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Sociodemographic Factors Influence Whether Orthopedic Surgery Patients Complete PROMs

Key findings

  • This retrospective analysis of 219,891 orthopedic surgery patients determined the proportion who completed all assigned patient-reported outcome measures (PROMs) before their visit and assessed factors associated with non-completion
  • Only 88,052 patients (40%) completed all questions of all assigned PROMs
  • Age ≥40, Black or "other" race, being a non-native speaker of English, not being covered by commercial insurance, and non-married status were significantly associated with non-completion of PROMs
  • Another significant factor was the lack of online portal activation, and there was significant variation of completion rates between orthopedic subspecialties
  • These results suggest PROM scores do not necessarily represent the entire patient population seeking care, which could negatively affect certain patient subgroups if a policy is enacted based on only the data presently available. Initiatives to better engage all patient populations to improve PROMs completion rates are needed

Measurement of patient-reported outcome measures (PROMs) is increasingly common in clinical care and clinical research, as well as for establishing preliminary benchmarks for healthcare policy. Moreover, given their financial incentives for healthcare systems to collect PROM scores, payers will likely start using PROMs as a key metric for assessing healthcare quality.

To ensure appropriate measurement of PROMs, orthopedic surgeons must understand the proportion of patients who complete assigned questionnaires and the variables associated with successful completion. In JBJS Open Access, Massachusetts General Hospital researchers provide information relevant to these questions, gleaned from a very large retrospective study.

The authors are David N. Bernstein, MD, MBA, MEI, of the Harvard Combined Orthopaedic Residency Program, Mitchel B. Harris, MD, chief of the Department of Orthopaedics, Daniel G. Tobert, MD, an orthopaedic spine surgeon in that department, and colleagues.


The researchers studied 219,891 patients who attended an orthopedic clinic visit at Mass General between June 15, 2016, and December 31, 2020. 

Per protocol at Mass General, patients were asked to use the electronic medical records patient portal to complete PROMs before their clinic visit. The predetermined set of PROMs varied by subspecialty. Still, all included certain PROMs from the Patient-Reported Outcomes Measurement Information System (PROMIS) and questionnaires specific to the pathology or anatomic region of interest.

Patients who did not complete their PROMs on the patient portal were asked to complete them on a tablet computer when they came to the clinic. Some appointments (number not tracked) began before the patient could finish.

Completion of PROMs

88,052 patients (40%) completed their assigned PROM set (i.e., answered all questions of each required PROM).

155,685 patients in the cohort (71%) were registered in the online portal, but 66,141 patients who completed all PROMs (75%) did so in the clinic.

Factors Associated With Non-Completion

Demographic variables that significantly increased the likelihood of not completing assigned PROMs were:

  • Black race (OR, 1.24)
  • Race other than Black, white or Asian (OR, 1.07)
  • Age 40 to 64 (OR, 1.15)
  • Age ≥65 (OR, 1.23)
  • Primary language other than English (OR, 1.90)
  • Marital status other than married (greatest OR, 1.20 for being widowed)
  • Insurance other than commercial (greatest OR, 1.17 for self-pay or uninsured)

Other significant variables associated with non-completion were:

  • Patient not registered in the online portal (OR, 1.62)
  • Type of subspecialist consulted (the OR with foot and ankle surgery as the reference ranged from 0.04 for spine surgery to 0.28 for hand surgery)

Looking Ahead

According to other published literature, efforts to increase PROM completion rates have included helping patients enroll in online portals, providing reminders, and using the PROMIS computerized adaptive tests (CATs). Judging from this study, another obvious improvement would be to make PROMs available in a wide range of languages.

This work is important because a more thorough representation of patients being treated will improve the accuracy of clinical research and healthcare policy-making that rely on using PROM scores for outcomes measurement.

of orthopedic surgery patients did not complete patient-reported outcome measures before their clinic visit

greater odds that orthopedic surgery patients who were Black would not complete patient-reported outcome measures before their clinic visit

greater odds that orthopedic surgery patients who were non-native speakers of English did not complete patient-reported outcome measures before their clinic visit

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