PUTTING PATIENTS AT THE CENTRE OF HEALTH CARE: THE USE OF PROMS IN PRIMARY CARE NETWORKS

Transcription

1 PUTTING PATIENTS AT THE CENTRE OF HEALTH CARE: THE USE OF PROMS IN PRIMARY CARE NETWORKS Fatima Al Sayah, PhD, University of Alberta Rick Leischner, CPA, CA, Alberta Health Ann Makin, BPE, Bow Valley PCN Scott Oddie, PhD, Alberta Health Services Arto Ohinmaa, PhD, University of Alberta APCC 2017 Calgary AB

2 PRESENTER LOGISTICS Presenter: Fatima Al Sayah Rick Leischner Ann Makin Scott Oddie Arto Ohinmaa Relationships that may introduce potential bias and/or conflict of interest: No relationships to declare.

3 AGENDA The value of measuring PROMs Fatima Al Sayah AH perspective primary care indicators Rick Leischner PCN perspective on PROMs Ann Makin Using the EQ-5D at a provincial level Scott Oddie National and international applications of PROMs Arto Ohinmaa

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6 ECONOMIC CONTEXT Since 1998, health-care spending in Alberta has increased by 317.1% - faster than in any other Canadian province outpacing population growth, inflation, growth, government spending on other programs, and provincial economic growth. Health-care spending consumed 34.1% of the province s budget in 1998, increasing to 42% in Given this trend, it is projected that health-care spending could consume 47% of the province s budget by 2030.

7 MEASURING VALUE IN HEALTH/HEALTHCARE! Patient Healthcare system Tax payer Government All of the above!

8 when we want your opinion We ll give it to you Why does it matter?

9 THE CLINICAL CONTEXT The surgeon said that my brain surgery was successful. I m in pain, I m very anxious, they said it will affect my eyesight, I don t know if I ll be able to function normally; my life has changed forever The surgery was very successful! We were able to remove the tumor, and the patient survived!

10 PATIENT-REPORTED OUTCOMES (PROS) A PRO is directly reported by the patient without interpretation of the response by a clinician or anyone else and pertains to the patient s health, quality of life, or functional status. The P could be patient or people Subjective

11 RELIABILITY OF CLINICAL MEASURES & PROMS Height (1.00) Weight (0.99) SF-36 Physical functioning (0.93) Bedside Glucose screening (0.92) PHQ-9 (0.85) SF-36 Pain (0.80) Heart rate (0.68) Diastolic Blood Pressure (0.60) SF-36 Social functioning (0.60) Tachypnea (0.60)

12 PROMs are tools and instruments that report the status of patients : - Health status - Functioning - Symptoms/symptom burden - Quality of life that comes directly from patients/people, without interpretation of their response by anyone else. - Health-related quality of life: EQ-5D-3L/5L/Y, WHOQOL, SF-36/12 - Symptoms: ESAS, pain assessment scales - Depression: PHQ-2/8/9 - Anxiety: GAD-2/7 - Distress: PAID-5

13 THE EQ-5D The EQ-5D is a generic preference-based patientreported outcome measure of health related quality of life. It can be used to generate utility values for use in economic evaluation. It is the most commonly used preference based measure around the world. EQ-5D is a trademark of the EuroQol Research Foundation. Descriptive System Visual Analogue The best Scale health you can imagine The worst health you can imagine

14 Value of PROMs in Clinical Practice Decision making in the diagnostic process (Screening tools) Risk stratification and prognosis (Identification of vulnerable patients and patients at risk ) Prioritization and goal setting Decision making in indication for treatment (Medical/surgical) Monitoring of: General health status, Response to treatment/management Facilitating communication: 1) Between patients and health professionals, 2) Within teams and between professionals

15 SUMMARY The introduction of PROMs reflects a growing recognition throughout the world that the patient s perspective is highly relevant to efforts to improve the quality and effectiveness of health care. PROMs are likely to become a key part of how all health care is funded, provided and managed. (Devlin & Appleby, 2010) PROMs: Have the potential to systematically incorporate patient input for improvement in both quality and cost of care. Can be used by various users at different levels (clinical, administrative, policy). Inform and improve patientcentered care, and allows the shift to a valuebased healthcare delivery model. Can be used for performance management/b enchmarking and quality improvement. Complement existing clinical and administrative data and other health indicators.

