The PROMs Programme in the NHS in England Veena Raleigh Senior Fellow, The King s Fund HCQI, 7 November 2013
The background Improving NHS quality a government priority since 2008 Quality defined as: effectiveness, patient experience, safety NHS Outcomes Framework: includes indicators on PE and PROMs Supported by a national programme of PE and PROMs surveys PROMs: patient-reported outcomes of health interventions Initial focus on 4 elective procedures
Why collect PROMs? Improving quality and productivity Local use Contract monitoring Quality monitoring P4P Resource allocation Health inequalities Regulation»» Benchmarking against peers for improvement»» Commissioners holding providers to account»» Telling the story about performance»» Financial rewards for high patient-reported quality»» Allocating resources efficiently»» Appropriate access for given needs»» Setting minimum standards Patient choice»» Choosing high quality providers
The PROMs programme Introduced in 2009 Currently covers 4 procedures: hip and knee replacement, groin hernia and varicose veins surgery Includes all providers of NHS-funded care (NHS and private) Two sets of instruments used: - condition-specific measures tailored to particular procedures AND - a generic health measure EQ-5D for all 4 procedures: to compare health gain across different procedures on a standard basis - widely used in economic evaluations of health care (EQ-5D covers mobility, self-care, usual activities, pain/discomfort, anxiety/depression)
The methods Instruments: - hip replacement (EQ-5D and Oxford Hip Score) - knee replacement (EQ-5D and Oxford Knee Score) - varicose veins surgery (EQ-5D and Aberdeen Score) - groin hernia surgery (EQ-5D only) Pre- and post- op questionnaires for all patients (self-completed) Pre- and post- op health status and health gain assessed Post-op questionnaires ask about complications Linkage of patients questionnaires to their hospital records, to enable case-mix adjustment for reliable comparisons across providers (variables - age, sex, deprivation, co-morbidities etc) Data analysed by commissioner and provider 2011/12: 248,000 eligible procedures Overall response rate 75%
Response rates, 2011/12: patients completing the pre-op questionnaire 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Groin Hernia Hip Replacement Knee Replacement Varicose Vein
Response rates, 2011/12: patients completing the post-op questionnaire 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12 Groin Hernia Hip Replacement Knee Replacement Varicose Vein
Patients reporting health gain, 2011/12 Procedure EQ-5D Procedurespecific instrument Hip replacement 87.3% 95.7% Knee replacement 78.4% 91.6% Varicose veins surgery 53.2% 83.1% Groin hernia surgery 49.9% -
Adjusted Health Gain Hip replacement, EQ-5D score: Case-mix adjusted health gain by provider, 2011/12 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 0 100 200 300 400 500 600 700 800 900 Number of procedures 95% control limits 99.8% control limits England
Adjusted Health Gain 30 Hip replacement, Oxford Hip Score: Case-mix adjusted health gain by provider, 2011/12 28 26 24 22 20 18 16 14 12 10 0 100 200 300 400 500 600 700 800 900 1000 Number of procedures 95% control limits 99.8% control limits England
Knee replacement, Oxford Knee Score: Case-mix adjusted health gain by provider, 2011/12
Post-operative complications, 2011/12 Percent of patients reporting complications* Procedure Readmission Further surgery Varicose veins surgery 5.3% 15.0% Groin hernia surgery 5.5% 16.0% Knee replacement 9.6% 3.7% Hip replacement 7.6% 2.7% * As reported in the post-op questionnaires.
Extension of PROMS: next steps Pilots underway: - coronary artery bypass grafts - angioplasties - secondary care treatment of depression PROMs in development or under consideration - HIV - renal dialysis - musculoskeletal - trauma - MH: depression, dementia, psychological therapies - children & young people - other surgery
Further information Queries to Jo Partington, PROMs Insight Account Manager, NHS England: jo.partington@nhs.net Data published by the Health and Social Care Information Centre: http://www.hscic.gov.uk/proms Research published by the London School of Hygiene and Tropical Medicine: http://proms.lshtm.ac.uk/