The National Program for Quality Indicators In Community Healthcare:  Methodological Issues
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The National Program for Quality Indicators In Community Healthcare: Methodological Issues Orly Manor 7th meeting of the Eastern Mediterranean Region of the International Biometric Society (EMR-IBS) Tel-Aviv April 22-25, 2013.

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The National Program for Quality Indicators In Community Healthcare: Methodological Issues

Orly Manor

7th meeting of the Eastern Mediterranean Region of the International Biometric Society (EMR-IBS)

Tel-Aviv April 22-25, 2013


“Efforts to improve quality require Healthcare: Methodological Issuesefforts to measure it”(Casalino, 2000:NEJM)


Healthcare in israel
Healthcare in Israel Healthcare: Methodological Issues

National Health Insurance law (1995)

  • Universal healthcare

  • Standard basket of medical services

  • Four health plans (kupot cholim)

  • “Justice, equity and solidarity…medical services will be offered based on medical considerations, with reasonable quality.”


Healthcare in israel1
Healthcare in Israel Healthcare: Methodological Issues

  • Health Tax - progressive , paid to the National Insurance Institute (funds are distributed to the health plans according to a capitation formulae) + modest copayment directly to health plan for specific services

  • Open enrollment, no option to reject applicant, annual option to switch plans

  • Managed competition between plans (uniform benefits)

  • Competition is based on quality and nature of services


Israel National Program for Quality Indicators Healthcare: Methodological Issuesin Community Healthcare (QICH)

  • Supervisory bodies were established “to follow and assess the influence of the NHI law on health services in Israel, their quality, effectiveness and cost"

  • QICH started as a research project (Porath & Rabinovitz, 2002) and later adopted as a national program.

  • Full cooperation and support by all four health plans


Mission
Mission Healthcare: Methodological Issues

To provide the public and policy-makers information on the quality of community healthcare provided in Israel. This information covers various health categories and is intended to promote and improve the standard of healthcare in Israel.


Main product
Main Product Healthcare: Methodological Issues

Annual report presenting national results

of quality indicators in community healthcare

Enables

  • the evaluation of developments and changes in healthcare over time

  • the early identification of risk factors in the Israeli population and in sub-populations

  • the comparison of healthcare quality in Israel with other countries


8 Healthcare: Methodological Issues

"Not everything that counts can be counted,

and not everything that can be counted counts."

Einstein


Quality indicators methods
Quality Indicators- Methods Healthcare: Methodological Issues

9

  • Measures of clinical performance (structure, process, outcome)

  • Based on electronic health records from the four health plans

  • All indicators are rates

  • Some indicators are conditional on others

  • Covariates: age, sex, SEP (proxy)


Quality indicators 2013
Quality indicators (2013) Healthcare: Methodological Issues

10


Example diabetes
Example: Diabetes Healthcare: Methodological Issues

11

  • Blood glucose levels of individuals with diabetes are directly related to the development of complications: cardiovascular disease, blindness, kidney failure

  • Monitoring blood glucose by periodic hemoglobin A1c testing and achieving adequate glycemic control


Example diabetes1
Example: Diabetes Healthcare: Methodological Issues

12

Prevalence measure:

  • Rate of individuals with diabetes mellitus from the entire population (overall and by age and gender)

    Process measure:

  • Rate of individuals with diabetes with documented levels of hemoglobin A1c (HbA1c)

    Outcome (intermediate) measure:

  • Rate of individuals with controlled levels of HbA1c from patients with diabetes with documented levels of hemoglobin A1c (HbA1c)


Methodological issues
Methodological Issues Healthcare: Methodological Issues

  • Criteria

  • Population coverage

  • Data quality-measurement error

  • Data sources

  • Consistency of measures

  • Reporting


Criteria
Criteria Healthcare: Methodological Issues

Implementation


Population coverage
Population Coverage Healthcare: Methodological Issues

  • Population-based, near-complete coverage (not sample)

  • Transfers between health plans

  • Births/deaths

  • Other populations: e.g., soldiers


Data quality misclassification error
Data Quality- misclassification error Healthcare: Methodological Issues

16

  • Estimating the prevalence of a medical condition in the absence of neither a gold standard nor an additional classification.

  • We wish to estimate - prevalence, sensitivity and specificity , yet df=1.

