1) The document provides background on the national PROMs (patient-reported outcome measures) programme in the UK, which collects data on patient outcomes and experiences before and after various surgical procedures. 2) It discusses how PROMs data can be used to identify variations in outcomes across different provider trusts nationally and help trusts investigate areas for improvement. 3) It presents a case study from Northumbria Healthcare NHS Trust where they used their PROMs data to identify better outcomes associated with a particular knee replacement implant. They were able to significantly improve outcomes by changing to this implant. 4) It also discusses a study they did which found that preserving the infrapatella fat pad during knee replacements led to

1. Making the most of your
PROM data
Jo Partington, Rafael Goriwoda (NHS England)
and Tom Partridge (Northumbria Healthcare NHS Trust)
Pop Up University 5
10am; 2nd September 2015

2. Appleby and Devlin 2010
“The first health system
internationally to measure what
it produces in terms of health.”

3. Content
I – Backgroundto the national PROMs programme
What are PROMs?
How does the national PROMs programme relate to wider NHS policy.
II – Variationin outcomes (nationally)
How PROMs data canbe usedto identify goodperformanceorareas forconcern.
III – So what?
How provider trusts caninvestigate theirPROMs data to improve outcomes.
Northumbria case study.

4. What are PROMs?
National data collections
Since 2009, patients undergoing
Hip Replacement,Knee
Replacement,VaricoseVeinand
GroinHernia surgery are asked
to participate
Objective
To measure and improve the
quality of treatment and
care patients receive,in
order to positively affect
outcomes forpatients.
Definition
Measures of the outcomes of
treatment,whichare based
upon asking patients to report
ontheir ownhealth
outcomes.
Scope
In2013/14: 139,774 patients
gave feedback ontheir health
state before andafter surgery.
255,000
Episodes
139,000
complete
answers
Participation
• 3/4 patients fill out a
questionnaire before surgery.
• Of these, 3/4 respondto the
post-operative questionnaire.
55% of patients
gave pre- and post-op
feedback in13/14
Non responders

5. Wider policy context
• NHS Outcomes Framework: 3.1
• NHS Mandate
• NHS Standard contract
• Five Year Forward View
• Personalised Health and Care 2020 : Using
Data and Technology to Transform
Outcomes for Patients and Citizens –
National Information Boardstrategy
• Best practice tariff

6. New developments in PROMs
• Cancers (breast, prostate,bowel, bladder,
non-Hodgkin’s lymphoma, womb, ovary and
cervix): the pilot PROM reporton living with
and beyond bladder cancer will be published
shortly. Prostate Cancer UK are the first charity
to solely fund a UK-wide PROM project.
• Cardiovascular revascularisation:pilot data
collected, linkage with NICOR on-going and
then the analysis and final reportdue.
• Renal replacement: Being developed at the
UKRR; will look at the link between Patient
Activation Measures, Patient Experience and
PROMs.
• Major Trauma – Pilot sites already collecting
data – some investment from the Medical
Directorate
• Dementia: DEMQoL developmentthrough
National Institute for Health Research (NIHR)
• Long-term conditions: As for dementia,
development through NIHR.
PROMs pilots beyondthe national programme
• Publication on MyNHS and NHS Choices
• Upcoming “Insight Strategy Short Guide
to PROMs”
• Work with ISIS Outcomes at the
University of Oxford to support the
development of electronic PROMs
Making better use of what we have

7. My problemsare
much better after
surgery.
My problemsarea
littlebetter or much
the same.
My problemsare
worsethan before.
19 out of 20
patientssay
theirproblems
were much
betterfollowing
hipreplacement
18 out of 20
patientssay their
problemswere
much better
followingknee
replacement
1 out of 20
patientssay
theirproblems
were worse
followinghip
replacement
1 out of 13
patientssay their
problemswere
worse following
knee
replacement
17 out of 20
patientssay their
problemswere
much better
followingvaricose
veinsurgery
10 out of 20
patientssay their
problemswere
much better
followinggroin
herniarepair
3 out of 20
patientssay their
problemswere
worse following
varicose vein
surgery
3 out of 20
patientssay their
problemswere
worse following
groin hernia
Hip Knee Varicose Vein Groin hernia
What PROMs tells us: most patients report successful
procedures

8. -15
-10
-5
0
5
10
15
20
25
0 100 200 300 400 500 600 700 800 900
AdjustedHealthGain
Number of Modelled Records (Trust Size)
95% control limits
99.8%control limits
England
All
Trust ATrust B
Trust C
Trust D
Using PROMs to identify variation across provider
trusts
Organisation
Name
Significa
nce
Interpretation
Trust A Upper
99.8%
Amongthe best
outcomes
Trust B Averageoutcomes
Trust C Lower
95%
Belowaverage
outcomes
Trust D Lower
99.8%
Amongthe worst
outcomes
TrustD would notreceive
the BPT for hip andknee
replacements
The chanceof
patientsata trust
havingaverage
outcomes belowthis
level by random
chanceis1 in 1000.
Taking into account
each trust’s case-
mix!

