Outcome measurement – International experience, key success factors and a possible approach for SA

Neil Soderlund

A sporting analogy

1896 Olympics, Athens, Greece, 100 meter dash

A sporting analogy

2012 Olympics, London, UK

A sporting analogy

Outcomes measurement and reporting saves money

-4000

-3000

-2000

-1000

0

1000

2000

3000

4000

5000

6000

2009 2010 2011 2012 2013

Cumulative Benefits & costs attributed to Victorian Prostate Cancer Registry

Change in PSM Rates Change in PRIAS compliance

Build costs Cumulative Central costs

Data collection costs Cumulative net run rate

Source : Australian Commission for Safety and Quality in Healthcare. November 2016. Economic evaluation of clinical quality registries

$000 Cumulative

Total benefits$5.2m

Total costs$2.7m

Over Period 2009-2013Benefit to cost ratio = 2:1

RegistryCurrent

BCR

Extrapolated

National BCR

Victorian PCR 2:1 5:1

VSTR (Trauma) 6:1 12:1

ANZICS (ICU) 4:1 4:1

ANZDATA

(Renal Failure)7:1 7:1

AOANJRR

(Arthroplasty)5:1 5:1

Sweden and Netherlands show national gains from outcomes measurement

2

4

6

8

4 5 6 7 8 9 10 11

Health Outcome: 30-day inhospital mortality rate (AMI) (%)

2007

2000

Proxy for cost: Average length of stay (AMI)

2000

2000

2007

2006

2009

2007

Select OECD country AMI mortality rates over time

Netherlands

Sweden

United States

Germany

This all sounds obvious - so what is new?

• Ambition for making change happen: Moving outcomes measurement and registries beyond academic research into:

• Clinician change management

• Health system decision-making

• Long term health care efficiency improvement

• Scale: Coalescence of measurement initiatives across hospitals, cities and provinces, and now countries

• Technology: Digitisation of health information makes it cheaper and quicker to collect store and analyse

Busting myths about outcomes measurement

• Data generate change by informing public choices of doctor and hospital

• Outcomes data collection needs to operate under the aegis of national governments

• Clinicians can create and operate registries on their own

• You need sophisticated hospital IT systems to collect outcomes data

• Outcomes based reimbursement (Pay for Performance) is a dangerous and unnecessary step

• Outcomes can be measured and improved across all diseases at once

• Patient experience measures (PREMS) are a valuable and necessary step towards measuring outcomes

Myth

• Benefits are largely from feedback to clinicians and hospitals prompting them to change practices

• Virtually all successful efforts globally have been run by consortia of clinicians and patient groups

• While their participation in collecting and using data is essential, most successful initiatives have 'professionalized' operations

• Many successful initiatives ran for years on pen & paper Routine claims data form a very useful "spine" for adding on patient specific outcomes information

• In most health systems, hospitals currently earn more when things go wrong. This needs to change to reinforce good behaviours

• Successful initiatives start focused – yielding accurate and precise insights for one disease at a time

• There is very little correlation between experience and outcomes. Optimising experience can lead to reduced healthcare value

Reality

Simply collecting and publishing data is not enough

0

10

6

% mortality within 30 days after AMI

8

2010

Year

4

2

200820062004200220001998

3rd Quartile

Median

1st Quartile

12

Source: Swedish RIKS-HIA

Sweden AMI 30 day Mortality

3rd Quartile CAGR: -8%Median CAGR: -9%1st Quartile CAGR: -11%

2

0

Year

20102009

12

Deaths within 30 days of emergencyadmission to hospital: (AMI)

10

8

6

4

20082007200620052004200320022001

3rd Quartile CAGR: -5%Median CAGR: -5%1st Quartile CAGR: -4%

UK AMI 30 day Mortality

Reimbursement models need to change to embed quality improvements

Surgical patients with 1 or more complication generated greater contribution margin than patients without a complication

• Privately insured patients with 1+ complication

generated 330% greater contribution margin

($39K more per patient)

• Medicare patients with 1+ complication

generated 190% greater contribution margin

($2K more per patient)

1. Journal of the American Medical Association is a major peer-reviewed academic journal that is widely ranked within Top 3 medical journals, with The Lancet and New England Journal of Medicine

Typical US hospitals lose revenue and contribution margin

when they improve surgical quality!

