Patient reported outcomes introducion and overview
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Patient-Reported Outcomes: Introducion and Overview. Pythia Nieuwkerk, PhD Department of Medical Psychology Academic Medical Center, Amsterdam. Outline presentation. What are patient–reported outcomes (PROs)? How do PROs complement traditional clinical outcome measures?

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Patient reported outcomes introducion and overview

Patient-Reported Outcomes:Introducion and Overview

Pythia Nieuwkerk, PhD

Department of Medical Psychology

Academic Medical Center, Amsterdam


Outline presentation

Outline presentation

  • What are patient–reported outcomes (PROs)?

    • How do PROs complement traditional clinical outcome measures?

  • How can we measure PROs?

    • Type of measures

  • How are PROs used in clinical research?

    • Examples


What is a patient reported outcome

What is a Patient-Reported Outcome?

  • A PRO is any report of the status of a patient’s health condition that comes directly from the patient

    • without interpretation of the patient’s response by a clinician or anyone else.1

  • The term PRO addresses the source of the report, and not the concept or content of the report.2

1. FDA, 2009, 2. Patrick et al. 2007


What concepts do pro instruments measure

What concepts do PRO instruments measure?

  • Concepts measured by PROs differ in their degree of complexity:

    • From simple

      • eg, presence of a symptom

    • To more complex concepts

      • eg, ability to carry out activities of daily living

    • To even more complex concepts

      • eg, health-related quality of life


What is health related quality of life

What is health-related quality of life?

Health:

A state of complete physical, social,

and mental well-being, not merely

the absence of disease or infirmity

WHO, 1948


Who based consensus of quality of life

WHO-based consensus of “Quality of Life”

Multi-dimensional

Physical

Functioning

Social

Functioning

Mental

Functioning

Affected by disease/treatment

Subjective


Subjectivity and objectivity

Subjectivity and Objectivity

HRQoL is not subjective in the usual sense of the term

It can be measured accurately in an individual, and in a group

It is “subjective” in that it:

derives from the individual patient.

represents what is important to the individual patient.


How do pros complement traditional clinical outcome measures

How do PROs complement traditional clinical outcome measures?


Wilson cleary model of health outcomes

WILSON-CLEARY MODEL OF HEALTH OUTCOMES

Characteristics of Individual

Biological and Physiological Variables

Symptoms

Functional Status

General Health Perceptions

Quality of Life

Characteristics of Environment

Wilson & Cleary JAMA (1995)


Motivations for pro qol research

Motivations for PRO/QOL research

  • Changing the concept of treatment model

    • Switching from biomedical model to patient-centered model

    • Living longer and comfortable, especially for cancer patients, elderly population, etc.


Number of papers on quality of life published each year pubmed

Number of papers on “quality of life” published each year (PubMed)


Motivations for pro qol research1

Motivations for PRO/QOL research

  • Some treatment effects are known only to the patient

    • eg, pain intensity and fatigue

  • Capturing different aspects of health outcomes extended beyond biomedical / clinical indicators

    • eg, symptoms and functioning, comprehensive assessment of impact of disease and treatment


When are pros most relevant

When are PROs most relevant

  • When no survival gain is expected (e.g. palliative treatments)

  • When no significant differences in survival are expected

  • Where survival is gained at the expense of major toxicity and treatment burden


How can we measure pros

How can we measure PROs?


Patient reported outcomes introducion and overview

www.proqolid.org


Type of health outcomes instrument

Type of health outcomes instrument

HEALTH PROFILE

Health states and impact on

daily functioning and well-being

Generic

measure

Disease-specific

measure

SF-36

WHOQOL-100

MOS-HIV

EORTC QLQ C30


Generic instrument sf 36

Generic instrument- SF-36

Health profile: 8 domains

  • Physical functioning (10 items)

  • Role limitations/physical (4 items)

  • Role limitations/emotional (3 items)

  • Social functioning (2 items)

  • Emotional well-being (5 items)

  • Energy/fatigue (4 items)

  • Pain (2 items)

  • General health perceptions (5 items)


Does your health now limit you in walking more than a mile

Does your health now limit you in walking more than a mile?

(If so, how much?)

No, not limited at all

Yes, limited a little

Yes, limited a lot


How much of the time during the past 4 weeks have you been happy

How much of the time during the past 4 weeks have you been happy?

