Utilising patient-reported outcomes for goal-directed therapy of hip fracture patients: a sequential controlled trial

Abstract

Background

Hip fracture patients (HFPs) frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals between medical-personnel and patients is not always effective. Patient-reported outcomes (PROs) can outline personal goals and help promote quality health care in HFPs. Few studies have been published on this topic. The study’s aim was to outline the process of using PROs for goal-directed therapy among HFPs.

Methods

This sequential controlled trial was conducted among HFPs from two medical centres. The control and the intervention group received integrative rehabilitation. PROs were measured in both groups using the SF36 questionnaire three times postsurgery: 24–48 hours, 2 weeks and 3 months. During the first round of questioning, only the intervention group was asked ‘what matters most to you?’ during the rehabilitative process. Accordingly, agreed-upon goals that were determined by the SF36’s eight topics and were incorporated into the HFP’s rehabilitative process. A Likert scale of 1–5, ‘1’ indicating no-achievement and ‘5’ full-achievement, was used to assess the goal achievement 4–6 months post-fracture.

Results

84 HFPs participated in the study: 40 and 44 in the intervention and control group, respectively. In both groups, PROs declined after the HF, then improved somewhat 3 months later, but did not return to prefracture scores. Among the intervention group, 39% reached their specific goals (Likert level 5). Patients who achieved their goals had better PROs in comparison to others. The intervention group indicated PROs helped them articulate their desires and introduced them to new areas of care.

Conclusions

Shifting from asking ‘what’s the matter?’ to ‘what matters most to you?’ can improve the understanding of HFPs’ own priorities, promote quality outcomes and enhance patient-centred care. Using PROs as a guide for goal-directed therapy can create a more inclusive process that includes the patients’ most important health determinants and needs.

WHAT IS ALREADY KNOWN ON THIS TOPIC?

• Hip fracture patients are usually older adults that frequently have multiple underlying conditions, necessitating that agreed-upon goals take these complications into consideration. Communication regarding goals and expected outcomes between the medical staff and their patients is not always effective. Others have recommended using patient-reported outcomes (PROs) for this purpose. However, few studies have been published on the use of PROs for this purpose, and to our knowledge, none have been published in hip fracture patients.

WHAT THIS STUDY ADDS?

• This study used PROs not only to assess patient status and quality of care but also to demonstrate how they can be used for goal directed therapy. Using the PRO questionnaire as a guide enabled for richer and more comprehensive communication between hip fracture patients and their medical staff regarding therapeutic goals. This process shifted the focus of the treatment to promote the goals that are the most important to the patient. Patients who achieved their goals had better PROs in comparison to other patients.

HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY?

• Clinicians can use PROs to improve the understanding of what matters most to hip fracture patients during the lengthy rehabilitation process. The approach used in this study may be pertinent for a wider range of patients; therefore, we recommend that future studies examine the effect of using PROs for goal-directed therapy in other health issues.

Introduction

Hospital admission rates of patients with hip fracture (HF) have grown substantially in the past decade.¹ HFs in older adults are associated with poor outcomes, high costs and a lengthy rehabilitation process.^{2 3} Rehabilitation following HF has been geared towards reducing the impact of long-term disability,⁴ improving quality of life⁵ and decreasing the risk of mortality.⁶ Patients with HF often have multiple underlying conditions. Thus, setting agreed-upon goals and taking these complications into consideration is necessary.⁷ Patient participation in goal-directed healthcare can improve outcomes and health-related quality of life.⁸ Goal setting is a major core component in treatment of geriatric patients^{9 10} and has been found to help facilitate recovery in rehabilitation following HF.^11–13 Asking patients what matters most to you?¹⁴ and setting and documenting the progress in achieving agreed-upon milestones can promote positivity in the patient and preserve their perspective during the prolonged rehabilitation process.¹⁵

However, patients’ involvement in goal-setting is not always optimal.^{16 17} Barriers such as not having a structured method for communication, older age and declining cognitive status have been reported as possible causes.¹⁶ As a consequence, goal-setting is often determined and led by the medical team with limited involvement of the patient. Additionally, there is an inconsistency in how the goals and their measurement are applied, prompting a need for standardisation.^{18 19} Other studies have reported that communication regarding goals and expected outcomes among medical personnel²⁰ and between medical personnel and patients is not always effective.^21–24 This kind of miscommunication has been associated with deficient patient care.²⁵ Moreover, when physicians document goals they often refer to disease and/or biological measures²⁶ and not to quality-of-life outcomes.²⁷

In recent years, there has been an increase in the use of patient-reported outcome (PROs) in healthcare.^{28 29} PROs enable a measurement of patient value outcomes³⁰ and can outline personal goals while promoting quality healthcare in patients with HF.²⁹ However, few studies have been published that explore the use of PROs for this purpose³¹ and none that describes the use of PROs for goal-directed therapy specifically among patients in rehabilitation after HF. The aim of the study was to evaluate and describe the process of using PROs for goal-setting in a sequential interventional trial among patients following HF.

