Patient-Reported Outcomes in Colorectal Surgery

Abstract

Given the increased life expectancy and improvements in the treatment of colorectal patients, the success of a treatment course can no longer be determined only by objective outcomes. Health care providers ought to take into consideration the impact an intervention will have on the quality of life of patients. Endpoints that take into account the patient's perspective are defined as patient-reported outcomes (PROs). PROs are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires.

PROs are especially important in colorectal surgery, whose procedures can often be associated with some degree of postoperative functional impairment.

Several PROMs are available for colorectal surgery patients. However, while some scientific societies have offered recommendations, there is no standardization in the field and PROMs are seldom implemented in clinical practice. The routine use of validated PROMs can guarantee that functional outcomes are followed over time; this way, they can be addressed in case of worsening.

This review will provide an overview of the most commonly used PROMs in colorectal surgery, both generic and disease specific, as well as a summary of the available evidence in support of their routine utilization.

The advancements made in the field of medicine have changed the landscape in which health care providers operate. The colorectal patient population has a longer life expectancy, with higher chances of survival and management of conditions that were considered terminal or severely impairing just a few decades ago. ^{1 2} As patients live longer with their diseases, treatment outcomes should be measured not only in terms of objective response to intervention but also in terms of the impact the intervention has on their quality of life (QoL). ³

With global health moving toward a value-based framework, it is of paramount importance to reach a common definition of value in health care. ⁴ The success of a treatment course can no longer be determined by a single outcome measure, for example, survival. While survival remains the ultimate hard endpoint, the value of health care interventions ought to consider a patient's ability to proceed through life in a functional and satisfactory manner, free of symptoms, and without significant impairment in the areas that patients consider relevant. These endpoints are defined as patient-reported outcomes (PROs).

PROs include “any report of the status of a patient's health condition that comes directly from the patient, without interpretation of the patient's response by a clinician or anyone else” as per the Food and Drug Administration (FDA) definition. ⁵ They are assessed through patient-reported outcome measures (PROMs), usually in the form of questionnaires. PROs include domains such as symptoms, side effects, functional outcomes, and QoL.

Colorectal surgery is a varied specialty that encompasses several benign and malignant diseases. Acute postoperative complications after colorectal surgery are reported as occurring in up to 30% of cases; ⁶ however, this rate underestimates the burden of long-term functional impairment that often accompanies colorectal procedures, especially those involving the pelvis. ⁷ Functional complications may include incontinence, constipation, pain, urinary impairment, erectile dysfunction, dyspareunia, body image issues, infertility, need for dietary modifications, and impairment in activities of daily living and social functioning.

Some degree of postsurgical functional impairmentmay not be preventable but, if properly investigated and treated, it can become manageable. The routine use of validated PROMs can guarantee that all relevant questions are asked at each time point. This way, each patient's functional outcomes can be followed over time and acted upon in case of worsening.

In this review, we will provide an overview of the most commonly used PROMs in colorectal surgery, as well as a summary of the available evidence in support of their routine utilization.

Value of Patient-Reported Outcomes in Colorectal Surgery: Why Does My Patient Need a Survey?

Implementation in Clinical Trials

PROs utilization in clinical trials has increased over the last two decades, ^{8 9} reflecting an increased interest in patient-centered data. PROs can be primary endpoints, for example, in trials that evaluate a functional intervention such as sacral nerve stimulation for incontinence. Most often, they are set as secondary endpoints and are used to better interpret the benefits of the examined interventions and make cost-benefit evaluations. For example, in the Clinical Outcomes of Surgical Therapy trial 93-46-53, ¹⁰ patients randomized to open versus laparoscopic colectomy had similar survival overall and recurrence-free survival, but patients who underwent laparoscopic colectomy had significantly improved QoL measures 18 months after surgery.

