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TOWARDS HEALTH CARE PLANNING AND EVALUATION

Professor Michael Clarke Dept of Epidemiology & Public Health

Are we doing the right thing? - evidence based medicine To the right people? - appropriate care Often enough - meeting needs

People have health care Needs Health services are the responses to the Needs Good Quality Health services must be: (i) effective (ii) efficient (iii)equitable ie work for the lowest cost, and be fairly distributed

A Taxonomy of Need

Needs : Items of service, or resources, felt to be required, either by consumers or providers………………… Demands : …………….. which are applied for …….

Met (demands) ……….. provided and utilised …… (admissions, consultations) Unmet (demands) …… and the request is rejected or, (more usually) cannot be met at that time (waiting lists)

CONSUMER DEFINED NEED NEED DEMAND MET NEED DEM.

UNMET NEED

CONSUMER DEFINED NEED NEED DEMAND MET NEED DEMAND MET (UTILISATION) NEED DEM.

UNMET NEED DEM.

UNMET NEED NEED PROVIDER DEFINED NEED

CONSUMER DEFINED NEED NEED DEMAND MET NEED DEM.

UNMET NEED DEMAND MET DEM.

UNMET NEED PROVIDER DEFINED NEED

CONSUMER DEFINED NEED NEED DEMAND MET NEED DEMAND UTILISATION NEED DEM.

UNMET NEED DEM.

UNMET NEED NEED PROVIDER DEFINED NEED INAPPROPRIATE / INEFFECTIVE CARE

Examples of Inappropriate Care

UK Approximate % 50 Coronary angiography and bypass surgery in Trent 60 Cholecystectomies in North West Thames USA 66 Carotid endarterectomies – 65+ 25 Gastrointestinal endoscopies 25 Coronary angiographies 25-66 Coronary artery bypass ops Brook, R.H. Brit. Med. J. (1994) 308, 218-9

Factors which influence Quality of health care STRUCTURES (RESOURCES) Capital Facilities Hospitals Doctors Surgeries Ambulances Trained Personnel

Factors which influence Quality of health care STRUCTURES (RESOURCES) PROCESSES (USE OF RESOURCES) Capital Facilities Hospitals Doctors Surgeries Ambulances Trained Personnel Consultations Procedures Admissions etc (Ethical Relevant Effective Socially acceptable)

Factors which influence Quality of health care STRUCTURES (RESOURCES) PROCESSES (USE OF RESOURCES) OUTCOMES Capital Facilities Hospitals Doctors Surgeries Ambulances Trained Personnel Consultations Procedures Admissions etc (Ethical Relevant Effective Socially acceptable) Death Disease Disability Discomfort Dissatisfaction Debt

Derived from Donabedian, A. Evaluating the Quality of Medical Care. Milb. Mem. Fund Quart. 44(3) Part2:116-323, July 1963.

Q A How do we know what are the best structures or processes?

(i) Judgemental method ‘human rights’ avoidable factors in care Consensus Conferences (ii) Comparative approach confounders case mix differences

Case Study of the Comparative Method

Paediatric Intensive Care

Provision of intensive care for children A geographically integrated service may now be achieved A study comparing illness adjusted mortality for children living in the ‘Trent’ region, where paediatric intensive care provision is fragmented among 19 centres, with that in the two paediatric intensive care units in Victoria, Australia – which has similar size of child population and similar rate of admission to paediatric intensive care – showed both an excess mortality and a greater length of stay in Trent Jane Ratcliffe, Consultant Paediatric Intensivist, Alder Hey Childrens Hospital, Liverpool BMJ Editorial Vol. 316, 1547, 23 May 1998

Should paediatric intensive care be centralised? Trent versus Victoria

Lancet (1997), 349, 1213-17 Gale Pearson, Frank Shann, Peter Barry, Julian Vyas, David Thomas, Colin Powell, David Field

ONS Population Data for Trent 1994 &1996 Population Total <16 years 1994 913,700 1996 4,781,000 975,000 Deaths aged 1 month to <15 years Number Rate per 100,000 < 15 years (+/- 95% ci) 268 29.3

(26.0–33.0) 312 32.0

(28.6-35.7)

