Optimization of Healthcare Operations: the e-Health Added Value.
European Collaboration for Healthcare Optimization An ... · European Collaboration for Healthcare...
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ECHO – European Collaboration for Healthcare Optimization An international project on healthcare performance
Enrique Bernal-Delgado on behalf of the ECHO consortium
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-1.5
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ENG POR SLV SPNStd Rate/10,000 15.58 17.84 14.12 11.05 EQ5-95 1.88 1.84 2.29 2.34 SCV 0.10 0.18 0.06 0.10
Hysterectomy in benign conditions
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ENGLAND Standard Rate (SR) ENGLAND SCV
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PORTUGAL Standard Rate (SR) PORTUGAL SCV
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SLOVENIA Standard Rate (SR) SLOVENIA SCV
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SPAIN Standard Rate (SR) SPAIN SCV
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Challenges in international comparison
• Adapting the rationale to contextual elements – Supply in non existing o strongly intervened markets – Preference-sensitive in a context of limited choice – Maps boundaries do not necessarily mean the same
• Methods – Apples and Pears à the need of a common language – Variation also depends on the basal rates – Size is so different in Europe –
• Geographic representation have to be changed • Some additional statistics are required.
• Explaining variations: the need of profiling institutions
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Challenges in international comparison
• Adapting the rationale to contextual elements – Supply in non existing o strongly intervened markets – Preference-sensitive in a context of limited choice – Maps boundaries do not mean necessarily the same
• Methods – Apples and Pears à the need of a common language – Variation also depends on the basal rates – Size is so different in Europe –
• Geographic representation have to be changed • Some additional statistics are required.
• Explaining variations: the need of profiling institutions
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0 0.05 0.1 0.15 0.2 0.25 0.3 0.35 0.4 0.45
Stan
dardized
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CSV
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Challenges in international comparison
• Adapting the rationale to contextual elements – Supply in non existing o strongly intervened markets – Preference-sensitive in a context of limited choice – Maps boundaries do not mean necessarily the same
• Methods – Apples and Pears à the need of a common language – Variation also depends on the basal rates – Size is so different in Europe –
• Geographic representation have to be changed • Some additional statistics are required.
• Explaining variations: the need of profiling institutions
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A heterogeneous reality (lowest level areas )
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Challenges in international comparison
• Adapting the rationale to contextual elements – Supply in non existing o strongly intervened markets – Preference-sensitive in a context of limited choice – Maps boundaries do not mean necessarily the same
• Methods – Apples and Pears à the need of a – Variation also depends on the basal rates – Size is so different in Europe –
• Geographic representation have to be changed • Some additional statistics are required.
• Explaining variations: the need of profiling institutions
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Former 99 units New 28 areas
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Challenges in international comparison
• Adapting the rationale to contextual elements – Supply in non existing o strongly intervened markets – Preference-sensitive in a context of limited choice – Maps boundaries do not mean necessarily the same
• Methods – Apples and Pears à the need of a common language – Variation also depends on the basal rates – Size is so different in Europe –
• Geographic representation have to be changed • Some additional statistics are required.
• Explaining variations: the need of profiling institutions
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Proper statistics in measuring systematic variation
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Coefficient of Variation
Coefficient of Variation vs. EB statistic
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England: knee replacement and prostatectomy
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SUR EBPGrr EBLNrr EBMarshall
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SUR EBPGrr EBLNrr EBMarshall
16.3 12.2 4.5 9.9
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Estimating SUR: adding spatial correlation SUR vs BYM –areas98
SFV: 0.55
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Challenges in international comparison
• Adapting the rationale to contextual elements – Supply in non existing o strongly intervened markets – Preference-sensitive in a context of limited choice – Maps boundaries do not mean necessarily the same
• Methods – Apples and Pears à the need of a common language – Variation also depends on the basal rates – Size is so different in Europe –
• Geographic representation have to be changed • Some additional statistics are required.
