Transcript Slide 1

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 Practitoners
Public Health
Clinical Professionals
Hospital Based services (Secondary Care)
Consultants
NCHDs
Nursing
Clinical 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 acquisition
National databases
Cancer Registry
Intellectual Disability database
National Physical and Sensory Database
Quantitation of activity in secondary care
Activity levels in acute hospitals
Waiting 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 acquisition
National databases
Cancer Registry
Intellectual Disability database
National Physical and Sensory Database
Quantitation of activity in secondary care
Activity levels in acute hospitals
Waiting lists
Health Status of Population:
Measurables
Notifiable Diseases/ Conditions
Primary care based data acquisition
National databases
Cancer Registry
Intellectual Disability database
National Physical and Sensory Database
Quantitation of activity in secondary care
Activity levels in acute hospitals
Waiting 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 acquisition
National databases
Cancer Registry
Intellectual Disability database
National Physical and Sensory Database
Quantitation of activity in secondary care
Activity levels in acute hospitals
Waiting 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
Epidemiology of MND in Ireland
6.0
5.7
5.3
4.7
Per 100,000 population
5.0
5.7
5.7
4.8
4.1
4.0
3.0
1.9
2.3
2.3
2.0
1.6
2.0
2.0
2000
2001
1.4
1.0
0.0
1995
1996
1997
1998
Year
1999
Prevalence rates
Incidence rates
Frequency of Review by a
Neurologist in Ireland
100%
80%
60%
40%
20%
0%
MS
m
>1
2
m
12
ev
er
N
th
s
on
th
s
on
on
m
6
M
on
th
l
th
y
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
Neurologists in Europe
Distribution of neurologists in Europe
Distribution of neurologists in Europe
8 100
It a ly
It a ly
N o rw a y
18 400
N o rw a y
D e nma rk
D e nma rk
Gre e c e
21 200
21 300
A us t ria
23 200
A us t ria
Lux e mb o urg
23 900
Lux e mb o urg
N e t he rla nd s
25 800
29 100
N e t he rla nd s
S w it z e rla nd
Gre e c e
S w it z e rla nd
P o rt ug a l
33 100
P o rt ug a l
Sweden
35 600
Sweden
38 500
F ra nc e
F ra nc e
177 000
UK
UK
333 300
Ire la nd
0
400000
Population per neurologist
Ire la nd
0
25
50
75
100
Neurologists per million population
125
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
M
ac
k
D
is
or
de
le
m
s
r
Di
se
as
e
M
e
M
ne
ya
ig
st
it s
he
ni
a
G
ra
vi
s
s
n
ND
CI
DP
M
St
ro
ke
Sc
le
ro
si
s
ile
ps
y
Ep
Pr
ob
so
n
Pa
rk
in
er
si
o
ca
lB
le
ul
t ip
Co
nv
ed
i
M
In Patient Services to Neurology
Beaumont Hospital 2003
140
120
100
80
Admissions
60
40
20
0
ed
i
S
Ne
o
4
pl
as
m
CI
DP
s
4
CN
G
ra
vi
le
m
s
s
r
6
a
Pr
ob
yo
si
ti
de
7
ya
st
he
ni
ac
k
M
is
or
9
M
ca
lB
D
ND
10
M
n
M
29
ve
rs
io
S
30
Co
n
M
ile
ps
y
60
St
ro
ke
Ep
No of Admissios
Admissions from A+E
Top Ten A&E Admissions
51
50
40
27
20
3
2
0
ta
lA
dm
y
20
17
10
A
ta
dm
lA
dm
C
ID
P
Re
A
dm
80
Re
100
To
To
Number of
Admissions
Re
ile
ps
Ep
140
A
dm
ta
lA
dm
M
S
Re
To
ta
A
lA
dm
dm
St
ro
ke
Re
To
A
ta
dm
lA
dm
M
ND
To
Readmission Rates
128
120
91
67
60
43
40
24
4
10
0
13
Length of Stay for top 4 Diagnoses
30
27.9
25
23.2
20
Mean length of
15
Stay in Days
10
18.5
15.9
14.3
12
8.7
A&E
12.5
12
11
11
Elective
8.8
5
0
Epilepsy
MS
Transfers
Stroke
Diagnosis
MND
How Do We Compare?
