Sills MR. Evolution of PRO Measure for Cardiovascular Cohorts in SAFTINet. Slides for teleconference to facilitate discussion of Cardiovascular PRO Measure Selection by SAFTINet Stakeholders. 2 May 2012.

1. +
Evolution of a PRO for Cardiovascular Cohorts in
SAFTINet
May 2, 2012

2. +
Overview
Describe
evolution of
CV PRO
ideas
Present 2
PRO options
under
consideration
Questions for
the PEC
about next
directions

3. +
Patient Risk Understanding:
Overview
 General concept: how well patients know their a CV-related risk
value and/or how well they understand their CV risk level
 Discussions:
 Convocation: CV PRO must align with
 other organizational initiatives (e.g., meaningful use (MU))
 clinical utility
 April 4 PEC call: discussed patient understanding especially
regarding how well patients know and understand their BMI and
BP—related to MU requirement to document counseling had been
done
 Mid-April PEC email about ideas for PRO related to patient risk
understanding: reviewed 4 PRO ideas “4A-4D”

4. +
Patient Risk Understanding:
Four Options Presented
 Email to PEC sought feedback on 4 about ideas for PRO
related to patient risk understanding
 4A. Patient knowledge of own BP status
 4B. Patient knowledge of own BMI category
 4C. Patient knowledge of own heart attack risk, using a risk
calculator
 4D. Patient knowledge of own overall cardiovascular risk (all major
CV events, not just heart attacks), using a risk calculator

5. +
Patient Risk Understanding:
Feasibility
 Email also sought feedback about timing and feasibility of 4C
and 4D—2 options presented
 calculate risk before visit based on prior visit risk data and discuss
risk with patient in person
 calculate risk based on visit data and transmit risk to patient a day
or so after visit

6. +
Patient Risk Understanding:
Feedback from PEC
 PEC feedback on email: related to 4C and 4D (the risk calculator
options)
 Strong ethical concerns about providing a risk calculation without
then having time for consultation about what to do with it.
 Risk calculator is time consuming and involves staff resources we
cannot spare.
 The data to make the calculation isn’t always available except at
POC. If you create a provider data collection form to capture data
for the risk calculation, it will require a significant amount of work.
 Patients could feel overwhelmed by being asked a percentage.
Consider “likelihood”. Consider asking patients their rationale for
that answer.

7. +
Patient Risk Understanding:
Feedback from PEC
 PEC feedback on email: related to 4C and 4D (the risk calculator options)
 I’m most worried about our patients’ understanding the concept of risk.
The literature suggest that various tools including visual aids can help
communicate risk to patients. Any intervention has been shown to be
better than nothing in improving health understanding.
 One computer-based tool for patient data entry that has been
successful using kiosks is this tool (http://www.health-e-solutions.org/ )
followed by discussion. It’s free and prints outs a summary.
 We may not be able to trust what patients report as a percentage
without an anchor for the percentage points (e.g., some patient may
have a tendency to over- or under-estimate risk).
 Waiting a day to give risk feedback could lessen the impact on the
patient. Also, the patient would have to actively contact the practice to
ask questions.

8. +
Patient Risk Understanding: Sample
Tool

9. +
Patient Risk Understanding: Sample
Tool

10. +
Patient Risk Understanding:
Feedback from PEC
 More general PEC feedback to email
 Patient risk-understanding is not necessarily “actionable”. Most
patients DO seem to know their risks but the problem is that they
aren’t doing what they need to do to REDUCE their risk.
 Why is this the case? (what prevents them from taking steps to
decrease their risk?)
 How can we change it?
 Would rather see a PRO looking at what could we be doing to better
engage the patient to take steps to decrease risk.
 What does research show is most motivating to patients? Knowing
what will best engage patients in risk-reduction is essential before
we put resources into a PRO.

11. +
Patient Risk Understanding: What
is the Evidence?
 Under certain circumstances and for certain populations,
patient CV risk understanding can impact subsequent health
behavior
 More generally, CV risk understanding has low impact on
health behavior
 What has a higher impact on health behavior risk perception?
Patients’ self-efficacy or engagement.
Patient risk
understanding
Patient self
efficacy
CV risk
behavior
change

12. +
Patient Engagement
 Suggested questions for measuring patient engagement
 Worry and concern about risk (risk understanding)
Based on your current BP, how worried are you about your risk of
[MACE]?
 Self-efficacy for change
How confident are you that you could change [risk behavior] in a way
that will decrease your risk of [MACE]?
 Barrier and facilitator identification
What kinds of things would make it harder for you to change your [risk
behavior]? What kinds of things would make it easier?
 Intentions to change
To what extent do you intend to work on changing your [risk behavior]?

13. +
Patient Engagement
 Suggested questions for measuring patient engagement
 Worry and concern about risk (risk understanding)
 if patients are already worried/perceive high risk, the next step
could be focusing on building self-efficacy and planning
 but what if they are not worried? it is tricky, but still possible, to
help patients revise their risk perception
 Self-efficacy for change
 Barrier and facilitator identification
 Intentions to change

14. +
CER/PEC Discussion About
Feedback to Email
 2 general options for PRO:
 Option 1: PRO assessing CV risk understanding
 Option 2: PRO assessing self-efficacy for changing a risk behavior
Patient risk
understanding
Patient self
efficacy
CV risk
behavior
change

15. +
CER/PEC Discussion About
Feedback to Email
 2 general options for PRO:
 Option 1: PRO assessing CV risk understanding
 Option 2: PRO assessing self-efficacy for changing a risk behavior
 Also important to consider
 clinical utility: need to target a risk behavior where primary care
intervention has been shown to have sustained effects
 organizational utility: does this help the organization meet other
requirements (e.g., meaningful use)
Patient risk
understanding
Patient self
efficacy
CV risk
behavior
change
Sustained CV
risk behavior
change
?
Organizational
utility

16. +
CER/PEC Discussion About
Feedback to Email
 2 general options for PRO:
 Option 1: PRO assessing CV risk understanding
 Option 2: PRO assessing self-efficacy for changing a risk behavior
 Also important to consider clinical utility: need to target a risk
behavior where primary care intervention has been shown to
have sustained effects
 none of the lifestyle interventions (except gastric bypass) have
demonstrated sustained effects past 2 years
 medications have been shown to have sustained benefit in patients
with high BP and high cholesterol so from a clinical utility standpoint,
our best target is medication adherence

17. +
Summary of CV PRO Options
 Option 1: PRO assessing CV risk understanding
 specific (BMI-only or BP-only) or more general (broader CV risk)
 different options for administering PRO and providing feedback to
patient
 as all patients are at risk, all (adult?) patients would receive the
PRO
 Option 2: PRO assessing self-efficacy for changing a risk
behavior
 more complicated if patient is not worried about risk
 most clinically effective target for risk behavior change: medication
adherence for BP and cholesterol drugs
 if we targeted medication adherence, only patients prescribed these
medications would receive the PRO

18. +
Questions for PEC
 What are your thoughts on these two options? More
specifically, what are your thoughts with regard to the options’
 clinical utility
 organizational utility (e.g., meeting MU requirements)
 feasibility and resource-use