Evaluation of Outcomes in Health
Orla Hardiman MD,FRCPI, FAAN
Director of Neurology
Beaumont Hospital
Health Services in Ireland
Community Based services (Primary Care)General PractitonersPublic HealthClinical Professionals
Hospital Based services (Secondary Care)Consultants NCHDsNursingClinical Professionals
Combined care programmes
Deloitte &Touche Report
Deloitte & Touche Executive Summary
Current Measures of Efficiency(defined by Deloitte Touche report)
• …”high utilisation of capacity, and increased use of day surgery…”
• .Casemix
Measuring Health Service
• Mortality Data: Rates and causes of death
• % Spending of total GDP
• Health Status /Disease Status of Population
Death Rates in Ireland
Health Status of Population:Measurables
Notifiable Diseases/ Conditions
Primary care based data acquisitionNational databases
Cancer RegistryIntellectual Disability databaseNational Physical and Sensory Database
Quantitation of activity in secondary careActivity levels in acute hospitalsWaiting lists
Health Status Indicators ( Dept of Health Statistics)
• Infectious Diseases• New cancers• Inborn errors of metabolism• Low birth weight• Accidental Injuries• Alcohol consumption• Satisfaction rating
Health Indicators:Satisfaction Rating
(Eurostat)
Health Status of Population:Measurables
Notifiable Diseases/ Conditions
Primary care based data acquisitionNational databases
Cancer RegistryIntellectual Disability databaseNational Physical and Sensory Database
Quantitation of activity in secondary careActivity levels in acute hospitalsWaiting lists
Health Status of Population:Measurables
Notifiable Diseases/ Conditions
Primary care based data acquisitionNational databases
Cancer RegistryIntellectual Disability databaseNational Physical and Sensory Database
Quantitation of activity in secondary careActivity levels in acute hospitalsWaiting lists
Strategies to Adjust Provision of Care based on Available Statistics
• Health Strategy
• Cardiovascular Strategy
• Cancer Strategy
• Waiting List Initiative / National Treatment Purchase Fund (NTPF)
Equity of Access to Hospital Care
Waiting Lists: Caveats
• Partial Data
• Data based on “census-type” measures rather than “throughput-type” data
• Reliability of data not verified (frequent validation of lists required)
• Determinants for inclusion on waiting list, and rate of ascension to the top of the list not subject to audit
Martin defends hospital waiting lists
04 May 2004 22:30
The Minister for Health, Micheál Martin, has said that there has been a significant fall in hospital waiting lists.
Figures released by the National Treatment Purchase Fund this afternoon show that 37% of patients have now been
waiting between three and six months. The figures also indicate that 43% of patients have been
waiting between six and 12 months for surgery..
Assessment of Neurological Services as a Model of Health
Care Provision
What is a Neurological Condition?
• A condition that affects the brain, spine or muscle
• Can be roughly divided into 3 categories– Physically disabling– Non-Physically disabling– Loss of cognitive ability (Dementia)
Health Status of Population:Measurables
Notifiable Diseases/ Conditions
Primary care based data acquisitionNational databases
Cancer RegistryIntellectual Disability databaseNational Physical and Sensory Database
Quantitation of activity in secondary careActivity levels in acute hospitalsWaiting lists
Prevalence of Neurological Conditions in Ireland
• Approx 500,000 suffer from a neurological disorder in the Republic of Ireland
• Not notifiable
• No publicly funded national databases
• No curative treatment
• Not suitable for NTPF:
