A ‘PROM’ising Future Esther Kwong Academic F2 Dept Primary Care and Public Health The Relationship Between Patient Reported and Other Process Outcomes at Trust Level Project Supervisor: Dr Paul Aylin Educational Supervisor: Dr Graham Easton Dept Primary Care and Public Health
A ‘ PROM’ising Future. The Relationship Between Patient Reported and Other Process Outcomes at Trust Level. Esther Kwong Academic F2 Dept Primary Care and Public Health. Project Supervisor: Dr Paul Aylin Educational Supervisor: Dr Graham Easton Dept Primary Care and Public Health. - PowerPoint PPT Presentation
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
A ‘PROM’ising Future
Esther KwongAcademic F2 Dept Primary Care and Public Health
The Relationship Between Patient Reported and Other Process
Outcomes at Trust Level
Project Supervisor: Dr Paul AylinEducational Supervisor: Dr Graham Easton
Dept Primary Care and Public Health
Contents
The Context –Setting the Scene for PROMs NHSWhat are OutcomesMeasuring Patient Reported OutcomesNational PROMs Program OverviewResearch QuestionMethodsResults Discussion & ConclusionsWhat have I learnt…
The Past
“Despite a century of developments in medical technology, and vast improvements in the ability of medical science to prevent, diagnose and treat disease and ill health, attempts to measure the outputs of health care in terms of their impact on patients’ health have not progressed beyond Florence Nightingale’s time.”
Getting the most out of PROMs Kings Fund 2010
The Context
Reasons for Healthcare:Live Longer
Better Quality of Life= Better Health Outcome
But health services traditionally focused on
one outcome Mortality
Setting the Scene for PROMS
Darzi Review “High Quality for All”
NHS White PaperEquity and Excellence: Liberating the NHS
Appraisal of new technologies –PRO data incorporated in the evaluation of new technologies
Routine measurement of pre/post elective surgery PROMsSince April 2009
DH Long Term Conditions PROMs Pilot Since 2010
Patient Centred
If quality is to be at the heart of everything we do, it must be
understood from the perspective of patients.
Patients pay regard both to clinical outcomes and their experience of the service...
Lord Darzi The ultimate measure by which to judge the
quality of medical effort is whether it
helps patients, as they see it.
Donald Berwick
What Are Outcomes
Traditional Ways of Planning = Measuring in terms of OUTPUT
• Quantifying what is produced, implemented, provided, and developed in the health service
Increasing Focus = Measuring in terms of OUTCOME
• Quantifying extent of any health impact on patients
• Change in various dimensions ~physiological (e.g. functional status) or psychological (e.g. attitudes)
• Can be harnessed from different sources
Sources of Outcomes
Outcomes
Clinical
Clinician Reported
Patient Reported
Measuring Patient Reported Outcomes
Patient Reported Outcomes (PRO)• Health status as perceived by the patient
Patient Reported Outcomes Measures (PROMs)• Measurement tools to harness this information• Can be used in two points in time to record change in health status• Can be assessed against patient progress or health interventions
received• Various types available• Much dedicated research and analysis on validating questionnaire
types
Types of PROMSEQ5D
For any condition
Different Disease states
Aggregation and comparison
Economic evaluations
Generic
Oxford Hip Score
Outperform on sensitivity
Centred on a particular aspect/ clinical detail
Focused – useful for informing
Condition Specific
National PROMs Program Overview
Since 1 April 2009 Providers required to collect and report PROMs
Four key NHS funded elective interventions• Unilateral hip replacements • Unilateral knee replacements• Groin hernia surgery• Varicose vein surgery
Expected to invite patients to complete a pre-operative PROMs questionnaire (Q1)
Post-operative questionnaires (Q2) are then sent to patients following their operation after a specified time period.
… the NHS will be the first health care system in the world to measure what it produces in terms of health, rather than in terms of the production of health care.Getting the most out of PROMs Kings Fund
… the NHS will be the first health care system in the world to measure what it produces in terms of health, rather than in terms of the production of health care.
