Peter Scherer, Counsellor, Employment and Social Affairs Directorate, Organisation for Economic Cooperation and Development Health Care Quality Indicators Project OECD World Forum on Key Indicators 10th November 2004 Draft 29/10/04

2 Outline of Presentation 1. Origins of OECD project 2. Initial indicator collection 3. New Priority Areas 4. Example: primary care and prevention panel 5. Concerns about initial panel reports 6. Current work 7. Ministerial endorsement

3 1. Origins of OECD Quality Indicators Project Inspiration came from work done in Commonwealth Fund sponsored project In addition, a Nordic network had been formed to develop comparable indicators of quality of care. OECD proposed that countries in these two networks should come together to develop common comparable indicators. Thus far, 21 countries have participated.

4 Goals of the Indicators Project: To develop a set of internationally-comparable, scientifically-valid indicators of the technical quality of health care This will include: 1. Assessing the feasibility of collecting internationally comparable measures for the technical quality of care 2. Responding to the need of policy makers to measure and benchmark health care system performance 3. The long term goal is to include some key quality indicators in OECD Health Data

5 Criteria for good quality indicators The overall importance of the aspects of quality being measured –Burden of disease –Effectiveness of the intervention The scientific soundness of the measures The feasibility of collecting data on the indicators

6 2. Initial Collection of Indicators At an initial meeting in January 2003, 13 indicators for initial data collection were identified. Most of these were drawn from Commonwealth Fund list. Preliminary results of this collection of these data were presented to second meeting of experts in September Experts agreed to modify the list, adding five more indicators

7 Initial Indicators collected in year survival rates, breast cancer (observed and relative) 5-year survival rates, cervical cancer (observed and relative) 5-year survival rates, colorectal cancer (observed and relative) Cervical cancer screening rate, age 20-69, within past 3 years Asthma mortality rate, ages day mortality rate following acute myocardial infarction 30-day mortality rate following stroke Proportion of diabetics with HbA1c > 9.5% Annual HbA1c test for patients with diabetes In-hospital waiting time for femur fracture surgery Proportion of children completing basic vaccination program Incidence rates for pertussis, measles, hepatitis B

8 Initial Indicators collected in 2004 Mammography rates Influenza vaccination rates >65* Smoking rates* Rate of retinal exams in diabetics Major amputation rates in diabetics * Data are available for Influenza vaccination rates >65 and Smoking rates through OECD Health Data.

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10 21 Participating Countries Australia Austria Canada Denmark Finland France Germany Iceland Ireland Italy Japan Mexico The Netherlands New Zealand Norway Portugal Spain Sweden Switzerland United Kingdom United States

11 Availability of Initial Indicators Cancer Screening –Mammography (11) –Cervical (14) 5- Year Survival Rates –Breast (18) –Cervical (18) –Colon (18) Health Promotion –Smoking Rate (20) Asthma –Mortality age 5-39 (18) Infectious Disease Immunization –Basic Vaccination age 2 (15) –Influenza Vaccination over 65 (16) Incidence –Pertussis, Measles and Hepatitis B (19) Note: Number of countries providing data in parentheses

12 Availability of Initial Indicators (cont.) Diabetes –Patients tested for HbA1c in last year (4) –Patients with poor glucose control (HbA1C>9.5%) in last year (8) –Retinal exams in diabetics (6) –Major amputations in diabetics (7) Access/Timeliness –% of Femur Fractures operated within 48 hours, age 65 or older (4) Stroke Care –30-day in-hospital case fatality rate for hemorrhagic stroke (11) –30-day in-hospital case fatality rate for ischemic stroke (11) Cardiac Care –30-day in-hospital case fatality rate for AMI (12) Note: Number of countries providing data in parentheses

13 Concerns about initial collection At the September 2003 meeting concerns were raised about the validity of the collection in four respects: 1.The partial and rather scattered nature of the indicators collected. 2.The reliability and validity of the data themselves. 3.The need these concerns implied for a conceptual framework to guide this work 4.The difficulty for all countries to adhere to prescribed definitions (e.g. reference periods-- three years for cancer screening) Some delegates argued that the OECD was in a different position to the Commonwealth Fund –data it releases carry an authority which makes it vital that their validity is verified These issues will need to be addressed to achieve consensus to release the data.

