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Evolution of a PRO for Cardiovascular Cohorts in SAFTINet

May 2, 2012

+Overview

Describe evolution of

CV PRO ideas

Present 2 PRO options

under consideratio

n

Questions for the PEC about next directions

+Patient Risk Understanding: Overview General concept: how well patients know their a CV-related

risk value and/or how well they understand their CV risk level

Discussions: Convocation: CV PRO must align with

other organizational initiatives (e.g., meaningful use (MU)) clinical utility

April 4 PEC call: discussed patient understanding especially regarding how well patients know and understand their BMI and BP—related to MU requirement to document counseling had been done

Mid-April PEC email about ideas for PRO related to patient risk understanding: reviewed 4 PRO ideas “4A-4D”

+Patient Risk Understanding:Four Options Presented Email to PEC sought feedback on 4 about ideas for PRO

related to patient risk understanding 4A. Patient knowledge of own BP status 4B. Patient knowledge of own BMI category 4C. Patient knowledge of own heart attack risk, using a risk

calculator 4D. Patient knowledge of own overall cardiovascular risk

(all major CV events, not just heart attacks), using a risk calculator

+Patient Risk Understanding:Feasibility Email also sought feedback about timing and feasibility

of 4C and 4D—2 options presented calculate risk before visit based on prior visit risk data and

discuss risk with patient in person calculate risk based on visit data and transmit risk to

patient a day or so after visit

+Patient Risk Understanding: Feedback from PEC PEC feedback on email: related to 4C and 4D (the risk calculator

options) Strong ethical concerns about providing a risk calculation

without then having time for consultation about what to do with it.

Risk calculator is time consuming and involves staff resources we cannot spare.

The data to make the calculation isn’t always available except at POC. If you create a provider data collection form to capture data for the risk calculation, it will require a significant amount of work.

Patients could feel overwhelmed by being asked a percentage. Consider “likelihood”. Consider asking patients their rationale for that answer.

+Patient Risk Understanding: Feedback from PEC PEC feedback on email: related to 4C and 4D (the risk calculator

options) I’m most worried about our patients’ understanding the concept of

risk. The literature suggest that various tools including visual aids can help communicate risk to patients. Any intervention has been shown to be better than nothing in improving health understanding.

One computer-based tool for patient data entry that has been successful using kiosks is this tool (http://www.health-e-solutions.org/ ) followed by discussion. It’s free and prints outs a summary.

We may not be able to trust what patients report as a percentage without an anchor for the percentage points (e.g., some patient may have a tendency to over- or under-estimate risk).

Waiting a day to give risk feedback could lessen the impact on the patient. Also, the patient would have to actively contact the practice to ask questions.

+Patient Risk Understanding: Sample Tool

+Patient Risk Understanding: Sample Tool

+Patient Risk Understanding: Feedback from PEC More general PEC feedback to email

Patient risk-understanding is not necessarily “actionable”. Most patients DO seem to know their risks but the problem is that they aren’t doing what they need to do to REDUCE their risk. Why is this the case? (what prevents them from taking

steps to decrease their risk?) How can we change it?

Would rather see a PRO looking at what could we be doing to better engage the patient to take steps to decrease risk.

What does research show is most motivating to patients? Knowing what will best engage patients in risk-reduction is essential before we put resources into a PRO.

+Patient Risk Understanding: What is the Evidence? Under certain circumstances and for certain

populations, patient CV risk understanding can impact subsequent health behavior

More generally, CV risk understanding has low impact on health behavior

What has a higher impact on health behavior risk perception? Patients’ self-efficacy or engagement.

Patient risk understandingPatient self efficacy

CV risk behavior change

+Patient Engagement

Suggested questions for measuring patient engagement Worry and concern about risk (risk understanding)Based on your current BP, how worried are you about your risk of [MACE]? Self-efficacy for change How confident are you that you could change [risk behavior] in a way that will decrease your risk of [MACE]? Barrier and facilitator identification What kinds of things would make it harder for you to change your [risk behavior]? What kinds of things would make it easier? Intentions to change To what extent do you intend to work on changing your [risk behavior]?

+Patient Engagement

Suggested questions for measuring patient engagement Worry and concern about risk (risk understanding)

if patients are already worried/perceive high risk, the next step could be focusing on building self-efficacy and planning

but what if they are not worried? it is tricky, but still possible, to help patients revise their risk perception

Self-efficacy for change Barrier and facilitator identification Intentions to change

+CER/PEC Discussion About Feedback to Email 2 general options for PRO:

Option 1: PRO assessing CV risk understanding Option 2: PRO assessing self-efficacy for changing a risk

behavior

Patient risk understandingPatient self efficacy

CV risk behavior change

+CER/PEC Discussion About Feedback to Email 2 general options for PRO:

Option 1: PRO assessing CV risk understanding Option 2: PRO assessing self-efficacy for changing a risk

behavior

Also important to consider clinical utility: need to target a risk behavior where primary

care intervention has been shown to have sustained effects organizational utility: does this help the organization meet

other requirements (e.g., meaningful use)Patient risk understandingPatient self efficacy

CV risk behavior change

Sustained CV risk behavior change

?Organizational utility

+CER/PEC Discussion About Feedback to Email 2 general options for PRO:

Option 1: PRO assessing CV risk understanding Option 2: PRO assessing self-efficacy for changing a risk

behavior

Also important to consider clinical utility: need to target a risk behavior where primary care intervention has been shown to have sustained effects none of the lifestyle interventions (except gastric bypass)

have demonstrated sustained effects past 2 years medications have been shown to have sustained benefit in

patients with high BP and high cholesterol so from a clinical utility standpoint, our best target is medication adherence

+Summary of CV PRO Options

Option 1: PRO assessing CV risk understanding specific (BMI-only or BP-only) or more general (broader CV risk) different options for administering PRO and providing feedback to

patient as all patients are at risk, all (adult?) patients would receive the

PRO

Option 2: PRO assessing self-efficacy for changing a risk behavior more complicated if patient is not worried about risk most clinically effective target for risk behavior change:

medication adherence for BP and cholesterol drugs if we targeted medication adherence, only patients prescribed

these medications would receive the PRO

+Questions for PEC

What are your thoughts on these two options? More specifically, what are your thoughts with regard to the options’ clinical utility organizational utility (e.g., meeting MU requirements) feasibility and resource-use