PATH: Preview of indicators · PATH: Preview of indicators A-L. Guisset World Health Organization...

PATH:

Preview of indicators

A-L. Guisset

World Health Organization regional office for Europe

[email protected]


� Rationale, generic definition

� Results and lessons learnt from PATH-pilot and

PATH-II

� International organizations, partners

� Key issues for data collection

� Assess relevance/interest, burden of data

collection (+ when alternatives: admin.

database vs. ad-hoc data collection?)

� Recommend priorities


� Balance

� Dimensions

� Source data :

Prospective – retrospective;

Databases – ad-hoc data collection (audits, surveys)

� Structure – process- outcomes

� International – local relevance

Priorities

� If you had to select only 1(or 3) indicators in

each dimension?

� If you had to exclude 1 (or 3) indicators in each

dimension?

� In what additional dimensions (sub-dimensions

or domains of care) would you suggest

developing indicators?

Structure of the descriptive sheets

Descriptive sheet (2 pages)

� Definition

� WHAT it means (what is really being measured, how to

position it in relation to the “comprehensive picture” of

organizational performance)

� Rationale: WHY measure this indicator (importance:

prevalence, burden, potential impact; validity)

� Interpretation

� International reference points

� Dissemination of results:

� Who is to look at the data and what questions to ask?

(checklist)

� Action – what’s next? – to go further…:

� Reference to networks or audit/improvement tools

Structure of the descriptive sheets

� Data collection procedure:

Algorithm, step by step, audit tools or questionnaires

if relevant, instructions for translation or adaptation to

local context if relevant (what data, where, how to get

organized for data collection in the hospitals,

minimum number of cases, inclusion and exclusion,

computation of indicator, test for data quality or

“cleaning data sets”, etc.)

� Signature of expert or partner organization (“seal”)

and contact details and developer or user of the

original indicator (e.g. AHRQ for c-section)

PATH-II: discussion of results

� Sample: number of participating hospitals on selected indicators

781016Prophylactic antibiotic

47555CTM3 (discharge

preparation)

671548Needle injuries

841558C-section

1161547LOS

1201558Mortality

# participating

hospitals

Potential #

hospitals

# countriesIndicator

PATH – 09 Indicators

� Clinical Effectiveness –

� Safety -

� Utilisation -

Indicators derived from

Hospital Patient Administrative Databases

ESQH-Office for Quality Indicators

DK-National Indicator Project

Indicators

� C-section Rate

� In-Hospital Case fatality rate – Myocardial

Infarction

� In Hospital Case fatality rate – Stroke

� Postoperative Pulmonary Embolism or Deep

Vein Thrombosis



Source of Indicators – technical information

and rationale

� OECD (Heath at a Glance, Technical Manuals

– www.OECD.org)

� AHRQ Quality / Patient Safety Indicators –

www.qualityindicators.ahrq.gov/

� PATH Data Specification Manual (Coming

Soon)



Source of Data

� National Patient Registries (Scandinavia)

� National/Regional Billing Databases – DRG

registries

� Hospital Administrative Databases

Various levels of data quality e.g.:- Unique patient identifier

- Verification of sources



Minimum Information content requirements

� Coded primary and secondary diagnoses –

ICD9, ICD10

� Coded Interventions (operative procedures) –

ICD9, Other Systems

� Age/Sex of Patient

� Date of Admission/Discharge

� In-Hospital Death



Cesarean-section Rate

� Rationale: Utilization of Healthcare (Significant

between-Country and within-Country variation,

quality/cost considerations) Effectiveness ?

