentalise their health in this way. Because of this, body region specific PROMs (e.g. Oxford Hip or Knee Scores) should be interpreted carefully and alongside other measures, such as EQ-5D, to support a more rounded interpretation of the patient’s progress.
It is also important to recognise response bias. Patients who complete PROMs may not be fully representative: those with very positive or very poor outcomes may be more likely to respond, while others may disengage once treatment feels complete. As a result, PROMs data can reflect a more polarised view of outcomes and should be interpreted carefully.
Patient attitudes towards health data
Mr Kosuge believes that nowadays, patients are “more curious about their health” and their own data, particularly among younger patients.
Providing patients with access to their own PROMs data may:
- Help them monitor their progress over time
- Offer reassurance when recovery is on track (an upward or flat trend in PROMs)
- Prompt earlier conversations if concerns arise (a downward trend in PROMs)
He also notes that definitions of surgical “success” can vary significantly between patients:
- Some prioritise avoiding further surgery (e.g. NJR data)
- Others focus on functional outcomes (e.g. PROMs)
- Others value overall experience and satisfaction (e.g. patient feedback)
As access to personal health data increases – particularly through tools like the NHS App – this demand for information is likely to grow. In addition to this, advances in wearable technology introduce new datasets that can be utilised to assess patients’ recovery from surgery.
Considerations for publishing PROMs data
While there is growing interest in transparency, publishing PROMs at consultant level presents challenges, especially around case-mix. As Mr Kosuge explained, consultants treating more complex patients may appear to have worse outcomes compared to those dealing with more straightforward cases. Without appropriate adjustment, this risks:
- Misinterpretation of data
- Unfair comparisons
- Unintended behavioural changes (e.g. consultants avoiding complex patients)
He suggested that improvements in case-mix adjustment may make publication more feasible over time, but careful consideration is required. PHIN’s view aligns with this: PROMs should not be used to 'punish' consultants, but to better understand what drives high-quality care and outcomes.
Key learnings:
- PROMs enable more personalised discussions about treatment expectations.
- Explaining their relevance to individual care is key to patient engagement.
- Introducing PROMs early helps make them part of routine care.
- Engagement remains the main challenge , rather than access.
- Patients are increasingly interested in their own health data .
- Response bias is likely and should be considered when interpreting results.
- PROMs data has most value when it is actively used to improve care.
- PROMs should complement other metrics to provide a holistic view. This includes registry information, patient feedback, other clinical scale results, and physical diagnostics.
- Ease of use and accessibility are more important than complex system features.
- Reminders, particularly timely and repeated ones, are critical to maintaining engagement.
