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Outcome scores and patient-reported outcome measures

What PROMs measure and what they do not. Instruments (DASH, QuickDASH, SPADI, ASES, PRWE), their validity, reliability and responsiveness, minimal clinically important difference, and the distinction between tracking an individual's change over time, comparing populations in research, and — separately — deciding treatment, which a score does not do.

58 citationsUpdated Sep 2026

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Overview

Patient-reported outcome measures (PROMs) are standardised, validated questionnaires completed by patients to measure their perceptions of their own functional status and wellbeing [4]. Although the term PROM is a relatively new designation, these measures have existed since at least the 1960s [52]. PROMs are critical for capturing the patient's perspective on health status, which cannot be observed through clinical tests or imaging [21]. Consequently, physical outcome measures are being changed for the use of patient reported outcomes [11], as range of motion and strength are not as reliable measures as one would think [11]. Health systems and payers are expanding their definition of healthcare quality to include patient-reported health outcomes [33]. PROMIS measures are efficient and precise tools [33], and the use of PROMIS measures is expected to continue to increase across medical and surgical specialties [33].

The current data collection of patient-reported outcome measures (PROMs) is neither uniform nor complete across the world's registries [3]. The lack of uniform and complete data collection for PROMs across registries may impact data validity and the ability to compare outcomes [3]. To address this, the authors propose a standardized reporting of patient-reported outcome measures (PROMs) that incorporates the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS) [1]. A 'clinical relevance ratio' is introduced to report the proportion of patients achieving clinical importance rather than relying solely on mean changes [1]. The FDA evaluates patient-reported outcome (PRO) instruments used as effectiveness endpoints in clinical trials [5], and sponsors can use study results to support claims in approved product labeling [5].

There are a number of challenges in using patient-reported outcomes in clinical practice [6]. The patient reported outcome measures (PROMs) movement has largely been driven by the agenda of researchers or service payers [16], and it has failed to focus effectively on improving the quality of care from the patient's perspective [16]. Limitations of PROM use may explain why PROM use does not always improve patient outcomes [57]. These limitations provide considerations for the design and implementation of future PROM initiatives [57]. Successful implementation of patient-reported outcome measures should be tailored by identifying and addressing potential barriers according to setting [12].

How It Works

Definition and Scope

Patient-reported outcome measures (PROMs) serve as valuable tools for patient-centered health outcome assessment, shared decision-making, and routine postoperative care [31]. They are arguably the best tools available to orthopaedic providers for delivering patient-centered care [43]. This emphasis on PROMs reflects a shift away from physical outcome measures such as range of motion and strength, which are not as reliable as previously thought [11].

Standardization and Selection

Current data collection of PROMs is neither uniform nor complete across global registries, a gap that may impact data validity and the ability to compare outcomes [3]. Consequently, there is a need for recommendations regarding the selection of patient-assessed measures of health outcome [9] and a plea for greater standardization in the use of outcome measurement instruments [15]. In advanced musculoskeletal physiotherapy practice, no key measure was identified to capture functional status, with 15 different tools utilized, further highlighting the need for greater standardization [35]. To address these issues, authors propose a standardized reporting of PROMs that incorporates the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS) [1].

Measurement Properties and Reliability

To assess test-retest reliability for PROMs, the two-way mixed-effect analysis of variance model with interaction for the absolute agreement between single scores is recommended [13]. Consensus has been reached on components of outcome measurement instruments, specifically regarding potential sources of variation [7], and on a set of 71 items for inclusion in a reporting guideline for studies on measurement properties of PROMs [56]. Despite these standards, all PROMs require further validation studies to fill gaps in their measurement properties [38]. A comprehensive evaluation of the psychometric quality and soundness of PRO assessment measures should incorporate the study of ERS as a potential nuisance dimension affecting the accuracy and validity of scores [58].

Interpretation and Clinical Significance

Investigators can choose thresholds to dichotomize responses on HRQL based on absolute scores or change scores to facilitate interpretation [14]. The MCID of a PROM is not perfect in detecting patients experiencing a clinically important improvement, a limitation reflected in its accuracy metrics such as sensitivity and specificity [54]. There is a need for better standardization in the establishment of MCIDs for orthopaedic PROMs and better study design, specifically utilizing the anchor-based within-cohort design based on Food and Drug Administration recommendations [53].

