Can a composite indicator summarize hospital care quality?

14 Jan

Josep Maria ArgimonJosep Maria Argimon, Director AQuAS

The “Central de Resultados” (Results Central) mission is to measure, evaluate and distribute the results achieved by different public health care system centres. The aim is to facilitate better decision-making with regards to the quality of the health care service provided to citizens. The reports feature results from patient satisfaction to the efficiency in the use of resources. The ultimate goal is to foster an internal review of the elements that influence the results, especially in organizations that repeatedly show indicators which are worse than others. To encourage this task, the institutions are nominally identified: not as a punishment but as an incentive to improvement.

Last November the “Agència de Qualitat i Avaluació Sanitària de Catalunya” (AQuAS) released the results for 2013 for hospital and primary care, social care mental health and addiction treatment. The “Central de Resultados” report for hospital care consists of 99 indicators and presents some new features over previous editions. One of the most important is the inclusion of a synthetic indicator of adequacy, in which avoidable hospitalizations for heart failure, diabetes or chronic obstructive pulmonary disease weigh heavily, but where other indicators are also given their due significance. Given its complexity, this new indicator of adequacy was the subject of a detailed explanation during the public presentation of the results and, at the same time, is one of the most featured in the media. In this case, among other centres, the Hospital de la Santa Creu and Sant Pau are examples of the hospitals which should improve this indicator, and thus the media picked on the aforementioned report.

Summarizing the quality of health care provided by a hospital based on a single indicator is very difficult. Now, since the media highlighted the results of this particular indicator, the responsibility for it shall not rest with the messenger but with the issuer, in this case, me. Surely, the communication was poor because if we continue to analyze the report to its full extent we can observe other relevant indicators. For example, the indicator of mortality at 30 days after discharge for selected causes – another novelty of the presented report – shows how a hospital that let’s say has poor results in the synthetic indicator of adequacy, can at the same time have excellent results in the indicator of mortality, such is the case of the Hospital de la Santa Creu and Sant Pau. This is an indicator that is made public in very few public health systems, and some agencies, among which American and British, have promoted its use. Similarly, in other indicators, such as satisfaction with the emergency services, the same Hospital de la Santa Creu and Sant Pau obtained the top positions, as has been well reflected in the media.

We have to keep in mind that the same indicators, despite many efforts, do present some shortcomings, starting with the absence of important outcomes such as the functional ability of patients and their quality of life related to health. But there’s something else that also escapes and that only very specific studies can analyze. I’m talking about the culture of the organization that is largely configured for all the staff that belongs to it; what values they share and the feelings they have towards it. Those organizations that – despite facing serious external problems and discouraging  states of mind, present in any collective, –  believe in the values that inspire their work;  have as their objectives continuous quality improvement; where everyone is involved regardless of age or position (from the manager to the warden), have a better communication and coordination between professional and technical groups;  know without shame or guilt how to examine the causes of their mistakes or failures;  participate and get involved in improvement proposals; all these difficult to collect and analyze features at the organizational and staff level are at the moment of truth, the ones making a difference.

The Results Central is not a perfect instrument, but provides data for evaluating public policies, helping to insure that the established objectives are met and that an efficient allocation of public resources is made. Furthermore, transparency in policy making and accountability in the management of public resources is a requirement of citizenship, a democratic and ethical obligation of governments, and a key element in the development of a country.

The Department of Health, through AQuAS, does not avoid discussing sensitive issues, such as the reports from the Central de Resultados presented last November or the report on the effects of the economic crisis on the population’s health. The press has always addressed these issues with appropriate importance, seriousness and rigor. Therefore, it’s a shame that due to an issuer’s (not a messenger’s) miscommunication they can misinterpret the results and end up detracting from the outstanding work performed by professionals in extremely difficult conditions, so that the thousands of citizens served, cared for and cured on a daily basis know they are in the best possible hands.

