This article, titled “Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review“, is an open-access protocol published in Systematic Reviews. Authored by Guillaume Fontaine and a team of researchers, it outlines the methodology for a comprehensive umbrella review focused on understanding the factors influencing the adoption and sustained use of patient-reported measures in healthcare settings.
The background for this research highlights that Patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) are evidence-based, standardized questionnaires designed to capture patients’ perspectives on their health and healthcare. PROMs specifically focus on a patient’s health, functioning, and quality of life, while PREMs gather information on patients’ experiences while receiving care. Despite significant investments in their implementation globally—such as payer mandates in the USA, benchmarking in the UK, and integration across healthcare sectors in Denmark—their use remains fragmented and limited in many settings. These measures are crucial because they can enhance the charting of patient needs, improve patient-clinician communication, and lead to better symptom management, quality of life, reduced healthcare utilization, and even increased survival rates.
The current challenge in implementing PROMs/PREMs stems from a lack of consistent use of state-of-the-art implementation science frameworks to analyze multi-level barriers and enablers. Factors that hinder or facilitate implementation can exist at various levels, including:
- Patient level (e.g., low health literacy).
- Clinician level (e.g., challenges in obtaining results from external digital platforms).
- Service level (e.g., lack of integration into clinic workflows).
- Organizational/system level (e.g., organizational policies conflicting with PROM implementation goals).
The primary objective of this umbrella review is to consolidate existing evidence from quantitative, qualitative, and mixed-methods systematic and scoping reviews to identify these influential factors. Specifically, the review aims to address several key questions:
- What factors hinder or enable the implementation of PROMs and PREMs, and what is the level of confidence in the evidence supporting these factors?
- How do these barriers and enablers compare across different settings and geographical regions?
- What are the similarities and differences in the perceptions of barriers and enablers among patients, clinicians, managers, and decision-makers?
- What implementation theories, models, and frameworks have been utilized in this field of research?
The methodology for this umbrella review is robust, adhering to the guidelines of the Joanna Briggs Institute (JBI). It involves:
- Systematic searches across eight bibliographical databases: CINAHL, Cochrane Database of Systematic Reviews, Evidence-Based Medicine Reviews, EMBASE, ERIC, PsycINFO, PubMed (including MEDLINE), and Web of Science.
- Inclusion of qualitative, quantitative, and mixed-methods reviews focusing on the implementation of PROMs and/or PREMs across all healthcare settings.
- All review steps, from screening to data extraction, will be conducted independently by two reviewers, with disagreements resolved by discussion or a third reviewer.
A crucial aspect of the methodology involves four steps for appraising and analyzing included reviews:
- Assessing methodological quality: This will be done using the JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses, which evaluates aspects like clear review questions, appropriate inclusion criteria, and search strategies.
- Extracting data: A modified JBI Data Extraction Form for Umbrella Reviews will be used to collect comprehensive information, including review aims, context, population, methodology, and implementation frameworks.
- Theory-based coding of barriers and enablers: The Consolidated Framework for Implementation Research (CFIR) 2.0 will be applied. CFIR 2.0 is a meta-theoretical framework that provides standardized constructs across five domains—Innovation, Outer Setting, Inner Setting, Individuals, and Implementation Process—to guide the exploration of determinants. This ensures a comprehensive, multi-level analysis of factors influencing implementation.
- Identifying barriers and enablers best supported by reviews: The Grading of Recommendations Assessment, Development and Evaluation–Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach will be used to assess the level of confidence in the identified barriers and enablers. GRADE-CERQual evaluates evidence based on methodological limitations, coherence, adequacy of data, and relevance.
The anticipated findings of this umbrella review are expected to be highly informative for policymakers, researchers, managers, and clinicians. By identifying factors that hamper or enable the adoption and sustained use of PROMs and PREMs, and by assessing the confidence in the supporting evidence, the review will provide key insights. This understanding is crucial for orienting the selection and adaptation of tailored implementation strategies. The use of CFIR 2.0 is a significant strength, as it will address a limitation in current research by enabling the identification of multi-level factors (beyond just provider and patient levels), and allow for mapping these to relevant implementation strategy taxonomies, such as the Expert Recommendations for Implementing Change (ERIC) Taxonomy. This systematic approach aims to streamline the design of effective interventions, ultimately saving resources and improving the uptake of PROMs/PREMs in healthcare.
Reference: Fontaine, G., Poitras, M.-E., Sasseville, M., Pomey, M.-P., Ouellet, J., Ould Brahim, L., Wasserman, S., Bergeron, F., & Lambert, S. D. (2024). Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review. Systematic Reviews, 13, 96. https://doi.org/10.1186/s13643-024-02512-5
