9Greenhalgh hypothesizes that effective communication between physician and
patient may lead to initiation of a treatment regime that optimally corresponds with
the patient’s treatment goals and therefore facilitate treatment adherence.
It has been suggested that PROs designed for standard care should first and fore-
most be feasible in view of scarce time in busy clinics. Specifically this means that
PROs designed for use in the clinic should be amenable to being scored and reviewed
easily during standard clinical care and patients should be able to complete them in
a few minutes [ 4 ]. Consequently many PROs that have been developed for use in the
clinic, such as the Modified Health Assessment Questionnaire are short (8 items),
and easy to complete and score [ 39 ]. However, these have been frequently associ-
ated with unfavorable measurement properties such as floor or ceiling effects and
low reliability, which is easily explained by a limited number of items. These par-
ticular shortcomings seriously undermine the utility of such measures for monitor-
ing individual level outcomes over time on the one hand because patients at the
ceiling of a scale cannot improve further (and vice versa) and on the other hand
because measurement error has a larger attenuating effect on individual scores com-
pared with aggregated scores. Consequently measurement instruments for use at the
individual levels actually need higher reliability compared with measurement
instruments for use at the group level.
Quality Assurance
Recently there is also increased interest in the use of PROs in the assessment and
documentation of quality of care. PROs are expected to playa prominent role in
assessing performance, particularly because of this growing emphasis on patient-
centered care and value-based payment approaches. The central tenets of value-
based healthcare are that value can be defined as health outcome per unit of costs
expended and that if all healthcare system participants have to compete on value,
value will improve [ 40 ]. According to Porter and Teisberg, competition for resources
should take place on the level of specific conditions and over the full cycle of care,
rather than the level of specific interventions [ 40 ]. Furthermore, competition should
focus on results—that is, patient outcomes achieved per unit of cost expended. This
requires that results are measured and made widely available. Healthcare providers
are increasingly expected to provide evidence that the care they have delivered pro-
duced value for the patient—as reported by the patient. To this end the performance
of healthcare providers in terms of HRQOL benefits are frequently benchmarked,
potentially allowing payers to link reimbursement to evidence of the effectiveness
of their treatment. The international consortium for health outcomes measurement
is one initiative that aims to “unlock the potential for value-based healthcare by
defining consensus-based global standard sets of outcome measures that really mat-
ter to patients for the most relevant medical conditions and by driving adoption and
reporting of these measures worldwide” to be used across healthcare providers for
1 PROMs and Quality of Care