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