1. Dr Rod Jones (ACMA) Healthcare Analysis & Forecasting Camberley, UK hcaf_rod@yahoo.co.uk Mobile: 07890 640399 Supporting your commitment to excellence

2. Aims Discuss the technical issues Suggest an approach to clinically meaningful comparisons Supporting your commitment to excellence

3. From experience The benchmarks are flawed Supposed differences are often artefacts of the benchmark! Capitation formula allocation to PCT and subsequent PbR payment to Trusts rely on different assumptions financial asymmetry Serious problems with the Data Standards What works? Adjust for age &deprivation (IMD) Analyse using both HRG and OPCS procedure code HRG are composites & the language of finance HRG X does not mean the same thing at different sites Some OPCS procedure codes do not map to a HRG! Look at the trend over time Step changes & trends Use FCE (not Spell) especially for procedures Supporting your commitment to excellence

4. From experience (contd) Small differences are impossible to implement & measure Concentrate on high volume Anything within ± 2 SD of expected can be left alone Add EL + EM for final analysis EL/EM boundary is not the same in all hospitals NHS site-based processes of counting & coding are different Each site has a unique signature (especially small PCT run units!) Analyse (EL & EM) zero day stay admissions separately Greater effect on the diagnosis-based HRG and on specific procedure-based HRG Net off financial effect of over- and under- before deciding to take action Supporting your commitment to excellence

5. Index of Multiple Deprivation Intervention rates are only as good as the adjustment used to account for deprivation IMD is very important and is highly non-linear Supporting your commitment to excellence

6. The danger of averaging (Modifiable Area Unit Property) The average IMD for this LSOA is 29.9 The HRG described by red line has an apparent rate of 3 but a real rate of 3.7 for the benchmark Supporting your commitment to excellence

7. IMD Key Points IMD gives excellent correlations for all acute events IP, OP, DNA rate, etc The multiple criteria appear to give a balanced view Capitation formula only uses a single measure of deprivation IMD is highly non-linear Aggregated values damp down the effect of IMD Cannot use averaged data, i.e. LSOA, ward, LA Must use Output Area data and sum up over area required Capitation formula uses ward averages & assumes linear effects Better Value indicators use LSOA average placed into 5 bands IMD analysis is site specific Related to the site-specific nature of counting & coding Explains why Dr Foster & capitation formula analysis are flawed Supporting your commitment to excellence

8. Counting & Coding Is national average a valid benchmark? High level of ambiguity over data definitions Mainly in zero day admissions Particular HRG appear vulnerable Show up as an apparent intervention rate problem Moderate ambiguity in the coding process Each hospital site is shifted ± relative to the average Diagnosis more so than procedure Higher for emergency admission Plus real differences in the underlying interventions Supporting your commitment to excellence

9. OPCS Procedure – excess as SD Description % EM04/0505/0606/07Comments Q20 Other operations on uterus7%194348Mainly biopsy of lesion of uterus, outpatient procedures? L13 Transluminal ops pulmonary artery53%322533Check the validity of clinical coding, far too high to be real X29 Continuous infusion therap substance13%22126Oncology outpatient procedures re-classified as IP H25 Endoscopic exam of lower bowel7% 02321Endoscopy - rate is high W19 Primary open reduction of fracture84%2 921Change in coding in 05/06 or is this A&E work? H22 Endoscopic exam of colon2%-91014Endoscopy - rate is high, step change M45 Endoscopic exam of bladder2%121413Endoscopy - rate is high X40 Compensation for renal failure8%51113Renal dialysis - comissioning to clarify L91 Other vein related operations20%81112Insertion of catheter - Oncology,etc OP procedures M49 Other operations on bladder6%2412Introduction of therapeutic substance - OP Oncology? B28 Other excision of breast1%9911Excision of lesion V54 Other operations on spine1%548Injection around spinal facet - OP/IP? G45 Endoscopic exam upper GI tract9%-2185Jump is OP re-classified to IP, step change F09 Surgical removal of tooth1%4 36Review of Dental Supporting your commitment to excellence

10. Hospital-based analysis Output areas are the fundamental census units Around 300 head of population Homogeneous socio-economic groups Full census data Each OA can be mapped to LSOA, Ward, Local Authority, PCT Hospital catchment area PCT is the sum of multiple hospital catchments Supporting your commitment to excellence

11. In Conclusion To make real & lasting change you need to understand the real issues Need to do specific local analysis Suggested approach Use both OPCS & HRG codes to do a first sweep Use LA level data, EM+EL combined, Zero day stay included Will detect high profile coding/activity differences Select codes for detailed analysis Zero day stay separate, OA data Analyse by hospital site and with IMD adjustment Agree an approach to deal with counting/coding issues Suggest net off over- and under- to get overall difference Negotiate if net difference is +ve Supporting your commitment to excellence