—Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H.
As healthcare quality reporting continues to evolve in this era of value-based purchasing (VBP), players on both the giving and receiving ends of performance incentives agree on the need to improve the accountability metrics with which providers are measured, ranked, rewarded, and penalized. Many of the measures currently in use—e.g., Centers for Medicare & Medicaid Services’ (CMS) core process measures and patient satisfaction ratings, the gross outcome metrics of mortality, infection, and readmission rates—are blunt instruments in need of refinement.
Entities such as the National Quality Forum (NQF), the American Medical Association’s Physician Consortium for Performance Improvement (PCPI), and the National Quality Measures Clearinghouse (NQMC) recognize the need to develop and endorse more timely, credible, and patient-centered outcome metrics. Largely missing from the current crop of outcome measure sets is a meaningful account of the patient’s perspective.
Enter patient-reported outcomes (PROs), defined as “any report of the status of a patient’s health condition that comes directly from the patient, without interpretation of the patient’s response by a clinician or anyone else.”1 PRO tools “measure what patients are able to do and how they feel by asking questions” (see “Types of Patient-Reported Outcomes [PROs],” p. 19).
If successfully adapted for public reporting on a wide scale, PROs could become the next evolutionary step in healthcare quality reporting, integrating health status and patient experience data into outcome metrics that truly matter to patients. They could enable a richer understanding of their clinical experiences and responses to therapy, and help providers target necessary improvements with greater precision.
“As a provider, I care about my patients not developing infections, getting the right medications, and not being readmitted. Patients, however, have a different set of priorities around issues like ‘How quickly will I be able to return to work? When will I be able to chase my grandkids around the yard? How much is this care going to cost me out of pocket?’” says healthcare quality expert Gregg Meyer, MD, MSc, chief clinical officer and executive vice president for population health for the Dartmouth-Hitchcock Health System in Lebanon, N.H. “This next generation of accountability will allow us to move from being provider- and payor-centered to becoming truly patient-centered, and will serve as a key reminder that patients are no longer passive participants. They are key partners, in both the delivery of care and the measurement of that care.”
The idea of PROs is one whose “time has finally arrived,” according to medical outcomes researcher David Cella, PhD, professor and chair of the Department of Medical Social Sciences at Northwestern University Feinberg School of Medicine in Chicago.
“The case for inclusion of outcomes that matter most to patients, like the effect of treatment upon their symptoms, function, and overall well-being, has always been compelling as an ideal to strive toward,” Cella adds. “PROs can and should be considered as true treatment outcome measures, and their ability to capture quality information efficiently make them well-suited for this role.”
The FDA even permits PROs (i.e. pain, anxiety, depression, sleep, and physical and social functioning) to be used as experimental endpoints for clinical trials to support claims in medical product labeling.2
The Patient Voice
The Department Health and Human Services (HHS) is searching for ways to fill current gaps in outcome measures, and has funded a patient outcomes project by the NQF to help ramp up patient-focused measure development activities within the federal government. In a recent report stemming from that project, the NQF states: “The patient’s voice is not readily captured in traditional health records and data systems, yet the beneficiary of healthcare services is often in the best position to evaluate the effectiveness of those services.”3
The NQF also is conducting foundational work to evaluate the most promising and viable PROs for quality measurement use and methodological issues involved in collecting and aggregating PRO data for provider performance assessment, says Helen Burstin, MD, MPH, NQF’s senior vice president for performance measures.
“PROs provide the opportunity to hear about the outcome of a clinician’s intervention directly from the patient—for example, visual improvement after cataract surgery, relief from nausea after chemotherapy, and mobility enhancement and pain relief after a hip or knee replacement,” she says. “The goal is to develop reliable and valid PRO performance measures that are applicable across multiple settings of care and/or multiple conditions, which the NQF can endorse for accountability and quality-improvement purposes.”
Specific NQF recommendations regarding PROs and performance measurement are expected to be available for review and comment this month, with a 30-day public and member comment period.
A wide variety of patient-level instruments to measure PROs have been used for clinical research purposes, many of which have been evaluated and catalogued within a system of assessment tools known as the National Institutes of Health’s (NIH) Patient-Reported Outcome Measurement Information System (PROMIS), Dr. Burstin says. PROMIS questionnaires prompt patients to measure such outcomes as how much difficulty they experience when walking a block on flat ground, getting in and out of bed, or doing strenuous activities, such as bicycling or jogging. NIH-funded studies using PROMIS tools are taking place at 12 sites across the country (http://nihpromis.org/default).