� Definition/Inclusion Criteria: Number of C-

sections/100 deliveries (Specified exclusion

criteria)

� Definition� TITLE : % of caesarean sections of total deliveries NUMERATOR:

number of Caesarean sections (C-sections) DENOMINATOR: All

deliveries

� EXCLUSION CRITERIA: exclude patient with abnormal presentation,

preterm, foetal death, multiple gestation, breech procedure, delivery

within 37 weeks or less of pregnancy (AHRQ definition, focus on low

risk deliveries, for increase homogeneity of patient population)

� TAILORED

� number of primary C-sections over number of primary deliveries

� vaginal deliveries over all deliveries with a previous caesarean

section

� http://www.qualityindicators.ahrq.gov/downloads/iqi/iqi_guide_v31.

pdf

C-section delivery rate




0

10

20

30

40

50

60

70

80

90

100

coun

try 1

coun

try 2

coun

try 3

coun

try 4

coun

try 5

AHRQ

_US

International comparison on average c-section rate within country



18.40

21.80

12.30

21.40

12.30

67.60

55.40

22.80

30.30

19.70

17.40

8.209.7010.90

10.60

28.0033.10

15.00

32.50

16.60

0.00

20.00

40.00

60.00

80.00

100.00

country 1 country 2 country 3 country 4 country 5

International comparison on average c-section rate within country (min, 1st

quartile, mediane, 3rd quartile, max)


PATH’09: discussion issues

Inclusion criteria ? (All deliveries or defined

subgroups)

Interpretation

Applications ? (trends, peer comparisons,

possibility of defining targets for good practice ?)

Compliance with antibioprophylaxis guidelines

� Definition

� % of patients who received prophylactic antibiotic according to

local guidelines

� NUMERATOR : Patients that received the antibiotic

� DENOMINATOR : Patients that should have received antibiotics

� TRACER PROCEDURES : planned surgery for colorectal cancer,

coronary artery bypass graft (CABG), hip replacement, and hysterectomy

� TAILORED : 1) patients whose prophylactic antibiotics was initiated

within 1 hour of incision, 2) patients whose prophylactic antibiotics were

discontnued within 24 h after surgery end time


C2 – Compliance with antibioprophylaxis

guidelines

� Bottle 3/4th full or 1/4th empty?



0%

20%

40%

60%

80%

100%

tot

other

under

over

OK

� Inter-hospital variations



91,8

59,3

24,5

79,1

73,8

38,3

0 0

100 100 100 100

100

88,3 86,4

100

0

20

40

60

80

100

country 1 country 2 country 3 country 4

Inter- and within-country distribution of % of patients receiving antibioprophylaxis in

compliance with local guidelines for hysterectomy (minimum, 1st quartile, 3rd quartile,

maximum)

C2 – Compliance with antibioprophylaxis guidelines

Data collection

� Who assessed compliance?

� Compliance was assessed againstwhat guidelines? Local? National? Content (molecule, doses, timing)?

� How were records identified?

Interpretation

� What is your rate of compliance?

� Did results come as a surprise orwere they expected?

� How do you relate those results to post-surgical infection rates?

� What goals do you set up?

Best practices� Who is responsible for

developing guidelines? Reviewing them? For communication? For monitoringcmpliance? For setting up structure to ensure proper timing?

Impact� To whom were the results

presented?

� How was awareness raised?

� Was it assessed again? Is it part of routine (now)?

Next steps?




� Tracers

� Number of records to be audited per tracer? Audits performedlocally or centrally? ToR for auditor? Test reliability?

� Compare against local guidelines, national guidelines, international guidelines?

� Provide a tool to assess local and national guidelines?

� Include elements that need to be included in the guideline (timing before/after, dose, type, exclusion criteria, etc.) – providestandard algorithm as illustration

� How to facilitate comparisons of national guidelines beforeimplementation of indicators?

� How much time is needed between

� Whom to involve for local development, measurement and interpretation of this indicator?



C4 – Readmission within 30 days

� Definition� Numerator: Total number of unplanned admissions within a fixed follow

up period (30 days) from the same hospital and with a readmission

diagnosis relevant to the initial care.

