Monitoring infections, complications and
incidents, and registration of failure costs
László Gulácsi, ENQual country coordinator for Hungary
Associate Professor
Budapest University of Economic Sciences
Unit of Health Economics and Health Technology
Assessment HunHTA
Presented at the second ENQual workshop
STAKES, Helsinki 2 April, 2004
Envisioning health care quality
in Hungary
Examples:
Surgical Site Infection Surveillance
Pressure Ulcer Surveillance
Breast Cancer Management
Acknowledgement
Hungarian Hospital Quality Improvement Forum
dr. Rózsa Báthy, dr. Édua Berényi, dr. Ágnes Dobos, Zsuzsa
Kovács, dr. Ilona Málovics, dr. Zsuzsa Molnár, Zsuzsa
Molnár, dr. Kamilla Nagy, dr. Vera Obbágy, dr. Piroska
Orosi, dr. Márta Orosz, dr. Erzsébet Rákay, dr. Zsuzsa
Tatár, dr. József Topár
&
Prof. Donald A. Goldmann, W. Charles Huskins
Harvard Medical School, Children’s Hospital, Boston, USA
HunHTA Unit of Health Economics and Health Technology Assessment
What was heard related to accountability
during the 7th European Forum so far?
Official Opening: Mr. Malcolm Chisholm, Scottish
Minister of Health and Community Services
-
competence of the doctors and nurses, staff
-
openness
-
transparency
-
national overview – breast cancer, ovarian cancer …
-
quality audit of the local health care services
-
investigation of every surgical death
„We are committed to offer public access to clinical information.”
HunHTA Unit of Health Economics and Health Technology Assessment
The main issue
The field of health care accountability is caught in a
struggle between the demands by many interest
groups to immediately release data on quality of
care to the public (as well as to government and
purchasing agencies) and the reality that much of
the available information on hospital quality is
poorly specified, often misleading and potentially
dangerous when misinterpreted.
HunHTA Unit of Health Economics and Health Technology Assessment
Background - SSI and PU
Surveillance
• No data from active, prospective surveillance of
nosocomial infections and PU prevalence
• 0.3 - 0.4 SSI / 100 procedures and 0.2 PU / 100 patients
by passive reports to governmental agencies
• Retrospective chart review suggested that SSI and PU
were underreported; inconsistency with international
literature
HunHTA Unit of Health Economics and Health Technology Assessment
Objectives
• Describe risk-adjusted SSI rates and PU
rates for frequently performed procedures in
Hungarian hospitals using a standardized
surveillance methodology and investigate
the economic burden
• Identify areas for further study and
intervention
HunHTA Unit of Health Economics and Health Technology Assessment
Methods
• Surveillance Methodology
– Hospitals in Europe Link for Infection Control through
Surveillance (HELICS)
– 1992/97 CDC definition of SSI
• Hospital Selection:
• Procedures:
convenience sample
frequently performed procedures as defined by
HELICS
• Training of Infection Control Professionals
• Data analysis:
– adjustment by NNIS risk index
– percentile ranks compared to NNIS hospitals
HunHTA Unit of Health Economics and Health Technology Assessment
NNIS SSI Risk Index
Score
Wound Class
Clean or clean-contaminated
Contaminated or dirty infected
ASA score
0
1
1 or 2
3, 4, or 5
Duration of Surgery
0
1
 Time T*
 Time T*
*T = 75% rounded to the nearest hour
0
1
HunHTA Unit of Health Economics and Health Technology Assessment
Procedure-specific, Risk-Adjusted SSI
Rates and NNIS Percentile Ranks
Risk Index Category
0
Colon surgery
Hip prosthesis
Mastectomy
-1.7 (75-90%)
0 (25%)
1
2
5.9 (50-75%)
10.8 (50-75%)
2.0† (50-75%†)
--
15.9 (>90%)
--
Abd. hysterectomy 1.2 (50-75%)
9.1 (>90%)
--
Laparotomy
6.1 (75-90%) 16.7‡ (>90%‡)
--
HunHTA Unit of Health Economics and Health Technology Assessment
Procedure-specific, Risk-Adjusted SSI
Rates and NNIS Percentile Ranks
Risk Index Category
0
1
Cholecystectomy
1.1 (75-90%) 1.2 (25-50%)
Herniorrhaphy
1.6 (75%)
Appendectomy
0.5 (50-75%) 2.8 (25-50%)
2.9 (50-75%)
Open red. of fracture 0.8 (50-75%) 3.0 (>90%)
2
5.1
(50-75%)
-9.3† (>90%†)
--
HunHTA Unit of Health Economics and Health Technology Assessment
Results - SSI Surveillance
• Feasibility Phase
– 3 months; 25 hospitals; >10,000 procedures
– cumulative rate:
7.2 SSI / 100 procedures
• Investigation Phase
– 6-9 months; 20 hospitals; 9,625 procedures
– cumulative rate:
3.9 SSI / 100 procedures
HunHTA Unit of Health Economics and Health Technology Assessment
Conclusions - SSI Surveillance
• SSI rates 10-20 fold higher than described