Methods

Study design

A controlled, multicentre, sequential interventional trial of HF patients. The study was prepared following the Consolidated Standards Of Reporting Trials statement.³²

Study setting

Patients were recruited while they were hospitalised at one of the two largest tertiary medical centres in the Middle East, from December 2021- August 2022.

Participants

Inclusion criteria: patient who (a) were age 60 years and older; (b) had undergone HF stabilisation: anatomical femoral neck fractures and per-trochanteric; (c) were able to understand and sign the informed consent form; (d) understand Hebrew. Exclusion criteria: patients with (a) pathological fractures; (b) severe hearing disabilities. The patients were recruited when they were hospitalised in the department of orthopaedics or rehabilitation after surgery. The control group also participated in a separate study that compared PROs of HF patients in home vs inpatient rehabilitation.

Instruments

The short form (SF)−36 questionnaire has been found to be suitable as a PRO in patients with HF³³ and for evaluating recovery after lower extremity trauma.³⁴ Though the SF36 is a general questionnaire, it addresses specific conditions and is significantly shorter (5–15 vs 20–30 min for completion) than the condition-specific questionnaire, the Osteoporosis Assessment Questionnaire.^{35 36} It consists of 36 questions covering eight topics: physical functioning, physical role limitation, bodily pain, general health, vitality, social functioning, emotional role limitation and mental health. Interpretation of the results can be obtained from a calculation of each topic and a summarisation of several topics that generate a physical component score (PCS) and mental component score (MCS).^{37 38}

SF36 data were scaled, so that possible scores ranged from 0 (poor health) to 100 (excellent health) for the eight domains. PCS and MCS were also calculated as these summaries were found to be responsive in orthopaedic conditions.³⁹ The calculations were done according to the RAND Corporation website (36-Item Short Form Survey (SF-36) | RAND) and the oblique (correlated) factor solution that is recommended for orthopaedic patients.⁴⁰

Intervention

For both groups, the intervention and control, PROs were measured using the SF36 questionnaire three times as recommended³³: 24–48 hours postsurgery while still hospitalised (T1), 2 weeks later (T2), while hospitalised or by phone and again 3 months later by phone (T3). The first questioning is retrospective and reflects the patients’ health status before the fracture. As suggested,⁴¹ the initial round of questioning was conducted soon after the injury; reports have found that recall evaluation of pre-fracture status is reliable.^{42 43}

To avoid possible contamination between the intervention and control group, sequential control recruitment occurred first and then recruitment to the intervention group was started. The control group included patients hospitalised from December 2021 to mid-March 2022. This group received standard rehabilitation care that included an integrative treatment approach, carried out by a multidisciplinary staff. The rehabilitation contained daily (7 days a week) visits and care by nurses and geriatricians; physiotherapy and occupational therapy on all the weekdays (5 days a week); at least two meetings with the social worker; at least one dietitian consultation; on request, consultations of orthopaedic and rehabilitation specialists and emotional and speech therapy. The intervention group included patients hospitalised from mid-March to August 2022. This group also received integrative rehabilitation care by the multidisciplinary staff. In addition, during the first PRO questioning the intervention group, were asked what matters most to you?. Accordingly, the development of the patients’ goals was obtained by a fusion of (1) patients reflecting on their daily activities before the fracture, while using the SF36 as guide, and then determining which of the listed activities are most important for them to resume and (2) patients choosing specific future events that are important for them to attend and listing the steps required to achieve the selected goals. This process enabled for the scripting of agreed-upon goals with the patients. The goals were determined using the PROs as a guide and defined by the research team according to the eight topics of the SF36.³⁸ Goals were introduced by the researcher to the department head who presented them to the clinical staff during their bi-weekly meetings and documented them in the patients’ medical files. Additionally, the department head personally contacted any involved caregiver who had not attended the meeting and presented the patients’ goals. The multidisciplinary rehabilitation team integrated and adjusted the treatment to match the patients’ goals. For example, for patients who set goals such as being able to climb stairs the physiotherapy team modified the exercise regimen to enable for more stair-climbing training. Patients who set emotional/mental health, goals of not being depressed’ or not suffering from anxiety received psychological treatment and/or were integrated into therapeutic groups.

