https://orcid.org/0000-0001-7802-9696
Figures
Abstract
Objective
We aimed to provide an up-to-date synthesis of the effectiveness of patient reported outcome measures (PROMs) to self-monitor symptoms compared to conventional follow-up care in rheumatic disease patients. The effect of providing feedback via PROMs was also evaluated.
Methods
This review was guided by the Preferred Reporting Items for Systematic review and Meta-Analysis guidelines. Articles published before December 2024 were retrieved from PubMed®, Cochrane Library®, Embase®, and PsycINFO® (Ovid). Studies were included if they (1) compared PROMs against no PROMs use, or (2) or if they utilized PROMs as an intervention with feedback provided to healthcare professionals or patients for comparison against PROMs use without feedback. Non-English articles and abstract-only articles were excluded. Results were synthesized in a narrative manner. Methodological quality was assessed using the Risk of Bias tool and the Risk of Bias in Non-randomized Studies of Interventions tool.
Results
A total of 18, 159 articles were screened, and 9 articles were included. All 9 studies reported on the use of PROMs as an intervention against a control where no PROMs were used. 4 of the studies included reported improvements in symptom control; 1 study observed improvement in health-related quality of life (HRQoL) when PROMs were used. High patient satisfaction was observed in 5 studies, but the results were statistically insignificant. 1 found that PROMs use facilitated shared decision making. 3 studies reported on clinic visits with mixed results. No studies reported on survival/mortality. Out of the 9 studies, 2 studies compared PROMs with feedback to patients and/or healthcare professionals against PROMS without feedback. There was conflicting evidence whether PROMs with feedback improved patient satisfaction in clinical care. Three studies were identified to be of moderate to high risk of bias.
Conclusion
The use of PROMs self-symptom monitoring may contribute to improving symptom control, HRQoL, patient perception, promote shared decision making, and reduce clinic visits. Our study may have limited generalizability to other rheumatic disease beyond RA as most of our study is in rheumatoid arthritis. More studies in other rheumatic diseases are needed.
Registration
The protocol was registered in OpenSci Framework (https://doi.org/10.17605/OSF.IO/ZU9XM).
Citation: Kwan YH, Oh L, Ang PK, Xiong Z, Chong PX, Yoon S, et al. (2025) A systematic review of the effectiveness of self-symptoms monitoring with Patient Reported Outcome Measures in rheumatic disease patients. PLoS One 20(12): e0338935. https://doi.org/10.1371/journal.pone.0338935
Editor: Thomas Rulleau, CHU Nantes: Centre Hospitalier Universitaire de Nantes, FRANCE
Received: September 10, 2024; Accepted: November 28, 2025; Published: December 30, 2025
Copyright: © 2025 Kwan et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Data Availability: All relevant data are within the paper and its Supporting information files.
Funding: This study received grant funding from SingHealth Duke-NUS Academic Medical Centre through grants Pitch-For-Funds 03/FY2024/P2/26-A148 and AM-HEARTS AM/HRT048/2025 (SRDUKAMR25H8), and from the National Medical Research Council of Singapore through grant PHRGNIG24jul-0002 to Dr Kwan Yu Heng. The study also received grant funding from Reverie Rheumatology Research Fund (SPERO program – 03/FY2020/EX/13-A56) to A/Prof Warren Fong. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
Introduction
Rheumatic diseases are one of the most common chronic diseases worldwide [1]. Some examples include rheumatoid arthritis, spondylarthritis and psoriatic arthritis. The goals of treatment in rheumatic diseases are to achieve remission or low disease activity [1]. Therefore, symptom monitoring is crucial as it is a cornerstone for management of rheumatic diseases [2,3]. Usual clinical care encompasses clinicians conducting a detailed history of symptoms patients are experiencing, which can be time-consuming. Patients may also find it difficult to accurately articulate their symptoms during visits, which can lead to suboptimal treatment decisions and poor disease control [4]. Frequent symptom monitoring also requires additional follow-up visits. However, long waiting times can be cumbersome and reduce patient compliance to follow-up visits. For example, a study in Malaysia reported an average waiting time of 1–2 hours for a consultation of only 10–15 minutes [5]. In patients with well-controlled symptoms, follow-up visits can be reduced.
