PATIENT REPORTED OUTCOMESInternational Forum on Quality and Safety in HealthcareBreakfast SessionAndrew Vallance-OwenGroup Medical Director7 April 2011
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 2
BUPA Hospitals rates for clinical indicators(Most indicators <0.5% of discharges)
0.0
0.1
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1.0
Hospital
% o
f to
tal d
isch
arg
es
% Surgical Deaths
% Transfers
% Re-ops
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 3
BUPA Hospitals rates for clinical indicators(What about the other 99.5% of patients?)
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Hospital
% o
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es
% Surgical Deaths
% Transfers
% Re-ops
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 4
Generic questionnaire used by NHS
EQ-5D
• 5 questions and a visual analogue scale
• Disadvantage:
◦ Not as sensitive
• Advantage:
◦ Can convert data into QALYs for health economics
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 5
EQ-5D
Kind, P. et al. BMJ 1998;316:736-741
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 6
Disease-specific vs. generic tools
Trade-off between:
• measuring all health issues affecting patients, and
• using the tool most sensitive to the expected change
Cataracts for example:
• SF-36 shows cataract surgery having negligible benefit, whilst:
• VF-14 shows the same surgery making significant improvement
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 7
VF-14 (Visual Function) – extract from 14 questions
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 8
0
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30
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50
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0 3 5 8 11 13 16 19 21 24 27 29 32 35 38 40 43 46 48 51 54 56 59 62 64 67 70 72 75 78 80 83 86 88 91 94 96 99
Percentage of patients (N=824)
VF
-14
sco
re
(10
0 =
no
vis
ua
l p
rob
lem
s)Baseline data can be interesting in their own right:VF-14 pre-op scores, where 100 = no visual problems
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 9
PROMS - NHS
Standard NHS Contract for Acute Services, April 2008
requirement to report from April 2009 :
•Other procedures may be added later, e.g. cataract surgery•Future - Long term conditions in primary care
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 10
Recruitment varies by procedure% of patients completing baseline questionnaire, NHS data
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
90.0%
100.0%
Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10
Groin Hernia Hip Replacement Knee Replacement Varicose Vein
Hips and knees – 70 to 80%
Hernia – 50 to 60%
Varicose vein – 40 to 50%
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 11
EQ-5D responsiveness?
Note number “Same” and “Unknown”
Oxford /
Aberdeen
Change (%)
Groin
Hernia
Hip
Replacement
Knee
Replacement Varicose Vein
Increase 95.8% 91.6% 83.7%
Same 0.6% 1.4% 0.1%
Decrease 3.6% 7.0% 16.3%
Unknown 2.5% 3.6% 2.9%
EQ-5D Index
Change (%)
Groin
Hernia
Hip
Replacement
Knee
Replacement Varicose Vein
Increase 49% 87% 77% 53%
Same 33% 6% 11% 33%
Decrease 18% 7% 12% 14%
Unknown 6% 11% 11% 8%
… compared with condition-specific tools:
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 12
How NHS data have been presented (as experimental statistics)http://www.hesonline.nhs.uk/Ease/servlet/ContentServer?siteID=1937&categoryID=1295
Groin Hernia - EQ-5D Index - Adjusted Health Gain
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
Organisation A National Organisation B
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 13
How the NHS data can be shown - funnel plotOxford Hip change scores by hospital, April ’09 to April ’10 dataNHS Experimental Statistics
Hip replacement outcomes (OHS)
10.000
12.000
14.000
16.000
18.000
20.000
22.000
24.000
26.000
28.000
0 50 100 150 200 250 300 350 400 450 500 550 600
Volume (Linked Q1-Q2-HES)
Ca
se-m
ix a
dju
ste
d O
HS
sc
ore
-3σ
mean
-σ
+2σ
-2σ
+3σ
+σ
Patient Reported Outcomes – International Forum on Quality and Safety in Healthcare – Amsterdam 2011 7 April 2011 14
The future of PROMS? The ‘howRu’
howRu 35 words
EQ-5D 230 words
SF-12 451 words
SF-36 779 words