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Improving Use of Patient-Reported Outcome Measures of Health and Psychological Status


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This project will develop an electronic prototype for collecting information from patients about health behaviors, including physical activity, stress, anxiety, depression and tobacco use. The study will involved four safety-net clinics to address the infrequent and inconsistent assessment of behavioral risk factors in primary care.

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Improving Use of Patient-Reported Outcome Measures of Health and Psychological Status

  1. 1. A Safety Net Collaboratory to Improve the Use of Patient-Reported Outcome Measures of Health Behaviors and Psychological Status Beth Glenn, PhD, Hector Rodriguez, PhD, Roshan Bastani, PhD. Community Partner: Bridget Hogan Cole, MPH,Building Clinic Capacity for Quality (BCCQ), a program of Community Partners® CERP Meeting 9/20/2012
  2. 2. Background• Health behaviors and psychological status (e.g., tobacco use, poor diet, depression) are infrequently and inconsistently assessed in primary care despite their negative effects on health outcomes• Standardized collection of patient-reported data on these health topics is an important first step• Establishment of clinic protocols to also systematically address behavioral factors in primary care are critically needed ▫ Methods that maximize use of EHR hold the greatest promise for routinization, institutionalization and sustainability• Inclusion of safety net clinics and the vulnerable patients they serve in these efforts is vital to reduce widening health disparities
  3. 3. NIH-Funded Pilot Study (10/11-9/12)• Implemented a brief questionnaire to assess patient reported data for 10 domains in 4 Federally Qualified Health Clinics in Southern California• Paper-and-pencil administration of “Patient Health Update” in English, Spanish, and Chinese
  4. 4. Patient-Reported Behavioral Health DomainsDomain Final Measure (Source)1.Demographics 9 items: Sex, date of birth, race, ethnicity, English fluency, occupation, household income, marital status, education, address, insurance status, veteran’s status. Multiple sources including: Census Bureau, IOM, and National Health Interview Survey (NHIS)2. Overall Health Status 1 item: BRFSS Questionnaire3. Eating Patterns 3 items: Modified from Starting the Conversation (STC). (Adapted from Paxton, AE et al. Am J Prev Med, 2011; 40(1):67-71.)4. Physical Activity 2 items: The Exercise Vital Sign (Sallis, R. Br J Sports Med 2011; 45(6):473–474)5. Stress** 1 item: Distress Thermometer (Roth AJ, et al. Cancer 1998; 15(82):1904-1908.)6. Anxiety and 4 items: Patient Health Questionnaire - Depression & Anxiety (PHQ-4)Depression (Kroenke K, et al. Psychosomatics 2009; 50(6):613-621.)7. Sleep 2 items: a. Adapted from BRFSS b. Neuro-QOL (Item PQSLP04)8. Smoking/ Tobacco 2 items: Tobacco Use Screener (Adapted from YRBSS Questionnaire)Use**9. Risky Drinking** 1 item: Alcohol Use Screener (Smith PC, et al. J Gen Intern Med 2009; 24(7):783-788)10. Substance Use ** 1 item: NIDA Quick Screen (Smith PC, et al. Arch Intern Med 2010, 170(13): 1155- 1160.)
  5. 5. Physical Activity Level Q2a. How many days did you get moderate to strenuous exercise?Q2b. On those days, how many minutes, on average, do you exercise at this level? 33, 12% Positive: Less than 150 min/week Negative: More than 150 min/week 75, 26% Missing 176, 62%
  6. 6. Alcohol Use: Risky DrinkingQ7. How many times in the past year have you had X or more drinks in a day? (Where X is 5 for men, and 4 for women) 5, 2% 70, 25% Positive: 1 or more times Negative: Never Missing 209, 73%
  7. 7. Anxiety Q4a. Feeling nervous, anxious, or on edgeQ4b. Not being able to stop or control worrying 17, 6% 56, 20% Positive: Total score of 4 or more Negative: Total score of less than 4 Missing 211, 74%
  8. 8. 10.00% 20.00% 30.00% 40.00% 50.00% 60.00% 70.00% 80.00% 90.00% 0.00% FRTSVGQ1b Fruit & Veg Svgs 85.56%Q2 Activity Physical EXERCISE 61.97%Q9 HEALTH Overall Health 58.10% STRESSQ3 Stress 54.58%Q1c Bev Soda/SweetSODA 30.28%Q7 Alcohol ALC 24.65% Anxiety ANX/WOR PHQQ4a&b 19.72%Q5 SNORE/SLEEP Snore/Sleep 13.38% DepressionPHQ DEP/INT 9.51%Q4c&d Percentage of Positive-Screens by MeasureQ6a SMOKE1 Smoking 8.80% Fast Food FSTFOODQ1a 4.58% UseQ8 Drug DRUGUSE 3.87% Smokeless Tob. SMOKE2Q6b 1.06%