None of the time

A little of the time

Some of the time

Most of the time

All of the time


Patient reported outcomes introducion and overview

Physical Health

Physical function

Role function-physical

Pain

General Health

SF-36 Physical Health


Sf 36 mental health

Mental Health

Emotional Well-Being

Role function-emotional

Energy

Social function

SF-36 Mental Health


Generic instrument whoqol 100

Generic instrument – WHOQOL-100

Health profile: 6 domains

  • Physical health (12 items)

  • Psychological health (20 items)

  • Level of independence (16 items)

  • Social relationship (12 items)

  • Environment (32 items)

  • Spirituality, religiousness & personal beliefs (4 items)


Same domain different content

Same domain, different content

Social domain:

Social functioning versus social well being

  • Social functioning: limitations due to disease/treatment (SF36, EORTC-QLQ-C30)

    • More likely to respond to medical treatment

  • Social wellbeing: closeness with family and friends (FACT-G)

    • More likely to respond to psychosocial interventions


Generic versus disease specific pros

Generic versus Disease specific PROs

Generic PRO

  • Intended for use across broad chronic disease populations

  • Allow comparisons across these groups

  • Disadvantage: may not permit adequate disease-specific focus

    • Disease caused symptoms

    • Treated related symptoms


Relative disease burden generic pros allow for cross disease comparison of disease impact

Type-2 Diabetes

Depression

Congestive Heart Failure

Average Adult

Average Well Adult

Chronic Lung Disease

Asthma

30

40

50

34

36

55

SF-36’s Physical Component Summary (PCS)

RELATIVE DISEASE BURDEN: Generic PROs allow for cross-disease comparison of disease impact

Ware & Kosinski, 2001


Generic versus disease specific pros1

Generic versus Disease specific PROs

Disease specific PRO

  • Focus on the impact of a particular condition on the patient’s functioning and experience

  • Responsive to disease-related changes

  • Cannot be used across populations with other diseases


Wilson cleary model of health outcomes1

WILSON-CLEARY MODEL OF HEALTH OUTCOMES

Characteristics of Individual

Biological and Physiological Variables

Symptoms

Functional Status

General Health Perceptions

Quality of Life

Characteristics of Environment

Wilson & Cleary JAMA (1995)


Combining pro measures

Combining PRO measures

Disease-specific and Generic PROs are complementary:

  • When both are included in a study, it is possible to capture:

    • Disease-specific concepts

    • Generic concepts, compare to norm: (relative) burden of illness / benefit of treatment


Measuring pros hrql

Measuring PROs/HRQL

  • No standard scale, need to specify what we want to measure

    • What is your research question?

    • Who are your patients?

    • What do you anticipate what will happen?

  • Appropriateness of the measure to the question or issue of concern.

  • Correspondence between the content of the measure and goals of the study.


How are pros used in clinical research

How are PROs used in clinical research?


Study goals

Study Goals

  • Characterizing the burden of disease and treatment

  • Characterizing treatment-specific outcomes for use in shared decision making

  • Predicting patient outcomes

  • Evaluating the effectiveness of interventions


Patient reported outcomes introducion and overview

The EORTC QLQ-C30

Physical functioning

Role functioning

Functional scales

Cognitive functioning

Emotional functioning

Social functioning


Patient reported outcomes introducion and overview

The EORTC QLQ-C30

Physical functioning

Role functioning

Functional scales

Cognitive functioning

Emotional functioning

Social functioning

Fatigue

Nausea andVomiting

Pain

Symptoms

Dyspnea

Insomnia

Appetiteloss

Constipation

Diarrhea

Financial difficulties


Patient reported outcomes introducion and overview

The EORTC QLQ-C30

Physical functioning

Role functioning

Functional scales

Cognitive functioning

Emotional functioning

Social functioning

Fatigue

Nausea and Vomiting

Pain

Symptoms

Dyspnea

Insomnia

Appetite loss

Constipation

Diarrhea

Financial difficulties

Global health

status scale

Global health status

Overall QoL


Patient reported outcomes introducion and overview

The EORTC QLQ-C30

Standardized score

Physical functioning

Role functioning

Range 0 - 100

Functional scales

Cognitive functioning

Emotional functioning

Social functioning

Fatigue

Nausea and Vomiting

Pain

Symptoms

Dyspnea

Insomnia

Appetite loss

Constipation

Diarrhea

Financial difficulties

Global health

status scale

Global health status

Overall QoL


Patient reported outcomes introducion and overview

The EORTC QLQ-C30

Standardized score

Physical functioning

Role functioning

Range 0 - 100

A higher score

indicates a higher

level of functioning

Functional scales

Cognitive functioning

Emotional functioning

Social functioning

Fatigue

Nausea and Vomiting

Pain

A higher score

indicates a higher

level of symptoms

Symptoms

Dyspnea

Insomnia

Appetite loss

Constipation

Diarrhea

Financial difficulties

A higher score

indicates a

higher

level of QoL

Global health

status scale

Global health status

Overall QoL


Patient reported outcomes introducion and overview

Profiles

100 = Good QOL

0 = Poor QOL

71

96

Physical functioning

63

93

Role functioning

83

94

Functional scales

Cognitive functioning

62

Emotional functioning

77

Social functioning

71

91

Global health status

64

71

O= No symptoms

100 = Many symptoms

14

38

Fatigue

2

10

Nausea and Vomiting

14

Pain

31

6

Dyspnea

28

Symptoms scales

Insomnia

34

14

4

20

Appetite loss

2

11

Constipation

4

Diarrhea

7

Healthy women (50-59 years) (Schwarz et al. Eur J Cancer, 2001)

