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Patient Reported Outcomes (PROs) in Care Managed Patients: Potential and Challenges

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Patient Reported Outcomes (PROs) in Care Managed Patients: Potential and Challenges

  1. 1. Patient Reported Outcomes (PROs) in Care Managed Patients: Potential and Challenges Jennifer Tabler, MS, PhD Candidate Debra L. Scammon, PhD Knut Hoversten, MD student Michael K. Magill, MD And the Care by Design Research Team
  2. 2. Care Management Program • Care Managers as member of care team • Target Population – Patients with chronic conditions (DM, CAD, CHF) • Care Manager Tools – Goal Setting – Patient Reported Outcomes (PAM, PHQ9, RAND 36) • Patient Self-Management Tools – Weight --Exercise – Blood Glucose --Blood Pressure
  3. 3. Clinically Relevant Measures • General – Health-related quality-of-life – Satisfaction with care or treatment – Dimensions of patient experience • (e.g., depression and anxiety) • Disease-specific – Health status assessments – Symptom reporting
  4. 4. PRO data to clinician Improved Clinician-Patient Communication • Shared treatment plan/goals • Monitor treatment response and health status Clinician changes patient management Patient changes behavior Improved patient satisfaction Improved health outcomes Adapted from: Chen, Ou and Hollis 2013 BMC Health Services Research, 13:211
  5. 5. Patient Reported Outcome Measures • PAM - Patient Activation Measure – Beliefs, motivations, actions for self-care • PHQ-9 – Depression severity • RAND 36 Health quality of life – Perceived well-being in physical, mental, and social domains; functional limitations to daily life
  6. 6. Methods for obtaining PRO data – Initial Responses were on paper-based instruments – Follow up responses either paper-based or entered via My Chart (EMR Patient Portal)
  7. 7. Quantitative Assessment of PROs • Assess changes over time in PROs & health outcomes (two-tailed T-tests) • Link assessments to clinical outcomes (OLS regression)
  8. 8. Completed at least 1 time Completed 2 times Completed 3 times or more PAM 45.8% 8.8% 2.2% RAND36 37.2% 3.8% 0.7% PHQ9 44.8% 5.9% 1.2% All sites combined, n = 1,381 Utilization of PROs
  9. 9. PRO Measure Earliest Score (S1) Mean/Std Dev Most recent Score (S2) Mean/Std Dev T-Test Change S1 to S2 t- stat prob PHQ9 (n=78) Functional Impairment 1.09 (1.09) 0.944 (1.00) 0.93 0.352 Severity Score 2.05 (2.38) 2.15 (2.25) -0.27 0.786 Depression Score 0.57 (1.14) 0.59 (1.21) -0.09 0.923 RAND 36 (n=52) General Health Score 48.14 (21.84) 43.56 (19.81) 1.11 0.267 Social Functioning Score 73.56 (29.57) 68.63 (29.28) 0.858 0.393 Energy/Fatigue Score 47.06 (25.46) 42.60 (22.46) 0.944 0.347 PAM (n=122) Activation Score 63.98 (15.96) 62.74 (15.31) 0.619 0.537 Repeated Measures (Consented Patients)
  10. 10. Coeff P-value PAM 1 and First BMI (N=369) -0.08 0.015 PAM 1 and First LDL (N=389) 0.026 0.822 PAM 1 and First HbA1C (N=389) 0.004 0.531 •OLS Regression results (controlling for gender, age, and race/ethnicity) Relationship between Initial PAM scores and Initial Clinical Outcomes
  11. 11. Coeff P-value PAM 1 and Final BMI (N=325) -0.003 0.673 PAM 1 and Final LDL (N=344) -0.068 0.489 PAM 1 and Final HbA1C (N=337) 0.007 0.254 •OLS Regression results (controlling for gender, age, and race/ethnicity, as well as initial health outcome score Relationship between Initial PAM scores and Final Clinical Outcomes
  12. 12. Coeff P-value Change in PAM and Change in BMI (N=82) -0.012 0.45 Change in PAM and Change in LDL (N=93) 0.143 0.461 Change in PAM and Change in HbA1C (N=89) -0.021 0.042 •OLS Regression results (controlling for gender, age, and race/ethnicity) Relationship between Change in PAM scores and Change in Clinical Outcomes
  13. 13. Qualitative Assessment of PROs • Care Manager experience with PROs – Semi-structured interviews with 6 Care Managers • Incorporation of PROs into workflow • Perceived value of assessments to patient care
  14. 14. Care Managers’ Experiences • Complex patient population – Low literacy – refugees, prisoners, non-native English speakers – Mental illness – patients in crisis – Patient motivation – “no shows”, not ready to change • Perception of value of assessments – PAM easier to administer and of more value – RAND 36 long and redundant – Already using PHQ-2; don’t see incremental value with PHQ-9
  15. 15. • Challenges – Developing capacity to collect and use PROs effectively • Consider using alternative methods to acquire PRO data (Smart Phones, electronic monitoring devices) – Obtaining PROs during first care management visit increases opportunity for re-assessment • Develop system to obtain PROs early and often • Room for improvement – Education & re-education of care managers, patients Discussion

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