Patient-reported outcome measures (PROMs) are useful tools to assess a patient’s quality of life from the patient’s perspective through a series of standardized and validated questionnaires [2]. Therefore, PROMs provide a unique opportunity in chronic disease management. Clinicians can use PROMs in routine patient care to monitor disease progression prior to patient visits to aid in effective treatment selection. Clinical manpower can be utilized more effectively by prioritizing patients with acute symptoms and reduce visits for patients with well-controlled symptoms, saving time and costs [6]. PROMs can also improve patient-physician communications by allowing patients to discuss their symptoms [7,8]. Additionally, providing feedback on PROM scores can encourage patients to track their symptoms regularly, and empower them with skills to manage their conditions better [8,9]. However, the effectiveness of feedback on PROMs with regards to effects on patient outcomes remain inconclusive [10].
Prior systematic reviews have ranged from evaluating the effects of PROMs feedback intervention in oncology [11,12], to evaluating the impact of integrating PROMs in routine pediatric clinical care [13]. A meta-analysis assessed the impact of using PROMs as a remote monitoring intervention in inflammatory arthritis [14]. However, they included studies that did not compare against conventional follow-up care. A scoping review identified the feasibility and utility of electronic PROMs and mobile health technology in rheumatic diseases; however, they did not assess patient outcomes [1]. Studies on rheumatic diseases have ranged from identifying commonly used PROMs in the routine care of rheumatoid arthritis [15], to assessing the impact of integrating PROMs use via qualitative methods from the perspectives of patients with rheumatoid arthritis, clinicians, and other staff [16,17]. To date, there is no comprehensive review that summarizes the effectiveness of PROMs use in self-symptom monitoring in rheumatic diseases.
Therefore, we aimed to provide an up-to-date synthesis of the effectiveness of PROMs use to self-monitor symptoms compared to conventional follow-up care in patients with rheumatic diseases. We also compared the effect of providing PROMs feedback to patients and/or healthcare professionals to a control group in which PROMs feedback was not provided.
Methods
This study was conducted with reference to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines [18]. The protocol of this review was lodged in the OpenSci Framework [19]. (https://doi.org/10.17605/OSF.IO/ZU9XM).
Search strategy
A systematic search was performed in October 2023 in PubMed, Embase, Cochrane Library Database and PsycINFO. The search terms were chosen in a way that any description that resembled or related to the use of PROMs to self-monitor symptoms in patients would be discovered by the search (S1 Table). Additional articles were identified by examining the reference lists of reviewed articles. The search was updated as of December 2024 and the start date for articles was unrestricted.
Study selection
The study selection consisted of a two-phase process performed by two researchers. Two independent researchers (LO and PK) reviewed the database search results based on the titles and abstracts according to the inclusion and exclusion criteria. Articles that were unclear were carried forward into the full-text review. Full-text reports were sourced and independently evaluated by the same two reviewers (LO and PK). A third reviewer (ZH) was consulted in the event of a disagreement between the two researchers to independently assess the article.
Studies were eligible for inclusion when they used a PROM as an intervention for self-symptom monitoring in patients, with or without feedback to patients or healthcare professionals, compared with not using a PROM. Feedback received could be a summary of results or treatment advice based on the results of the PROM. Patients (18 years old or greater) with rheumatic diseases were included, and no specific care settings were in- or excluded. Randomized control trials, cohort studies, case control studies, case series and case reports were included. Studies were excluded if they were non-English language articles and abstract-only publications.
Data extraction
Two reviewers (LO and PK) used a standardized data extraction form to independently extract data. The following study characteristics were extracted from each study: author, year, country, setting, study population, number of participants, study design, intervention, control, method in which PROMs are implemented and frequency (Table 1).
Risk of bias
Risk of bias evaluation of all included studies was performed independently by the same two reviewers using the Cochrane Collaboration Risk of Bias (ROB) Tool for randomized controlled trials [20]. The Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) was used to assess non-randomized studies [21]. These tools are crucial in evaluating the quality of evidence by identifying potential bias and limitations of the included studies which may influence the interpretation of findings in this systematic review.
Data synthesis and analysis
Two independent reviewers (LO and PK) performed data synthesis and analysis. Extracted outcomes and experiences were synthesized in a narrative matter and categorized into one of five categories: health-related quality of life (HRQoL), symptoms/morbidity, patient perception (level of understanding of their disease, patient satisfaction regarding care), process indicators (number of topics discussed, management/treatment actions, patient-doctor communication), and clinic outcomes (reduction in number of clinic visits). Subsequently, we compared the effect of providing feedback via PROMs to a control group in which PROMs feedback was not provided.
Results
Study characteristics
After removal of duplicates, 18,159 references were identified through the initial search. After screening the titles and abstracts, forty-five articles were eligible for full-text review. During full-text screening, 18 were identified as potential review articles for hand-searching. 3 additional studies were included by searching the reference lists of previously published literature reviews [22–24]. Out of 27 primary literature, 6 studies met the inclusion criteria. As such, a total of 9 articles were included in the final analysis (Fig 1).
