Transcript PROs in clinical practice

Patient-Reported Questionnaires in Clinical
Practice: Just Another Laboratory Test
David Cella, Ph.D.
Professor and Chair
Department of Medical Social Sciences
Feinberg School of Medicine
Health Reform 2010
• Major Commitment of the Obama Administration
• Sweet Spot:
• Right treatment to the right people
• Avoid unnecessary / inappropriate treatments
• Universally available and affordable
• Chronic diseases
• Major expense
• Rarely “cured”
• Most important outcome is often quality of life
The Problem
Health care providers do not routinely use
health-related quality of life (HRQL) data to
guide diagnosis, treatment, or performance
improvement.
…if they did, would it make a difference?
…how should HRQL data be presented?
Measurement Science: Not the Problem
In chronic illness care, the problem is not the lack of
HRQL measures
• a large selection of generic and diseasespecific measures exist
The problem is the unhelpful way the data are presented
to clinicians
Continuum of Disease-specific and
Generic Health Measures
Clinical
Markers
Specific
Symptoms
Impact of
Diseasespecific
Problems
(1)
(2)
(3)
Generic
Functioning,
Well-being and
Evaluation
(4)
Adapted from: Wilson and Cleary, JAMA, 1995
Ware, Annual Rev. Pub. Health, 1995
5
5
Continuum of Disease-specific and
Generic Health Measures
Spirometry
dd
Shortness
of Breath
Over the last 4 weeks I
have had shortness of
breath
Almost every day
Several days a week
A few days a month
Not at all
Clinical
Markers
Specific
Symptoms
Impact of
Diseasespecific
Problems
(1)
(2)
(3)
Generic
Functioning,
Well-being and
Evaluation
(4)
Adapted from: Wilson and Cleary, JAMA, 1995
Ware, Annual Rev. Pub. Health, 1995
6
6
Continuum of Disease-specific and
Generic Health Measures
Spirometry
dd
Shortness
of Breath
Over the last 4 weeks I
have had shortness of
breath
Almost every day
Several days a week
A few days a month
Not at all
Respiratory
-specific
How much did your
lung/respiratory
problems limit your
usual activities or
enjoyment of everyday
life?
Not at all
A little
Moderately
Extremely
Clinical
Markers
Specific
Symptoms
Impact of
Diseasespecific
Problems
(1)
(2)
(3)
Generic
Functioning,
Well-being and
Evaluation
(4)
Adapted from: Wilson and Cleary, JAMA, 1995
Ware, Annual Rev. Pub. Health, 1995
7
7
Continuum of Disease-specific and
Generic Health Measures
Spirometry
dd
Shortness
of Breath
Over the last 4 weeks I
have had shortness of
breath
Almost every day
Several days a week
A few days a month
Not at all
Respiratory
-specific
How much did your
lung/respiratory
problems limit your
usual activities or
enjoyment of everyday
life?
Not at all
A little
Moderately
Extremely
Clinical
Markers
Specific
Symptoms
Impact of
Diseasespecific
Problems
(1)
(2)
(3)
Generic
In general, would you
say your health is…
Excellent
Very good
Good
Fair
Poor
Generic
Functioning,
Well-being and
Evaluation
(4)
Adapted from: Wilson and Cleary, JAMA, 1995
Ware, Annual Rev. Pub. Health, 1995
8
8
Can Patient Reported Outcomes
(PROs) be Treated as Just Another
Lab Result?
9
What Do We Need to Launch a
Useful Clinical PRO Lab
• Outcomes that matter to patients and
providers
• Practical (brief) and inexpensive
• Covers a range, including normal
• Greater precision
• Comparability of scores
• Ease of interpretation
• Reference values / normal ranges
10
SyMon-L Symptoms Tracked
•
•
•
•
•
•
•
•
•
•
•
•
•
Pain
Fatigue (lack of energy)
Shortness of breath
Coughing
Chest tightness
Difficulty breathing
Nausea
Poor appetite
Weight loss
Bothered by treatment side effects
Emotional distress
Cognitive dysfunction
Dissatisfaction with HRQL
Symptom Summary Report
Results: Clinical intervention responses to
symptom alerts
Types of intervention
N
%
Medical/clinical (e.g., medications, MD appt)
233
20%
Education
420
36%
Support, coping
455
39%
Coordination of care (e.g., referrals)
50
4%
Critical (e.g., PE, ER visit, admission)
22
3%
Important (e.g., change in meds, clinic visit, IV therapy)
103
16%
Standard of care (e.g., reassessment, education)
