Patient-Reported Outcome Measurement (PROMs) in British Columbia:

What has been achieved so far and where next?

Stirling Bryan PhD, David Whitehurst PhD

Thursday February 28th, 2013 Quality Forum 2013

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Not this type of PROM…

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Overview

• Measuring health outcomes: what are PROMs? – traditional uses – the case for routine measurement – role within high-performing health care systems

• Interactive session – EQ-5D completion and feedback

• BC initiatives within primary and secondary care – QI in cataracts – program evaluation in integrated primary and community

care (IPCC)

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Measuring Health Outcomes

• Not a new concept: mortality and morbidity

• A wealth of information on outcomes – but with limits – Statistics Canada – Canadian Institute for Health Information (CIHI) – poor outcomes and system failures

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Measuring Health Outcomes

• Not a new concept: mortality and morbidity

• A wealth of information on outcomes – but with limits – Statistics Canada – Canadian Institute for Health Information (CIHI) – poor outcomes and system failures

• What about the patient? – ‘Measurement of “success” in terms of improvements in

patients health status… is virtually non-existent in Canadian health care’ (McGrail et al, 2012)

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Measuring Health Outcomes

• Not a new concept: mortality and morbidity

• A wealth of information on outcomes – but with limits – Statistics Canada – Canadian Institute for Health Information (CIHI) – poor outcomes and system failures

• What about the patient? – “We believe it is the duty of every hospital to establish a

follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians”

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Measuring Health Outcomes

• Not a new concept: mortality and morbidity

• A wealth of information on outcomes – but with limits – Statistics Canada – Canadian Institute for Health Information (CIHI) – poor outcomes and system failures

• What about the patient? – “We believe it is the duty of every hospital to establish a

follow-up system, so that as far as possible the result of every case will be available at all times for investigation by members of the staff, the trustees, or administration, or by other authorized investigators or statisticians”

(Codman, 1915)

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Patient-Reported Outcome Measures

• Measures of health status (or HRQoL) – completed by patients – commonly as a short questionnaire

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Patient-Reported Outcome Measures

• Measures of health status (or HRQoL) – completed by patients – commonly as a short questionnaire

• Used to assess an individual’s health status – cross-sectional snap-shot – multiple time points (longitudinal collection)

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Patient-Reported Outcome Measures

• Measures of health status (or HRQoL) – completed by patients – commonly as a short questionnaire

• Used to assess an individual’s health status – cross-sectional snap-shot – multiple time points (longitudinal collection)

• A large number of PROMs exist – condition-specific measures – generic measures (e.g. EQ-5D, Health Utilities Index, SF-36)

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EQ-5D completion

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‘Traditional’ PROM Uses

• Clinical research – e.g. randomized controlled trials, cohort studies, registries

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‘Traditional’ PROM Uses

• Clinical research – e.g. randomized controlled trials, cohort studies, registries

• Economic evaluation – comparative analysis of two or more interventions in terms

of both costs and benefits – generic preference-based PROM measures – quality-adjusted life years (QALYs)

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‘Traditional’ PROM Uses

• Clinical research – e.g. randomized controlled trials, cohort studies, registries

• Economic evaluation – comparative analysis of two or more interventions in terms

of both costs and benefits – generic preference-based PROM measures – quality-adjusted life years (QALYs)

• Availability of alternatives requires consideration

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Economic Evaluation of Falls Prevention Strategies

Table 5. Community-dwelling: incremental cost per fall avoided, hospitalisation avoided and QALY gained

Church J, et al. An economic evaluation of community and residential aged care falls prevention strategies in NSW. New South Wales Public Health Bulletin 2011; 22: 60–68

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Routine PROMs Data…

• The patient who has undergone surgery asks: – Is my recovery post-surgery similar to that of other patients or should I

be worried?

• The surgeon asks: – Which of my patients are experiencing on-going health problems and

might benefit from early clinical review?

• The health sector manager asks: – Which are the high-performing surgical teams and what lessons can

they offer to other groups?