• Frequently undiagnosed : Poor access to relevant specialist
• Reliable data generated by investigators. No official data
5.75.75.7
4.85.3
4.7
4.1
2.02.0
1.41.6
2.32.31.9
0.0
1.0
2.0
3.0
4.0
5.0
6.0
1995 1996 1997 1998 1999 2000 2001
Year
Pe
r 1
00
,00
0 p
op
ula
tio
n
Prevalence rates
Incidence rates
Epidemiology of MND in Ireland
Frequency of Review by a Neurologist in Ireland
0%20%40%60%80%
100%
MS
MND
Measuring Neurological Services: Available Data
• Health Status /Disease Status of Population UNKNOWN
• % Spending of total GDP UNKNOWN
• Number of doctors per capita
• Waiting lists and Hospital Activity
Distribution of neurologists in Europe
8 100
18 400
21 200
21 300
23 200
23 900
29 100
33 100
35 600
38 500
177 000
333 300
25 800
0 400000
Ireland
UK
France
Sweden
Portugal
Switzerland
Netherlands
Luxembourg
Austria
Greece
Denmark
Norway
Italy
Population per neurologist
Distribution of neurologists in Europe
0 25 50 75 100 125
Ireland
UK
France
Sweden
Portugal
Switzerland
Netherlands
Luxembourg
Austria
Greece
Denmark
Norway
Italy
Neurologists per million population
Neurologists in Europe
Problems in Current System based on Waiting Lists
• Excessive reliance on unverified / inaccurate data, including waiting list data
• Minimal audit of waiting list management:– Equity
• Assumption that “outcome” is associated with “procedure” (usually surgical)
Problems with Current System based on Waiting Lists
• Absence audit data for non-surgical hospital-based clinical activity
• Absence of audit /efficiency monitoring data for out-patient services
• Absence of tools to measure outcomes for chronic conditions for which procedures are not indicated
• Absence of measurement tools to assess continuity of care between hospital and community services
• NO INCENTIVE TO PRACTICE EVIDENCE-BASED MEDICINE
Waiting Lists
In Patient Services to Neurology Beaumont Hospital 2003
0
20
40
60
80
100
120
140
Admissions
Admissions from A+E
Top Ten A&E Admissions
51
29 27
9 7 6 4 4 3 2
0
10
20
30
40
50
60
No
of
Ad
mis
sio
s
Readmission Rates
128
17
91
10
67
4
43
10
2413
0
20
40
60
80
100
120
140
Number of Admissions
Length of Stay for top 4 Diagnoses
8.7
14.3
1211
8.8
12
27.9
23.2
15.9
11
18.5
12.5
0
5
10
15
20
25
30
Mean length of Stay in Days
Epilepsy MS Stroke MND
Diagnosis
A&E
Transfers
Elective
How Do We Compare?Top 5 Dx, Beaumont and
Massachusetts General Hospital
Mean Length of Stay
02468
101214161820
Day
s MGH
Beaumont
Cost Analysis
17380
31284
20692
41452984
0
5000
10000
15000
20000
25000
30000
35000
Cost in €
Epilepsy Stroke MS MND CIDP
Cost Analysis for Year 2003 (Diagnositic Related only)
Disease Assessment:Measurables
• Survival rates• Symptoms, signs, disability measures
and complications of condition and treatment• Health Status and Quality of Life• Experiences of patients and their carers• Costs of use of resources
(UK Department of Health, 1992)
Preliminary Studies of Outcome for Neurological Conditions
Survival
Survival of Irish ALS patients according to the clinic type attended
• Median survival of ALS clinic patients = 677 days versus 448 days for general neurology clinic
• Beneficial effect persisted throughout follow-up: four year mortality rate decreased by 13.4% in the ALS clinic cohort
0
.2
.4
.6
.8
1
Cum
ulat
ive
surv
ival
0 250 500 750 1000 1250 1500 1750 2000 Time from diagnosis (days)
ALS clinic (n = 82)
General Neuro clinic (n = 262)
229 days
29.7%
10.7%13.4%
Treatment with Riluzole
0
.2
.4
.6
.8
1
Cu
mul
ativ
e s
urv
iva
l
0 1 2 3 4 5 6 Time (years)
Riluzole (n = 149)
No Riluzole (n = 97)
97)
Outcome Assessment: Management of Symptoms,
Signs, Complications