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17 AH PERSPECTIVE USING PROMS IN PRIMARY CARE Measurement requirement PCNs are aware of the requirement to report on the indicator in Schedule B: Percent of Residents on the PCN s Enrolment List (the PCN s patients) with a chronic condition or disease who report maintaining or improving quality of life as measured by the EQ- 5D TM Health Status Instrument.

18 AH PERSPECTIVE USING PROMS IN PRIMARY CARE (CONTINUED) Further guidance has not been provided on how to approach this so there has been no request to report this in the PCN Annual Reports. The task group working on this measure, as a first step, must determine how to proceed with measuring and reporting. The ultimate goal is to have an indicator that measures the health of the general population of Albertans that are living with a chronic disease.

19 AH PERSPECTIVE USING PROMS IN PRIMARY CARE (CONTINUED) From a provincial perspective the EQ-5D TM survey instrument may be a useful tool to inform one aspect of success of the PHC system and the work we are doing with Patient s Medical Home The EQ-5D TM tool can also provide useful information at a clinical level. Our challenge is to find a way to support implementation that provides value, is practical, and aligns with clinical work processes.

20 AH PERSPECTIVE USING PROMS IN PRIMARY CARE (CONTINUED) MEWG supports the work done by APERSU to promote EQ-5D TM APERSU will work with other programs such as AIM and TOP, as well as PCN specific change resources, to support PCNs and providers as they use the tool to meet clinical and program information needs, We will evaluate whether this initiative demonstrates value for the tool from a practice perspective and also identify the supports needed to make measurement efficient and useful The task group and MEWG will rely on this information to set out a pathway for measurement going forward.

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23 PCN PERSPECTIVES ON PROMS APERSU & the RDC-AHS Health Research Collaborative Group Key Findings: 1. All confirmed use of EQ-5D for mean utilization of 12 months 2. Top 3 Most Common Uses: Program evaluation; outcome measurement & reports / Schedule B compliance 3. Main Implementation Facilitators: Electronic administration & availability of dedicated/trained staff 4. Main Implementation Barriers: Lack of EMR integration; staff expertise & training; administration & provider buy-in

24 COLLECTIVE PCN RECOMMENDATIONS Develop standardized electronic systems / PROMs templates to be integrated into EMRs Develop practice toolkit for implementation in primary care setting APERSU to continue collaborating with Alberta Health Services (PHC), PCNs & Alberta Health to support PROMs implementation

25 COMMUNICATION IS KEY

26 EQ-5D-5L AT THE PCN LEVEL

27 EQ-5D-5L AT THE PROGRAM LEVEL Health Status & Quality of Life Outcomes - Chronic Pain Clinic n= EQ5D VAS Score Baseline 3 month 6 month

28 % of clients that improved

29 PROMS PUT PATIENTS FIRST Engage patients in their own care & health outcomes Gain insight into the patient s perspective Data informs patient care, program management & resource allocation

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31 OBJECTIVE Provide some examples from other collection methods and provincial work. Demonstrate value of using PROMs

32 400 Respondents Panel Sample Characteristics

33 Comparison of Clinic to Zone and Provincial Norms 80.00% 70.00% 60.00% 50.00% 40.00% 30.00% 20.00% 10.00% 0.00% 43.1% Clinic 21.8% 19.4% 13.2% 5.2% 5.4% Central zone Provinical Clinic Level 5 Level 4 Level 3 Level 2 Central zone Provinical 40.6% Clinic 23.4% 21.6% Central zone Provinical 70.1% Clinic 59.9% 54.6% Central zone Provinical Mobility Self-Care Usual Activities Pain and discomfort 43.9% 36.9% 36.9% Clinic Central zone Provinical Anxiety and Depression

34 Dimensional Analysis by Age 80.0% Level 5 Level 4 Level 3 Level % 60.0% 50.0% 45.6% 48.3% 54.9% 40.0% 30.0% 23.5% 29.4% 34.8% 20.0% 16.7% 10.0% 0.0% Mobility