PROMIS System

The NIH PROMIS network derived a consensus-based framework for self-reported health and systematically reviewed available instruments and datasets that address the initial PROMIS domains [51]. PROMIS item banks and their short forms provide evidence that they are reliable and precise measures of generic symptoms and functional reports comparable to legacy instruments [42]. Global health scales derived from PROMIS can be used to efficiently summarize physical and mental health in patient-reported outcome studies [39]. Today, both PROMIS and legacy scores are collected for tracking patient outcomes and research purposes [25]. With further refinement, PROMIS is predicted to replace legacy patient-reported outcome measures [25]. PROMIS measures are efficient and precise tools, and their use is expected to continue to increase across medical and surgical specialties as health systems and payers expand their definition of healthcare quality to include patient-reported health outcomes [33].

Administration and Context

Outcomes assessed on numeric rating scales and reported with text-messages on mobile phones or with questionnaires completed with pen and paper provide comparable scores [24]. The PROMs movement has largely been driven by the agenda of researchers or service payers and has failed to focus effectively on improving the quality of care from the patient's perspective [16].

How It Is Used

Patient-reported outcome measures (PROMs) are standardized, validated questionnaires completed by patients to measure their perceptions of their own functional status and wellbeing [4]. The objectives of routine use in clinical practice are to assess the impact on the process of care, patients' and professionals' experiences of care, and health outcomes [17]. Integrating standardized patient-reported outcomes into routine orthopaedic visits is feasible and improves practice efficiency by providing actionable objective data for shared decision-making [26]. The ability to collect patient-reported outcome (PRO) data in real time and share this information with patients to inform clinical decision making represents the future of value-based healthcare [18]. Routine use of PROMs has the potential to help transform healthcare [29].

Current Adoption and Barriers: Only 57% of primary medical providers are using patient reported outcome measures within their practice, with the information largely used for research rather than clinical decision-making [20]. The current data collection of patient-reported outcome measures (PROMs) is neither uniform nor complete across the world's registries, which may impact data validity and the ability to compare outcomes [3]. Comparative effectiveness research requires accurate assessments of patient numbers, follow-up completeness, clinical outcomes, and care settings [48].

Data Collection Modalities: Patient-reported outcomes should be collected routinely, preferably via registries using computerized adaptive technology, to enable accurate comparisons and shared decision-making [32]. Text messaging methodology has application for clinical research in any setting utilizing patient-reported outcomes at single and multiple time points to prospectively collect data [49]. Limiting follow-up to automated methods may have the potential to transform the way that outcome-based research is designed and conducted to provide substantially better research value in large prospective cohorts [59]. The use of proxy-reported patient-reported outcomes might better characterize functional impairment and pain in a vulnerable patient population and could decrease selection bias in outcomes research [19].

Interpretation and Reporting Standards: Standardized health-related outcome measures require evidence for change and a way to interpret change within individuals or difference between groups [30]. The authors propose a standardized reporting of patient-reported outcome measures (PROMs) that incorporates the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS), introducing a 'clinical relevance ratio' to report the proportion of patients achieving clinical importance rather than relying solely on mean changes [1]. The majority of interventional studies reporting PROMs do not report CIs around between-group differences in outcome and do not define a clinically meaningful difference [34]. These global health scales can be used to efficiently summarize physical and mental health in patient-reported outcome studies [39].

Measurement Properties and Validity: To assess test-retest reliability for patient-reported outcome measures, the two-way mixed-effect analysis of variance model with interaction for the absolute agreement between single scores is recommended [13]. Consensus was reached on components of outcome measurement instruments, i.e. the potential sources of variation [7]. This paper serves as a practical guide to help clinicians and researchers interpret reports of measurement properties for patient-reported outcome measures (PROMs) [2]. This paper reviews the current literature on how to assess the validity and reliability of patient reported outcome measures (PROMs) [8]. The authors plea for more standardization in the use of outcome measurement instruments [15]. Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions [23].

Regulatory and Future Directions: The FDA evaluates patient-reported outcome (PRO) instruments used as effectiveness endpoints in clinical trials and how sponsors can use study results to support claims in approved product labeling [5]. The article summarizes findings from a conference on implementing patient-reported outcome measures (PROMs) in value-based payment reform [22]. Physical outcome measures are being changed for the use of patient reported outcomes, and range of motion and strength are not as reliable measures as one would think [11]. Today, both PROMIS and legacy scores are collected for tracking patient outcomes and research purposes; the authors predict that with further refinement, PROMIS will replace legacy patient-reported outcome measures [25].