In Michigan, the dominant payer has adopted a very hands off approach to quality

Trust and clinical leadership foundation of CQIs

▪ Overall CQI program is stewarded by payers and

providers together

▪ Evaluation focuses on state-wide quality and cost

impact

▪ Individual CQIs led by clinicians

▪ Most leads are academics but not all

▪ Clinical champions join from all participating

institutions

▪ CQIs free to set their own quality and cost

improvement agenda based on needs

• Coordinating centres provide the infrastructure and data

management for individual CQIs

• Payers contribute funding and longitudinal data

• The contracts with CQIs require improving value for

money over time – but not release of data

• Contracts with providers require full participation in

registries within 2 years

Dutch Institute for Clinical Audit (DICA) supports over 17 registries

• 2009 – Dutch Surgical Colorectal Audit (DSCA) established

• 2011 – Improvement in Colorectal cancer surgery outcomes evident, and DSCA becomes blueprint for other registries, with DICA created to support their operation

• 2012 – DICA supports breast cancer, Gastric and esophageal cancer, and Lung Surgery

• 2014 – Supports 17 registries, and 60 staff

1. Colorectal cancer

2. Breast cancer

3. Gastric and esophageal cancer

4. Aneurysm

5. Melanoma

6. Lung cancer

7. Pancreatic cancer

8. Pediatric Surgery

9. Bariatrics

10. Carotid surgery

11. Liver cancer (DHBA)

12. Gynaecological Oncology

13. Spinal surgery

14. Stroke

15. Parkinson's disease

16. Thoracic Surgery

17. Breast implants

DICA emerged from successful Colorectal cancer surgery registry … to support 18 registries today

Government

Payers/

Insurers

Academics and

3rd parties

Provider

groups/(incl

prof. orgs)

Individual

clinicians

Government actions are best focused at the beginning and end of registry evolution

FundingDatabase Platform creation

Defining required metrics

Provider Feedback

AnalysisCompara-

tivereporting

Guidelines & Policy

Reimburse-ments

Recruit-ment & Record

population

Consent legislation & ethics

approvals

National enablers Clinician EngagementValue Identification321

Data Use4

ICHOM has developed minimum Standard Sets to simplify measurement globally

2016 releases▪ Dementia▪ Frail elderly care▪ Heart Failure

▪ Chronic Kidney Disease▪ Inflammatory bowel disease▪ Hypertension▪ Facial palsy

▪ Pregnancy and childbirth▪ Breast cancer

▪ Type 1 Diabetes▪ HIV▪ Oral Health▪ Congenital hand malformations

▪ Craniofacial Microsomia▪ Colon cancer

▪ Overactive bladder & incontinence▪ General Adult Health▪ General Paediatric Health

Planned for 2017

Example of ICHOM health outcome data set for low back pain

Demographic Factors Age

Sex

Education level

Baseline Functional Status

Work status

Duration of sick leave

Disability (ODI)

Back and leg pain (NPRS)

Health-related QoL (PROMIS-10)

Prior treatment Need for contiguous analgesic use

Prior interventions

Baseline Clinical Factors Smoking Status

Comorbidities (SCQ)

Duration of back/leg pain

Body mass index

Diagnostic classification (glassman)

Morbidity state (ASA)1

Indication for surgery (Swespine)1

Treatment Variables2 Type of procedural intervention

Level of procedural intervention

Acute complications of Treatment1

Operative mortality

Nerve root injury

Wrong site procedure

Vascular injury

Dural tear

Other complications

30-day mortality

Need for rehospitalisation

Deep wound infection

Pulmonary embolus

Disease Recurrence1 Need for reoperation

Patient-Reported Health Status

Work status

Need for continuous analgesic use

Disability (ODI)

Back and leg pain (NPRS)

Health-related QoL (PROMIS-10)

Where might we get to eventually?

400 pages of comparisons between

every health service region in

Sweden

170 different conditions covered

Population health, behaviour, clinical

and patient reported outcomes

covered

Produced every 2 years

Data drill down available that allows

comparison of individual hospitals,

patient subsets and managing

clinicians

Bowel cancer