SYM16: The Value and Future of PROMs in Hand Surgery

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SYM16: The Value and Future of PROMs

in Hand Surgery

Moderator(s): Michael B. Gottschalk, MD and Eric R. Wagner, MD

Faculty: Warren C. Hammert, MD, Robin Neil Kamal, MD, Nikolas H. Kazmers, MD,

MSE, and Amy L. Ladd, MD

Session Handouts

Saturday, October 03, 2020

75TH VIRTUAL ANNUAL MEETING OF THE ASSH

OCTOBER 1-3, 2020

822 West Washington Blvd

Chicago, IL 60607

Phone: (312) 880-1900

Web: www.assh.org

Email: [email protected]

http://www.assh.org/

mailto:[email protected]

9/2/2020

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SYM16: The Value and Future of PROMs in Hand Surgery

Moderators:Michael B. Gottschalk, MD

Eric R. Wagner, MD

Faculty: Nikolas H. Kazmers, MD, MSE

Robin Neil Kamal, MDWarren C. Hammert, MD

Amy L. Ladd, MD

DISCLOSURES

Nikolas H. Kazmers, MD, MSE

Speaker has no relevant financial relationships with commercial interest to disclose.

© U N I V E R S I T Y O F U T A H H E A L T H , 2 0 1 8

PROMs: Which Questionnaires Should we

be Asking?Nikolas H. Kazmers, MD MSE

Department of Orthopaedics

October 3, 2020

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DISCLOSURES

• No financial disclosures

• JHS Associate Editor


OVERVIEW OF PROMS

• PROMs incorporate the patient’s perspective on how a condition, or its treatment, impact their wellbeing

• Adjunct to traditional study outcomes:– ROM & Strength– Complication rates– Radiographic parameters

• Union• Presence of arthritis


OVERVIEW OF PROMS

• PROMs may be used to:– Measure the efficacy of, and response to,

medical care– Tailor treatments to improve outcomes– Determine the value of care

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OVERVIEW OF PROMS

• Instruments exist to measure:– Symptoms

• Carpal tunnel symptoms (BCTQ Symptom Severity Scale)

• Pain (VAS Pain)

– Patient Function• Physical• Emotional• Social


PROMS IN HAND SURGERY

• “No single-consensus best measure”1

– Secondary to:• Broad spectrum pathology (bony, nerve, vascular,

etc)• Wide age range (pediatric through geriatric)

• However, a breadth of PROMs have been validated for hand and upper extremity applications

1. Hammert and Calfee; JHS 2020

NK1


PROMS IN HAND SURGERY

• Two Categories of PROMs:1. Fixed-length scale metrics:

• Standardized, pre-determined list of questions that are the same for each patient

• May be specific to: – A domain (DASH, qDASH)– A disease (BCTQ)– A specific body part (PRWE)

2. Patient-Reported Outcomes Measurement Information System (PROMIS) Metrics• Short Forms• Computer Adaptive Testing (CAT)• Examples: Upper Extremity (UE), Physical Function (PF),

Pain Interference (PI), Depression, or Anxiety CATs

NK1

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NK1 Nikolas Kazmers, 8/31/2020

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PROMS: IMPORTANT CONCEPTS

Minimal Clinically Important Difference (MCID):• Represents a clinically-relevant change or difference in an outcome

score

• Useful for power calculations, or when interpreting outcomes studies for clinical relevance

NK1


PROMS: IMPORTANT CONCEPTS

The Biopsychosocial Model:• Interplay between function and aspects of mental health

– Resilience, depression, anxiety, pain interference, coping

• These factors contribute to ~50% of the variability in patient-reported disability among hand surgery patients.1-2

– Critical to consider these factors when interpreting a patient’s function or improvement in function using PROMs data

1. Das De S; JBJS 20132. Menendez ME; JBJS 2013

NK1


PROMS IN HAND SURGERY: FUNCTION

DASH: • Measures: Composite bilateral upper extremity disability• Responder burden: 38 questions, approximately 4.5

minutes• Scoring: Range 0-100 (a higher score represents greater

disability) • Additional details:

– MCID: Range of 10-11– Floor effect of 1%– Ceiling effect of 5%

• May demonstrate greater ceiling effects in an athletic population

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QuickDASH: • Measures: Composite bilateral upper extremity disability• Responder burden: 11 questions, or approximately 2 minutes• Scoring: Range 0-100 (a higher score represents greater disability) • Additional details:

– MCID: Range of 7-19– Highly correlated with the DASH– Responsive to patient-reported functional change– Sensitive to missing data (requires response to ≥ 10 questions)



Patient-Rated Wrist Evaluation (PRWE): • Measures: Wrist function and pain• Responder burden: 15 questions• Scoring: Question scores range from 0-10 (10 is the worst pain, or worst

disability). Pain and function scores are weighted equally and converted to a score ranging from 0-100.

