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D8 Bryan Stirling - Patient-Reported Outcome Measurement (PROMs) in BC: What has been achieved so far and where next?
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D8 Bryan Stirling - Patient-Reported Outcome Measurement (PROMs) in BC: What has been achieved so far and where next?

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    D8 Bryan Stirling - Patient-Reported Outcome Measurement (PROMs) in BC: What has been achieved so far and where next? D8 Bryan Stirling - Patient-Reported Outcome Measurement (PROMs) in BC: What has been achieved so far and where next? Presentation Transcript

    • 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
    • Not this type of PROM… 2
    • 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) 3
    • 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 4
    • 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) 5
    • 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” 6
    • 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) 7
    • Patient-Reported Outcome Measures• Measures of health status (or HRQoL) – completed by patients – commonly as a short questionnaire 8
    • 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) 9
    • 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) 10
    • EQ-5D completion 11
    • 12
    • ‘Traditional’ PROM Uses• Clinical research – e.g. randomized controlled trials, cohort studies, registries 13
    • ‘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) 14
    • ‘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 15
    • Economic Evaluation of Falls Prevention Strategies Table 5. Community-dwelling: incremental cost per fall avoided, hospitalisation avoided and QALY gainedChurch J, et al. An economic evaluation of community and residential aged care fallsprevention strategies in NSW. New South Wales Public Health Bulletin 2011; 22: 60–68 16
    • 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? 17
    • Settings for PROM data collection Routine care delivery Program evaluationHealth research Quality improvement Individual patient Policy decision making managementHealth research Program management Contexts for use of PROMs data 18
    • 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 19
    • 20
    • Pre-operative Catquest-9SF scores: National Swedish Cataract Register 21Source: Lundstrom & Pesudovs (2009)
    • Settings for PROM data collection Routine care delivery Program evaluationHealth research Quality improvement Individual patient Policy decision making managementHealth research Program management Contexts for use of PROMs data 22
    • 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. 23
    • Burden Time for Number of Word Completion FleschInstrument Items Count (min) Reading EaseAQoL-8D 35 1,188 5 73.0EQ-5D 6 239 “few minutes” 68.8SF-12® 12 453 2 72.2SF-36® 36 692 10 71.7HUI3® 15 1,173 8 - 10 66.8NHP 38 353 5 - 15 92.3QWB-SA 80 1,934 15 73.2 62.8WHOQOL-BREF 26 607 5 67.4PROMIS/GHS 10 217 2 24
    • Domain coverage% of all items for each instrument 100% 2 1 7 1 1 5 8 2 4 11 80% 12 10 2 1 9 5 11 3 60% 2 Other 16 3 2 Social Health 14 16 40% 6 2 Mental Health 4 46 1 8 Physical Health Function 6 20% 2 4 2 Physical Health Symptoms 1 8 5 1 1 6 2 1 General Health 3 1 0% 25
    • Psychometric Evidence Strengths WeaknessesEQ-5D Discriminates between groups with Not as comprehensive. Not sensitive clinical variations in health. 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 Lacking in mental health. Less with clinical variations in health, reliability. Less responsive in and widespread use in a variety of populations of fairly good health. cultural contexts.PROMIS Good internal consistency, Smaller evidence base. responsiveness and correlation with other instruments. 26
    • Some examples of generic PROMsJurisdiction Organisation(s) Project / Area PROMAlberta Alberta Health Services Albertas Caring for Diabetes Project EQ-5DAlberta Alberta Health Services Province-wide use of PROMs EQ-5D, SF-12BC All regional HAs Knee arthroplasty (PEAK) SF-12, EQ-5DBC Vancouver Coastal Health Elective surgery (VALHUE project) EQ-5DManitoba Winnipeg Hip / knee replacement SF-12Ontario Cancer Care Ontario Ontario PROs of Symptoms and EQ-5D ToxicityCanada Statistics Canada Canadian Community Health Survey HUI, RANDEngland NHS England Selected elective surgeries EQ-5DUS Medicare Health Outcomes Survey VR-12US Veterans Administration Various studies VR-36, VR-12 27
    • EQ-5D feedback 28
    • EQ-5D (www.euroqol.org) - 5 dimensions, each with 3 levels - defines 243 health states (35) - scores range from -0.594 to 1.000 29