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Methodological and statistical Methodological and statistical consulting to policy makers in consulting to policy makers in
health care financehealth care finance
Jules EllisJules Ellis
Radboud University NijmegenRadboud University Nijmegen
My styleMy style ListenListen
E.g. Stork managerE.g. Stork manager Determine who advise and who decidesDetermine who advise and who decides
Compare advice to studentsCompare advice to students Ask the substantive contextAsk the substantive context
People often start in abstract statistical termsPeople often start in abstract statistical terms (E.g. is X correlated to Y -> gender is related to aggression)(E.g. is X correlated to Y -> gender is related to aggression)
Change the questionChange the question To something that can be done (toolbox)To something that can be done (toolbox) To something that you think will be interesting for the client (E.g. To something that you think will be interesting for the client (E.g.
is group program correlated with well-being -> does a group is group program correlated with well-being -> does a group program influence well-being)program influence well-being)
Offer alternativesOffer alternatives E.g. PCA versus ADFE.g. PCA versus ADF
Be pragmaticBe pragmatic Time, moneyTime, money Prior concepts Prior concepts (e.g. clusters vs. factors groups vs scores)(e.g. clusters vs. factors groups vs scores) PrejudicePrejudice
There must be 7 clustersThere must be 7 clusters Dichotomization is good / badDichotomization is good / bad Nobody/ everybody is doing thisNobody/ everybody is doing this
Client Client mustmust understand it within available time understand it within available time Explain at right level (common sense)Explain at right level (common sense) WriteWrite
After consult (compare physician)After consult (compare physician) After analysisAfter analysis
EducateEducate
Organizational hierarchyOrganizational hierarchyDepartment
(VWS)
Accountancy (PWC)
Ass. Nursing Homes(Arcares)
Ass. Health Insurance Companies(ZN)
VLP CCC Prismant
I I
Tasks in the hierarchyTasks in the hierarchy
Cost Model
Costs; Efficiency; Best Practice Organizations
Care for clients Pay for care
Client Need Caring Time Quality of Care
Old cost modelOld cost model
Depends on Depends on locationlocation of client of clientNursing homes: € Nursing homes: € xx per client / day per client / dayAssisted Living Facilities (Caring homes): € Assisted Living Facilities (Caring homes): € yy
per client / dayper client / dayHome Health Care (Extramural care) € Home Health Care (Extramural care) € zz per per
client / dayclient / dayAdult Day Care ServicesAdult Day Care Services
Limitations of old cost modelLimitations of old cost model
Ignores client differences in needIgnores client differences in need Ignores overlap in client populationsIgnores overlap in client populationsEmphasis on somatic careEmphasis on somatic careSupply driven, not demand drivenSupply driven, not demand driven
Time lineTime line
Pilot: 10 homes (2000 clients)Pilot: 10 homes (2000 clients)Test: 100 homes, automatingTest: 100 homes, automatingBenchmark 1: 1000 homesBenchmark 1: 1000 homesBenchmark 2: 1000 homesBenchmark 2: 1000 homes
Assessment of client needsAssessment of client needs
Two central caring employees observe Two central caring employees observe client during two weeksclient during two weeks
Both fill in one questionnaire of 24 items Both fill in one questionnaire of 24 items about clientabout client
Two sum scores are computed:Two sum scores are computed:Sumlic: Somatic need for careSumlic: Somatic need for careSumpsy: Psycho-social problemsSumpsy: Psycho-social problems
Items for client needsItems for client needs1 Is in dressing / undressing 1 Is in dressing / undressing Not / A little / Not / A little /
Partially / Very Partially / Very much / Totally much / Totally dependentdependent
2 Is in movements2 Is in movements3 Is in eating or drinking3 Is in eating or drinking4 Is in the bathroom4 Is in the bathroom……
10 Is incontinent in urine or faeces10 Is incontinent in urine or faeces Never / Rarely / Never / Rarely / Sometimes / Often Sometimes / Often / Always/ Always
11 Is irritated 11 Is irritated 12 Has difficulties to remember12 Has difficulties to remember13 Shows restless behavior13 Shows restless behavior14 Is lonely14 Is lonely……24 Is aware about what happens around him/ 24 Is aware about what happens around him/ herher
Assessment of caring timeAssessment of caring time
Pilot: Observers make one round every 20 Pilot: Observers make one round every 20 minutes (-> chaos)minutes (-> chaos)
Later: Employees receive a handheld computerLater: Employees receive a handheld computer Beeps every 20 minutes, at random moment, Beeps every 20 minutes, at random moment,
whole week 16 hour / daywhole week 16 hour / day Employee records own behavior in one of 32 Employee records own behavior in one of 32
actions, + clientactions, + client Total caring time in various categories per client Total caring time in various categories per client
per day is estimated from thisper day is estimated from this
Items for caring timeItems for caring time Direct Client RelatedDirect Client Related
Individual Individual Client RelatedClient Related General daily life support (eat, General daily life support (eat,
wash, …)wash, …) Assistence in preparing food Assistence in preparing food
and/ or drinkand/ or drink Individual treatmentIndividual treatment Communication with familyCommunication with family Housekeeping for individualHousekeeping for individual Preserved actionsPreserved actions
