ARS Toscana Firenze, 7 maggio 2015

Transcription

1 ARS Toscana Firenze, 7 maggio 2015 Bernard Burnand Using routinely collected data to measure quality and safety in healthcare: international and Swiss developments IUMSP Institut universitaire de médecine sociale et préventive

2 Presentation Plan Organisation of the Swiss healthcare system Quality of care in Switzerland Context Quality of care and safety indicators Research and development in quality and safety Switzerland International

3 Svizzera Confederation 26 cantons 8,2 millions inhabitants G 64%, F 24%, I 8% Life expectancy F : 84.8 H : healthcare systems Mandatory insurance Healthcare 11,4% GNP / individual / year

4 Swiss health care system OECD / WHO 2011 Performing well, but costly - in general and for a sizable number of persons/families Needs to face increasing burden of chronic diseases in an aging population: increasing volume of care, few integrated care - networks Improve healthcare information (quality of care) Improve assessment of quality of care and of healthcare technologies Shortage of healthcare professionals Too many hospitals / hospital beds Lack of coordination in prevention and health promotion Insufficient governance and coordination in healthcare system

5 Swiss health care system Quality of care law In the framework of the mandatory healthcare insurance, all paid care must be effective, appropriate and economical (Art. 32 LAMal)

6 Swiss health care system Quality of care law Warranting quality (Art. 58 LAMal) the Federal Council (FC) can manage to organise scientific and systematic assessments to monitor and warrant appropriateness and quality of care The following information should be communicated:. f. quality of care indicators

7 Swiss health care system Quality of care history Numerous attempts, more or less collaborative, to manage and monitor quality of care - medical associations & organisations, insurance, hospitals, cantons, Patientensicherheit (2003) Association Nationale pour la Qualité - anq (CIQ + AIQ) (2009)

8 anq National association for the development of quality in hospitals Members Cantons, insurances Healthcare providers - Association of hospitals Aim: Assess and inform about quality Develop quality Improve quality

9 anq Quality of care indicators - acute somatic hospital care Patient satisfaction since 2009 Post-operative infections since 2010 Potentially avoidable surgical reintervention Potentially avoidable rehospitalisation Prevalence of falls and decubitus ulceration since 2010 since 2010 since 2011 Implant registry since 2012

10 anq Quality of care indicators - rehabilitation hospital care Patient satisfaction since 2013

11 anq - Quality of care indicators - psychiatric hospital care Assessment of quality in diagnosis and therapeutic process (in German only) Use of quality assessment in practice (in German) Comparative evaluation of quality measures between hospitals Comparative report for inpatient psychiatric care in children and teens

12 Ufficio federale della sanità pubblica UFSP Indicatori di qualità degli osp

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15 Current developments in Switzerland IMPROVING QUALITY OF CARE

16 The Federal Council wants to improve healthcare quality and efficiency Bern, Launch of national programmes to monitor quality and safety Systematic check of the efficacy and efficiency of healthcare interventions (healthcare technology assessment) National Centre : quality and healthcare technology assessment Better coordination of public and private initiatives New law on quality Consultation process and modifications

17 Project of new federal law Main tasks proposed Launch national programmes targeting quality of care and safety issues Develop quality indicators, especially for the ambulatory sector Systematic Health Technology Assessment Evaluate appropriateness of care

18 Project of new federal law Consultation process 2014 Hearings Law project revision 2015 Current status, Spring 2015 «Network» instead of an «Institute» Report for Federal Council Message for parliament (end of 2015)

19 RESEARCH & DEVELOPMENT ON QUALITY OF CARE A - SVIZZERA I

20 Quality of care R & D initiatives - Svizzera Variation of care Patient satisfaction and experiences Appropriateness of care, over- and underuse of care Adaptation and implementation of clinical practice guidelines Potentially avoidable hospitalisation Retrospective survey of hospital adverse events: 1 survey in 1 hospital

21 Quality of care R & D initiatives - Svizzera Quality and safety indicators based on routinely collected data / administrative data Potentially avoidable re-hospitalisation Potentially avoidable surgical re-intervention Swiss Anaesthesia Databank (ADS) Patient Safety Indicators (AHRQ)

22 Quality and safety indicators To use selected Patient Safety Indicators (PSI - AHRQ) and their algorithm refinement for assessing the impact of DRG implementation in Switzerland (SNF - Sinergia) 1. To explore and document the frequency, variations and potential biases of PSI, using Swiss hospital data collected by the Federal Office of Statistics 2. To evaluate trends in PSI in Swiss hospitals Impact of 2012 changes in DRG implementation 3. To assess the accuracy of a subset of PSI