374
59%
Non-essential (e.g., follow-up)
98
15%
System-related (e.g., study questions)
37
6%
Acuity of Interventions
Symptom Monitoring Report
QoL predicts survival in NSCLC
Study
What predicts?
Stanley (1980)
Initial PS
Kaasa, Mastekaasa & Lund (1989)
General sx (pain, fatigue)
Psychosocial well being
Overall QoL
Ganz et al. (1991)
Loprinzi et al. (1994)
Ruckdeschel (1994)
Physician-rated PS
Patient-rated PS
Patient-reported QOL
Herndon et al. (1999)
Pain
Montazeri et al. (2001)
Pre-diagnosis overall QoL
Eton et al (2003)
Patient-reported QoL
Quality of Life FACT-L
Symptoms
(LCS)
Social
Functional
Emotional
Physical
Baseline patient characteristics
predicting survival
Order of entry
FACT TOI
Metastatic symptoms
ECOG PS
Stage (IIIB vs IV)
Paclitaxel (Arm A vs B/C)
Risk ratio* p value
0.98
1.44
1.57
1.39
0.81
<0.001
<0.001
<0.001
0.016
0.039
*Risk of death
Other possible explanatory variables included age,
sex, g-csf, weight loss, disease symptoms, systemic
symptoms, comorbidity and other FACT subscales
Initial TOI and improvement at
6 weeks* (n=352)
1.0
Proportion
surviving
0.8
0.6
0.4
0.2 Initial,
<58, no
improved?
>58, no
>58, yes
<58, yes
0.0
0 1
2
3
4
*Patients with missing QoL
5
6
7
8
9 10 11 12
Eton et al, JCO,
LCS Mean Change By Week
By Objective Response, Trial 39
16
PR
SD
PD
14
LCS Score Change
12
10
8
6
4
2
0
-2
-4
-6
-8
0
2
4
6
8
10 12 14 16 18
Weeks fromRandomization
20
22
24
26
Survival by Disease-related Symptom Improvement
Subset surviving > 8 weeks
1.0
P r o b a b ility
0.8
0.6
0.4
0.2
At Risk
84
100
Yes
No
Failures
35
85
Median
in Months
.
4.8
0.0
0
1
2
3
4
5
6
7
8
9
Months from Randomization
10
11
12
13
14
Survival by Response & Symptom Improvement
Subset surviving > 8 weeks
1.0
P r o b a b ility
0.8
0.6
0.4
0.2
At Risk
22
84
99
PR
LCS imp.
Other
Median
in Months
.
.
4.8
Failures
3
35
85
0.0
0
1
2
3
4
5
6
7
8
9
Months from Randomization
10
11
12
13
14
Survival by Symptom Improvement in SD Subset
Subset surviving > 8 weeks *
1.0
P r o b a b ility
0.8
0.6
0.4
0.2
At Risk
44
62
18
SD + LCS imp.
SD
SD - LCS imp.
Median
in Months
.
9.4
4.6
Failures
19
32
13
0.0
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Months from Randomization
* All patients with an objective response of SD survived > 8 weeks.
Content of Widely-Used PatientReported Outcome Measures
CONCEPTS
Physical functioning
Social functioning
Role functioning
Psychological distress
Health perceptions (general)
Pain (bodily)
Energy/fatigue
Psychological well-being
Sleep
Cognitive functioning
Quality of life
Reported health transition
SIP
HIE
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l
l
l
Psychometric
NHP COOP DUKE MOS MOS PROMIS
FWBP SF-36
l
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SIP = Sickness Impact Profile (1976)
HIE = Health Insurance Experiment surveys (1979)
NHP = Nottingham Health Profile (1980)
QLI = Quality of Life Index (1981)
COOP = Dartmouth Function Charts (1987)
DUKE = Duke Health Profile (1990)
MOS FWBP = MOS Functioning and Well-Being
Profile (1992)
Source: Adapted from Ware, 1995
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l
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l
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l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
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l
l
Utility Related
QWB EURO HUI SF-6D
-QOL
l
l
l
l
l
l
l
l
l
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MOS SF-36 = MOS 36-Item Short-Form Health Survey (1992)
= Quality of Well-Being Scale (1973)
PROMIS = Patient Reported Outcomes Measurement Information
System
QWB = Quality of Well-Being Scale (1973)
EUROQOL = European Quality of Life Index (1990)
HUI = Health Utility Index (1996)
SF-6D = SF-36 Utility Index (Brazier, 2002)
23
PROMIS integrates the fields of…
Information
Technology
Psychometrics
PROMIS
Qualitative
Research
Survey
Research
Items from
Instrument
Items from
Instrument
Items from
Instrument
A
B
C
New
Items
Item Pool
Content Expert
Review
 