9. Differences that matter to patients: results at a
repeat outlier
Domain Trust score National
Patients sayingresults were fair at best 18.9% 11.2%
Patients sayingproblems now worse 6.6% 4.2%
Patients reachingexcellent score (42+),Hip 26% 51%
Patients reachingexcellent score (42+),Knee 18% 30%
Patient withextreme difficulty kneelingdownand getting up again
afterwards,Knee
63.7% 53.5%
.. Dressingthemselves,Hip 23.9% 12.2%
Patients havinghad urinary problems 15.9% 11.5%
… problems with the woundhealing. 15.7% 11.3%
… anallergy or adverse reactionto drug. 13.4% 10.3%
… problems with their wound bleeding. 8.7% 6.4%

10. So What? Putting PROMs into practice
• PROMs is used in a variety of ways:
• Audit & Effectiveness Committees – local
• Quality Boards - local
• Best Practice Tariff
• Care Quality Commission “Intelligent Monitoring”
• “Beyond Compliance”
• “Getting It Right First Time”
• Examples from HSCIC benefitrealisation study:
• Enhanced recovery pathways implemented; PROMs used to evaluate success of
components
• Revised pain management regimes => earlier mobilisation; improved rehab ++ = better
outcomes
• Analysis of themes where people struggled post-operatively, and exercises included in
post-op appointments
• Better wound management protocols
• Altered mode of knee surgery treatment

11. QUALITY IMPROVEMENT USING
PROMS IN TOTAL KNEE
REPLACEMENT
Presenter: Mr T Partridge MBBS, MRCS
Northumbria Healthcare NHS Foundation Trust
Co-authors: Muller S, Emmerson KP, Carluke I, Partington PF, Reed
MR

12.  Large provider
 Vast geography
 4 main sites
 Over 2000 hip and knee
replacements/year (3rd
largest nationally)

13. INTRODUCTION
PROMs introduced in 2009
 Evaluate quality of care
 Drive patient choice
 Empowercommissioners
Total Knee Replacement
 Pre and 6 month post procedure OKS and EQ5D
 Remuneration on compliance and outcome

14. QUALITY IMPROVEMENT USING PROMS
 IMPROVING PROMS IN TOTAL KNEE
REPLACEMENT BY CHANGING IMPLANT: A
QUALITY IMPROVEMENT PROJECT
 DOES PRESERVATION OF THE INFRAPATELLA
FAT PAD IMPROVE PROMS IN TOTAL KNEE
REPLACEMENT?

15. PROMS – TKR OKS adjusted
funnel plot
Volume of modeled records
OKSimprovementscore

16. BACKGROUND
Significant variation in PROMs improvement
scores between TKR brands

17. METHODOLOGY
• Mass move to ‘best’ TKR brand
– 6 month transition period
– Re-training
• Retrospective cohort study using PROMs database
– April 2009 to March 2014 Northumbria Healthcare TKR
– Incomplete records/transition period excluded

18. PROMs improvement scores pre and post
implant change
Implant Q1 SCORE EQ5D GAIN OKS GAIN
Pre-change
Brand A
(581)
Brand B
(246)
20.4
(19.8-21.0)
20.7
(19.7-21.6)
0.256
(0.230-0.281)
0.265
(0.225-0.305)
13.7
(13.1-14.6)
14.2
(12.9-15.4)
Post-change
Brand C
(796)
20.5
(19.9-21.0)
p=(0.866)
0.288
(0.264-0.312)
(p=0.07)
16.6
(15.6-17.1)
(p=0.007)

19. PROMS – TKR OKS adjusted
funnel plot 2013-14
Volume of modeled records
OKSimprovementscore

20. STUDY CONCLUSIONS
• Significant improvement in TKR outcome by change of TKR brand
• Evidence based practice - highlighted by PROMs/NJR project
• Showcase national PROMs agenda

21. DOES PRESERVATION OF THE
INFRAPATELLA FAT PAD IMPROVE
PROMS IN TOTAL KNEE REPLACEMENT

22. THE FATPAD IN TKR
 Removal of the infrapatella fat pad remains controversial
 blood supply to the patella tendon
 biomechanics of the knee
 inflammatory modulator
VS
 improved access
 visualisation

23. AIM AND METHODOLOGY
 To determine if the default removal of the infrapatella fat pad
affects patient outcome in TKR.
 Retrospective cohort study using PROMs database
 OKS and EQ5D pre-operatively and at 6 months.
 Correlated with consultant default practice of
 excising
 partially removing
 preserving the infrapatella fat pad.

24. PROMs improvement scores per default
infrapatella fatpad practice
NUMBER OKS CHANGE EQ5D CHANGE
EXCISED 297 15.0 (13.8-16.3) 0.262
PARTIAL 178 16.6 (15.3-18.0) 0.295
PRESERVED 169 17.3 (15.7-18.9) 0.327

25. Mean Change in OKS (95% CI) comparing
individual consultant fat pad default practice
8
10
12
14
16
18
20
22
MeanChangeinOKS(95%CI)
PRESERVER PARTIAL EXCISER

26. Components of OXFORD KNEE SCORE
improvement comparing excisers and preservers
OKS EXCISER PRESERVER P-VALUE
PAIN 2.03 2.37 0.007
NIGHTPAIN 1.38 1.82 0.003
WASHING 0.68 0.78 0.301
TRANSPORT 0.88 1.01 0.259
WALKING 1.14 1.18 0.762
STANDING 1.22 1.32 0.382
LIMPING 2.01 2.18 0.233
KNEELING 0.67 0.83 0.267
WORK 1.41 1.7 0.16
CONFIDENCE 1.52 1.59 0.554
SHOPPING 1.07 1.34 0.036
STAIRS 1.04 1.21 0.146
OKS CHANGE 15.04 17.33 0.031

27. STUDY CONCLUSION
 Patients report better outcomes if their surgeons default to
preserving the infrapatella fat pad
 Pain is reported difference
 In the absence of a randomised trial surgeons should consider fat
pad preservation

28. PROMS – TKR OKS adjusted
funnel plot 2013-14
Volume of modeled records
OKSimprovementscore

29. PROMS
• Show case PROMs agenda
• Local projects vs national projects
• Publication of trust PROMs and the possibility of performance based
remuneration makes self-evaluation of practice ever more important.
• Excellent opportunity for quality improvement

30. Thank you