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population increase due to boundary changes – 1996 includes Grimsby & Scunthorpe 1994 – 28% deaths <15 years occur in PICU’s (74 deaths)

Population Total <16 yrs Deaths 1 month – 16 yrs Number Rate/100,000<16 PICU Admissions No. per year Per 1000 <16 Deaths in ICU Deaths per 1000 ICU admissions Trent 4,2000,000 913,700 266 (100%) 29.1

1014 1.22

74 (28%) 73 Victoria 4,500,000 1,011,000 257 (100%) 25.4

1194 1.18

60 (23%) 50

PICU Admissions No. per year Per 1000 <16 Deaths in ICU Deaths per 1000 ICU admissions PICU Admissions No. per year per 1000 <16 Deaths in ICU Deaths per 1000 ICU admissions Trent 1014 1.22

74 (28%) 73 1414 1.55

74 (28%) 52 Victoria 1194 1.18

60 (23%) 50 1194 1.18

60(23%) 50

Next Steps 1. Undertake Prospective Study – as initial step in developing a continuing evaluation of P.I.C.

2. Establish a simple Enquiry into all Paediatric Mortality in Trent

When Comparing Health Care Systems BEWARE !

1. Population errors 2. Cases missed, not admitted (unmet need) 3. Differences in case definitions, admissions policies 4. Counting people or admissions 5. Differences in case mix

Q How do we know what are the best structures or processes?

A (i) Judgemental method ‘human rights’ avoidable factors in care consensus Conferences (ii) Comparative approach confounders case mix differences (iii) Experimental (RCTs) Methods

Theory Explore relevant theory to ensure best choice of intervention Strategic design issues Pre-clinical Continuum of increasing evidence

Modelling Theory Explore relevant theory to ensure best choice of intervention Strategic design issues Identify the intervention, and the underlying mechanisms by which they will influence outcomes.

Pre-clinical Phase I Continuum of increasing evidence

Modelling Exploratory Trial Theory Explore relevant theory to ensure best choice of intervention Strategic design issues Identify the intervention, and the underlying mechanisms by which they will influence outcomes.

Design a feasible protocol for comparing the intervention to an appropriate alternative Pre-clinical Phase I Phase II Continuum of increasing evidence

Theory Explore relevant theory to ensure best choice of intervention Strategic design issues Definitive RCT Modelling Exploratory Trial Identify the intervention, and the underlying mechanisms by which they will influence outcomes.

Theory Explore relevant theory to ensure best choice of intervention Strategic design issues Long-term Implementation Definitive RCT Modelling Exploratory Trial Identify the intervention, and the underlying mechanisms by which they will influence outcomes.

Design a feasible protocol for comparing the intervention to an appropriate alternative Compare a fully defined intervention to an appropriate alternative that is an adequate control Determine whether others can reliably replicate your intervention and results in uncontrolled settings over the long tern Pre-clinical Phase I Phase II Phase III Continuum of increasing evidence Phase IV

RCTs can be simple or complex (i) a) drugs b) appliances - simple (ii) a) management e.g. length of stay b) personnel e.g. nurse practitioner (iii) Preventive services - complex e.g. screening programmes

SUMMARY

1. Evaluation is essential if we are to get the best “bang for the buck” 2. Evaluation of health services needs the best quality clinical science 3. Best clinical science includes patient outcomes from a variety of perspectives, measured over the longer term

PHARMACEUTICAL RESEARCH PRECLINICAL -pharmacology, animal toxicity PHASE 1 TRIALS Clinical pharmacology and toxicity Drug metabolism and bioavailability Healthy volunteers PHASE II TRIALS Initial treatment studies on small numbers of patients PHASE III TRIALS Large scale randomised trials comparing a standard treatment with a new treatment PHASE IV TRIALS Postmarketing surveillance Long term safety The yellow card system Promotional activity Changing prescribing behaviour HEALTH SERVICE RESEARCH BASIC LABORATORY SCIENCE CLINICAL SCIENCE Service Innovation EXPLANATORY TRIALS PRAGMATIC TRIALS Economic assessment Patient compliance Patient satisfaction PROGRAMME EVALUATION Long-term monitoring Dissemination of Research findings Health gain