1.0
Cognitive
Testing
Questionnaire
administered to large
representative sample
Secondary
Data Analysis



2.5
2.0
0.8
Psychometric
Testing
0.6
0.4
0.2
0.0
-3
-2
-1
0
1
2
3
Information
Probability of Response
Focus
Groups
1.5
1.0
0.5
0.0
-3
-2
-1
0
1
2
Theta
Theta
Item Bank
Short Form
Instruments
(IRT-calibrated items reviewed for
reliability, validity, and sensitivity)
CAT
3
PROMIS v1.0 bank
Upper Extremities: dexterity
CaPS bank in development
Lower Extremities: mobility
PROMIS area tested but no bank developed
for v1.0
Physical Function*
PROMIS Domain
Framework
Central: neck and back
Activities: Instrumental Activities of Daily Living
Area addressed (in part) by bank within
lineage
Quality
Behavior
Area not addressed yet
Pain
Impact*
* = Additional cancer-specific PROMIS bank
Fatigue*
Physical Health
Symptoms
Other
Sleep/Wake
Function*
Sleep Disturbance
Experience
Impact
Satisfaction
Wake Disturbance
Alcohol Abuse
Sexual Function
Anxiety*
Emotional Distress
Selfreported
Health
Mental Health
Cognitive Function
Depression*
Meaning & Spirituality
Anger
Stress Response
Substance Abuse
Self-concept
Negative Impact of Illness
Social Isolation
Satisfaction
Positive
Psychological
Function
Satisfaction
Meaning & Spirituality
Positive Impact of Illness
Coping
Mastery & Control (self-efficacy)
Subjective Well-Being (positive
affect)
Self-concept
Social Connection
Social Roles
Social Function
Satisfaction with Participation*
Social Health
Satisfaction
Ability to Participate*
Social
Relationships
Social Isolation
Quantity of Social Support
(Integration)
Discretionary Social Activities
Social Roles
Discretionary Social Activities
Emotional Support
Instrumental/Informational
Quality of Social Support
Companionship
What Do We Need to
Launch a Useful Clinical
PRO Lab?
• Outcomes that matter to patients
and providers
• Practical (brief) and inexpensive
• Covers a range, including normal
• Greater precision
• Comparability of scores
• Ease of interpretation
27
• Reference values / normal ranges
PROMIS Profile Short Forms
8
6
4
Mental
Anxiety
29
Depression
28
Fatigue
95
Physical
Pain Impact
41
Sleep Disturbance
27
Physical Function
86*
Social
Social Role
14
* reduced set (the full bank has 112 items) was
used for real data simulation purposes
28
PROMIS Profile Short Forms
29
PROMIS Profile Subscales: Test Information Functions
Anxiety
Depression
Fatigue
Pain Impact
60
25
30
30
rel.=.95
50
20
rel.=.95
20
15
20
40
rel.=.95
30
rel.=.90
10
rel.=.90
10
10
20
rel.=.90
5
10
0
0
10
30
50
70
90
0
10
30
T-score
50
70
90
rel.=.95
rel.=.90
0
10
30
50
70
T-score
T-score
Sleep Disturbance
Social Role
90
10
30
50
70
T-score
rel.=.95
Physical Function
40
15
40
30
rel.=.90
30
10
20
10
20
rel.=.95
5
rel.=.90
0
10
0
10
30
50
T-score
70
90
SF 8
SF 6
SF 4
rel.=.95
rel.=.90
0
10
30
50
T-score
70
90
10
30
50
T-score
70
90
30
90
PROMIS Profile Subscales: Correlations with Full Banks
2
3
4
5
6
7
8
2
3
4
5
6
7
8
1.00
0.85
0.80
1
2
3
4
5
6
Sleep Disturbance
Social Role
4
5
Length
6
7
8
8
0.95
0.85
0.80
1
2
3
4
5
Length
6
7
8
1
2
3
4
5
Length
1
2
3
4
5
Length
0.90
Correlation
0.95
0.80
0.85
0.90
Correlation
0.95
0.90
0.85
3
7
1.00
Physical Function
1.00
Length
1.00
Length
2
0.90
Correlation
0.95
1.00
0.95
0.85
0.80
1
Length
0.80
1
Pain Impact
0.90
Correlation
0.95
0.80
0.85
0.90
Correlation
0.95
0.90
0.80
0.85
Correlation
1
Correlation
Fatigue
1.00
Depression
1.00
Anxiety
6
7
8
6
7
8
“Ceiling Effect”
What Do We Need to
Launch a Useful Clinical
PRO Lab?
•Outcomes that matter to patients
and providers
• Practical (brief) and inexpensive
• Covers a range, including normal
• Greater precision
• Comparability of scores
• Ease of interpretation
• Reference values / normal ranges32
PROMIS-57 Profile by General Health Rating:
In general, would you say your health is:
70
60
40
