monitoring infections, complications and incidents, and registration of failure costs lászló...

Monitoring infections, complications and incidents, and registration of failure costs

László Gulácsi, ENQual country coordinator for Hungary

Associate Professor

Budapest University of Economic Sciences

Unit of Health Economics and Health Technology Assessment HunHTA

Presented at the second ENQual workshop

STAKES, Helsinki 2 April, 2004

Envisioning health care quality in Hungary

Examples:

Surgical Site Infection Surveillance

Pressure Ulcer Surveillance

Breast Cancer Management

HunHTA Unit of Health Economics and Health Technology Assessment

Acknowledgement

Hungarian Hospital Quality Improvement Forumdr. Rózsa Báthy, dr. Édua Berényi, dr. Ágnes Dobos, Zsuzsa

Kovács, dr. Ilona Málovics, dr. Zsuzsa Molnár, Zsuzsa Molnár, dr. Kamilla Nagy, dr. Vera Obbágy, dr. Piroska Orosi, dr. Márta Orosz, dr. Erzsébet Rákay, dr. Zsuzsa

Tatár, dr. József Topár

&

Prof. Donald A. Goldmann, W. Charles Huskins

Harvard Medical School, Children’s Hospital, Boston, USA


What was heard related to accountability during the 7th European Forum so far?

Official Opening: Mr. Malcolm Chisholm, Scottish Minister of Health and Community Services

- competence of the doctors and nurses, staff

- openness

- transparency

- national overview – breast cancer, ovarian cancer …

- quality audit of the local health care services

- investigation of every surgical death

„We are committed to offer public access to clinical information.”


The main issue

The field of health care accountability is caught in a struggle between the demands by many interest groups to immediately release data on quality of care to the public (as well as to government and

purchasing agencies) and the reality that much of the available information on hospital quality is

poorly specified, often misleading and potentially dangerous when misinterpreted.


Background - SSI and PU Surveillance

• No data from active, prospective surveillance of nosocomial infections and PU prevalence

• 0.3 - 0.4 SSI / 100 procedures and 0.2 PU / 100 patients by passive reports to governmental agencies

• Retrospective chart review suggested that SSI and PU were underreported; inconsistency with international

literature


Objectives

• Describe risk-adjusted SSI rates and PU rates for frequently performed procedures in Hungarian hospitals using a standardized surveillance methodology and investigate the economic burden

• Identify areas for further study and intervention


Methods• Surveillance Methodology

– Hospitals in Europe Link for Infection Control through Surveillance (HELICS)

– 1992/97 CDC definition of SSI

• Hospital Selection: convenience sample

• Procedures: frequently performed procedures as defined by HELICS

• Training of Infection Control Professionals

• Data analysis:– adjustment by NNIS risk index

– percentile ranks compared to NNIS hospitals


NNIS SSI Risk IndexScore

Wound Class

Clean or clean-contaminated 0

Contaminated or dirty infected 1

ASA score

1 or 2 03, 4, or 5 1

Duration of Surgery Time T* 0 Time T* 1*T = 75% rounded to the nearest hour


Procedure-specific, Risk-Adjusted SSI Rates and NNIS Percentile Ranks

Risk Index Category

0 1 2

Colon surgery -- 5.9 (50-75%) 10.8 (50-75%)

Hip prosthesis 1.7 (75-90%) 2.0† (50-75%†) --

Mastectomy 0 (25%) 15.9 (>90%) --

Abd. hysterectomy 1.2 (50-75%) 9.1 (>90%) --

Laparotomy -- 6.1 (75-90%) 16.7‡ (>90%‡)


Procedure-specific, Risk-Adjusted SSI Rates and NNIS Percentile Ranks

Risk Index Category

0 1 2

Cholecystectomy 1.1 (75-90%) 1.2 (25-50%) 5.1 (50-75%)

