Making the most of your PROM data, pop up uni, 10am, 2 september 2015
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1) The document provides background on the national PROMs (patient-reported outcome measures) programme in the UK, which collects data on patient outcomes and experiences before and after various surgical procedures. 2) It discusses how PROMs data can be used to identify variations in outcomes across different provider trusts nationally and help trusts investigate areas for improvement. 3) It presents a case study from Northumbria Healthcare NHS Trust where they used their PROMs data to identify better outcomes associated with a particular knee replacement implant. They were able to significantly improve outcomes by changing to this implant. 4) It also discusses a study they did which found that preserving the infrapatella fat pad during knee replacements led to
Making the most of your PROM data, pop up uni, 10am, 2 september 2015
- 1. Making the most of your PROM data Jo Partington, Rafael Goriwoda (NHS England) and Tom Partridge (Northumbria Healthcare NHS Trust) Pop Up University 5 10am; 2nd September 2015
- 2. Appleby and Devlin 2010 “The first health system internationally to measure what it produces in terms of health.”
- 3. Content I – Backgroundto the national PROMs programme What are PROMs? How does the national PROMs programme relate to wider NHS policy. II – Variationin outcomes (nationally) How PROMs data canbe usedto identify goodperformanceorareas forconcern. III – So what? How provider trusts caninvestigate theirPROMs data to improve outcomes. Northumbria case study.
- 4. What are PROMs? National data collections Since 2009, patients undergoing Hip Replacement,Knee Replacement,VaricoseVeinand GroinHernia surgery are asked to participate Objective To measure and improve the quality of treatment and care patients receive,in order to positively affect outcomes forpatients. Definition Measures of the outcomes of treatment,whichare based upon asking patients to report ontheir ownhealth outcomes. Scope In2013/14: 139,774 patients gave feedback ontheir health state before andafter surgery. 255,000 Episodes 139,000 complete answers Participation • 3/4 patients fill out a questionnaire before surgery. • Of these, 3/4 respondto the post-operative questionnaire. 55% of patients gave pre- and post-op feedback in13/14 Non responders
- 5. Wider policy context • NHS Outcomes Framework: 3.1 • NHS Mandate • NHS Standard contract • Five Year Forward View • Personalised Health and Care 2020 : Using Data and Technology to Transform Outcomes for Patients and Citizens – National Information Boardstrategy • Best practice tariff
- 6. New developments in PROMs • Cancers (breast, prostate,bowel, bladder, non-Hodgkin’s lymphoma, womb, ovary and cervix): the pilot PROM reporton living with and beyond bladder cancer will be published shortly. Prostate Cancer UK are the first charity to solely fund a UK-wide PROM project. • Cardiovascular revascularisation:pilot data collected, linkage with NICOR on-going and then the analysis and final reportdue. • Renal replacement: Being developed at the UKRR; will look at the link between Patient Activation Measures, Patient Experience and PROMs. • Major Trauma – Pilot sites already collecting data – some investment from the Medical Directorate • Dementia: DEMQoL developmentthrough National Institute for Health Research (NIHR) • Long-term conditions: As for dementia, development through NIHR. PROMs pilots beyondthe national programme • Publication on MyNHS and NHS Choices • Upcoming “Insight Strategy Short Guide to PROMs” • Work with ISIS Outcomes at the University of Oxford to support the development of electronic PROMs Making better use of what we have
- 7. My problemsare much better after surgery. My problemsarea littlebetter or much the same. My problemsare worsethan before. 19 out of 20 patientssay theirproblems were much betterfollowing hipreplacement 18 out of 20 patientssay their problemswere much better followingknee replacement 1 out of 20 patientssay theirproblems were worse followinghip replacement 1 out of 13 patientssay their problemswere worse following knee replacement 17 out of 20 patientssay their problemswere much better followingvaricose veinsurgery 10 out of 20 patientssay their problemswere much better followinggroin herniarepair 3 out of 20 patientssay their problemswere worse following varicose vein surgery 3 out of 20 patientssay their problemswere worse following groin hernia Hip Knee Varicose Vein Groin hernia What PROMs tells us: most patients report successful procedures
- 8. -15 -10 -5 0 5 10 15 20 25 0 100 200 300 400 500 600 700 800 900 AdjustedHealthGain Number of Modelled Records (Trust Size) 95% control limits 99.8%control limits England All Trust ATrust B Trust C Trust D Using PROMs to identify variation across provider trusts Organisation Name Significa nce Interpretation Trust A Upper 99.8% Amongthe best outcomes Trust B Averageoutcomes Trust C Lower 95% Belowaverage outcomes Trust D Lower 99.8% Amongthe worst outcomes TrustD would notreceive the BPT for hip andknee replacements The chanceof patientsata trust havingaverage outcomes belowthis level by random chanceis1 in 1000. Taking into account each trust’s case- mix!