Interpreting the Results

General Interpretation and Reporting Standards

Patient-reported outcome measures (PROMs) are critical for capturing the patient's perspective on health status, a dimension that cannot be observed through clinical tests or imaging [21]. Routine use of these measures has the potential to transform healthcare [29]. However, the majority of interventional studies reporting PROMs do not report confidence intervals around between-group differences in outcome and do not define a clinically meaningful difference [34]. To address this, investigators can choose thresholds to dichotomize responses on health-related quality of life based on absolute scores or change scores to facilitate interpretation [14]. A standardized reporting approach incorporates the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS), introducing a 'clinical relevance ratio' to report the proportion of patients achieving clinical importance rather than relying solely on mean changes [1]. PROMs must be responsive, reliable, and validated; measures of clinical significance such as MCID, PASS, and substantial clinical benefit are essential for conveying patient satisfaction, as statistically significant differences may not equate to clinically important differences [47]. The ability to collect patient-reported outcome data in real time and share this information with patients to inform clinical decision making represents the future of value-based healthcare, moving beyond research-focused assessments to guide treatment consistent with patient preferences [18].

Minimal Clinically Important Difference (MCID)

The MCID is an imperfect solution to a complicated problem, and different methods used to calculate it lead to highly heterogeneous values [41]. Clinicians must be cautious in accepting an MCID score at face value given the wide variability of established MCID scores available for a single outcome scale [28]. The MCID is a point estimate that should always be reported with its associated 95% CI, as there is no basis for considering a sample-derived MCID a singular threshold to be crossed [37]. The calculation of the MCID needs to be correlated with changes in scores on the rating scale and external anchors [46]. There is no universally applicable MCID, substantial clinical benefit (SCB), or PASS for any specific outcome score, as values vary by institution and patient population; the authors recommend improving MCID calculation by using anchor questions and ROC curves to better correlate with patient satisfaction and clinical benefit [50]. The MCID is a low bar that patients do not seek when undergoing surgery; instead, they aim for substantial clinical benefit or a patient acceptable symptom state (PASS) [40].

The recommended approach is to estimate the minimal important difference based on several anchor-based methods, with relevant clinical or patient-based indicators, and to examine various distribution-based estimates (i.e., effect size, standardized response mean, standard error of measurement) as supportive information, and then to triangulate on a single value or small range of values for the MID [27]. A systematic approach to triangulate on the MCID uses both distribution-based and anchor-based methods [36].

Measurement Properties and Reliability

No key measure was identified to capture functional status, with 15 different tools utilized, highlighting the need for greater standardization of outcome measurement in musculoskeletal clinical practice, service evaluation and research [35].

Implementation and Clinical Utility

This guidance describes how the FDA evaluates patient-reported outcome (PRO) instruments used as effectiveness endpoints in clinical trials and how sponsors can use study results to support claims in approved product labeling [5].

Limitations and Pitfalls

Measurement Properties and Reliability

All patient-reported outcome measures (PROMs) require further validation studies to fill the gaps in their measurement properties [38]. A 10-item computerized adaptive test (CAT) eliminated floor and decreased ceiling effects, achieving a small standard error (≤ 2.2) across scores from 20 to 50 with reliability ≥ 0.95 for a representative US sample [55].

Minimal Clinically Important Difference (MCID)

MCIDs expressed as effect sizes reduce bias, which mainly results from dependency on the baseline score [61].

Standardization and Reporting

The International Society of Arthroplasty Registries PROMs Working Group recommendations identify issues that may be important to most registries such as the need to make decisions about survey times and collection methods, as well as how to select generic and joint-specific surveys, handle missing data and attrition, report data, and ensure representativeness of the sample [60].

Clinical Implementation and Adoption

The patient reported outcome measures (PROMs) movement has largely been driven by the agenda of researchers or service payers and has failed to focus effectively on improving the quality of care from the patient's perspective [16].