The use of PROs as outcomes in clinical trials has been endorsed by several agencies and societies, including the American Society of Clinical Oncology, the European Society for Medical Oncology, and the FDA. The FDA published a first set of recommendations on the use of PROMs in clinical trials in 2006 ( Fig. 1 ). In their guidelines, ¹¹ they provided specific guidance on how to develop and evaluate PRO instruments for validity, reliability, and ability to detect meaningful change. They endorsed the use of validated and established instruments for PRO evaluation as endpoints of clinical trials. In 2021, the FDA made an update ⁵ focusing on cancer clinical trials, where they recommended the use of core PROs. Domains evaluated in core PROs should include disease-related symptoms, overall side effects from treatment, physical function, and role function. ³ Core PROs should be part of a core outcomes set developed by experts in a specific field to be used in all related clinical trials, as sponsored by the Core Outcome Measures in Effectiveness Trials initiative. ¹² Core outcome sets contain the minimum outcome domains to be measured and reported in all trials investigating a particular disease or treatment. ¹³ Core outcome sets in colorectal surgery have been developed for inflammatory bowel disease (IBD) ¹⁴ and colorectal cancer. ^{15 16} The development of core outcome sets for postoperative ileus and small bowel obstruction ¹⁷ and key standards for colorectal surgery prehabilitation ¹⁸ are ongoing.

Fig. 1.

Assessment criteria for patient reported outcomes from the FDA guidance “Patient-Reported Outcome Measures: Use in Medical Product Development to Support Labeling Claims.”

Implementation in Daily Practice

While using PROs in clinical trials is pivotal to correctly interpret outcomes, the ultimate goal should be to routinely implement PROs into clinical practice. PROs have been shown to improve patient–physician communication and mutual satisfaction ^{19 20 21} without increasing the duration of outpatient visits. ²⁰ Their use stimulates patient engagement and shared decision-making ²⁰ and has been linked to better outcomes ²² and improvements in health-related QoL (HR-QoL). ^{19 23 24} It has been demonstrated that clinicians miss or underestimate approximately half of their patients' symptoms. ^{25 26} The use of PROs can bridge this gap, ensuring that patients get optimized treatment for their symptoms and reducing visits to the emergency room from preventable causes. ^{27 28}

PROs can also help modify hard outcomes. Basch et al, ²⁹ in their randomized controlled trials on PRO symptom monitoring versus usual care during routine cancer treatment, found that the use of PROs not only enhanced HR-QoL, but patients with metastatic cancer randomized to PRO symptom monitoring had a significantly longer overall survival than the usual care group. ²²

The Patient-Centered Outcomes Research Institute was created in 2010 in the United States to support research generated through patient-centered methods. ³⁰ Their mission is the following: “help people make informed health care decisions, and improve health care delivery and outcomes, by producing and promoting high-integrity, evidence-based information that comes from research guided by patients, caregivers, and the broader healthcare community.”

Overview of Patient-Reported Outcome Measures in Colorectal Surgery: How Do I Pick One?

Health-Related Quality of Life Measures

Generic PROMs can be useful to get a broader picture of the patient's health condition than disease-specific PROMs. They may assess domains that would not be investigated with disease-specific PROMs and may be useful to make comparisons with other patient populations or with the general population. The most used HR-QoL PROMs in colorectal surgery are the Short Form 36, ³¹ the EuroQol-5 Dimension (EQ-5D), ³² and their variations. Long-term data from the National Health Service ³³ have shown that both instruments are valid, reliable, and sensitive, and work well in a variety of conditions. The EQ-5D takes less than 5 minutes to complete; however, it is more prone to the ceiling effect than the SF-36, ³⁴ meaning patients tend to give answers closer to the upper range. The biggest drawback of the SF-36 is the completion time, which can take up to 15 minutes. The SF-12, a shorter version with similar validity and reliability, can be administered instead. ^{35 36} Other generic PROMs are shown in Table 1 .

Table 1. List of generic and disease-specific PROMs used in colorectal surgery.

