Value-based cancer care and the use of PROs, …...2019/08/06 · Satisfaction, experience of...
34
Value-based cancer care and the use of PROs, PROMs, PREMs Prof. Isabelle Peytremann Bridevaux June 18, 2019 Bern
Transcript of Value-based cancer care and the use of PROs, …...2019/08/06 · Satisfaction, experience of...
Value-based cancer care and the use of
PROs, PROMs, PREMs
Prof. Isabelle Peytremann BridevauxJune 18, 2019
Bern
Outline
• Background and context
- What are PROMs & PREMs ?
- Why collect PROMs & PREMs ?
• Value-based healthcare: the role of PROMs
• Barriers & facilitators to the implementation of
PROMs & PREMs
• PROMs & PREMs international initiatives
• Conclusions
3
PROs, PRMs, PROMs, PREMs, …
2 «umbrella» terms
PRO: patient-reported outcomes
PRM: pateint-reported measures
PROMs:
Patient-reported outcome
measures
PREMs:
Patient-reported experience
measures
4
What are PROMs (Patient-reported
outcomes measures) ?
• «Any report of the status of a patient’s health
condition that comes directly from the patient,
without interpretation of the patients’s response
by a clinician or any one else»
• PROMs measure outcomes of care
• Examples:
Functional status, well-being, (health-related) quality of
life, symptoms, treatment adherence, social functioning,…
5
What are PROMs (Patient-reported
outcomes measures) ?
• Generic
- EQ-5D
- SF-36 (SF-12)
- PROMIS instruments
• Condition-specific:
- Cancer: EORTC
- COPD: CRQ or St-Georges questionnaire
- Diabetes: ADDQoL
6
What are PREMs (Patient-reported
experiences measures) ?
• A measure of the patients’ perception and views
of their experiences of care, focusing on the
delivery of care
• PREMs encompass a range of interactions that
patients have with the healthcare system
• Examples:
Satisfaction, experience of processes of care (e.g. waiting
time, treated with respect and dignity), observation of care
providers behavior (e.g. discharge information given, patients’
documents available during consultation)
7
Why collect PROMs - PREMs ?
8
Why collect PROMs - PREMs ?
0
500
1000
1500
2000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
PROMs PROMs & cancer
9
Why collect PROMs & PREMs ?
At which level
• Micro level:
• Meso level:
• Macro level:
- Support patient-centred care and shared
decision making
- Monitor disease progression, treatment
effcacy and safety
- Drive healthcare quality improvement
initiatives
- Performance comparisons (benchmarking
+/- public reporting)
- Population health monitoring (nat. surveys)
- Reimbursment decisions (HTA) /payment
models
- Macro-level healthcare performance
Desomer A, www.kce.fgov.be, 2018
10
Why collect PROMs - PREMs ?
Value-based healthcare (VBHC)
• VBHC: aims to improve quality of care by
measuring and improving outcomes reflecting
value (and not volume)
• Value = multidimensional concept
Health outcome per dollar spent (Porter, NEJM 2010)
The relationship betwen outcomes and costs,
expressed as the net health benefit (McGray Lancet 2013)
11
Value-based healthcare
12
Value-based healthcare
13
14
Drug costs
Dolgin E, Nature 2018
15
«Despite the growth in alternative payment and
delivery models in cancer, threre is limited eivdence to
evaluate their efficacy»
Cancer 2018;3293-306
16
«Despite the growth in alternative payment and
delivery models in cancer, threre is limited eivdence to
evaluate their efficacy»
No model included an analysis of PROMs !