33
In general, w ould you say your health is:
SO R
PHF
SLP
PA I
FAT
DEP
ANX
50
40
30
60
70
80
SO R
PHF
SLP
PA I
FAT
DEP
ANX
40
30
50
T-Score
50
70
60
40
70
80
SO R
PHF
SLP
PA I
FAT
DEP
ANX
60
T-Score
50
70
50
40
30
80
Poor
Fair
Good
Very good
Excellent
30
Poor
Fair
Good
Very good
Excellent
80
Poor
Fair
Good
Very good
Excellent
30
SF - 4 Items
60
50
40
30
SF - 6 Items
T-Score
60
70
80
SO R
PHF
SLP
PA I
FAT
DEP
ANX
30
40
50
T-Score
60
70
80
Poor
Fair
Good
Very good
Excellent
SF - 8 Items
80
Full Bank
PROMIScore - PSF
34
0.6
0.5
g
What Do We Need to
Launch a Useful
Clinical PRO Lab?
0.4
0.3
0.2
0.1
0
-2.5
-1.5
-0.5
0.5
1.5
2.5
• Outcomes that matter to patients and
providers
• Practical (brief) and inexpensive
• Covers a range, including normal
• Greater precision
• Comparability of scores
• Ease of interpretation
• Reference values / normal ranges 35
Computerized Adaptive Testing (CAT)
• Estimates location (severity; capability) of a
person on a domain (concept) by selecting
questions based on that person’s prior
answers
• Iteratively estimates a person’s standing on
the domain (e.g., depressive symptoms)
and administers only the most informative
items, achieving precision with a minimum
possible number of questions.
Best Item-I felt depressed
Beginning of CAT
1.0
Item 15
0.6
0.4
0.2
Probability
0.8
1
2
3
4
5
SE = 10
0.0
T-Score = 50
20
30
40
50
60
70
80
70
80
T-Score
Item 15
Max at T-Score=56
Items: 15
5
80
4
70
3
Information
50
2
T-Score
Posterior Distribution
60
1
40
20
20
30
40
50
T-Score
60
70
80
T-Score: 50 SEM: 10
0
1
2
3
4
5
Items Administered
|
0
30
6
7
8
20
30
40
50
T-Score
60
Next Best Item-I felt like a failure
I felt depressed
Never
Rarely
Sometimes
Often
Always
1.0
Item 10
0.4
0.6
0.8
1
2
3
4
5
0.2
Probability
1.
2.
3.
4.
5.
SE = 4
0.0
T-Score = 52
20
30
40
50
60
70
80
70
80
T-Score
Item 10
Items: 15
Max at T-Score=57
5
80
Posterior Distribution
4
70
3
Information
50
2
T-Score
60
1
40
20
20
30
40
50
T-Score
60
70
80
T-Score: 52 SEM: 4
0
1
2
3
4
5
Items Administered
|
0
30
6
7
8
20
30
40
50
T-Score
60
Next Best Item-I felt worthless
I felt like a failure
Never
Rarely
Sometimes
Often
Always
1.0
Item 1
0.4
0.6
0.8
1
2
3
4
5
0.2
Probability
1.
2.
3.
4.
5.
SE = 3
0.0
T-Score = 53
20
30
40
50
60
70
80
70
80
T-Score
Item 1
Items: 15,10
Max at T-Score=59
5
80
Posterior Distribution
4
70
3
Information
50
2
T-Score
60
1
40
20
20
30
40
50
T-Score
60
70
80
T-Score: 53 SEM: 3
0
1
2
3
4
5
Items Administered
|
0
30
6
7
8
20
30
40
50
T-Score
60
Next Best Item-I felt helpless
I felt worthless
Never
Rarely
Sometimes
Often
Always
1.0
Item 3
0.4
0.6
0.8
1
2
3
4
5
0.2
Probability
1.
2.
3.
4.
5.
SE = 2
0.0
T-Score = 55
20
30
40
50
60
70
80
70
80
T-Score
Item 3
Items: 15,10,1
Max at T-Score=58
5
80
Posterior Distribution
4
70
3
Information
50
2
T-Score
60
1
40
20
20
30
40
50
T-Score
60
70
80
T-Score: 55 SEM: 2
0
1
2
3
4
5
Items Administered
|
0
30
6
7
8
20
30
40
50
T-Score
60
I felt that nothing could cheer me up
1.
2.
3.
4.
5.
Never
Rarely
Sometimes
Often
Always
T-Score = 55
SE = 2
Items: 15,10,1,3,21,2,5
80
Posterior Distribution
70
T-Score
60
50
40
30
20
20
30
40
50
T-Score
60
70
80
T-Score: 55 SEM: 2
0
1
2
3
4
5
Items Administered
6
7
8
IRT expands the range of what we
can measure
measurement precision (standard error)
0.6
0.5
0.5
SF-12 items
0.4
0.4
SF-36 items
SE = 0.32
rel = 0.90
0.3
0.3
HAQ items
SE = 0.22
rel = 0.95
0.2
0.2
CAT 10 items
Full Item Bank
0.1
0.1
rheumatoid arthritis
patients
representative
sample
0
0
10
-4
20
-3
30
-2
40
-1
50
0
60
+1
70
+2
normed theta values
Rose et al, J Clin Epidemiol 2007 (accepted)
US-Representative
Sample
80
PROMIS Fatigue Short Form
In the past 7 days …
FATEXP
20
FATEXP
5
FATEXP
18
FATIMP
33
FATIMP
30
FATIMP
21
FATIMP
40
Never Rarely
SomeOften Always
times
How often did you feel tired?