• Additional details:– MCID: 11.5 – 14 points– Reliable, responsive, and valid in the setting of wrist trauma



Michigan Hand Questionnaire (MHQ):• Measures:

– Six domains include hand function, daily activities, work activities, pain, appearance, and satisfaction.

– Measured separately for both hands.• Responder burden: 71 questions, approximately 15 minutes. • Scoring: Range 0-100 for the total combined score, and sub-domains. A

greater score represents greater function, with the exception of a higher pain score representing more pain.

• Additional details:– Useful if hand-specific outcomes, or a comparison between hands, are needed– MCID: Range of 8-13 for the total score. Highly variable depending on the domain,

disease process, and method of calculation. – A brief 12-question version exists

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Boston Carpal Tunnel Questionnaire (BCTQ): • Measures:

– The severity of symptoms (SSS), and functional status (FSS), of carpal tunnel syndrome patients

• Responder burden: 19 questions• Scoring: Scores for both dimensions range from 1-5 (greater score

represents greater symptom severity and disability). • Additional details:

– Recommended as a primary outcome measure for carpal tunnel syndrome trials.– MCID: 1.55 and 2.05 points for symptom and functional scales in diabetic patients, and 1.45

and 1.60 points for non-diabetics, respectively.



PROMIS Physical Function (PF) CAT:• Measures: The ability to perform activities of daily living and instrumental

activities of daily living• Responder burden: Mean of 9 questions, or approximately 1 minute• Scoring: Scoring range is 0-100, with a population mean of 50 and

standard deviation of 10 (theoretically)



PROMIS Physical Function (PF) CAT:• Additional details specific to hand and upper extremity

populations:– May be administered by phone, on paper, personal digital assistant with similar scores,

reliability, and validity (in medical patients)– Permissible to combine scores from v1.2 and v2.0– Ceiling effect 1.3%, and floor effect 0.5%. Other studies have not revealed a ceiling or

floor effect.– Upper extremity questions within the CAT question bank demonstrate a high ceiling

effect among orthopaedic surgery patients– Responsive to patient-reported functional change & highly correlated with the

QuickDASH

– MCID: • Thumb CMC OA: 3.5 – 3.9• Nonoperative DRF patients: 3.6 – 4.6• CTR: 4.6, or 1.8 to 2.8

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PROMIS Upper Extremity (UE) CAT:• Measures: The ability to perform activities of daily living and instrumental

activities of daily living specific to the upper extremity• Responder burden:

– Mean of 6 questions– Takes less time to complete than the QuickDASH (70 seconds)

• Scoring: Scoring range is 0-100, with a population mean of 50 and standard deviation of 10 (theoretically)

– Max score of 61 noted for v2.0



PROMIS Upper Extremity (UE) CAT:• Additional details:

– Scores from v1.2 and v2.0 are NOT interchangeable– Ceiling effect: v1.2 10.8%, v2.0 6.9%– Floor effect: v1.2 1.6%, v2.0 1.0%– Responsive to patient-reported functional change & highly correlated with

the QuickDASH

– MCID v1.2:• General non-shoulder hand population: 2.1• CTR population: 3.4 (distribution-based) or 6.3 – 8.0 (anchor-based)

– MCID V2.0:• None published• 3.0 to 4.1 (ASSH 2020 abstract)


PROMS IN HAND SURGERY: BIOPSYCHOSOCIAL FACTORS

PROMIS Pain Interference (PI) CAT:• Measures: The extent to which pain interferes with accomplishing goals

or engaging in activities, or the consequences of pain on relevant aspects of one’s life

• Responder burden: Variable question number, 30 seconds• Scoring: Scoring range is 0-100, with a population mean of 50 and

standard deviation of 10 (theoretically)• Additional Details:

– Advocated as the metric of choice to evaluate biopsychosocial factors for hand and upper extremity patients1

– May be dynamic (change over treatment course)

1. Kortlever; CORR 2015

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PROMIS Depression CAT:• Measures: Self-reported mood, views of self, social cognition, and

decreased positive affect and engagement. Somatic symptoms are not included.

