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

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  • 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. 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. 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. 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. 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. 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. Quantitative Assessment of PROs Assess changes over time in PROs & health outcomes (two-tailed T-tests) Link assessments to clinical outcomes (OLS regression) 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. 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. 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. 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. 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. 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. 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; dont see incremental value with PHQ-9 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