How often did you experience extreme exhaustion?





How often did you run out of energy?










How often were you too tired to think clearly?





How often were you too tired to take a bath or shower?





1
2
3
4
5
How often did your fatigue limit you at work
(include work at home)?
How often did you have enough energy to exercise
strenuously?
1
1
1
1
1
1
2
2
2
2
2
2
3
3
3
3
3
3
Garcia SF et al, J Clin Onc, 2007.
© 2007 Reprinted with permission of the PROMIS Health Organization and the PROMIS Cooperative Group
4
4
4
4
4
4
5
5
5
5
5
5
Comparison of Measurement Precision
Full-length Item Bank vs. Legacy vs. CAT vs. Short-form
0.6
7-item Short-form
7-item CAT
98-item Bank
Standard Error
0.5
0.4
SE=0.32 (r=0.90)
0.3
SE=0.22 (r=0.95)
0.2
0.1
0
-2.5
No Fatigue
-1.5
-0.5
0.5
1.5
2.5
Severe Fatigue
Assess Health Dynamically When
Necessary
Patient
scores
here
CAT
CAT = Computerized Adaptive Testing
45
What Do We Need to
Launch a Useful Clinical
PRO Lab?
• Outcomes that matter to patients and
providers
• Practical (brief) and inexpensive
• Covers a range, including normal
• Greater precision
• Comparability of scores
• Ease of interpretation
• Reference values / normal ranges46
We Need the Health Equivalent of a
Two-Sided Tape Measure
52 centimeters = 20.5 inches
…and easy-to-use conversion tables with
reference data and action thresholds
47
60
60
PROMIS Depression Bank and CES-D
50
40
0
10
20
30
CESD
30
20
10
0
0
100
250
-2
-1
0
1
2
3
4
2
3
4
Depression
0 80
CESD
40
50
r =0.84
-2
-1
0
1
Depression
Fatigue
• Experience
and Impact
• 95-item bank
• Legacy
Instruments
• SF-36 Vitality Scale (4 items)
• FACIT-Fatigue Scale (13 items)
Comparison of Measurement Precision
Full-length Item Bank vs. Legacy vs. CAT vs. Short-form
0.6
4-item SF36/Vitality
4-item CAT
13-item FACIT-Fatigue
13-item CAT
98-item Bank
0.5
Standard Error
0.4
SE=0.32 (r=0.90)
0.3
SE=0.22 (r=0.95)
0.2
0.1
0
-2.5
No Fatigue
-1.5
-0.5
0.5
1.5
2.5
Severe Fatigue
What do the
results
mean?
What Do We Need to
Launch a Useful Clinical
PRO Lab?
• Outcomes that matter to patients
and providers
• Practical (brief) and inexpensive
• Covers a range, including normal
• Greater precision
• Comparability of scores
• Ease of interpretation
52
• Reference values / normal ranges
What Does a Change in Score Mean?
50% reduction in disease burden
33% reduction in hospitalization
Substantial increase in work productivity
Subsequent cost savings
Asthma
Before
Rx
Congestive
Heart Failure
Chronic Lung
Disease
Asthma
After
Rx
Diabetes
Type II
Average
Adult
Average
Well Adult
Treatment
30
40
50
Physical Component Summary (PCS)
53
Interpretation Aids
PRO Bank Person Score
Low
Likely







