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Non-Randomized Study Protocols and Methods (Non-eHealth) (544) Patient-Reported Outcome Measures (PROMs) (275)

Published on in Vol 12 (2023)

Preprints (earlier versions) of this paper are available at https://preprints.jmir.org/preprint/43230, first published .
Digital Outcome Measurement to Improve Care for Patients With Immune-Mediated Inflammatory Diseases: Protocol for the IMID Registry

Digital Outcome Measurement to Improve Care for Patients With Immune-Mediated Inflammatory Diseases: Protocol for the IMID Registry

Digital Outcome Measurement to Improve Care for Patients With Immune-Mediated Inflammatory Diseases: Protocol for the IMID Registry

Authors of this article:

Agnes E M Looijen1 Author Orcid Image ;   Reinier C A van Linschoten2, 3 Author Orcid Image ;   Jan-Dietert Brugma4 Author Orcid Image ;   Dirk Jan Hijnen5 Author Orcid Image ;   Pascal H P de Jong1 Author Orcid Image ;   P Hugo M van der Kuy6 Author Orcid Image ;   Jan A M van Laar7 Author Orcid Image ;   C Janneke van der Woude2 Author Orcid Image ;   Annelieke Pasma1 Author Orcid Image
Article Authors Cited by Tweetations (5) Metrics

    Protocol

    1Department of Rheumatology, Erasmus MC, Rotterdam, Netherlands

    2Department of Gastroenterology and Hepatology, Erasmus MC, Rotterdam, Netherlands

    3Department of Gastroenterology and Hepatology, Franciscus Gasthuis & Vlietland, Rotterdam, Netherlands

    4Department of Outpatient Pharmacy, Erasmus MC, Rotterdam, Netherlands

    5Department of Dermatology, Erasmus MC, Rotterdam, Netherlands

    6Department of Clinical Pharmacy, Erasmus MC, Rotterdam, Netherlands

    7Departments of Internal Medicine and Immunology, Erasmus MC, Rotterdam, Netherlands

    ‡Written on behalf of the Erasmus MC IMID registry steering group

    Corresponding Author:

    Agnes E M Looijen, MD

    Department of Rheumatology

    Erasmus MC

    Dr. Molewaterplein 40

    Postbus 2040

    Rotterdam, 3000 CA

    Netherlands

    Phone: 31 623554548

    Email: a.e.m.looijen@erasmusmc.nl


    Background: Despite enormous clinical improvements, due to better management strategies and the availability of biologicals, immune-mediated inflammatory diseases (IMIDs) still have a significant impact on patients’ lives. To further reduce disease burden, provider- as well as patient-reported outcomes (PROs) should be taken into account during treatment and follow-up. Web-based collection of these outcomes generates valuable repeated measurements, which could be used (1) in daily clinical practice for patient-centered care, including shared decision-making; (2) for research purposes; and (3) as an essential step toward the implementation of value-based health care (VBHC). Our ultimate goal is that our health care delivery system is completely aligned with the principles of VBHC. For aforementioned reasons, we implemented the IMID registry.

    Objective: The IMID registry is a digital system for routine outcome measurement that mainly includes PROs to improve care for patients with IMIDs.

    Methods: The IMID registry is a longitudinal observational prospective cohort study within the departments of rheumatology, gastroenterology, dermatology, immunology, clinical pharmacy, and outpatient pharmacy of the Erasmus MC, the Netherlands. Patients with the following diseases are eligible for inclusion: inflammatory arthritis, inflammatory bowel disease, atopic dermatitis, psoriasis, uveitis, Behçet disease, sarcoidosis, and systemic vasculitis. Generic and disease-specific (patient-reported) outcomes, including adherence to medication, side effects, quality of life, work productivity, disease damage, and activity, are collected from patients and providers at fixed intervals before and during outpatient clinic visits. Data are collected and visualized through a data capture system, which is linked directly to the patients’ electronic health record, which not only facilitates a more holistic care approach, but also helps with shared decision-making.

    Results: The IMID registry is an ongoing cohort with no end date. Inclusion started in April 2018. From start until September 2022, a total of 1417 patients have been included from the participating departments. The mean age at inclusion was 46 (SD 16) years, and 56% of the patient population is female. The average percentage of filled out questionnaires at baseline is 84%, which drops to 72% after 1 year of follow-up. This decline may be due to the fact that the outcomes are not always discussed during the outpatient clinic visit or because the questionnaires were sometimes forgotten to set out. The registry is also used for research purposes and 92% of the patients with IMIDs gave informed consent to use their data for that.

    Conclusions: The IMID registry is a web-based digital system that collects provider- and PROs. The collected outcomes are used to improve care for the individual patient with an IMID and facilitate shared decision-making, and they are also used for research purposes. The measurement of these outcomes is an essential step toward the implementation of VBHC.

    International Registered Report Identifier (IRRID): DERR1-10.2196/43230

    JMIR Res Protoc 2023;12:e43230

    doi:10.2196/43230

    Keywords

    immune-mediated inflammatory diseases; IMID; value-based health care; patient-reported outcomes; web-based; tool; disease; patient; inflammatory; medicine; dermatology; rheumatology; gastroenterology; immunology; quality of life; mHealth; web-based tool; digital system 


    Background

    Immune-mediated inflammatory diseases (IMIDs) represent a group of chronic conditions that share common pathophysiological pathways that cause acute or chronic inflammation [1,2]. Any organ system can be affected, resulting in a broad variety of conditions including inflammatory arthritis (IA), inflammatory bowel disease (IBD), cutaneous inflammatory conditions, and several immunologic disorders [1,2].

    Many IMIDs are treated with immunosuppressive medication, such as biologicals and disease-modifying antirheumatic drugs [1-9]. Over the years, the innovation of management approaches and the development of new treatment options have led to significant improvement in clinical outcomes [1]. However, IMIDs still have a large impact on patients’ lives, including lower quality of life, more disability, and productivity loss [10-12]. Moreover, treatment is also often associated with medication-related adverse events [1,13]. Therefore, we should not only focus on clinical outcomes, such as disease activity measures, but also on outcomes that are relevant for the individual patient.

