Implementing patient-centred outcome measures in palliative care clinical practice. An updated systematic review of facilitators and barriers

Implementing patient-centred outcome measures in palliative care clinical practice. 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An updated systematic review of facilitators and barriers Bárbara Antunes, Stephen Barclay, Isla Kuhn, Kathy Eagar, Claudia Bausewein, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7358185/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 12 Feb, 2026 Read the published version in BMC Palliative Care → Version 1 posted 12 You are reading this latest preprint version Abstract Background . Patient-centred outcome measures (PCOMs), when well implemented, are powerful tools facilitating patient, family and clinical communication to better respond to patient needs throughout the disease trajectory. Their routine use in palliative care practice still faces challenges. Objective . To update a systematic review of PCOMs implementation, reviewing and synthesising new evidence on facilitators, barriers, lessons learned, measures used, models of implementation, costs, implementation outcomes, and consequences in clinical practice. Methods . We searched eight information sources supplemented by hand-searching and citations of the original review and studies identified by the expert advisory committee. This prospectively registered review included studies using a PCOM during clinical care of adult patients with advanced disease in all settings and extracted data on: PCOMs used, models of implementation, facilitators, barriers, lessons learned, costs, and implementation outcomes. We employed narrative synthesis and tabulated findings, following all PRISMA reporting guidelines. Results . We included 114 studies. A major new facilitator was the integration of electronic/digital PCOMs into Information Technology systems. Main barriers remain largely unchanged and relate to healthcare professionals’ beliefs. Implementation was highlighted as a complex intervention, needing planning, assessment and fine tuning throughout. Sixty-two included studies mentioned at least one implementation outcome. Eighteen models, frameworks and theories were identified in 25 included studies. No studies reported on costs of implementation. Conclusion . This updated review reveals a comprehensive body of work regarding the complexity of implementing PCOMs in palliative care clinical practice needing planning, piloting, assessment and fine tuning throughout, at different levels and with all stakeholders involved. Patient-centred outcome measurement patient-reported outcome measurement palliative care systematic reviews implementation barriers facilitators complex interventions Figures Figure 1 Figure 2 Key Statements What is already known about the topic The importance of using patient-centred outcome measures (PCOMs) to understand the effect and effectiveness of health interventions has been established: they are an essential component of evidence-based clinical practice. Data collected at individual patient-level can be used immediately by healthcare professionals to act on any identified distressing symptoms or palliative needs. Despite the development of PCOMs in the past three decades, their routine use in clinical practice remains challenging in most countries. What this paper adds Having a coordinator onsite and training clinicians are key to the initial implementation of PCOMs in clinical practice. Embedding PCOMs at point of care is critical to their ongoing implementation in practice. The integration of electronic/digital PCOMs into Information Technology systems is a new development that is still emerging Evidence is scarce on the models of PCOMs implementation used in clinical practice and their associated financial costs. Implication for practice, theory or policy Successful implementation requires embedding outcome measures at the point of care and tailoring the implementation process to local circumstances and contexts. Constant feedback of patient-level outcomes to clinicians is vital. Implementing PCOMs in palliative care clinical practice is a complex intervention and guidelines and statements on complex interventions should be followed. Background The importance of patient-centred outcome measures (PCOMs) in palliative care clinical practice is well established: they allow for clinical care to respond to real-time need, and longitudinal comprehensive measurement of patient and family outcomes across physical, psychological, existential, emotional, and practical domains [1-5]. When used properly, PCOMs become powerful communication tools, keeping all involved in patient care at the same level of knowledge regarding patient and family outcomes [6-8]. Additionally, PCOMs data, collected at patient level, can be aggregated for audit, research, quality improvement, and benchmarking. Ultimately those data can be used by policy makers to improve patient and family care [9-11]. Regardless of the recognition and importance PCOMs have in patient and family care, their implementation in clinical practice remains challenging [12, 13]. We have updated and expanded a 2013 systematic review on implementation of PCOMs in palliative care. 1 We updated the original review objectives and recommendations and added four more objectives, with review questions as follows: 1. What are the PCOMs implemented in palliative care clinical practice? 2. What are the facilitators to PCOMs implementation in palliative care clinical practice? 3. What are the barriers to PCOMs implementation in palliative care clinical practice? 4. What are the lessons learned on implementing PCOMs in PC clinical practice? 5. What are the implementation models used in PCOMs implementation in palliative care clinical practice? 6. What implementation outcomes were measured and how, when implementing PCOMs in palliative care clinical practice? 7. What are the financial costs of implementing PCOMs in palliative care clinical practice? 8. Are there new recommendations since the previous literature review to inform the implementation process in palliative care clinical practice for all stakeholders? Methods We conducted a systematic literature review and narrative synthesis. PRISMA reporting guidelines were followed, including PRISMA, PRISMA-Abstracts [14] and PRISMA-Search [15]. The review protocol has been published elsewhere in open access [16]; we briefly describe the methods below. On 14 November 2022, we searched MEDLINE, Embase, Emcare, CINAHL, PsycINFO, BNI, Web of Science Core Collections (SSCI, SCI, ESCI), and Scopus with no date, language, publication type, or publication status limitations [17], supplemented by a list of studies recommended by the expert advisory committee and hand-searching references of included studies. We included primary empirical studies using PCOMs in clinical care for adult patients with advanced disease in palliative care settings. We included studies using a PCOM during clinical care of adult patients with advanced disease in all settings and extracted data on: PCOMs used, models of implementation, facilitators, barriers, lessons learned, costs, and implementation outcomes. We used Gough’s Weight of Evidence Framework [18] to appraise each included study’s internal validity, appropriateness and contribution in answering the review questions: studies were weighted by two reviewers independently (B.B., S.E.), with a third consulted if needed (S.B.) to achieve consensus. The narrative synthesis was undertaken in the same way. Finally, we map the updated recommendations, and reiterated those from our previous review, on the updated MRC Framework for Developing and Evaluating Complex Interventions [19]. The Framework has four phases; develop/identify intervention, feasibility testing, evaluation, and implementation. Each of these phases have six core elements: context, programme theory, stakeholders’ engagement, key uncertainties, intervention refinement and economic considerations. We updated the original 2022 search by a scoping search using our main keywords on 9 February 2025 to identify any new relevant studies. Results We included 114 studies (117 reports) [2, 7, 8, 13, 26-138] which are shown in Table 1. The update scoping search identified seven relevant studies [10, 20-25], which confirmed the existing findings rather than adding any new information. Figure 1 depicts the PRISMA flow chart reporting the literature search and selection of articles. Figure 2 shows the distribution of countries where included studies were conducted. Compared to the original review, which yielded studies from 9 countries (United Kingdom, United States, Netherlands, Australia, Canada, Israel, Italy, Malaysia and Vietnam). The appearance of most countries with one study on the map is because of an online multi-country web-based survey from healthcare professionals from these counties; for more details, see Table 1 of Included Studies. Data that cannot be displayed on the map are as follows: United Kingdom (21), Republic of Ireland (6), Italy (4), Netherlands (3), Belgium (2), New Zealand (2), Portugal (2), Denmark (1), Eswatini (1), Greece (1), Japan (1), Lesotho (1), Rwanda (1), Sierra Leone (1), Singapore (1), Taiwan (1), and Thailand (1). In this updated review we present results by objective and provide quotations from studies when relevant. Recommendations are reported using the updated Medical Research Council Framework for Developing and Evaluating Complex Interventions [19]. We use their definition of complex intervention: “ An intervention might be considered complex because of properties of the intervention itself, such as the number of components involved; the range of behaviours targeted; expertise and skills required by those delivering and receiving the intervention; the number of groups, settings, or levels targeted; or the permitted level of flexibility of the intervention or its components .” [PLACE TABLE 1 HERE] 1. PCOMs implemented in clinical practice Just over 70 different PCOMs were reported to be implemented in palliative care clinical practice; half of these were only used once, therefore appearing in only one study each. The Palliative Care Outcome Scale (POS) and its family of measures were the most used family of measures with 30 mentions, followed by the Edmonton Symptom Assessment Scale (ESAS) original, revised and renal with 26 mentions. Australia is the only country that has adopted one measure, the Symptom Assessment Score (SAS) as the national standard, which is used by all specialist palliative care services in the country and the IPOS is the recommended measure for use in UK. See Appendix 1 for the full list of measures by primary studies and reviews. 