1. EVALUATION OF THE EFFICIENCY OF MEDICAL ACTIVITY Elena A. Abumuslimova Ph.D., Associate Professor Department of Public Health and Health Care, Northern-West State Medical University named after I.I. Mechnikov, Saint- Petersburg

2. 2 Evaluation of the efficiency of medical activity is a logical and explicit framework to health care workers, decision-makers, governments or society at large, to make choices on how best to use resources.

3. 3 There is difference between "effect" and "efficiency" of medical activity. The concept of "effect" means the result of the actions, consequences of effect of any reason. For example, spending the economic resources to treat the patient, the doctor receives recovery or improvement of the patient’s condition. The term "efficiency" refers to the degree of achievement of results in relation to the inputs spending for the treatment. Evaluating the effectiveness shows how to use the material, human and financial resources in any medical method, intervention, treatment or prevention.

4. 4 The concept of "effectiveness of medical care" shouldn’t be identified with general economic category, with the corresponding criterion in the sphere of material production. It is possible to have "zero" or even "negative" economic outcome in health care, even with the most skilled labor and the use of modern medical technology.

5. 5 efficiency effectiveness The concept of efficiency is close to the notion of effectiveness. Effectiveness Effectiveness is generally understood as the degree of achievement of positive outcomes, without regard to the cost of their implementation. From this point of view, the efficiency can be defined as the effectiveness in relation to the costs. But high effectiveness can be achieved with the excessive effort and expense that sharply lowers economic efficiency.

6. 6 two groups of factors Efficiency and effectiveness of health care may be in direct and inverse relationship. This is due to the action of two groups of factors : 1. The influence on the treatment’s outcome of the individuality of a patient. Thus for the same treatment in different patients may be expected a different outcomes and when the same result can be achieved with different costs. 2. Different criterion for evaluating of the effectiveness of different levels of care. By assigning a patient a potent and expensive medicine doctor evaluates the positive results as obtained at minimum cost, while total hospital inputs can be high and low efficiency.

7. 7 Effectiveness of general health care, its services and separate activities is measured as a set of criteria and indicators, each of them characterizes some aspect of the process of medical practice.

8. 8 the health care industry The effectiveness of the health care industry is expressed by the criteria close to macroeconomic ones: its impact on maintaining and improving public health, reducing the costs of health and social care, the cost savings in other sectors of the economy, an increase in the growth of national income. public health establishments The effectiveness of public health establishments will be determined by a set of indicators approved by the relevant health authorities (morbidity, disability, demographic and other criteria). the private health organizations The efficiency of the private health organizations will mostly be defined such a macroeconomic indicator as the size of the resulting profits. the doctor working in the medical establishments The effectiveness of the doctor working in the medical establishments, mainly will be measured by the structure of outcomes of treated patients, the positive dynamics of the patients under observation, etc.

9. 9 Directions for estimation of efficiency in public health care: By a type of efficiency: By a type of efficiency: medical, social, economic. By a level: By a level: the level of the physician, the level of work units, the level of health establishment, the level of the health care industry, the level of the national economy. By stages or sections of work: By stages or sections of work: the preventive stage of the disease, the treatment stage, the rehabilitation stage.

10. 10 Directions for estimation of efficiency in public health care: Volume of work: Volume of work: the effectiveness of treatment and preventive measures, the effectiveness of medical-social programs. According to the method of measurement results: According to the method of measurement results: by estimation a reduction of a loss of resources; be counting the saving of resources; an additional result, the integrated index which takes into account all the results. According to the cost: According to the cost: cost of public labor; total ratio of costs of living and social labor. By types of factors: By types of factors: standard indicators of population health; indicators of labor costs, cost parameters.

11. 11 Unlike other sectors of the economy the results of therapeutic measures in health care are analyzed from the standpoint of the three types of efficiency: social, medical and economic. The most priorities of which are medical and social efficiency. Without taking into account medical and social efficiency economic efficiency can’t be determined. There is a relationship and interdependence between these three types of efficiency.

12. 12 Medical efficiency there is degree of achievement of objectives for the prevention, diagnosis, treatment and rehabilitation of diseases.

13. 13 Medical efficiency Medical effectiveness is evaluated on several levels. one specific patient On the level of one specific patient medical efficiency is healing or improvement of health, recovery of lost functions of specific organs and systems. health facilities and public health industry On the level of the health facilities and public health industry in general medical effectiveness is measured by many specific indicators: share of recovered patients, the reduction of cases of transition to the chronic form of the disease, reducing the frequency of morbidity among the population, etc.

