OECD’s Health Care Quality Indicator
Project
Conceptual, Methodological and Policy Challenges
in International Health System Comparison
1
OECD’s Health Care Quality Indicators Project

Niek Klazinga, OECD, Paris, France

Patrick Romano, UC Davis US

Saskia Droesler
Droesler, Niederrhein Uni
University,
ersit German
Germany

Jan Mainz
Mainz, Aarhus University,
University Denmark
2
History OECD’s
OECD s Health Care Quality Indicator
Project








Ministerial Conference Ottawa 2000
Founding work Nordic Countries and Commonwealth Fund
Expert group and subgroups (37 countries in 2010)
Conceptual framework
S stematic selection of q
Systematic
quality
alit indicators and pilot testing
Refinement methodology
Publication in Health at a Glance (2007
(2007,2009)
2009)
Ministerial October 2010
3
Conceptual Framework for OECD
Health Care Quality Indicator
(HCQI) Project.
(shaded area represents the current focus of
th HCQI Project)
the
P j t)
Source: Arah OA, et al. A conceptual framework for the OECD
Health Care Quality Indicators Project. International Journal
Quality Health Care. 2006; Sep 18; Suppl.1:5-13.
4
4
Area’ss of interest
Area
•
•
•
•
•
•
Health promotion,
promotion prevention and primary care
Acute care
M
Mental
l Health
H l hC
Care
Cancer care
Patient safety
Patient experiences
Health Promotion,
Prevention and
Primaryy Care
Indicators related to
“a oidable” hospital admissions
“avoidable”
5.1.1. Asthma admission rates, aged 15 and over, 2007
United States1 (2006)
Korea
Finland
United Kingdom
New Zealand
Poland2 (2006)
Japan (2005)
Austria (2006)
Ireland
Belgium (2006)
OECD
Spain
France
Denmark
Norway
Iceland
Switzerland (2006)
Netherlands (2005)
Sweden
Germany
Canada
Italy (2006)
120
97
92
75
73
62
58
54
52
52
51
44
43
43
42
34
32
26
25
21
18
17
150
100
50
Age-sex standardised rates per 100 000 population
0
164
72
70
101
94
111
100
50
98
47
73
51
60
57
57
51
68
35
62
39
64
38
61
23
54
32
57
29
57
25
52
17
25
35
17
32
16
16
10
12
0
38
26
25
Female
Male
21
50
100
150
Age-standardised rates per 100 000 population
1. Does not fully exclude day cases. 2. Includes transfers from other hospital units, which marginally elevate the rates.
5 1 2 COPD admission rates,
5.1.2.
rates aged 15 and over
over,
2007
Ireland
384
Austria (2006)
Admissions per 100 000 population
322
Denmark
320
New Zealand
5 1 3 COPD admission rates and prevalence rates
5.1.3.
rates,
2007 (or latest year)
350
DNK
308
P l d1 (2006)
Poland1
293
Norway
Iceland
NZL
300
243
POL
240
United Kingdom
250
236
Korea
NOR
GBR
R² = 0.26
206
United States2 (2006)
203
OECD
201
Sweden
192
Canada
190
Belgium (2006)
USA
NLD
150
189
Germany
KOR
200
ITA
100
PRT
184
Finland
170
Netherlands (2005)
154
Italy (2006)
148
Spain
50
JPN
0
139
Switzerland (2006)
0
100
Portugal
95
France
5
10
Prevalence of COPD (%)
79
Japan (2005)
33
0
100
200
300
400
500
Age-sex standardised rates per 100 000 population
1. Includes transfers from other hospital units, which marginally
elevate the rates. 2. Does not fully exclude day cases.
Source: OECD HCQI Data 2009. Rates have been age-sex standardised to the 2005 OECD population. 95% confidence intervals are
represented by H
H.
15
5.3.1. CHF admission rates, aged 15 and over, 2007
352
331
308
306
289
276
234
234
206
202
192
188
176
171
169
165
155
146
134
117
110
600
400
200
Age-sex standardised rates per 100 000 population
395
395
Poland1 (2006)
United States2 (2006)
Germany
Austria (2006)
Italy (2006)
Finland
Sweden
France
OECD
Spain
p
New Zealand
Iceland
Ireland
Norway
Portugal
Netherlands3 (2005)
Belgi m (2006)
Belgium
Denmark
Switzerland (2006)
Canada
Japan (2005)
United Kingdom
Korea
474
441
0
307
274
258
264
408
406
377
363
399
371
214
209
193
290
213
257
167
261
129
317
149
256
148
242
158
199
142
211
137
216
114
235
120
206
119
184
117
153
96
147
123
88
0
200
575
501
Female
Male
400
600
Age-standardised rates per 100 000 population
1. Includes transfers from other hospital units, which marginally elevate the rates. 2. Does not fully exclude day cases. 3. Includes
admissions for additional diagnosis codes, which marginally elevate the rate.