Of the included studies, 6 (67%) were randomized controlled trials while 3 (33%) were cohort studies. All the studies were conducted in an outpatient setting. Patients with various rheumatic conditions such as rheumatoid arthritis, osteoarthritis, axial spondylarthritis and psoriatic arthritis participated in the studies. The full characteristics of the studies are in Table 1.
Majority of the studies were conducted in Europe (n = 6). One study was conducted in China, and two were conducted in the USA. A range of PROMs were used in the studies such as the Rheumatoid Arthritis Disease Activity Index-5 score, Bath Ankylosing Spondylitis Disease Activity Index score, Treatment Satisfaction Questionnaire for Medication, Rheumatoid Arthritis Impact of Disease score, PROMs Hip disability and Osteoarthritis Outcome Score–Physical function short form and Knee disability and Osteoarthritis Outcome Score–Physical function short form. The Routine Assessment of Patient Index Data-3 (n = 5) was the most used PROMs.
Risk of bias
S2 Table summarizes the risk of bias of RCT studies using the Cochrane RoB Tool [20]. Only one study was rated to be at high risk of bias [25]. Bias from the randomization process was high as the method of randomization was not stated. The extent of missing outcome data was not reported, and sensitivity analyses were not conducted to correct for potential bias [25]. Additionally, the investigators were not blinded.
S3 Table summarizes the risk of bias of non-randomized studies using the ROBINS-I tool [21]. Two studies were rated to be of moderate risk of bias [26,27], while one study was rated to be of low risk [28]. The moderate risk of confounding in the two studies was attributed to baseline differences between the groups. The study by Shaw et al was rated to be of moderate risk for missing data as it lacked measures of disease activity for patients with undifferentiated arthritis [27]. Furthermore, information on the proportion of missing outcome data was missing between the intervention groups. Another study lacked information on the extent of missing data [26].
PROM as intervention compared with not using a PROM
All nine included studies compared the use of a PROM as an intervention to no PROM use as a control [22–27,29,30]. In six studies, PROM scores were provided to both the healthcare professional and the patient [22–24,27–30]. Feedback in the form of PROM scores was provided only to the patient in two studies [25,26], and scores were only available to the healthcare professional if the patient proactively shared them [25]. Lastly, in one study, PROM scores were only provided to the healthcare professional [28] (Table 2).
Symptoms and morbidity
Symptoms control/morbidity was the most assessed outcome in evaluating PROM interventions.
In terms of morbidity, three studies did not identify significant differences between the intervention and the control group [25,27]. Solomon et al [28], found that the intervention group had slightly fewer flares reported (25%) compared to the control (28.5%). In Gossec et al [25] the Rheumatic Arthritis Impact of Disease (RAID) changes did not differ between both groups, but both saw improvements in RAID scores at 12 months in rheumatoid arthritis patients. However, Shaw et al [27] found that for patients with higher disease activity at baseline, they were less likely to achieve low disease activity by their last PROM visit but were likely to have improved disease activity clinically as determined by the physician. The study looked at patients with rheumatoid arthritis, axial spondylarthritis and psoriatic arthritis.
Conversely, Seppen et al conducted a non-inferiority trial and established non-inferiority between the intervention and control groups [24]. The mean difference in the Disease Activity Score-28 for Rheumatoid Arthritis with Erythrocyte Sedimentation Rate was within the noninferiority limit of –0.04, in favor of the intervention group (95% CI –0.39, 0.30). This resulted in a 38% decrease in rheumatologist consultations in rheumatoid arthritis patients with low disease activity. Additionally, four studies showed an improvement in symptom control in the intervention group [22,23,29,30]. Salaffi et al found that a higher percentage of patients in the intervention achieved remission (P < 0.01), and the time to achieve remission was significantly shorter [22]. Three randomized controlled studies reported that the intervention group had lower disease scores [23,29,30].
HRQoL
Pers et al reported that the intervention group had significant improvements in HRQoL with the use of PROMs, with all Short Form-12 domains showing a greater increase [23].
Patient perception
Five studies reported on patient perception regarding patient-physician communication, quality of care, and the app used to administer PROMs [22–25,30].
While four of the studies did not report whether the results were statistically significant, high patient satisfaction was observed in the intervention groups in these categories. Only one study reported that there was no statistically significant difference between the intervention and control groups in their satisfaction towards health care [24].