Key Evidence

  • [L5] The authors propose a standardized reporting of patient-reported outcome measures (PROMs) that incorporates the minimum clinically important difference (MCID) and the patient acceptable symptom state (PASS), introducing a 'clinical relevance ratio' to report the proportion of patients achieving clinical importance rather than relying solely on mean changes. [1] (10.2106/jbjs.21.00030)
  • [L5] This paper serves as a practical guide to help clinicians and researchers interpret reports of measurement properties for patient-reported outcome measures (PROMs). [2] (10.1136/bjsports-2012-091704)
  • [L4] The current data collection of patient-reported outcome measures (PROMs) is neither uniform nor complete across the world's registries, which may impact data validity and the ability to compare outcomes. [3] (10.1097/corr.0000000000001918)
  • [Paper] Patient reported outcome measures (PROMs) are standardised, validated questionnaires that are completed by patients to measure their perceptions of their own functional status and wellbeing. [4] (10.1136/bmj.c186)
  • [Paper] This guidance describes how the FDA evaluates patient-reported outcome (PRO) instruments used as effectiveness endpoints in clinical trials and how sponsors can use study results to support claims in approved product labeling. [5] (10.1186/1477-7525-4-79)
  • [L5] However, there are a number of challenges in using patient-reported outcomes in clinical practice. [6] (10.1007/s11136-008-9379-5)
  • [Paper] Consensus was reached on components of outcome measurement instruments, i.e. the potential sources of variation. [7] (10.1186/s12874-020-01179-5)
  • [L5] This paper reviews the current literature on how to assess the validity and reliability of patient reported outcome measures (PROMs). [8] (10.1177/2050640614558345)
  • [L4] Recommendations for the selection of patient assessed measures of health outcome are needed. [9] (10.1136/bmj.324.7351.1417)
  • [Paper] Physical outcome measures are being changed for the use of patient reported outcomes, and range of motion and strength are not as reliable measures as one would think. [11] (10.1016/j.injury.2019.11.017)
  • [L2] Successful implementation of patient-reported outcome measures should be tailored by identifying and addressing potential barriers according to setting. [12] (10.1177/0269216313491619)
  • [L5] To assess test-retest reliability for patient-reported outcome measures, the two-way mixed-effect analysis of variance model with interaction for the absolute agreement between single scores is recommended. [13] (10.1007/s11136-018-2076-0)
  • [L5] Investigators can choose thresholds to dichotomize responses on HRQL based on absolute scores or change scores to facilitate interpretation. [14] (10.1186/1477-7525-4-62)
  • [L5] The authors plea for more standardization in the use of outcome measurement instruments. [15] (10.1590/bjpt-rbf.2014.0143)
  • [L5] The patient reported outcome measures (PROMs) movement has largely been driven by the agenda of researchers or service payers and has failed to focus effectively on improving the quality of care from the patient's perspective. [16] (10.1136/bmj.g7818)
  • [Paper] The objectives are to assess the impact of the routine use of patient-reported outcomes in clinical practice on the process of care, patients' and professionals' experiences of care, and health outcomes. [17] (10.1002/14651858.cd011589)
  • [L5] The ability to collect patient-reported outcome (PRO) data in real time and share this information with patients to inform clinical decision making represents the future of value-based healthcare, moving beyond research-focused assessments to guide treatment consistent with patient preferences. [18] (10.1007/s11999-016-4813-4)
  • [L2] The use of proxy-reported patient-reported outcomes might better characterize functional impairment and pain in a vulnerable patient population and could decrease selection bias in outcomes research. [19] (10.5435/jaaos-d-17-00644)
  • [L4] Only 57% of primary medical providers are using patient reported outcome measures within their practice, with the information largely used for research rather than clinical decision-making. [20] (10.1177/2325967119s00107)
  • [L5] This editorial argues that Patient Reported Outcome Measures (PROMs) are critical for capturing the patient's perspective on health status, which cannot be observed through clinical tests or imaging. [21] (10.1136/bjsports-2014-093707)
  • [Paper] The article summarizes findings from a conference on implementing patient-reported outcome measures (PROMs) in value-based payment reform. [22] (10.1016/j.jval.2017.02.003)
  • [L2] Further studies are needed to provide validated outcome measures to ensure accuracy of the reported results and conclusions. [23] (10.1016/j.injury.2019.07.002)
  • [L4] Outcomes assessed on numeric rating scales and reported with text-messages on mobile phones or with questionnaires completed with pen and paper provide comparable scores. [24] (10.1186/1471-2288-14-52)
  • [L5] Today, both PROMIS and legacy scores are collected for tracking patient outcomes and research purposes; the authors predict that with further refinement, PROMIS will replace legacy patient-reported outcome measures. [25] (10.1016/j.arthro.2022.08.032)
  • [L4] The authors conclude that integrating standardized patient-reported outcomes into routine orthopaedic visits is feasible and improves practice efficiency by providing actionable objective data for shared decision-making. [26] (10.1007/s11999-013-3143-z)
  • [L5] The recommended approach is to estimate the minimal important difference based on several anchor-based methods, with relevant clinical or patient-based indicators, and to examine various distribution-based estimates (i.e., effect size, standardized response mean, standard error of measurement) as supportive information, and then to triangulate on a single value or small range of values for the MID. [27] (10.1186/1477-7525-4-70)
  • [L5] Clinicians must be cautious in accepting an MCID score at face value given the wide variability of established MCID scores available for a single outcome scale. [28] (10.1179/2042618612y.0000000001)
  • [L5] Routine use of patient reported outcome measures (PROMs) has the potential to help transform healthcare. [29] (10.1136/bmj.f167)
  • [L4] Standardized health-related outcome measures require evidence for change and a way to interpret change within individuals or difference between groups. [30] (10.1016/j.rdc.2018.01.011)
  • [L5] Patient-reported outcome measures (PROMs) are valuable tools for patient-centered health outcome assessment, shared decision-making, and routine postoperative care. [31] (10.2106/jbjs.20.00624)
