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

Appleby and Devlin 2010

“The first health system

internationally to measure what

it produces in terms of health.”

Content

I – Background to the national PROMs programme

What are PROMs? How does the national PROMs programme relate to wider NHS policy.

II – Variation in outcomes (nationally)

How PROMs data can be used to identify good performance or areas for concern.

III – So what?

How provider trusts can investigate their PROMs data to improve outcomes. Northumbria case study.

What are PROMs?

National data collections

Since 2009, patients undergoing Hip Replacement, Knee Replacement, Varicose Vein and Groin Hernia surgery are asked to participate

Objective

To measure and improve the quality of treatment and care patients receive, in order to positively affect outcomes for patients.

Definition

Measures of the outcomes of treatment, which are based upon asking patients to report on their own health outcomes. Scope

In 2013/14: 139,774 patients gave feedback on their health state before and after surgery.

255,000 Episodes 139,000 complete answers

Participation

• 3/4 patients fill out a questionnaire before surgery.

• Of these, 3/4 respond to the post-operative questionnaire.

55% of patients gave pre- and post-op feedback in 13/14 Non responders

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 Board strategy

• Best practice tariff

New developments in PROMs

• Cancers (breast, prostate, bowel, bladder, non-Hodgkin’s lymphoma, womb, ovary and cervix): the pilot PROM report on 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 report due.

• 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 development through National Institute for Health Research (NIHR)

• Long-term conditions: As for dementia, development through NIHR.

PROMs pilots beyond the 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

My problems are much better after

surgery.

My problems are a l ittle better or much

the same.

My problems are worse than before.

19 out of 20 patients say

their problems were much

better following hip replacement

18 out of 20 patients say their

problems were much better

following knee replacement

1 out of 20 patients say

their problems were worse

following hip replacement

1 out of 13 patients say their problems were worse following

knee replacement

17 out of 20 patients say their

problems were much better

following varicose vein surgery

10 out of 20 patients say their problems were

much better following groin

hernia repair

3 out of 20 patients say their

problems were worse following

varicose vein surgery

3 out of 20 patients say their

problems were worse following

groin hernia

Hip Knee Varicose Vein Groin hernia

What PROMs tells us: most patients report successful

procedures

-15

-10

-5

0

5

10

15

20

25

0 100 200 300 400 500 600 700 800 900

Ad

jus

ted

He

alt

h G

ain

Number of Modelled Records (Trust Size )

95% control limits

99.8% control limits

England

All

Trust A Trust B

Trust C

Trust D

Using PROMs to identify variation across provider

trusts Organisation Name

Significance

Interpretation

Trust A Upper 99.8%

Among the best outcomes

Trust B Average outcomes

Trust C Lower 95%

Below average outcomes

Trust D Lower 99.8%

Among the worst outcomes

Trust D would not receive the BPT for hip and knee replacements

The chance of patients at a trust having average outcomes below this level by random chance is 1 in 1000.

Taking into account each trust’s case-mix!

Differences that matter to patients: results at a

repeat outlier

Domain Trust score National

Patients saying results were fair at best 18.9% 11.2%

Patients saying problems now worse 6.6% 4.2%

Patients reaching excellent score (42+), Hip 26% 51%

Patients reaching excellent score (42+), Knee 18% 30%

Patient with extreme difficulty kneeling down and getting up again afterwards, Knee

63.7% 53.5%

.. Dressing themselves, Hip 23.9% 12.2%

Patients having had urinary problems 15.9% 11.5%

… problems with the wound healing. 15.7% 11.3%

… an allergy or adverse reaction to drug. 13.4% 10.3%

… problems with their wound bleeding. 8.7% 6.4%

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 benefit realisation 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

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

Large provider

Vast geography

4 main sites

Over 2000 hip and knee

replacements/year (3rd

largest nationally)

INTRODUCTION

PROMs introduced in 2009

Evaluate quality of care

Drive patient choice

Empower commissioners

Total Knee Replacement

Pre and 6 month post procedure OKS and EQ5D

Remuneration on compliance and outcome

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?

PROMS – TKR OKS adjusted

funnel plot

Volume of modeled records

OK

S im

pro

vem

ent

sco

re

BACKGROUND

Significant variation in PROMs improvement

scores between TKR brands

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

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)

PROMS – TKR OKS adjusted

funnel plot 2013-14

Volume of modeled records

OK

S im

pro

vem

ent

sco

re

STUDY CONCLUSIONS

• Significant improvement in TKR outcome by change of TKR brand

• Evidence based practice - highlighted by PROMs/NJR project

• Showcase national PROMs agenda

DOES PRESERVATION OF THE

INFRAPATELLA FAT PAD IMPROVE

PROMS IN TOTAL KNEE REPLACEMENT

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

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.

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

Mean Change in OKS (95% CI) comparing individual consultant fat pad default practice

8

10

12

14

16

18

20

22

Me

an C

han

ge in

OK

S (9

5%

CI)

PRESERVER PARTIAL EXCISER

Components of OXFORD KNEE SCORE

improvement comparing excisers and preservers OKS EXCISER PRESERVER P-VALUE

PAIN 2.03 2.37 0.007

NIGHT PAIN 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

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

PROMS – TKR OKS adjusted

funnel plot 2013-14

Volume of modeled records

OK

S im

pro

vem

ent

sco

re

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

Thank you