    These “patient-reported outcomes” (PROs) cover topics, such as fatigue, pain, treatment satisfaction, and quality of life, without interpretation by a health care provider [14]. They are measured with PRO measures that mostly consist of validated questionnaires. The measurement of PROs in daily practice has several potential benefits as they could (1) improve care for the individual patient, (2) provide real-world data for research purposes, and (3) serve as a valuable part in the shift toward value-based health care (VBHC).

    As PROs provide insight in disease burden and its treatment from a patient’s perspective, they could be complementary to conventional clinical measures that are normally used during outpatient clinic visits. The use of PROs in daily practice helps both the physician and patient in preparing the consultation, but also facilitates the prioritization of topics that need to be addressed, resulting in a more efficient and problem-focused consultation [15]. The health care provider may also have the opportunity to tailor the treatment to the patients’ needs and recognize problems that might otherwise be overlooked [15]. Moreover, visualizing PROs over time makes it easier for both patient and physician to monitor progress or deterioration of outcomes [15]. Lastly, measuring and reviewing PROs together with the patients could contribute to shared decision-making [16,17]. All these advantages contribute to a more patient-centered care approach.

    Data generated within registries can also be used for research purposes. These real-world data are very valuable because they, among others, show us the community effectiveness [18]. Community effectiveness studies often show less benefit than efficacy studies or randomized controlled trials. Community effectiveness is determined by the following variables: efficacy, access (coverage), diagnostic certainty, upholding management guidelines by the treating physician, and patient compliance [18]. Furthermore, the organization and delivery of care may differ between medical specialists who treat IMIDs. For example, current rheumatoid arthritis guidelines do not have a laboratory monitoring program for tumor necrosis factor inhibitors, but the European psoriasis vulgaris guideline has one [19-21]. Another example is the use of therapeutic drug monitoring for tumor necrosis factor inhibitors in daily practice, which is more common in IBDs compared to rheumatic diseases [22,23]. The ability to use these data gives us the opportunity to better understand not only the differences between the organization and delivery of care, but also the differences or similarities in clinical outcomes as well as PROs between IMIDs. These data might help us improve the care of the individual patient through direct implementation of our research findings.

    Finally, routine outcome measurements could be the first step toward the implementation of VBHC. VBHC aims to improve care by focusing on value instead of volume [24]. Value is defined as gained health divided by resources spent [24]. Gained health includes clinical outcomes as well as PROs and is therefore broader than we are currently used to [25,26]. As IMIDs are chronic conditions with fluctuating disease activity, longitudinal measurement of outcomes is necessary to evaluate the sustainability of health, incidence of complications, and side effects [25].

    Implementation of longitudinal outcome measurement is currently upcoming. This is challenging because both health care providers and patients may find it time-consuming or impractical [27]. Therefore, there should be a practical way for physicians and patients to report and access these data, which could be through a web-based system. Electronic distribution of surveys before and during outpatient clinic visits has several benefits [28]: (1) patients can fill them out at home, (2) it streamlines the data-entry process, and (3) it allows for computer adaptive testing to reduce user burden. It also allows for easy data visualization and linkage with the electronic health record (EHR) for easy access by the health care providers.

    The IMID registry was developed to implement digital routine outcome measurements in daily practice (1) to improve individual patient care, including shared decision-making, (2) for research purposes, and (3) as a first step toward the implementation of VBHC in patients with an IMID.

    Objectives of the IMID Registry

    The objectives of the IMID registry include (1) improving patient care on an individual level through a patient-centered care approach, including shared decision-making; (2) collecting real-world data for research purposes, including evaluating community effectiveness; and (3) implementing VBHC for patients with IMIDs, for which—in our opinion—collection of patient- and provider-reported outcomes is a fundamental component.


    Study Design

    The IMID registry is a single-center prospective cohort within the Erasmus MC in Rotterdam, the Netherlands. Patients are recruited from the departments of rheumatology, immunology, gastroenterology, and dermatology. A steering committee was also formed and included representatives of all participating departments. All representatives were involved in the design of the registry and selection of outcome measures. The cohort combines provider-reported outcomes and PROs. On request, clinical and administrative data can be exported from the EHR and pharmacy database. These data may include disease activity measures, the number of outpatient clinic visits in a certain time period, laboratory results, and medication, including administration and dosage.

    Patients

    All adult patients diagnosed with one of the following conditions are eligible: IA (rheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis, and spondyloarthritis), atopic dermatitis, psoriasis, IBD (Crohn disease and ulcerative colitis), uveitis, Behçet disease, sarcoidosis, or systemic vasculitis. Patients are excluded if they have insufficient knowledge of the Dutch language or are unable to fill out web-based questionnaires. Health care providers of each department ask eligible patients for informed consent, after which patients are included in their specific trajectory of the registry, which is based on the diagnosis that is made by the treating physician.

    Outcome Measures

    For IBD and IA, the questionnaires were aligned with the corresponding International Consortium for Health Outcomes Measurement (ICHOM) outcome sets to make sure that all recommended questionnaires were included in the registry [29,30]. Generic and disease-specific outcomes that are used for each diagnosis include disease activity, disease damage as a result of active disease or complications (eg, changes in anatomy, physiology, pathology, or function), disease-specific and generic quality of life, treatment satisfaction, side effects, medication adherence, beliefs about medication, work productivity, disability, fatigue, and substance use. If available, validated questionnaires are used to measure these PROs. To reduce patient burden, the shortest versions of the questionnaires are used. See Table 1 for overarching outcomes and Table 2 for disease-specific outcomes. These outcomes can be linked to data from the EHR, such as medication, health care use, and disease duration.