2. Facilitators of implementing PCOMs in clinical practice Most facilitators remained the same, apart from the facilitator of integration of electronic/digital PCOMs into Information Technology (IT) systems and routine care structures, including user experiences and user interface. “Desirable features focused on hardware (lightweight, durable, and easy to disinfect), software (simple, user-friendly interface, multi-linguistic, integration with e-health systems). ” [113] We changed and added new facilitator categories, for example the “Planning, Process and Logistics” category which includes eight sub-categories: healthcare systems and politics; training, knowledge, perception, and acceptance; organisational culture and structure; team and champions; personal characteristics; patient factors; communication; information flow, action, visible outcomes and time needed to implement. “Senior staff and managers, actively participating in the implementation and use of PCOMs.” [139] See Appendix 2 for the full list of categories and sub-categories of facilitators. 3. Barriers to implementing patient-centred outcome measures in clinical practice The main barriers remain similar to those identified in the original review and are mainly related to healthcare professionals, including: resistance to change, negative attitudes towards changing routine, scepticism regarding the necessity and usability of data collected, and belief that data collection is a burden to patients but also for themselves, given high workload: “ Practitioners were suspicious of ESAS-r use in service evaluation, distrusting accuracy of patients' reports.” [114] “Worry that use of a formal instrument may interfere with, or be meant to substitute for, the patient interview.” [46] Regarding resources, lack of training, time constraints, access to the tool and equipment to support electronic tools, were widely mentioned, as were unwell and complex patients who might not be able to fill the measures or have a rapidly changing condition that they felt the measure might not reflect: “Interviewees criticise that standardised PROs do not adequately reflect the subjective reality of the patients and the complexity of their needs.” [108] Regarding the measures themselves, there were concerns relating to complexity, adaptability, interpretation, individualisation, comprehensibility, timing of use, numerical scoring, acceptability, and lack of consensus on what tool to use and their psychometric properties. See Appendix 3 for the full list of categories and sub-categories of barriers. 4. Lessons learned on implementing PCOMs in clinical practice Implementing a PCOM in palliative care clinical practice is a complex intervention which needs planning, assessment and fine tuning throughout its course at different levels and with all involved.[90] We identified the following, mainly taken from the discussion section of included studies. Guidance. Step by step guides specifically designed to implement PROMs in clinical practice [27, 30]. Clinical Staff . Important to integrate nursing staff in the implementation process early with specific training and feedback. Consider individual attitudes and motivation to use new evidence-based practice. Changes that require clinicians to modify the interpersonal aspects of their care, or that are more complex, may be perceived as more difficult to implement [2, 26, 28, 52, 59, 98, 133]. Measure. Measures must be psychometrically sound and comparable [2, 39, 50, 52, 64]. Measurement frequency. When managing poorly controlled symptoms, measurement is needed multiple times a day [2, 27, 30, 46, 52, 80]. Stability of measures . Once a measure is introduced, there needs to be a commitment for it to remain in place for a long period. Changing versions and measures should not be undertaken lightly as every change requires changes in IT and staff training and comes at a considerable cost [41]. Setting. The context in which measures are introduced and used is important. There are currently no palliative care measures for Intensive Care Unit (ICU) and paediatric palliative care settings. It has been suggested that the use of PCOMs in the palliative radiotherapy settings may not be possible, due to the large variety in pathologies, radiation schemes and treatment indications [30, 39, 50, 51, 61,66, 70, 98, 111, 120]. Implementation. Implementation is a time-consuming and long-term process and needs continuous attention and flexibility. Using the principles of change management, factors other than those relating to individual professionals are important, and greater use of theories of change may help to explain whether change is possible. Using PCOMs in palliative care clinical practice is a complex intervention; organisations’ aims must align with the effort to aid their clinical teams, with quality of care at the forefront as the rationale for implementing PCOMs [27, 43, 44, 46, 48, 49, 52, 90, 120, 124, 133]. Feedback. There is strong evidence for the beneficial impact of PCOMs feedback on processes of care. Patients, family caregivers and health professionals value objective feedback from PCOMs, even in the face of deteriorating health [7, 13, 3, 41, 44, 52, 59]. Patients. It is important to distinguish between patient burden and patients being too unwell to complete measures. Patients who trigger electronic clinical alerts tend to be younger and more recently diagnosed, to have greater comorbidities, and to be from racial/ethnic minority groups. Clinicians and patients perceive that, when used in first assessments, individualised PCOMs supported relationship-building because they enable patients to ‘tell their story’: however, if the clinicians feel they cannot resolve an issue, there is a tendency to disregard and close the conversation [13, 44, 59, 67, 68, 80, 108]. Technology. Future digital health approaches in palliative care require a good understanding of the needs of the target population [26, 28, 35, 39, 98, 100]. See Appendix 4 for full list. 5. Implementation models used when implementing PCOMs A total of 18 models, frameworks and theories were identified as used in just 25 of included studies, most commonly Plan-Do-Study-Act (PDSA) [139], Promoting Action on Research Implementation in Health Services Framework (PARIHS) [140, 141], and Consolidated Framework for Implementation Research (CFIR) [142] PDSA is an iterative, four-stage model that asks three questions: what are we trying to accomplish, how will we know that a change is an improvement and what changes can we make that will result in an improvement? PARISH identifies three key components of the implementation process: evidence, context, and facilitation. Implementation is more likely to occur when evidence is scientifically robust, aligns with practitioner and patient beliefs and local experience, the context is receptive to change, and there is appropriate input from internal and external facilitators. CFIR, updated in 2022, has five domains to guide systematic assessment of potential barriers and facilitators, tailor implementation strategies and needed adaptations, and explain outcomes (individuals, inner setting, outer setting, implementation process and innovation/change to be implemented) [143] See Appendix 5 for a complete list of the implementation models and frameworks identified. 6. Implementation outcomes measured, and how, when implementing PCOMs Sixty-two included studies mentioned at least one implementation outcome. Of the eight implementation outcomes developed by Proctor et al. in 2011 (acceptability, fidelity, feasibility, adoption, appropriateness, penetration, sustainability, and cost [144]), most studies reported only on feasibility of implementing a PCOM or e-PCOM in clinical practice and the acceptability to patients and healthcare professionals of the measure used. Only one study mentioned appropriateness: this was the only study to consider three implementation outcomes [122]. It was concluded that by documenting evidence of pain assessment and screening for spiritual distress, the number of referrals improved and was maintained 12 months and more clinicians agreed that palliative care domains were comprehensively assessed post-intervention [122]. 7. Financial costs of implementing PCOMs No included studies reported on the costs of implementation. Some provided suggestions in relation to costs, for example suggesting that the way to rationalise PCOMs implementation is for these to replace routine procedures [26, 33] or as a complement to existing practices without requiring additional resources [78]. Others suggested that implementation would be costly in the short-term but cost-saving in the long term by reducing the workload [26, 35, 122]. Studies suggested that the possible costs of implementation include: cost of the PCOMs [26, 111]; cost of healthcare staff time and capacity [46]; cost of creating, maintaining and updating electronic systems and integration into existing IT systems [46, 72, 122, 135]; costs to healthcare system of reimbursement and pay-for-performance incentives [35, 46, 97, 126] setting-dependent costs including models of care, clinical competencies and resourcing [41]; unavailability of reimbursement/insurance plans to cover staff time in the US; 46 lack of funding in charitable organisations [111]; and costs associated with the outcomes of implementation including resources to respond to patients’ issues identified [8, 46]. Some solutions were proposed to save costs [8, 26, 46, 49, 55, 107, 122]. See Appendix 6 for a full list of facilitators and barriers regarding financial costs. 