Generic PROMs	EuroQol-5 Dimension 32 Short Form 36 34 Short Form 12 36 Health Utility Index 98 WHOQoL-BREF 99 Sickness Impact Profile Score 100 Nottingham Health Profile 101 PROMIS-10 Global Physical Health 102
Colorectal cancer	Functional Assessment of Cancer Therapy—Colorectal 40 European Organization for the Research and Treatment of Cancer 41 QLQ Quality of life—cancer survivors 103 Cancer Problems in Living Scale 104
Inflammatory bowel disease	32-item Inflammatory Bowel Disease Questionnaire (IBDQ-32) 58 Short Inflammatory Bowel Disease Questionnaire 105 The 9-item IBDQ 106 Rating Form of IBD Patient Concerns 107 Cleveland Global Quality of Life 108 Crohn's Life Impact Questionnaire 109 Crohn's and Ulcerative Colitis Questionnaire 110 IBD Disability Index 111 Crohn's Disease Burden Questionnaire 112 IBD-Control 59
Pelvic floor	Initial Measurement of Patient-Reported Pelvic Floor Complaints 67 Pelvic Floor Distress Inventory 113 Pelvic Floor Impact Questionnaire 113
Stoma	Ostomy Adjustment Scale 114 Stoma Quality of Life Scale 115 Stoma-QOL 70 City of Hope-Quality of Life-Ostomy Questionnaire 71 Ostomy Self-Care Index 116
Diverticular disease	Diverticulitis Quality of Life 73
Fecal incontinence	Browning and Parks Incontinence Score 117 Cleveland Clinic Fecal Incontinence Score/Wexner 75 Fecal Incontinence Severity Instrument 77 St. Mark's Fecal Incontinence Score 118
Constipation	Knowles-Eccersley-Scott Symptom Questionnaire 78 Cleveland Clinic Constipation Score 79 Patient Assessment of Constipation Quality of Life 80
Low snterior resection syndrome	LARS Score 82 MSKCC Bowel Function Instrument 45
Sexual function	Changes in Sexual Functioning Questionnaire 119 Derogatis Interview for Sexual Functioning 120 International Index of Erectile Function 90 Female Sexual Function Index 91
Fatigue	Fatigue Severity Scale Krupp 1989 Multidimensional Fatigue Inventory 121 Functional Assessment of Chronic Illness Therapy 122 Piper Fatigue Scale 123 Modified Fatigue Impact Scale 124
Depression and anxiety	Beck Depression Inventory 125 State Trait Anxiety Inventory 126

Abbreviations: PROM, patient-reported outcome measures; PROMIS-10, Patient-Reported Outcomes Measurement Information System; QLQ, Quality of Life Questionnaire; WHOQoL-BREF, The World Health Organization Quality of Life Brief Version.

Disease-Specific Patient-Reported Outcome Measures

Disease-specific PROMs include domains that are specifically tailored to a specific patient population. They can be administered on their own or, preferably, in combination with a generic instrument.

Colorectal Cancer

QoL is becoming a key outcome for cancer patients, ³⁷ and colorectal cancer is no exception. A study by Soerjomataram et al ² in 2012 found that colorectal cancer survivors have a high likelihood of spending the rest of their lives with an acceptable QoL. Cancer stage has a high correlation with survival, as can be expected, but also with QoL.

The use of PROMs in cancer patients is important for those with both early and late-stage disease. Patients with early-stage colorectal cancer have a high chance of long-term survival after treatment and thus emphasis should be put on preserving and optimizing QoL after cancer treatment. Patients with stage IV disease have a severely diminished life expectancy, especially in the presence of poor prognostic features. These patients spend a portion of their life after diagnosis in poor health; this is related to the pain and symptoms caused by their condition or induced by the treatment, as well as the financial and psychological burden that comes with treatment itself. A recent editorial by Gupta et al ³⁸ highlighted the time toxicity of cancer care: when offering treatment, providers should also consider what proportion of their expected time alive the patient will spend in health care, and whether other treatment options, or even comfort care, may increase the time alive spent in a better setting (“Time spent at the beach is time well spent. Time spent at the hospital is time not well spent.” ³⁸ )

The most used PROMs in colorectal cancer ³⁹ are the European Organization for the Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire (QLQ) and the FACT-C (Functional Assessment of Cancer Therapy—Colorectal). ⁴⁰ The colorectal cancer-specific EORTC-QLQ are the EORTC-QLQ-C38 ⁴¹ and its newer version, the EORTC-QLQ-C29, ⁴² which are delivered in conjunction with the generic EORTC-QLQ-C30. ⁴³ Both the EORTC-QLQ-C38/29 and the FACT-C have been extensively validated and show high reliability. ⁴⁴

A consensus study on core outcomes for colorectal cancer surgery was published in 2016 by McNair et al. ¹⁵ Four QoL core outcomes were selected: physical function, sexual function, fecal incontinence, and fecal urgency. The measures to assess such outcomes have yet to be defined. Similarly, a comprehensive patient-centered outcomes measurement set for colorectal cancer was published in 2017 by the Colorectal Cancer Working Group of the International Consortium for Health Outcomes Measurement. ¹⁶ In their consensus, they recommended the use of the EORTC-QLQ-C30 and EORTC-QLQ-C29 for patients undergoing surgery, as well as the MSKCC Bowel Function dietary subscale ⁴⁵ to investigate dietary issues.