CollectiveCollective Client Related Client Related Collective medicationCollective medication Collective treatmentCollective treatment House keeping for groupHouse keeping for group
Indirect Client RelatedIndirect Client Related Individual Client RelatedIndividual Client Related
Coordination for individualCoordination for individual
Collective Client RelatedCollective Client Related Coordination for individualCoordination for individual
Organization RelatedOrganization Related WaitingWaiting BreakBreak EducationEducation TravellingTravelling
Employee relatedEmployee related MissingMissing Personal timePersonal time
Time categoriesTime categories
Categories:Categories: Client relatedClient related
DirectDirect IndividualIndividual CollectiveCollective
IndirectIndirect IndividualIndividual CollectiveCollective
Organization relatedOrganization related Employee relatedEmployee related
Functions:Functions: Housekeeping Housekeeping
servicesservices Personal carePersonal care NursingNursing Supportive assistanceSupportive assistance Activating assistanceActivating assistance TreatmentTreatment
Other dataOther data
ClientsClients24 services24 servicesOn which days presentOn which days presentMembership of collective time groupsMembership of collective time groups
EmployeesEmployees35 35 professionsprofessionscontractscontractsOn which days presentOn which days present
Analysis schemeAnalysis scheme
Best Practice
Efficiency Quality
Output Costs
Client needs Caring time
Question 1:Question 1:Cluster the clients on basis of Cluster the clients on basis of
needsneeds7 or 87 or 8 clusters clustersHomogenous in Homogenous in timetime and and costcost Include psychological needsInclude psychological needsApplicable in Applicable in Nursing HomesNursing Homes and Assisted and Assisted
Living Facilities. Living Facilities. ““Recognizable”Recognizable”
Answer to question 1Answer to question 1
Select items on inter observer agreement, and Select items on inter observer agreement, and variance > 1variance > 1
Factor analysis on the items -> 2 factorsFactor analysis on the items -> 2 factors Define 2 subscales: somatic and psycho-social.Define 2 subscales: somatic and psycho-social. Reliability analysis (internal consistency)Reliability analysis (internal consistency) Divide the scores of each subscale in 4 quartiles Divide the scores of each subscale in 4 quartiles
(Light, Medium, Serious, Very serious)(Light, Medium, Serious, Very serious) Result: 4 x 4 = 16 groupsResult: 4 x 4 = 16 groups
Psychosocial problemsPsychosocial problems
LightLight(0-6)(0-6)
MediumMedium(7-18)(7-18)
SeriousSerious(19-31)(19-31)
Very Very seriousserious(32-56)(32-56)
Somatic Somatic care care needneed
Light (0-3)Light (0-3) II IIII IIIIII IVIV
Medium (4-13)Medium (4-13) VV VIVI VIIVII VIIIVIII
Serious (14-Serious (14-31)31) IXIX XX XIXI XIIXII
Very serious Very serious (32-40)(32-40) XIIIXIII XIVXIV XVXV XVIXVI
ReasonsReasons Cluster Cluster analysis -> only somatic factoranalysis -> only somatic factor We have already 7 groups for nursing homes alone, We have already 7 groups for nursing homes alone,
which were formed as 3 x 3 groups and combining some which were formed as 3 x 3 groups and combining some of these.of these.
The partition on the somatic axis should contain at least The partition on the somatic axis should contain at least these 3 groups (these 3 groups (to satisfy the nursing homesto satisfy the nursing homes) + another ) + another one to accomodate the Assisted Living Facilities. one to accomodate the Assisted Living Facilities.
Similarly for the psychosocial axis.Similarly for the psychosocial axis. So we need 4 x 4 groups to begin with -> 16 So we need 4 x 4 groups to begin with -> 16 typestypes Without time & cost data we cannot know how to Without time & cost data we cannot know how to
combine these groups and respect homogeity.combine these groups and respect homogeity. But perhaps we can combine some groups later.But perhaps we can combine some groups later.
First evaluationFirst evaluation
Initially accepted with reluctanceInitially accepted with reluctanceAs of 2006: There are still 16 client typesAs of 2006: There are still 16 client types It took years to accept thatIt took years to accept that
Question 2: Compute reference Question 2: Compute reference timestimes
Compute mean individual client time (ICT) Compute mean individual client time (ICT) for each client typefor each client type
The mean can be used in the cost model, The mean can be used in the cost model, e.g. to compute the total ICT that the e.g. to compute the total ICT that the home should deliver.home should deliver.
How reliable is this?How reliable is this?
First answer to Question 2First answer to Question 2
Using client types is an unnecessary loss of Using client types is an unnecessary loss of informationinformation
Conduct a multiple regression analysis, with Conduct a multiple regression analysis, with dependent variable = ICT, independent variables dependent variable = ICT, independent variables = somatic need, psychosocial need= somatic need, psychosocial need
Compute the predicted ICT score for each clientCompute the predicted ICT score for each client Take the mean of the predicted scores for each Take the mean of the predicted scores for each
home.home. This was not accepted: This was not accepted: Too difficult (3 Too difficult (3
parameters?!)parameters?!); there had to be groups.; there had to be groups.