  • [L5] Patient-reported outcomes should be collected routinely, preferably via registries using computerized adaptive technology, to enable accurate comparisons and shared decision-making. [32] (10.1007/s11999-013-3224-z)
  • [L4] PROMIS measures are efficient and precise tools, and their use is expected to continue to increase across medical and surgical specialties as health systems and payers expand their definition of healthcare quality to include patient-reported health outcomes. [33] (10.5435/jaaos-d-24-00432)
  • [L1] The majority of interventional studies reporting PROMs do not report CIs around between-group differences in outcome and do not define a clinically meaningful difference. [34] (10.2106/jbjs.20.00474)
  • [L2] No key measure was identified to capture functional status, with 15 different tools utilized, highlighting the need for greater standardization of outcome measurement in musculoskeletal clinical practice, service evaluation and research. [35] (10.1002/msc.1200)
  • [L5] The authors describe a systematic approach to triangulate on the Minimal Clinically Important Difference (MCID) using both distribution-based and anchor-based methods. [36] (10.1016/j.apmr.2019.12.008)
  • [L5] The Minimal Clinically Important Difference (MCID) is a point estimate that should always be reported with its associated 95% CI, as there is no basis for considering a sample-derived MCID a singular threshold to be crossed. [37] (10.1177/03635465231189223)
  • [L1] However, all PROMs require further validation studies to fill the gaps in their measurement properties. [38] (10.1016/j.ejvs.2014.12.002)
  • [L4] These global health scales can be used to efficiently summarize physical and mental health in patient-reported outcome studies. [39] (10.1007/s11136-009-9496-9)
  • [L5] The minimal clinically important difference (MCID) is a low bar that patients do not seek when undergoing surgery; instead, they aim for substantial clinical benefit or a patient acceptable symptom state (PASS). [40] (10.1016/j.arthro.2023.10.014)
  • [L5] The minimal clinically important difference (MCID) is an imperfect solution to a complicated problem, and different methods used to calculate MCID lead to highly heterogeneous values. [41] (10.1177/03635465231189222)
  • [L5] PROMIS item banks and their short forms provide evidence that they are reliable and precise measures of generic symptoms and functional reports comparable to legacy instruments. [42] (10.1016/j.jclinepi.2010.04.011)
  • [L5] Patient-reported outcome measures (PROMs) are arguably the best tools available to orthopaedic providers for providing patient-centered care. [43] (10.2106/jbjs.22.00587)
  • [L5] The calculation of the minimal clinically important difference (MCID) needs to be correlated with changes in scores on the rating scale and external anchors. [46] (10.1177/03635465231193405)
  • [L5] Patient-reported outcome measures need to be responsive, reliable, and validated, and measures of clinical significance such as MCID, PASS, and SCB are essential for conveying patient satisfaction, as statistically significant differences may not equate to clinically important differences. [47] (10.1016/j.arthro.2022.08.020)
  • [L5] Comparative effectiveness research requires accurate assessments of patient numbers, follow-up completeness, clinical outcomes, and care settings. [48] (10.1007/s11999-013-3194-1)
  • [L4] This methodology has application for clinical research in any setting utilizing patient-reported outcomes at single and multiple time points to prospectively collect data. [49] (10.1016/j.fertnstert.2015.12.103)
  • [L5] There is no universally applicable MCID, SCB, or PASS for any specific outcome score, as values vary by institution and patient population; the authors recommend improving MCID calculation by using anchor questions and ROC curves to better correlate with patient satisfaction and clinical benefit. [50] (10.1016/j.arthro.2023.11.007)
  • [Paper] The NIH PROMIS network derived a consensus-based framework for self-reported health and systematically reviewed available instruments and datasets that address the initial PROMIS domains. [51] (10.1097/01.mlr.0000258615.42478.55)
  • [L4] The term PROM is a relatively new designation for a range of measures that have existed since at least the 1960s. [52] (10.1111/hex.13254)
  • [L4] This current concepts review demonstrates the need for better standardization in the establishment of MCIDs for orthopaedic patient-reported outcome measures and better study design, specifically utilizing the anchor-based within-cohort design based on Food and Drug Administration recommendations until a universally accepted MCID derivation exists. [53] (10.1177/03635465211053869)
  • [L5] The MCID of a PROM is also not perfect in detecting patients experiencing a clinically important improvement, and this is reflected in its accuracy (eg, sensitivity and specificity). [54] (10.1177/0194599819852604)
  • [L5] A 10-item CAT eliminated floor and decreased ceiling effects, achieving a small standard error (≤ 2.2) across scores from 20 to 50 with reliability ≥ 0.95 for a representative US sample. [55] (10.1016/j.jclinepi.2006.06.025)
  • [L5] Consensus was achieved on a set of 71 items for inclusion in a reporting guideline for studies on measurement properties of PROMs. [56] (10.1007/s11136-021-02822-4)
  • [L4] These limitations shed some light on why PROM use may not always improve patient outcomes and provide considerations for the design and implementation of future PROM initiatives. [57] (10.1007/s11136-021-03003-z)
  • [Paper] A comprehensive evaluation of the psychometric quality and soundness of PRO assessment measures should incorporate the study of ERS as a potential nuisance dimension affecting the accuracy and validity of scores and the impact of PRO data in clinical research and decision making. [58] (10.1186/s12874-016-0161-z)
  • [L2] Limiting follow-up to automated methods may have the potential to transform the way that outcome-based research is designed and conducted to provide substantially better research value in large prospective cohorts. [59] (10.2106/jbjs.19.00531)
  • [L4] The International Society of Arthroplasty Registries PROMs Working Group recommendations identify issues that may be important to most registries such as the need to make decisions about survey times and collection methods, as well as how to select generic and joint-specific surveys, handle missing data and attrition, report data, and ensure representativeness of the sample. [60] (10.1097/corr.0000000000001852)
  • [Paper] MCIDs expressed as effect sizes reduce bias, which mainly results from dependency on the baseline score. [61] (10.1016/j.jclinepi.2016.11.016)

