NHS experience with the EQ-5D as an Outcome Measure


Published on

Prof Devlin discusses the rationale for the PROMs programme and provides an overview of the various uses of the EQ-5D in England—for example by NICE in health technology assessment, in population surveys and in the English NHS PROMS program. The presentation also reviews how EQ-5D data are collected, analysed and used in the UK to inform decisions by health care providers, payers and patients.

Published in: Health & Medicine
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide

NHS experience with the EQ-5D as an Outcome Measure

  1. 1. NHS experience with the EQ-5D as an Outcome Measure Professor Nancy J Devlin Patient-Reported Outcome Measurement in Alberta: Potential of the EQ-5D SymposiumHealth Quality Council of Alberta, the Institute of Health Economics and Alberta Health Services Canmore, Canada • 18 -19 October 2012
  2. 2. Content1. Use of the EQ-5D in the NHS2. The NHS PROMs programme and rationale3. Recent and planned developments4. Analysing EQ-5D data: profiles, index-weighted profiles and EQ-VAS5. What insights have been generated?6. Who uses the data and how?7. What is the value of routine outcomes measurement?
  3. 3. 1. The use of the EQ-5D in the NHS
  4. 4. • EQ-5D is the instrument recommended by NICE for use in evidence submitted to its HTA process • Informs decisions about reimbursement and (under VBP) pricing of new technologies• EQ-5D is included in population health surveys • Informs ‘needs based’ allocations of budgets between regions• EQ-5D is included in the NHS PROMs programme • Multiple uses of these data e.g.. assessing provider performance
  5. 5. 2. The NHS PROMS programme
  6. 6. Background• Concerns about productivity in the NHS• Increased emphasis on patient choice • but little information available for patients about provider performance in terms of patient health• Prospective reimbursement for providers intended to promote technical efficiency • but the incentives focused on activity, not outcomes.• Concerns about effectiveness and cost effectiveness in the NHS • especially relevant in a period of fiscal restraint • disparity between HTA processes and knowledge about extant services
  7. 7. Why PROMs?• Patients’ own assessment of their health “The use of PRO instruments is part of a general movement toward the idea that the patient, properly queried, is the best source of information about how he or she feels”. [FDA 2006]• PROMs put patient’s views at the heart of NHS decision making “If quality is to be at the heart of everything we do, it must be understood from the perspective of the patient.”• Patients welcome being asked/involved; avoidance of observer bias; increases public accountability• Appropriate for most health care, as patients seek • Reduction in symptoms • Reduction in disability • Improvements in quality of life
  8. 8. The PROMs programme• From 2009: routine collection of generic (EQ-5D) and disease specific PROMs via paper and pencil questionnaires• In hospital at pre-surgery; by post 3 (or 6) months after surgery• A contractual obligation for providers of NHS care to collect these data• Provide ‘snapshots’ of patients self-reported health before and after treatment; observed changes in health used to explore differences in provider performance.• 4 elective procedures: hip and knee surgery; hernia repair; varicose veins.• These procedures were selected on the basis of: – High volume procedures – Significant resource cost – Potential variation in quality
  9. 9. • Survived a change of Government • Central to continued efforts to improve effectiveness and cost effectiveness of NHS services“Information generated by patients themselves will becritical…and will include wider use of effective tools like PatientReported Outcome Measures (PROMs)…At present, PROMs,other outcome measures …are not used widely enough. TheDepartment …will extend PROMs across the NHS whereverpracticable”
  10. 10. Participation rates • As at August 2012, over 510,000 pre-operative questionnaires have been completed, which is around 70% of all eligible activity. • As at August 2012, over 330,000 post-operative questionnaires have been returned. Response rates are usually around 80%. Procedure Pre-operative Post-operative questionnaires questionnaires completed returned Groin Hernia Repair 119,000 76,000 Hip Replacement 163,000 111,000 Knee Replacement 185,000 125,000 Varicose Vein Surgery 44,000 25,000
  11. 11. 3. Recent and planned developments
  12. 12. Recent developmentsNew arrangements for data collection • Shift away from central data collection, to collection/reporting of PROMs via a Framework • Aims to make ensure data collection efficient as possible. • Four suppliers currently on the Framework, pre-approved by DH • Providers can choose which to use. • Allows local innovation e.g. electronic data capturePROMs data ‘clearing house’. • Single landing point for PROMs data from multiple sources. • Multiple functions: • Linkage to HES and/or other clinical datasets ; case-mix adjustment; scoring of PROMs measures; publish official statistics; data release to providers.Open access to patient-level anonymised data