Outcome measurements

Several outcomes were measured:

1. The intervention group was asked 4–6 months postfracture to rate the extent to which they had achieved their specific goals on a scale of 1–5, ‘1’ indicating no achievement and ‘5’ full achievement.

2. SF36 scores were calculated and compared at T1, T2 and T3 for: (A) all the participants, (B) the intervention and control groups separately (C) participants with a grade over 4 and others, (D) patients over and under 85 years old to detect whether this age group was disparate from the others^{44 45} since older patients are at higher risk for mental and physical deterioration following HF.

3. Assuming that a change of 9 points in one of the subscales and 2 points on the PCS and MCS of the SF36 is considered the minimal important difference (MCID),^{46 47} MCID was calculated and compared between the intervention and control groups at T1, T2 and T3.

Statistical measures

Descriptive statistics were used to outline the patients’ demographics and medical history. T-test and χ² were used to detect differences in characteristics of the groups. Goals’ mean score results were measured and compared using the one-way Analysis of Variance (ANOVA). Mixed effect logistic regression was used for comparison of PROs. The PROs were adjusted for age, sex and Charlson comorbidity index (CCI),⁴⁸ a predictive score of health outcomes in HF patients.^{3 49} Naturally, the subgroup analysis of participants over and under 85 years old was not controlled for age.

The data were managed with Excel 2016 and analysed using IBM SPSS Statistics for Windows V.27 and Stata V.15.0.

Sample size

Sample size was calculated using Winpepi V.11.65. To detect a difference of 9 points on the subscale⁴⁶ assuming a SD of 10 points and a power of 80% and p<0.05, sample size of 20 in each group is required. Accounting for the possible loss of follow-up due to the unfortunate increased risk for deterioration and mortality following HF,⁵⁰ we set a goal to increase each group by at least 50% to reach a total of a minimum 30 participants in each subgroup.

Results

Characteristics of participants

A total of 84 patients with HF participated in the study, 40 in the intervention group and 44 in the control group (see figure 1 for description of study participants’ groups and follow-up 2 weeks and 3 months later). The two groups had similar characteristics (see table 1) with the exception of CCI that was significantly (p<0.05) higher in the control group. No significant differences were found (p >0.05) in demographic, clinical and social characteristics between patients who participated in the study vs those who declined participation (n=143) for self-reported reasons such as health issues or other reasons.

Figure 1.

Description of study participants’ groups and follow-up 2 weeks and 3 months later. *HF, hip fracture.

Table 1.

Comparison of characteristics of intervention and control groups

	Intervention group n=40	Control group n=44	P value
Age, mean (SD)	80.1 (8.2)	82.4 (7.6)	0.18
Female gender, n (%)	27 (67.5)	33 (75)	0.81
Charlson co-morbidity score, mean (SD)	4.6 (1.7)	5.3 (1.6)	0.04
Days from hospitalisation to surgery, mean (SD)	1.18 (1.63)	1.6 (1.2)	0.94
Extracapsular fracture, n (%)	23 (58)	33 (75)	0.17
PFNA (or other nailing) n (%)	23 (58)	33 (75)	0.14

PFNA, Proximal Femoral Nail Antirotation.

Goal setting

The PROs served as a guide to specify what mattered most to the patients. Patients detailed 2–3 areas of intervention for a total of 111 goals, thereby setting personal objectives. A summary is presented in table 2. Most of the goals related to physical and functional aspects of rehabilitation; however, patients described social, mental and emotional objectives as well. Patients indicated that the PROs helped them articulate factors that may hinder their recovery, in addition to the physical aspects of the HF. To quote a participant, I didn’t know I could get psychological help in rehabilitation.

Table 2.

