UsingPROMsatindividuallevel(intro,theory,
evidence,andprimarycare) JoseMValderas
ProfessorofHealthServices&PolicyResearch
GeneralPrac66oner
UseofPROMsinclinicalprac?ce
Levelofaggrega+onofPROdata
Individual
Group
Screening
Usedatthe
clinician–
pa+ent
interface
Yes
Monitoring Decisionaids
Promo?ngpa?entcentredcare
No
Facilita?ng
communica?onwithin
mul?disciplinaryteams
Popula?onmonitoring
andassessingqualityof
care
GreenhalghJ.QualLifeRes2009
UseofPROMsinclinicalprac?ce
Levelofaggrega+onofPROdata
Individual
Group
Screening
Usedatthe
clinician–
pa+ent
interface
Yes
Monitoring Decisionaids
Promo+ngpa+entcentredcare
No
Facilita?ng
communica?onwithin
mul?disciplinaryteams
Popula?onmonitoring
andassessingqualityof
care
GreenhalghJ.QualLifeRes2009
Clinicalapplica?onsofindividual
PROMsdata
•  Suppor?ngdecisionmakinginthediagnos?cprocess:
–  Screening
–  Diagnosis
•  Informingriskstra?fica?onandprognosis(iden?fica?onofvulnerable
pa?entsandpa?ents“atrisk”)
•  Suppor?ngpriori?sa?onandgoalseUng
•  Suppor?ngdecisionmakinginindica?onfortreatment(medical/surgical)
•  Facilita?ngmonitoringof
–  Generalhealthstatus
–  Responsetotreatment/management
•  Facilita?ngcommunica?on
–  Betweenpa?entsandhealthprofessionals
–  Withinteamsandbetweenprofessionals:consistentusealongthecare
pathway
4
Evidence
•  Systema?creviewofRCT(2008):28studies
•  Interven?on:feedbackofPROMstohealthprofessionals
(+/-addi?onalinterven?ons)comparedtonofeedback
•  Mentalhealth(50%),generichealthstatus,other
•  65%studiesshowedsomeimpactonprocesses
(diagnosis,advice/educa?on/counselling)
•  47%studiesshowedsomeimpactonoutcomes(PROMs)
•  Mostclearbenefitforscreening/diagnosisofdepression
•  Morerecentaddi?onalstudiesareshowingincreased
impactonoutcomes
ValderasJMetal.QualLifeRes,2008
5
Whatseemstowork?
•  SpecificPROMstraining(validity,reliability,
interpreta?on)
•  Frequentand?melyfeed-back
•  Feed-backprocesswellalignedwithrou?ne
care
•  Informa?onintegratedintoavailable
informa?onsystems
•  Informa?onthatislinkedtospecificac?on
GreenhalghJ,QualLifeRes2009;ValderasJMetal.QualLifeRes,2008;
6
PROMSforDepressioninPrimaryCare
TheQualityandOutcomesFramework(QOF)hasincen?vizedGeneral
Prac??onerstomeasuretheseverityofdepressionwithavalidated
ques+onnaireatthestartoftreatmentinalldiagnosedcases(sinceApril
2006)(Recommendedtools:PHQ-9,HADS,BDI-II)
DEP6
Inthosepa?entswithanewdiagnosisofdepression,recordedbetweenthe
preceding1Apriland31March,thepercentageofpa?entswhohavehadan
assessmentofseverityatthe?meofdiagnosisusinganassessmenttoolvalidated
foruseinprimarycare.
DEP7
Inthosepa?entswithanewdiagnosisofdepressionandassessmentofseverity
recordedbetweenthepreceding1Aprilto31March,thepercentageofpa?ents
whohavehadafurtherassessmentofseverity2–12weeks(inclusive)ajerthe
ini?alrecordingoftheassessmentofseverity.Bothassessmentsshouldbe
completedusinganassessmenttoolvalidatedforuseinprimarycare.
17
50–90%
8
45–80%
7
PROMSforDepressioninPrimaryCare
DP6
DP7
Mean:78%
pa?ents
Mean:54%
pa?ents
Mean:15.8points
(outof17)
Mean:5.9points
(outof8)
8
PROMSforDepressioninPrimaryCare
•  Pa?entsfavouredthemeasures.
•  Theysawthemasanefficientandstructuredsupplementto
medicaljudgment
•  Theysawthemasevidencethatgeneralprac??onerswere
takingtheirproblemsseriouslythroughafullassessment.
DowricketalBMJ2009;LeydonetalBJGP2011
9
PROMSforDepressioninPrimaryCare
•  BothPa?entsandGPsconsideredthatassessmentsof
severityshouldbeseenasoneaspectofholis+ccare.
•  Theybothwereawareofthepoten+alformanipula+onof
indicators:foreconomicreasons(GPs),toavoids?gmaor
meetexpecta?onsfordesiredoutcomes(pa?ents)
DowricketalBMJ2009;LeydonetalBJGP2011
10
PROMSforDepressioninPrimaryCare
•  GPswerecau+ousaboutvalidityandu?lityandscep+calaboutthereal
mo?vesbehindtheirintroduc?on.