    Table 1. Generic outcomes and questionnaires.
    Outcome measureUsed questionnaireTime point


    		Baseline3 months6 monthsYearlyIndicated time (minutes)
    Treatment

    		Side effectsa
    		✓✓✓✓<0.5

    		Beliefs about medicationBMQb necessity-concerns differential [31,32]✓

    		✓1.5

    		Medication adherenceMARS-5c [33]
    		✓✓✓0.5

    		Treatment satisfactionVASd 0-100✓✓✓✓0.5
    Disease impact

    		Quality of lifeEQ-5D-5Le [34,35]✓✓
    		✓1

    		Quality of lifePROMIS-10f [36,37]

    		✓✓1.5

    		Quality of lifeSF-36g,h [38,39, 40]

    		✓✓4.5

    		FatigueNRSi 0-10✓✓✓✓0.5

    		Work disabilityWPAIj [41]✓

    		✓1

    		Physical activityiPAQk short form [42,43]h✓✓
    		✓3

    		ParticipationParticipation scale [44]h✓✓
    		✓3.5

    aQuestionnaire reported by patients and physician.

    bBMQ: Beliefs About Medicine Questionnaire.

    cMARS-5: 5-item Medication Adherence Report Scale.

    dVAS: visual analog scale.

    eEQ-5D-5L: 5-level EQ-5D.

    fPROMIS-10: 10-item Patient-Reported Outcomes Measurement Information System.

    gSF-36: RAND 36-item short form survey.

    hThese questionnaires were used earlier, but are not part of the questionnaire set anymore.

    iNRS: numeric rating scale.

    jWPAI: Work Productivity and Activity Impairment Questionnaire.

    kiPAQ: International Physical Activity Questionnaire.

    Table 2. Disease-specific outcomes and questionnaires.
    Disease group, disease, and questionnaires usedOutcome measure

    		Disease activityDamageQuality of lifeOtheraIndicated time (minutes)
    Inflammatoryarthritis

    		DASb-28c [45]✓




    		Disease damagec
    		✓

    		<0.5

    		HAQ-DId [46,47]


    		✓2.5

    		DMARDe side effectsc


    		✓<0.5

    		BASDAIc,f (spondyloarthritis) [48,49]✓


    		1
    Inflammatory bowel disease

    		IBDg-control-8 [50,51]✓


    		1

    		iMTAh PCQi [52]

    		✓
    		1

    		Manitoba IBD Index [53]✓


    		0.5

    		Montreal classificationc,j [54]

    		✓
    		0.5

    		Disease damagej
    		✓

    		<0.5

    		IBDQk [55]j

    		✓
    		5.5

    		Harvey Bradshaw Index (Crohn disease) [56]j✓


    		0.5
    Immunology

    		BDCAFl,m (Behçet disease) [57]✓


    		2.5

    		Sarcoidosis disease activityc (sarcoidosis)✓


    		0.5

    		VFQn-25 (uveitis) [58]

    		✓
    		10

    		BVASc,o (vasculitis) [59]✓


    		0.5

    		VDIc,p (vasculitis) [60]
    		✓

    		0.5
    Dermatology

    		ADCTq [61]✓


    		0.5

    		NRSr disease burdenc
    		✓

    		0.5

    		DLQIs [62]
    		✓

    		1.5

    		PGAt or IGAu scalec✓


    		<0.5

    		PASIc,v (psoriasis) [63]✓


    		0.5

    		POEMw (atopic dermatitis) [64]✓


    		1

    		EASIx (atopic dermatitis) [65]✓


    		1

    aQuestionnaires involving side effects, physical functionality, and productivity loss.

    bDAS: Disease Activity Score.

    cQuestionnaire reported by physician only.

    dHAQ-DI: Health Assessment Questionnaire Disability Index.

    eDMARD: disease-modifying antirheumatic drug.

    fBASDAI: Bath Ankylosing Spondylitis Disease Activity Index.

    gIBD: inflammatory bowel disease.

    hiMTA: Institute for Medical Technology Assessment.

    iPCQ: Productivity Cost Questionnaire.

    jThese questionnaires were asked earlier, but are not part of the questionnaire set anymore.

    kIBDQ: Inflammatory Bowel Disease Questionnaire.

    lBDCAF: Behçet Disease Current Activity Form.

    mQuestionnaire reported by patients and physician.

    nVFQ: Visual Function Questionnaire.

    oBVAS: Birmingham Vasculitis Activity Score.

    pVDI: Vasculitis Damage Index.

    qADCT: Atopic Dermatitis Control Tool.

    rNRS: numeric rating scale.

    sDLQI: Dermatology Life Quality Index.

    tPGA: patient global assessment.

    uIGA: Investigator’s Global Assessment.

    vPASI: Psoriasis Area and Severity Index.

    wPOEM: Patient-Oriented Eczema Measure.

    xEASI: Eczema Area and Severity Index.

    Generic Outcomes

    Patient- and Physician-Reported Side Effects

    Because health care providers might underreport side effects, both patients and physicians are asked about the occurrence of side effects [66]. If any side effects occur, respondents are asked to clarify the time of onset, severity, and if there are any persisting side effects after medication dosage was changed or stopped. The physician is asked to clarify if medication is switched or if additional medication (eg, antibiotics) is needed.

    Beliefs About Medication

    The Beliefs About Medicine Questionnaire has been validated for assessing medication beliefs in patients with somatic chronic illnesses and consists of a specific and general section [31,32]. For this cohort, we only use the “specific” section that measures patient beliefs about the necessity of prescribed medication to treat their disease and their concerns about potential adverse events of taking the medication. All questions are rated on a 5-point Likert scale. Higher scores indicate stronger beliefs about necessity of their medication or concerns.

    Medication Adherence

    The 5-item Medication Adherence Report Scale is used to assess nonadherence to medication using a 5-point Likert scale [33]. It addresses nonadherence in a nonjudgmental way, encourages patients to answer truthfully and avoid socially desirable answers. Higher scores indicate higher levels of self-reported adherence.