• Responder burden: Variable question number• Scoring: Same



PROMIS Anxiety CAT:• Measures: : Self-reported fear, anxious misery, hyperarousal, and somatic

symptoms related to arousal• Responder burden: Variable question number• Scoring: Same



Legacy Instruments:• Brief Resilience Scale (BRS)• Pain Catastrophizing Scale (PCS)• Pain Inflexibility in Pain Scale (PIPS)• Pain Self-Efficacy Questionnaire (PSEQ)

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RECOMMENDATIONS FOR GENERAL CLINICAL USE

Function:• QuickDASH• PROMIS UE CAT v2.0

Biopsychosocial Factors:• PROMIS PI CAT• Legacy Scale (BRS, PCS, other)

Other questions to assist in the interpretation of changes in PRO scores over time:• Anchor question(s): “How much functional / pain improvement did you

experience since your last visit?”• Comorbidity question: “Do you have another body part, in addition to

what you are being seen for today, that is limiting the function of your upper extremities?”

• A question about new injuries, surgeries, or upper extremity diagnoses


THANK YOU

DISCLOSURES

Robin N. Kamal, MD

Consulting Fees: Acumed

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The Value and Future of PROMS In Hand Surgery

Collection: How Should We be Collecting PROMs Efficiently?

Robin Kamal MD MBA

Assistant Professor I Medical Director

Department of Orthopaedic Surgery

Stanford University

The Value and Future of PROMS In Hand Surgery• Collection: How Should We be Collecting PROMs

Efficiently?

Delivering High Quality Care

• Structure

• Process

• Outcome

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Delivering High Quality Care

• Structure

• Process

• Outcome

Efficiency

• “the ratio of the useful work performed by a machine or in a process to the total energy expended”

• How do I get the most bang for my buck when collecting PROMS?

• First, how am I going to USE PROMS?

• What best supports that use?

How to Collect PROMs Efficiently (?)

1. Use PROMs that are meaningful to your patient

2. Use PROMs as communication aids

3. No consensus on which PROM to collect – balance reporting with patient care

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Making PROMs Patient Centered?

Assumptions:

1. When I collect PROMs, the questions mean something to patients

2. I can collect and show a patient a graph

3. Improving on a PROM is reassuring to the patient

4. The PROM reflects the patient’s goals/values

5. Patient and Surgeon agree the PROM is the correct measurement stick

“PROMs may differ little from traditional instruments unless they truly incorporate the patient’s perspective and not just the perspectives of clinicians and researchers. Efforts to develop new PROMs that provide a more patient‐centered outcome assessment should use qualitative and participatory methods to capture and incorporate patient perspectives and values”

“we should not infer that ‘patient reported’ means that the information so obtained actually reflects patient concerns”

• Survey adult cancer patients, oncologists, PROM researchers

• Randomized to receive• Different Line graphs (”better/worse,” “more/less,” and ”normed”)

• 629 patients (75% college/post), 139 clinicians, 249 researchers

• Patients: 56%, 41%, 39%

• Clinicians: 70%, 65%, 65%

Do Patients Understand PROMs?

Tolbert, MDM 2018

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Do PROMs Reflect the Patient’s Goals/Values?(QuickDASH versus the Patients Specific Functional Scale)

“Well, so many of those questions didn’t apply to my situation”

“The questionnaire is not specific, but it’s in the ballpark. There are so many things I can’t do, like my recreational activities, cooking, hair washing, dressing. It doesn’t really measure my progress”

“Yeah, you know they’re kind of vague”

“Those kinds of questions are always, you know, can be nebulous. They’re relative to the person, you know. One person’s pain you know is a great, great pain is someone else’s discomfort depending on how well they deal with pain”

Shapiro et al

How Do PROMs Compare?

• Standardized instrument versus Patient Specific Instrument

Shapiro et al

Can PROMs be Used to Facilitate Communication?

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• “This study has identified goals important to patients with low back pain, these were varied, and most did not correspond with current clinical measures”

1) Maybe PROMs = Goals?

• Can we efficiently collect what’s important to patients ‐ goals?

