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

Jennifer Tabler, MS, PhD CandidateDebra L. Scammon, PhD

Knut Hoversten, MD studentMichael K. Magill, MD

And the Care by Design Research Team

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

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

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 patientsatisfaction

Improved health outcomes

Adapted from: Chen, Ou and Hollis 2013 BMC Health Services Research, 13:211

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

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)

Quantitative Assessment of PROs• Assess changes over time in PROs & health

outcomes (two-tailed T-tests)• Link assessments to clinical outcomes (OLS

regression)

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

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 0.352Severity Score 2.05 (2.38) 2.15 (2.25) -0.27 0.786Depression 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 0.267Social Functioning Score 73.56 (29.57) 68.63 (29.28) 0.858 0.393Energy/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)

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

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

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

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

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

• 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