� Denominator: Total number of patients admitted for selected tracer

conditions

� Exclusion criteria: Patient who died during the index hospitalization or

who were discharged to another acute care hospital


0

2

4

6

8

10

12

AMI Stroke Community

acquired

pneumo

Hip fracture

country 1

country 2

country 3

country 4

Global readmission rates (in %) per country and tracer



0

5

10

45-64 65-79 80-89 90 and more

country 1

country 2

country 3

country 4

Global

Stroke

0

5

10

15

45-64 65-79 80-89 90 and more

country 1

country 2

country 3

country 4

Global

Community acquired pneumonia

C4 – Readmission

within 30 days



3.85

00.93

0

10.26

7.75

14.88

13.61

2.86

0 0.490

8.04

4.17 4.362.59

0

5

10

15

20

25


01.91

2.01

4.17

16.1115.38

12.00

0 001.46

1.09

5.175.64

7.22

0

5

10

15

20

25


7.17

4.78

0.330

23.26

16.94

10.20

17.54

4.00

0 00

16.55

12.39

7.35

1.21

0

5

10

15

20

25


AMIStroke

Community acquired pneumonia Hip fracture

0 00

4.86

16.6717.24

9.71

11.76

0 00

1.960.98

4.626.06

7.72

0

5

10

15

20

25




� Tracers (see OECD)

� Unique identifier?

� Alternative 2 includes algorithm to review

records�� Unplanned? Avoidable?

� Agregation of tracers into summary indicator?


Readmissions within 30 days

C8 – Median length of stay

� Definition

� This indicator assesses the median number of days of

hospitalization (admission and discharge date count for one day)

for cases admitted with acute myocardial infarction (ICD-9: 431,

433, 434, 436 and ICD-10: I63, I64, I65, I66).

� Data collected over a 12 months time period from the 1st January

to 31st December 2006 (unless this data was not available then

the most recent data covering a 12 months period)

� Patients transferred to/from other hospitals were excluded.

� The reported data is NOT adjusted for age and sex.


Tracer 1: Acute Myocadial Infraction Tracer 3: Community acquired pneumonia


0

10

20

30

country 1 country 2 country 3 country 4 country 5 Global

0

10

20

30

country 1 country 2 country 3 country 4 country 5 Global


� LOS and age? ---- No risk adjustement


0

10

20

30

45-64 65-79 80-89 90 and more

country 1

country 2

country 3

country 4

country 5

Global

0

10

20

30

45-64 65-79 80-89 90 and more

country 1

country 2

country 3

country 4

country 5

Global

Tracer 1: Acute Myocadial InfractionTracer 3: Community acquired

pneumonia



9.909.90

7.44

8.409.60

11.17

21.80

18.00

12.80

15.40

7.308.50

5.50

7.10 7.00

14.3013.50

9.15

10.6011.90

0

10

20

30


Tracer 1: Acute Myocadial Infraction Tracer 3: Community acquired pneumonia

9.107.607.648.40

15.1015.7015.60

11.41

8

3.60

4.865

11.30

8.909.07

11.20

0

10

20

30




� Tracers (see OECD)

� Alternative 2: risk adjustement? DRGs?

� Agregation of tracers into summary indicator?


Median length of stay

Myocardial Indfarction/Stroke within hospital

30 days case fatality rates

� Rationale: Effectiveness – safety – (Outcome

measure associated with evidence-based practice)

� Definition: Denominator Number of deaths

(Age +15) in the same hospital that occurred

within 30 d of admission Numerator No

admission (Age +15) to hospitals with a

primary diagnosis of Stroke/Myocardial

Infarction



� Definition ctd: Specified ICD- codes



� Discussion issues:

� Risk Adjustment ? (Need for additional data

collection ?)

� Interpretation ? (Possibility of Benchmarking)

� Internal improvement activity (Utility as a

trigger for audit-improvement of key processes

?)

