Outcome measurement – International experience, key success factors and a possible approach for SA
Neil Soderlund
A sporting analogy
1896 Olympics, Athens, Greece, 100 meter dash
A sporting analogy
2012 Olympics, London, UK
A sporting analogy
Outcomes measurement and reporting saves money
-4000
-3000
-2000
-1000
0
1000
2000
3000
4000
5000
6000
2009 2010 2011 2012 2013
Cumulative Benefits & costs attributed to Victorian Prostate Cancer Registry
Change in PSM Rates Change in PRIAS compliance
Build costs Cumulative Central costs
Data collection costs Cumulative net run rate
Source : Australian Commission for Safety and Quality in Healthcare. November 2016. Economic evaluation of clinical quality registries
$000 Cumulative
Total benefits$5.2m
Total costs$2.7m
Over Period 2009-2013Benefit to cost ratio = 2:1
RegistryCurrent
BCR
Extrapolated
National BCR
Victorian PCR 2:1 5:1
VSTR (Trauma) 6:1 12:1
ANZICS (ICU) 4:1 4:1
ANZDATA
(Renal Failure)7:1 7:1
AOANJRR
(Arthroplasty)5:1 5:1
Sweden and Netherlands show national gains from outcomes measurement
2
4
6
8
4 5 6 7 8 9 10 11
Health Outcome: 30-day inhospital mortality rate (AMI) (%)
2007
2000
Proxy for cost: Average length of stay (AMI)
2000
2000
2007
2006
2009
2007
Select OECD country AMI mortality rates over time
Netherlands
Sweden
United States
Germany
This all sounds obvious - so what is new?
• Ambition for making change happen: Moving outcomes measurement and registries beyond academic research into:
• Clinician change management
• Health system decision-making
• Long term health care efficiency improvement
• Scale: Coalescence of measurement initiatives across hospitals, cities and provinces, and now countries
• Technology: Digitisation of health information makes it cheaper and quicker to collect store and analyse
Busting myths about outcomes measurement
• Data generate change by informing public choices of doctor and hospital
• Outcomes data collection needs to operate under the aegis of national governments
• Clinicians can create and operate registries on their own
• You need sophisticated hospital IT systems to collect outcomes data
• Outcomes based reimbursement (Pay for Performance) is a dangerous and unnecessary step
• Outcomes can be measured and improved across all diseases at once
• Patient experience measures (PREMS) are a valuable and necessary step towards measuring outcomes
Myth
• Benefits are largely from feedback to clinicians and hospitals prompting them to change practices
• Virtually all successful efforts globally have been run by consortia of clinicians and patient groups
• While their participation in collecting and using data is essential, most successful initiatives have 'professionalized' operations
• Many successful initiatives ran for years on pen & paper Routine claims data form a very useful "spine" for adding on patient specific outcomes information
• In most health systems, hospitals currently earn more when things go wrong. This needs to change to reinforce good behaviours
• Successful initiatives start focused – yielding accurate and precise insights for one disease at a time
• There is very little correlation between experience and outcomes. Optimising experience can lead to reduced healthcare value
Reality
Simply collecting and publishing data is not enough
0
10
6
% mortality within 30 days after AMI
8
2010
Year
4
2
200820062004200220001998
3rd Quartile
Median
1st Quartile
12
Source: Swedish RIKS-HIA
Sweden AMI 30 day Mortality
3rd Quartile CAGR: -8%Median CAGR: -9%1st Quartile CAGR: -11%
2
0
Year
20102009
12
Deaths within 30 days of emergencyadmission to hospital: (AMI)
10
8
6
4
20082007200620052004200320022001
3rd Quartile CAGR: -5%Median CAGR: -5%1st Quartile CAGR: -4%
UK AMI 30 day Mortality
Reimbursement models need to change to embed quality improvements
Surgical patients with 1 or more complication generated greater contribution margin than patients without a complication
• Privately insured patients with 1+ complication
generated 330% greater contribution margin
($39K more per patient)
• Medicare patients with 1+ complication
generated 190% greater contribution margin
($2K more per patient)
1. Journal of the American Medical Association is a major peer-reviewed academic journal that is widely ranked within Top 3 medical journals, with The Lancet and New England Journal of Medicine
Typical US hospitals lose revenue and contribution margin
when they improve surgical quality!