 
 
 
 
High
Q Q Q Q Q Q QQ Q Q Q Q Q QQ Q Q
Unlikely
Q Q QQ Q Q Q Q QQ Q Q Q
Q Q QQ Q Q Q Q Q Q Q
Q Q Q Q Q Q Q
Q Q Q
Item Location
People and Items Distributed on the
Same Metric: Fatigue
People with
more fatigue
People with
less fatigue
C e ilin g e ffe c t
0.0
Items more likely
to be endorsed
Items less likely
to be endorsed
Interpretation Aids
PRO Bank Person Score
Low
Likely







 
 
 
 
High
Q Q Q Q Q Q QQ Q Q Q Q Q QQ Q Q
Unlikely
Q Q QQ Q Q Q Q QQ Q Q Q
Q Q QQ Q Q Q Q Q Q Q
Q Q Q Q Q Q Q
Q Q Q
Item Location
Interpretation Aids
PRO Bank Person Score
Low







 
 
 
 
30
40
50
60
M = 50, SD = 10
70
High
Interpretation Aids: Cancer example
Fatigue Score=60
Low







 
 
 
 
30
40
50
60
High
70
This patient’s fatigue score is 60, significantly worse than average (50). Cancer
patients who score 60 on fatigue tend to answer questions as follows:
…”I have been too tired to climb one flight of stairs: VERY MUCH
…”I have had enough energy to go out with my family: A LITTLE BIT
Click here if you would like to see this patient’s individual answers
Interpretation Aids: Cancer example
Fatigue Score=40
Low







 
 
 
 
30
40
50
60
High
70
This patient’s fatigue score is 40, significantly better than average (50). People
who score 40 on fatigue tend to answer questions as follows:
…”I have been too tired to climb one flight of stairs: SOMEWHAT
…”I have had enough energy to go out with my family: VERY MUCH
Click here if you would like to see this patient’s individual answers
How Long Per Concept?
It depends
•
Population monitoring
• 1-2 questions
• Group-level outcomes monitoring
• 5-7 questions
• Patient-level measurement/management
• 10-12 questions or CAT
60
Matching Methods to Applications
Population
Monitoring
7
5
Noisy
Individual
3
Classification
Group-Level
Outcomes
Monitoring
Patient-Level
Management
7
7
6
6
5
5
4
3
2
Very Accurate
4
Individual
3
Classification
2
Most Functionally Impaired
1
Single-Item
1
Multi-Item
Scale
1
“Item Pool”
(CAT Dynamic)
61
www.nihpromis.org
PROMIS Family of Delivery Platforms
(2009 )
Telephone
Interview
Personal
Interview
TV
Self
Administered
Multiple
Assessment
Options
Handheld
Device
Internet
Administered
Interactive
Voice
Recognition
Conclusions
• Patient-reported outcomes are:
• Well characterized
• Easily measured
• Increasingly interpretable
• Rarely used in Clinical Practice
• Going forward, clinician engagement is the key to setting
and applying outcome targets and practice standards