Shared Decision Making (SDM)
Shaw et al reported that the PROMs use with feedback group was more likely to be satisfied with SDM and physician disease tracking, whereas the PROMs-only group had similar levels of satisfaction as compared to the non-PROM users [27].
Process indicators
Two studies reported on patient-physician interaction with mixed results [24,25]. Seppen et al [24] did not find any significant differences between the groups. However, Gossec et al [25] reported that there was a significant difference between the groups (intervention vs control), with a small improvement in the patient-physician interaction score, measured using the Perceived Efficacy in Patient-Physician Interactions-5 score.
Lee et al [30] interviewed the physicians providing care to the participants with mixed responses. Of the responses collected, 27% felt that collecting information on PROMs via an app led to earlier medication changes, 45% felt that it did not improve communication and 9% felt that it increased their workflow instead.
Clinic outcomes
Three studies investigated the change in clinic visits [23,24]. In the randomized controlled trial by Seppen et al [24], the number of telephone consultations and outpatient clinic visits in the intervention group was significantly lower. The total visit rate ratio was lower compared to the control group (P < 0.01). Another study reported that while the total number of physical visits reduced in the intervention group, there was an increase in phone-call visits [23]. This resulted in no statistical significance observed in terms of total number of visits (i.e., sum of physical and phone-call visit) between the intervention and control groups. Solomon et al [28] compared the reduction in monthly visits volume between the intervention and control group, regardless of whether it was before the PROMs was used, or in the same year that the PROMs was used. There was no significant difference in the differences between the two groups.
Others
Ackermans et al [26] found that patients with a higher level of self-efficacy were associated with a higher level of patient empowerment and satisfaction.
In the randomized controlled trial by Seppen et al [24], no significant differences were observed between groups in medication adherence or self-management.
PROMs with feedback to patients and/or healthcare professionals in an intervention group versus PROMs without feedback in a control group
Two studies compared the use of PROMs as intervention with feedback provided to patients, against a control group in which PROMs were also used, but feedback regarding PROM scores was not provided [26,27] (Table 3). In Shaw et al [27], there was an additional intervention group where feedback was provided to both the patient and the physician.
Patient perception
One study did not find significant differences between the two groups in terms of their satisfaction scores or in the patients’ perception of the patient-physician relationship [26].
However, Shaw et al [27] found that the intervention group was more satisfied with using an app to monitor their symptoms. The app was easy to use to document their symptoms, and charts were used to reflect PROMs scores as feedback. This made it easier for the patients to understand their symptoms and discuss their results with their healthcare professional.
Discussion
This systematic review summarizes the evidence of using PROMs in clinical settings. To the best of our knowledge, this is the first systematic review that evaluates the effectiveness of PROMs in the setting of rheumatic diseases, which was the first aim of this paper. We did not find evidence that PROMs use could affect survival and mortality in patients with rheumatic diseases. However, our study revealed that PROMs may improve symptom control, HRQoL, SDM, patient satisfaction and reduce clinic visits.
Our findings were largely consistent with other studies that demonstrated improved patient outcomes in other diseases such as symptom control, HRQoL, SDM, patient satisfaction and reduced clinic visits with the use of PROMs. This is because research has proven that regular collection and symptom monitoring using PROMs improves symptom management [7,12]. It allows clinicians to detect complications quickly, intervene early in patients who require treatment modifications, and therefore take immediate action to reduce the symptom burden on the patient [6]. This contributes to better symptom control and thus, patients can report an improved HRQoL and greater satisfaction. Frequent symptom monitoring also allows clinicians to identify stable patients and thus reduce their appointment frequencies, resulting in fewer visits [6].
While we observed improvements in HRQoL and reduction in clinic visits, an interesting finding from Pers et al [23] was the addition of a clinical case manager (CCM) in addition to PROMs use in the intervention group. Hence, the positive results (e.g., improvement in HQRoL, reduction in physical consultation and the number of trips to the hospital) could be confounded by the additional support of the CCM [23]. Furthermore, the reduction in physical visits may have been due to more phone-call visits being conducted because patients needed reassurance for the lack of physical visits. Another intriguing finding from Solomon et al [28] was that the monthly visit volume remained similar in both groups before and after using the PROM application in the intervention. This could be attributed to factors such as that PROMs are not designed to change visit frequency but are instead validated measures of symptom control; and there were physicians’ concerns about longer time intervals between visits. Longer time intervals for follow-up would require greater laboratory monitoring and patient education [28].
The lack of findings on survival and mortality outcomes differs from other systematic reviews that found that PROMs could increase the survival rate of patients with cancer [11,12]. This could be because patients with rheumatic diseases tend to have longer life expectancy and mortality is likely due to other comorbidities as compared to other chronic diseases like cancer [31]. Better management of rheumatic diseases can help to reduce mortality.