by passive surveillance methodology to
governmental agencies
• Rates for moderate-high risk categories of
some procedures are higher than US
hospitals
HunHTA Unit of Health Economics and Health Technology Assessment
Conclusions - Pressure Ulcer
(PU) Surveillance
• The actual PU prevalence is estimated to be 16-27
folds higher than the officially published rate
• The annual direct cost of PU is more than 1% of the
total cost of health care
• On average 1-2,5% of the direct cost of PU
treatment under the current DRG mechanism
HunHTA Unit of Health Economics and Health Technology Assessment
The effectiveness and costeffectiveness of the breast cancer
management, Hungary
• Screening mammography
- inappropriate indication, in at least one third of the cases
- screening in 136 centres, low sample size
- compliance below 30%
• Breast cancer treatment
- in 126 hospitals (164 hospitals in total in Hungary)
- < 50 cases in 56% and < 30 cases/year/hospital in 44% of
hospitals
HunHTA Unit of Health Economics and Health Technology Assessment
Accountability - the concept
• The maximisation of ‘something’ with
available resources
• I fully support
• So, no fundamental problem with the
destination
• But some concerns with the transport
HunHTA Unit of Health Economics and Health Technology Assessment
Thomas Nolan
• What are we trying to accomplish?
• How will we know that a change is an
improvement?
• What changes can we make that will lead
to improvement?
HunHTA Unit of Health Economics and Health Technology Assessment
Accountability: Questions
• Who?
-
Physicians vs. Hospital?
• To whom?
- governmental agencies? (0.3 - 0.4 SSI and 0.2 PU / 100)
- to the public? (3.9 - 7.2 SSI and 3.7 - 5.7 PU / 100)
- fellow colleagues (do they really want to know?)
• Based on what?
• For what care?
• At what level?
- what should be achieved and communicated (willingness to learn,
willingness to improve? quality management or/and quality?)
HunHTA Unit of Health Economics and Health Technology Assessment
Accountability related issues I.
• EBM (Evidence or Economic Based Medicine)
- No systematic method to translate scientific evidence into clinical decision
making and clinical practice
- A great deal of ineffective technology is in use
• Lack of consensus on what constitutes quality
and cost containment
- Quality of health care was neither defined nor debated, the concepts and
goals of cost containment were neither explored nor explained; the
relation between the two was never discussed.
HunHTA Unit of Health Economics and Health Technology Assessment
Accountability related issues II.
• Reluctance to define and rank goals as well as to evaluate
results
• Lack of reliable data on health care
• Limited use of important QI tools such as indicators
• Various elements of QI are imported and implemented
without adaptation (QI tools shopping)
• Accountability Mimicry: health care settings might absorb
innovations/changes without them changing.
HunHTA Unit of Health Economics and Health Technology Assessment
Accountability related issues III.
• Hundreds of clinical conditions could be assessed, and developing
measures for each condition would entail an overwhelming amount of
work.
• Given the fact, that health care is delivered by a team of providers, it
is not clear how outcomes are influenced by physician decision
making, patient compliance with medical recommendations, nursing
care nor organisation of a diverse set of laboratory, pharmacy,
physical therapy and other support services.
• Health care institutions cannot be accountable for the care thy provide
if professionals operate with complete autonomy.
• QI committees are not the center of power in most hospitals, and
quality continues to appear unmeasurable and unmanageable to many
physicians and executives who hold the power.
HunHTA Unit of Health Economics and Health Technology Assessment
Recommendations
• QI should be identified as an important tool of health
policy and planning. Some form of QI activity has to be in
place in order to allow for a particular problem, and the
extent of the burden it creates, to be identified
• Although, data collection and processing are often
successful the analysis of the data is done at a very basic
level. Training is needed.
• Steps have to be taken in order to achieve the support of
the health care professionals and professional
organisations.
Measure! Measure Measure!
QUALITY INDICATORS
HunHTA Unit of Health Economics and Health Technology Assessment