- 9. Differences that matter to patients: results at a repeat outlier Domain Trust score National Patients sayingresults were fair at best 18.9% 11.2% Patients sayingproblems now worse 6.6% 4.2% Patients reachingexcellent score (42+),Hip 26% 51% Patients reachingexcellent score (42+),Knee 18% 30% Patient withextreme difficulty kneelingdownand getting up again afterwards,Knee 63.7% 53.5% .. Dressingthemselves,Hip 23.9% 12.2% Patients havinghad urinary problems 15.9% 11.5% … problems with the woundhealing. 15.7% 11.3% … anallergy or adverse reactionto drug. 13.4% 10.3% … problems with their wound bleeding. 8.7% 6.4%
- 10. So What? Putting PROMs into practice • PROMs is used in a variety of ways: • Audit & Effectiveness Committees – local • Quality Boards - local • Best Practice Tariff • Care Quality Commission “Intelligent Monitoring” • “Beyond Compliance” • “Getting It Right First Time” • Examples from HSCIC benefitrealisation study: • Enhanced recovery pathways implemented; PROMs used to evaluate success of components • Revised pain management regimes => earlier mobilisation; improved rehab ++ = better outcomes • Analysis of themes where people struggled post-operatively, and exercises included in post-op appointments • Better wound management protocols • Altered mode of knee surgery treatment
- 11. QUALITY IMPROVEMENT USING PROMS IN TOTAL KNEE REPLACEMENT Presenter: Mr T Partridge MBBS, MRCS Northumbria Healthcare NHS Foundation Trust Co-authors: Muller S, Emmerson KP, Carluke I, Partington PF, Reed MR
- 12. Large provider Vast geography 4 main sites Over 2000 hip and knee replacements/year (3rd largest nationally)
- 13. INTRODUCTION PROMs introduced in 2009 Evaluate quality of care Drive patient choice Empowercommissioners Total Knee Replacement Pre and 6 month post procedure OKS and EQ5D Remuneration on compliance and outcome
- 14. QUALITY IMPROVEMENT USING PROMS IMPROVING PROMS IN TOTAL KNEE REPLACEMENT BY CHANGING IMPLANT: A QUALITY IMPROVEMENT PROJECT DOES PRESERVATION OF THE INFRAPATELLA FAT PAD IMPROVE PROMS IN TOTAL KNEE REPLACEMENT?
- 15. PROMS – TKR OKS adjusted funnel plot Volume of modeled records OKSimprovementscore
- 16. BACKGROUND Significant variation in PROMs improvement scores between TKR brands
- 17. METHODOLOGY • Mass move to ‘best’ TKR brand – 6 month transition period – Re-training • Retrospective cohort study using PROMs database – April 2009 to March 2014 Northumbria Healthcare TKR – Incomplete records/transition period excluded
- 18. PROMs improvement scores pre and post implant change Implant Q1 SCORE EQ5D GAIN OKS GAIN Pre-change Brand A (581) Brand B (246) 20.4 (19.8-21.0) 20.7 (19.7-21.6) 0.256 (0.230-0.281) 0.265 (0.225-0.305) 13.7 (13.1-14.6) 14.2 (12.9-15.4) Post-change Brand C (796) 20.5 (19.9-21.0) p=(0.866) 0.288 (0.264-0.312) (p=0.07) 16.6 (15.6-17.1) (p=0.007)
- 19. PROMS – TKR OKS adjusted funnel plot 2013-14 Volume of modeled records OKSimprovementscore
- 20. STUDY CONCLUSIONS • Significant improvement in TKR outcome by change of TKR brand • Evidence based practice - highlighted by PROMs/NJR project • Showcase national PROMs agenda
- 21. DOES PRESERVATION OF THE INFRAPATELLA FAT PAD IMPROVE PROMS IN TOTAL KNEE REPLACEMENT
- 22. THE FATPAD IN TKR Removal of the infrapatella fat pad remains controversial blood supply to the patella tendon biomechanics of the knee inflammatory modulator VS improved access visualisation
- 23. AIM AND METHODOLOGY To determine if the default removal of the infrapatella fat pad affects patient outcome in TKR. Retrospective cohort study using PROMs database OKS and EQ5D pre-operatively and at 6 months. Correlated with consultant default practice of excising partially removing preserving the infrapatella fat pad.
- 24. PROMs improvement scores per default infrapatella fatpad practice NUMBER OKS CHANGE EQ5D CHANGE EXCISED 297 15.0 (13.8-16.3) 0.262 PARTIAL 178 16.6 (15.3-18.0) 0.295 PRESERVED 169 17.3 (15.7-18.9) 0.327
- 25. Mean Change in OKS (95% CI) comparing individual consultant fat pad default practice 8 10 12 14 16 18 20 22 MeanChangeinOKS(95%CI) PRESERVER PARTIAL EXCISER
- 26. Components of OXFORD KNEE SCORE improvement comparing excisers and preservers OKS EXCISER PRESERVER P-VALUE PAIN 2.03 2.37 0.007 NIGHTPAIN 1.38 1.82 0.003 WASHING 0.68 0.78 0.301 TRANSPORT 0.88 1.01 0.259 WALKING 1.14 1.18 0.762 STANDING 1.22 1.32 0.382 LIMPING 2.01 2.18 0.233 KNEELING 0.67 0.83 0.267 WORK 1.41 1.7 0.16 CONFIDENCE 1.52 1.59 0.554 SHOPPING 1.07 1.34 0.036 STAIRS 1.04 1.21 0.146 OKS CHANGE 15.04 17.33 0.031
- 27. STUDY CONCLUSION Patients report better outcomes if their surgeons default to preserving the infrapatella fat pad Pain is reported difference In the absence of a randomised trial surgeons should consider fat pad preservation
- 28. PROMS – TKR OKS adjusted funnel plot 2013-14 Volume of modeled records OKSimprovementscore
- 29. PROMS • Show case PROMs agenda • Local projects vs national projects • Publication of trust PROMs and the possibility of performance based remuneration makes self-evaluation of practice ever more important. • Excellent opportunity for quality improvement
- 30. Thank you