Virginia Warren FFPH

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Virginia Warren FFPH
Using Patient Reported Outcome Measures for
Quality Improvement
Andrew Vallance-Owen Group Medical
Director
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The NHS view

• Lord Darzi High Quality Care For All, June
  2008
• Change in emphasis from Quantity to Quality
• Quality
• Patient safety
• Patient satisfaction/experience
• Effectiveness of treatment did it actually
  work?
• The patient is in the best position to decide

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NHS Planning

• Requirement to publish Quality Accounts
• Verification by Care Quality Commission
• NHS Information Centre publishes circ 250
  indicators
• CQuin Funding (Commission for Quality and
  Innovation)
• Up to 3 of hospitals income by 2010
• And if a General Election intervenes
• Conservative Party proposals outcomes vs.
  targets

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Clinical Performance Indicators

• Deaths/survival rates
• Unexpected re-admissions
• Unexpected re-operations
• Infection rates
• Adverse incidents
• Clinical complaints

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Why do we collect PROMs?

• Finding bad apples
• Ledward
• Continuous quality improvement
• competition
• Measuring productivity
• Worthwhile interventions?
• Enabling choice
• feedback to GPs and patients
• The surgery was a technical success but..
• The TURP patients flow rate is much improved
  but he wishes he had never

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Bupas experience

• Routine collection of PROMS since 1998
• 100,000 patient episodes
• Initially a wide range of procedures
• Focus on the most meaningful
• 9 sentinel procedures, 1 or 2 per specialty
• SF-36, VF-14 and Oxford Hip/Knee
• Published on website after research amongst GPs
  and public

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SF-36 (Short Form 36) - extract from 36 questions
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EQ-5D
Kind, P. et al. BMJ 1998316736-741
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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

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VF-14 (Visual Function) extract from 14
questions
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Baseline data can be interesting in their own
rightVF-14 pre-op scores, where 100 no visual
problems
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How we did achieved good response rates

• One size doesnt fit all
• Send questionnaire with TCI, or wait until
  admitted
• Admin staff or nursing staff to collect the forms
• Internal admin processes will vary by site
• Careful design of questionnaire pack simple,
  minimal
• Letter and FAQs all part of the form
• Targets for management (Bupas was gt60
  recruitment at baseline)
• Train the admin nursing staff PROMs role in
  CQI process
• Reinforcement of message by nurse / doctor to the
  patient makes a big difference at follow-up
• Monitor and challenge site-by-site recruitment

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Health outcomes - NHS

• Standard NHS Contract for Acute Services, April
  2008
• requirement to report from April 2009 on patient
  reported outcome measures (PROMs)

• other procedures may be added later, e.g.
  cataract surgery

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The DH expects.
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Bupas experience of response rates

• Generally 85-90 at baseline
• Some variation by type of questionnaire
• perceived relevance, or urgency of need for
  surgery, or satisfaction with results?
• At follow up
• Oxford Hip 85-90
• VF-14 (cataract) 70-72
• SF-36 (various ops) 55-60
• So even after huge effort, total capture 48-78

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Presenting the information
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or it could look like this
This is your hospital
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Turning the distribution into a Shewhart chart
Special cause variation
Audit line
2 SDs
Common cause variation
-2 SDs
Special cause variation
Audit line
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Shewhart Control Chart.
Source Bupa Hospital, hip replacement
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and added summary data to management dashboard
Sentinel procedure outcomes, against internal
quarterly target
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Website design for PROMS information

• Market research amongst GPs and the public
  focus groups, professional researchers
• Strong preference for simplicity (even amongst
  GPs)
• Complete unfamiliarity with subject (2005/6)
• No complex statistics confidence intervals, SDs
• Data summarised at the highest level of detail
• Comparison of each site with national data
• Simple charts

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Information to the public, via website
The challenge of how to explain complex
statistics in very simple terms
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Spire Healthcares approach to public use
Pre-and post-op scores for Oxford Hip and VF-14
(cataract)
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Conclusions

• Choose your tools well generic or disease
  specific
• Embed the process of PROMs collection in your
  care pathways
• Train staff and educate patients in their
  importance
• Govern, monitor and perhaps even incentivise
• PROMs are a good idea but only one part of the
  clinical dashboard