Exploring the perspective of patients with musculoskeletal health problems in primary care on the use of patient-reported outcome measures to stimulate quality improvement in physiotherapist practice; a qualitative study

Figures & data

Table 1. The domains, themes, and subthemes on the patient ‘s perspective using PROMs in clinical practice

Fleuren‘s domains	Theme	Subtheme
✓ Organization✓ Innovation	1. Practicality	Applicability Administering PROMs Efficiency Required time investment
✓ User✓ Innovation	2. Interaction with the PT for decision-making	Communication Diagnostics and evaluation Patient-centeredness Self-awareness Reflection on results
✓ Socio-political context✓ Innovation	3. Sharing information outside the clinical context	Using data for quality improvement Sharing data with insurance companies

Table 2. Quotes related to the theme ‘practicality’

Subthemes	Quotes
Applicability	“Yes, the patient reported outcome measures (PROMs) are applicable to my health problem, and therefore, it’s relevant to answer such questions.” “The disadvantage of such questionnaires is that they measure a specific moment in time. That is difficult since my health problems differ each day. Every once in a while when I fill in the questionnaire on a relatively good day I wonder if my physiotherapist gets a representative picture”
Administering PROMs	“Well, we are asked to complete the questionnaire using a computer and that is a little difficult for me because I am a little older and … well, it is only recently that we have had a computer”.
Efficiency	“I think it is more convenient to fill in the questionnaire when you are at home, at a time that it suits yourself. At least then it will not go at the expense of your consultation time … or it prevents that you will have to stay at the practice to fill in the questionnaire after the treatment … ”
Required time investment	“So, doing the follow-up and building up a patient-file, will take up more time … However, I think that the advantages of building up such a file outweigh the disadvantages.”

Table 3. Quotes related to the theme ‘interaction with the PT for decision-making’

Subthemes	Quote
Communication	“PROMs are probably useful for patients who visit their PT for the first time. For me, they are not useful anymore. I have visited my PT before with these health problems. Therefore, I know why I visit my PT, I know my PT treats me well, and I know that ‘the’ treatment is effective. Therefore, I wonder: why should I keep on completing these questionnaires, even though we already know what ‘the’ treatment looks like.”
Diagnostics and evaluation	“Obviously the benefit of using PROMs is that PTs can prepare themselves for my visit. Using the PROM-results, your PT can analyze what might trigger the health problem and think about the intervention they might use. At a later phase, when the PROMs are completed again, they could analyze the progression did the pain decrease or is it completely resolved?“
Patient-centredness	“By administering questionnaires, the PT can optimally adjust his treatment plan, with the advantage, I presume, for the patient that a sort of a custom-fit plan arises. You’ll get more personal advice, and therefore, a more personal trajectory.”
Reflection on results	“I must say that this reflection upon the results really has an added value. It unravels the underlying thoughts, which might explain differences between the answers on the questionnaire and the things that have been said during the intake.”
Self-awareness	“I think that the questionnaires have helped me clarify my health problems, as completing the questionnaire provides me with a clearer picture of my health problems. … And when I am at the PT practice and am asked about my health problems, then I only start to think about it at that time … then you wonder at what moments during the week is the pain actually present. … the benefit of using the questionnaires is that you’ve already written that down. Indeed I must say that that is a real big benefit.”

Table 4. Quotes related to the theme ‘sharing information outside the clinical context’

Subtheme	Quote
using data for quality improvement	“It might trigger PTs to learn from each other when results are compared.”
sharing data with insurance companies	“Well, as soon as the collected data become publicly available and end up in the commercial circuit … then you are absolutely not sure that it will trigger the positive effect that is pursued. Therefore, I think that is a disadvantage of using the data toward insurance companies, to obtain external transparency … because insurance companies are commercial entities, for whom obtaining profit is a central theme. Also, I doubt in what way the data will be used … .”.

