How do aggregated patient reported outcome measures (PROMs) data stimulate health care improvement? A realist synthesis

Objectives:
Internationally, there has been considerable debate about the role of data in supporting quality improvement in health care. Our objective was to understand how, why and in what circumstances the feedback of aggregated patient-reported outcome measure (PROMs) data improved patient care.

Methods:
We conducted a realist synthesis. We identified three main programme theories underlying the use of PROMs as a quality improvement strategy and expressed them as nine ‘if then’ propositions. We identified international evidence to test these propositions through searches of electronic databases and citation tracking, and supplemented our synthesis with evidence from similar forms of performance data. We synthesised this evidence through comparing the mechanisms and impact of PROMs and other performance data on quality improvement in different contexts.

Results:
Three programme theories were identified: supporting patient choice; improving accountability; and enabling providers to compare their performance with others. Relevant contextual factors were: extent of public disclosure; use of financial incentives; perceived credibility of the data; and the practicality of the results.

Available evidence suggests that patients or their agents rarely use any published performance data when selecting a provider. The perceived motivation behind public reporting is an important determinant of how providers respond. When clinicians perceived that performance indicators were not credible but were incentivised to collect them, gaming or manipulation of data occurred. Outcome data do not provide information on the cause of poor care: providers needed to integrate and interpret PROMs and other outcome data in the context of other data. Lack of timeliness of performance data constrains their impact.

Conclusions:
Although there is only limited research evidence to support some widely held theories of how aggregated PROMs data stimulate quality improvement, several lessons emerge from interventions sharing the same programme theories to help guide the increasing use of these measures.