    Treatment Satisfaction

    Patients are asked to indicate their feeling of satisfaction with the effect of their current treatment on disease activity on a visual analog scale (VAS) from 0 to 100. Higher scores indicate higher treatment satisfaction.

    Fatigue

    This questionnaire asks patients to rate their fatigue level in the last 7 days using a numeric rating scale of 1 to 10. A higher score corresponds with more fatigue experienced.

    (Health-Related) Quality of Life

    (Health-related) quality of life is measured with 2 different questionnaires: the 5-level EQ-5D and the Patient-Reported Outcomes Measurement Information System (PROMIS-10) [34-37]. The 5-level EQ-5D is used to measure utility scores based on the Dutch reference values and consists of 5 questions representing 5 dimensions of health, namely, mobility, self-care, daily activities, pain and discomfort, and anxiety and depression [34,35,67]. Each dimension can be scored on a 5-point Likert scale. Higher scores indicate more reported problems in the stated health dimension. The sixth question consists of a VAS general health.

    The PROMIS-10 measures general health-related quality of life using 10 questions on physical, mental, and social health, pain, fatigue, and overall perceived quality of life [36,37]. Answers are given using a 5-point Likert scale or a VAS from 0 to 10. Outcomes are summarized into a summary score for global physical health and global mental health with accompanying t scores that compare the patients’ health to the general population.

    Work Productivity

    The Work Productivity and Activity Impairment questionnaire [41] measures sick leave or unemployment (absenteeism) and work impairment due to the disease (presenteeism) during the past 7 days. The questionnaire contains 6 questions regarding the effect of disease on work and productivity.

    Other Questionnaires

    Over the years, some of the used questionnaires have changed or have been adapted based on feedback from health care providers and patients. These questionnaires are shown in Tables 1 and 2.

    Disease-Specific Outcome Measures

    For each disease (group), disease-specific outcome measures were chosen. They cover outcomes about disease activity and damage, quality of life, functional ability, side effects, and productivity loss. These outcome measures along with their accompanying questionnaires are shown in Table 2.

    Patient and Public Involvement

    Patients were not involved in the design of the registry, but our patient participation panel and included IMID registry patients will be regularly asked to evaluate the questionnaire system, including the number and relevance of the questionnaires. The registry will be optimized based on their feedback.

    Data Collection

    To limit user burden, the questionnaires are divided over different time points. At baseline and 2 weeks before the outpatient clinic visits, an invitation to fill out new questionnaires is sent to the patient by email. The health care providers fill out the surveys during or right after the consultation. After 1 year, the questionnaires are filled out yearly. However, an exception is made for patients with IA, IBD, and atopic dermatitis, because they are asked to fill out questionnaires before each outpatient clinic visit or at fixed intervals, which were added on request of the participating departments. Surveys are filled out using a web-based questionnaire form (LimeSurvey) [68]. The questionnaires are managed by a data capture system (GemsTracker) [69], which is integrated in the EHR.

    Data Visualization

    Data are accessible through a web-based form, which is linked to the EHR. PRO scores are shown in the same manner as, for example, laboratory results and are also directly accessible through the EHR and visualized in graphs over time. For IA and atopic dermatitis, a dashboard has been developed, which allows visualization of several outcome measures over time in a comprehensive manner.

    Training and Monitoring of the Implementation Process

    Group trainings were given at the participating departments on the usage of the registry and how to access the data from the EHR. During the implementation phase, health care providers were supported during their consultations on the use of the data and how to discuss and interpret the PRO outcomes with the patients, including shared decision-making. Every 3 months, the IMID steering group comes together to discuss the progress of the registry, and every month multidisciplinary (scientific) meetings are held for all participating health care providers.

    Ethics Approval

    The IMID registry is a quality of care improvement initiative. Therefore, written informed consent is not mandatory for this purpose. Patients are asked by their health care provider to participate and give oral informed consent. In the web-based questionnaire form, they can opt-in for the use of their pseudonymized data for future scientific research. The Medical Ethics Committee of the Erasmus MC deemed the study to not be subject to Dutch law (WMO; Medical Research Involving Human Subjects Act) and provided a waiver (MEC-2018-1075).


    The IMID registry is an ongoing cohort with no end date. Inclusion started in April 2018. Until September 2022, a total of 1417 patients have been included in the registry. The included patients belong to the dermatology (n=477, 34%), immunology (n=153, 11%), gastroenterology (n=327, 23%), and rheumatology (n=460, 32%) departments.

    The mean age at inclusion was 46 (SD 16) years, and 56% of the included patients are female. In Table 3, the demographics and baseline response rates are given, stratified for medical specialty. A total of 84% of patients filled out their questionnaires at baseline, which declined to 72% after 1 year of follow-up. In addition, a total of 92% of patients gave written informed consent for usage of their pseudonymized data for research purposes.

    Table 3. Demographics and baseline response rate stratified for medical specialty.
    Medical specialtyResponse rate,a n (%)Age (years), mean (95% CI)Sex (female), %
    Dermatologyb (N=477)378 (79)41 (39-42)43
    Immunologyc (N=153)126 (82)50 (47-52)58
    Gastroenterologyd (N=327)314 (96)46 (44-47)53
    Rheumatologye (N=460)415 (90)49 (47-51)68

    aPercentage of patients who filled in the patient satisfaction questionnaire at baseline.

    bAtopic dermatitis, psoriasis, and unclassified dermatologic diseases.

    cUveitis, Behçet disease, sarcoidosis, and systemic vasculitis.

    dCrohn disease and ulcerative colitis.

    eRheumatoid arthritis, psoriatic arthritis, juvenile idiopathic arthritis, and spondyloarthritis.


