Patient-Reported Outcome Measures Within a National Multispecialty Surgical Quality Improvement Program

Abstract

ImportancePatient-reported outcome measures (PROMs) are increasingly recognized for their ability to promote patient-centered care, but concerted health information technology (HIT)–enabled PROM implementations have yet to be achieved for national surgical quality improvement.ObjectiveTo evaluate the feasibility of collecting PROMs within a national surgical quality improvement program.Design, Setting, and ParticipantsThis was a pragmatic implementation cohort study conducted from February 2020 to March 2023. Hospitals in the US participating in the American College of Surgeons National Surgical Quality Improvement Program and their patients were included in this analysis.ExposuresStrategies to increase PROM collection rates were identified using the Institute for Healthcare Improvement (IHI) Framework for Spread and the Consolidated Framework for Implementation Research and operationalized with the IHI Model for Improvement’s Plan-Do-Study-Act (PDSA) cycles.Main Outcomes and MeasuresThe primary goal was to accrue more than 30 hospitals and achieve collection rates of 30% or greater in the first 3 years. Logistic regression was used to identify hospital-level factors associated with achieving collection rates of 30% or greater and to identify patient-level factors associated with response to PROMs.ResultsAt project close, 65 hospitals administered PROMs to 130 365 patients (median [IQR] age, 60.1 [46.2-70.0] years; 77 369 female [59.4%]). Fifteen PDSA cycles were conducted to facilitate implementation, primarily targeting the Consolidated Framework for Implementation Research domains of Inner Setting (ie, HIT platform) and Individuals (ie, patients). The target collection rate was exceeded in quarter 3 (2022). Fifty-eight hospitals (89.2%) achieved collection rates of 30% or greater, and 9 (13.8%) achieved collection rates of 50% or greater. The median (IQR) maximum hospital-level collection rate was 40.7% (34.6%-46.7%). The greatest increases in collection rates occurred when both email and short-message service text messaging were used, communications to patients were personalized with their surgeon’s and hospital’s information, and the number of reminders increased from 2 to 5. No identifiable hospital characteristic was associated with achieving the target collection rate. Patient age and insurance status contributed to nonresponse.Conclusions and RelevanceResults of this cohort study suggest that the large-scale electronic collection of PROMs into a national multispecialty surgical registry was feasible. Findings suggest that HIT platform functionality and earning patient trust were the keys to success; although, iterative opportunities to increase collection rates and address nonresponse remain. Future work to drive continuous surgical quality improvement with PROMs are ongoing.

Adding Patient-Reported Outcomes to the American College of Surgeons National Surgical Quality Improvement Program

“…Having shown the feasibility of a national platform to collect PROs 12 and integrate them into the NSQIP, many additional opportunities exist. We could measure only one postoperative timepoint in this current iteration.…”

“…Second, complication rates in this cohort were very low, preventing us from examining them individually, and all complications were weighted equally in our analyses. Third, nonresponse and selection biases are inherent in these data, and, while tremendous improvements in response rates were made during this study, 12 additional work to increase response rates and to understand the impact of nonresponse on the ability to detect quality improvement opportunities is necessary. 43,44 Nevertheless, as we have shown, a major benefit of PROs is that they can be measured even when patients do not have complications, providing more precise estimates.…”

“…13,14 Briefly, the demonstration project aimed to achieve response rates ≥ 30%, which was accomplished and consistent with other national survey-based programs in health care. 12,15 Patients sampled and accrued into the NSQIP following standard operating procedures completed PROMs using an encrypted, HIPAA-compliant weblink distributed through email or SMS text messaging. Patients could complete PROMs up to 90 days after surgery and were reminded up to five times.…”

“…10,11 To advance the surgical quality improvement paradigm from one that focuses solely on postoperative complications and resource utilization to one that also includes PROs, the American College of Surgeons (ACS) embarked on a large-scale demonstration project across 65 hospitals to collect PROMs into the National Surgical Quality Improvement Program (NSQIP) for continuous quality improvement. 12,13 Herein, we describe the PROs measured from this initial patient cohort and examine their relationships with typical 30-day NSQIP surgical outcomes, paying particular attention to patients without complications.…”