Metastatic breast cancer baseline (Bottomley et al 2003)

Metastatic breast cancer at cycle 2 of doxorubicin/cyclophosphamide


Study goals1

Study Goals

  • Characterizing the burden of disease and treatment

  • Characterizing treatment-specific outcomes for use in shared decision making

  • Predicting patient outcomes

  • Evaluating the effectiveness of interventions


Changes in hrql from start to 18 months of antiretroviral therapy for hiv infection

Changes in HRQL from start to 18 months of antiretroviral therapy for HIV-infection

Cognitive function

Physical function

Health distress

Social function

General health

Role function

Mental health

Overall QoL

Vitality

Pain


Study goals2

Study Goals

  • Ccharacterizing the burden of disease and treatment

  • Characterizing treatment-specific outcomes for use in shared decision making

  • Predicting patient outcomes

  • Evaluating the effectiveness of interventions


Predicting survival in hiv infection

Predicting survival in HIV infection

  • 560 HIV infected patients starting HAART.

  • Completed the MOS HIV between 1998-2000.

  • All cause mortality established in March 2008.

  • 66 patients (11.8%) died during follow-up.

  • Physical Health Summary score (MOS HIV) significant predictor of survival, independent of other (clinical) parameters.

de Boer-van der Kolk: CID 2010


Physical health summary score mos hiv

Physical Health summary score (MOS-HIV)

de Boer-van der Kolk: CID 2010


Predicting outcomes

Predicting Outcomes

  • Baseline HRQL has been shown to be an independent predictor for overall survival

    • Overview of 36 trials that assessed baseline PROs and mortality (Gotay, JCO 26:1355, 2009)

  • PRO is a complex biomarker that can be highly predictive

    • Help signal those patients who are in need of medical attention

    • Can be an early warning useful for clinical decision making

    • Can be used as a stratification variable in research


Study goals3

Study Goals

  • Characterizing the burden of disease and treatment

  • Characterizing treatment-specific outcomes for use in shared decision making

  • Predicting patient outcomes

  • Evaluating the effectiveness of interventions


Vital study prevention of coronary heart disease

VITAL study Prevention of Coronary Heart Disease

Intervention to enhance adherence to statin therapy and life-style recommendations


R isk c ounseling

Risk counseling

  • Protocolized (nurse practitioner).

  • Identification individual risk factors.

  • Calculation Absolute Cardiovascular Risk (Framingham risk score)

  • Graphical presentation personal risk

     Risk Passport.

  • Life style counseling (stop smoking, weight reduction)


R isk passport

Risk Passport


Patient reported outcomes introducion and overview

Inclusion Criteria

> 18 yrs

Indication for statin therapy- primary prevention- secondary prevention

Subjects

(n = 201, from outpatient clinics)


Study endpoints

Study endpoints

  • Primary endpoints

    • LDL cholesterol levels

    • Adherence to statins

    • Anxiety

  • Secondary endpoint

    • Quality of Life (QOL)


Patient reported outcomes introducion and overview

PROs

  • Adherence to statins:

    Please estimate the percentage of prescribed lipid lowering medication that you have taken during the last month

    • 9 point scale (<30% to 100%)

  • Anxiety (HADS)

  • Quality of Life (SF-12)


Patient reported outcomes introducion and overview

Routine care

Questionnaire

Weight, RR

LDL cholesterol

Questionnaire

Weight, RR

LDL cholesterol

Questionnaire

Weight, RR

LDL cholesterol

Questionnaire

Weight, RR

LLDL cholesterol

03918(month)

Questionnaire

Weight, RR

LDL cholesterol

risk counseling

risk calculation

Questionnaire

Weight, RR

LDL cholesterol

risk counseling

risk calculation

Questionnaire

Weight, RR

LDL cholesterol

risk counseling

risk calculation

Questionnaire

Weight, RR

LLDL cholesterol

risk counseling

risk calculation

Extended care


Result ldl cholesterol

Extended care

Routine care

Result: LDL cholesterol

Secondary prevention

Primary prevention


Results anxiety and adherence

Extended care

Routine care

Results: Anxiety and adherence


Results hrql

Extended care

Routine care

Results: HRQL


Summary

Summary

  • PROs can be used to assess the impact of disease and treatment from the patient perspective.

  • Various PRO measures are available from which you can choose depending on your study goals.

  • PROs can complement traditional clinical outcome measures when applied in clinical research.


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