Herniorrhaphy 1.6 (75%) 2.9 (50-75%) --

Appendectomy 0.5 (50-75%) 2.8 (25-50%) 9.3† (>90%†)

Open red. of fracture 0.8 (50-75%) 3.0 (>90%) --


Results - SSI Surveillance

• Feasibility Phase– 3 months; 25 hospitals; >10,000 procedures

– cumulative rate: 7.2 SSI / 100 procedures

• Investigation Phase– 6-9 months; 20 hospitals; 9,625 procedures

– cumulative rate: 3.9 SSI / 100 procedures


Conclusions - SSI Surveillance

• SSI rates 10-20 fold higher than described by passive surveillance methodology to governmental agencies

• Rates for moderate-high risk categories of some procedures are higher than US hospitals


Conclusions - Pressure Ulcer (PU) Surveillance

• The actual PU prevalence is estimated to be 16-27 folds higher than the officially published rate

• The annual direct cost of PU is more than 1% of the total cost of health care

• On average 1-2,5% of the direct cost of PU treatment under the current DRG mechanism


The effectiveness and cost-effectiveness of the breast cancer

management, Hungary• Screening mammography- inappropriate indication, in at least one third of the cases- screening in 136 centres, low sample size- compliance below 30%

• Breast cancer treatment - in 126 hospitals (164 hospitals in total in Hungary)

- < 50 cases in 56% and < 30 cases/year/hospital in 44% of hospitals


Accountability - the concept

• The maximisation of ‘something’ with available resources

• I fully support

• So, no fundamental problem with the destination

• But some concerns with the transport


Thomas Nolan

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will lead to improvement?


Accountability: Questions• Who?

- Physicians vs. Hospital? • To whom?- governmental agencies? (0.3 - 0.4 SSI and 0.2 PU / 100)

- to the public? (3.9 - 7.2 SSI and 3.7 - 5.7 PU / 100)

- fellow colleagues (do they really want to know?)

• Based on what?

• For what care?

• At what level?- what should be achieved and communicated (willingness to learn,

willingness to improve? quality management or/and quality?)


Accountability related issues I.• EBM (Evidence or Economic Based Medicine) - No systematic method to translate scientific evidence into clinical decision

making and clinical practice

- A great deal of ineffective technology is in use

• Lack of consensus on what constitutes quality and cost containment

- Quality of health care was neither defined nor debated, the concepts and goals of cost containment were neither explored nor explained; the relation between the two was never discussed.


Accountability related issues II.

• Reluctance to define and rank goals as well as to evaluate results

• Lack of reliable data on health care

• Limited use of important QI tools such as indicators

• Various elements of QI are imported and implemented without adaptation (QI tools shopping)

• Accountability Mimicry: health care settings might absorb innovations/changes without them changing.


Accountability related issues III.

• Hundreds of clinical conditions could be assessed, and developing measures for each condition would entail an overwhelming amount of work.

• Given the fact, that health care is delivered by a team of providers, it is not clear how outcomes are influenced by physician decision making, patient compliance with medical recommendations, nursing care nor organisation of a diverse set of laboratory, pharmacy, physical therapy and other support services.

• Health care institutions cannot be accountable for the care thy provide if professionals operate with complete autonomy.

• QI committees are not the center of power in most hospitals, and quality continues to appear unmeasurable and unmanageable to many physicians and executives who hold the power.


Recommendations• QI should be identified as an important tool of health

policy and planning. Some form of QI activity has to be in place in order to allow for a particular problem, and the extent of the burden it creates, to be identified

• Although, data collection and processing are often successful the analysis of the data is done at a very basic level. Training is needed.

• Steps have to be taken in order to achieve the support of the health care professionals and professional organisations.

Measure! Measure Measure! QUALITY INDICATORS

monitoring infections, complications and incidents, and registration of failure costs lászló...

Documents

scottish minister of

pu surveillance

usa slide

intervention slide

surveillance helics

quality of care

international literature

pu rates