Avoidable hospital admission rates, 2007
Asthma
COPD
Diabetic acute complications
Austria
3
United States1
CHF
Belgium
2.5
United Kingdom
Canada
2
1.5
1
Switzerland
Denmark
0.5
0
-0.5
Sweden
Finland
-1
-1.5
-2
Spain
Germany
Poland2
Iceland
Norway
Ireland
New Zealand
Netherlands3
Italy
Korea
Note: Data from Austria, Belgium, Italy, Poland, Switzerland and the United States refer to 2006. Data from the Netherlands refer to 2005.
1. Data does not fully exclude day cases. 2. Data includes transfers from other hospitals and/or other units within the same hospitals, which marginally elevate the rates. 3. Data for CHF
includes admissions for additional diagnosis codes, which marginally elevate the rate.
Source: OECD Health Care Quality Indicators Database, 2009
A t Hospital
Acute
H
it l Care
C
30 day case-fatality rates
AMI and Stroke
5.4.1. In-hospital case-fatality rates within 30 days after admission for AMI, 2007
9.6
8.1
7.6
9.9
10.7
9.1
10.9
Slovak Republic
66
6.6
L
Luxembourg
b
(2006)
6.6
Netherlands (2005)
6.3
United Kingdom
6.1
9.2
7.7
Czech Republic
5.1
United States (2006)
5.1
Ireland
8.3
7.7
4.9
OECD
4.9
Finland
11.0
7.7
4.5
5.6
4.5
6.6
5.3
6.4
15
10
Rates per 100 patients
6.6
Italy (2006)
New Zealand
3.2
Norway
2.9
Denmark
2.9
3.6
5
Canada
3.3
4.6
Crude rates
Poland
4.2
Sweden
2.1
Iceland
0
8.7
7.1
6.0
6.7
5.8
6.5
5.6
5.5
5.1
5.4
49
4.9
5.0
5.2
4.9
4.9
4.2
5.6
4.6
4.5
4.5
4.5
4.4
4.0
4.3
3.7
3.2
3.3
3.4
3.0
3.1
2.7
2.9
3.0
0.9
3.3
Austria (2006)
4.0
6.9
48
4.8
Spain
5.3
70
7.0
Age-sex standardised rates
8.9
7.2
8.1
7.0
Korea
0
Female
Male
5
10
15
Age-standardised rates per 100 patients
5.4.2. Reduction in in-hospital case-fatality rates within 30 days after admission for AMI, 2003-2007 (or
nearest year)
2003
2005
2007
Age-sex standardised rates per 100 patients
12
10
8
3.7
3
3.4
2.9
4.7
3.9
2.9
4.9
4.2
3
3.2
4.8
3.7
33.3
5.3
5.2
4.2
6.0
5.2
4.5
6.9
5.7
4.5
6.3
5.2
4.7
5.8
5.2
4.9
7.7
6.6
6.1
8.1
6.6
8.3
6.6
6.5
6.2
5.1
2
3.8
4
8.8
8.5
8.1
6
0
Source: OECD HCQI Data 2009. Rates have been age-sex standardised to the 2005 OECD population (45+). 95% confidence intervals are
represented by H.
