Let’s All Go to the PROM

Stirling Bryan PhD, David Whitehurst PhDThursday March 8th, 2012

Quality Forum 2012: BC Patient Safety & Quality Council

The PROMs we’re not be talking about!

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

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)

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)

‘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

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

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

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

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.”

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?

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

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

Pre-operative visual function

0-4 5-9 10-14 15-19 20-24 25-29 30-34 35-39 40-44 45-49 50-54 55-59 60-64 65-69 70-74 75-79 80-84 85-89 90-94 95-100

0

5

10

15

20

25

30

35

RESIO First eye only

Fraser Health all first eye

Preoperative VF-14 (Range 0-100)

Perc

ent P

atien

ts

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

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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Example 3: Learning from Sweden?

• http://p2icare.se/en/filmer/

How’s your health?

• Your data...