•  Lackofspecifictraining.
•  PROMsseenasanintrusionintotheconsulta?on,prac?calwisdomand
clinicaljudgmentmoreimportantthanobjec?veassessments
•  Wereconcernedthattheassessmentsreducedthehuman
elementoftheconsulta?on.
•  GPconcernsseemedtobeshapedbyaveryprac+cal
concernofpreciselyhowandwhenameasure
shouldbeintroduced,withoutintrudingintothe
consulta?on.
•  Themeasurewasnotviewedasanintegratedpartofpa?ent
assessmentanddiagnosis.
DowricketalBMJ2009;LeydonetalBJGP2011
11
PROMSforDepressioninPrimaryCare
•  GPsmanagedtheques?onnairesdifferently
–  Forpa?entstotakeawaywiththem
–  Forpa?entstocompleteinthewai?ngroom
–  Comple?ngthemwiththepa?entduringthe
consulta?on
–  Memorizinganswersandcomple?ngajerthe
consulta?on
–  Comple?ngthemoverthephone
•  Pharmacologicaltreatmentandreferralrates
linkedtoseveritybutsubstan?alvaria?onwithin
eachstratum
KendricketalBMJ2009;DowricketalBMJ2009;MitchellCBJGP2011
12
Whatseemstowork?
•  SpecificPROMstraining(validity,reliability,
interpreta?on)
•  Frequentand?melyfeed-back
•  Feed-backprocesswellalignedwithrou?ne
care
•  Informa?onintegratedintoavailable
informa?onsystems
•  Informa?onthatislinkedtospecificac?on
GreenhalghJ,QualLifeRes2009;ValderasJMetal.QualLifeRes,2008;
13
Whatseemstowork?
•  SpecificPROMstraining(validity,reliability,
interpreta?on)
•  Frequentand?melyfeed-back
•  Feed-backprocesswellalignedwithrou?ne
care
•  Informa?onintegratedintoavailable
informa?onsystems
•  Informa?onthatislinkedtospecificac?on
GreenhalghJ,QualLifeRes2009;ValderasJMetal.QualLifeRes,2008;
14
Reliabilityofclinicalmeasuresand
PROMs
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
Height(1.00)
Weight(0.99)
SF-36Physicalfunc?oning(0.93)
BedsideGlucosescreening(0.92)
PHQ9(0.85)
SF-36Pain(0.80)
Heartrate(0.68)
DiastolicBloodPressure(0.60)
SF-36Socialfunc?oning(0.60)
Tachypnea(0.60)
HahnMayoClinProc,2007
15
16
Selec?ngtherightPROMforclinicalprac?ce
•  ...,butwhatiftheproblemisdifficultyhearing?
Whatifchroniccough?Whatifdiabetes?
•  ...,butwhatifthereismorethanoneproblem?
•  ...,butwhatiftheproblemdoesnotbotherthe
pa?ent?Whatiftheproblemisminorbut
impactsonareasofgreatimportance?Whatif
theareasarenotevenconsidered(mostthings
thatpeopleenjoydoing!)?
17
Selec?ngtherightPROMforclinicalprac?ce
IndividualizedPROMsgiverespondentsthe
possibilitytotailormeasurementtorelevant
andmeaningfulaspectsoftheirlife
•  SchedulefortheEvalua?onofIndividual
QualityofLife(SEIQOL)
•  Pa?entGeneratedIndex
•  MYMOP
•  GoalArainmentScale
18
19
Goalorientedcare
Pa?entreported
outcome
measures
Pa?ent
General
Prac??oner
Careplan
10-12-16
Clinicaltargets
JoseMValderas
20
Clinical
management
Pa+ent
centredcare
Whole
person
approach
Disease
focus
Biomedical
model
Psychosocial
model
Measure
ment
Goal
seMng
Standardized
PROMs
Individualized
PROMs
Rou?neclinicaluseofPROMsin
PrimaryCare
•  PrimaryCarepa?entswithmul?-morbidity
•  GoalseUngandmonitoringofcareand
outcomes
•  PROMs
–  Individualized(Pa?entGeneratedIndex)
–  Standardized(EQ5DVASandcondi?onspecific)
•  Partofannualreview(Qualityandoutcomes
framework)
22
Rou?neclinicaluseofPROMsin
PrimaryCare
Disease
specific
Annualreview
(GeneralPrac??oner/NursePrac??oner)
Careplan
asthma
COPD
depression
diabetes
heartfailure
osteoarthri?s
EQ5D
PGI
23
Summary
•  PROMsarehealthmeasurementselicitedfrom
thepa?ents
•  PROMsneedtodemonstrategoodpsychometric
proper?esalongwithevidenceforacceptability
•  Therearerepositoriesandstandardizedtoolsto
assisttheiden?fica?onofthebesttoolfora
givenpurpose
•  PROMsareheretostay
•  Individualizedmeasurementisnecessarybutnot
sufficientforanefficientuseofPROMsinclinical
prac?ce