Summary of categories and topics that emerged from asking ‘what matters most to you?’ while using the SF36 questionnaire as a guide

Category	Topic
Physical functioning	‘Return to physical functions at home - go to the bathroom alone, be able to go to the grocery store’ ‘The ability to perform all types of physical activities without limitation’ ‘To be able to move around the home independently, so that I do not have to move to a nursing home’ ‘To have the ability to make myself a cup of coffee at home independently’ ‘Return to physical function - to be able to go to the bathroom, shower and dress independently " ‘Being able to walk outside without a walker’ ‘Return to being able to walk independently with a cane’ ‘Because I live alone, it is important for me to return to being independent at home and outside the home’ ‘It is very important for me to return to walking independently and without limping’ ‘To be able to go up and down stairs, so that I can return to my home that has stairs’ ‘To be able to go for walks with my dog’ ‘Interested in returning to being independent at home and being physically able to care for my garden’ ‘To be able to go out to cafes, movies and classes again’
Physical role limitation	‘Return to informal roles – to be able to go to the supermarket alone, cook and take care of household chores’ ‘Go shopping independently at the mall and the supermarket’ ‘To be able to go to exercise classes and attend to garden work’ ‘To be physically able to return to the routine of arranging the house, make flower arrangements and be with the family’ ‘To be able to return to my job’
Bodily pain	‘Providing pain relief before physical therapy’ ‘Being able to perform the exercises in physical therapy without being limited because of pain’ "The pain limits my functioning and also impairs my mental resilience. I have received treatment but am still sufferings from very severe pain’ ‘I am suffering from a lot of pain that prevents me from performing the necessary actions in rehabilitation’ ‘The pain limits my ability to perform the rehabilitative activity’
Social role	‘Having the ability to go to the country club and meet friends’ ‘Be able to go to the senior citizens’ social club’ ‘To take care of my spouse who is independent. Host and cook for the grandchildren’ ‘To be able, physically and emotionally, to spend time with close friends’ "It is very important for me to be able to go independently to the senior citizens’ social club. I live alone so it is very important for me to be able to go out and meet friends’ ‘To be able to return and assist my son with sorting the mail’ ‘Being able to visit and host family and friends’ ‘To be present at the birth-shower of my daughter’s baby, in two months’ "It is important for me to be able to cook and entertain. To host my family, children, grandchildren and great-grandchildren, without physical difficulty’ ‘To be physically able to attend family events and be hosted on Saturdays and holidays by my family’ ‘Go on trips with friends’
Emotional role limitation	‘Ability to perform daily activities without limitation due to emotional problems (anxiety about recurring falls)" "I am seeking help for the anxiety I have about a recurrent fall. I feel the anxiety limits my ability to perform the physical actions required for rehabilitation and return to independent functioning’ ‘I am suffering from depression due to the situation and the uncertainty about ‘what will happen’ after the rehabilitation. I am seeking mental support to deal with the trauma of the fall and the uncertainty’ ‘To receive help for the anxieties that I have following the fall and the deterioration of my functional condition’
General health	‘A belief that my health is excellent’ ‘To have better management of the medications I take’ ‘Since the operation, I sometimes suffer from constipation that makes me uncomfortable and impairs my sleep’ ‘Treatment that can help with dizziness’ ‘To return to be sexually active’
Mental health	‘To have a sense of peace, joy and calm’ "I am very depressed almost all the time. Some of this also existed before, since my husband passed away. However, the current situation, with the fracture and hospitalization has exacerbated the situation. I am seeking mental assistance’ ‘I am very depressed from my condition and also in great anxiety that is expressed in troublesome thoughts" ‘Since the fall I am very depressed and have anxiety about ‘what will happen now’. I am seeking mental help’

As described in table 3, 43 (39%) patients in the intervention group reached their specific goals 4–6 months postfracture (Likert level 5) and only seven (6%) goals were not achieved at all (Likert level 1). The highest achievement was in goals that related to social functioning (62%), emotional role limitation (50%), physical role limitation (43%) and physical function (25%). The mean and median ratings of achievement, according to the 5-point Likert scale, was 3.55 (SD=1.26) and 3, respectively, with a range of 1–5.

Table 3.