“PROMIS provides two distinct advantages to the PRO performance metric landscape,” argues Cella, who is principal investigator of the Statistical Center for PROMIS. “It has a computerized adaptive testing option, so efficient and accurate assessment is now possible at the individual patient level, with just a few questions per area. It also standardizes its scoring and reporting, such that many other similar measures can be used and their scores reported on a common, PROMIS metric.”
“The voice of the clinician is also needed during this PRO development process,” Dr. Burstin says. “We welcome hospitalists to engage in our projects and weigh in about the most meaningful and actionable patient outcomes that are relevant to their practice.”
“Taking PROs and applying them to hospital medicine is really doable if you take into account the lessons learned from providers who have already used PROs successfully in clinical settings,” says Pat Courneya, MD, medical director for HealthPartners Health Plan in Minnesota.
HealthPartners recently began using PROs in a quality measurement and reward program, offering financial bonuses to physical therapists who achieve a high PRO score relative to resource use (number of PT sessions required). “Having objective PRO measurements allows clinicians to create benchmarks for their patients regarding how much functional improvement they expect to achieve, and how many PT sessions are required to achieve that degree of improvement,” Dr. Courneya says. Using an interactive, Web-based PRO assessment tool, the program has helped tailor care to the expectations of patients while also significantly reducing the overall number of PT visits, especially by medically complex, post-operative patients.
HealthPartners has successfully used PROs as part of an innovative care model for managing patients with depression. At the outset of treatment, patients are administered the PHQ-9, a nine-item patient health questionnaire designed to assess depression symptoms and functional impairment, and derive a severity score. Patients receive care by a team composed of a primary-care physician, a care manager, and a consulting psychiatrist, after which their degree of symptom improvement is again measured. With this program, HealthPartners has achieved significantly more patients with depression into remission by six months compared with typical primary-care treatment, Dr. Courneya says. This model of care has since garnered a CMS Innovation Grant, managed by the HealthPartners Institute for Education and Research and directed by Minnesota’s Institute for Clinical Systems Improvement, aimed at spreading the model to five other states.
“PROs are potentially as useful for hospital medicine as for any other type of medical practice,” says Shaun Frost, MD, SFHM, SHM president and associate medical director of care delivery systems for HealthPartners Health Plan. “There is a big opportunity for hospitalists to incorporate shared decision-making to learn patients’ preferences, such as expectations of when they will be discharged, and understanding of therapeutic options.”
Peri-surgical care is a particularly important opportunity for hospitalists to demonstrate their value by leveraging PROs, according to Dr. Frost. “Patients sometimes come to the table with unrealistic prior expectations that physicians can make pain go away completely. We need to clarify their expectations preoperatively, when we meet them for the very first time, so that they establish a realistic baseline,” he says. “We then need to have a diligent conversation with them immediately after their operation to discuss their pain-management goals, a realistic physical therapy schedule, and post-discharge expectations.”
By clearly understanding patient objectives, hospitalists can “adjust the therapy they’re getting to their expectations, maximizing its effectiveness while minimizing delays in care and transitions to other care settings,” Dr. Frost says.
Chris Guadagnino is a freelance medical writer in Philadelphia.
- National Quality Forum. Patient-reported outcomes. National Quality Forum website. Available at: http://www.qualityforum.org/Projects/n-r/Patient-Reported_Outcomes/Patient-Reported_Outcomes.aspx. Accessed Oct. 2, 2012.
- U.S. Food and Drug Administration. The Patient-Reported Outcomes Consortium. U.S. Food and Drug Administration website. Available at: http://www.fda.gov/AboutFDA/PartnershipsCollaborations/PublicPrivatePartnershipProgram/ucm231129.htm. Accessed Oct. 2, 2012.
- National Quality Forum. National voluntary consensus standards for patient outcomes 2009.National Quality Forum website. Available at: http://www.qualityforum.org/Publications/2011/07/National_Voluntary_Consensus_Standards_for_Patient_Outcomes_2009.aspx. Accessed Oct. 2, 2012.