Second answer to Question 2Second answer to Question 2
Use answer 1 but change the Use answer 1 but change the presentationpresentation a littlea little
Compute the predicted ICT score for each Compute the predicted ICT score for each clientclient
Compute the mean of the predicted scores Compute the mean of the predicted scores for each client type in each homefor each client type in each home
Compute the mean in each homeCompute the mean in each home
exampleexample
All homesAll homes
(y’ = 2x)(y’ = 2x)
This homeThis home
TypeType SomaticSomatic ICTICT ICT’ICT’ SomaticSomatic ICTICT ICT’ICT’
II 55 88 1010 66 88 1212
IIII 1010 2222 2020 99 2222 1818
IIIIII 1515 3030 3030 1616 3030 3232
IVIV 2020 4242 4040 2222 4242 4444
VV 2525 4848 5050 2727 4848 5454
MeanMean 1515 3030 3030 1616 3030 3232
First evaluationFirst evaluation Sceptical first, embraced the idea laterSceptical first, embraced the idea later Reliability of estimatesReliability of estimates More consistent outputMore consistent output
Employees in nursing homes typically argue that their Employees in nursing homes typically argue that their client type X is a little more serious than in other client type X is a little more serious than in other homeshomes
Reply: Indeed, and therefore we didn’t use the mean Reply: Indeed, and therefore we didn’t use the mean time of other homes but corrected it.time of other homes but corrected it.
Negative beta-weightNegative beta-weight of psychosocial problems of psychosocial problems Assistance needed in further researchAssistance needed in further research Assistance needed automationAssistance needed automation
Question 3: How reliable are the Question 3: How reliable are the time measurements?time measurements?
TIME
AC
TIO
N
11 00 00 11 11 00 00 11 11 11
= 153 min
t = 6 * 20 min
x = 6, n = 10, p = 0.6
Existing answerExisting answer
Why this formula? (the method was Why this formula? (the method was bought)bought)
Sometimes extreme large n needed. Sometimes extreme large n needed. Why?Why?
How many weeks observation are How many weeks observation are needed?needed?
p
nppityunreliabil
/)1(96.1
Answer to question 3Answer to question 3
Make a distinction between absolute unreliability Make a distinction between absolute unreliability (AU) and relative unreliablity (RU)(AU) and relative unreliablity (RU)
Require only that AU is small.Require only that AU is small. For example, if t = 1 For example, if t = 1 0.5 minute, then RU = 0.5 minute, then RU =
50% but AU = 30 sec (who cares)?50% but AU = 30 sec (who cares)? The average time can be reliable even though The average time can be reliable even though
the composing times are unreliable.the composing times are unreliable. Distinguish also other forms of unreliability Distinguish also other forms of unreliability
(sampling of clients, homes, weeks)(sampling of clients, homes, weeks)
(Details)(Details)
Note that t = pT, where T is the total Note that t = pT, where T is the total observation period (fixed).observation period (fixed).
AU(p) = 0.5 length of confidence interval AU(p) = 0.5 length of confidence interval for pfor p
RU(p) = AU/pRU(p) = AU/pAU(t) = AU(p)*TAU(t) = AU(p)*TRU(t) = RU(t)RU(t) = RU(t)
First evaluationFirst evaluation
Relevant people understood and accepted Relevant people understood and accepted the idea immediately (the idea immediately (why?)why?)
One week of observation would be enough One week of observation would be enough if if every week is the sameevery week is the same
Helped to convince nursing homesHelped to convince nursing homes
The aftermathThe aftermath
ElectionsElectionsSector wide model (including Sector wide model (including
handicapped, psychatric patients, etc.)handicapped, psychatric patients, etc.)Association of nursing homes refused to Association of nursing homes refused to
make the data available to othersmake the data available to othersPWC -> KPMG, VLP -> ? , CCC -> PWC -> KPMG, VLP -> ? , CCC -> 16 Client types -> 9 Care Heaviness 16 Client types -> 9 Care Heaviness
ProfilesProfilesReference times -> Indication timesReference times -> Indication times
ConclusionsConclusions
Prior concepts and prejudices are Prior concepts and prejudices are persistentpersistent
Large deviations from this will be rejectedLarge deviations from this will be rejectedSmall deviations are accepted if they are Small deviations are accepted if they are
explained at explained at common sensecommon sense level levelWrite it down with relevant examplesWrite it down with relevant examples ““A good method is a method that makes A good method is a method that makes
my life easier”?my life easier”?
Methodological and statistical Methodological and statistical consulting to policy makers in health consulting to policy makers in health
care financecare finance
Comments byComments by Marieke Timmerman, Marieke Timmerman,
University of Groningen,University of Groningen,
The NetherlandsThe Netherlands