Quality Improvements in the Saudi Private Healthcare sector: Patient Reported Measures (PRMs)

What is a PRM?

These are surveys completed by patients that objectively reflect how they feel about the clinical impact (PROMs, the O is for ‘outcomes’) of an intervention and their satisfaction (PREMs, the E is for ‘experience’) with the care they have received.

Why is this being implemented?

According to the Saudi Council of Health Insurance (CHI):

“No Value-Based Healthcare without Patient Reported Measures” and “Patient reported measures drive improvement of health outcomes”. Source: here.

But let’s forget the CHI for a minute. And think of the stakeholders involved in healthcare:

• The healthcare delivery team,
• Payers,
• Regulators,
• Service design managers,
• Others, and
• The patient

We all say that the patient is or should be at the heart of healthcare delivery. But all the stakeholders above have different priorities. For example, imagine a hypertensive patient who has been prescribed propranolol to lower blood pressure. The drug is effective in lowering the patient’s blood pressure but causes nightmares, an established side effect of this drug. For all the stakeholders listed above, the patient is receiving care that achieves the primary aim of treatment. But the patient does not feel any benefit of taking the drug, in fact their quality of life has only declined because they sleep so badly now.

Having PRMs would enable a systematic method of collecting patient feedback on elements of care that matter to patients, not to everyone else, but specifically to the individual patient. Ideally, different stakeholder interests should align but real life is messy. For example, is it always appropriate to give very old patients drugs that lower cholesterol, even if they are taking a laundry list of medicines? What about a pregnant woman in labour who insists on having a Caesarean even though vaginal delivery is safer? What about patients who undergo surgery to reduce weight, but the surgical experience was fraught with difficulties and complications, coupled with weight loss, was it worth doing?

One use case for PRMs is to answer the questions above on a patient, by patient basis.

What does the literature say?

PRMs are not new. There are several national (Netherlands, USA and Wales) programs that aimed to establish them in various conditions, but the systematic application across the private sector is something unique to Saudi (I think!).

Broadly speaking, the literature seems to be in agreement that PRMs are a good thing and valuable for improving healthcare quality. However, these are some implementation difficulties:

• IT infrastructure and this new function: I won’t get in to the technicalities but I suspect that nphies will be able to manage this new task. Of course, there will be teething pains but interoperability between systems is the main requirement and that is already catered for by nphies.
• Only effective if a nationwide policy is adopted: Literally, the approach taken in Saudi.
• The validity of PRMs may not apply for policy decision making: PRMs were originally developed for evaluating therapy efficacy during clinical trials so “their potential use and validity in these settings [clinical practice and policy evaluation] might be limited”. However, international organizations like the OECD and ICHOM recommend their systemic use in routine care.
• Time is a bottle neck: This is another task for the healthcare team to complete and their time is a finite resource. This is a serious limitation which has prevented the sustained implementation of a PRMs program for obstetrics in the Netherlands.
• Manual processes for survey collection are never sustainable: It is (almost) 2025, automation is mandatory.

Sources

CHI document: Hage D. CHI. The importance of Patient-Centered Outcome Measures. Available here. Accessed Dec 2024.

Difficulties cited in: Migchels C, Zerrouk A, Crunelle CL, Matthys F, Gremeaux L, Fernandez K, Antoine J, van den Brink W, Vanderplasschen W. Patient Reported Outcome and Experience Measures (PROMs and PREMs) in substance use disorder treatment services: A scoping review. Drug Alcohol Depend. 2023 Dec 1;253:111017. doi: 10.1016/j.drugalcdep.2023.111017. Epub 2023 Nov 3. PMID: 37995391.

Wales PRMs study: Withers K, Palmer R, Lewis S, Carolan-Rees G. First steps in PROMs and PREMs collection in Wales as part of the prudent and value-based healthcare agenda. Qual Life Res. 2021 Nov;30(11):3157-3170. doi: 10.1007/s11136-020-02711-2. Epub 2020 Nov 29. PMID: 33249539; PMCID: PMC7700742.

PRMs program for obstetrics in the Netherlands: Depla AL, Pluut B, Lamain-de Ruiter M, Kersten AW, Evers IM, Franx A, Bekker MN. PROMs and PREMs in routine perinatal care: mixed methods evaluation of their implementation into integrated obstetric care networks. J Patient Rep Outcomes. 2023 Mar 9;7(1):26. doi: 10.1186/s41687-023-00568-w. PMID: 36894797; PMCID: PMC9998006.