• Explaining variations: the need of profiling institutions
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www.echo-health.eu Institutional features in service provision
Joumard I, André C, Nicq C (2010) Healthcare systems efficiency and Institutions. OECD Economics. WP#769 OECD Publishing
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more at www.echo-health.eu
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Country differences in CSV – weighted by average rate
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-5-4.5-4
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ENG POR SLV SPN
Std Rate/10,000 21.45 7.92 22.17 12.05
EQ5-95 3.12 18.81 3.57 22.52
SCV 0.61 0.89 0.60 0.53
C-section low risk deliveries 2009 (women 15-55 yo)
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www.echo-health.eu Radical Mastectomy
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ENGLAND Standard Rate (SR) ENGLAND SCV
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PORTUGAL Standard Rate (SR) PORTUGAL SCV
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SLOVENIA Standard Rate (SR) SLOVENIA SCV
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SPAIN Standard Rate (SR) SPAIN SCV
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Radical mastectomy in breast cancer 2009
Std Rate/10,000 88.08 13.25 28.99 12.66
EQ5-95 4.29 1.63 4.40 1.82
SCV 1.52 0.60 0.29 0.60
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England Portugal
Slovenia Spain
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www.echo-health.eu C-section LR over time
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PORTUGAL Standard Rate (SR) PORTUGAL SCV
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SLOVENIA Standard Rate (SR) SLOVENIA SCV
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SPAIN Standard Rate (SR) SPAIN SCV
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The concept
• ECHO has set about the task of bringing together patient-level data from Austria, Denmark, England, Portugal, Slovenia and Spain, making them comparable.
• ECHO is expanding the usual approach in healthcare performance
international comparison, by adding the variation framework
• Performance dimensions: utilization, equitable access to effective care, quality, and efficiency, in terms of opportunity costs, and provider-level efficiency.
• Healthcare areas or hospital providers will be flagged as good- or poor performers – not a diagnostic tool but a screening tool
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Geographic-perspective Hospital-perspective 1. Effective care (hip fracture,
colectomy in colorectal cancer, breast surgery in breast cancer, etc)
2. Uncertain benefit/harm balance in “non-average” patients (CABG, knee replacement, etc.)
3. Doubtful/ lower value care and opportunity costs (tonsillectomy, spinal fusion, prostatectomy, etc.)
1. In-hospital case fatality rates for a condition (admissions with principal diagnosis of acute myocardial infarction, ischemic stroke);
2. In-hospital case fatality rates after a procedure (in hospital mortality after CABG, PCI, non-ruptured abdominal aortic aneurysm, hip replacement)
3. Patient safety event rates (Trauma after vaginal delivery with and without instrumentation, Catheter-related infection, Pulmonary Thromboembolism or Deep venous thrombosis, Postoperative sepsis)
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Some messages from ECHO … … with potential impact in policy making
Utilization of effective procedures Equity Value - quality Value - efficiency
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Utilization of effective procedures
• At population level, the burden of ischemic disease does barely explain variation in revascularization;
• Might be a symptom of under or overuse
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Q1 Q2 Q3 Q4 Q5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19
Q1 Q2 Q3 Q4 Q5
PCI, CABG and burden of ischemic disease
PCI CABG
Pop
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Burden of ischemic disease Burden of ischemic disease
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www.echo-health.eu Flagging areas beyond the expected PCI
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Equity
• Revascularization is performed differently across income quintiles, not always coherent with need.
• Differences beyond need might represent inequities in access.
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PCI CABG
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Standardise
d Ra
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Standardise
d Ra
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AMI
Spain
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Quality
Case-fatality rates varies dramatically across high-volume hospitals, irrespective of the differences in patient case-mix Hospital f lagged as poor (or good) performers are likely to behave consistently overtime.
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Patient at risk
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SloveniaSpain
CI-90CI-95
CABG fatality rates in high volume hospitals
B1
C1 D1
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A1 A3
A2
C2
C3 D3
D2
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Efficiency (value)
Variation in low-value procedures is huge, within and across countries.
Areas with high number of low-value procedures are facing high opportunity costs
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-5-4.5-4
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ENG POR SLV SPN
Std Rate/10,000 21.45 7.92 22.17 12.05
EQ5-95 3.12 18.81 3.57 22.52
C-section in low-risk deliveries
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Efficiency (value)
Hospitals are getting different outcomes regardless patients’ differences. On the other hand, hospitals are managing differently those resources devoted to treat similar patients. Hospital with poor outcomes and higher use of resources are likely providing lower-value care.
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SHO
RTER
LOS
LESS MORTALITY
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DENMARK
Calculated for female patient, aged 18-55, no comorbidities
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SLOVENJA
Calculated for female patient, aged 18-55, no comorbidities
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SPAIN
Calculated for female patient, aged 18-55, no comorbidities
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PORTUGAL
Calculated for female patient, aged 18-55, no comorbidities
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ENGLAND
Calculated for female patient, aged 18-55, no comorbidities