Methodological innovations in Central de Resultats 2014

1 Dec

OLYMPUS DIGITAL CAMERAJosep Maria Argimon, AQuAS Director

Central de Resultats’ reports consolidate some data and some analysis based on: patient-centered care, appropriateness, patient safety, efficiency, economic sustainability and training. This is thus a repository of knowledge tuned each year by counting on experience and innovation.

Regarding the issue of the Central de Resultats for 2014 (based on data 2013) the following methodological developments are the most remarkable:

  1. Primary care report’s innovations. The most highlighted technical novelty for primary care is that for the first time the data from Central de Resultats feed from minimum basic data set (EHR), which opens a new range of possibilities for future processes. Another novelty is the incorporation in this report of the segmentation based on Clinical Risk Group differentiated for the population assigned to each of the 369 primary care teams of the public network.
  2. Monograph report of diabetes. Since 1993, when the program of continuous improvement of the care quality was initiated from the indicators of “Group study of diabetes in primary care” (GEDAPS), there has been a gradual improvement in diabetes care, both of process indicators and of outcome. For this reason, this year it has been convenient to entrust a monograph report to “Diabetes Epidemiological Research Group from Primary Care – IDIAP J. Gol”, in order to confirm that the strategy of enhancing competency among teams of primary care in this clinical process is the most appropriate.
  3. Hospital activity’s synthetic appropriateness index. The appropriate use of hospitals, the most expensive resource of all health care systems is key to the overall sustainability for the health sector. After a couple years of internal testing, now a monograph on this new synthetic indicator is presented which consists of 10 specific indicators that reflect: a) ambulatory care sensitive conditions for 5 chronic diseases, b) appropriate use of hospital emergencies, c) excessive consumption of hospital stays for femur fractures and ictus, and d) surgical overacting (caesarean section rate). The results of the synthetic adequacy index are shown both for hospitals as well as for each territory.
  4. Mortality at 30 days from hospital admission. The traditional way to measure hospital mortality is the one that emerges from the hospital minimum basic data set (MBDS), when the circumstance of hospital admission records the “death”. Clearly, this is a very limited source for the analysis of mortality, since after hospitalization for certain severe diseases, people can die in a geriatric home, at home or in another hospital admission that differs from the first. Motivated by this limitation of traditional indicators of mortality, several agencies, most notably Medicare in the US and Dr. Foster Intelligence in the UK, have promoted the intersection of databases to detect mortality at 30 days from the hospital admission, regardless of the place of death. Following this same hint, this Central de Resultats edition, after crossing, from MSIQ – CatSalut, the MBDS with the central registry of insured, offers the novelty of hospital mortality at 30 days of admission duly adjusted for age, sex and morbidity, for a group of selected diseases, but also, specifically, for 5 conditons.
  5. New specific indicators for 3 clinical processes: myocardial infarction code, stroke code and hip fractures. From the heart attack and stroke codes sources and from the arthroplasty (RACat) data, this year the Central de Resultats incorporates circuits’ efficacy data (time to effective clinical intervention: angioplasty, fibrinolysis or surgery).
  6. Information technology and communication trends map. The hospitals report includes, this year, the TICSalut map of trends in information technology and communication. The indicator consisting of eHealth Benchmarking IC-EU27, which puts Catalan hospitals on a high level of development of these technologies and, specifically, the electronic health record, is notable.
  7. Novelties in the report for chronic care area. This second report for the chronic care area is more dynamic and functional than the first, in the sense that not only performance data and sustainability of suppliers are provided, but also the lines of analysis that make sense for groups of well defined patients has been open: the end of life period, dementia and neurological diseases with disabilities. The report also contains a section for older people with chronic conditions, that provides a significant methodological innovation due to the fact that it combines the hospital and chronic care stays for patients with hip fracture and stroke.

Acknowledgments. The Central de Resultats’ exercise of transparency emanates from a political decision of the Department of Health, but to make this possible, the innovative cleverness of professionals working in the different information systems from the Department of Health, CAtSalut, AQuas Observatori de Salut and specific directory plans, has been essential. To all of them, I want to express my appreciation and my plea not to lose the drive which is indispensable to consolidating the experience, while continuing to refine the proposed analysis.