module 1 webinar - home | united hospital fund...module 1 webinar guest presenter: dr. kurt kroenke...
TRANSCRIPT
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UHF Quality Institute
Patient-Reported Outcomes in Primary Care – New YorkPROPC-NY
Module 1 WebinarGuest presenter: Dr. Kurt Kroenke
December 13, 2016
Supported by The Engelberg Foundation
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Agenda
1. Welcome and Roll Call2. Presentation by Dr. Kroenke3. Q & A4. Discussion/Round Robin5. What’s Ahead
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Dr. Kurt Kroenke, MD, MACP
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Patient-Reported Outcomes Moving PROs into Practice
Kurt Kroenke, MD, MACPRegenstrief Institute
Indiana University School of MedicineVA HSR&D Center for Health
Information and Communication Indianapolis, IN, USA
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Symptoms Must be Measured & Monitoredlike any other disease
Sphygmomanometer
Peak Flow Meter
Glucometer
“Symptometer”
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Pragmatic Psychometrics Mantra
Measures developed for research
are seldom taken up in clinical practice
Measures developed for clinical practice
are sometimes taken up in research
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Outline
• PHQ Family of Scales
• Choosing a Scale
• SPADE Trial
• Implementing Scales
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PHQ GenealogyPRIME-MD
PHQ
PHQ-9
PHQ-8 PHQ-2
GAD-7
GAD-2
PHQ-15
SSS-8PHQ-4
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PrimeMD/PHQ-9
More than NearlyNot Several half the every
at all days days day0 1 2 3
PHQ – 9 Depression Scale
a. Little interest or pleasure in doing things
b. Feeling down, depressed, or hopeless
c. Trouble falling or staying asleep, or sleeping too much
d. Feeling tired or having little energy
e. Poor appetite or overeating
f. Feeling bad about yourself, or that you are a failure . . .
g. Trouble concentrating on things, such as reading . . .
h. Moving or speaking so slowly . . .
i. Thoughts that you would be better off dead . . .
1. Over the last 2 weeks, how often have you been bothered by the following problems?
Subtotals: 3 4 9
SCORE = 16
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PHQ-9 as Severity Measure• Cutpoints for depression severity:
≥ 5 mild≥ 10 moderate≥ 15 moderately severe≥ 20 severe
• Significant improvement = 5 point ↓• Response = 50% ↓ or score < 10• Remission = score < 5
10
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PHQ-9 Thresholds for Treatment
≥ 15 Start treatment
10-14 Consider treatment
5-9 Monitor; no treatment
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PHQ-9 vs. Competing Scales in 3 Special Populations
Population Competitor Verdict
Elderly Geriatric DepressionScale PHQ better
Postpartum Edinburgh Postnatal (EPDS)
Probablycomparable
Adolescent Beck (BDI-PC) Either
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Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
(0)
Several days
(1)
More than half the days
(2)
Nearly every day(3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it is hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
GAD-7 Anxiety Scale
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Over the last 2 weeks, how often have you been bothered by the following problems?
Not at all
(0)
Several days
(1)
More than half the days
(2)
Nearly every day(3)
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
PHQ-4
GAD-2
PHQ-2
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Outline
• PHQ Family of Scales
• Choosing a Scale
• SPADE Trial
• Implementing Scales
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5 Characteristics of a Pragmatic PROKroenke et al, J Clin Epidemiol 2015
Characteristic DefinitionActionable Scores guide diagnostic or
therapeutic decision-makingSelf-administered Completed by patient (rather
than by interview)All-purpose Screening; Severity assess-
ment; Treatment monitoringSimple Brief; Easy to score;
Memorable cutpointsAccessible Public domain; Download-
able; Translations
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The MMSE had been freely available since its initial publication in 1975, but in 2000, its authors --Marshal Folstein, MD, Susan Folstein, MD, and Paul McHugh, MD --transferred the copyright to a company they founded, which then licensed the test to PAR in 2001.