Outcome Evaluation: Clinical Signs and Disability Measures
• Generic Scales
• Disease Specific Scales
• Individualised Measures
Natural Course of Multiple Sclerosis
Relapses and Disability Total MRI-Lesion load MRI-Activity
Secondary ProgressiveRelapsing Remitting
First exacerbation
Clinical MS
Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA
Relapses and Disability Total MRI-Lesion load MRI-Activity
Secondary ProgressiveRelapsing Remitting
Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA
First exacerbation
Clinical MS
Beta Interferon therapy modifies the course of Multiple Sclerosis
SPMS delayed
EARLY TREATMENT
CIDP: Evaluation of Treatment Outcome
Individualised Measurement pre- and post- IVIg
Maximal Voluntary Isometric Contraction
(Quantitative Muscle Assessment)
MVIC Values Lower Limbs
0
5
10
15
20
25
30
35
40
45
HFLL HFLR KEXL KEXR KFLL KFLR ADFL ADFRMovement
Kgs
Pre Rx
PostRx
Medianfor age
Graph 4 : The patient was tested before and after treatment on 8 occasions (abscissa) and the change in muscle strength in 18 muscles was plotted (ordinate). Following the
fifth treatment the patient felt that his muscle strength had deteriorated (not shown) . The patient was treated with plasmapheresis (cycle 6). This failed to improve his muscle
strength. A further course of IVIg did not improve his clinical status (cycle 7) He was then treated with a CD 20 antibody (Rituximab). He did not require further IVIg infusion for 5
months. Re-introduction of IVIg infusions following treatment with Rituximab (cycle 8) led to an improvement in muscle strength
Effect of Rx on muscle strength
-15
-10
-5
0
5
10
15
20
cycles of treatment
Dif
fere
nc
e in
mu
sc
le
str
en
gth
pre
v p
os
t rx
Disease Assessment:Measurables
• Survival rates• Symptoms, signs, disability measures
and complications• Health Status and Quality of Life• Experiences of patients and their carers• Costs of use of resources
(UK Department of Health, 1992)
Quality of Life: What does it mean?
Quality of Life
Health-related QoL
Health Status (ALSAQ5) v Functional Disability Scale
(ALSFRS)
alsfrs-r
50403020100
alsa
q5100
80
60
40
20
0
N=31, r = -0.78, significant at p = 0.01
Relationship between Quality of Life & Functional Disability
functional disablilty
3.02.52.01.51.0.50.0
qu
ality
of
life
100
80
60
40
20
0
disease
PPS
MS
MND
Disease Assessment:Measurables
• Survival rates
• Symptoms,signs and complications
• Health Status and Quality of Life
• Experiences of patients and their carers
• Costs of use of resources
(UK Department of Health, 1992)
Cost Analysis
17380
31284
20692
41452984
0
5000
10000
15000
20000
25000
30000
35000
Cost in €
Epilepsy Stroke MS MND CIDP
Cost Analysis for Year 2003 (Diagnositic Related only)
Costs of Managing MND
Demography by Year
0
5
10
15
20
25
30
35
1996 1997 1998 1999 2000
Year
no. ofnew Patients
Male Limb
Male Bulbar
Female Bulbar
Female Limb
Prevalence per100,000 pop. over15years of age
Audit Costs IRL£ Patient care Transport
YEARNew
Equip. attendants of equip. Storage Totals1996 109,000 15,000 17,000 5,000 146,0001997 117,000 27,000 25,000 5,000 174,0001998 191,000 28,000 33,000 5,000 257,0001999 114,000 33,000 34,000 5,000 186,0002000 108,000 51,000 40,000 5,000 204,000
Equipment cost- Total/year
050,000
100,000150,000200,000250,000300,000350,000400,000
1996 1997 1998 1999 2000
Year
IRL£
Equipment Funding
050,000
100,000150,000200,000250,000
1996 1997 1998 1999 2000
Year
IRL£
IMNDA
National Lottery
Gov. Grant
How Can Evidence-Based Medicine Be Used to Change the Practice of Medicine in Ireland?
Quis custodiet ipsos custodes?
Proposed Structure of Health Service
Proposed Structure of Health Service
CONCLUSION