5.5.1. In-hospital case-fatality rates within 30 days after
admission for ischemic stroke , 2007
9.0
United Kingdom
Canada
7.6
Slovak Republic
7.5
Ireland
6.6
Spain
6.5
New Zealand
6.3
Czech Republic
6.2
Netherlands (2005)
5.9
Luxembourg (2006)
5.6
5.0
OECD
Sweden
3.9
G
Germany
38
3.8
Austria (2006)
3.7
Italy (2006)
3.7
Norway
3.3
Finland
3.2
Slovak Republic
29.3
29.5
11.6
United Kingdom
26.3
32.1
12.1
United States (2006)
12.9
10.7
10.8
9.4
10.5
2.3
Iceland
0
Spain
24.2
28.2
Czech Republic
24.0
27.3
New Zealand
23.8
26.8
Canada
23.2
27.3
19.8
23.5
OECD
9.0
8.4
Iceland
19.8
Ireland
19.4
22.5
It l (2006)
Italy
17.2
17
2
20.8
7.0
Denmark
16.7
21.3
7.3
Germany
14.5
19.7
Norway
13.7
19.9
7.7
7.4
11.0
11 3
11.3
Korea
Age-sex standardised rates
Crude rates
10.8
13.1
Austria (2006)
5
10
15
20
Rates per 100 patients
Age-sex standardised rates
Crude rates
9.5
11.1
Finland
5.8
29.2
12.8
17.2
Sweden
5.9
2.4
3.6
Korea
25.5
26.0
25.2
31.0
Netherlands (2005)
11.4
3.1
53
5.3
Denmark
30.3
32.6
Luxembourg (2006)
17.4
4.2
6.0
United States (2006)
5.5.2. In-hospital case-fatality rates within 30 days after
admission for hemorrhagic stroke , 2007
0
10
20
30
40
Rates per 100 patients
5.5.3. In-hospital case-fatality rates within 30 days after
admission for ischemic and hemorrhagic stroke, 2007
5.5.4. Reduction in in-hospital case-fatality within 30 days
after admission for stroke, 2002-2007
Ischemic stroke
Hemorrhagic stroke
0.4
0.5
Luxembourg 1
Age-sex standardised case-fatality rates for hemorrhagic stroke (%)
16.4
New Zealand
35
R² = 0.54
LUX
30
USA
CZE
25
GBR
ESP
NZL
20
ISL
15
NOR
KOR
10
1.6
5.5
5.4
Spain
9.7
25.6
Ireland
CAN
11.6
16.5
14.1
OECD (13)
IRL
ITA
DNK
5.0
2.5
Denmark
Canada 2
SVL
NLD
1.2
6.5
Sweden
DEU
15.7
24.2
Finland
SWE
AUT
17.6
16.8
17.8
Germany 2
FIN
35.7
Netherlands 2
5
18.9
22.9
20.4
Korea 2
14.0
Austria
0
0
2
4
6
8
10
28.6
39.8
Norway
33.8
Age-sex standardised case-fatality rates for ischemic stroke (%)
0
10
20
30
40
50
% decline over period (standardised rates)
1. Based on change from 2002-2003 to 2006. 2. Based on a threeyear period only.
Source: OECD HCQI Data 2009. Rates are age-sex standardised to the 2005 OECD population (45+). 95% confidence intervals are
represented by H in the relevant charts.
M t lH
Mental
Health
lth C
Care
Re-admission rates
schizophrenia
p
and bi-polar
p
disorders
5.6.1. Unplanned schizophrenia re-admissions to the same hospital, 2007
31.9
32.2
31.8
28.2
25.9
25.3
20.6
24.7
20.3
19 2
19.2
23.1
18.2
18.0
16.7
18.7
15.9
17.2
17.6
15 1
15.1
13.3
16.3
10.4
11.5
8.8
8.2
5.7
6.9
Finland
27.0
Sweden
23.2
Denmark
22.6
Norway
21.4
Ireland
18.1
OECD (12)
17.7
Belgium (2006)
16.5
New Zealand
16 4
16.4
Canada (2005)
Italy (2006)
14.8
Spain
10.9
United Kingdom
8.5
Slovak Rep. (2006)
6.3
40
30
20
10
Age-sex standardised rates per 100 patients
0
0
Female
Male
10
20
30
40
Age-standardised rates per 100 patients
5.6.2. Unplanned bipolar disorder re-admissions to the same hospital, 2007
33.9
36.9
30.5
30
5
28.3
22.0
26.6
19.4
18.0
20.4
17.7
19.1
16.8
19.3
17.5
16.1
16.7
14.1
14.7
12.5
11 1
11.1
11.2
10.6
11.1
7.0
6.4
5.6
6.8
Fi l d
Finland
25.1
Sweden
23.2
Ireland
19.4
Denmark
18.4
Norway
17.8
New Zealand
16.8
OECD (12)
15.4
Canada (2005)
13.6
Belgium (2006)
11.1
Spain
10.9
Italy (2006)
United Kingdom
6.7
Slovak Rep. (2006)
6.2
40
30
20
10
Age-sex standardised rates per 100 patients
0
0
Female
Male
10
20
30
40
Age-standardised rates per 100 patients
Source: OECD HCQI Data 2009. Rates are age-sex standardised to the 2005 OECD population. 95% confidence intervals are represented
by H.
