Health Care Quality Indicators
Project
OECD World Forum on Key Indicators
10th November 2004
Draft 29/10/04
Peter Scherer, Counsellor,
Employment and Social Affairs Directorate,
Organisation for Economic Cooperation and Development
Outline of Presentation
1.
2.
3.
4.
5.
6.
7.
Origins of OECD project
Initial indicator collection
New Priority Areas
Example: primary care and prevention
panel
Concerns about initial panel reports
Current work
Ministerial endorsement
2
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.
3
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
4
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
5
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 2003.
Experts agreed to modify the list, adding five more
indicators
6
Initial Indicators collected in 2003












5-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 5-40
30-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
7
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.
8
Influenza Vaccination Rate (>65)
0.9
0.8
0.7
Percentage Immunized
0.6
0.5
0.4
0.3
0.2
0.1
0
C
ad
an
a
D
m
en
k
ar
a
nl
Fi
nd
e
c
an
Fr
e
G
an
rm
y
Ita
ly
p
Ja
an
o
ic
ex
M
N
h
et
nd
la
er
s
N
ew
Z
l
ea
d
an
N
y
wa
or
Sp
n
ai
la
er
nd
itz
w
S
U
d
te
ni
Ki
d
ng
om
U
9
te
ni
d
a
St
s
te
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
10
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
11
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)
12
Note: Number of countries providing data in parentheses
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.
13
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.
14
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)
15
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
16
Examples of Proposed Primary Care
and Prevention indicators (cont’d)

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
17
Examples of prevention indicators
already in use in OECD Countries

Australia
– 57% of women 50-69 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 50-64 get breast ca. screening
– 83% of women 25-64 get cervical ca. screening

United States
– 62% of smokers get smoking cessation advice at routine
office visit
18
Percentage of hypertensives taking medication for
high blood pressure and health expenditure per capita
% Hypertensives taking medication
60
50
United States
40
Canada
Italy
Spain
Sweden
Finland
England
30
20
Germany
10
0
0
500
1000
1500
2000
2500
3000
Total health expenditure / capita, US$PPP 1995
3500
4000
Sources: OECD Health Data 2003 and Wolf-Maier, K. et al. (2003) JAMA; 289: 2363-2369. 19
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).
20
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.
21
7. Ministerial Endorsement



Health Ministers from OECD countries met for
the first time at the OECD on 13 and 14 May
2004.
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:
22
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:
.....
23
Ministerial Communiqué (cont’d)
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.
24