    The IMID registry is a web-based system linked to the EHR that collects provider-reported outcomes and PROs. These outcomes are not only used to improve care for the individual patient with IMIDs including facilitation of shared decision-making, but they are also used for research purposes. Moreover, routine outcome measurements are an essential component in the implementation of VBHC. The registry has been used by the departments of rheumatology, gastroenterology, dermatology, and immunology, since 2018. Over the years, the outcome sets have been improved and adapted based on feedback from health care providers, patients, and current scientific insights. During the first 4 years, more than 1400 patients were included, which represents a broad uptake from all participating departments.

    Previous publications have shown that patients with IMIDs may cope with lower quality of life, more disability, increased fatigue, pain, and productivity loss, but they also have more psychiatric comorbidity and medication-related adverse events [1,10-13,70]. The questionnaires were chosen to cover all aforementioned topics in a comprehensive manner to best reflect our overall health status of patients with IMIDs, but we also included the domains that matter most to our patients.

    We chose to use generic questionnaires for several types of IMIDs, since these diseases may share common problems and patients may suffer from overlapping conditions within the IMID spectrum [1]. These diseases also share treatment strategies that may cause similar adverse events [1-9,13]. Generic questionnaires about these topics may lead to (1) evaluation of outcomes across patients with different conditions, (2) feedback from a larger patient-panel, and (3) improvements through the steering group’s broad perspective.

    Although the IMID registry has improved over the years, the cohort has some limitations. First, patients did not participate in the design of this registry. Currently, the IMID registry has been evaluated by 42% (n=467) of the patients that filled out a questionnaire in the past year. The survey included questions on the use of the system and length and content of the questionnaires. They also provided feedback on which topics they would like to discuss during consultations. The registry was adjusted based on their feedback. A couple of examples are rephrasing of some questions to make them more understandable, lowering the number of questionnaires before each visit, and changing the user interface to make them accessible for phone or tablet users. These evaluation rounds will be planned regularly.

    The generalizability of the registry might be limited due to selection bias. Not all treating physicians use the registry during their outpatient clinic visits, and also not all patients are included or fill out their questionnaires. This could be due to the fact that patients cannot read or understand Dutch, have problems using a digital system, or the fact that the PROs are not discussed during consultation. Moreover, only patients who need specialized care are treated at the Erasmus MC. Finally, patients who tend to avoid care may cause nonresponse or selection bias. Although most of the included patients filled out their questionnaires at baseline, this percentage declines during follow-up. This is partly due to patients not filling out the questionnaires, but also on occasion, the questionnaire were not sent to the patient before the follow-up visit. In the near future, we hope to address these limitations by automatic inclusion of patients, giving them the opportunity to fill out questionnaires in the waiting room as well as by providing validated questionnaires in different languages. Providing more information about the use of the data, automatic distribution of questionnaires, as well as providing feedback about the filled out questionnaires during every consultation could also increase the response rate during follow-up.

    We will also keep improving the IMID registry to optimize its relevance and feasibility. Currently, data are collected and visualized using a separate data collection tool, which is linked to the EHR. In the future, we will incorporate data collection directly into the EHR, as well as making it possible for the patient to visualize the data in a mobile app. Although routine outcome measurements are—in our opinion—a fundamental component in the implementation of VBHC, we hope to incorporate more VBHC principles in the future, as well as collaborating with other hospitals in the region, which has already been established for IBD and will soon be established for rheumatology [71].

    In conclusion, the IMID registry provides a web-based outcome measurement system, which could facilitate the principles of VBHC, improve care on an individual patient level, and provide real-world data for research purposes.

    Data Availability

    Data are available from the corresponding author on reasonable request.

    Authors' Contributions

    All authors were involved in the writing or revision of the manuscript and approved the final version. JDB, JAMvL, DJH, PHPdJ, PHMvdK, and CJvdW were part of the IMID registry steering group and took part in the design or evaluation of the cohort.

    Conflicts of Interest

    CJvdW received grants and fee for advisory boards and presentations from Pfizer, Abbvie, Celltrion, Falk Benelux, Takeda, Janssen, and Ferring outside the submitted work. DJH is an investigator for AbbVie, Almirall, LEO Pharma, AstraZeneca, Novartis, and Sanofi and a consultant for Abbvie, Sanofi, LEO Pharma, AstraZeneca, Novartis, Janssen, Pfizer, and Lilly.