Cancer care
Screening and survival rates
breast,, cervical and colorectal
cancer
5.7.1. Cervival cancer screening, percentage of women
screened aged 20-69, 2000 to 2006 (or nearest year)
5.7.2 Cervical cancer five-year relative survival rate, 19972002 and 2002-2007 (or nearest period)
83.5
United States 1
United Kingdom 1
79.4
Sweden 1
78.6
75.6
Norway 1
72.8
Canada 2
72.4
France 2
76.5
74.1
Korea
Canada
71.9
61.9
Iceland
71.0
Japan
70.6
Finland
69.0
66.0
Iceland 1
71.0
Netherlands
69.0
63.3
New Zealand 1
70.6
New Zealand
67.7
63.0
Finland 1
70.5
France
67.3
Netherlands 1
69.6
United States
67.0
66.4
Denmark 2
69.4
Norway
65.9
67.8
Sweden
65.8
62.9
OECD (14)
65.6
Ireland
63.3
54.1
Czech Republic
61.6
62.0
Belgium 1
65.3
OECD
64 0
64.0
62.2
Ireland 1
60.6
Australia 1
41.7
Luxembourg 1
2006
2003
2000
27.5
Hungary 1
24.5
Japan 2
0
1. Programme. 2. Survey.
20
40
61.3
65.5
Denmark
38.5
Italy 1
60
80
100
Percentage
57.6
United Kingdom
50.1
Poland
0
20
2002-2007
1997-2002
40
60
80
100
Age-standardised rates (%)
5.7.3. Cervical cancer mortality, females, 1995 to 2005 (or nearest year)
Age-standardised rates per 100 000 females
18
1995
2000
2005
16
14
12
10
0
Sources: OECD HCQI Data 2009. Survival rates are age standardised to the International Cancer Survival Standards population. OECD
Health Data 2009 (cancer screening; mortality data extracted from the WHO Mortality Database and age standardised to the 1980 OECD
population). The 95% confidence intervals are represented by H in the relevant charts.
0.6
0.7
1.1
1.2
1.3
1.5
1.6
1.7
1.9
1.9
2.0
2.1
2.1
2.1
2.2
2.4
2.4
2.4
2.9
2.9
3.0
3.4
3.7
4.33
55.7
4.7
2
6.0
4
6.9
6
11.4
8
5.8.1. Mammography screening, percentage of women
aged 50- 69 screened, 2000 to 2006 (or nearest year)
5.8.2 Breast cancer five-year relative survival rate, 19972002 and 2002-2007 (or nearest period)
Netherlands 2
89.0
United States
90.5
88.6
Finland 1
86.2
Iceland
88.3
Canada
87 1
87.1
85.6
Sweden
86.1
83.8
I l d1
Ireland
78 1
78.1
Norway 1
76.7
72.5
United States 2
Japan
86.1
Finland
86.0
82.0
Luxembourg 1
63 5
63.5
Netherlands
85.2
80.0
80
0
OECD
62.2
France
82.6
Iceland 1
62.0
Denmark
82.4
76.2
New Zealand
82.1
77.0
Norway
81.9
80.5
OECD (14)
81.1
70.7
United Kingdom 1
70.4
Canada 2
Hungary 1
60.2
New Zealand 1
60.1
Italy 1
59 6
59.6
Belgium 1
59.0
56.2
Australia 1
47.1
France 1
35.6
Czech Republic 1
2006
23 8
23.8
Japan 2
2003
2000
19.5
Slovak Republic 1
0
1. Programme. 2. Survey.
50
100
Percentage
United Kingdom
77.9
Ireland
76.2
72.2
Korea
75.5
76.9
C
Czech
hR
Republic
bli
75 4
75.4
70.8
61.6
Poland
2002-2007
1997-2002
0
20
40
60
80
100
Age-standardised rates (%)
5.8.3. Breast cancer mortality, females, 1995 to 2005 (or nearest available year)
1995
2000
2005
Age-standardised rates per 100 000 females
40
30
0
1. Rates for Iceland and Luxembourg are based on a three-year average.
Sources: OECD HCQI Data 2009. S urvival rates are age standardised to the International Cancer Survival Standards population. OECD
Health Data 2009 (cancer screening; mortality data extracted from the WHO Mortality Database and age standardised to the 1980 OECD
population). The 95% confidence intervals are represented by H in the relevant charts.