• Can those goals be used to assess outcomes?

• Can those goals be used as a PROM?

• Randomized controlled trial

• 96 patients

• Goal elicitation sheet (tell us 2 goals of care today)

• Led to improved perceived involvement in care

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PSFS

• Track goals longterm

• +Communication

• Most musculoskeletal conditions

2) PROM Scores Stable

• 112 Patients

• What happens when you do the tasks on the instrument?

• (PROM Scores Improve)

Shapiro et al, CORR, 2019

PROM Scores are NOT Stable – Mindset Matters

• PROM scores may not reflect activity levels or objective function

• Instead, they may reflect the mindset of a patient

• Process to use PROM scores to trigger a conversation

• Address psychosocial factors?

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3) No consensus on which PROM to Collect and How

• Top 10: Primary TKA, Primary THA, Revision TKA, Revision THA, Fix FN Fx, Arthroplasty FN Fx, Total Shoulder, Carpal Tunnel, Rotator Cuff, Knee Arthroscopy

• No “cross cutting” PROM common conditions

• Generic vs Disease Specific

• Mental Health?

• Systematic review of upper extremity PROMS

• Assessed Reliability, Validity, and Responsiveness of instruments for Hand/Wrist Trauma

• Only 2 instruments underwent this testing for this population(DASH, PRWE)

• Which PROM do I use?

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Efficiency in PROM collection comes from how we use the Data

“it is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.”

‐ William Osler

Conclusions

• Pick PROMs that are meaningful to your patients

• Use PROMs as communication tools

• Incorporate PROMs that are meaningful into longitudinal tracking when picking what to collect

Thank [email protected]

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Symposium 16 – The Value of PROM’s in Hand Surgery

2020 ASSH Annual Meeting

October 3, 2020

PROMIS: How to use it clinically

Warren C. Hammert, MD

University of Rochester

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DisclosureI have no financial relationships relevant to this presentation to disclose

Challenges

You can not manage what you can not measure

If you want to know how your patients are doing…..

Just ask them

Specific InstrumentsHand surgery uses multiple instruments•Symptom/Condition specific – OA index, CTQ•Region specific – MHQ, DASH,PRWHE

Confusing for research as there is not one agreed upon instrument

Papers on the same topic may use different instruments

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PROMIS: A New Breed of PRO

Patient Reported Outcome Measurement Information System

•15-year, $150 million effort by NIH

•New psychometric methods to improve the PRO

•Large bank of questions - computer adaptive

•Each instrument asks on average 4-5 questions

•Biopsychosocial approach

PROMIS

•Domain specific not disease specific•Standardized across domains

•1-100 with 50=mean score for US population•t-score (10pts = 1 standard deviation)

• Follow patients throughout Health Care System• Produces validated data quickly “Smart Testing”

•Computer Adapted Technology•Item Response Theory

Bio- Psycho- Social

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IRT/ CATUses a statistical model based on item response theory (IRT) to determine scores

IRT gives computer software the information it needs to select the best follow up question given the response to an initial question

Using CAT, the patient only needs to answer 4-8 questions per instrument

Average PROMIS instrument can be given in under a minute

What Domains to Collect? Physical Function

Upper Extremity

Pain Interference

Depression

Anxiety

PASS question

Anchor Question – How are you now compared to:• First visit• Most recent visit

Total, Sept 20192.4 million scores

252K unique patients12 million questions

Start, Feb 2015

Patient Reported Outcome Collections

2.4 minutes

Median time to complete assessment

12 questions

98.2%completed

PROMISAdult

Domains2.0 million scores (84%)

Physical Function

Pain Interference

Depression

PROMISPediatric /

Parent Proxy Domains174,469 scores (7%)

Non‐PROMIS210,584 scores (9%)

PROMIS CATs

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Outcomes areNot just for research anymore

Set Up/ Delivery

Administered via tablet (or paper forms)

Sync and stored in EMR (RED Cap for Research)

Stored and delivered to patients via applications like My Chart

Set Up

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PROMISHow do we use the data clinically?