NEJM 2011
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The Promise of PROMIS Measures• > $100 million dollars spent by NIH (& counting)
• CAT versions – can use large item bank (e.g, 50-80 items) to tailor questions so respondent requires only ∼ 7-8 items
• Fixed forms (4-8 items) – profiles & short forms
• Raw scores can be converted to T-score, where 50 is population norm, and each 10 points is 1 SD better or worse. (e.g., 60 on a symptom score is 1 SD worse than general population)
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PROMIS Depression (8-item)
4-item6-item
1 2 3 4 5
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Normal Raw Scores (t-score = 50) on PROMIS 4-item profiles
Domain “Normal” Raw ScoreDepression 5-6Anxiety 5-6Pain 5-6Fatigue 8-9Sleep 9-10Physical function * 19-20Social role satisfaction* 15-16
* LOWER scores on 2 non-symptom scales are WORSE
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Converting Raw to
T-Scores4-item
PROMIS Depression
Scale
Raw.Score T.Score4 41.05 49.06 51.87 53.98 55.79 57.3
10 58.911 60.512 62.213 63.914 65.715 67.516 69.417 71.218 73.319 75.720 79.4
Cutpoint for “Clinically Depressive Symptoms”since T-score
≥ 55 represents effect size of 0.5
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Decisions in Using PROMIS Measures
1. Should I use a PROMIS or a non-PROMIS legacy measure (PROMIS depression vs. PHQ-9)?
2. Should I use fixed PROMIS scales vs. CAT?
3. Should I use raw or T-scores (probably latter)?
4. Are there PROMIS scales for which brief public domain non-PROMIS measures are lacking (anger, sleep, fatigue, social satisfaction)
5. Is PROMIS measure responsive (e.g., therapy)?
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Equivalence of Depression ScalesMH-CAT 45 item bank with positive & negative mood itemsPROMIS-D CAT 28 item bank with negative mood itemsPHQ-9 fixed 9-item scale250 primary care patients, half with depression
9-item scale AUCMH-CAT 0.92PROMIS-CAT 0.90PHQ-9 0.89
Rose, …, Kroenke (under review)
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IOM Report on 12 Social Determinants to Include in Electronic Health Records
Race/ethnicity Physical activity
Education Residential address
Tobacco use Social connections/isolation
Alcohol use Financial constraints
Stress Census-tract median income
Depression Intimate partner violence
Adler & Stead, N Engl J Med 2015;372:698-7-1
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Garg et al. Avoiding the Unintended Consequences of Screening for Social Determinants of Health, JAMA 2016;8:813-14
• “Screening for social determinants can detect adverse exposures and conditions that typically require resources well beyond the scope of clinical care. Screening for any condition in isolation without the capacity to ensure referral and linkage to appropriate treatment is ineffective and, arguably, unethical.”
• “Ensuring linkage to the many sectors critical for addressing adverse social determinants (e.g., housing, food and nutrition, transportation, mental health, human welfare, and employment) requires effective care coodination and cross-sector collaboration.”
• “Such screening could yield expectations that, if unfulfilled, could lead to frustration for patients and physicians alike.”
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Current Level of Actionability in Primary Care
Level Examples
A Labs (A1C, LDL), BP, Weight
B Symptoms (depression, pain)
C Function, Quality of Life
D Employment, Housing
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Outline
• PHQ Family of Scales
• Choosing a Scale
• SPADE Trial
• Implementing Scales
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SPADE Symptom Cluster
• S leep• P ain• A nxiety• D epression• E nergy
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To paraphrase “Animal Farm” …
All symptoms
are created equal,
but some symptoms
are more equal than others.
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5 Reasons for choosing SPADE pentad
1. The most prevalent, chronic, & undertreated symptoms in clinical practice
2. Cause additive impairment and adversely affect treatment response of one another
3. Cross-cutting in that they occur across most medical and mental disorders
4. Commonly “cluster” hard to unbundle5. Account for 5 of the 7 domains in PROMIS
profiles (other 2 = physical function & social)
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Anxiety
Depression
Fatigue
Pain
Sleep
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Study Design
Randomize
3-Month Follow-up Assessment
SPADE Screener (5 items)
PROMIS Scales (20 items)
Control Group
(n = 150)
Feedback Group
(n = 150)
≥ 1 Symptom +
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Checking your “symptometer”
Do you have a “fever”?