Getting the most out of PROMs Kings Fund
PROMs Used for the National Program• Multi-dimensional – five areas• Responses record three levels of severity• Scores are weighted and combined to give a
single index
EQ5D index score
• Self rating health related quality of life• Places self reported health state on a point in a
line• Line ranges from 0 to 100
EQ5D Visual Analogue Scale
• Validated tool specific for Total Hip Replacements• 12 questions to assess function and pain, 0-4
points• Given as a single summed score from 0 to 48
Oxford Hip Score
• Validated tool specific for Total Knee Replacements
• 12 questions to assess function and pain, 0-4 points
• Given as a single summed score from 0 to 48
Oxford Knee Score
Research Topic
Aim: To explore the relationship between routinely collected patient reported and other process outcomes at trust level
Null Hypothesis:There is no relationship between patient reported and other process outcomes at trust level
Methods:Aggregate analysis conducted using STATA 11 on trust level data
Participation and Coverage 2010
Participation rate of 69.7%.
•245,488 eligible hospital episodes •171,080 pre-operative questionnaires returned
Return rate of 75.8%
•147, 974 post-operative questionnaires sent out• 112,163 returned
National PROMs Key Final Results 09-10 Overview
EQ-5D Index score87.2% of hip replacement respondents
77.6% of knee replacement respondents Recorded an increase in general
health following operation
Oxford Hip and Knee Score95.7% of hip replacement respondents
91.4% of knee replacement respondents Recorded an improvement following
operation
Data Sources
Aggregate Trust Level Data
2010
Dr Foster Data
Orthopaedic Revision RatesOrthopaedic Readmission
CaseloadStaff to bed ratio
HSMR
National Joint Registry Data
Orthopaedic Procedures Caseload
HES Inpatient Data
Elective Surgery Waiting TimesEmergency Admission Caseload
Weak positive correlations between Hip and Orthopaedic Procedures Caseload and all Hip PROMs health gain • Suggests the more procedures a trust does the better its quality
of hip replacement procedure perceived by patient• This is an expected correlation direction
Weak negative correlations between Emergency Admission Caseload and all Knee PROMs health gain • Suggests the more emergency admissions a trust has the worse
the patient perceived outcome for a knee replacement procedure• unexpected correlation direction, warrants further exploration into
relational factors – such as trust specialisation and quality relationship
Discussion -Important Findings 2
Weak Positive Correlation Between EQ5D Visual Analogue Scale and Oxford Hip Score health gain for hip patients and Waiting Times for Elective Surgery
• Suggests the longer a patient waits for elective surgery in a trust the more health gain perceived from hip operation
• Unexpected correlation direction • Disease progression factors are adjusted for• May be explained by expectation management‘Patient Satisfaction = Patient Experience - Patient Expectation’• Longer waiting times may decrease expectation affecting
perceived outcome • Lead time difference
Discussions Limitations
Recruitment Bias• LSHTM Report to Dept of Health on PROMs recorded correlation
coefficient of -0.38 between EQ5D score and every 20% increased recruitment, suggesting low recruitment rates can introduce bias
• The report recommended a target recruitment rate of 80%
Response Bias• Studies suggest non responders were younger in all PROMs, This is
particularly evidenced in orthopaedic PROMs
Patient Reported Outcome Measures (PROMs) in Elective Surgery Report to the Department of Health, London School of Hygiene and Tropical Medicine
Conclusions
Weak/ Lack of Correlations suggests Patient Reported Outcomes are capturing an added dimension of quality that traditional process outcome and clinical indicators were not measuring
Weak correlations findings at trust level maybe due to aggregation, this could eliminate clinical variation within and between hospital services as well as patient characteristics• Evidence from clinical governance concluded acute hospitals services were
‘A mix of good and bad’• Analysis of PROMs at clinical level and unadjusted data may provide further
explanations and strengthen correlations
Lack of evidence/ data available for statistical relationship significance for correlations • Further work building larger aggregate data set on PROMs• Analysis on new PROMs data, or analysis spanning two years of PROMs data
What I learnt from this Academic RotationNature of Rotation2 days a week in GP surgery clinical duties3 days a week dept based research and
teaching activities
Research
Literature search on PROMsInsight in health services researchHandling aggregate dataData managementStatistical analysis on STATASeminars and Journal ClubExperience of life as an academic!