14 3. New Priority Areas The January 2003 meeting identified five priority areas for future development of additional indicators –Cardiac Care –Diabetes Mellitus, –Primary Care/Health Prevention and Promotion, –Patient Safety and –Mental Health Expert Panels were formed to make recommendations on suitable and reliable indicators in each of these areas The reports of the expert panels were circulated in first draft at the time of the September 2003 meeting, and have now been released as OECD Health Technical Papers. They do not include a detailed investigation of availability -- or of the international comparability of the available data -- for the indicators proposed.

15 4. Example: OECD Primary Care and Prevention Panel Membership –Professor Sheila Leatherman (US) –Mr Charlie Hardy (Ireland) –Professor Niek Klazinga (Netherlands) –Dr Eckart Bergmann (Germany) –Dr Luis Pisco (Portugal) –Dr Jan Mainz (Denmark) –Professor Martin Marshall (UK)

16 Examples of Proposed Primary Care and Prevention indicators Health Promotion –Obesity prevalence –Physical activity –Smoking rate Diagnosis and Treatment/Primary Care –Congestive heart failure readmission rate –First visit in first trimester –Smoking cessation counselling for asthmatics –Blood pressure measurement –Re-measurement of blood pressure for those with high blood pressure –Initial laboratory investigations for hypertension

17 Examples of Proposed Primary Care and Prevention indicators (contd) Preventive care –Blood typing and antibody screening for prenatal patients –Low birthweight rate –Adolescent immunisation –Anaemia screening for pregnant women –Cervical gonorrhoea and Hepatitis B screening for pregnant women –Hepatitis B, influenza and pneumococcal immunisation for high-risk groups

18 Examples of prevention indicators already in use in OECD Countries Australia –57% of women get breast cancer screening through national programme (likely understatement of total) –objective is 70% –equity of access is also an objective United Kingdom –69% of women get breast ca. screening –83% of women get cervical ca. screening United States –62% of smokers get smoking cessation advice at routine office visit

19 Percentage of hypertensives taking medication for high blood pressure and health expenditure per capita Sources: OECD Health Data 2003 and Wolf-Maier, K. et al. (2003) JAMA; 289:

20 5. Concerns about Initial Panel Reports There remains a need for a clear conceptual framework to guide such an ambitious programme Concerns about the validity of outcome measures against process measures for assessing the quality of care –This issue also arose in formulating the initial US AHRQ Report A bias towards US or at least English-speaking countries sources and measures in some of the current panel reports: insufficient attention to European Union initiatives Adjustment of indicators for the risk profile of the population –some experts consider this to be essential. –others argue that in assessing outcomes one wants to know how well a country has adjusted its system to the risk profile of its population (e.g. heart disease in Finland).

21 6. Current Work Complete inquiry about data for initial set of 17 indicators Review comparability and availability of initial indicators Produce paper presenting collected data, scientific soundness, policy relevance and comparability of each indicator. Solicit and integrate written comments of member countries into reports on Priority Areas Draft initial paper on conceptual framework for developing and collecting such indicators.

22 7. Ministerial Endorsement Health Ministers from OECD countries met for the first time at the OECD on 13 and 14 May Meeting chaired by Mexican Secretary for Health, with US Secretary and Hungarian Minister as Vice Chairs They specifically endorsed the programme of work on indicators of quality of care, saying:

23 Ministerial Communiqué... many gaps remain in health data and in analysis at the international level. We look forward to the OECD increasing the importance of its work on health to help fill these gaps, as it is centrally placed to provide international comparisons and economic analyses of health systems. Subject to sufficient resources being made available from the regular OECD budget and from specific funds, a future OECD work agenda on health should:.....

24 Ministerial Communiqué (contd) iii. Develop, in collaboration with national experts, indicators of the quality of health care and indicators of other aspects of health care system performance. Once consensus on a scientifically-based set of reliable indicators has been reached, we should endeavour to coordinate different actors and levels of government to supply the information in a consistent manner.