Rating distributions of the intervention groups' specific goals, 4–6 months postfracture (1–5 Likert scale)

Category	N	No achievement n (%)	Likert 2 n (%)	Likert 3 n (%)	Likert 4 n (%)	Full achievement n (%)
Physical function	28	3 (11)	7 (25)	7 (25)	4 (14)	7 (25)
Physical role limitation	21	3 (14)	3 (14)	3 (14)	3 (14)	9 (43)
Social functioning	21	0 (0)	2 (10)	3 (14)	3 (14)	13 (62)
Mental health	19	0 (0)	0 (0)	9 (47)	5 (26)	5 (26)
Bodily pain	11	0 (0)	2 (18)	2 (18)	2 (18)	5 (45)
General health	6	1 (17)	1 (17)	1 (17)	1 (17)	2 (33)
Emotional role limitation	4	0 (0)	0 (0)	2 (50)	0 (0)	2 (50)
Vitality	1	0 (0)	0 (0)	1 (100)	0 (0)	0 (0)
Total	111	7 (6)	15 (14)	28 (25)	18 (16)	43 (39)

*Each participant from the intervention group (n=40) detailed 2–3 goals making for a total of 111 goals.

Patient-reported outcomes

Response rates were 100%, 98% and 92% for T1, T2 and T3, respectively. As presented in figure 2, in both groups, the physical and the mental summary scores plummeted after the HF (T2), then improved somewhat 3 months after the fracture (T3), but did not return to prefracture scores (T1). The decline in PROs between the prefracture status and 2 weeks postfracture was lower than the predefined MCID in both groups, in all of the health domains and the summary scores. The patients’ improvement 3 months after the fracture was higher than the predefined MCID primarily for the physical health domains (PCS, physical function, physical role limitation and pain).

Figure 2.

Comparison of PROs summary scores in the intervention and control group, at T1, T2, T3, adjusted to sex, age and CCI. *CCI, Charlson comorbidity index; MCS, mental component score; PCS, physical component score; PROs, patient-reported outcomes.

The intervention and control groups had different PRO scores at T2 and T3. With the exception of ‘general health’, in all of the SF36 health domains, the intervention group had a sharper decline 2 weeks postfracture, compared with their prefracture status (see online supplemental appendix). When comparing the differences of the two groups’ PRO improvement from T2 to T3, they were not statistically significant, with the exception of two measures: general health and vitality.

The PRO outcomes were different in participants with a goal grade above 4 versus the other participants. As described in the online supplemental appendix, a participant with a grade above 4 had statistically higher physical, emotional and mental health PROs in comparison to the others. When comparing the two groups’ improvement from T1 to T3, the differences were not statistically significant in all measures except for vitality.

Patients over 85 years old had lower SF36 grades in comparison to patients under 85 years old. In particular, the PROs at T3 were significantly (p<0.05) lower among participant 85 and older in all the SF36 measures, in comparison to participants under 85. However, the differences in PROs between timelines, T1–T2, T2–T3 and T1–T3, were not statistically significant.

Discussion

In this study using PROs as a guide for goal-directed therapy in patients following a HF, we found that patients who achieved their goals had better PROs in comparison to other patients. Social and emotional-mental goals were achieved more often than physical and functional goals. This is especially important as rehabilitation following HF has traditionally emphasised physical and functional aspects of care rather than focusing on social and mental difficulties. In both groups, PRO scores declined, between the prefracture status and 2 weeks postfracture, then improved, but did not return to the prefracture status, 3 months postfracture. Our findings suggest that PROs can help facilitate a shared decision process of goals in patients with HF.

Others have reported that physicians criticise the use of PROs as being purposeless, a process of collecting information that has no practical benefit or use.⁵¹ This study demonstrated that PROs can be used for goal setting beyond their role in assessing patient status and in quality measurement. Using the PRO questionnaire as a guide enabled richer and more comprehensive communication between HF patients and their medical staff regarding therapeutic goals. This process shifted the focus of the treatment to promote the goals that are the most important to the patient. This is especially important due to reports^{16 52} that patients are not always involved or even aware of the goals that have been set for their treatment by the multidisciplinary staff. Although the rehabilitation team recognises the importance of patient participation in goal setting,^{19 53} they also have been reported to sometimes decide on their own.^{17 53 54} Using a structured tool such as PROs for goal-setting can promote effective communication that is associated with better rehabilitative outcomes,^{54 55} greater patient-perceived autonomy and more motivation in seeking relevant goals.^{52 56}

Others⁵⁷ have reported that using PROs for goal setting may result in less heterogeneity in goals. In this study, patients stated the contrary, emphasising that the PROs helped them identify areas of care that hindered their recovery process such as mental health, social functioning and emotional role-limitation. For example, patients’ ‘fear of falling’ or anxiety of ‘what will happen now’ prevented them from executing the physiotherapy exercises. In fact, the PROs helped the patients voice sensitive and delicate topics that they would otherwise would not share, such as mental distress. The use of PROs for this purpose in surgical patients has been documented by others.⁵¹ Surgeons have found that the PROs enabled the patients to elaborate on the scope of symptoms they were experiencing. Meerhoff et al⁵⁸ reported that PROs helped patients with musculoskeletal health problems to be more aware of their health problems. This enabled them to communicate their difficulties to the medical staff in a more comprehensive manner, without leaving out important issues that mattered most to them.