8. Updated recommendations for PCOMs implementation Based on the new evidence synthesis, we have updated recommendations, and reiterated those from our previous review, by mapping them on the updated MRC Framework for Developing and Evaluating Complex Interventions [19]. Table 2 presents a summarised description of the recommendations mapped on the MRC Framework in the form of actions. Below, we describe the main considerations arising from those actions. [PLACE TABLE 2 HERE] A. Intervention development/identification Implementation of a PCOM in palliative care can occur in a range of clinical contexts including hospital, home, hospice, or care home. These contexts have different rules, different resources available, and different support from managers and different outcomes the team wish to measure [2, 7, 39, 41, 43, 90, 111,115]. Clinicians may not have experience or training in using PCOMs [26, 27, 43, 52, 66, 133]. Patient populations will differ, being more or less complex and in a more or less advanced stage of illness [13, 35, 51, 52, 90, 98, 111]. Very ill patients may have missing data [2, 51, 59, 90], in which case a PCOM which allows for proxy ratings may be appropriate [2, 39]. These factors will all influence the measure(s) selected [2, 51, 59, 80, 90]. The use of theory to underpin implementation models is generally considered beneficial, as it provides a structured foundation for understanding and guiding the implementation process. From the theories available in the literature, it will be important to select one which is appropriate for the clinical context in which the implementation will be conducted [27, 43, 52, 111, 126]. Engaging stakeholders from the initial planning phase is vital, including: patients, families and other informal caregivers, healthcare professionals from all the teams involved, managers, policy makers, and decision makers [13, 27, 43, 45, 52, 59, 111, 115, 133]. Identification of key uncertainties, including the adjustments to be made during the different steps is key [2, 26, 30, 43, 52, 59, 90, 133]. Consideration needs to be given to: when will patients be asked to complete the measure, who will ask the patient, will patients choose paper or electronic formats, whether a family or staff member will be able to act as a proxy if the patient is unable to complete the measure, will the institution provide IT resources for optimal use of the PCOM information, when will the feedback happen to healthcare professionals and patients, how will responses be used to support or improve patient care (and/or quality improvement), when will the team meet to discuss implementation [7, 13, 35, 41, 44, 52, 59]. Other uncertainties will arise as the implementation moves forward and clinicians become more familiar with the new routine [2, 8, 35, 59, 68, 79, 80, 90,133]. Refining of the intervention can only take place after the team has met to review how the implementation is going and changes needed [45, 90, 133]. Consideration needs to be given in the planning phase to minimising missing data (this appears to improve with electronic data capture), how often will clinicians use the results and how will this be reported, how engaged are all members of the clinical team in the new routine, and other ways to improve the implementation [2, 27, 30, 41, 43, 59]. Economic considerations must be contemplated from the outset [2, 38, 49, 126]: for example, is there additional resource to support the implementation or will this be within current resources and workforce time available [8, 35, 41, 46, 69, 72, 78, 122]; what IT and administrative support will be available initially and long term to store, synthesise and present data from the measure to clinicians [55, 84, 97, 111, 135, 137]. B. Feasibility Feasibility testing, against predefined progression criteria [2, 39, 50], assesses feasibility and acceptability of implementing the PCOM(s) in the clinical setting concerned [2, 13, 39, 52]. This allows decisions to be made about progression to the next stage. Consideration of the optimal way to integrate the use of the measures and the use of their results in clinical practice [2, 59, 90] requires team leads to all be on board and meet periodically to discuss the six core elements as the phase progresses [2, 8, 13, 50, 59, 80, 133]. Context includes the setting where care is delivered, the institutional culture, the staff members involved, the physical setting in which patients will fill in the measure and when they will do so [43, 59, 90, 114, 115, 133]. The theory employed needs review regarding how well it fits with the implementation setting [43, 62, 88, 106]. Stakeholder engagement needs to involve patients and family members, clinicians, decision makers and policy makers [2, 13, 27, 30, 41, 43, 59], in order to understand if it is feasible to implement the selected PCOM, identify key uncertainties and how they will be explored and resolved [27, 52, 133]. One important issue raised in the included papers was the course of action when a patient reports a very high score for one or more items, when that indicates the worst possible state [2, 13, 27, 30, 39, 41,44, 52, 59, 68, 74, 79, 98, 111, 112, 114, 133]. Regarding economic considerations, it is important to understand how much time the clinical, administrative and IT teams will spend on the implementation and whether that will be resourced [2, 27]. C. Evaluation The evaluation phase investigates whether and how the intervention works, the usefulness of the information gained, how it interacts with the clinical context and contributes to improved outcomes for patient and families and system change [27, 44, 45, 46, 50, 59, 80, 90, 98, 126, 133]. Strong networking relationships are likely to be established with formal and informal sectors outside of the organisation [43, 45, 46, 59, 90], including identification of outcomes which capture changes to the wider healthcare system [2, 13, 26, 41, 46, 50, 52, 59, 77]. When refining the theory, it is important to consider the interpretation of data and how it will have an impact on clinical processes and outcomes [43, 62, 88, 106]. If the results of the PCOMs are being used, that should lead to improved levels and quality of care and improved patient and family outcomes [2, 27, 39, 41, 59, 77, 87, 133]. When healthcare professionals are trained to interpret and act on PCOM feedback, care becomes more responsive to patients’ changing needs. Furthermore, using PCOMs systematically allows for benchmarking and continuous quality improvement at an organizational level, creating a feedback loop that fosters accountability and patient-centered service development. These mechanisms can ultimately contribute to better alignment of care with patient goals and improved experiences at the end of life. This underscores the importance of systematically assessing not only whether PCOMs are implemented, but also how they influence clinical practice and patient trajectories. Evaluation should explore the mechanisms through which PCOMs inform care—such as changes in clinical decision-making, timeliness of interventions, or communication with families—as well as measurable improvements in health outcomes and satisfaction. Additionally, the evaluation phase provides an opportunity to examine contextual factors, such as staff engagement or organizational readiness, that may mediate or moderate the impact of PCOM use. Evaluation should primarily focus on the performance and sustainability of measures within routine, long-term practice settings, rather than being limited to isolated or short-term studies [31]. The best example are the PCOC measures which have been collected in Australia continuously for 20 years. D. Implementation After developing and planning the implementation, piloting it, assessing how that first stage went and making changes, it is expected that there will be a “second try” that is better adapted to the reality of each clinical team, as an ongoing process. The six core elements will be unique to each clinical team and dependent on the previous work carried out. If the main issues which arose in the pilot phase were addressed in the evaluation phase, the implementation should run more smoothly with less issues to resolve, as illustrated in the Tavares AP et al. study describing all four steps of implementing a PCOM in an inpatient palliative care service [133]. By rigorously evaluating these components, we can determine whether and how PCOMs contribute to better patient-centred outcomes and generate transferable insights to guide future implementation and scale-up. Discussion This updated review highlights the complexity of implementing PCOMs in palliative care clinical practice and emphasises that this is a complex intervention [ 90 ]. The PCOMs most widely used continue to be the POS and the ESAS families of measures. There are a plethora of outcome measures which appeared only once in this review. Despite a large increase in the volume of literature on PCOMs implementation since the original review (117 vs 33 studies), in a lot more countries, illustrating how the field has expanded internationally since 2012, evidence on facilitators and barriers to implementation of PCOMs is largely unchanged since 2014. An exception to this is increased focus on the integration of electronic/digital PCOMs into IT systems and routine care structures, including user experiences and user interface as a facilitator to implementation. Organisational culture and privacy/confidentiality issues are more evident as barriers in this updated review. We have synthesised new data on implementation models and outcomes in relation to PCOMs. One of our new objectives was to identify the implementation models used, which the MRC guidance considers a core element for each phase. “ Frameworks provide a base set of concepts, terms, and definitions by which to articulate dynamic complex contexts and develop much needed measures of context .” [ 143 ]. Clinical teams need to recognise the ongoing iterative nature of implementation, using theory to structure the main actions and changes that need to take place when implementing PCOMs [ 145 ]. Although most included studies mention implementation outcomes, the majority only mention one or two out of the eight developed by Proctor et al. [ 144 ]. Future studies need to take into consideration a greater number of implementation outcomes. Many healthcare systems focus more on organizational efficiency and cost containment than promoting person-centred care, ascribing value to “bureaucratic models” of task-based care. 84 However, “the rationale for implementing pain assessment systems in palliative care should be based on quality of care rather than reduction of visits” 87 . Stiel et al. (2012) [ 130 ] list eight outcome assessments related to the economy of the healthcare system in relation to palliative care: costs, length of stay, reasons for admission, quality of care, discharge disposition, number of admissions, funding of palliative care, and