Psychosocial mechanisms underpinning PROMs in clinical practice for pain: a realist review and theoretical framework

Abstract

Background: The theoretical basis underpinning the use of Patient Reported Outcome Measures (PROMs) in clinical practice remains underdeveloped; research has tended to focused on the impact PROMs may have in clinical practice rather than the psychosocial mechanisms underpinning any effects. This realist review aimed to identify the psychosocial processes by which PROMs might influence health outcomes when used in routine clinical practice for non-malignant pain. Methods: A realist review was conducted examining reviews, letter, editorials, commentaries and discussion articles to identify theories and less formal ideas concerning how PROMs might work in routine clinical practice. All text from papers was coded inductively with codes then aggregated to create themes; this permitted the development of a preliminary conceptual explanation of the processes by which clinical applications of PROMs might impact patients’ health. Findings: Sixty-one papers were identified as relevant. The review suggests that PROMs may affect patients through multiple processes: increasing clinicians’ knowledge of patients, facilitating patient-doctor interaction, enabling patient-centered care, monitoring, informing strategies to improve care, enhancing therapeutic relationships, improving patient satisfaction, and encouraging positive patient health behaviour. Factors which moderate clinicians’ use of PROMs were also identified. Discussion: The processes identified through the review tended to focus on clinical processes with little attention to psychological processes. To address this limitation, we then reviewed the findings in relation to formal psychological theories. We thus developed a novel theoretical framework depicting the multiple components of PROMs within routine clinical practice and specifying hypothesised outcomes, mechanisms and parameters.