PROMs and PREMs in government programs Catherine Katz – Director, Safety and Quality Improvement Systems and Intergovernmental Relations
This presentation covers: ➢ The Commission’s background ➢ Patient reported measures ➢ PREMs and PROMs and the Commission’s role in patient reported measurement ➢ Governments’ interest ➢ The PaRIS project 2
About the Commission The Commission’s role is to lead and coordinate national improvements in the safety and quality of health care. The Commission works in four priority areas: 1. Patient safety 2. Partnering with patients, consumers and communities 3. Quality, cost and value 4. Supporting health professionals to provide care that is informed, supported and organised to deliver safe and high-quality health care. 3
Evaluation of safety and quality of care A robust safety and quality monitoring system requires Atlas of Variation triangulation of Clinical Trials Clinical Quality Registries multiple measurements from Hospital Incident Acquired multiple surveillance Complications perspectives • Clinical and Holistic picture Clinical care Staff of safety and standard administrative experience quality indicators performance data • Patient Patient Audits/ point experience and prevalence perspective PROMs studies (PROMs and Core Hospital- Based NSQHS PREMs) Outcome Standards Indicators Sentinel Events 4
Patient Reported Measures • Patient reported measures (PRMs) provide insight into the effect that health interventions have from the perspective of the service user/patient. • They evaluate either outcome (patient reported outcome measures - PROMs) or experience (patient reported experience measures – PREMs) • There are other patient reported measures such as patient reported incident measures (PRIMs) which are safety indicators of perceived harm. 5
PREMs vs PROMs Patient-reported experience measures Patient reported outcome measures (PREMs) (PROMs) Patient’s assessment of: Patient’s assessment of the impact of a period of care or a particular (a) whether or not, and how often, they intervention, in terms of factors such as observed certain events during an level of pain, symptoms, mobility, ability episode of care or consultation, and to carry out daily activities and fulfil usual roles and psychosocial wellbeing. (b) the quality of their encounters with staff, healthcare environments, care Usually measures are completed by the delivery processes such as pain same patient at multiple time points to management, and administrative assess change in health status over time processes during that episode of care or or pre- and post- intervention consultation 6
Patient experience measurement in Australia: measurement activity by jurisdiction Australia (population = 23.71 million) Currently no national- level assessment of recent patients’ experiences that can be used for quality improvement • Australian Bureau of Statistics conducts a population-based survey of experiences, part of a larger health survey, not useful for health services to identify areas for improvement • Private hospital groups a nd insurance funds use their own measurement tools (principally HCAHPS) Northern Territory Queensland No territory-wide survey Periodic state-wide PEx surveys (CATI) Some hospitals and services for Emergency Department (ED), Small measure PEx independently. Hospitals, Maternity, Outpatient clinics Western Australia New South Wales Pioneer of Australian PEx – Rolling state-wide PEx surveys (PAPI established survey 15 years and online) for overnight hospital ago. Annual state-wide survey inpatients, ED, children, Outpatients, (CATI) for hospital inpatients Cancer Outpatients, Maternity, and ED patients Small and Rural Hospitals South Australia Australian Capital Territory State-wide PEx survey (CATI; Tasmania (0.52 million) Canberra Hospital patient survey CAPI in development) for Some hospitals and services overnight hospital inpatients; measure PEx independently. developing CAPI survey for Tasmania disadvantaged populations No state-wide survey Some hospitals and services Victoria measure PEx independently Rolling online survey one month post- discharge for ED patients, hospital inpatients, maternity, children and parents Population density map (2012) source: AIHW analysis of ABS ASGS data 2010, 2013 7
Australian Hospital Patient Experience Question Set (AHPEQS) • Aim - development of national tool at the request of the Commonwealth and state and territory governments • 12 question core set of patient experience questions developed by the Commission as nationally consistent PREM tool • Based on conceptual framework developed with 16 patient focus groups and refined with clinicians, managers and policymakers • Non-proprietary, for use in private and public sectors • Final set finished in 2017 – now in a trial phase 8
Building momentum • 160+ hospitals and health services already collecting AHPEQS nationally (c. 80,000 completed surveys since Jan 2018 – as of Aug 2018) • Public and private sector uptake • All public hospitals in Tasmania and SA • WA and Victoria – active interest for state-wide use • DVA trialling prior to national rollout 9
Next step is national specification Visit https://ahpeqs.safetyandquality.gov.au 10
Patient-Reported Outcome Measures • ‘A PRO is directly reported by the patient without interpretation of the patient’s response by a clinician or anyone else and pertains to the patient’s health, quality of life, or functional status associated with health care or treatment ’. * • Measurement tools are generic (health related quality of life) or specific (function or symptoms such as pain related to a specific disease) – there are many around • Measurement requires pre- and post- intervention to compare outcomes • Aim: to shift from clinical specific outcomes to health outcomes that matter to the patient * Weldring, T & Smith SMS. Patient-reported Outcomes (PROs) and Patient-Reported Outcome Measures (PROMs) Health Serv Insights 11 2013 6: 61-68
Various assessments and measures • health status assessments • health-related quality of life (HRQoL) • symptom reporting measures • satisfaction with care • treatment satisfaction measures • economic impact measures • specific dimensions of patient experience such as depression and anxiety. 12
PROMs can lead to improved healthcare safety and quality • Logical chain of activities at various stages: data collection, aggregation and use • Activities (mechanisms) are undertaken by stakeholders at three levels: micro, meso, macro • Outcomes also occur at these three levels • All elements in the model interact (feedback effects)
Stage Macro level Meso level Micro level Context for data collection: intrinsic motivation, external sanctions or incentives, resources, systems, organisational culture Data collection Funders provide Policy makers Researchers and Healthcare Clinicians Patients complete resources for provide leadership, implementation organisations encourage PROMs implementation, promote research experts guide support and patients to external incentives and knowledge PROMs collection, promote PROMs complete PROMs and/or sanctions sharing, establish analysis and collection or assist them standards for interpretation during collection consultations Context for data use: as above, plus data quality, completeness, accessibility, relevance, timeliness, presentation, interpretability, integration with other data Data use Funders use Policy makers use Researchers use Healthcare Patients, Patients use own aggregated aggregated PROMs data for organisations use clinicians, multi- PROM data for PROMs for PROMs for comparative own and others’ disciplinary teams self-management purchasing performance effectiveness aggregated use individual and and/or to initiate decisions measurement, research, PROMs data to aggregated discussion with population outcomes improve PROMs to inform clinicians; patients surveillance measurement, processes of care care during and compare own exploring links after consultations PROM data to between care aggregated processes and PROMs outcomes Context for outcomes: as above, plus data credibility, opportunities and appetite for knowledge sharing, competing priorities, perverse incentives Outcomes Effective resource Evidence-based Evidence-based Quality Shared decision Improved self- allocation, value- policy and program treatments, clinical improvement, making, person- management, based healthcare design, standards, guidelines and sharing of best centred care informed choice of public reporting models of care; practice among treatment or benchmarks clinicians and/or healthcare against standards healthcare provider organisations
Example: Quantifying impact of an intervention on patient-reported mobility - CQRs 15
Äldre pall Source: Evalill Nilsson The National Board of Health and Welfare, Sweden
New Australian Health Performance Framework Source: COAG documents https://www.coaghealthcouncil.gov.au/Portals/0/OOS318_Attachment%201.pdf 17
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