Table 5. A summary of the identified barriers and facilitators per subtheme

Subtheme	Barrier and facilitator
● Applicability¥	● In general, patients identified the applicability as sufficient, which facilitated the use of PROMs. In patients with fluctuating health problems deciding how to score the items of the PROM was difficult and perceived to be a barrier.
● Administering PROMs¥	● Only in patients with fewer computer skills, the digital administration of PROMs was seen as a barrier. All other patients perceived it as a facilitator.
● Efficiency¥	● Patients who were able to fill in the PROMs before their consult perceived the PROMs to be a facilitator, since their physiotherapist was able to better prepare himself. Patients who needed to fill in the PROMs at the consult perceived a lower efficiency and identified it as a barrier since their time to be treated was less.
● Required time investment¥	● None of the patients perceived the required time investment to be a barrier.
● Communication^§, ● Diagnostics and evaluation^§, ● Patient-centeredness^§	● Patients that visited their PT with a new health problem thought PROMs to be facilitators, and patients that visited their PT with recurrent health problems identified them as barriers. ● PROMs are identified as facilitators, stimulating self-awareness of patients and the reflection upon the results between
● Self-awareness^§, ● Reflection on results^§	● patients and physiotherapists.
● Sharing data with insurance companies^Ɣ	● Some patients perceived this to be a facilitator, to enable the insurance companies to fulfill their societal role to increase healthcare quality and maintain affordability. Others perceived this as a barrier since they were suspicious about the way the data would be used by these commercial organizations.
● Using data for quality improvement^Ɣ	● All patients perceived this to be a facilitator.

^§Theme 1: Interaction with the PT for decision-making

^¥Theme 2: Practicality

^ƔTheme 3: Sharing information outside the clinical context

Table 6. Implications for practice and policy

Implication	Subtheme(s)	Theme(s)	Domain(s) of Fleuren
Administer the PROMs outside the consultation to increase efficiency. This can be done by e-mailing the PROM in advance or, when computer skills are lacking, help the patient use a tablet in the waiting room	Administering PROMs, Efficiency	Practicality	Organization Innovation
Create a visual/verbal presentation form explaining why PROMs are being administered (for clinical and aggregated purposes) minimizing the necessity to give an explanation at the cost of valuable consultation time, especially for patients with recurrent health problems; it increases the understanding and acceptance of patients.	Efficiency,	Practicality	Organization, Innovation
	Communication, Diagnostics and evaluation, Patient-centredness	Interaction with PT for decision-making	Innovation User
If needed, provide training for professionals to enable them to give a verbal explanation to patients on why PROMs are being administered (for clinical and aggregated purposes).	Communication, Diagnostics and evaluation, Patient-centredness	Interaction with PT for decision-making	Innovation User
Select the appropriate PROM, outweighing the balance between the essential questions and the length of the questionnaire.	Communication, Diagnostics and evaluation, Patient-centredness	Interaction with PT for decision-making	Innovation User
To overcome the reluctance toward sharing information with insurance companies there is a need to make contractual agreements, ensuring that the data is only used in a pre-defined way that has been approved by all stakeholders.	Sharing data with insurance companies	Sharing information outside the clinical context	Socio-political context Innovation

Table

Name	Gender	Credentials	Occupation	Experience
X	Male	MSc.	PT, Junior Researcher, Senior policy advisor	Qualitative research methods in health care introduction.
X	Female	Dr.	PT, Senior researcher	Implementation research, qualitative and quantitative studies.
X	Female	Dr.	PT, Senior Researcher, Senior Lecturer	Implementation research, Qualitative research. Teaches qualitative research module in PhD pogram.
X	Female	BSc.	Research assistant	Data analysis in qualitative and quantitative research methods.
X	Female	Prof. Dr.	PT, Professor of Allied Health	Quantitative and qualitative methods. Multiple studies with quantitative, qualitative, and mixed methods studies in health sciences.
X	Male	Prof. Dr.	PT, Professor of Allied Health Sciences	Implementation science, quantitative and qualitative methods. Teaches qualitative research module in PhD program. Multiple quantitative, qualitative and mixed methods studies.

PT: physiotherapist