    1. Kuek A, Hazleman BL, Ostör AJK. Immune-mediated inflammatory diseases (IMIDs) and biologic therapy: a medical revolution. Postgrad Med J 2007;83(978):251-260 [FREE Full text] [CrossRef] [Medline]
    2. McInnes IB, Gravallese EM. Immune-mediated inflammatory disease therapeutics: past, present and future. Nat Rev Immunol 2021;21(10):680-686 [FREE Full text] [CrossRef] [Medline]
    3. Smolen JS, Landewé RBM, Bijlsma JWJ, Burmester GR, Dougados M, Kerschbaumer A, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2019 update. Ann Rheum Dis 2020;79(6):685-699 [FREE Full text] [CrossRef] [Medline]
    4. van der Heijde D, Ramiro S, Landewé R, Baraliakos X, Van den Bosch F, Sepriano A, et al. 2016 update of the ASAS-EULAR management recommendations for axial spondyloarthritis. Ann Rheum Dis 2017;76(6):978-991 [FREE Full text] [CrossRef] [Medline]
    5. Gossec L, Baraliakos X, Kerschbaumer A, de Wit M, McInnes I, Dougados M, et al. EULAR recommendations for the management of psoriatic arthritis with pharmacological therapies: 2019 update. Ann Rheum Dis 2020;79(6):700-712 [FREE Full text] [CrossRef] [Medline]
    6. Lamb CA, Kennedy NA, Raine T, Hendy PA, Smith PJ, Limdi JK, IBD guidelines eDelphi consensus group, et al. British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut 2019;68(Suppl 3):s1-s106 [FREE Full text] [CrossRef] [Medline]
    7. Hatemi G, Christensen R, Bang D, Bodaghi B, Celik AF, Fortune F, et al. 2018 update of the EULAR recommendations for the management of Behçet's syndrome. Ann Rheum Dis 2018;77(6):808-818. [CrossRef] [Medline]
    8. Baughman RP, Valeyre D, Korsten P, Mathioudakis AG, Wuyts WA, Wells A, et al. ERS clinical practice guidelines on treatment of sarcoidosis. Eur Respir J 2021;58(6):2004079. [CrossRef] [Medline]
    9. Golbari NM, Porter ML, Kimball AB. Current guidelines for psoriasis treatment: a work in progress. Cutis 2018;101(3S):10-12. [Medline]
    10. Jacobs P, Bissonnette R, Guenther LC. Socioeconomic burden of immune-mediated inflammatory diseases—focusing on work productivity and disability. J Rheumatol Suppl 2011;88:55-61. [CrossRef] [Medline]
    11. Russell AS, Gulliver WP, Irvine EJ, Albani S, Dutz JP. Quality of life in patients with immune-mediated inflammatory diseases. J Rheumatol Suppl 2011;88:7-19. [CrossRef] [Medline]
    12. Spierings J, Sloeserwij A, Vianen ME, de Boer JH, Sigurdsson V, van de Wijgert JHHM, et al. Health-related quality of life in patients with immune mediated inflammatory diseases: a cross-sectional, multidisciplinary study. Clin Immunol 2020;214:108392 [FREE Full text] [CrossRef] [Medline]
    13. van Lint JA, Jessurun NT, Hebing RCF, Hoentjen F, Tas SW, Vonkeman HE, et al. Patient-reported burden of adverse drug reactions attributed to biologics used for immune-mediated inflammatory diseases. Drug Saf 2020;43(9):917-925. [CrossRef] [Medline]
    14. U.S. Department of Health and Human Services FDA Center for Drug Evaluation and Research, U.S. Department of Health and Human Services FDA Center for Biologics Evaluation and Research, U.S. Department of Health and Human Services FDA Center for Devices and Radiological Health. Guidance for industry: patient-reported outcome measures: use in medical product development to support labeling claims: draft guidance. Health Qual Life Outcomes 2006;4:79 [FREE Full text] [CrossRef] [Medline]
    15. Campbell R, Ju A, King MT, Rutherford C. Perceived benefits and limitations of using patient-reported outcome measures in clinical practice with individual patients: a systematic review of qualitative studies. Qual Life Res 2021;31(6):1597-1620. [CrossRef] [Medline]
    16. Bitton A, Onega T, Tosteson ANA, Haas JS. Toward a better understanding of patient-reported outcomes in clinical practice. Am J Manag Care 2014;20(4):281-283 [FREE Full text] [Medline]
    17. Noonan VK, Lyddiatt A, Ware P, Jaglal SB, Riopelle RJ, Bingham CO, et al. Montreal accord on patient-reported outcomes (PROs) use series—Paper 3: patient-reported outcomes can facilitate shared decision-making and guide self-management. J Clin Epidemiol 2017;89:125-135. [CrossRef] [Medline]
    18. Suarez-Almazor ME. In quest of the holy grail: efficacy versus effectiveness in rheumatoid arthritis. J Rheumatol 2002;29(2):209-211. [Medline]
    19. Rigby WFC, Lampl K, Low JM, Furst DE. Review of routine laboratory monitoring for patients with rheumatoid arthritis receiving biologic or nonbiologic DMARDs. Int J Rheumatol 2017;2017:9614241 [FREE Full text] [CrossRef] [Medline]
    20. Singh JA, Saag KG, Bridges SL, Akl EA, Bannuru RR, Sullivan MC, et al. 2015 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol 2016;68(1):1-26. [CrossRef] [Medline]
    21. Pathirana D, Ormerod AD, Saiag P, Smith C, Spuls PI, Nast A, et al. European S3-guidelines on the systemic treatment of psoriasis vulgaris. J Eur Acad Dermatol Venereol 2009;23 Suppl 2:1-70. [CrossRef] [Medline]
    22. Martín-López M, Carmona L, Balsa A, Calvo-Alén J, Sanmartí R, Tornero J, et al. Serum drug levels of biologic agents in the management of rheumatoid arthritis and spondyloarthritis: a systematic review. Rheumatol Int 2018;38(6):975-983. [CrossRef] [Medline]
    23. Eustace GJ, Melmed GY. Therapy for Crohn's disease: a review of recent developments. Curr Gastroenterol Rep 2018;20(5):19. [CrossRef] [Medline]
    24. Porter ME. What is value in health care? N Engl J Med 2010;363(26):2477-2481. [CrossRef]
    25. Porter ME. Measuring health outcomes: the outcome hierarchy, supplement to: What is value in health care? N Engl J Med 2010;363(26):2477-2481. [CrossRef] [Medline]