• The health service researcher asks: – How variable are surgical health outcomes across BC and what are the

main drivers of such variation?

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Settings for PROM data collection

Health research Program evaluation

Quality improvement

Routine care delivery

Health research Program management

Individual patient management

Contexts for use of PROMs data

Policy decision making

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QI work at VCH: cataract surgery • Goal:

– To implement a cataract surgery outcome measurement strategy as a routine quality assessment tool within VCH.

• Data being collected: – Patient characteristics – Indications for surgery – Visual function before and after surgery (Catquest-9SF) – Clinical information

• Mechanisms for data collection: – Modified surgery booking form – Operative record – Baseline survey: in office, paper-based – Post-surgery: online, telephone and postal

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Pre-operative Catquest-9SF scores: National Swedish Cataract Register

Source: Lundstrom & Pesudovs (2009)

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Settings for PROM data collection

Health research Program evaluation

Quality improvement

Routine care delivery

Health research Program management

Individual patient management

Contexts for use of PROMs data

Policy decision making

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PROMs and integrated primary and community care in BC

• Review work for BC Ministry of Health, funded by CIHR (Expedited Knowledge Synthesis)

• Project objective: – To explore the utility of existing generic PROMs in

obtaining reliable, valid and useful information from patients in assessing the impact of primary and community health care reform initiatives in Canada.

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Burden

Instrument Number of

Items Word Count

Time for Completion

(min) Flesch

Reading Ease AQoL-8D 35 1,188 5 73.0 EQ-5D 6 239 “few minutes” 68.8 SF-12® 12 453 2 72.2

SF-36® 36 692 10 71.7 HUI3® 15 1,173 8 - 10 66.8 NHP 38 353 5 - 15 92.3 QWB-SA 80 1,934 15 73.2 WHOQOL-BREF 26 607 5 67.4 PROMIS/GHS 10 217 2 62.8

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Domain coverage

1 1

6 3 1

1 5

1

1

2

8

8

46

2

2 6

2

4

14

3

16

11

4

2

16

1 5

12

4

9

11

6

2

8 1

1 2 5

2

3

2

7

10

1

0%

20%

40%

60%

80%

100%

% o

f all

item

s for

eac

h in

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men

t

OtherSocial HealthMental HealthPhysical Health FunctionPhysical Health SymptomsGeneral Health

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Psychometric Evidence Strengths Weaknesses

EQ-5D Discriminates between groups with clinical variations in health.

Not as comprehensive. Not sensitive to small changes, limited responsiveness in healthy populations.

SF-36 Top instrument in most psychometric categories. Widely used, multiple cultural contexts, and many versions available.

HUI Can distinguish between groups with clinical variations in health, and widespread use in a variety of cultural contexts.

Lacking in mental health. Less reliability. Less responsive in populations of fairly good health.

PROMIS Good internal consistency, responsiveness and correlation with other instruments.

Smaller evidence base.

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Some examples of generic PROMs Jurisdiction Organisation(s) Project / Area PROM Alberta Alberta Health Services Alberta's Caring for Diabetes Project EQ-5D

Alberta Alberta Health Services Province-wide use of PROMs EQ-5D, SF-12

BC All regional HAs Knee arthroplasty (PEAK) SF-12, EQ-5D

BC Vancouver Coastal Health Elective surgery (VALHUE project) EQ-5D

Manitoba Winnipeg Hip / knee replacement SF-12

Ontario Cancer Care Ontario Ontario PROs of Symptoms and Toxicity

EQ-5D

Canada Statistics Canada Canadian Community Health Survey HUI, RAND

England NHS England Selected elective surgeries EQ-5D

US Medicare Health Outcomes Survey VR-12

US Veterans Administration Various studies VR-36, VR-12

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EQ-5D feedback

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EQ-5D (www.euroqol.org) - 5 dimensions, each with 3 levels - defines 243 health states (35) - scores range from -0.594 to 1.000