35 Dimensional Analysis by Age 80.0% 70.0% 60.0% Level 5 Level 4 Level 3 Level % 74.2% 72.5% 69.6% 58.8% 58.8% 50.0% 50.0% 40.0% 30.0% 20.0% 10.0% 0.0% Pain/discomfort

36 Dimensional Analysis by Age 80.0% Level 5 Level 4 Level 3 Level % 60.0% 58.8% 61.8% 50.0% 40.0% 30.0% 40.6% 43.7% 44.2% 33.3% 20.0% 16.7% 10.0% 0.0% Anxiety Depression

37 PCN CDM PROGRAM CHANGE Canadian Health Advanced Nutrition and Graded Exercise Impact on Quality of Life Index Score IS Difference = 0.05 (IS difference > = clinically significant improvement) 0.86 * p< N = % Male 51% Female Average Age = 60 years old 0.7 Baseline 6 Months

38 CLINICAL INDICATORS Body Mass Index 110 Normal range Above 90cm = obesity 7.2 Normal = 6.1 mmol/l *p < *p<.0001 Centimeters Waist Circumference mmol/l FBS 26 Baseline 6 Months 90 Baseline 6 Months 6.4 Baseline 6 Months Percentage HgA1c Normal range = 4% - 5.6% *p =.007 mmol/l Total Cholesterol 5.0 Normal < 5.2 mmol/l 4.5 *p = mmol/l HDL Normal > 1.04 mmol/l *p < Baseline 6 Months 3.5 Baseline 6 Months 1.0 Baseline 6 Months mmol/l LDL Normal < 3.35 mmol/l Baseline 6 Months mmol/l Triglyceride Normal mmol/l Baseline *p = Months

39 REPORTING COST EFFECTIVENESS 39

40 LESSONS LEARNED Several methods used to collect EQ5D Informed assessment of patient-reported health status to inform service and program planning Zone and provincial level norms effective comparators Index scores can demonstrate minimally important differences relevant to clinical setting Co-occur with significant changes in clinical indicators Assess cost effectiveness We have build the capacity to analyze and interpret this PROM

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42 EXAMPLES OF APPLICATIONS IN OTHER AREAS/CONTEXTS Applications of PROMs in: - Population Health - Clinical Practice - Quality improvement - Economic evaluation / healthcare resource allocation

43 ALBERTA POPULATION NORMS FOR EQ-5D INDEX SCORE (HQCA) Mean EQ-5D index score for Alberta population sample by age/sex

44 EQ-5D/PROMs use at ABJHI Source: Dr. Deborah Marshall To describe To inform To Predict Patient Decision Aids

45 PROMS AT THE NHS DECISION MAKING Patients information and choice Hospitals managing clinical quality Commissioners provider performance and value-for-money Clinicians clinical decision making Example of summary PROMs data in Quality Accounts Source: Devlin N, Appleby J. Getting the most out of PROMs: Putting health outcomes at the heart of NHS decision-making. The King s Fund 2010.

46 EQ-5D IN HEALTHCARE RESOURCE ALLOCATION Cost-Effectiveness of Physician Notification and Follow-up or Collaborative Care for Patients with Diabetes Who Screen Positive for Depression in Primary Care: Results from a Controlled Trial (Johnson et al. American Journal of Preventative Medicine, in press) To evaluate the cost-effectiveness of three strategies to improve depressive symptoms in patients with T2D (N=227) Interventions: Usual care vs. screening for depression & physician notification vs. comprehensive care model. HRQL measure: EQ-5D-5L. Measurement: 0, 6, 12 mon Conclusion: Physician notification and follow-up is a clinically effective strategy compared with usual care, but investing more up-front resources in collaborative care yielded the most costeffective strategy. Cost-Effectiveness Analysis Based on Quality-Adjusted Life-Years (Cost-Utility analysis)

47 IN CANADA At a provincial level Alberta BC At a national level National surveys CIHI

48 INTERNATIONALLY ROUTINE OUTCOME MEASUREMENT USING PROMS UK NHS Sweden Norway New Zealand (underway)

49 THANK YOU