Diabetes is a demanding chronic condition requiring comprehensive, ongoing individualized multi-disciplinary medical, psychosocial, and self-management care and support, and our VBHC-PROMS research and development team at Aalborg University Hospital (VBS-PRO-DIA), North Denmark Region, early on identified a significant and urgent need to advance delivery of person-centered and individualized diabetes care in order to improve outcomes, care for vulnerable populations, and overall reduce the burden of disease. At the same time, we realized, that healthcare systems face major resource constraints, which have worsened since. We executed the participatory development of a scalable, multi-dimensional patient reported outcomes measures (PROMS) with the aim of fully IT-enabled integration into routine diabetes care to facilitate multiple components of person-centered diabetes care and better clinical, quality of life, and cost outcomes.
The PROMS tool is now fully clinically implemented in all 4 hospitals in Region North Denmark, and it is in use across Denmark in several regions and all 98 municipalities have signed up to implement the PROMS diabetes tool, and currently undergoing testing and implementation in general practice.
Feature 1: IT-platform
A unique feature is a our supreme user-friendly platform (questionnarie + IT platform) co-created with PWD and HCPs, supplying a questionnarie, that is answered effortlessly on a smart phone, pad og laptop, and immediately presented as a ”dashboard” on the monitor in the hospital (one-click). This dashboard shows nine value-based domains, to be included in the consultations. If there is a challenge, action plans can be supplied via the ”dashboard”.
Feature 2: Person-centred
The questionaire scores from nine domains are used to alert the HCP about individual needs from the PWD. It identifying areas of need and exerts focused treatment through specific actions plans, thereby enhancing person-centred treatment. Targets and domains include mental well-being, health-anxiety, perceived health, rare overlooked symptoms, access to healthcare etc.
Feature 3. Trending
At this time 4015 PWD have answered their first questionnaire in one of our hospitals and 3118 have answered their second, third and fourth questionnaires. We are now able to detect, if our individual treatment plans are efficacious, judging on the scores within nine domains and clinical indicators in common. A response rate of 71% of all 7133 questionnaires, stable from year to year.
Feature 4: Management
All data are available instantly for clinical use, but are also instantly uploaded to the national Danish data-infrastructure And this data source has now been selected as PROMS-indicators by the national Danish diabetes database. Equally importantly, data uploads to the BI-unit (Business Intelligence) for regional management of the care of 36.000 people with diabetes in our region. This allows access to both psycho-social and clinical data at an individual level and at a population level. And we believe this will enhance not only the quality of health care delivery but also cost-effectiveness, reducing expenditure.
Reference:
Ph.D.-dissertation 2021, Skovlund, SE.
The use of systematic approaches to patient involvement in the development and evaluation of a patient reported outcomes tool for use in routine diabetes care — Aalborg University’s Research Portal (aau.dk)