14. 14 Medical efficiency = Number of cases of achievement of objectives for the treatment Number of all evaluated cases

15. 15 Medical efficiency reflects the extent of achievement of aims in diagnostic and treatment of diseases in the context of quality criteria, adequacy and effectiveness. Medical intervention may be more effective if the scientific level and their implementation provide the best result of health care at the lowest cost of all resources. But even under ideal quality of medical work the main goal for this activity – person’s health - can be don't achieved.

16. 16 Social efficiency is the extent of achievement of social results.

17. 17 Social efficiency two levels This kind of efficiency in health care is also assessed at two levels : at the level of a specific patient at the level of a specific patient : his return to work and an active social life, satisfaction with quality of medical aid; at the level of the public health industry: at the level of the public health industry: increasing of the life expectancy of the population, reducing criteria of mortality and disability, satisfaction of society with quality of medical aid system as a whole.

18. 18 Social efficiency = Number of cases with satisfaction of quality of medical aid Number of all evaluated cases

19. 19 Economical efficiency of health care is the economic effect of the medical establishments activity correlating with the amount of money spent on public health care. Economical efficiency = Economical effect that was achieved Amount of money spent on the treatment

20. 20 Assessing the benefits and costs, economic analysis can compare various medical programs, technologies, services aimed at qualitatively similar results, but obtained with different efficiencies. Health care specific feature is that often the medical therapeutic and preventive measures can be economically unfavorable, but the medical and social effects demand their carrying out. Thus the organization of health care action for older people with chronic and degenerative diseases, patients with mental problem, etc. has the apparent positive medical and social effectiveness but on the other hand economic effect will be negative.

21. 21 Medical and social effects are achieved by using modern medicine, intensive care - the man's life is saved, but he/ she can become disabled and lose the opportunity to engage in socially useful work. However the cost effectiveness in the health care don't determines the choice of certain therapeutic measures. But the criteria of economic efficiency along with medical and social efficiency can help in prioritizing of certain medical activities in conditions of limited resources.

22. 22 The main objectives comparing health costs with the level of social and economic society’s losses from morbidity and mortality The main objectives of economic analysis in public health are comparing health costs with the level of social and economic society’s losses from morbidity and mortality. The next aim is receiving economical effect by improving public health. Generally improving public health accelerates the development of social production and the growth of national income and welfare. search for the most economical use of available resources Cost-effectiveness is associated with the search for the most economical use of available resources. This criterion is a necessary element in the assessment of the functioning health care system as a whole, its certain departments and agencies, as well as economic feasibility of measures for the protection of health of population.

23. 23 Economic efficiency in health care is considered in two ways: at the first, for compare the effectiveness of using of different types of resources, secondly, in terms of evaluating of influence of public health on the development of social production in general.

24. 24 Methodological approaches in determining of the cost-effectiveness of health care is based primarily on determining of the cost of the special types of medical care and epidemiological service and the amount of damage caused by various diseases. costs of medical aid economic effect Cost parameters of medical care are the initial points for comparing the costs of medical aid and economic effect in evaluation of the economic effectiveness of health care.

25. 25 Economic effect - is prevented economic damage, that is the damage was prevented as a result of the complex medical measures.

26. 26 directindirect There are also direct and indirect economic effects. The direct economic effect The direct economic effect is got due to improved methods or organization of any medical activity leading to its cheaper. E.g., introduction of new forms of organization of work for health workers and using of new forms of medical aid (department of nursing, one day hospital, hospital at home, day hospital care) lead to savings of beds fund. Using of cheaper and more effective methods of diagnosis and treatment allow reducing the cost of patient’s treatment and cost per bed-day. Indirect economic effect Indirect economic effect is a result of medical and social effects leading to a reduction of costs through the savings of resources spent on a treatment of diseases and reducing economic losses due to population’s disability and death.

27. 27 actualexpected economic effect There are actual and expected economic effect. When planning an activity we are dealing with the expected effects. In a retrospective evaluation of the results we calculate actual effect.

28. 28 direct indirect economic losses There are also direct and indirect economic losses. Direct economic losses Direct economic losses - are the direct costs for treatment, prevention, sanitary-epidemiological service, scientific research and development, training of medical personnel, payment of benefits for temporary incapacity and disability pensions. Indirect economic damage Indirect economic damage - is the economic losses associated with the reduction of productivity of work, non-produced products and a reduction of the national income level of the economy as a result of illness, disability or premature death.

29. 29 The most noticeable economic damage The most noticeable economic damage among the working population is due to the temporary or permanent disability. An employee unable to work isn’t involved in the production of the social product and the society spends on he/ she its resources in the form of grants, pensions, medical aid, education of disable people due to the re-qualification and all kinds of social benefits.

