The online survey was completed by 100 GPs across England (Table 1). Seventy seven GPs reported using one or more PROM; however, 17% (38/224) of the measures reported were not PROMs (for example cardiovascular risk scores). The majority of PROMs reported were for mental health (n=85 PROMs), urology (n=37 PROMs), sleep apnoea (n=25 PROMs) or orthopaedics (n=19 PROMs).
The most common reasons for PROM use were to aid clinical management (n= 66) or as a screening/ diagnostic tool (n= 61) (Table 2). GPs most frequently accessed PROMs through clinical systems (n=56), clinical templates (n=49) or online (n=47). PROMs were usually completed during the consultation (n=72), using paper (n=68) or GP administered interviews (n=51), and were reviewed by GPs (n=84). The main barriers reported for PROM use were time constraints (n=77) and being mandated to use (n=55). When asked “how do you think your patients feel about completing PROMs?”, most GPs responses were positive or neutral (n= 47 and n=31, respectively).
Similar to current PROM use, the most common areas GPs considered PROMs could provide the most benefit were to aid clinical management (n=66), as a screening/ diagnostic tool (n=62) or facilitate shared-decision making (n=60) (Table 3). GPs would prefer to access PROMs through clinical templates (n=65) or clinical systems (n=63) and considered patients would prefer to complete PROMs during the consultation (n=34). The preferred format for patients to complete PROMs was considered to be paper (n=43) or online (n=21), and the preferred format for GPs recording PROM results was electronic: as part of the electronic health record (n=78). GPs viewed that doctors would be the most appropriate people to interpret PROM results (n=78). The patient groups/conditions where GPs considered there would be the most benefit from completing PROMs was mental health (n=20), all/ most patients (n=15) and patients with chronic conditions (n=14). GPs considered PROMs should be collected for chronic disease monitoring annually (n=36) or as clinically indicated (n=27). Most GPs felt development of PROM systems should be designed to meet clinician/ patient needs (n=68) rather than designed primarily for audit, benchmarking or commissioning (n=3). Integrated clinical systems (n=29), more time (n=12) and easy access (n=12) were the most common features GPs reported that could facilitate/ support the use of PROMs in primary care.
The final sample comprised 25 GPs, participant characteristics are detailed in Table 4 and eTable 1 (see appendix). Interviews lasted between 18 and 59 minutes.
Current use of PROMs
PROMs were considered useful to aid shared decision making, the ability of PROMs to provide an objective measure that could be used in subsequent discussions of treatment was described.
“It does help direct the discussion regarding future management, especially the mental health patients because it allows them to objectively score how they feel and what’s going on, and allows me to help discuss treatment options with them.” GP12
By completing PROMs with patients, one GP described how they facilitated the discussion with a patient about their symptoms.
“I have sometimes filled in the questionnaires with the patients, and actually I see the value of that because we actually get a better picture with the discussion around filling the form with the patient as opposed to just getting a figure just attached to the referral letter.” GP13
Facilitators to PROM use
GPs knowledge and understanding of the value/benefits of PROMs to their clinical practice was an important factor in their use with some GPs considering that better communication of the evidence-base for PROMs could be an important driver for their take-up.
“For me I am quite evidence based personally, and if someone was to show me like you’re doing, if I’m the outlier and most GPs love PROMs and I would actually be thinking hand on I’m the outlier here, actually maybe I’ll just get more on board. If there was a study saying this particular PROM if they said PHQ-9 shortened a ten minute consultation down to five minutes, improves on patient outcomes, reduces re-attendance rates, improve compliance to medications, then I would say right we’ve got to get on board and do that.” GP18
Related to the reliability of the evidence base one GP described how they were more likely to use PROMs if they heard about them from multiple sources, corroborating perceptions of their utility.
“… I am unlikely to go and start using some new coeliac disease PROM when I have just been to a talk from a private gastroenterologist or something like that. I am more likely to use something that is appearing to me in lots of different areas of my CPD or medical education. So if I might see a paper about it, and then I might hear a colleague talking about it, and then I might see something on GP Notebook or something like that. So you’re getting over exposed to it, and then try it out and see how well it resonates, and how useful it is and how quick and easy to remember it is.” GP24
Barriers to PROM use
Some GPs were unconvinced of the benefits of PROMs instead placing the onus on clinical data. This appeared at least in part due to concerns of the reliability of patients whose responses might be influenced by attempts to manipulate the output for their own purposes.
“…sometimes the patient can fill them in with what they think the clinician might want them to say rather than what they actually feel. So sometimes patients can underplay their symptoms, and equally sometimes patients can overplay their symptoms if there might be some perhaps secondary gain for them in terms of certification from work or whether they want some help with some other part of their care. So I think they can potentially be a bit skewed by that.” GP19
Though the use of PROMs can be encouraged at a policy level, this top-down approach for mandatory PROM completion was objected to by GPs and did not convince them of the value of PROMs. For example one GP felt obliged to use a PROM solely due to the financial incentive offered by the National Health Service (NHS) pay-for-performance QOF in the absence of any clinical value.
“so the big one is PHQ-9, it’s pushed very hard and for example with people with chronic diseases as well it flags up in the QOF box on EMIS. But in reality it’s irrelevant to assisting you that much in terms of referral and management, so there’s no point in doing it.” GP18
Lack of time in the consultation to complete, analyse and integrate an additional source of information was described and one GP felt this was a barrier to their routine use.
“In a pressurised rushing surgery and you’ve only got ten minutes the person usually would need at least 20 minutes to solve their issues, and if you were to include a questionnaire on top of that you would be definitely talking about 30 minutes at least, and you can’t afford to be doing that on a regular basis. You can do it as a one off thing and then you have an idea, but you would be pressurised to just do things quickly...” GP2
Lack of integration with clinical systems was also identified as a potential barrier; in some cases PROMs were integrated in clinical systems but they were not easy to use.
“So we do have some which are integrated into the system, but they are not quite integrated enough to be user friendly, … I’m actually thinking here of the dementia screening test which isn’t really a PROM I guess, but you have to input the data and then the score is added up wrong because the template is set up wrong, so you end up having to override it and do it yourself anyway which makes it a bit of a waste of time it being integrated, and I think sometimes with the clunky way that clinical computer systems sometimes work it be difficult during the consultation to use that tool there and then. So I think there could be better integration, it could be more fluid, and I suppose depends on which clinical system is used, which PROMs are used locally and how easy they are to integrate into the system, because I guess some are going to be more objective than others.” GP19
Though large numbers of PROMs have been produced there appeared no systematic method of communicating their identity and availability to practice staff. For one GP the subsequent lack of awareness significantly reduced their uptake.
“To make me want to use a PROM first of all I would have to hear about it, and that is the main problem that we wouldn’t hear about it and therefore people get them on committees as mandatory things to put down on referrals. That happens because we don’t hear…” GP20