    26. Porter ME. Value in healthcare, supplement to: What is value in health care? N Engl J Med 2010;363(26):2477-2481. [CrossRef] [Medline]
    27. Boyce MB, Browne JP, Greenhalgh J. The experiences of professionals with using information from patient-reported outcome measures to improve the quality of healthcare: a systematic review of qualitative research. BMJ Qual Saf 2014;23(6):508-518 [FREE Full text] [CrossRef] [Medline]
    28. Mercieca-Bebber R, King MT, Calvert MJ, Stockler MR, Friedlander M. The importance of patient-reported outcomes in clinical trials and strategies for future optimization. Patient Relat Outcome Meas 2018;9:353-367 [FREE Full text] [CrossRef] [Medline]
    29. Oude Voshaar MAH, Das Gupta Z, Bijlsma JWJ, Boonen A, Chau J, Courvoisier DS, et al. International Consortium for Health Outcome Measurement set of outcomes that matter to people living with inflammatory arthritis: consensus from an International Working Group. Arthritis Care Res (Hoboken) 2019;71(12):1556-1565 [FREE Full text] [CrossRef] [Medline]
    30. Kim AH, Roberts C, Feagan BG, Banerjee R, Bemelman W, Bodger K, et al. Developing a standard set of patient-centred outcomes for inflammatory bowel disease-an international, cross-disciplinary consensus. J Crohns Colitis 2018;12(4):408-418. [CrossRef] [Medline]
    31. Horne R, Weinman J, Hankins M. The beliefs about medicines questionnaire: the development and evaluation of a new method for assessing the cognitive representation of medication. Psychol Health 1999;14(1):1-24. [CrossRef]
    32. de Ridder D, Theunissen N. De rol van ziektepercepties in therapietrouw bij hypertensie. Gedrag en Gezondheid 2003;31(4):237-245.
    33. Chan AHY, Horne R, Hankins M, Chisari C. The medication adherence report scale: a measurement tool for eliciting patients' reports of nonadherence. Br J Clin Pharmacol 2020;86(7):1281-1288 [FREE Full text] [CrossRef] [Medline]
    34. EuroQol Group. EuroQol—a new facility for the measurement of health-related quality of life. Health Policy 1990;16(3):199-208. [CrossRef] [Medline]
    35. Herdman M, Gudex C, Lloyd A, Janssen M, Kind P, Parkin D, et al. Development and preliminary testing of the new five-level version of EQ-5D (EQ-5D-5L). Qual Life Res 2011;20(10):1727-1736 [FREE Full text] [CrossRef] [Medline]
    36. Gershon RC, Rothrock N, Hanrahan R, Bass M, Cella D. The use of PROMIS and assessment center to deliver patient-reported outcome measures in clinical research. J Appl Meas 2010;11(3):304-314 [FREE Full text] [Medline]
    37. Terwee CB, Roorda LD, de Vet HCW, Dekker J, Westhovens R, van Leeuwen J, et al. Dutch-Flemish translation of 17 item banks from the patient-reported outcomes measurement information system (PROMIS). Qual Life Res 2014;23(6):1733-1741. [CrossRef] [Medline]
    38. Ware JE, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. Med Care 1992;30(6):473-483. [Medline]
    39. Hays RD RD, Sherbourne CD, Mazel RM. The rand 36-item health survey 1.0. Health Economics 1993;2(3):217-227. [CrossRef]
    40. van der Zee KI, Sanderman R. Het meten van de algemene gezondheidstoestand met de RAND-36, een handleiding. Groningen: Rijksuniversiteit Groningen, Noordelijk Centrum voor gezondheidsvraagstukken 1992 [FREE Full text]
    41. Reilly MC, Zbrozek AS, Dukes EM. The validity and reproducibility of a work productivity and activity impairment instrument. Pharmacoeconomics 1993;4(5):353-365. [CrossRef] [Medline]
    42. Craig CL, Marshall AL, Sjöström M, Bauman AE, Booth ML, Ainsworth BE, et al. International physical activity questionnaire: 12-country reliability and validity. Med Sci Sports Exerc 2003;35(8):1381-1395. [CrossRef] [Medline]
    43. Lee PH, Macfarlane DJ, Lam TH, Stewart SM. Validity of the international physical activity questionnaire short form (IPAQ-SF): a systematic review. Int J Behav Nutr Phys Act 2011;8:115 [FREE Full text] [CrossRef] [Medline]
    44. van Brakel WH, Anderson AM, Mutatkar RK, Bakirtzief Z, Nicholls PG, Raju MS, et al. The participation scale: measuring a key concept in public health. Disabil Rehabil 2006;28(4):193-203. [CrossRef] [Medline]
    45. Prevoo ML, van 't Hof MA, Kuper HH, van Leeuwen MA, van de Putte LB, van Riel PL. Modified disease activity scores that include twenty-eight-joint counts. Development and validation in a prospective longitudinal study of patients with rheumatoid arthritis. Arthritis Rheum 1995;38(1):44-48 [FREE Full text] [CrossRef] [Medline]
    46. Fries JF, Spitz P, Kraines RG, Holman HR. Measurement of patient outcome in arthritis. Arthritis Rheum 1980;23(2):137-145. [CrossRef] [Medline]
    47. Boers M, Jacobs JWG, van Vliet Vlieland TPM, van Riel PLCM. Consensus Dutch health assessment questionnaire. Ann Rheum Dis 2007;66(1):132-133. [CrossRef] [Medline]
    48. Garrett S, Jenkinson T, Kennedy LG, Whitelock H, Gaisford P, Calin A. A new approach to defining disease status in ankylosing spondylitis: the Bath Ankylosing Spondylitis Disease Activity Index. J Rheumatol 1994;21(12):2286-2291. [Medline]
    49. Spoorenberg A, van der Heijde D, de Klerk E, Dougados M, de Vlam K, Mielants H, et al. A comparative study of the usefulness of the Bath Ankylosing Spondylitis Functional Index and the Dougados Functional Index in the assessment of ankylosing spondylitis. J Rheumatol 1999;26(4):961-965. [Medline]
    50. Bodger K, Ormerod C, Shackcloth D, Harrison M, IBD Control Collaborative. Development and validation of a rapid, generic measure of disease control from the patient's perspective: the IBD-control questionnaire. Gut 2014;63(7):1092-1102 [FREE Full text] [CrossRef] [Medline]
