B5 Let’s All Go to the PROM - S. Bryan and D. Whitehurst


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B5 Let’s All Go to the PROM - S. Bryan and D. Whitehurst

  1. 1. Let’s All Go to the PROM Stirling Bryan PhD, David Whitehurst PhD Thursday March 8th, 2012Quality Forum 2012: BC Patient Safety & Quality Council
  2. 2. The PROMs we’re not be talking about!
  3. 3. Overview• Measuring health outcomes: what are PROMs?• Traditional use of PROMs• The case for routine measurement• Examples of PROM initiatives – Vancouver – late 1990s – Vancouver – 2012 – Sweden• Feedback on EQ-5D completion
  4. 4. Measuring Health Outcomes• Not a new concept: mortality & morbidity• A wealth of information on outcomes – but with limits – Statistics Canada – Canadian Institute for Health Information (CIHI) – Poor outcomes / 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. 5. Patient reported outcome measures (PROMs)• Measures of health status or health-related quality of life completed by patients, commonly as a short questionnaire• Used to assess a person’s health status at a particular point in time, or on a number of occasions• Large number of PROMs developed over ‘recent’ years – Condition-specific measures (e.g. cataract removal, varicose vein surgery, hip/knee replacement) – Generic measures, facilitating comparison between conditions (e.g. EuroQol EQ-5D, Health Utilities Index, SF- 36)
  6. 6. ‘Traditional’ PROM uses• Clinical research – E.g. Randomized controlled trials, cohort studies, registries• Economic evaluation research – Comparative analysis of two or more interventions in terms of both costs and benefits
  7. 7. Terms you may come across• Cost-benefit analysis• Cost-consequence analysis• Cost-minimisation analysis• Cost-effectiveness analysis• Cost-utility analysis Increasingly, these two are the dominant forms of evaluation
  8. 8. PROMs for Economic Evaluation• Generic preference-based PROM measures – Index scores interpreted on a 0 to 1 scale – 0 = health state ‘equivalent to death’ – 1 = full health• Quality-Adjusted Life Years (QALYs)• A number of alternatives exist
  9. 9. PROMs for Economic Evaluation (2)• EQ-5D (www.euroqol.org): a widely-used measure – 5 dimensions, each with 3 levels – Defines 243 health states (35) – Scores range from -0.594 to 1.000
  10. 10. Example CUAs• Statin therapy for secondary CHD prevention – Incremental cost per quality-adjusted life year (QALY) ranged from $15,000 to $22,000 – “Statin therapy is recommended for adults with clinical evidence of CVD.”• Anakinra for Rheumatoid Arthritis – Incremental cost per QALY in the region of $160,000 – “Anakinra should not normally be used as a treatment for rheumatoid arthritis. It should only be given to people who are taking part in a study on how well it works in the long term.”
  11. 11. 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?
  12. 12. Example 1: Vancouver, late 1990s• RESIO (Wright et al, 2002)• Participants – 138 surgeons and 5313 patients – cataract replacement, cholecystectomy, hysterectomy, lumbar discectomy, prostactectomy, hip replacement• Self-reported health-related QoL before and after – Generic measure: SF-36 – Disease-specific instruments: e.g. VF-14 (visual function)• Feedback of information to surgeons
  13. 13. Example 1: Results• Cataracts: – 31% of patients booked for cataract surgery had a visual function score of at least 91 (100 = no visual impairment) – Overall results positive (see figure) but 27% of patients showed either no change or deterioration.• Cost of the program: $12/patient• 47% of surgeons said the exercise was of little value and did not wish to continue receiving such information
  14. 14. Pre-operative visual function 35 30 RESIO First eye only 25 Fraser Health all first eyePercent Patients 20 15 10 5 0 Preoperative VF-14 (Range 0-100)
  15. 15. Example 2: VCH cataract outcomes• The task: – “To implement a cataract surgery outcome measurement strategy as a routine quality assessment tool within Vancouver Coastal Health (VCH).”• Background: – Key issue: need full engagement of the ophthalmology community in VCH – Culture amongst most physicians is not one of routine and standardized measurement of indications and outcomes
  16. 16. Example 2: The proposal• Development of a registry of all patients having cataract surgery done within VCH• Data will be collected on: – patient characteristics – indications for surgery – visual function before and after surgery (CATQUEST) – clinical information• Mechanisms for data collection include: – surgery booking form (to be expanded) – Postal/online survey of patients before and after surgery
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  18. 18. Example 3: Learning from Sweden?• http://p2icare.se/en/filmer/
  19. 19. How’s your health?• Your data...