facility size. Clinicians and researchers could usefully consider include all of these to provide clearer and in-depth information on costs. The main clinical and research implications of our findings highlight the central importance of staff engagement and training staff in PCOM tools, communication strategies, and cultural competence. The literature suggests that there is better continuity and coordination of care, when PCOMs are used longitudinally, improving shared decision making by sharing PCOMs results between patients, families and clinical teams. Simple cross-sectional studies using one measure do not test sustainability or equity, since they do not allow for comparisons at patient, team or policy maker levels. Future research needs to focus on implementation outcomes, costs and longitudinal study approaches. Finally, proxy-rated PCOMs remain essential in palliative care, particularly when patients are unable to self-report. While tools such as the IPOS have undergone robust validation in proxy-report formats, the development of novel proxy-specific methodologies remains limited, with recent research largely focused on validation rather than advancing implementation strategies. Strengths and Limitations A major strength of this updated and expanded review is the addition of more objectives to those of our previous review, including examination of frameworks and models of implementation, which provide a base set of concepts, terms, and definitions. One potential limitation is the greatly increased number of publications in this field over recent years, making a fully comprehensive review beyond the scope of our resources: however, it is reassuring that the findings of more recent studies continue to be in line with our original findings [ 10 , 20 – 25 ]. Conclusion Implementing a PCOM in palliative care clinical practice is a complex intervention which needs careful planning, piloting, assessment and fine tuning throughout its course, at different levels, working in partnership with the key stakeholders involved. As the field continues to evolve, future research studies need to use a theoretical framework to guide the implementation process and include clear implementation outcomes and assessment of costs to better inform and add to the evidence-base. Abbreviations BNI: British Nursing Index CINAHL: Cumulative Index to Nursing and Allied Health Literature CPHIR: Consolidated Framework for Implementation Research EMBASE: Excerpta Medica dataBASE EMCARE: Excerpta Medica database - Nursing and Allied Health ESAS: Edmonton Symptom Assessment Scale ICU: Intensive Care Unit IPOS: Integrated Palliative Care Outcome Scale IT: Information Technology MEDLINE: Medical Literature Analysis and Retrieval System Online MRC: Medical Research Council PARIHS: Promoting Action on Research Implementation in Health Services Framework PCOM: patient-centred outcome measures PDSA: Plan-Do-Study-Act POS: The Palliative Care Outcome Scale PRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses PsycINFO: Psychological Abstracts Information Services Declarations Ethics approval and consent to participate : not applicable. Consent for publication : not applicable. Availability of data and materials : all data generated or analysed during this study are included in this published article [and its supplementary information files]. Competing interests : The authors declare that they have no competing interests. Funding: Marie Curie (Grant reference MC-21-809). The funder is not involved in designing or conducting this study. FM is a UK National Institute for Health and Care Research (NIHR) Senior Investigator. The views expressed in this article are those of the author(s) and not necessarily those of the NIHR, or the Department of Health and Social Care. Author’s contributions : All authors contributed to the conception and design of the study. BA, SB, FS conducted most of the analysis. BA, SB, FS, SE and BB conducted most of the interpretation of data. All authors drafted the work and substantively revised it. All authors approved the submitted version. All authors have agreed both to be personally accountable for the author's own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature. Acknowledgements : not applicable. Footnotes : not applicable. Protocol registration: CRD42023398653 (13/02/2023): https://www.crd.york.ac.uk/PROSPERO/view/CRD42023398653 References Antunes B, Harding R and Higginson IJ. Implementing patient-reported outcome measures in palliative care clinical practice: a systematic review of facilitators and barriers. Palliat Med 2014; 28: 158-175. 2013/06/27. DOI: 10.1177/0269216313491619. Bausewein C, Daveson BA, Currow DC, et al. 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DOI: doi:https://dx.doi.org/10.1186/s12882-020-02206-9. Wu G, McBride K and Loudon J. Improving the use of patient-reported outcomes among patients receiving radiation therapy during the COVID-19 pandemic. Journal of Medical Imaging & Radiation Sciences 2022; 53: 328-333. DOI: doi:https://dx.doi.org/10.1016/j.jmir.2022.05.007. Deming WE. Out of the Crisis . Cambridge, Massachusetts: The MIT Press, 1982. Kitson A, Harvey G and McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care 1998; 7: 149-158. 1998/08/05. DOI: 10.1136/qshc.7.3.149. Rycroft-Malone J, Kitson A, Harvey G, et al. Ingredients for change: revisiting a conceptual framework. Qual Saf Health Care 2002; 11: 174-180. 2002/11/27. DOI: 10.1136/qhc.11.2.174. Damschroder LJ, Aron DC, Keith RE, et al. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4: 50. 2009/08/12. DOI: 10.1186/1748-5908-4-50. Damschroder LJ, Reardon CM, Widerquist MAO, et al. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci 2022; 17: 75. 2022/10/31. DOI: 10.1186/s13012-022-01245-0. Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2011; 38: 65-76. 2010/10/20. DOI: 10.1007/s10488-010-0319-7. Stover AM, Haverman L, van Oers HA, et al. Using an implementation science approach to implement and evaluate patient-reported outcome measures (PROM) initiatives in routine care settings. Qual Life Res 2021; 30: 3015-3033. 2020/07/12. DOI: 10.1007/s11136-020-02564-9. Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Supplementary Files Appendix4LessonsLearned.docx Appendix3Barriers.docx Appendix1ListofPCOMs.docx Appendix2Facilitators.docx Appendix5Modelsofimplementation.docx PRISMA2020checklist.docx Appendix6Costs.docx Tables.docx Cite Share Download PDF Status: Published Journal Publication published 12 Feb, 2026 Read the published version in BMC Palliative Care → Version 1 posted Editorial decision: Revision requested 11 Nov, 2025 Reviewers agreed at journal 11 Oct, 2025 Reviews received at journal 09 Oct, 2025 Reviews received at journal 04 Oct, 2025 Reviewers agreed at journal 18 Sep, 2025 Reviewers agreed at journal 13 Sep, 2025 Reviewers agreed at journal 04 Sep, 2025 Reviewers invited by journal 16 Aug, 2025 Editor invited by journal 14 Aug, 2025 Editor assigned by journal 13 Aug, 2025 Submission checks completed at journal 13 Aug, 2025 First submitted to journal 12 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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2","display":"","copyAsset":false,"role":"figure","size":429381,"visible":true,"origin":"","legend":"\u003cp\u003eCountries of included studies.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7358185/v1/a76c1c3ba78eb17ae7fcfa39.png"},{"id":102785209,"identity":"202fba76-32c0-4afa-a5a9-d1b06427ccdd","added_by":"auto","created_at":"2026-02-16 16:03:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1666743,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7358185/v1/b23114fc-2274-4e0a-8c49-8a660e21e8f6.pdf"},{"id":92575010,"identity":"d393ffe3-d20c-4c54-a327-e93d4eadd496","added_by":"auto","created_at":"2025-10-01 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08:17:13","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":55955,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix5Modelsofimplementation.docx","url":"https://assets-eu.researchsquare.com/files/rs-7358185/v1/bf6125095c69828a8785ec35.docx"},{"id":92575007,"identity":"2a9fcdf7-2910-4d57-af5f-892b69119491","added_by":"auto","created_at":"2025-10-01 08:17:14","extension":"docx","order_by":6,"title":"","display":"","copyAsset":false,"role":"supplement","size":32330,"visible":true,"origin":"","legend":"","description":"","filename":"PRISMA2020checklist.docx","url":"https://assets-eu.researchsquare.com/files/rs-7358185/v1/d636ec37e54ba05824583d69.docx"},{"id":92573733,"identity":"95598807-c2e6-4593-b91b-630cc915adce","added_by":"auto","created_at":"2025-10-01 08:09:18","extension":"docx","order_by":7,"title":"","display":"","copyAsset":false,"role":"supplement","size":27903,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix6Costs.docx","url":"https://assets-eu.researchsquare.com/files/rs-7358185/v1/e4b1dcee1f51ae5e076c7a59.docx"},{"id":92573732,"identity":"e683179a-ea53-42a3-91a7-3e85382d754e","added_by":"auto","created_at":"2025-10-01 08:09:18","extension":"docx","order_by":8,"title":"","display":"","copyAsset":false,"role":"supplement","size":77566,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-7358185/v1/5d5f759c7c4a175df82067bd.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Implementing patient-centred outcome measures in palliative care clinical practice. An updated systematic review of facilitators and barriers","fulltext":[{"header":"Key Statements","content":"\u003cp\u003e\u003cstrong\u003eWhat is already known about the topic\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eThe importance of using patient-centred outcome measures (PCOMs) to understand the effect and effectiveness of health interventions has been established: they are an essential component of evidence-based clinical practice.\u003c/li\u003e\n \u003cli\u003eData collected at individual patient-level can be used immediately by healthcare professionals to act on any identified distressing symptoms or palliative needs.\u003c/li\u003e\n \u003cli\u003eDespite the development of PCOMs in the past three decades, their routine use in clinical practice remains challenging in most countries.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eWhat this paper adds\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eHaving a coordinator onsite and training clinicians are key to the initial implementation of PCOMs in clinical practice.