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OBSERVATIONS: Nigel Hawkes How do we get the measure of patient care? BMJ 2008; 336: 249 [Full text]

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PROMs promote health gain and patient involvement

Andrew J Vallance-Owen, London WC1A 2BA   (3 February 2008)

Outcomes and systematic improvement

stephen black   (9 February 2008)

PROMs promote health gain and patient involvement 3 February 2008
Andrew J Vallance-Owen, Group Medical Director BUPA 15-19 Bloomsbury Way, London WC1A 2BA Send response to journal: Re: PROMs promote health gain and patient involvement	I was pleased to see discussion of patient reported outcome measures (PROMs) in Nigel Hawkes' piece (1), but concerned that he seemed to have swallowed the rather paternalistic line that what doctors do to patients is more important than the outcome as perceived by them. How can we know if a process brings benefits and continue to improve it without measuring the outcome, and how can we rely on process alone when the evidence shows such widespread variation and inconsistency in process within clinical practice? The latter well known to us doctors, but hardly transparent to the patient. We all know the old cynical saying "The operation (i.e. process) was a success but the patient died". Happily this is very rare but, for the patient anyway, there is much more to success than 'alive or dead'. How often have we heard: 'They said my hip replacement went well but I am now housebound' or 'He says I have a good flow rate in my by-pass graft, but I still get pain at 10 metres'? Process apparently fine, practical outcome for patient poor. It's not all negative though. The great thing about PROMs, unlike most of the other clinical measures used traditionally (re-admissions, infection rates, adverse incidents etc.), is that they usually measure health gain which is what actually happens to the majority of patients who interface with the healthcare system. We know this from our own experience; BUPA Hospitals (now Spire Healthcare) have been using PROMs for years and the high response rates now achieved show just how much value patients put on being asked about their outcome. Our work (using Outcome Technologies Ltd) and that of others is described in Professor Nick Black's recent paper (2). Routine measurement of patient reported outcome is quite easy to do and cost efficient. We are convinced that it can encourage continuous quality improvement and that the data when made available (properly risk adjusted) can help GPs and their patients make more informed choices about providers. We were delighted to see PROMs promoted in the NHS Operating Framework (3) and also supported by the Royal College of Surgeons of England. We believe they will in fact reduce the noise in the system, make it more transparent and help give patients the real say in their healthcare which they deserve. A J Vallance-Owen MBA FRCSEd Group Medical Director BUPA BUPA House 15-19 Bloomsbury Way LONDON WC1A 2BA Tel: +44 (0) 20 7656 2036 Fax: +44 (0) 20 7656 2708 vallanca@bupa.com www.bupa.com (1) Hawkes N. How do we get the measure of patient care? BMJ 2008;336:249.(2 February.) (2) Browne J, Black N, et al Report to the Department of Health. Patient reported outcome measures in elective surgery. www.lsthm.ac.uk/hsru/research/PROMs-Report-12-Dec-07.pdf (3) Department of Health. The NHS in England:The operating framework for 2008/9. London:Department of Health Competing interests: Outcome Technologies Ltd is a BUPA subsidiary
Outcomes and systematic improvement 9 February 2008
stephen black, management consultant london sw1w 9sr Send response to journal: Re: Outcomes and systematic improvement	I was struck by an observation Nigel Hawkes made that "Few operations are common enough for mortality statistics to be meaningful." which he seems to asume is probably true for many other outcome measures. There seems to be a strong inbuilt resistance in medicine to any attempt to judge performance (of providers as a whole or individual consultants) using measures of mortality or outcome. A range of theoretical and practical arguments have been arrayed against publication or use of outcome metrics from the potential to create perverse incentives to the basic lack of statistical significance of current data. But the opposition to outcome metrics seems to have completely distracted the debate from a much more significant issue: how do we improve medical performance? Those of us who don't start with the assumptions that "doctor knows best" and "current performance is as good as it can be" sometimes wonder just how the profession knows whether its treatments work or not. Nigel Hawkes may, statistically, be right about the lack of significance of outcome or mortality comparisons between hospitals or doctors, but he misses a much more significant observation: the reason it's hard to compare is because performance is shockingly variable. That variability is a strong sign of processes (treatments, interventions, care pathways...) that are out of control. No factory manager with this amount of variability in his quality or volume of output would rest until he had a strong grip on the causes of variability and started to eliminate them. Of course medicine isn't like a factory. But that is no excuse for delivering inconsistent care to patients. Process improvement techniques (which consist of carefully observing variation in what and how things are done and analysing how this affects the results of what is done) work in medicine. For an example of how to knock 50% off mortality see the story of American Military Medics' application of process improvement in Atul Gawande's book "Better: a Surgeon's Notes on Performance" (Profile Books, 2007). Even great doctors can improve, if they want to. Most doctors are not great and so should have more scope to improve. The biggest barrier to improvement is the belief that clinical autonomy is sacrosanct and can in no way be informed by the unworthy process improvement tools of manufactiuring industry. There are two ways this whole debate can go. The profession could start to improve itself (which might involve voluntary use of tools such as Patient Reported Outcome Measures(PROMS) which dare to ask patients whether they think medical intervention actually improved their condition). Or the medical profession's opposition to such measures could continue, in which case they will be imposed by government. I'm sure it would be better for all if the profession swallowed some humble pie and admitted that medical practice could be systematically improved. The prospect of yet more kakistocratic intervention by the centre doesn't fill me full of hope. Competing interests: None declared