References

[1] A Call for a Standardized Approach to Reporting Patient-Reported Outcome Measures. Journal of Bone and Joint Surgery. 2021. DOI: 10.2106/jbjs.21.00030

[2] Patient-reported outcome measures (PROMs): how should I interpret reports of measurement properties? A practical guide for clinicians and researchers who are not biostatisticians. British Journal of Sports Medicine. 2012. DOI: 10.1136/bjsports-2012-091704

[3] CORR Insights®: Collection and Reporting of Patient-reported Outcome Measures in Arthroplasty Registries: Multinational Survey and Recommendations. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000001918

[4] The routine use of patient reported outcome measures in healthcare settings. BMJ. 2010. DOI: 10.1136/bmj.c186

[5] Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims: draft guidance. Health and Quality of Life Outcomes. 2006. DOI: 10.1186/1477-7525-4-79

[6] Prospects and challenges in using patient-reported outcomes in clinical practice. Quality of Life Research. 2008. DOI: 10.1007/s11136-008-9379-5

[7] COSMIN Risk of Bias tool to assess the quality of studies on reliability or measurement error of outcome measurement instruments: a Delphi study. BMC Medical Research Methodology. 2020. DOI: 10.1186/s12874-020-01179-5

[8] Assessing patient reported outcome measures: A practical guide for gastroenterologists. United European Gastroenterology Journal. 2014. DOI: 10.1177/2050640614558345

[9] Quality of life measurement: bibliographic study of patient assessed health outcome measures. BMJ. 2002. DOI: 10.1136/bmj.324.7351.1417

[11] Physical outcome measures: The role of strength and range of motion in orthopaedic research. Injury. 2020. DOI: 10.1016/j.injury.2019.11.017

[12] Implementing patient-reported outcome measures in palliative care clinical practice: A systematic review of facilitators and barriers. Palliative Medicine. 2013. DOI: 10.1177/0269216313491619

[13] Assessing test–retest reliability of patient-reported outcome measures using intraclass correlation coefficients: recommendations for selecting and documenting the analytical formula. Quality of Life Research. 2018. DOI: 10.1007/s11136-018-2076-0