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEmbedding PCOMs at point of care is critical to their ongoing implementation in practice.\u003c/li\u003e\n \u003cli\u003eThe integration of electronic/digital PCOMs into Information Technology systems is a new development that is still emerging\u003c/li\u003e\n \u003cli\u003eEvidence is scarce on the models of PCOMs implementation used in clinical practice and their associated financial costs.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003e\u003cstrong\u003eImplication for practice, theory or policy\u003c/strong\u003e\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003eSuccessful implementation requires embedding outcome measures at the point of care and tailoring the implementation process to local circumstances and contexts.\u003c/li\u003e\n \u003cli\u003eConstant feedback of patient-level outcomes to clinicians is vital.\u003c/li\u003e\n \u003cli\u003eImplementing PCOMs in palliative care clinical practice is a complex intervention and guidelines and statements on complex interventions should be followed.\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"Background","content":"\u003cp\u003eThe importance of patient-centred outcome measures (PCOMs) in palliative care clinical practice is well established: they allow for clinical care to respond to real-time need, and longitudinal comprehensive measurement of patient and family outcomes across physical, psychological, existential, emotional, and practical domains [1-5].\u003c/p\u003e\n\u003cp\u003eWhen used properly, PCOMs become powerful communication tools, keeping all involved in patient care at the same level of knowledge regarding patient and family outcomes [6-8]. Additionally, PCOMs data, collected at patient level, can be aggregated for audit, research, quality improvement, and benchmarking. Ultimately those data can be used by policy makers to improve patient and family care [9-11].\u003c/p\u003e\n\u003cp\u003eRegardless of the recognition and importance PCOMs have in patient and family care, their implementation in clinical practice remains challenging [12, 13].\u003c/p\u003e\n\u003cp\u003eWe have updated and expanded a 2013 systematic review on implementation of PCOMs in palliative care.\u003csup\u003e1\u003c/sup\u003e We updated the original review objectives and recommendations and added four more objectives, with review questions as follows:\u003c/p\u003e\n\u003cp\u003e1. What are the PCOMs implemented in palliative care clinical practice?\u003c/p\u003e\n\u003cp\u003e2. What are the facilitators to PCOMs implementation in palliative care clinical practice?\u003c/p\u003e\n\u003cp\u003e3. What are the barriers to PCOMs implementation in palliative care clinical practice?\u003c/p\u003e\n\u003cp\u003e4. What are the lessons learned on implementing PCOMs in PC clinical practice?\u003c/p\u003e\n\u003cp\u003e5. What are the implementation models used in PCOMs implementation in palliative care clinical practice?\u003c/p\u003e\n\u003cp\u003e6. What implementation outcomes were measured and how, when implementing PCOMs in palliative care clinical practice?\u003c/p\u003e\n\u003cp\u003e7. What are the financial costs of implementing PCOMs in palliative care clinical practice?\u003c/p\u003e\n\u003cp\u003e8. Are there new recommendations since the previous literature review to inform the implementation process in palliative care clinical practice for all stakeholders?\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eWe conducted a systematic literature review and narrative synthesis. PRISMA reporting guidelines were followed, including PRISMA, PRISMA-Abstracts [14] and PRISMA-Search [15]. The review protocol has been published elsewhere in open access [16]; we briefly describe the methods below. On 14 November 2022, we searched MEDLINE, Embase, Emcare, CINAHL, PsycINFO, BNI, Web of Science Core Collections (SSCI, SCI, ESCI), and Scopus with no date, language, publication type, or publication status limitations [17], supplemented by a list of studies recommended by the expert advisory committee and hand-searching references of included studies. We included primary empirical studies using PCOMs in clinical care for adult patients with advanced disease in palliative care settings. We included studies using a PCOM during clinical care of adult patients with advanced disease in all settings and extracted data on: PCOMs used, models of implementation, facilitators, barriers, lessons learned, costs, and implementation outcomes. We used Gough\u0026rsquo;s Weight of Evidence Framework [18] to appraise each included study\u0026rsquo;s internal validity, appropriateness and contribution in answering the review questions: studies were weighted by two reviewers independently (B.B., S.E.), with a third consulted if needed (S.B.) to achieve consensus. The narrative synthesis was undertaken in the same way. Finally, we map the updated recommendations, and reiterated those from our previous review, on the updated MRC Framework for Developing and Evaluating Complex Interventions [19]. The Framework has four phases; develop/identify intervention, feasibility testing, evaluation, and implementation. Each of these phases have six core elements: context, programme theory, stakeholders\u0026rsquo; engagement, key uncertainties, intervention refinement and economic considerations.\u003c/p\u003e\n\u003cp\u003eWe updated the original 2022 search by a scoping search using our main keywords on 9 February 2025 to identify any new relevant studies.\u0026nbsp;\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eWe included 114 studies (117 reports) [2, 7, 8, 13, 26-138] which are shown in \u003cstrong\u003eTable 1.\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe update scoping search identified seven relevant studies [10, 20-25], which confirmed the existing findings rather than adding any new information.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1\u003c/strong\u003e depicts the PRISMA flow chart reporting the literature search and selection of articles.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 2\u003c/strong\u003e shows the distribution of countries where included studies were conducted. Compared to the original review, which yielded studies from 9 countries (United Kingdom, United States, Netherlands, Australia, Canada, Israel, Italy, Malaysia and Vietnam).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe appearance of most countries with one study on the map is because of an online multi-country web-based survey from healthcare professionals from these counties; for more details, see Table 1 of Included Studies. Data that cannot be displayed on the map are as follows: United Kingdom (21), Republic of Ireland (6), Italy (4), Netherlands (3), Belgium (2), New Zealand (2), Portugal (2), Denmark (1), Eswatini (1), Greece (1), Japan (1), Lesotho (1), Rwanda (1), Sierra Leone (1), Singapore (1), Taiwan (1), and Thailand (1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn this updated review we present results by objective and provide quotations from studies when relevant. Recommendations are reported using the updated Medical Research Council Framework for Developing and Evaluating Complex Interventions [19]. We use their definition of complex intervention: \u0026ldquo;\u003cem\u003eAn intervention might be considered complex because of properties of the intervention itself, such as the number of components involved; the range of behaviours targeted; expertise and skills required by those delivering and receiving the intervention; the number of groups, settings, or levels targeted; or the permitted level of flexibility of the intervention or its components\u003c/em\u003e.\u0026rdquo;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[PLACE TABLE 1 HERE]\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e1. PCOMs implemented in clinical practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eJust over 70 different PCOMs were reported to be implemented in palliative care clinical practice; half of these were only used once, therefore appearing in only one study each. The Palliative Care Outcome Scale (POS) and its family of measures were the most used family of measures with 30 mentions, followed by the Edmonton Symptom Assessment Scale (ESAS) original, revised and renal with 26 mentions. Australia is the only country that has adopted one measure, the Symptom Assessment Score (SAS) as the national standard, which is used by all specialist palliative care services in the country and the IPOS is the recommended measure for use in UK. See \u003cstrong\u003eAppendix 1\u003c/strong\u003e for the full list of measures by primary studies and reviews.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e2. Facilitators of implementing PCOMs in clinical practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMost facilitators remained the same, apart from the facilitator of integration of electronic/digital PCOMs into Information Technology (IT) systems and routine care structures, including user experiences and user interface.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Desirable features focused on hardware (lightweight, durable, and easy to disinfect), software (simple, user-friendly interface, multi-linguistic, integration with e-health systems).\u003c/em\u003e\u0026rdquo; [113]\u003c/p\u003e\n\u003cp\u003eWe changed and added new facilitator categories, for example the \u0026ldquo;Planning, Process and Logistics\u0026rdquo; category which includes eight sub-categories: healthcare systems and politics; training, knowledge, perception, and acceptance; organisational culture and structure; team and champions; personal characteristics; patient factors; communication; information flow, action, visible outcomes and time needed to implement.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Senior staff and managers, actively participating in the implementation and use of PCOMs.\u0026rdquo;\u0026nbsp;\u003c/em\u003e[139]\u003c/p\u003e\n\u003cp\u003eSee \u003cstrong\u003eAppendix 2\u003c/strong\u003e for the full list of categories and sub-categories of facilitators.