Postoperative Pulmonary embolism or Deep

Vein Thrombosis: NEW INDICATOR

� Rationale: Patient Safety – effectiveness

(occurence of DVT/Pulmonary embolism is one of the major potentially lethal – and preventable -complications to surgery)

� Definition: Denominator: Number of discharges with a secondary diagnosis of PE/DVT

Numerator: All surgical discharges with a codefor op. Procedure (Specified exclusions)

Postoperative Pulmonary embolism or Deep

Vein Thrombosis

� Issues for discussion:

� Coding practice –standardisation between

hospitals ? (Underreporting in administrative

databases)

� Interpretation: Need for risk adjustment ? (Patient factors – operative procedure factors)

� Coupling to internal QI-activity ?


� Assess both risk and presence / stade of ulcer

� Sample: hospital-wide or specific departement? Or

specific conditions? Focus on low-risk or high-risk?

� Training needs? Reliability?

� Previous experience with such exercice?


Prevalence study pressure sores

C16 – score on CTM3

� DEFINITION: The term “care transitions” refers to the movement patients make between health care practitioners and settings as their condition and care needs change during the course of a chronic or acute illness.

� The score (on a -100 scale) is built on responses (on 1-4 scale) to threeitems in questionnaire :

� 1. Preferences : The hospital staff took my preferences and those of myfamily or caregiver into account in deciding what my health care needswould be [when I left the hospital].

� 2. Health management : [When I left the hospital], I had a good understanding of the things I was responsible for in managing my health.

� 3. Medications : [When I left the hospital], I clearly understood the purpose for taking each of my medications

A higher score represents better transition from hospitals to home or other care settings


C16 – Score on CTM3

� Sample size:� INCLUSION CRITERIA : All patients discharged over the survey period.

MINIMUM 60 patients per tracer condition/procedure to be included in the sample.

� Most hospitals have provided valid data for between 50 patients (P25) and 144 patients (P75) for 6 tracers or more.

� Risk adjustement:� According to descriptive sheet: Age and sex BUT

� CTM developers indicate that

“the CTM is a patient centered measure that assesses the extent to which hospital staff accomplished essential care processes (...) to be extended universally, irrespective of disease burden or socio-demographic status. As a result, the CTM (...) does not employ risk-adjustment in calculating a summary score. (...). Each of the [empirical] analysis has confirmed that these variables [gender, age] does not bias CTM-3 response patterns”.

� PATH results: no association between age and sex and CTM3 score



0%

20%

40%

60%

80%

100%

Country 1 Country 2 Country 3 Total

strongly agree agree disagree strongly disagree

0%

20%

40%

60%

80%

100%

15 - 44 45 - 64 65 and more


0%

20%

40%

60%

80%

100%

AMI Stroke Hipfracture CAP Asthma Diabetes Other*



75,8 77,3 77,1

90,3 90,392,2

61,9 62,9 63,8

85,0 85,087,7

0,0

20,0

40,0

60,0

80,0

100,0

Preference Health management Medication

Variations in the international sample


C15 – Breastfeeding rate

� Definition: The percent of women with exclusive breastfeeding at

discharge. WHO defines exclusive breastfeeding when “the infant

receives only breast milk from his/her mother or a wet nurse, or

expressed breast milk, and no other liquids or solids with the exception of

drops or syrup consisting of vitamins, mineral supplements or medicine”.

� Numerator: Total number of mother included in the denominator

breastfeeding at discharge.

� Denominator: Total number of delivery fulfilling criteria for inclusion.

� Exclusion criteria: Neither mother nor infant has a medical condition for

which breastfeeding is contraindicated.