PRO data provided a richer understanding of HF patients’ outcomes, and their progress development, over time. As expected, the patients’ physical and functional status was altered by the fracture, and patients over 85 years old suffered more than others. A sharp decline in SF36 scores post-HF and only a partial recovery after rehabilitation has been reported before.⁵⁹ Jaglala⁶⁰ reported the same trend 6 months postfracture. This study also found that participants who reported that they achieved their goal (grade 4 and above) had better SF36 grades in comparison to the others. This may indicate that setting and achieving goals can influence PROs. However, these findings may not apply only for goal-setting but also require achievement of the goal. There are several possible explanations for these results. First, the intervention group had a more dramatic decline post-fracture in comparison to the control group; this may have influenced the ability of the intervention group to improve. Second, the expectations of the participants who set goals and did not achieve them were too high and resulted in low PRO grades. Additionally, due to the sequential methodology, there were deferential external unpredictable influences in the study’s setting between the two groups that influenced patients’ outcomes. Finally, perhaps the implementation of the intervention was not optimal for all the participants and requires further investigation.

Strengths and limitations

This study had several strengths. Few studies have examined the use of PROs for goal directed therapy, and to the best of our knowledge, this is the first study to make use of this method among patients following HF. The structured processes of goal setting and systematic evaluation of PROs support the value of patient-centred care. The approach used in this study may be pertinent for a wider range of patients; therefore, we recommend that future studies examine the effect of using PROs for goal-setting in other health issues. This study is also the first PRO study conducted among patients with HF in Israel. The study was done in two large tertiary hospitals and the results can serve as a benchmark for comparison of future PROs in patients with HF. This study had a relatively high response rate in all age groups in comparison to other HF PROs studies (15%–54%) that reported a lack of representation of older adults.^61–63 It could be explained by the use of a single questionnaire that led to less survey fatigue⁶⁴ and the use of sequential methods, in person and phone questioning, which has been associated with higher survey response rates.⁶⁵ As opposed to other studies,^{12 66} we collected patient prefracture PROs, and could evaluate the influence of the HF on the patient’s outcomes, making for a more balanced comparison.

A possible limitation of the study was that a randomised clinical trial could not be performed, since it would have been impossible to avoid contamination between the intervention group and the control group if they had been treated simultaneously on the same wards, thus we had to undertake a study design based on a sequential control followed by intervention. We recommend that future research be conducted in a randomised manner perhaps in a number of departments at a large medical centre. Additionally, masking the patients and/or the medical staff was not possible for practical reasons. The study demonstrates significant differences in PROs in patients who achieved their goals versus others; however, this difference was not significant when comparing the goal-setting group versus the control group. The difficulty of providing measurable outcomes that differ when initiating goal-setting rehabilitative settings has been reported before.⁹ However, our study adds clarity to the achievement of the specific goals and the attributed value that this process provided the patients. Another possible limitation is that the questioning at 3 months and some of the questioning at 2 weeks were done by telephone interviews. Telephone-administrated questionnaires have been reported to provide a more optimistic health-related quality of life measurement.^{67 68} This may imply that HF patients’ recovery was actually worse than the outcomes described in the study. Finally, the study was performed during the COVID-19 pandemic, which may have influenced patients and medical staff expected outcomes and goals.

Conclusions

Using PROs for goal-directed therapy enables a more structured and standardised communication process between patients and their medical team while focusing on rehabilitative goals that are most important for patients. PROs allow for a richer and more comprehensive understanding of healthcare outcomes of patients with HF. This process, which supports the value of patient-centred care, can improve quality healthcare in a growing population of patients.

Data availability statement

Data are available upon reasonable request.

Ethics statements

Patient consent for publication

Consent obtained directly from patient(s).

Ethics approval

The study was approved by the ethics committees of the two medical centres (#SMC-7933-20) and (#HMO-0691-21). All participants provided written informed consent forms before enrolling in the study. Participants gave informed consent to participate in the study before taking part.