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PROMIS Symptom Scores Visual Display
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SPADE Prevalence in Primary CarePROMIS 4-item symptom scale T-score ≥55
SPADE Symptoms
Chronic Pain(n=250)
SPADE screen +(n=300)
0 9.6 % 5.3 %1 20.0 % 11.0 %2 15.6 % 13.0 %3 22.8 % 18.0 % 4 11.6 % 21.3 %5 20.4 % 31.3 %
Davis, Kroenke, et al, Clin J Pain 2015; Kroenke et al, in preparation
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Symptom Improvement at 3 Months
1. Both groups had small improvements (median ES = 0.31, range 0.17 to 0.52)
2. Absolute change slightly favored feedback group.3. However, differences between groups not significant.
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Patient-Reported Symptom Discussion & Treatment at Index Visit and Residual
Desire for Treatment at 3 Month Follow-UpDis-
cussed%
Treated
%
Desire Treat-ment at 3 mo
%Pain 88 60 40Fatigue 78 37 36Sleep 78 44 31Anxiety 65 39 25Depression 64 39 23
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Patient-Reported Reasons for Not Discussing Symptom at Index Visit
Reason for not discussing (%)
There were more important medical issues to deal with during the visit
49
I did not need treatment for the symptom 47I did not want treatment for the symptom 29The doctor did not bring it up 21I did not feel comfortable talking about symptom 16The doctor did not seem comfortable talking aboutsymptom
9
The doctor seemed too busy 7
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SPADE Symptom Screener
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Outline
• PHQ Family of Scales
• Choosing a Scale
• SPADE Trial
• Implementing Scales
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3 Axioms for Clinical Use of a Measure
1. It is not about the measure but the measurement.
2. It is less about detection than monitoring.
3. It is rarely about the score but coupling it with patient preferences.
However, there may be an advantage to a “lingua franca”
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A Confusion of Tongues
PHQ-9
CES-D
BDI
PROMIS
HADS
QIDS
GDS
MHI-5WHO-5“That is why it was called Babel—because there the LORD confused the language of the whole world.”
Genesis 11:9
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Implementation Decisions for PROsDecision OptionsTarget Single or Multiple conditionsPurpose Screening (all) or Case-FindingAim Detection or MonitoringSite Clinic (pre-visit) or HomeMethod Paper or Laptop or I-PadEHR Separate from or Integrated intoDisplay Numerical or GraphicalReport Cross-sectional or Longitudinal
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3 things that might increase the use & utility of PROS
1. Competency in symptom management
2. Visit time or support (care manager, medical home, referral options)
3. Incentives (reimbursement, quality indicators, patient satisfaction)
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Key PHQ Resources• Website www.phqscreeners.com
• Review articles– Kroenke K, et al. The Patient Health Questionnaire
somatic, anxiety, and depressive symptom scales: a systematic review. Gen Hosp Psychiatry 2010;32:345-359.
– Kroenke K, et al. Pragmatic characterisics of patient-reported outcome measures are important for use in clinical practice. J ClinEpidemiology 2015;68:1085-1092.
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49
• Insert Dr. Kroenke’s slides
Please remember to limit background noise to facilitate effective discussion.
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Discussion/Round Robin
• Since we last met, how has your work progressed (e.g., success, challenge)?
• Is there anything you heard today that has triggered your attention and is relevant to your work?
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Coming Soon - Module 2
Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan FebIn-person meeting X X XDeep-dive call (or site visits) with each participating organization
X X X X X X
Collaborative call with all participants X X X
Webinars X X X X X
Module 1: Planning phase,establishing the foundation X X X X
Module 2: Process mapping of PROs and clinicalworkflows
X X X X X
Module 3: Piloting X X X X X X
Module 4: SynthesizeLearnings and Identify Next Steps
X X X
51*Tentative schedule – actual schedule will be flexible to the collaborative’s needs
September 2016 – February 2018*
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Upcoming Dates
• January: Module 2 begins– Process mapping and clinical workflows
• January 13: Module 1 Reporting Form due to [email protected]
• January 24, 1-2:30 pm: Webinar by faculty member Lucy Savitz, Intermountain Healthcare, UT
• February: Deep dive calls with each team
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Questions? Contact UHF Quality Institute
• Anne-Marie AudetSenior Medical [email protected]
• Lynn RogutDirector, Quality Measurement and Care [email protected]
• Roopa MahadevanPolicy and Program [email protected]
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Thank you for your hard work and commitment to PROPC-NY!