  9. 9. 70 Distribution of Sample for Number of 63/22% Positive Screenings 60 57/20% 50 48/17% 42/15% 40Frequencies 30 29/10% 22/8% 20 12/4% 10 5/2% 4/1% 1/<1% 1/<1% 0 0 0 Positive 1 Positive 2 Positive 3 Positive 4 Positive 5 Positive 6 Positive 7 Positive 8 Positive 9 Positive 10 Positive 11-13 Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Screenings Positive Screenings
  10. 10. CERP Pilot Project Aims • Project Aim 1: In collaboration with Building Community Capacity for Quality (BCCQ) convene a learning community comprised of 3-4 safety-net clinic organizations to understand current practices with regard to the assessment of patient-reported measures of behavioral risk factors and protocols to address these risk factors in primary care settings. (Relevant to CERP Aim 1) • Project Aim 2: Through a collaborative stakeholder engagement process, select a set of patient-reported measures that can be commonly collected across clinics participating in the learning community. (Relevant to CERP Aim 2) • Project Aim 3: Use data collected to inform development of a prototype of an electronic patient-reported outcome data collection and feedback system. (Relevant to CERP Aim 4)
  11. 11. Methods• Convene a Learning Collaborative to Facilitate Sharing of Best Practices: ▫ Half day event scheduled for November 2012 ▫ Working with BCCQ to select invitees-plan to include high level administrators or medical director and information technology staff ▫ Plan to involve 3-6 organizations to keep group small and interactive ▫ Goal of event: provide opportunity for sites to share “best practices” for electronic capture of behavioral risk factor data and using EHR and registry systems• Organizational Assessment: Collection of data from each clinic participating in the learning community with regard to current collection of patient-reported data for the behavioral domains (i.e., method of collection, frequency of collection, target population for assessment) and protocols in place for addressing these issues• Key Informant Interviews with Clinic Administrators and Staff: Conduct key informant interviews (2-3 informants per clinic) to understand stakeholder experiences of PRO data collection, challenges & facilitators, interoperability between EHR and other data systems, use of PRO data for reports and feedback
  12. 12. Methods• Develop PRO Data Collection and Feedback Prototype: Use data to develop a prototype that can be used to electronically capture data and facilitate providers in addressing “out of range” patient values ▫ Prototype to produce easy-to-use views of patient data to allow for tracking assessment over time and generating flags for “positive” results ▫ Goal to develop system that will be interoperable with many EHR systems ▫ Collaborating with technical team led by NIH’s Office of Behavioral and Social Sciences Research
  13. 13. CERP aims addressed• CERP Aim 1. Promote and sustain bidirectional knowledge sharing between community and academia.• CERP Aim 2. Strengthen community infrastructure for sustainable partnered research.• CERP Aim 4. Build health services research (HSR) methods into partnerships to accelerate design, production, and wide adoption of evidence-based practice and behavior.
  14. 14. TimelineFinalize the collaboratory participants Organizational assessments of community clinic structural capabilities (current use of electronic data and feedback systems) Develop a prototype for electronic PRO data collection and feedback Complete key (for later testing)Key informant interviews informant interview Convene learning of community clinic findings report collaborative Formal stakeholders Testing (November, 2012) (clinicians and staff) Develop a clinician Finalize the set of resource guide for use in PRO measures for next phase inclusion in prototype August-October, 2012 November 2012-February 2013
  15. 15. Added-Value from CTSI Funding• Recently completed pilot allowed us to collect data from 4 Federally Qualified Health Center using paper-based methods• CTSI funding allows us to take project to the next step: ▫ Focus on electronic capture of data ▫ Continued partnership with BCCQ will ensure involvement of clinics with more HIT experience to share ▫ Comprehensive assessment of current practice and solicitation of “best practices” in safety net will provide valuable foundation for future work ▫ Development of a prototype will greatly facilitate ability to address behavioral risk factors
  16. 16. Next Steps• Dissemination of “lessons learned” to safety net clinics• Use pilot to apply for external funding to evaluate the effect of prototype system more formally