PROMs to support informed
patient decision making
Nick Bansback, PhD
Assistant Professor
School of Population and Public Health
Scientist, Centre for Health Evaluation and Outcome Sciences
Associate, Centre for Clinical Epidemiology and Evaluation
School of Population and Public Health
Disclosures
• Member and recipient of funding from the
EuroQol group
• I am not aware of any other actual or
potential conflicts of interest in relation to this
presentation.
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PROMs
Expectations
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Health care
sustainability?
Expectations
• Patient perceived quality of life is the gap
between expectations and experience
• Unmet expectations are likely to result in
dissatisfaction
Calman KC. Quality of life in cancer patients—an hypothesis. J Med Ethics 1984;10:124-7.
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Expectations in TKA
• >60,000 TKA each year in Canada
• 1 in 5 dissatisfied post surgery ~ 12,000 TKA per year
• Predictors of dissatisfaction post surgery (ORs):
Age
Baseline extreme pain
Baseline WOMAC function
Complication
Low 1 year WOMAC pain
Low 1 year WOMAC stiffness
Low 1 year WOMAC function
Expectations not met
1.03
2.36
1.01
1.86
2.45
-0.64
2.46
10.66
Bourne, R.B., Chesworth, B.M., Davis, A.M., Mahomed, N.N. and Charron, K.D., 2010. Patient satisfaction
after total knee arthroplasty: who is satisfied and who is not?. Clinical Orthopaedics and Related
Research®, 468(1), pp.57-63.
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Unrealistic expectations in TKA
• Of patients who had TKA:
– 33% overestimated the average proportion of patients that
would have less pain post surgery
– 43% underestimated the average rate of serious complications
• “the patient’s expectations for joint replacement
surgery are achievable” is 1 of 6 measures of
“appropriateness” for TKA surgery
Stacey, D. et al. Impact of patient decision aids on appropriate and timely access to hip or knee arthroplasty
for osteoarthritis: a randomized controlled trial. Osteoarthritis and Cartilage, 2016. 24(1), pp.99-107.
Hawker G, Bohm ER, Conner-Spady B, De Coster C, Dunbar M, Hennigar A, et al. Perspectives of
Canadian Stakeholders on Criteria for Appropriateness for Total Joint Arthroplasty in Patients With Hip and
Knee Osteoarthritis. Arthritis Rheumatol Hoboken NJ. 2015 Jul;67(7):1806–15.
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1 review
Crystal Hotel Telupid
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PROMs
Expectations
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Health care
sustainability
PROMs
Expectations
• Feedback PROMs results
to
patients
25%
Scale
• Rating
Example
from the UK:25%
50%
>150,000 EQ-5D and Oxford Knee score responses
10%
over
5
years
nxiety and depression
53%
37%
Pain and discomfort
Severe pain
Pain and
discomfort
Moderate
pain
No pain
Usual activities
8%
24%
68%
11%
38%
51%
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10%
PROMs
iety and depression
53%
Expectations
37%
• Of the 654 males,8%
aged 60-65, with moderate baseline pain/
Pain and limitations
discomfort like you, who had
24%
TKA in the past year:
25%
68%
Rating Scale
25%
Usual
activities
50%
Severe Worsen
limitations
Moderate
limitations
Usual
Stayactivities
the same
No limitations
Improve
11%
38%
10%
nxiety and depression
51%
53%
37%
Pain and discomfort 11%
Self-care
Worsen
Severe
pain
Pain and
discomfort
Stay
the same
Moderate
pain
Improve
No
pain
Mobility
Usual activities
8%
64%
25%
24%
68%
4%
36%
60%
11%
38%
51%
worse
same
better
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PROMs
Expectations
• “After surgery, I’m looking for the problems that personally I’m
going to face when I get surgery. How do you, you know, work in
your house like you did before, get to bath or make your bed, do
laundry, grocery shopping, and all those things.”
• “This is useful. This is going to tell me, as accurately as possible, a
little bit more personalized information. [The conventional
information] doesn’t tell me anything except [it] scares the crap
out of me. But this, this is going to say from 654 [people like me], I
could actually expect to improve. Now that sounded pretty good.”
N Bansback, L Trenaman, S Bryan, J Johnson. Using routine Patient Reported Outcome
Measures to enhance patient decision making: a proof of concept study. QUALITY OF LIFE
RESEARCH, 2015
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PROMs
Expectations
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Health care
sustainability
Expectations
Health care sustainability
• Expectations that change behaviour (hotel example):
1. Preparation
Crystal Hotel Telupid
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Expectations
Health care sustainability
• Expectations that change behaviour (hotel example):
1. Preparation
Crystal Hotel Telupid
2. Change decision
Stay in the Sheraton instead
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Expectations
Health care sustainability
• Expectations that change behaviour (TKA):
1. Preparation
Post surgery physiotherapy
→ reductions in revisions, consults
2. Change decision
Delay surgery, choose non surgical
management
→ reductions in surgeries
Arterburn, David, et al. "Introducing decision aids at Group Health was linked to
sharply lower hip and knee surgery rates and costs." Health affairs 31.9 (2012):
2094-2104
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?
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•
•
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Response bias
PROM selection
PROMs for alternative options
Other issues with confounding
Context matters
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- Response bias
• Who completes pre and post PROMs?
• Tripadvisor has problems with people only
providing good or bad reviews
• Could PROM feedback increase response
rates?
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- PROM selection
• Oxford knee score more sensitive than EQ-5D
• But 12 questions to feedback
• And narrow focus
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- PROMs for alternative options
• Individuals who choose non surgical
management are currently not followed up
with a PROM
• For informed decision making, we require
PROMs for all options to help set expectations
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- Context matters
• Evidence suggests patients less likely to
choose surgery when informed of outcomes
• But in some contexts, could lead to increased
demand – treatments, screening etc
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Summary
• PROMs could have a role informing patients
expectations
• The key question is whether they will change
behavior
• Would require designing PROM collection with
a broader perspective than present
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Email: [email protected]
School of Population and Public Health