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e3. Barriers to implementing patient-centred outcome measures in clinical practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main barriers remain similar to those identified in the original review and are mainly related to healthcare professionals, including: resistance to change, negative attitudes towards changing routine, scepticism regarding the necessity and usability of data collected, and belief that data collection is a burden to patients but also for themselves, given high workload:\u003c/p\u003e\n\u003cp\u003e\u0026ldquo;\u003cem\u003ePractitioners were suspicious of ESAS-r use in service evaluation, distrusting accuracy of patients\u0026apos; reports.\u0026rdquo;\u0026nbsp;\u003c/em\u003e[114]\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003cem\u003e\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Worry that use of a formal instrument may interfere with, or be meant to substitute for, the patient interview.\u0026rdquo;\u0026nbsp;\u003c/em\u003e[46]\u003c/p\u003e\n\u003cp\u003eRegarding resources, lack of training, time constraints, access to the tool and equipment to support electronic tools, were widely mentioned, as were unwell and complex patients who might not be able to fill the measures or have a rapidly changing condition that they felt the measure might not reflect:\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u0026ldquo;Interviewees criticise that standardised PROs do not adequately reflect the subjective reality of the patients and the complexity of their needs.\u0026rdquo;\u0026nbsp;\u003c/em\u003e[108]\u003c/p\u003e\n\u003cp\u003eRegarding the measures themselves, there were concerns relating to complexity, adaptability, interpretation, individualisation, comprehensibility, timing of use, numerical scoring, acceptability, and lack of consensus on what tool to use and their psychometric properties. See \u003cstrong\u003eAppendix 3\u003c/strong\u003e for the full list of categories and sub-categories of barriers.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e4. Lessons learned on implementing PCOMs in clinical practice\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImplementing a PCOM in palliative care clinical practice is a complex intervention which needs planning, assessment and fine tuning throughout its course at different levels and with all involved.[90] We identified the following, mainly taken from the discussion section of included studies.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuidance.\u0026nbsp;\u003c/strong\u003eStep by step guides specifically designed to implement PROMs in clinical practice [27, 30].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical Staff\u003c/strong\u003e. Important to integrate nursing staff in the implementation process early with specific training and feedback. Consider individual attitudes and motivation to use new evidence-based practice. Changes that require clinicians to modify the interpersonal aspects of their care, or that are more complex, may be perceived as more difficult to implement [2, 26, 28, 52, 59, 98, 133].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasure.\u003c/strong\u003e Measures must be psychometrically sound and comparable [2, 39, 50, 52, 64].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurement frequency.\u003c/strong\u003e When managing poorly controlled symptoms, measurement is needed multiple times a day [2, 27, 30, 46, 52, 80].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eStability of measures\u003c/strong\u003e. Once a measure is introduced, there needs to be a commitment for it to remain in place for a long period. Changing versions and measures should not be undertaken lightly as every change requires changes in IT and staff training and comes at a considerable cost [41].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSetting.\u0026nbsp;\u003c/strong\u003eThe context in which measures are introduced and used is important. There are currently no palliative care measures for Intensive Care Unit (ICU) and paediatric palliative care settings. It has been suggested that the use of PCOMs in the palliative radiotherapy settings may not be possible, due to the large variety in pathologies, radiation schemes and treatment indications [30, 39, 50, 51, 61,66, 70, 98, 111, 120].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eImplementation.\u0026nbsp;\u003c/strong\u003eImplementation is a time-consuming and long-term process and needs continuous attention and flexibility. Using the principles of change management, factors other than those relating to individual professionals are important, and greater use of theories of change may help to explain whether change is possible. Using PCOMs in palliative care clinical practice is a complex intervention; organisations\u0026rsquo; aims must align with the effort to aid their clinical teams, with quality of care at the forefront as the rationale for implementing PCOMs [27, 43, 44, 46, 48, 49, 52, 90, 120, 124, 133].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFeedback.\u0026nbsp;\u003c/strong\u003eThere is strong evidence for the beneficial impact of PCOMs feedback on processes of care. Patients, family caregivers and health professionals value objective feedback from PCOMs, even in the face of deteriorating health [7, 13, 3, 41, 44, 52, 59].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePatients.\u0026nbsp;\u003c/strong\u003eIt is important to distinguish between patient burden and patients being too unwell to complete measures. Patients who trigger electronic clinical alerts tend to be younger and more recently diagnosed, to have greater comorbidities, and to be from racial/ethnic minority groups. Clinicians and patients perceive that, when used in first assessments, individualised PCOMs supported relationship-building because they enable patients to \u0026lsquo;tell their story\u0026rsquo;: however, if the clinicians feel they cannot resolve an issue, there is a tendency to disregard and close the conversation [13, 44, 59, 67, 68, 80, 108].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTechnology.\u0026nbsp;\u003c/strong\u003eFuture digital health approaches in palliative care require a good understanding of the needs of the target population [26, 28, 35, 39, 98, 100]. See \u003cstrong\u003eAppendix 4\u003c/strong\u003e for full list.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e5. Implementation models used when implementing PCOMs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eA total of 18 models, frameworks and theories were identified as used in just 25 of included studies, most commonly Plan-Do-Study-Act (PDSA) [139], Promoting Action on Research Implementation in Health Services Framework (PARIHS) [140, 141], and Consolidated Framework for Implementation Research (CFIR) [142] PDSA is an iterative, four-stage model that asks three questions: what are we trying to accomplish, how will we know that a change is an improvement and what changes can we make that will result in an improvement? PARISH identifies three key components of the implementation process: evidence, context, and facilitation. Implementation is more likely to occur when evidence is scientifically robust, aligns with practitioner and patient beliefs and local experience, the context is receptive to change, and there is appropriate input from internal and external facilitators. CFIR, updated in 2022, has five domains to guide systematic assessment of potential barriers and facilitators, tailor implementation strategies and needed adaptations, and explain outcomes (individuals, inner setting, outer setting, implementation process and innovation/change to be implemented) [143]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;See \u003cstrong\u003eAppendix 5\u003c/strong\u003e for a complete list of the implementation models and frameworks identified.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e6. Implementation outcomes measured, and how, when implementing PCOMs\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSixty-two included studies mentioned at least one implementation outcome. Of the eight implementation outcomes developed by Proctor et al. in 2011 (acceptability, fidelity, feasibility, adoption, appropriateness, penetration, sustainability, and cost [144]), most studies reported only on feasibility of implementing a PCOM or e-PCOM in clinical practice and the acceptability to patients and healthcare professionals of the measure used.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnly one study mentioned appropriateness: this was the only study to consider three implementation outcomes [122]. It was concluded that by documenting evidence of pain assessment and screening for spiritual distress, the number of referrals improved and was maintained 12 months and more clinicians agreed that palliative care domains were comprehensively assessed post-intervention [122].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e7. Financial costs of implementing PCOMs\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo included studies reported on the costs of implementation. Some provided suggestions in relation to costs, for example suggesting that the way to rationalise PCOMs implementation is for these to replace routine procedures [26, 33] or as a complement to existing practices without requiring additional resources [78]. Others suggested that implementation would be costly in the short-term but cost-saving in the long term by reducing the workload [26, 35, 122].\u003c/p\u003e\n\u003cp\u003eStudies suggested that the possible costs of implementation include: cost of the PCOMs [26, 111]; cost of healthcare staff time and capacity [46]; cost of creating, maintaining and updating electronic systems and integration into existing IT systems \u0026nbsp;[46, 72, 122, 135]; costs to healthcare system of reimbursement and pay-for-performance incentives [35, 46, 97, 126] setting-dependent costs including \u0026nbsp;models of care, clinical competencies and resourcing [41]; unavailability of reimbursement/insurance plans to cover staff time in the US;\u003csup\u003e46\u003c/sup\u003e lack of funding in charitable organisations [111]; and costs associated with the outcomes of implementation including \u0026nbsp;resources to respond to patients\u0026rsquo; issues identified [8, 46]. Some solutions were proposed to save costs [8, 26, 46, 49, \u0026nbsp;55, 107, 122]. See \u003cstrong\u003eAppendix 6\u003c/strong\u003e for a full list of facilitators and barriers regarding financial costs.