    51. de Jong ME, Taal E, Thomas PWA, Römkens TEH, Jansen JM, West RL, et al. Cross-cultural translation and validation of the IBD-control questionnaire in the Netherlands: a patient-reported outcome measure in inflammatory bowel disease. Scand J Gastroenterol 2021;56(2):155-161. [CrossRef] [Medline]
    52. Bouwmans C, Krol M, Severens H, Koopmanschap M, Brouwer W, Hakkaart-van Roijen L. The iMTA productivity cost questionnaire: a standardized instrument for measuring and valuing health-related productivity losses. Value Health 2015;18(6):753-758 [FREE Full text] [CrossRef] [Medline]
    53. Clara I, Lix LM, Walker JR, Graff LA, Miller N, Rogala L, et al. The Manitoba IBD index: evidence for a new and simple indicator of IBD activity. Am J Gastroenterol 2009;104(7):1754-1763. [CrossRef] [Medline]
    54. Satsangi J, Silverberg MS, Vermeire S, Colombel JF. The Montreal classification of inflammatory bowel disease: controversies, consensus, and implications. Gut 2006;55(6):749-753 [FREE Full text] [CrossRef] [Medline]
    55. Russel MG, Pastoor CJ, Brandon S, Rijken J, Engels LG, van der Heijde DM, et al. Validation of the Dutch translation of the Inflammatory Bowel Disease Questionnaire (IBDQ): a health-related quality of life questionnaire in inflammatory bowel disease. Digestion 1997;58(3):282-288. [CrossRef] [Medline]
    56. Harvey RF, Bradshaw JM. A simple index of Crohn's-disease activity. Lancet 1980;1(8167):514. [CrossRef] [Medline]
    57. Bhakta BB, Brennan P, James TE, Chamberlain MA, Noble BA, Silman AJ. Behçet's disease: evaluation of a new instrument to measure clinical activity. Rheumatology (Oxford) 1999;38(8):728-733. [CrossRef] [Medline]
    58. Mangione CM, Lee PP, Gutierrez PR, Spritzer K, Berry S, Hays RD, National Eye Institute Visual Function Questionnaire Field Test Investigators. Development of the 25-item National Eye Institute Visual Function Questionnaire. Arch Ophthalmol 2001;119(7):1050-1058 [FREE Full text] [CrossRef] [Medline]
    59. Luqmani RA, Bacon PA, Moots RJ, Janssen BA, Pall A, Emery P, et al. Birmingham Vasculitis Activity Score (BVAS) in systemic necrotizing vasculitis. QJM 1994;87(11):671-678. [Medline]
    60. Exley AR, Bacon PA, Luqmani RA, Kitas GD, Gordon C, Savage COS, et al. Development and initial validation of the vasculitis damage index for the standardized clinical assessment of damage in the systemic vasculitides. Arthritis Rheum 1997;40(2):371-380. [CrossRef] [Medline]
    61. Simpson E, Eckert L, Gadkari A, Mallya UG, Yang M, Nelson L, et al. Validation of the atopic dermatitis control tool (ADCT©) using a longitudinal survey of biologic-treated patients with atopic dermatitis. BMC Dermatol 2019;19(1):15 [FREE Full text] [CrossRef] [Medline]
    62. Finlay AY, Khan GK. Dermatology Life Quality Index (DLQI)—a simple practical measure for routine clinical use. Clin Exp Dermatol 1994;19(3):210-216. [CrossRef] [Medline]
    63. Fredriksson T, Pettersson U. Severe psoriasis—oral therapy with a new retinoid. Dermatologica 1978;157(4):238-244. [CrossRef] [Medline]
    64. Charman CR, Venn AJ, Williams HC. The patient-oriented eczema measure: development and initial validation of a new tool for measuring atopic eczema severity from the patients’ perspective. Arch Dermatol 2004;140(12):1513-1519. [CrossRef]
    65. Hanifin JM, Thurston M, Omoto M, Cherill R, Tofte SJ, Graeber M. The eczema area and severity index (EASI): assessment of reliability in atopic dermatitis. EASI Evaluator Group. Exp Dermatol 2001;10(1):11-18. [CrossRef] [Medline]
    66. Thomas PWA, Römkens TEH, West RL, Russel MGVM, Jansen JM, van Lint JA, et al. Discrepancy between patient- and healthcare provider-reported adverse drug reactions in inflammatory bowel disease patients on biological therapy. United European Gastroenterol J 2021;9(8):919-928 [FREE Full text] [CrossRef] [Medline]
    67. Versteegh MM, Vermeulen KM, Evers SMAA, de Wit GA, Prenger R, Stolk EA. Dutch tariff for the five-level version of EQ-5D. Value Health 2016;19(4):343-352 [FREE Full text] [CrossRef] [Medline]
    68. LimeSurvey.   URL: https://www.limesurvey.org/ [accessed 2023-02-28]
    69. GemsTracker.   URL: https://gemstracker.org/ [accessed 2023-02-28]
    70. Marrie RA, Walld R, Bolton JM, Sareen J, Walker JR, Patten SB, CIHR Team in Defining the Burden Managing the Effects of Psychiatric Comorbidity in Chronic Immunoinflammatory Disease. Increased incidence of psychiatric disorders in immune-mediated inflammatory disease. J Psychosom Res 2017 Oct;101:17-23 [FREE Full text] [CrossRef] [Medline]
    71. van Linschoten RCA, van Leeuwen N, Nieboer D, Birnie E, Scherpenzeel M, Verweij KE, Southwest Netherlands IBD Study Group. Value-based care pathway for inflammatory bowel disease: a protocol for the multicentre longitudinal non-randomised parallel cluster IBD Value study with baseline period. BMJ Open 2022;12(1):e050539 [FREE Full text] [CrossRef] [Medline]

    ‎
    EHR: electronic health record
    IA: inflammatory arthritis
    IBD: inflammatory bowel disease
    IMID: immune-mediated inflammatory disease
    PRO: patient-reported outcome
    PROMIS-10: Patient-Reported Outcomes Measurement Information System
    VAS: visual analogue scale
    VBHC: value-based health care

    Edited by A Mavragani; submitted 07.10.22; peer-reviewed by P van der Nat, A Allam, A Weel; comments to author 06.12.22; revised version received 30.01.23; accepted 31.01.23; published 30.03.23

    Copyright

    ©Agnes E M Looijen, Reinier C A van Linschoten, Jan-Dietert Brugma, Dirk Jan Hijnen, Pascal H P de Jong, P Hugo M van der Kuy, Jan A M van Laar, C Janneke van der Woude, Annelieke Pasma. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 30.03.2023.

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