In Michigan, the dominant payer has adopted a very hands off approach to quality
Trust and clinical leadership foundation of CQIs
▪ Overall CQI program is stewarded by payers and
providers together
▪ Evaluation focuses on state-wide quality and cost
impact
▪ Individual CQIs led by clinicians
▪ Most leads are academics but not all
▪ Clinical champions join from all participating
institutions
▪ CQIs free to set their own quality and cost
improvement agenda based on needs
• Coordinating centres provide the infrastructure and data
management for individual CQIs
• Payers contribute funding and longitudinal data
• The contracts with CQIs require improving value for
money over time – but not release of data
• Contracts with providers require full participation in
registries within 2 years
Dutch Institute for Clinical Audit (DICA) supports over 17 registries
• 2009 – Dutch Surgical Colorectal Audit (DSCA) established
• 2011 – Improvement in Colorectal cancer surgery outcomes evident, and DSCA becomes blueprint for other registries, with DICA created to support their operation
• 2012 – DICA supports breast cancer, Gastric and esophageal cancer, and Lung Surgery
• 2014 – Supports 17 registries, and 60 staff
1. Colorectal cancer
2. Breast cancer
3. Gastric and esophageal cancer
4. Aneurysm
5. Melanoma
6. Lung cancer
7. Pancreatic cancer
8. Pediatric Surgery
9. Bariatrics
10. Carotid surgery
11. Liver cancer (DHBA)
12. Gynaecological Oncology
13. Spinal surgery
14. Stroke
15. Parkinson's disease
16. Thoracic Surgery
17. Breast implants
DICA emerged from successful Colorectal cancer surgery registry … to support 18 registries today
Government
Payers/
Insurers
Academics and
3rd parties
Provider
groups/(incl
prof. orgs)
Individual
clinicians
Government actions are best focused at the beginning and end of registry evolution
FundingDatabase Platform creation
Defining required metrics
Provider Feedback
AnalysisCompara-
tivereporting
Guidelines & Policy
Reimburse-ments
Recruit-ment & Record
population
Consent legislation & ethics
approvals
National enablers Clinician EngagementValue Identification321
Data Use4
ICHOM has developed minimum Standard Sets to simplify measurement globally
2016 releases▪ Dementia▪ Frail elderly care▪ Heart Failure
▪ Chronic Kidney Disease▪ Inflammatory bowel disease▪ Hypertension▪ Facial palsy
▪ Pregnancy and childbirth▪ Breast cancer
▪ Type 1 Diabetes▪ HIV▪ Oral Health▪ Congenital hand malformations
▪ Craniofacial Microsomia▪ Colon cancer
▪ Overactive bladder & incontinence▪ General Adult Health▪ General Paediatric Health
Planned for 2017
Example of ICHOM health outcome data set for low back pain
Demographic Factors Age
Sex
Education level
Baseline Functional Status
Work status
Duration of sick leave
Disability (ODI)
Back and leg pain (NPRS)
Health-related QoL (PROMIS-10)
Prior treatment Need for contiguous analgesic use
Prior interventions
Baseline Clinical Factors Smoking Status
Comorbidities (SCQ)
Duration of back/leg pain
Body mass index
Diagnostic classification (glassman)
Morbidity state (ASA)1
Indication for surgery (Swespine)1
Treatment Variables2 Type of procedural intervention
Level of procedural intervention
Acute complications of Treatment1
Operative mortality
Nerve root injury
Wrong site procedure
Vascular injury
Dural tear
Other complications
30-day mortality
Need for rehospitalisation
Deep wound infection
Pulmonary embolus
Disease Recurrence1 Need for reoperation
Patient-Reported Health Status
Work status
Need for continuous analgesic use
Disability (ODI)
Back and leg pain (NPRS)
Health-related QoL (PROMIS-10)
Where might we get to eventually?
400 pages of comparisons between
every health service region in
Sweden
170 different conditions covered
Population health, behaviour, clinical
and patient reported outcomes
covered
Produced every 2 years
Data drill down available that allows
comparison of individual hospitals,
patient subsets and managing
clinicians
Bowel cancer