Top 5 Dx, Beaumont and
Massachusetts General Hospital
20
18
16
14
12
10
8
6
4
2
0
MGH
S
Hy
dr
oc
ep
h
M
ND
Beaumont
M
Ep
ile
ps
y
Ab
sc
es
s
Days
Mean Length of Stay
Cost Analysis
Cost Analysis for Year 2003 (Diagnositic Related only)
35000
31284
30000
25000
20692
20000
Cost in €
17380
15000
10000
4145
5000
2984
0
Epilepsy
Stroke
MS
MND
CIDP
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
1
General Neuro clinic (n = 262)
.8
Cumulative survival
• 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
29.7%
ALS clinic (n = 82)
.6
229 days
10.7%
.4
13.4%
.2
0
0
250
500
750 1000 1250 1500 1750 2000
Time from diagnosis (days)
Treatment with Riluzole
1
Cumulative survival
.8
No Riluzole (n = 97)
Riluzole (n = 149)
97)
.6
.4
.2
0
0
1
2
3
4
Time (years)
5
6
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
Relapsing Remitting
First
exacerbation
Total MRI-Lesion load
Secondary Progressive
Clinical MS
Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA
MRI-Activity
Beta Interferon therapy modifies
the course of Multiple Sclerosis
Relapses and Disability
Total MRI-Lesion load
Relapsing Remitting
Secondary Progressive
EARLY TREATMENT
Clinical MS
First
exacerbation
MRI-Activity
SPMS delayed
Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA
CIDP: Evaluation of Treatment
Outcome
Individualised Measurement preand post- IVIg
Maximal Voluntary Isometric Contraction
(Quantitative Muscle Assessment)
45
MVIC Values Lower Limbs
40
35
Kgs
30
Pre Rx
25
Post
Rx
20
15
Median
for age
10
5
0
HFLL HFLR KEXL
KEXR
KFLL
Movement
KFLR ADFL ADFR
Effect of Rx on muscle strength
Difference in muscle
strength pre v post rx
20
15
10
5
0
-5
-10
-15
cycles of treatment
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
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)
100
80
60
40
alsaq5
20
0
0
10
20
30
alsfrs-r
N=31, r = -0.78, significant at p = 0.01
40
50
Relationship between Quality of Life &
Functional Disability
100
80
60
40
disease
20
PPS
MS
0
MND
0.0
.5
1.0
functional disablilty
1.5
2.0
2.5
3.0
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
Cost Analysis for Year 2003 (Diagnositic Related only)
35000
31284
30000
25000
20692
20000
Cost in €
17380
15000
10000
4145
5000
2984
0
Epilepsy
Stroke
MS
MND
CIDP
Costs of Managing MND
Demography by Year
Male Limb
35
Audit Costs IRL£
Patient care Transport
30
Male Bulbar
25
no. of
new Patients
20
Female Bulbar
15
Female Limb
10
5
Prevalence per
100,000 pop. over
15years of age
0
1996
1997
1998
1999
2000
YEAR
1996
1997
1998
1999
2000
New
Equip.
109,000
117,000
191,000
114,000
108,000
attendants of equip. Storage
15,000
17,000
5,000
27,000
25,000
5,000
28,000
33,000
5,000
33,000
34,000
5,000
51,000
40,000
5,000
Totals
146,000
174,000
257,000
186,000
204,000
Year
Equipment cost- Total/year
Equipment Funding
400,000
350,000
300,000
250,000
IRL£ 200,000
150,000
100,000
50,000
0
250,000
200,000
150,000
IRL£
100,000
50,000
0
IMNDA
National Lottery
Gov. Grant
1996
1996
1997
1998
Year
1999
2000
1997
1998
Year
1999
2000
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