23 Methods : Data sources ICD-10 hospital discharge diagnoses codes - WHO ICD-10 since German modification since 2011 (ICD-10-GM) Medical and Surgical Procedures - CHOP (ICD-9-CM) Diseases Related Groups - SWISS-DRG, mandatory since 2012

24 Decubitus ulcer Bloodstream infection related to vascular catheter Postoperative physiological and metabolic disorders Post-operative Deep Vein Thrombosis and Pulmonary Embolism (VTE - Venous Thrombo-Embolism) Post-operative sepsis Methods : PSI Selection Obstetric Trauma during vaginal delivery with/without instrument

25 VTE PSI in patients undergoing hip arthroplasty Benchmark Baseline risk of Postoperative VTE in patients undergoing hip arthroplasty, under appropriate VTE prophylaxis - Systematic review (meta-analysis) - Januel JM. JAMA 2012 Estimation and comparison of adjusted occurrence rates of VTE PSI in patients undergoing hip arthroplasty Comparison between Switzerland and France and with a benchmark

26 Proportion of VTE (%) Comparisons stratified on length of stay Switzerland 76.4% 74.1% France LMWH = 0.58% (0.35% %) 0 < 8 days [8-18[ 18 days Expected values (from Models) using Swiss and French Nationwide Data, stratified by Length of Stay and by Year

27 RESEARCH & DEVELOPMENT ON QUALITY OF CARE B - INTERNATIONAL

28 Quality of care International R & D initiatives Quality and safety indicators based on routinely collected data / administrative data IMECCHI Consortium Contribution to new classification ICD-11 WHO Topic Advisory Group (TAG) on Quality and safety Conceptual and practical developments

29 ICD-11 for quality and safety Overview of the WHO Quality and Safety Topic Advisory Group (WHO-TAG Q&S) i. Cataloguing existing ICD-9 and ICD-10 quality and safety indicators ii. iii. Reviewing ICD morbidity coding rules for main condition, diagnosis timing, numbers of diagnosis fields and diagnosis clustering Substantial restructuring of the health-care related injury concepts coded in the ICD-10 chapters 19/20 Ghali WA et al. Int J Qual Health Care 2013;25:621-5

30 ICD-11 for quality and safety Overview of WHO-TAG Q&S iv. Mapping of ICD-11 quality and safety concepts to the information model of the WHO's International Classification for Patient Safety and the AHRQ Common Formats v. Review of vertical chapter content in all chapters of the ICD-11 beta version vi. Downstream field testing of ICD-11 prior to its official release Ghali WA et al. Int J Qual Health Care 2013;25:621-5

31 WHO-TAG Q&S International variation in the definition of main condition in ICD-coded health data main condition not defined in a consistent manner internationally reason for admission resource use a few countries have recently transitioned from one of these approaches to the other definition of main condition matters (DRG s, risk adjustment) Quan H et al. Int J Qual Health Care 2014;26:511-5

32 WHO-TAG Q&S International variation in the definition of main condition in ICD-coded health data WHO-TAG Q&S proposes a method of harmonizing the international definition to improve health data comparisons across countries and hospitals consistently inter-observer reliability of alternative harmonization approaches should be evaluated Quan H et al. Int J Qual Health Care 2014;26:511-5

33 WHO-TAG Q&S How many diagnosis fields are needed to capture safety events in administrative data? Findings and recommendations What is the optimal number of secondary diagnosis fields for meta-analyses? PSI information from administrative hospital data of OECD countries in 2009 and 2011 (+ CA &FL in USA) Comparison of PSI rates in 3 countries with expanded # of secondary diagnosis fields vs 6 countries with limited # secondary diagnosis fields Drösler SE et al. Int J Qual Health Care 2014;26:16-25

34 WHO ICD-11 TAG Q&S - number of secondary diagnoses fields Increased # of secondary diagnosis fields not associated with overall increase in PSI rates High proportions of PSI-related diagnoses appeared beyond the 6 th secondary diagnosis field Distribution of 3 PSI in CA and FL 89-90% of central venous catheter infections and 97-99% of retained foreign bodies and accidental punctures or lacerations captured within 15 secondary diagnosis fields Drösler SE et al. Int J Qual Health Care 2014;26:16-25

35 WHO ICD-11 TAG Q&S Capturing diagnosis-timing in ICD coded hospital data narrative literature review scan of national experiences focusing on countries currently using timing flags series of meetings formal recommendations regarding diagnosistiming reporting Sundararajan V et al. Int J Qual Health Care. Accepted