TeachingFormal Teaching courses/ training
Clinical Methods teaching 3rd year Imperial Students
Problem Base Learning facilitator
GPWealth of clinical experiences
Primary care setting exposure
Consultation simulation training
References
Bevan G , Skeller M, 2011 Competition between hospital and clinical quality BMJ 2011; 342:d3589Berwick D, Hiatt H, Janeway P, Smith R. 1997 An ethical code for everybody in health care BMJ 1997;315:1633Black N, Browne J, Cairns J. 2006. Health care productivity. British Medical Journal 333: 312–313.Brooks R, Rabin R, de Charro F. 2003. The Measurement and Valuation of Health Status using EQ-5D: A European Perspective. Kluwer: Dordrecht.Browne J, Jamieson L, Lawsey, J, van der Meulen J, Black N, Cairns J, Lamping D, Smith, S, Copley L,Horrockes, J. 2007. Patient Reported Outcome Measures (PROMs) in Elective Surgery. Report to theDepartment of Health. Available from: www.lshtm.ac.uk/hsru/research/PROMs-Report-12-Dec-07.pdf.Burge P, Devlin N, Appleby J, Gallo F, Nason E, Ling T. 2006. Understanding patients’ choices at the point of referral. Technical report TR359-DOH, Cambridge: RAND Europe. Available from: www.rand.org/pubs/technical_reports/TR359/.Darzi L. 2008. High Quality Care for All. NHS Next Stage Review: Final Report, Department of Health, London.Available from: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_085825.Dawson J, Rogers K, Doll H, Using Patient Reported Outcomes Routinely: An example in context of Shoulder surgery Open Epidemiology Journal 2010, 3,42-52 Department of Health. 2008. Guidance of the Routine Collection of Patient Reported Outcome Measures (PROMs).Department of Health document DH_081179[1].pdf.Devlin N, Appleby J. 2010. Getting the Most Out of PROMs: Putting Health Outcomes at the Heart of NHS Decision Making. Kings Fund/Office of Health Economics: London.Dolan P. 1997. Modelling valuations for EuroQol health states. Medical Care 35(11): 1095–1108.2010).Greenhalgh J, Long A, Flynn Rob, 2004 The use of patient reported outcome measures in routine clinical practice: Lack of theory or lack or impact. Social Science and Medicine 60 (2005) 833-843EuroQol Foundation. Springer: Rotterdam.Hospital Episode Statistics: Finalised Patient Reported Outcome Measures (PROMs) in England: April 2009 – March 2010 Isis Outcomes Patient Reported Outcome Measures from the University of Oxford, Orthopaedic Pros http://www.isis-innovation.com/outcomes/orthopaedic /
London School of Hygiene and Tropical Medicine Patient Reported Outcomes on Elective Surgery, Report To Department of Health Dec 2007, http://www.lshtm.ac.uk/php/hsrp/research/proms_report_12_dec_07.pdf NHS North West. 2010. Advancing quality. Available from: www.advancingqualitynw.nhs.ukNational Council on Ageing and Older People, 1998 health promotion strategy for older people in Ireland. Adding years to life and life to yearsNational Network of Libraries of Medicine Guide 3: Define Measurable Goals, Outputs and Outcomes http://nnlm.gov/outreach/community/goals.htmlOffice of Health Economics. 2008. NHS Outcomes, Performance and Productivity. Report of the Office of Health Economics Commission. OHE: London.Szende A, Oppe M, Devlin N. 2007. EQ-5D Valuation Sets: An Inventory, Comparative Review and Users’ Guide.
Acknowledgements
I want to thank all those in the department who have contributed their expertise and advice towards this project and towards my educational development
• Dr Paul Aylin, Dr Graham Easton, Dr Jenny Lebus, • Dr Michael Soljak, Dr Sonia Saxena• Dr Fiona Hamilton, Dr Matthew Harris, Dr Eszter Vamos• Elizabeth Cecil, Farzan Rahman, Dr Ghasem Yadegarfar