30. 30 If a disabled person retains a partial capacity to work and continues to work by profession or on the job is paid at least the same salary, then economical damages of society will be smaller, since they do not include losses related to non-production of new value. If as a result of partial disability patient moves to a work with lower salary it can be assumed that producing by him/ her national income for the certain year is reduced compared to the previous value of national income he/she was produced. This difference of reducing correlates with a share of reducing of an annual salary. Disability is detrimental to society as a whole and the patient’s family. This damage is manifested in for a number of years since determining of a disability up to restore of a workability, retirement or death.

31. 31 The analysis of the total cost of the disease - characterized by the total value of the costs incurred by the society, specific health establishment, family in connection with providing of all diagnostic and treatment activities during the treatment of the disease. C tcd = C dc + C ic, C tcd = C dc + C ic, C tcd C tcd – coefficient of total cost of diseases C dc C dc – coefficient of direct cost C ic C ic – coefficient of indirect cost

32. 32 Direct costs Direct costs - these are the costs of medical activities which are directly related to patient's care. These include: the costs of diagnostic, treatment and preventive measures, handling and procedures, the cost of medicines, patient’s feed and fees for the use of medical equipment and buildings, etc. Indirect costs Indirect costs are charges that are not directly related to the therapeutic process, but create the conditions for it. Indirect costs, as a rule, constitute the largest part of the costs of organization, but they are not related with the treatment's process directly. These types of expenses are related to the use of service units (community facilities, transports, information systems, communication services, etc.).

33. 33 Cost minimization analyses (CMA) Cost minimization analyses (CMA) allows comparative analysis of two or more interventions having the same therapeutic effect and safety, but different economic costs (for instance, a simple surgery in outpatient or inpatient conditions).

34. 34 Cost-effectiveness analyses (CEA) Cost-effectiveness analyses (CEA) is fundamental in the clinical-economic analysis. It reflects the costs to a one cured patient (per unit of effect). Cost effectiveness analysis shows the amount you have to spend to get the unit effect. Cost effectiveness coefficient allows to compare different methods of treating diseases, leading to the achievement of common goals (e.g. reduction of mortality).

35. 35 The main demand for the use of cost-effectivness analyses is the presence of the same units of measurement of the effect: the years of life saved; preventing deaths; prevention of disability; the number of cured patients; the number of prevented complications etc.

36. 36 Integral gain efficiency Integral gain efficiency - based on the principle of effective approach of care’s analyses and reflects the degree of achievement of specific results in certain costs. This coefficient depends primarily on the choice of medical technologies and their application, that is on the quality of medical care. specific results Under the specific results in depending on the estimated object refers indicators of a condition’s dynamic of the patient, changing specific health parameters of certain contingent (e.g. moving from one dispensary group to another in assessing clinical examination, customer satisfaction, which can be both patient and health care worker who has appointed any study).

37. 37 Cost-utility analysis (QUA) Cost-utility analysis (QUA) allows to evaluate the results of the intervention in terms of "utility" from the point of view of the health care consumer (e.g. improvement quality of life). The most often used integral index of "quality adjusted life years » (QALY). It is unacceptable in health care to consider economic efficiency in isolation from medical activities. And even more, the only effective medicine that provides a good clinical effect and brings the patient to the "utility" of 1.00, i.e. to a state of absolute health. "Utility" is expressed by a conventional unit as a "gain in life years" or "prevent death."

38. 38 Cost-utility ratio is considering the "utility" as a measure of results. In monetary terms the results are calculated as the cost per unit of "utility" or costs "for a year of healthy life taking into account health status» (QALY). The analysis of a cost-utility it is estimation not only the achievement of certain clinical outcomes but the opinion of the patient about health condition’s progress in terms of their “utility”, i.e. it is taken into account patient’s preference in choosing of a method of treatment and its outcome.

39. 39 Quality of life quality of life (QOL) well-being The term quality of life (QOL) references the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. Quality of life should not be confused with the concept of standard of living, which is based primarily on income. Instead, standard indicators of the quality of life include not only wealth and employment, but also the built environment, physical and mental health, education, recreation and leisure time, and social belonging.

40. 40 When the phrase is used in reference to medicine and healthcare as Health Related Quality of Life (HRQoL), it refers to how the individual’s wellbeing may be impacted over time by a disease, a disability, or a disorder.

41. 41 The current concept of HRQoL acknowledges that subjects put their actual situation in relation to their personal expectation. The latter can vary over time, and react to external influences such as length and severity of illness, family support, etc. As with any situation involving multiple perspectives, patients' and physicians' rating of the same objective situation have been found to differ significantly.

42. 42 physical, social, emotional, cognitive, work- or role-relatedspiritual aspects Consequently, HRQoL is now usually assessed using patient questionnaires. These are often multidimensional and cover physical, social, emotional, cognitive, work- or role-related, and possibly spiritual aspects as well as a wide variety of disease related symptoms, therapy induced side effects, and even the financial impact of medical conditions.