36 WHO ICD-11 TAG Q&S diagnosis-timing in ICD hospital data Recommendations yes/no classification of arising after admission permitted designations of unknown or clinically undetermined to facilitate coding while providing flexibility when there is coding uncertainty clear coding standards and guidelines ongoing coder education ensure reliability of diagnosis-timing flag Sundararajan V et al. Int J Qual Health Care. Accepted

37 WHO ICD-11 TAG Q&S New concept to capture harm & injuries Develop a new conceptual approach to capturing healthcare-related harms and injuries in ICD-coded data Four categories of source of event a) Medications and substances taken for therapeutic purposes b) Procedures c) Devices d) Other aspects of care

38 WHO ICD-11 TAG Q&S New concept to capture harm & injuries Proposed multiple coding approach Each source of harm coded with a combination of codes Use of new code clustering in ICD-11 cause of harm mode or mechanism of harm actual injury or harm that resulted from the event

39 Cause of harm - Substances - Procedures - Devices - Other Aspects of Care Mode or Mechanism of harm e.g. overdose/underdose for substances e.g. accidental perforation for procedures e.g. dislodgement/malfunction for devices e.g. mismatched blood used in transfusion for other aspects of care A cluster of codes to denote the "Injury or Harm" that resulted from the event

40 WHO ICD-11 TAG Q&S New concept to capture harm & injuries Proposed information model provides a more flexible, yet still simple and non-duplicative, approach to recording quality and safety events in ICD-coded data Linked to broader proposal from the Injury TAG for revision/enhancement for the external cause and injury chapters

41 WHO ICD-11 TAG Q&S New concept to capture harm & injuries Introduction of a diagnosis-timing capacity (i.e., distinguishing present on admission vs. arising during hospital stay) Revised set of codes in ICD-11 s Chapter 24 capturing Factors influencing health status and contact with health services

42 RESEARCH & DEVELOPMENT ON QUALITY OF CARE C - SVIZZERA II

43 Over- et underuse of upper gastro-intestinal endoscopy - possible public health impact Current use Overuse Underuse Gastroenterology, 1997; 112: Gastrointest Endosc, 1997; 45:13-19

44 Over- and underuse of colonoscopy Patients screened for enrolment n = 8760 With lower gastrointestinal symptoms n = 651 Referral for colonoscopy n = 78 No referral for colonoscopy n = 573 Procedure refused n = 12 Indication appropriate n = 66 Indication Inappropriate n = 11 Overuse Indication necessary n = 185 Underuse Gastrointest Endosc 2000;52:593 9.

45 Appropriateness of 5-ASA (5-aminosalicylates) treatment in patients with Crohn s disease Swiss Inflammatory Bowel Diseases Cohort Study Absence of evidence of effectiveness of 5- ASA in Crohn s disease patients 835 / 1420 patients (59%) treated with 5-ASA Perception of effectiveness of treatment by 46% of patients Subjective and may correspond to natural history of disease Schoepfer A et al. 2014

46 ADS Adverse events occurrence during surgical intervention according to ASA group ( ) N = % 40% 30% Other incidents Incidents specifically linked with anaesthesia Cardio-circulatory incidents Anaesthesia with incidents 20% 10% 0% P1 P2 P3 P4 P5 ASA class

47 Hypertension and adverse events occuring during surgery, multicenter registry in Switzerland (ADS) Beyer K. Anaesthesia 2009;64: Elective surgery, 24 hospitals, interventions, hypertensive patients (22%) 1 cardiovascular events (6%) Cardiovascular event in presence of hypertension - OR= 1.38 (95% CI ) Important variation by hospital - OR adjusted 0.41 up to 2.25 Persistence of increased anaesthesia risk in hypertensive individual Due to coding or practice variations? 47

48 Hypertension and adverse events occuring during surgery, multicenter registry in Switzerland (ADS) (Beyer K 2009) Journée régionale du jeudi 15 octobre 2009 à Bourg-en- Bresse 48

49 Svizzera Comments Quality of care and patient safety not enough considered and developed currently Lack of data and indicators Lack of research and specific support to health services research New federal concept ongoing

50 Comments International WHO - TAG Important contributions to ICD-11 to enhance capture of quality and safety issues Scientific approach to ICD revision by WHO-TAG Q&S New concept to capture harm & injuries related to healthcare in ICD-11

51 Grazie per l'attenzione