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e8. Updated recommendations for PCOMs implementation\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eBased on the new evidence synthesis, we have updated recommendations, and reiterated those from our previous review, by mapping them on the updated MRC Framework for Developing and Evaluating Complex Interventions [19]. \u003cstrong\u003eTable 2\u003c/strong\u003e presents a summarised description of the recommendations mapped on the MRC Framework in the form of actions. Below, we describe the main considerations arising from those actions. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e[PLACE TABLE 2 HERE]\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eA. Intervention development/identification\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eImplementation of a PCOM in palliative care can occur in a range of clinical contexts including hospital, home, hospice, or care home. These contexts have different rules, different resources available, and different support from managers and different outcomes the team wish to measure [2, 7, 39, 41, 43, 90, 111,115]. Clinicians may not have experience or training in using PCOMs [26, 27, 43, 52, 66, 133]. Patient populations will differ, being more or less complex and in a more or less advanced stage of illness [13, 35, 51, 52, 90, 98, 111]. Very ill patients may have missing data [2, 51, 59, 90], in which case a PCOM which allows for proxy ratings may be appropriate [2, 39]. These factors will all influence the measure(s) selected [2, 51, 59, 80, 90]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe use of theory to underpin implementation models is generally considered beneficial, as it provides a structured foundation for understanding and guiding the implementation process. \u0026nbsp;From the theories available in the literature, it will be important to select one which is appropriate for the clinical context in which the implementation will be conducted [27, 43, 52, 111, 126]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEngaging stakeholders from the initial planning phase is vital, including: patients, families and other informal caregivers, healthcare professionals from all the teams involved, managers, policy makers, and decision makers [13, 27, 43, 45, 52, 59, 111, 115, 133]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIdentification of key uncertainties, including the adjustments to be made during the different steps is key [2, 26, 30, 43, 52, 59, 90, 133]. Consideration needs to be given to: when will patients be asked to complete the measure, who will ask the patient, will patients choose paper or electronic formats, whether a family or staff member will be able to act as a proxy if the patient is unable to complete the measure, will the institution provide IT resources for optimal use of the PCOM information, when will the feedback happen to healthcare professionals and patients, how will responses be used to support or improve patient care (and/or quality improvement), when will the team meet to discuss \u0026nbsp;implementation [7, 13, 35, 41, 44, 52, 59].\u003csup\u003e\u0026nbsp;\u003c/sup\u003e Other uncertainties will arise as the implementation moves forward and clinicians become more familiar with the new routine [2, 8, 35, 59, 68, 79, 80, 90,133]. \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eRefining of the intervention can only take place after the team has met to review how the implementation is going and changes needed [45, 90, 133]. Consideration needs to be given in the planning phase to minimising missing data (this appears to improve with electronic data capture), how often will clinicians use the results and how will this be reported, how engaged are all members of the clinical team in the new routine, and other ways to improve the implementation [2, 27, 30, 41, 43, 59].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEconomic considerations must be contemplated from the outset [2, 38, 49, 126]:\u003csup\u003e\u0026nbsp;\u003c/sup\u003efor example, is there additional resource to support the implementation or will this be within current resources and workforce time available [8, 35, 41, 46, 69, 72, 78, 122]; what IT and administrative support will be available initially and long term to store, synthesise and present data from the measure to clinicians [55, 84, 97, 111, 135, 137].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eB. Feasibility\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eFeasibility testing, against predefined progression criteria [2, 39, 50], assesses feasibility and acceptability of implementing the PCOM(s) in the clinical setting concerned [2, 13, 39, 52]. This allows decisions to be made about progression to the next stage. Consideration of the optimal way to integrate the use of the measures and the use of their results in clinical practice [2, 59, 90] requires team leads to all be on board and meet periodically to discuss the six core elements as the phase progresses [2, 8, 13, 50, 59, 80, 133].\u003c/p\u003e\n\u003cp\u003eContext includes the setting where care is delivered, the institutional culture, the staff members involved, the physical setting in which patients will fill in the measure and when they will do so [43, 59, 90, 114, 115, 133]. The theory employed needs review regarding how well it fits with the implementation setting [43, 62, 88, 106]. Stakeholder engagement needs to involve patients and family members, clinicians, decision makers and policy makers [2, 13, 27, 30, 41, 43, 59], in order to understand if it is feasible to implement the selected PCOM, identify key uncertainties and how they will be explored and resolved [27, 52, 133]. One important issue raised in the included papers was the course of action when a patient reports a very high score for one or more items, when that indicates the worst possible state [2, 13, 27, 30, 39, 41,44, 52, 59, 68, 74, 79, 98, 111, 112, 114, 133].\u003c/p\u003e\n\u003cp\u003eRegarding economic considerations, it is important to understand how much time the clinical, administrative and IT teams will spend on the implementation and whether that will be resourced [2, 27].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC. Evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe evaluation phase investigates whether and how the intervention works, the usefulness of the information gained, how it interacts with the clinical context and contributes to improved outcomes for patient and families and system change [27, 44, 45, 46, 50, 59, 80, 90, 98, 126, 133]. Strong networking relationships are likely to be established with formal and informal sectors outside of the organisation [43, 45, 46, 59, 90], including identification of outcomes which capture changes to the wider healthcare system [2, 13, 26, 41, 46, 50, 52, 59, 77]. When refining the theory, it is important to consider the interpretation of data and how it will have an impact on clinical processes and outcomes [43, 62, 88, 106]. If the results of the PCOMs are being used, that should lead to improved levels and quality of care and improved patient and family outcomes [2, 27, 39, 41, 59, 77, 87, 133]. When healthcare professionals are trained to interpret and act on PCOM feedback, care becomes more responsive to patients\u0026rsquo; changing needs. Furthermore, using PCOMs systematically allows for benchmarking and continuous quality improvement at an organizational level, creating a feedback loop that fosters accountability and patient-centered service development. These mechanisms can ultimately contribute to better alignment of care with patient goals and improved experiences at the end of life. This underscores the importance of systematically assessing not only whether PCOMs are implemented, but also how they influence clinical practice and patient trajectories. Evaluation should explore the mechanisms through which PCOMs inform care\u0026mdash;such as changes in clinical decision-making, timeliness of interventions, or communication with families\u0026mdash;as well as measurable improvements in health outcomes and satisfaction. Additionally, the evaluation phase provides an opportunity to examine contextual factors, such as staff engagement or organizational readiness, that may mediate or moderate the impact of PCOM use.\u0026nbsp;Evaluation should primarily focus on the performance and sustainability of measures within routine, long-term practice settings, rather than being limited to isolated or short-term studies [31]. The best example are the PCOC measures which have been collected in Australia continuously for 20 years.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eD.\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eImplementation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAfter developing and planning the implementation, piloting it, assessing how that first stage went and making changes, it is expected that there will be a \u0026ldquo;second try\u0026rdquo; that is better adapted to the reality of each clinical team, as an ongoing process. The six core elements will be unique to each clinical team and dependent on the previous work carried out. If the main issues which arose in the pilot phase were addressed in the evaluation phase, the implementation should run more smoothly with less issues to resolve, as illustrated in the Tavares AP et al. study describing all four steps of implementing a PCOM in an inpatient palliative care service [133].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBy rigorously evaluating these components, we can determine whether and how PCOMs contribute to better patient-centred outcomes and generate transferable insights to guide future implementation and scale-up.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis updated review highlights the complexity of implementing PCOMs in palliative care clinical practice and emphasises that this is a complex intervention [\u003cspan citationid=\"CR90\" class=\"CitationRef\"\u003e90\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe PCOMs most widely used continue to be the POS and the ESAS families of measures. There are a plethora of outcome measures which appeared only once in this review.\u003c/p\u003e\u003cp\u003eDespite a large increase in the volume of literature on PCOMs implementation since the original review (117 vs 33 studies), in a lot more countries, illustrating how the field has expanded internationally since 2012, evidence on facilitators and barriers to implementation of PCOMs is largely unchanged since 2014. An exception to this is increased focus on the integration of electronic/digital PCOMs into IT systems and routine care structures, including user experiences and user interface as a facilitator to implementation. Organisational culture and privacy/confidentiality issues are more evident as barriers in this updated review.