5.8
10..4
11.0
16.7
19.2
19.3
19.3
19.5
19.5
19.9
20.0
20.3
20.5
20.7
20.8
21.1
21.3
21.5
22.4
22.4
23.1
23.9
24.9
25.1
25.8
27.0
24.2
10
28.4
29.5
20
5.9.1. Colorectal cancer, five-year relative survival rate, total and male/female, latest period
67.3
Japan (1999-2004)
66.0
68.7
66.1
Iceland (2003-2008)
63.2
69.2
65 5
65.5
62.0
Finland (2002-2007)
62.0
57.0
60.9
New Zealand (2002-2007)
62.3
59.6
60.7
Canada (2000-2005)
62.3
59.6
59.8
Sweden ((2003-2008))
64.5
55.2
55
2
58.1
Korea (2001-2006)
57.1
59.1
58.1
Netherlands (2001-2006)
58.2
58.4
57.8
Norway (2001-2006)
59.0
56.9
57.2
OECD
57.9
56.3
57.1
France (1997-2002)
58 5
58.5
56.6
54.4
Denmark (2002-2007)
54.8
54.2
52.3
Ireland (2001-2006)
54.3
50.7
50.7
United Kingdom (2001-2006)
51.5
50.1
46.8
40
20
48.5
45.6
45
6
Czech Republic (2001-2006)
(2001 2006)
38.1
100
80
60
Age-standardised rates (%)
65.1
65
1
65.9
United States (2000-2005)
0
Female
39.3
34.7
Poland (2002-2007)
0
20
40
Male
60
80
100
Age-standardised rates (%)
y
relative survival rate,,
5.9.2. Colorectal cancer,, five-year
1997-2002 and 2002-2007
65.5
62.5
United States 1
Finland 2
62.0
60.0
New Zealand
60 9
60.9
57.0
Canada 1
60.7
59.6
Sweden
60.1
57.4
K
Korea
3
58.1
52.3
Netherlands 3
58.1
56.9
OECD (11)
57.9
54.6
Norway 3
57.8
55.0
Denmark
54.4
50.2
Ireland 3
52.3
48.9
46.8
41.1
Czech Republic 3
0
20
2002-2007
1997-2002
40
60
80
Age-standardised rates (%)
y, 1995 to 2005 (or
( nearest
5.9.3. Colorectal cancer mortality,
year)
Hungary
Czech Republic
Slovak Republic
New Zealand
Denmark
Norway
y
Ireland
Poland
Netherlands
Belgium
Germany
Portugal
Spain
OECD (27)
Austria
Luxembourg
Canada
United Kingdom
Japan
France
Italy
S d
Sweden
Australia
Korea
Iceland
United States
Switzerland
Finland
Greece
Mexico
31.9
31.0
29.8
25.3
25.0
21.4
21.0
20.8
20.6
20.2
19.8
19.8
19.2
19 0
19.0
18.8
18.2
18.0
17.6
17.6
17.2
17.0
16 8
16.8
16.7
15.2
14.6
14.4
14.2
13.2
12.1
5.2
2005
1995
0
10
20
30
40
Age-standardised rates per 100 000 population
1. 2000-2005 rather than 2002-2007. 2. 1998-2003 rather than 1997-2002 3. 2001-2006 rather than 2002-2007.
Sources: OECD HCQI Data 2009. Survival rates are age standardised to the International Cancer Survival Standards population. OECD
Health Data 2009 ((mortality
y data extracted from the WHO Mortality
y Database and age
g standardised to the 1980 OECD p
population).
p
) The 95%
confidence intervals are represented by H in the relevant charts.
Patient Safetyy
Indicators
26
Indicators
– Foreign
g bodyy left in during
gp
procedure ((PSI 5)
– Catheter related bloodstream infections (PSI 7)
– Postoperative pulmonary embolism or deep vein thrombosis
(PSI 12)
– Postoperative sepsis (PSI 13)
– Accidental puncture and laceration (PSI 15)
– Obstetric trauma -- vaginal delivery with instrument (PSI 18)
– Obstetric trauma -- vaginal delivery without instrument (PSI
19)
27
Patient Experiences
• Common set of questions for population based
statistics under development on access,
autonomy and communication
• B
Basic
i set off principles
i i l ffor setting
i up national
i
l
systems for measuring patient experiences
Limitations National Information
I f
Infrastructures
•
•
•
•
•
Mortality Statistics
Registries
Ad i i
Administrative
i Data-Bases
D
B
Electronic Health Records
Household and Patient Surveys
National Information Infrastructures
• Mortality statistics
• Registries (cancer)
• Administrative
Databases
• Electronic Health
Records
• Surveys
• UPI’s/co-morbidity
UPI s/co morbidity
• UPI’s/coding-staging
• UPI
UPI’ss, present-atpresent at
admission codes,
g
secondaryy diagnoses
• Standardized secondary
data-use, privacy
concerns
• UPI’s
Recommendations ministerial October 2010




Legislation balancing
privacy and data need
quality led governance
quality-led
UPI, secondary diagnosis
g p
present-oncoding,
admission flags
EHR for population
statistics
National patient
experiences
p
measurement


Linking with Q policies on
health system input,
design monitoring and
design,
improvement
Good p
performance and
mutual learning
31