Inflammatory Bowel Disease

IBD is a group of disorders that cause chronic immune-mediated inflammation of the digestive tract. Its remitting and relapsing course, as well as its debilitating symptoms, have a detrimental impact on QoL and social functioning. ^{46 47} Patients with IBD are often diagnosed between 15 and 25 years of age, ⁴⁸ and physicians must be prepared to support them during their entire life course.

In a survey by Lönnfors et al ⁴⁹ on HR-QoL in 4,670 patients with IBD, respondents felt that IBD negatively affected their life regarding work and social relationships. In 48% of cases, IBD was felt to affect patient lives even during remission. Interestingly, 54% felt they were not able to disclose at least some relevant information to their physician, while 64% wished their gastroenterologist would ask more probing questions. Similarly, a study by Kappelman et al ⁵⁰ on 10,634 patients with IBD found that IBD patients had worse scores in several health domains compared with the general population. It has been shown there is considerable interclinician variation in the assessment of a patient's disease severity, ⁵¹ and clinicians' assessments do not reliably correlate to patients' perceptions. These concerns can be addressed by administering PROMs, especially when using specific instruments that contain detailed questions on symptoms and how those affect daily activities, including in domains that physicians may be less likely to discuss during an office visit, such as sexual activity. In patients with chronic illnesses like IBD, the routine administration of PROMs is particularly encouraged, as this can help keep track of their disease course and monitor changes that may be addressed with health interventions.

Currently, there is no gold standard for measuring disease activity in IBD. Several indices have been developed, for example the Crohn's Dosease Activity Index (CDAI) ⁵² and Mayo Clinic Score, ⁵³ but those are complex and time-consuming, and their application in clinical practice is limited. In addition, the FDA is shifting their recommendation from the use of CDAI to the combination of PROs and objective disease measures to be used as outcomes in clinical trials. ⁵⁴

Choosing which instruments to use is challenging. A recent systematic review identified more than 44 IBD-specific PROMs, ⁵⁵ of which 25 appeared to have sufficient content validity. Those are in addition to the countless nondisease-specific PROMs that may be utilized to assess specific domains in patients with IBD (work activity, body image, anxiety and depression, pain, etc).

McColl et al ⁵⁶ in 2004 suggested the use of one generic and one IBD-specific PROM, specifically the Short-Form 36 ⁵⁷ and the Inflammatory Bowel Disease Questionnaire (IBDQ). ⁵⁸ The IBDQ is certainly the most used IBD-specific questionnaire in clinical trials, though it is seldom applied in clinical practice due to its length and the need to acquire a license to use it.

In 2014, Bodger et al ⁵⁹ developed the IBD-Control questionnaire, a rapid and reliable survey that comprises 13 questions and a visual analog scale (0–100). The IBD-Control is included in the IBD core outcomes set created by Kim et al ¹⁴ in 2018. Their international, cross-disciplinary working group identified a minimum standard set of patient-centered outcomes for IBD, including four domains to be assessed at baseline and every 6 to 12 months:

• Symptoms, function, and QoL, tracked via the IBD-Control.

• Disutility of care: use of any systemic steroids, occurrence, and impact of complications from an IBD intervention.

• Healthcare utilization: time spent in hospital.

• Survival and disease control: anemia, disease activity and remission (tracked via the Manitoba IBD Index), colorectal cancer, overall survival, and cause of death.

Approximately 20% of patients with ulcerative colitis and 80% of patients with Crohn's disease will undergo surgery during their lifetime. ⁶⁰ In this subpopulation, the impact of surgery on QoL, as well as satisfaction with surgery, should also be assessed. The Cleveland Global Quality of Life Instrument (CGQLI) ⁶¹ is a simple, validated, and widely utilized questionnaire developed by Fazio et al to evaluate outcomes after restorative proctocolectomy with ileal ileal pouch-anal anastomosis. The CGQLI contains three domains: current QoL, quality of health, and energy level. It also evaluates patients' happiness with their pouch surgery, if they would undergo pouch surgery again, and if they would recommend pouch surgery to others. While originally developed for pouch patients, the CGQLI has been also validated in patients with IBD who underwent other surgical procedures. ^{61 62}

In 2022, Cavallaro et al ⁶³ conducted a Delphi consensus study on PROs after pouch surgery (PROPS study) involving patients, colorectal surgeons, gastroenterologists, and nurse specialists. They identified seven symptoms and seven consequences of Ileoanal Pouch Syndrome (IPS), as shown in Fig. 2 . IPS is diagnosed if a patient reports at least one symptom and one consequence. Five additional items were identified as important and worthy to be further investigated in future research ( Fig. 2 ). A scoring system for symptoms and consequences of IPS is currently under development.

