The PROMs Programme

in the NHS in England

Veena Raleigh

Senior Fellow, The King’s Fund

HCQI, 7 November 2013

The background

Improving NHS quality a government priority since 2008

Quality defined as: effectiveness, patient experience, safety

NHS Outcomes Framework: includes indicators on PE and PROMs

Supported by a national programme of PE and PROMs surveys

PROMs: patient-reported outcomes of health interventions

Initial focus on 4 elective procedures

Local use » » Benchmarking against peers for improvement

Contract monitoring » » Commissioners holding providers to account

Quality monitoring » » Telling the story about performance

P4P » » Financial rewards for high patient-reported quality

Resource allocation » » Allocating resources efficiently

Health inequalities » » Appropriate access for given needs

Regulation » » Setting minimum standards

Patient choice » » Choosing high quality providers

Why collect PROMs? Improving quality and productivity

The PROMs programme

Introduced in 2009

Currently covers 4 procedures: hip and knee replacement,

groin hernia and varicose veins surgery

Includes all providers of NHS-funded care (NHS and private)

Two sets of instruments used:

- condition-specific measures tailored to particular procedures

AND

- a generic health measure EQ-5D for all 4 procedures: to

compare health gain across different procedures on a standard

basis - widely used in economic evaluations of health care

(EQ-5D covers mobility, self-care, usual activities,

pain/discomfort, anxiety/depression)

The methods

Instruments: - hip replacement (EQ-5D and Oxford Hip Score)

- knee replacement (EQ-5D and Oxford Knee Score)

- varicose veins surgery (EQ-5D and Aberdeen Score)

- groin hernia surgery (EQ-5D only)

Pre- and post- op questionnaires for all patients (self-completed)

Pre- and post- op health status and health gain assessed

Post-op questionnaires ask about complications

Linkage of patients’ questionnaires to their hospital records, to

enable case-mix adjustment for reliable comparisons across

providers (variables - age, sex, deprivation, co-morbidities etc)

Data analysed by commissioner and provider

2011/12: 248,000 eligible procedures

Overall response rate 75%

Response rates, 2011/12: patients completing the pre-op questionnaire

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12

Groin Hernia Hip Replacement Knee Replacement Varicose Vein

Response rates, 2011/12: patients completing the post-op questionnaire

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Apr 11 May 11 Jun 11 Jul 11 Aug 11 Sep 11 Oct 11 Nov 11 Dec 11 Jan 12 Feb 12 Mar 12

Groin Hernia Hip Replacement Knee Replacement Varicose Vein

Procedure EQ-5D Procedure-

specific

instrument

Hip replacement 87.3% 95.7%

Knee replacement 78.4% 91.6%

Varicose veins surgery 53.2% 83.1%

Groin hernia surgery 49.9% -

Patients reporting health gain, 2011/12

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0 100 200 300 400 500 600 700 800 900

Ad

juste

d H

ealt

h G

ain

Number of procedures

95% control limits 99.8% control limits England

Hip replacement, EQ-5D score: Case-mix adjusted health gain by provider, 2011/12

Hip replacement, Oxford Hip Score: Case-mix adjusted health gain by provider, 2011/12

10

12

14

16

18

20

22

24

26

28

30

0 100 200 300 400 500 600 700 800 900 1000

Ad

juste

d H

ealt

h G

ain

Number of procedures

95% control limits 99.8% control limits England

Knee replacement, Oxford Knee Score: Case-mix adjusted health gain by provider, 2011/12

Post-operative complications, 2011/12

Percent of patients reporting complications*

Procedure Readmission Further surgery

Varicose veins

surgery

5.3% 15.0%

Groin hernia surgery 5.5% 16.0%

Knee replacement 9.6% 3.7%

Hip replacement 7.6% 2.7%

* As reported in the post-op questionnaires.

Extension of PROMS: next steps

Pilots underway:

- coronary artery bypass grafts

- angioplasties

- secondary care treatment of depression

PROMs in development or under consideration

- HIV

- renal dialysis

- musculoskeletal

- trauma

- MH: depression, dementia, psychological therapies

- children & young people

- other surgery

Queries to Jo Partington, PROMs Insight Account

Manager, NHS England:

jo.partington@nhs.net

Data published by the Health and Social Care

Information Centre:

http://www.hscic.gov.uk/proms

Research published by the London School of Hygiene

and Tropical Medicine:

http://proms.lshtm.ac.uk/

Further information