Cancer 2018;3293-306
17
Value-based healthcare
18
Effectiveness of use of PROMs :
evidence from systematice reviews (1) Author (year) Review type (n) Type of care
Greenhalgh (1999) Systematic review (13) General care
Espallargues (2000) Systematic review (21) General care
Gilbody (2001) Systematic review (9) Mental care
Gilbody (2002) Systematic review (9) Mental care
Gilbody (2003) Systematic review (16) Mental care
Marshall (2006) Structured review (38) General care
Valderas (2008) Systematic review (28) General care
Carlier (2012) Narrative review (52) Mental care
Boyce (2013) Narrative review (17) Primary care
Etkind (2015) Systematic review (13) Palliative care
Kendrick (2016) Systematic review (17) Mental care
Holmes (2016) Systematic review (13) Pain care
Greenhalgh (2017) Realist synthesis General care
Fonhus (2018) Systematic review (6) General care
Ishaque (2019) Systematic review (22) General care
19
Effectiveness of use of PROMs :
evidence from systematice reviews (2)
«weak evidence» – not strongly conclusive, but:
• Positive impact on processes of care via
improvements in patient-provider communication
& interaction:
- improvements on diagnosis and monitoring of treatment &
symptoms
- more referrals; higher providers adherence to
recommandations
- more discussion on QoL, higher patient experiences and
satisfaction
• Less impact on patients’ health status
20
Effectiveness in cancer care
Author (year) Review type (n) Results
Luckett T (2009)
Syst Rev(6 RCTs)
• Limited impact on patient outcomes• Improved provider-patient communication
Chen (2013)
Syst Rev(27 - 16 RCTs)
• Impact on health or institutional outcomes weakor non-existent
• Improved provider-patient communication; improved monitoring of tt responses and detection of unrecognised problems
Kotronoulas(2014)
Syst Rev
(24 - 20 RCTs)
• Limited impact on patient outcomes• Increased frequency of discussion of patients’
outcomes during consultations
Howell(2015)
Scoping review(30 - 7 RCTs)
• Impact on health outcomes not clear• Improved provider-patient communication
Yang (2018)
Syst Rev(43 - 16RCTs)
• Improved provider-patient communication
21
PROMs monitoring systems without
clinical care component
• Key findings (11 published studies for 7 systems):
- Countries: USA, NL, UK, Australia
- Aims: benchmarking/monitoring of quality indicator; use for
changes in supportive care, clinical practice and policy
- PROMs data: variety of nb and types, data collection
points and frequency of measures
- Measures: physical health (n=7), emotional health (n=4),
social health (n=4), (HR)QoL (n=6)
- Collection sites: hospitals/community-based sites/cancer
centres/academic centres & cancer registry to invitation
letter to identified eligible patients)
Corsini N, J Cancer Surviv 2017
22
PROMs monitoring systems without
clinical care component
Lessons learned:
• Feasible to use monitoring systems to identify, recruit and
collect PROMs
• Difficult to get representative samples
• Patients are willing to provide information on variety of
PROMs
• Need to better specify how PROMs data will be used, for
what purpose and by whom
• Lack of consistency of PROMs collected across
monitoring systems
Corsini N, J Cancer Surviv 2017
23
Barriers and facilitators to the
implementation and use of PROMs
24
General conditions,contextual factors
• Conflicting/competing priorities• Financial/operational pressure• Privacy legislation• Interoperability issues• Lack of PROMs/PREMs knowledge (general; international
initiatives)
PROMs/PREMS: selection, data collection & analyses, resultspresentation
• Confusion in definitions• Instrument: conflicting visions regarding its features - limited
flexibility/availability• Lack of standardisation of the use of the instrument• Burden for staff and patients • Lack of communication of results to others (I,II,III care)
Usefulness for stakeholders
• Difficulty to show impact of PROMs/PREMs on quality of care
• Delays with results/reports; difficulty to interpret results• Difficulty implementing changes after results ; lack of time
between implementation and next results
PROMs : implementation barriers
Desomer A, www.kce.fgov.be, 2018
25
PROMs : implementation facilitators
General conditions,contextual factors
• Leadership, vision, clear objectives• Political and economic drivers; legal basis• Organizational culture towards patient-centred care• Resources ($ - persons - IT)• Multidisciplinarity of initiative• Trust (appropriate collection/use/storage)• Communication, gradual implementation
PROMs/PREMS: selection, data collection & analyses, resultspresentation
• National framework - Use of standard sets of outcomes• Involvement of patients• External scientific expertise & support• Availability of infrastructure for data collection & storage• Clear instructions (standards) for data collection & analyses • Use of digital technology– interactive tools• Risk and case-mix adjustment
Usefulness for stakeholders
• Coordination & exchange of experiences between initiatives• Timely feedbacks/reports• Objective presentation of results; non blaming tone• Use of results (including pay-for-performance)• Monitoring and evaluation of the system
Desomer A, www.kce.fgov.be, 2018
26
SCAPE study
Etude transversale et multicentrique
Objectif : Décrire le vécu des patients en soins oncologiques
en Suisse romande
Patients éligibles :
- 6 types de cancer: sein, prostate, poumon, colorectal,
mélanome ou hémopathie maligne
- Traitement (ambulatoire ou stationnaire) entre 01.01-
30.06.18
Questionnaire: “NHS Cancer Patient Experiences”
27
International initiatives
28
OECD
29
OECD
30
31
32
33
Conclusions
• Essential to consider the collection of PROMs & PREMs
• Feasible and acceptable to consider a more routine use of
PROMS a & PREMs and implement them in practice
• Swiss context now favorable despite existing barriers
• All stakholders, including patients, need to be involved
• Cancer care represents an excellent opportunity
