PROMs Pilot for Long-Term Conditions in Primary Care

1. PROMs Pilot for Long-Term Conditions in Primary Care Ray Fitzpatrick Department of Public Health

2. Research team Ray Fitzpatrick - Chief Investigator Michele Peters - Project Manager Crispin Jenkinson – Principal Investigator Alastair Gray – Health Economist Helen Doll- Statistician Helen Boyce – Data Manager Elizabeth Gibbons - Interviewer Funding Department of Health, Policy Research Programme

3. Rationale

4. Patient-reported Outcome Measures (PROMs) • Developed in the last 30 years to involve patients directly in judgements of health status and outcomes of services • Variously termed measures of: • Health status, health-related quality of life, functional status, patient-reported outcome or outcome • Usually short self-report questionnaires • Generic (EQ-5D and SF-36) or disease-specific (QOLIE-89 for epilepsy)

5. The use of PROMs • Used in research or audit • Outcome measure in clinical trials • Health services research • Population survey • Individual patient care • Outcome measure for health services • From 2009, PROMs mandated for 4 elective surgical procedures (primary hip replacement, primary knee replacement, groin hernia repair and varicose vein procedures) • Used separately or jointly (generic and disease-specific in combination)

6. Why collect PROMs data? • If quality is to be at the heart of everything we do, it must be understood from the perspective of patients. Patients pay regard both to clinical outcomes and their experience of the service... • Quality of care should include effectiveness of care. This means understanding success rates from different treatments from different treatments for different conditions. Assessing this will include clinical measures such as mortality or survival rates, complication rates……. Just as important is the effectiveness of care from the patient’s own perspective which will be measured through patient-reported outcome measures (PROMs)… High Quality Care for All: NHS Next Stage Review Final Report.

7. Why collect PROMs data? • NHS Outcomes Framework domains • Effectiveness of treatment and care provided – measured by clinical outcomes and patient-reported outcomes • Safety of treatment and care provided • Broader experience patients have of the treatment and care they receive Department of Health. Equity and Excellence: Liberating the NHS. 2010

8. Aims and objectives • To evaluate the feasibility and acceptability of using PROMs for long-term conditions (LTCs) in primary care • To assess possible barriers to individuals with LTCs completing PROMs • To assess cost of collecting PROMs data • LTCs • asthma, COPD, diabetes, epilepsy, heart failure and stroke

9. PROMs Pilot Study Design

10. Design • Multi-method design (postal survey and qualitative interviews) • Two surveys • Cohort (one year apart) • Cross-sectional • Interviews with individuals with a LTC and professional stakeholders (managers, PCT senior staff, GPs)

11. PROMs Pilot RECRUIT PRACTICES GP DATABASE 50% 50% MAIL SURVEY MAIL SURVEY COHORT BASELINE 0 months COHORT FOLLOW-UP CROSS-SECTIONAL 12 months

12. PROMs pilot practice recruitment • Sample • 18 years or over • Approximately 4500 (750 per condition) • Location • London and North-West England(NWE) • Based on QOF prevalence, need approximately 40 practices, half in London and half in NWE • Recruited through Primary Care Trusts (PCTs) and PCRN (Primary Care Research Network)

13. What do practices need to do? Consent to automatic database search to identify patients Practice staff check of patient list Print address labels Attach labels to pre-packed questionnaires and reminders Mail questionnaires After 2 weeks, mail reminders

14. PROMs pilot database search • Automatic and remote search of GP QOF databases by Apollo Medical Systems Ltd. • Apollo developed software for • GP patient survey by the Department of Health • No information on patients will be available to Apollo or the research team • Search run over night to not disrupt practices day to day work

15. PROMs pilot qualitative interviews • Individuals with a LTC • 55 interviews • Both with responders (incomplete data) and non-responders to the survey • Aim to identify barriers for completing PROMs • Professional stakeholders • 30 interviews • Managers, PCT senior staff, GPs • Aim to identify value of using PROMs and any problems with administering PROMs

16. Analysis • Survey • Response rates and quality of information between the two surveys (cohort vs. cross-sectional), over time (cohort) and for the 6 LTCs • Qualitative interviews • Thematic analysis to identify barriers to completing PROMs (individuals with LTC) • Thematic analysis to identify value of using PROMs and barriers to PROMs (professional stakeholders)

17. Results and outputs • Report to the Department of Health • Presentations of findings to stakeholders • Opportunity for stakeholders to comment on the pilot methodology and findings • Summary of findings to all participating practices • Summary of findings on web-page for participants and professional stakeholders http://www.publichealth.ox.ac.uk/research/hsru/asking-you-about-your-health

18. Results and outcomes Results (response rates, completeness of data, estimation of cost) will inform DH decisions whether PROMs are an acceptable way of involving the public and measuring health outcomes of the NHS on a large, national scale Results will enable DH to decide whether PROMs can be more generally rolled out to engage the public in the assessment of quality of health care services for LTCs

19. Progress to date

20. Progress to date • Ethics Approval • NHS permissions • NIHR portfolio adoption • Service support costs for practices • Selecting and licensing PROMs • Apollo search • Recruitment of practices • Pilot

21. Ethics and NHS permissions Ethical approval obtained from National Research Ethics Committee Majority of NHS permissions obtained for the participating PCTs Adopted onto NIHR (National Institute of Health Research) portfolio http://public.ukcrn.org.uk/Search/StudyDetail.aspx?StudyID=8462 Application for service support costs for practices through CLRN in progress

22. Which PROMs? • Selected on basis of reviews by Oxford PROMs group and IP (Intellectual Property) review by the Department of Health • Questionnaires • One generic PROM – EQ-5D • One disease-specific PROM • Some additional socio-demographic and co-morbidity questions

23. Disease-specific PROMs Asthma - Mini Asthma Quality of Life Questionnaire COPD - Clinical COPD Questionnaire Diabetes – Diabetes Health Profile Epilepsy – Quality of Life in Epilepsy Heart Failure – Minnesota Living with Heart Failure Questionnaire Stroke – Stroke Impact Scale

24. Identification of patients • Search • Based on same Read Codes as QOF, including medication codes for asthma and epilepsy • Stroke does not include TIAs • Patients with ‘refused consent’ code are excluded • Patients only included for one LTC • Search developed for 3 clinical systems • Search produces patient list on practices computer from which address labels can be printed

25. Recruitment of practices • Through PCTs, PCRN and DRN (London) • Expression of interest • Return of ‘Practice Information Form’ • Practice contact details • Information on clinical systems • LTCs the practice wishes to cover • 12 London practices and 15 NWE • ‘Pilot’ sites

26. Key milestones Cohort baseline survey Analysis of cohort baseline data Qualitative interviews with patients Qualitative interviews with professionals Cross-sectional survey Cohort follow up survey Analysis of cross-sectional survey and cohort follow-up Feedback of results to stakeholders