Fig. 2.

Current diagnostic criteria for ileoanal pouch syndrome and additional items.

Complementary to validated PROMs, several health apps are also available for patients with IBD. ⁶⁴ Health apps can help patients be more involved in their own care, ⁶⁵ as well as provide clinicians with a clear picture of a patient's symptoms and disease activity. While evidence on health apps is limited, they appear to improve medication adherence ⁶⁶ and may improve QoL and reduce symptoms.

Pelvic Floor Disorders

Pelvic floor disorders (PFDs) are related to weakness, injury, or dysfunction of the muscles or connective tissue of the pelvic area. By definition, PFDs cause an impairment in QoL and regular function, and any intervention for PFDs should be evaluated for its benefit in improving the patient's symptoms and QoL. The most recent and robust recommendations on PROs assessment for PFDs come from the consensus statement published by the PFD Consortium Working Groups On Patient-Reported Outcomes in 2020. ⁶⁷ In their statement, they recommended at least one instrument for each domain that was considered relevant in the evaluation of patients with PFDs ( Fig. 3 ). By combining those instruments, they developed the IMPACT (Initial Measurement of Patient-Reported Pelvic Floor Complaints) tool, available in long and short forms. The IMPACT Long Form includes each instrument in its unaltered form, while the Short Form was created to avoid redundancy between the different instruments. The Short Form has 12 questions regarding fecal incontinence, constipation, urinary incontinence and lower urinary tract symptoms, and sexual function; it is an intuitive and fairly rapid tool that can be implemented in everyday clinical practice. Other available tools to assess PFDs are reported in Table 1 .

Fig. 3.

Domains contained in the Initial Measurement of Patient-Reported Pelvic Floor Complaints (IMPACT) tool.

Colostomy or Ileostomy

A permanent stoma can have a severe impact on physical and psychological well-being. Stoma-specific surveys should be used to monitor PROs in patients with a stoma, and patients should be offered appropriate support and interventions in case of impairment. Data on the QoL of patients living with permanent stomas can be helpful for clinicians when counseling prospective stoma patients. Many authors ^{68 69} report worse HR-QoL in patients living with stomas compared with the general population, with lower work, social and sexual functioning, and high rates of fatigue, depression, and body image issues.

Several stoma-specific PROMs have been developed, with the two most commonly utilized being the Stoma-QoL ⁷⁰ and the City of Hope-Quality of Life-Ostomy questionnaire. ⁷¹

Diverticular Disease

In the past, elective sigmoidectomy was recommended after two attacks of uncomplicated diverticulitis. This approach is now considered inappropriate and lacking cost-effectiveness, as elective colectomy may not be needed. ⁷² Surgery for uncomplicated diverticulitis should be based on patient-reported symptoms of diverticular disease, their frequency, and their impact on the patient's QoL and functioning. This can be assessed with PROs and help discriminate patients who have one mild episode a year and whose routine is not affected versus those who have to make adjustments to their daily lives because of symptoms or fear of a flare-up (e.g., changes in social activities, avoiding going on vacation away from home, etc.).

The diverticulitis quality of life (DV-QOL) instrument is a 17-item disease-specific instrument developed by Spiegel et al ⁷³ in 2015. DV-QOL evaluates four core domains: physical symptoms, behaviors, cognitions and concerns, and impact and consequences.

Incontinence

The three most used PROMs assessing fecal incontinence ⁷⁴ are the Cleveland Clinic Incontinence Score (CCIS), ⁷⁵ the Fecal Incontinence Severity Index (FISI), ⁷⁶ and the Fecal Incontinence Quality of Life Scale (FI-QOL). ⁷⁷ The FISI and CCIS are easy, quick questionnaires with a very low number of items, which makes them convenient for routine clinical use. The FI-QOL is a more thorough questionnaire that, instead of focusing only on function, takes into account the impact of incontinence on the patient's psychological and functional well-being.