  13. 13. Recent developmentsExtensions in coverage: PROMs included in the GPpatient survey.Changes in PROs: shift to the EQ-5D-5LCase mix adjustment methodology developed • Crucial to ensure that between-provider comparisons reflect differences in performance, not factors outside the hospitals’ control.
  14. 14. Planned developments• Extension of PROMs into a wide range of areas, including: • Coronary revascularisation; Muscular skeletal; Cancer survivorship; Cosmetic surgery • Can data collection be extended to privately-financed services?• Development of a new Outcomes and Experience questionnaire (OEQ)• Pilots about to complete and possible roll out of PROMs in long term conditions: • egg. asthma, diabetes, stroke, COPD, depression
  15. 15. 4. Analysing EQ-5D data:profiles, index-weighted profiles and EQ-VAS
  16. 16. EQ-5D profile
  17. 17. Profiles – distributions
  18. 18. Profiles – categorising change Feng, Parkin, Devlin (2012) Assessing the performance of the EQ-VAS in the NHS PROMs programme, OHE Research Paper 12/01.
  19. 19. Hospital performance by profile dimension Usual activities Pain/discomfort Gutacker N, Bojke C, Daidone S, Devlin N, Street A. (2012) Analysing hospital variations in health outcome at the level of EQ-5D dimensions. Research Paper No. 74, Centre for Health Economics, University of York.
  20. 20. Index weighted profiles • In cost effectiveness analysis, patients’ profiles assigned QoL ‘weights’: EQ Index • Reflect preferences (‘utilities’) of the general public obtained using stated preference methods. • Normative judgement – allocation of taxpayer resources • Do the same arguments apply to PROMs? • There is no ‘neutral’ way to summarise profiles • Each value set will have its own properties • Can bias statistical inference. Parkin D, Rice N, Devlin N. (2010) Statistical analysis of EQ-5D profiles: does the use of value sets bias inference? Medical Decision Making (forthcoming).
  21. 21. • EQ-VAS
  22. 22. EQ-VAS and EQ Index distributions Feng, Parkin, Devlin (2012) Assessing the performance of the EQ-VAS in the NHS PROMs programme, OHE Research Paper 12/01.
  23. 23. 3. What insights have been generated?
  24. 24. Hip replacement: variations in performance (OHS)
  25. 25. Hip replacement: variations in performance (∆ QALYs)
  26. 26. Cost/QALY (£000) 0 1 2 3 5 6 7 8 9 4 1 4 7 10 13 16 19 22 25 28 31 34 37 40 43 46 49 52 55 58 61 64 67 70 73Ordered hospitals 76 79 82 adjusted, upper/lower 95% CI 85 88 91 94 97 100 103 106 109 112 NHS hospitals: Cost per QALY: Degradation in health, case mix 115 118 121 124 127 130 133 136
  27. 27. The variation in NHS hospitals’ cost per QALY is closely related to variations in unit costs; amuch smaller proportion of the variation in cost per QALY is explained by variations in QALYs(R2=0.17).
  28. 28. Key insights• There is considerable variation between providers performance in improving patient health• The variation does not seem to be related to variations in provider cost • Implies that there is scope for providers to improve performance in improving patient health, without increasing costs. • Key to this is learning what it is that high performing providers are doing well (and poor performers are not).• Patients who are 11111 before surgery • need for more consistent, explicit approach to referral decisions?
  29. 29. 4. Who uses the data, and how do they use it?
  30. 30. • Providers are very active in accessing/using their own data • Monitoring clinical quality • Facilitates a dialogue between managers and clinicians• Patients are not using the data • Less than 5% patients consult any information on provider performance before choosing their hospital (Dixon et al 2010). • More efforts required to understand how to present data in the most meaningful way for patients?
  31. 31. 4. What is the value of routine outcomes measurement?
  32. 32. Clinical/hospital use of data »» Benchmarking against peers; admission criteriaLocal public reporting »» Telling the story about performanceQuality measure in contracts »» Pay for performancePatient choice »» Choosing high quality providers; informed treatment choicesResource »» Allocate scarce resources more efficientlyallocation/productivitymeasuresTackling health inequalities »» Appropriate access for given needsRegulation »» Assessing minimum standardsNational accounting »» Driving economy-wide productivity improvementsOutcomes Framework »» Holding the NHS to account
  33. 33. Resources on PROMs • University of Oxford website on PROM instruments http://phi.uhce.ox.ac.uk/perl/phig/phidb_search.pl • London School of Hygiene and Tropical Medicine website on PROMs-related papers and reports http://proms.lshtm.ac.uk/ • NHS Information Centre website on PROMs data http://www.hesonline.nhs.uk/Ease/servlet/ContentServer ?siteID=1937&categoryID=1295