C15 – Breastfeeding rate

WHO/UNICEF Baby

Friendly Hospital Initiative:

minimum threshold for label

Global rate

Individual indicators

94,3

80,7

57,9

100 100

84,391,7

57,9

40,6

99 100

70,7

0

20

40

60

80

100


0,00

10,00

20,00

30,00

40,00

50,00

60,00

70,00

80,00

90,00

100,00


C13 – Smoking prevalence

� NUMERATOR : number of staff smoking

� DENOMINATOR: total number of staff

� INCLUSION CRITERIA : All staff on the hospital payroll

� SOURCE OF DATA:

� The European Network of Smoke-free hospitals developed a survey measure including 13 standard questions to be able to compare differences between hospitals in various European countries. The first questions of the survey will be sufficient to gather information on staff smoking prevalence; the additional questions in the survey are optional for hospitals to fill in.

� Alternatively, if the information on staff smoking prevalence is already available from other sources (such as periodic staff health survey), these can be used.



Participating PATH hospitals General population


0.00

20.00

40.00

60.00

80.00

100.00

Poland Belgium country 2 Small

sample size

France

All

female

male

0

20

40

60

80

100

Poland Belgium Estonia Hungary Slovenia

All

Female

Male


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

other

countries


< 30

30-40

40-50

> 51

0

20

40

60

80

100

other

countries


all health prof.

all non prof. Health.

Evidence to target health promotion activities


C14 – Needle injuries

� This indicator assesses the number of needle injuries among FTE (Full

time equivalent) staff.

� DEFINITION: Needlestick injuries are wounds caused by needles or

other sharp objects that accidentally puncture the skin and may result in

exposure to blood or other body fluids.

� Data is obtained through a survey asking about incidences of needle

injuries in the last year.

� NUMERATOR: number of needlestick injuries over the last calendar year

� DENOMINATOR: Number of Full Time Equivalent (FTE) staff over the

same time period



0,0%

1,0%

2,0%

3,0%

4,0%

5,0%

6,0%

7,0%

8,0%

9,0%

10,0%

Poland country 1 country 2 country 3 country 4

nurses doctors technicians housekeeping total staff

2,81,6

0 0

18,5 18,2

13,6

0 0 0 0

8,16,8

3,15,4

0

5

10

15

20

25

Nurses

(N=98)

Doctors

(N=63)

Technicians

(N=61)

Housekeeping staff

(N=73)

Max = 45.5

Reference points:

Wide variations in leterature but

systematically much higher than

PATH results:

10.4 and 5.0 sharp injuries per

respectively 100 FTE medical or

nursing staff in Australia teaching

hospital

55.1% and 22.0% needle injuries

experienced by respectively for

medical and nursing staff in a

German university hospital

33.2 and 18.0 % incidence rate

for all staff in 9 teaching and 32

non teaching US hospitals (3)


� Higher risks in smaller hospitals? Random variations?

4,63,8 3,4 3,2

1,8 2,22,7

5,2

18,516,5

17,8

15

8,88,1 8,9

16,3

0 00,8

2,8

0,3 0,3

1,4 2,7

12,7

9,510,6

6,25,5 5,1

6,97,9

0

5

10

15

20

25

10-100

(N=16)

101-150

(N=16)

151-250

(N=14)

251-350

(N=9)

351-500

(N=15)

501-750

(N=13)

750-1000

(N=6)

1001-

more

(N=8)

Rate of injuries (in %)

Hospital size (in FTE nurses)

0

1,9 1,6 1,6 1,42,7

18,2

14,6

7,1 75,6

9,3

0 0 0 00,7

2,4

10,810

5,34

5 5

0

5

10

15

20

25

10-50

(N=14)

51-100

(N=12)

101-175

(N=12)

176-250

(N=13)

251-500

(N=6)

500 & more

(N=7)

Hospital size (in FTE doctors)


2,41,5 2,3 2,1

10,4

4,65,8

5,3

0,50,3

1,5 1,8

6,43,9 4

5,1

0

5

10

15

20

25

300-600

(N=21)

601-900

(N=8)

901-1400

(N=13)

1400 & more

(N=6)


Hospital size (in FTE total staff)

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PATH: Preview of indicators · PATH: Preview of indicators A-L. Guisset World Health Organization...

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