\u003c/p\u003e\u003cp\u003eWe have synthesised new data on implementation models and outcomes in relation to PCOMs. One of our new objectives was to identify the implementation models used, which the MRC guidance considers a core element for each phase. \u0026ldquo;\u003cem\u003eFrameworks provide a base set of concepts, terms, and definitions by which to articulate dynamic complex contexts and develop much needed measures of context\u003c/em\u003e.\u0026rdquo; [\u003cspan citationid=\"CR143\" class=\"CitationRef\"\u003e143\u003c/span\u003e]. Clinical teams need to recognise the ongoing iterative nature of implementation, using theory to structure the main actions and changes that need to take place when implementing PCOMs [\u003cspan citationid=\"CR145\" class=\"CitationRef\"\u003e145\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAlthough most included studies mention implementation outcomes, the majority only mention one or two out of the eight developed by Proctor et al. [\u003cspan citationid=\"CR144\" class=\"CitationRef\"\u003e144\u003c/span\u003e]. Future studies need to take into consideration a greater number of implementation outcomes.\u003c/p\u003e\u003cp\u003eMany healthcare systems focus more on organizational efficiency and cost containment than promoting person-centred care, ascribing value to \u0026ldquo;bureaucratic models\u0026rdquo; of task-based care.\u003csup\u003e84\u003c/sup\u003e However, \u0026ldquo;the rationale for implementing pain assessment systems in palliative care should be based on quality of care rather than reduction of visits\u0026rdquo; \u003csup\u003e87\u003c/sup\u003e. Stiel et al. (2012) [\u003cspan citationid=\"CR130\" class=\"CitationRef\"\u003e130\u003c/span\u003e] list eight outcome assessments related to the economy of the healthcare system in relation to palliative care: costs, length of stay, reasons for admission, quality of care, discharge disposition, number of admissions, funding of palliative care, and facility size. Clinicians and researchers could usefully consider include all of these to provide clearer and in-depth information on costs.\u003c/p\u003e\u003cp\u003eThe main clinical and research implications of our findings highlight the central importance of staff engagement and training staff in PCOM tools, communication strategies, and cultural competence. The literature suggests that there is better continuity and coordination of care, when PCOMs are used longitudinally, improving shared decision making by sharing PCOMs results between patients, families and clinical teams. Simple cross-sectional studies using one measure do not test sustainability or equity, since they do not allow for comparisons at patient, team or policy maker levels. Future research needs to focus on implementation outcomes, costs and longitudinal study approaches.\u003c/p\u003e\u003cp\u003eFinally, proxy-rated PCOMs remain essential in palliative care, particularly when patients are unable to self-report. While tools such as the IPOS have undergone robust validation in proxy-report formats, the development of novel proxy-specific methodologies remains limited, with recent research largely focused on validation rather than advancing implementation strategies.\u003c/p\u003e\u003cp\u003eStrengths and Limitations\u003c/p\u003e\u003cp\u003eA major strength of this updated and expanded review is the addition of more objectives to those of our previous review, including examination of frameworks and models of implementation, which provide a base set of concepts, terms, and definitions. One potential limitation is the greatly increased number of publications in this field over recent years, making a fully comprehensive review beyond the scope of our resources: however, it is reassuring that the findings of more recent studies continue to be in line with our original findings [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan additionalcitationids=\"CR21 CR22 CR23 CR24\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eImplementing a PCOM in palliative care clinical practice is a complex intervention which needs careful planning, piloting, assessment and fine tuning throughout its course, at different levels, working in partnership with the key stakeholders involved. As the field continues to evolve, future research studies need to use a theoretical framework to guide the implementation process and include clear implementation outcomes and assessment of costs to better inform and add to the evidence-base.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eBNI: British Nursing Index\u003c/p\u003e\n\u003cp\u003eCINAHL: Cumulative Index to Nursing and Allied Health Literature\u003c/p\u003e\n\u003cp\u003eCPHIR: Consolidated Framework for Implementation Research\u003c/p\u003e\n\u003cp\u003eEMBASE: Excerpta Medica dataBASE\u003c/p\u003e\n\u003cp\u003eEMCARE: Excerpta Medica database - Nursing and Allied Health\u003c/p\u003e\n\u003cp\u003eESAS: Edmonton Symptom Assessment Scale\u003c/p\u003e\n\u003cp\u003eICU: Intensive Care Unit\u003c/p\u003e\n\u003cp\u003eIPOS: Integrated Palliative Care Outcome Scale\u003c/p\u003e\n\u003cp\u003eIT: Information Technology\u003c/p\u003e\n\u003cp\u003eMEDLINE: Medical Literature Analysis and Retrieval System Online\u003c/p\u003e\n\u003cp\u003eMRC: Medical Research Council\u003c/p\u003e\n\u003cp\u003ePARIHS: Promoting Action on Research Implementation in Health Services Framework\u003c/p\u003e\n\u003cp\u003ePCOM: patient-centred outcome measures\u003c/p\u003e\n\u003cp\u003ePDSA: Plan-Do-Study-Act\u003c/p\u003e\n\u003cp\u003ePOS: The Palliative Care Outcome Scale\u003c/p\u003e\n\u003cp\u003ePRISMA: Preferred Reporting Items for Systematic Reviews and Meta-Analyses\u003c/p\u003e\n\u003cp\u003ePsycINFO: Psychological Abstracts Information Services\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e: all data generated or analysed during this study are included in this published article [and its supplementary information files].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e Marie Curie (Grant reference MC-21-809). The funder is not involved in designing or conducting this study. FM is a UK National Institute for Health and Care Research (NIHR) Senior Investigator. The views expressed in this article are those of the author(s) and not necessarily those of the NIHR, or the Department of Health and Social Care.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s contributions\u003c/strong\u003e: All authors contributed to the conception and design of the study. BA, SB, FS conducted most of the analysis. BA, SB, FS, SE and BB conducted most of the interpretation of data. All authors drafted the work and substantively revised it. All authors approved the submitted version. All authors have agreed both to be personally accountable for the author\u0026apos;s own contributions and to ensure that questions related to the accuracy or integrity of any part of the work, even ones in which the author was not personally involved, are appropriately investigated, resolved, and the resolution documented in the literature.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFootnotes\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003eProtocol registration: CRD42023398653 (13/02/2023):\u003c/p\u003e\n\u003cp\u003ehttps://www.crd.york.ac.uk/PROSPERO/view/CRD42023398653\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAntunes B, Harding R and Higginson IJ. 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DOI: 10.1007/s11136-020-02564-9.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":true,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Patient-centred outcome measurement, patient-reported outcome measurement, palliative care, systematic reviews, implementation, barriers, facilitators, complex interventions","lastPublishedDoi":"10.21203/rs.3.rs-7358185/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7358185/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e. Patient-centred outcome measures (PCOMs), when well implemented, are powerful tools facilitating patient, family and clinical communication to better respond to patient needs throughout the disease trajectory. Their routine use in palliative care practice still faces challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e. To update a systematic review of PCOMs implementation, reviewing and synthesising new evidence on facilitators, barriers, lessons learned, measures used, models of implementation, costs, implementation outcomes, and consequences in clinical practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e. We searched eight information sources supplemented by hand-searching and citations of the original review and studies identified by the expert advisory committee. This prospectively registered review included studies using a PCOM during clinical care of adult patients with advanced disease in all settings and extracted data on: PCOMs used, models of implementation, facilitators, barriers, lessons learned, costs, and implementation outcomes. We employed narrative synthesis and tabulated findings, following all PRISMA reporting guidelines.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e. We included 114 studies. A major new facilitator was the integration of electronic/digital PCOMs into Information Technology systems. Main barriers remain largely unchanged and relate to healthcare professionals’ beliefs. Implementation was highlighted as a complex intervention, needing planning, assessment and fine tuning throughout. Sixty-two included studies mentioned at least one implementation outcome. Eighteen models, frameworks and theories were identified in 25 included studies. No studies reported on costs of implementation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e. This updated review reveals a comprehensive body of work regarding the complexity of implementing PCOMs in palliative care clinical practice needing planning, piloting, assessment and fine tuning throughout, at different levels and with all stakeholders involved.\u003c/p\u003e","manuscriptTitle":"Implementing patient-centred outcome measures in palliative care clinical practice. 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