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.