In the second aim of the review, we investigated the effect of providing feedback via an app on PROMs use to patients and/or health care professionals. One study found that feedback increased patient satisfaction [27]. This was attributed to physician feedback providing a platform to talk about their symptoms, facilitating SDM and hence improving physician-patient interactions. Our finding is similar to Graupner et al who also revealed that receiving feedback resulted in better symptom control, higher patient satisfaction and improved patient-physician communication during cancer care [11]. Conversely, another study reported that there was no difference regardless of whether feedback was provided [26]. This could be due to the feedback being provided only over a single visit and the study period was relatively short, hence it might not be conclusive to dismiss its effectiveness. More studies are needed to determine if regular feedback provided over a longer period could improve patient outcomes and satisfaction.
Our study possesses several strengths. We conducted a comprehensive search across four databases and used sensitive search filters to capture as many potentially relevant articles as possible. The rigor of the study was established using the PRISMA statement, which is well regarded as a consensus-based standard.
However, our study also has limitations. The quality appraisal revealed that three of the included studies were of moderate to high risk of bias. Missing outcome data can raise issues to the validity and generalizability of these studies [25–27]. Secondly, the selection and evaluation of articles by the reviewers were subjective in nature and may be prone to judgment bias. Nevertheless, the requirement by PRISMA to have two independent reviewers and the need for a third reviewer to reach a consensus in the case of any discrepancies has helped reduce the risk of judgment bias. Thirdly, the data synthesis was narrative due to large variety across all studies such as PROMs types, evaluated outcomes, feedback given to patient, and follow-up time. It was therefore difficult to perform any type of quantitative synthesis or compare individual studies to each other. Fourthly, as our patient sample primarily consisted of rheumatoid arthritis patients, there was a lack of diversity which limits the generalizability of our findings. Despite this, even though patients with SLE may experience different symptoms and lab results that do not always align with each other, PROMs are still useful for symptom monitoring as well. For example, SLE patients can experience persistent fatigue and pain that affects their HRQoL although their condition may be in remission [32]. However, physicians may not associate these symptoms with SLE and thus may not address these unmet medical needs during consultations. In systemic sclerosis patients, initial symptoms such as fatigue tend to be non-specific and Raynaud’s phenomenon is typically episodic and can be difficult to measure using objective methods. As a result, this often leads to delays in diagnosis and treatment [33]. Fifthly, we acknowledge that the analysis of the effectiveness providing feedback via an app on PROMs would be more comprehensive if the feedback on PROMs was classified through a conceptual framework. However, there is no suitable framework in the current literature that allows for the classification of feedback on PROMs. Lastly, PROMs differ in structure, frequency, administration mode, and associated interventions. For example, even when the PROMs administered to patients is identical, the method of administration may differ. Both studies administered RAPID-3 to patients, but Seppen et al utilized a smartphone application while Pers et al utilized an email-prompted web-based questionnaire [23,24]. The heterogeneity in the implementation of PROMs may result in unexpected differences in the effectiveness of PROMs in symptom monitoring, Nevertheless, despite these limitations, our review still offers valuable insights into the effectiveness of PROMs in symptom monitoring.
Future research could delve into the potential implication of integrating PROMs into clinical practice. With information on patient experience in clinical care and how it influences treatment choices, it aims to enhance personalized care for patients. Additionally, investigating the impact of PROMs on healthcare resource utilization seeks to make healthcare more accessible and affordable. Further studies could also examine the effectiveness of PROMs across a wider range of rheumatic diseases, to support a broader implementation of PROMs into clinical practice.
In conclusion, we found that PROMs use can improve symptom control, HRQoL and reduce clinic visits in rheumatic diseases, particularly in rheumatoid arthritis. There was conflicting evidence on patient satisfaction when providing feedback to the patient and/or healthcare professional. However, providing feedback on PROMs use in rheumatic diseases can facilitate shared decision making. This review has provided evidence that the use of PROMs in clinical care may improve patient outcomes in patients with rheumatic diseases.
Supporting information
S2 Table. Cochrane risk of bias of individual studies.
https://doi.org/10.1371/journal.pone.0338935.s002
(DOCX)
S3 Table. Risk of bias in non-randomized studies of intervention of individual studies.
https://doi.org/10.1371/journal.pone.0338935.s003
(DOCX)
Acknowledgments
The authors would like to thank Ms Wong Suei Nee for helping us to develop our search strategy.
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