Thumb Arthritis - UE

Thumb Arthritis- PI

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DRF - UE

Mental Health

HSQ

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Patients with higher levels of depression or PI recovered slower and not to the same extent following elective hand surgery

Compared PROMIS to MHQ and Boston CTQ questionnaires

UE and PI correlated well with MHQ total and BCTQ symptom severity

PF poor correlation

Minimum Clinically Important Difference

Varies depending on method of calculation

Distribution method

Anchor method

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PROMIS Data

Changes in PROMIS scores and MCID are helpful in designing research studies and following groups

For individuals, following trends and directions of scores rather then using MCID to determine success of a procedure

PROMIS LimitationsOther conditions can affect scores/ outcomes

May not be sensitive or specific enough for common hand conditions

UE has ceiling and floor effect

ConclusionWe currently do not have one ideal outcome measure

PROMIS comparable to other UE instruments

Continued research to determine MCID,…

Values, such as MCID, likely better for groups than to evaluate an individual

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Thank You

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Amy L. Ladd, MD

Intellectual Property: Loci OrthopaedicsContracted Research: NIHOwnership Interests: Loci, Intuitive Surgical, Stryker

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Single Assessment Numeric Evaluation (SANE)

Is the future of PROMs in the HandSimilar to its Evolution in the Shoulder?

Amy L Ladd MDCo-authors: Jacob D Gire MD, Jayme C B Koltsov PhD, Nicole A Segovia

PhD, Deborah E Kenney MS, OTR, Jeffrey Yao MD

Disclosures

Intellectual Property: Loci Orthopaedics

Contracted Research: NIH

Ownership Interests: Loci, Intuitive Surgical, Stryker

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Questions

• What is the1-question SANE?

• How does it compare to other instruments?

• Is it good enough?

SANE

O N E Q U E S T I O N I N S T R U M E N T

Single Assessment Numeric Evaluation

-1-What is the SANE?

• Shoulder literature• Williams, Arciero Am J Sp Med 1999

• 294 PubMed references 8.30.20• 49 publications 2020 so far

• No robust validation studies until 2020• Lack of comparison to instruments, ceiling, clinical utility

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-2-Hand surgery – how does it compare?

SANE - Single assessment numeric evaluation

Methods

Retrospective review of all patients with outcome measures

Included those that underwent one of the seven most common hand surgery procedures

Isolated, unilateral with preop and/or postop outcome data

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Included hand procedures

1. Carpal tunnel release

2. Trigger finger release

3. Carpometacarpal arthroplasty

4. Wrist arthroscopy

5. Distal radius fixation

6. First dorsal compartment release

7. Cubital tunnel release

Abbreviated questionnaires & computer adaptive testing (CAT)

PROMIS-UE

QuickDASH

Compared to validated instruments

Results

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Convergent validity

Moderate to strong correlation between SANE score, QuickDASH, and PROMIS upper extremity at all time points (R 0.63 - 0.82, p<.001)

Coverage

ResponsivenessN Median IQR Range ES SRM p‐value

SANE

Baseline 165 50 30 ‐ 70 0 ‐ 95

Follow

Up151 75 60 ‐ 90 0 ‐ 100 1.0 0.9 < 0.001

Change 103 20 7 ‐ 40 ‐40 ‐ 90

QuickDASH

Baseline 132 45 32 ‐ 57 11 ‐ 91

Follow

Up122 23 11 ‐ 39 0 ‐ 70 1.1 1.1 < 0.001

Change 86 ‐18 ‐29 ‐ ‐8 ‐66 ‐ 23

PROMIS‐UE

Baseline 165 34 29‐38 15 ‐ 56

Follow

Up153 37 34‐42 24 ‐ 56 0.8 0.7 < 0.001

Change 104 5 0‐11 ‐8 ‐ 33

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-3-Is it good enough?

• For clinical assessment

• To show patients

• For cost and efficiency

-3-Is it good enough?

• For clinical and research trials

• For multiple conditions affecting same limb

• For specific task assessment

Safe conclusions - SANE

Reasonable measure to evaluate outcomes common hand procedures

Demonstrates comparable psychometric properties to the PROMIS-UE and QuickDASH outcome scores.

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Relevance to clinical practice

SANE score allows patients to self rate their outcome and response to treatment over time

SANE score incorporates other factors that lead to a patient feeling “normal”

Single item lacks granularity of a function specific measure such as QuickDASH or PROMIS upper extremity

Thank you

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Michael B. Gottschalk

Associate Professor

Emory Department of Orthopedics

Director of Clinical Research

Hand Division Chief

Upper Extremity Hand Fellowship Director

Patient Reported Outcomes (PROs)

• Definition:

•“Any response directly from the patient about a patient’s health condition without interpretation from a physician” – National Health Council

• What are they not?

