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Measuring what matters to patients:
concepts & cases
The Health Foundation
Improvement Science Development
Group
January 7, 2013
Eugene C. Nelson, DSc, MPH
The Dartmouth Institute
Dartmouth-Hitchcock Health System
Acknowledgements: J. Weinstein, R. Reid, S. Lindblad, J. Wasson, C. Kerrigan, J.
Kirk, P. Batalden, et al and financial support from The Dartmouth Institute, The
Dartmouth Center for Healthcare Delivery Science, the Robert Wood Johnson
Foundation, PCORI and NIH-NIA.
Wayne Gretzky
2
Gretzky Group: Health Affairs 2013Short
Answer
Value:
Outcomes
+
Experiences
+
Costs
Key Patient Outcomes
Experience
Disease Function
Risks Costs
Competence
Person ClinicianCo-Production
** Clinical microsystems, i.e., the place where patients and providers meet and interact for the benefit of patients (12)
Aim: measures to support co-production of health* & health care in microsystems**
Clinical Microsystem
Key measures Health Determinants*
• Genetics
• Environment
• Lifestyle
• Health care
At risk
New condition
Recover/Reduce Burden
An old story … great clinical results &
better functional outcomes …
because of functional screening
4
Insert JAMA article
Jack Kirk, MD
Founder
Dartmouth COOP Project
JAMA 1983
x
Case 1
55
Using PROMs with Individuals:
Dartmouth Spine Center
© 2000, Trustees of Dartmouth College, Batalden, Nelson, Wasson
Referral or VisitRequest
Orientation&
PROMs
InitialWork Up
Plan of Care
FunctionalRestoration
Chronic CareManagement
AcuteCare
Management
DiseaseStatus
ExpectationsFor Good Care
Sunk Costs
Functional &Risk Status
DiseaseStatus
ExperienceAgainst
Need
IncrementalCosts
Functional &Risk Status
Palliative Care
People withhealthcare needs
People withhealthcareneeds met
Feed Forward
Feedback
Improvement registry
Public reports website
SPORT & research
Case 2
Patient Perception of OutcomesHistory &
Symptoms
Red Flags
The summary report generated from patient-reported data is critical to
a physician's ability to care for a patient: same page careFunctional
Status
Risk Status
Disease
Status
“practicing without it …flying a plane without instruments”
1.64
QALY
1.44
QALY
Functional
Clin
ical
Costs
Satis
factio
n
Reduced
Oswestry
Symptoms
Satisfied With
Improvement
Total Direct &
Indirect Costs
Physical SF-36
ImprovementHerniated Disk Outcomes @ 2 Years
Non-SurgerySurgery
44 Ave Age
43% Female
30 Ave Age
45% Female
Cost Per Quality
Adjusted Life Year Added
By Surgery $34,355
$74,870
44
30
59%
78%
-25
-37
$13,108
$27,341
$34,355
Moving research results
back to patient care …
risk calculator
used at point of care
for Shared Decision
Making about likelihood
of outcomes based on
different treatments
My risk calculator
Sweden: Rheumatology
Quality Registry (SRQ)
• SRQ uses PROMs feed forward data in
flow of care: better care for individuals,
practice improvement, new care models,
retrospective & prospective research &
better measured outcomes for Sweden
RA patients
8
Staffan Lindblad, MD
Case 3
Dashboard for a
Rheumatology
Patient
Swedish National
Quality Registry …
patient is
doing better …
N of 1 experiment…
Responded to biologics
January - March
June - December
Functional Outcomes
Clinical Outcomes
By the way … Swedish health system is doing betterAll Patients in the SRQ, from 1994 – 2006*
*Black line shows DAS at initial visit and blue after 6 months and turquoise after 12 months.
Patients sicker at 1st visit
Patients better at 12 months
From front line practice
to national policy
11
My
Health
Status
My
Healthcare
Decisions
My
Healthcare
Plan
My
Health
Outcomes
Patient Reported Metrics + Clinical Metrics =
Guidance System for Getting It Right …
•Health care decisions right for Amy
•Health care plans right for Amy
•Health care outcomes best for Amy
•Thus, Amy is able to co-produce her care
What measures matter most to patients
at the front lines is DYNAMICAmy
Case 4