Attribution of patient reported outcomes to the effects of care providers

Lead Research Organisation: University of Manchester
Department Name: Medical and Human Sciences

Abstract

Until this year, the NHS has not collected information routinely on the health of patients receiving different types of treatments from different health care providers. Consequently, it has been limited in its ability to perform three important functions: (1) spot well-performing and poorly-performing hospitals and general practices; (2) identify where its resources are best spent; and (3) offer useful information to patients when they have a choice of where to go for treatment or of the types of treatment they could receive. The collection of information on health and well-being is being rapidly introduced for all patients across the country. This is likely to show substantial variations between providers and treatments. Variations like these may reflect differences in the effectiveness and quality of different providers. However, there is a substantial amount of variation in levels of health experienced by different individuals that has little or nothing to do with the care they have received. To compare providers and interventions on a ?like-for-like? basis, and be sure we are really seeing variations in effect, we need to examine how the outcomes for the same (or very similar) patients change when they receive treatment from different providers. This is complicated by the fact that patients with long-term health problems often receive treatment from many different providers. We propose to use methods that economists have recently developed to separate out the effects of care providers from the large variation we observe between individual patients. We will apply these to the data that the NHS is currently collecting on patient outcomes and five datasets that have been collected in other recent research projects. By comparing the results across these six datasets, we will be able to make recommendations on the amount of data that needs to be collected from patients and how variations between care providers should be interpreted. Our team involves individuals with expertise in different types of analysis and medicine. These include two senior NHS managers who have responsibility for promoting the effective use of resources. They will ensure we communicate our findings effectively to local and national decision-makers.

Technical Summary

Patient-reported outcomes are being collected routinely for four elective surgical procedures and will be extended to more patient groups and services over the next few years. Publication of their mean levels for care providers and interventions are intended to enable better patient and commissioner choice and increase allocative efficiency. These scores may be misleading if they do not accurately reflect the true effects of providers and interventions. A significant contribution to the variation in these scores will be heterogeneity between individual patients. Only a small proportion of this heterogeneity can be captured by measured patient characteristics. We have assembled a team containing health economic, econometric, statistical, clinical and health services research expertise and senior NHS roles. We propose to apply and develop techniques recently adopted by labour econometricians for estimating and separating effects attributable to employees and employers in matched datasets. These fixed-effect models allow flexibly for correlation between individual and group heterogeneity and we can use them to retrieve estimates of the extent to which there is selection or assortative matching of patients and providers. Thus, we can identify when variations in patient outcomes can be reliably attributed to provider and/or intervention ?effects?. We propose to apply these techniques to six datasets containing patient-reported outcomes. The datasets have widely-varying design properties, including different extents of longitudinal data on individuals, focuses on acute and long-term conditions, and numbers and types of providers. They are therefore a good representation of the types of outcomes datasets that will exist. We will compare the performance of the estimation techniques that can be applied to datasets with these design properties in terms of their theoretical appeal, the empirical distribution of provider effects that they produce and the results of applying placebo tests where pseudo-provider effects are implausible. Through effective presentation and dissemination, and the close involvement of two senior NHS economists, we will ensure that our results feed into national and local processes for analysing and interpreting this valuable new source of information on patient outcomes.
 
Description President's Doctoral Scholar PhD studentship
Amount £50,000 (GBP)
Organisation University of Manchester 
Sector Academic/University
Country United Kingdom
Start 10/2013 
End 09/2016
 
Description The new models of care Vanguard programme in England: national programme evaluation.
Amount £1,289,342 (GBP)
Organisation London School of Hygiene and Tropical Medicine (LSHTM) 
Department Department of Health Services Research and Policy
Sector Academic/University
Country United Kingdom
Start 03/2017 
End 03/2020
 
Description Conference presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach Regional
Primary Audience Health professionals
Results and Impact PROMS and Health Economics. Manchester Conference Centre. 6th December 2012

Engagement with local clinicians and NHS managers on the use of PROMs.
Year(s) Of Engagement Activity 2012
URL http://proms2.org/1st-national-proms-summit-6th-dec-2012/
 
Description Conference presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Paper Presentation
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact International Health Economics Association, Sydney, July 2013.

Large audience from across the world
Year(s) Of Engagement Activity 2013
URL https://www.healtheconomics.org/congress/2013/
 
Description Conference presentation 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Paper Presentation
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact American Society for Health Economics. Minneapolis. June 2012

Engagement of American economists in the use of PROMs.
Year(s) Of Engagement Activity 2012
URL http://ashecon.org/2012-2/
 
Description Kings Fund conference 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach National
Primary Audience Health professionals
Results and Impact Forthcoming
Year(s) Of Engagement Activity 2013
URL http://www.kingsfund.org.uk/events/patient-reported-outcome-measures-proms-research-conference-0
 
Description Seminar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Paper Presentation
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact Seminar presented by Mark Harrison to Clinical Epidemiology, Vancouver.

Facilitated future collaboration.
Year(s) Of Engagement Activity 2013
 
Description Seminar 
Form Of Engagement Activity A talk or presentation
Part Of Official Scheme? No
Type Of Presentation Keynote/Invited Speaker
Geographic Reach International
Primary Audience Other academic audiences (collaborators, peers etc.)
Results and Impact 30 people attended a talk describing the PROMS scheme

Subsequent invites to speak at international conferences. Links between Canadian policy makers and UK policy makers.
Year(s) Of Engagement Activity 2012