Constipation

Constipation can develop as a side-effect of colorectal surgery or, more commonly, present as a chief complaint. Since surgery for constipation is purely related to the functional outcome and QoL improvement, PROs should be central in its assessment. Three PROMs can be used to evaluate constipation: the Knowles–Eccersley–Scott Symptom Questionnaire, ⁷⁸ the Cleveland Clinic Constipation Score, ⁷⁹ or the Patient Assessment of Constipation Quality of Life. ⁸⁰

Low Anterior Resection Syndrome

Low anterior resection syndrome (LARS) identifies a complex of anorectal and genitourinary symptoms that can develop in up to 60 to 90% of patients after sphincter-preserving resection for rectal cancer. ⁸¹ The two surveys that specifically assess LARS are the LARS score ⁸² and the MSKCC Bowel Function Instrument. ⁴⁵ The LARS score is a short, five-item survey that results in a composite score identifying either no LARS (score < 21), minor LARS (score 21–29), or major LARS (score 30–42). The MSKCC Bowel Function Instrument, on the other hand, is composed of 18 questions and is intended for a more thorough assessment. A more comprehensive scoring system is under development by the LARS International Collaborative Group. ⁸³

Sexual Function

Sexual dysfunction is a common complication of pelvic surgery. It can be associated with rectal cancer surgery ^{84 85} or after surgery for benign disease, such as pelvic pouch formation. ^{86 87} Proper counseling for sexual dysfunction is often an unmet need in colorectal surgery patients, ⁸⁸ especially in females, who have a reportedly higher rate of dysfunction ⁸⁹ but are less likely to get their issues investigated and treated. ⁸⁸ Physicians may feel questions about sexual function to be inappropriate, or the physician's implicit biases may prevent them from asking important questions (e.g., age, gender, relationship status, sexual orientation of the patient, and gender mismatch between patient and provider). Similarly, the patient may be reluctant to spontaneously discuss any concerns regarding sexual function. This can be addressed by routinely administering PROMs on sexual function. Sexual function can be assessed in males with the International Index of Erectile Function ⁹⁰ and in females with the Female Sexual Function Index. ⁹¹

Challenges to Patient-Reported Outcome Measures Implementation in Colorectal Surgery: The Invisible Brick Wall of Patient and Provider Noncompliance

The routine collection of PROMs requires significant buy-in from all stakeholders, including health care providers, patients, and hospital administrators.

Hospital administrators must be willing to make structural changes that will integrate PROMs into the clinical workflow. This can most effectively be accomplished by including PROMs into the electronic health record, ⁹² but other strategies can also be considered. Depending on the context, paper surveys administered during outpatient clinics may be just as effective.

Health care providers should receive educational training on the clinical benefits of PROs and should be involved in all steps of the decision-making process ( Fig. 4 ).

Fig. 4.

Decision-making process for the routine implementation of patient-reported outcomes in clinical practice.

A recent study by Sibert et al ⁹³ involving 12 clinicians working in colorectal cancer centers in Germany found that while attitudes toward PROs were mostly positive, most providers had limited knowledge about PROs. In their study, several clinicians expressed skepticism about the clinical usefulness of the routine use of PROs. Since health care providers are, ultimately, those in charge of administering and interpreting PROs in the clinical setting, they need to perceive that the benefit will outweigh the effort. A possible way to do this is the “knowledge-to-action” framework described by Graham et al, ⁹⁴ which puts particular emphasis on transmitting knowledge as a way to drive behavioral change.

Finally, actions must be taken to ensure patient compliance. In an article by Atherton et al, ⁹⁵ patient compliance to PROMs collection was above 90% in most included studies. The reason for patient noncompliance was patient refusal in 22% cases (59% for unknown reasons, 29% for physical reasons, and 10% for emotional reasons), while it was staff errors in 33% of cases. Improving compliance can be addressed in different ways.

• Choosing PROMs that patients find relevant, easy to understand, easy to complete, and worth completing.

• Having PROMs on a platform that is user-friendly, graphically pleasing, easy to read, and easy to fill out.

• Supporting patients in completing PROMs by having a dedicated team tasked with ensuring compliance, and compliance management tools such as online forms and email reminders.

The amount of effort necessary for PROM implementation is undisputable. Routine use of PROMs, however, has been shown to be feasible, ⁹⁶ as well as beneficial for patient-provider communication, symptom monitoring, clinical decision-making, and possibly survival outcomes. ^{22 97} It seems an effort worth making.

Conclusion

PROs are essential to evaluate the value of care for patients undergoing colorectal surgery and should be considered in routine clinical practice. Many instruments are available for patient-reported outcome assessment, both generic and disease-specific. While no univocal consensus exists on which patient-reported outcome measures to choose, the recommendation is to consistently use validated, broadly utilized instruments.