•Objective measurements (e.g. 30 day readmission, %90 day mortality, antibiotic stewardship, OR utilization, RVU benchmarks

Why Collect PROs?

• Quality / Value

• Research

• Registries

• Billing

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Why do physicians not collect them?

• Difficult to collect (need a WORKING system to store, analyze, and report them; may cost time/money to practice and inconvenience to patient)

• Can’t determine which outcome measure to use

• Like “Press Ganey”, need patient buy in/responses

• Concern that PRO’s may be used for reimbursement/payment

Patient Centered Practice

• Can review patient progress

PROMs are Powerful

• Predictive analytics for patients yet to undergo surgery (e.g. SCB, PASS, MCID)

• Contrasting two surgeries to each other (value comparison outcome/cost of procedure)

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Revenue Generator

• Remote patient monitoring (99091)

• What do you need to bill for PROs

Patient Consent

Active feedback loop in real time

Reconsent within every year

Used no more than once every 30 days and not within global period; must document time spent and consent

Thank you for your time!

Introducing the Emory Upper Extremity Fellowship Inaugural Year 2021

[email protected]

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PROMS: What is the Value to the Patient???

PROMS: What is the Value to the Patient???

Eric R. Wagner, MD MSDivision of Upper Extremity Surgery

Department of Orthopaedic SurgeryDirector of Upper Extremity Research

Emory University, Atlanta GA

[email protected]

Eric R. Wagner, MD MSDivision of Upper Extremity Surgery

Department of Orthopaedic SurgeryDirector of Upper Extremity Research

Emory University, Atlanta GA

[email protected]

Value and PROM Collection MentorValue and PROM Collection Mentor

Value: Michael PorterValue: Michael Porter

Surgeon

Patient

Hospital

Value =Outcome(patient satisfaction,

complications)

Costs

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Value: HospitalValue: Hospital

Value (Hospital)

=IncomeOutcomes

Costs

Surgeon

Patient

Hospital

VolumeComplicationsReoperationsUtilization, Costs

0.0%

0.5%

1.0%

1.5%

2.0%

2.5%

1‐14 15‐31 32‐57 58+ 1‐16 17‐53 54+

Quartile SSLR

90‐Day Revision Rate

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

1‐14 15‐31 32‐57 58+ 1‐5 6‐25 26‐47 48‐71 72‐105 106+

Quartile SSLR

Increased Cost (> Median)

Value: SurgeonValue: Surgeon

Value (Surgeon)

=Income

Outcomes

Time

Surgeon

Patient

Hospital

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Why Measure??Why Measure??

1. To Improve Outcomes

2. To Improve Personal Skills

3. To Innovate

4. To Reduce Costs

5. To Gain Advantage over Competition

1. To Improve Outcomes

2. To Improve Personal Skills

3. To Innovate

4. To Reduce Costs

5. To Gain Advantage over Competition

Experts: Why Measure??Experts: Why Measure??

Experts: Why Measure??Experts: Why Measure??

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Expert??Expert??

Learning CurveLearning Curve

1979

Learning CurveLearning Curve

*40*>20

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Value: PatientValue: Patient

Incidence

Patient

Value

Value (Patient) =

Cost

Outcomes

Return to Work/Play

Value to the PatientValue to the Patient


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Value Driven Outcomes Tool

Value Driven Outcomes Tool

Improved Quality and Costs

Improved Quality and Costs


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Primary TSA

Primary RSA

Revision RSAASES

SSV

VAS

How Fast Will I Recover???How Fast Will I Recover???

What is My Risk of Complications??What is My Risk of Complications??

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Why NOT Measure??Why NOT Measure??

1. Lack of Time

2. Blissful Ignorance

3. Lack of Resources

4. Don’t know what or how to measure

1. Lack of Time

2. Blissful Ignorance

3. Lack of Resources

4. Don’t know what or how to measure

Why NOT Measure??Why NOT Measure??

Value to the PatientsValue to the Patients

Value =Outcome(patient satisfaction,

complications)

Costs

PROMs

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Value to the PatientsValue to the Patients

Thank you for your time!

[email protected]

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Documents

SYM16: The Value and Future of PROMs in Hand Surgery