Patient Reported Outcomes: Unpacking Quality Measures Andrew L Brickman, PhD Richard Taaffe, Discussant, CEO WHCHC June 23, 2018

Transcription

1 Patient Reported Outcomes: Unpacking Quality Measures Andrew L Brickman, PhD Richard Taaffe, Discussant, CEO WHCHC June 23,

2 Are patient reported outcomes a new thing? Is this the next shiny object? This medicine will make you feel better. Go home and whenever you have pain in your belly, on a 1-10 scale, write down how much it hurts. Doctor My belly hurts! 2

3 Are patient reported outcomes a new thing? Let s see Belly ache at the coliseum today. I give it a 4 3

4 Are patient reported outcomes a new thing? Doctor studies patient reported outcome. Hmmm Coliseum phobia with co-occurring gladiator fixation. Rx: poppies! 4

5 Are patient reported outcomes a new thing? Clinician enters patient reported outcomes in Health Record. 5

6 Next Step is a Research Question: Do patient reported outcomes improve clinical outcomes? Frequency of bellyaches is significantly less in patients who recorded their symptoms (p 0.05). Or Nope. Didn t make a difference. 6

7 Fast forward 4000 years Don t forget Galileo 7

8 Measure what is measurable, and make measurable what is not. Heresy! Galileo ( ) 8

9 A really cool patient reporting gadget A Cerner toy. If the heart is damaged, its ability to pump blood is impaired. When the kidneys detect diminished blood flow, hormones are activated to retain fluid and sodium, to boost blood volume. Reliable Valid Clinically significant Affordable Scalable So cool Weight change is the earliest sign of a problem with fluid balance. Doctor needs to know! 9

10 Just because it says it makes a difference, doesn t make it so. Rapid Evidence Review of Mobile Applications for Self-Management of Diabetes Hundreds of apps for diabetes self-management are commercially available Lit review identified health outcomes studies on only 11 apps Only 5 were associated with clinically significant improvements in HbA1c Difficult to distinguish the effect of additional interactions with health care providers and living situation. Veazie S, Winchell K, Gilbert J, et al. Rapid Evidence Review of Mobile Applications for Self-Management of Diabetes. J Gen Intern Med May 3. 10

11 OUTCOME (HgA1c < 7 or Systolic BP < 130) Quality Metric = # of outcomes above threshold = % # diagnosed Diagnosis (Diabetes or Hypertension) 11

12 OUTCOME (HgA1c < 7 or Systolic BP < 130) Quality Metric = # of outcomes above threshold = % # diagnosed Diagnosis (Diabetes or Hypertension) 12

13 OUTCOME (HgA1c < 7 or Systolic BP < 130) Let s focus on OUTCOME Quality Metric = # of outcomes above threshold = % # diagnosed Diagnosis (Diabetes or Hypertension) 13

14 Our quality measures are averages 14

15 This is what we report 15

16 We care for populations. Within populations, there are multiple distributions of data. Systolic BP -- All Systolic BP African Am Systolic BP -- Hispanic 16

17 70% 70% 60% 60% 50% 50% 40% 40% Not Homeless Hga1c 55% 59% 30% 30% 20% 20% 10% 20% 18% 15% 13% 11% 10% 0% < > 9 Missing

18 90% 90% 80% 80% 70% 70% 60% 60% 50% 50% 40% 40% 30% 30% 20% 10% 0% Private Medicaid Insurance Hga1c 57% 35% 28% 20% 21% 12% 16% 10% < > 9 Missing

19 14 HbA1c by Zip Code Median Household Income $30,000 $35,000 $40,000 $45,000 $50,000 $55,000 $60,000 $65,000 $70,000 $75,000

20 What is driving OUTCOMES? OUTCOME (HgA1c < 7 or Systolic BP < 130) 20

21 Patient Behaviors Glucose monitoring Diet Medication adherence BP monitoring Cognitive capacity Social Determinants Transportation Affordability of meds Pharmacy errors Systemic Factors Appointment ease Sole clinician v team approach Evidence based practice What is driving OUTCOMES? OUTCOME (HgA1c < 7 or Systolic BP < 130) 21