[14] Interpreting the results of patient reported outcome measures in clinical trials: The clinician's perspective. Health and Quality of Life Outcomes. 2006. DOI: 10.1186/1477-7525-4-62

[15] The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) and how to select an outcome measurement instrument. Brazilian Journal of Physical Therapy. 2016. DOI: 10.1590/bjpt-rbf.2014.0143

[16] Patient reported outcome measures in practice. BMJ. 2015. DOI: 10.1136/bmj.g7818

[17] Routine provision of information on patient-reported outcome measures to healthcare providers and patients in clinical practice. Cochrane Database of Systematic Reviews. 2015. DOI: 10.1002/14651858.cd011589

[18] Value-based Healthcare: Patient-reported Outcomes in Clinical Decision Making. Clinical Orthopaedics & Related Research. 2016. DOI: 10.1007/s11999-016-4813-4

[19] Reliability of Proxy-reported Patient-reported Outcomes Measurement Information System Physical Function and Pain Interference Responses for Elderly Patients With Musculoskeletal Injury. Journal of the American Academy of Orthopaedic Surgeons. 2019. DOI: 10.5435/jaaos-d-17-00644

[20] THE USE OF PATIENT REPORTED OUTCOME MEASURES BY PRIMARY MEDICAL PROVIDERS IN THE PEDIATRIC SPORTS POPULATION. Orthopaedic Journal of Sports Medicine. 2019. DOI: 10.1177/2325967119s00107

[21] Patient Reported Outcome Measures (PROMs) have arrived in sports and exercise medicine: Why do they matter?. British Journal of Sports Medicine. 2015. DOI: 10.1136/bjsports-2014-093707

[22] The Role of Patient-Reported Outcome Measures in Value-Based Payment Reform. Value in Health. 2017. DOI: 10.1016/j.jval.2017.02.003

[23] Assessing outcome measures used after rib fracture: A COSMIN systematic review. Injury. 2019. DOI: 10.1016/j.injury.2019.07.002

[24] Collection of patient-reported outcomes; - text messages on mobile phones provide valid scores and high response rates. BMC Medical Research Methodology. 2014. DOI: 10.1186/1471-2288-14-52

[25] Editorial Commentary: Legacy Patient‐Reported Outcome Measures Remain Important Today Despite Responder Burden, but With Further Refinement, Patient‐Reported Outcomes Measurement Information System Could Replace Legacy Instruments in the Future. Arthroscopy. 2023. DOI: 10.1016/j.arthro.2022.08.032

[26] Integrating Patient-reported Outcomes Into Orthopaedic Clinical Practice: Proof of Concept From FORCE-TJR. Clinical Orthopaedics & Related Research. 2013. DOI: 10.1007/s11999-013-3143-z

[27] Responsiveness and minimal important differences for patient reported outcomes. Health and Quality of Life Outcomes. 2006. DOI: 10.1186/1477-7525-4-70

[28] Clinimetrics corner: a closer look at the minimal clinically important difference (MCID). Journal of Manual & Manipulative Therapy. 2012. DOI: 10.1179/2042618612y.0000000001

[29] Patient reported outcome measures could help transform healthcare. BMJ. 2013. DOI: 10.1136/bmj.f167

[30] Minimal Clinically Important Difference. Rheumatic Disease Clinics of North America. 2018. DOI: 10.1016/j.rdc.2018.01.011

[31] Meaningful Clinical Applications of Patient-Reported Outcome Measures in Orthopaedics. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00624

[32] The Importance of Outcome Measurement in Orthopaedics. Clinical Orthopaedics & Related Research. 2013. DOI: 10.1007/s11999-013-3224-z

[33] Use of Patient-Reported Outcomes Measurement Information System Measures in Orthopaedic Specialties: Results of a Scoping Review for 2018 to 2022. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00432

[34] Interpreting Patient-Reported Outcome Measures in Orthopaedic Surgery. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.20.00474

[35] Patient‐reported outcome measures in advanced musculoskeletal physiotherapy practice: a systematic review. Musculoskeletal Care. 2017. DOI: 10.1002/msc.1200

[36] A Standard Method for Determining the Minimal Clinically Important Difference for Rehabilitation Measures. Archives of Physical Medicine and Rehabilitation. 2020. DOI: 10.1016/j.apmr.2019.12.008

[37] The Minimal Clinically Important Difference: Letter to the Editor. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231189223