22 Patient Behaviors Glucose monitoring Diet Medication adherence BP monitoring Cognitive capacity Social Determinants Transportation Affordability of meds Pharmacy errors Systemic Factors Appointment ease Sole clinician v team approach Evidence based practice Do mediators work the same in all populations? OUTCOME 22

23 Patient Behaviors Glucose monitoring Diet Medication adherence BP monitoring Cognitive capacity Social Determinants Transportation Affordability of meds Pharmacy errors Systemic Factors Appointment ease Sole clinician v team approach Evidence based practice For example, are social determinants the same across populations? OUTCOME 23

24 What if we ask the question, Do communities impact our populations in the same way? 24

25 Do our communities impact our populations in the same way? Neighborhood Characteristics and Components of the Insulin Resistance Syndrome in Young Adults The Coronary Artery Risk Development in Young Adults (CARDIA) Study Roux AV, Jacobs DR & Kiefe CI. Diabetes Care 2002 Nov; 25(11):

26 Because patients with DM must conduct daily management activities, no insurance and/or sub-optimal social determinants of health can create barriers to successful DM management and care. Community-level SDH Metrics Built Environment Fast food restaurants per 100,000 population Race/Ethnic Count and percent by race Composition Residential segregation (dissimilarity, exposure) Neighborhood Resources Neighborhood Socioeconomic Composition Social Deprivation Index Modified retail food environment index (# of healthy food stores divided by all food stores) Percent of people in a county living more than 1 mile from a supermarket or large grocery store if in an urban area, or more than 10 miles if in a rural area Percentage of population living within ½ mile of a park Recreation facilities per 100,000 population Urban Classification Code Percent of population with bachelor's degree or higher Median household income Percent below 100% of federal poverty level (FPL); percent below 200% of FPL Unemployment rate Composite measure of social deprivation validated to be more strongly associated with poor access to healthcare and poor health outcomes than a measure of poverty alone 26

27 HgA1c x distance from clinic or Income x distance from clinic Hypothesis Testing 27

28 Measure what is measurable, and make measurable what is not. Yes! Galileo ( ) 28

29 What s next? Brainstorm have a beer think out of the box. What do you think drives your outcomes? CAN YOU MEASURE IT? Write a testable hypothesis: Calling patients once a month to ask how they re doing improves [whatever]. Can you collect the data and get it into a computer? 29

30 Questions? Woof!

31 Hypotheses Testing Older more adherent than younger 1 Forgetting is most frequent barrier to adherence 1 Odds of nonadherence increase with number incidents reported 1 Odds of adherence increase with report of multiple strategies 1 1 Walker EA et al. Predictors and outcomes in the diabetes prevention program, Diabetes Care, 29 (9): 2006.

32 Do we care if someone drops from one category to another, or do we simply want to know if they improved. 32

33 70% 60% White Other Black 68% 50% 55% 52% 40% 30% 20% 10% 0% 21% 20% 14% 15% 12% 11% 12% 10% 8% < > 9 Missing

34 70% Patients Age % 65% 50% 50% 40% 30% 20% 10% 20% 16% 11% 10% 13% 14% 0% < > 9 Missing

35 60% Female Male 50% 57% 55% 40% 30% 20% 10% 21% 18% 14% 10% 11% 0% < > 9 Missing

36 60% Non Hispanic 50% 55% 57% 40% 30% 20% 10% 20% 19% 14% 10% 11% 0% < > 9 Missing

37 Top Performing Centers -- UDS Hypertension Compliance State FQHC UDS NM LCDS 77.9% FL Miami Beach 77.5% FL Citrus 75.1% FL Banyan 69.8% FL Pinellas 69.7% Diabetes Compliance State FQHC UDS FL Citrus 77.5% FL Banyan 76.3% FL Miami Beach 76.1% FL Family Health SW FL 75.8% MA Choptank 75.2% 37

38 Parallel and Rapidly Advancing Epidemics Obesity Diabetes 38

39 Neighborhoo d and Built Environment Economic Stability Health and Health Care SDOH Education Social and Community Context 39

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41 SESSION SURVEY