[38] Assessing the Quality of Available Patient Reported Outcome Measures for Intermittent Claudication: A Systematic Review Using the COSMIN Checklist. European Journal of Vascular and Endovascular Surgery. 2015. DOI: 10.1016/j.ejvs.2014.12.002

[39] Development of physical and mental health summary scores from the patient-reported outcomes measurement information system (PROMIS) global items. Quality of Life Research. 2009. DOI: 10.1007/s11136-009-9496-9

[40] Editorial Commentary : The Minimal Clinically Important Difference Is Less Important Than It Sounds: Patients Seek to Achieve Substantial Clinical Benefits and Not Minimally Perceptible Improvements When They Undergo Arthroscopic Surgery. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.10.014

[41] The Minimal Clinically Important Difference: Response. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231189222

[42] The Patient-Reported Outcomes Measurement Information System (PROMIS) developed and tested its first wave of adult self-reported health outcome item banks: 2005–2008. Journal of Clinical Epidemiology. 2010. DOI: 10.1016/j.jclinepi.2010.04.011

[43] AOA Critical Issues: Patient-Reported Outcome Measures. Journal of Bone and Joint Surgery. 2023. DOI: 10.2106/jbjs.22.00587

[46] The Minimal Clinically Important Difference Changes Greatly Based on the Different Calculation Methods: Letter to the Editor. The American Journal of Sports Medicine. 2023. DOI: 10.1177/03635465231193405

[47] Guidelines for Proper Reporting of Clinical Significance, Including Minimal Clinically Important Difference, Patient Acceptable Symptomatic State, Substantial Clinical Benefit, and Maximal Outcome Improvement. Arthroscopy. 2022. DOI: 10.1016/j.arthro.2022.08.020

[48] Challenges in Outcome Measurement: Clinical Research Perspective. Clinical Orthopaedics & Related Research. 2013. DOI: 10.1007/s11999-013-3194-1

[49] Text messaging yields high research response rate to track menstrual cycles and patient-reported outcomes. Fertility and Sterility. 2016. DOI: 10.1016/j.fertnstert.2015.12.103

[50] Does Calculation of the Minimal Clinically Important Difference Make Sense? Ways to Improve. Arthroscopy. 2024. DOI: 10.1016/j.arthro.2023.11.007

[51] The Patient-Reported Outcomes Measurement Information System (PROMIS). Medical Care. 2007. DOI: 10.1097/01.mlr.0000258615.42478.55

[52] Patient‐reported outcome measures (PROMs): A review of generic and condition‐specific measures and a discussion of trends and issues. Health Expectations. 2021. DOI: 10.1111/hex.13254

[53] The Minimal Clinically Important Difference: A Review of Clinical Significance. The American Journal of Sports Medicine. 2021. DOI: 10.1177/03635465211053869

[54] Understanding the Minimal Clinically Important Difference (MCID) of Patient‐Reported Outcome Measures. Otolaryngology–Head and Neck Surgery. 2019. DOI: 10.1177/0194599819852604

[55] Evaluation of a preliminary physical function item bank supported the expected advantages of the Patient-Reported Outcomes Measurement Information System (PROMIS). Journal of Clinical Epidemiology. 2008. DOI: 10.1016/j.jclinepi.2006.06.025

[56] COSMIN reporting guideline for studies on measurement properties of patient-reported outcome measures. Quality of Life Research. 2021. DOI: 10.1007/s11136-021-02822-4

[57] Perceived benefits and limitations of using patient-reported outcome measures in clinical practice with individual patients: a systematic review of qualitative studies. Quality of Life Research. 2021. DOI: 10.1007/s11136-021-03003-z

[58] Measurement and control of bias in patient reported outcomes using multidimensional item response theory. BMC Medical Research Methodology. 2016. DOI: 10.1186/s12874-016-0161-z

[59] Value in Research: Achieving Validated Outcome Measurements While Mitigating Follow-up Cost. Journal of Bone and Joint Surgery. 2019. DOI: 10.2106/jbjs.19.00531

[60] Collection and Reporting of Patient-reported Outcome Measures in Arthroplasty Registries: Multinational Survey and Recommendations. Clinical Orthopaedics & Related Research. 2021. DOI: 10.1097/corr.0000000000001852

[61] The minimal clinically important difference raised the significance of outcome effects above the statistical level, with methodological implications for future studies. Journal of Clinical Epidemiology. 2017. DOI: 10.1016/j.jclinepi.2016.11.016

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