  • We can use a Bayesian approach- simultaneous inferences of the prevalence, sensitivity and specificity and positive and negative predictive value (Joseph et al 1995)

  • Selecting priors- experts’ opinion, understanding sources of data and errors (Greenland 2009)


Data quality consistency of measures
Data Quality- Consistency of Measures Healthcare: Methodological Issues

17

Uniform definitions across health plans

  • Membership

  • Data collection period

  • Numerator and denominator


Data sources
Data Sources Healthcare: Methodological Issues

  • Medical records (e.g., documentation of BMI)

  • Nurse’s records (e.g., documentation of vaccination)

  • Pharmacy claim records (e.g., medication purchase)

  • Laboratory results (e.g., HbA1c levels)

  • Hospital procedure codes (e.g., CABG)

  • Other (e.g., mammography)


Data quality sources of data and sources of error
Data Quality – Sources of Data and Sources of Error Healthcare: Methodological Issues

  • Medical records (e.g., documentation of BMI)

  • Nurse’s records (e.g., documentation of vaccination)

  • Pharmacy claim records (e.g., medication purchase)

  • Laboratory results (e.g., HbA1c levels)

  • Hospital procedure codes (e.g., CABG)

  • Other (e.g., mammography)

Automated vs manual data input

(variation between and within health plans)

Pop-up options vs typing in vaccine name, historical data

(variation between health plans)

ATC vs YARPA/LARGO

(variation between health plans)

Standardized values for calibration

(variation between laboratories)

MOH codes used for billing

(too broad)

Self reported, billing-based


Data quality checks and audit
Data Quality – Checks and Audit Healthcare: Methodological Issues

  • Internal (health plans)

    • Data checks (BI)

    • Feedback loops/criterion validity

  • Quasi-external (directorate)

    • Between and within health plan data checks (outliers)

    • Comparison with existing national data

  • External (independent auditor)

    • Process audit of infrastructure changes

    • Process audit of indicator implementation


Reporting
Reporting Healthcare: Methodological Issues

  • Transparency + court ruling of the public reporting of indicators by health plan

  • Case mix: substantial differences between health plans by SEP

  • Limited available data on SEP

Friedberg et al. (2011). Rand Corporation: Methodological Issues in Public Reporting


Reporting adjusting for case mix
Reporting - Adjusting for Case Mix Healthcare: Methodological Issues

22

  • Israel is divided into statistical areas.

  • The Israel Central Bureau of Statistics calculates SEP scores for each statistical area using recent census information

  • Currently-using GIS each person’s address (unidentified data) is linked to his statistical area and the respective SEP score


Reporting benchmarking
Reporting -Benchmarking Healthcare: Methodological Issues

23

  • Setting benchmarks: setting, testing, comparing??


Diabetes care
Diabetes care Healthcare: Methodological Issues


Diabetes care1
Diabetes care Healthcare: Methodological Issues

Diabetes care includes routine monitoring and proper control of:

  • Blood glucose levels (93%)

  • Cholesterol levels (90%)

  • Blood pressure measurement (92%)

  • BMI assessment (86%)

  • Eye examination (65%)

  • Influenza (55%) and pneumococcal vaccination (77%)


Diabetes care2
Diabetes care Healthcare: Methodological Issues

26


International comparisons diabetes care 2010
International comparisons – Diabetes care (2010) Healthcare: Methodological Issues

*US data from the National Committee for Quality Assurance, HEDIS data set for 2010


Diabetes care israel and england qof 2009
Diabetes care – Israel and England (QOF) (2009) Healthcare: Methodological Issues


Thank you
Thank you Healthcare: Methodological Issues

Directorate: Orly Manor, Arie Ben-Yehuda, Amir Shmueli, Ora Paltiel, Ronit Calderon and Dena Jaffe

Directorate staff: Wiessam Abu Ahmad, Galit Shefer.

Clalit

Chaim Bitterman

Orit Ya’akobson

Arnon Cohen

Margalit Goldsprecht

Tamara Koren

Maccabi

YairBirenboim

EinatElran

Nesya Gordon

Rachel Marom

Guy Levy

Meuhedet

Liora Valinsky

Yossi Zini

Alon Yaffe

Leumit

Daniel Vardi

Eran Matz

Doron Dushnitzky

Nirit Peretz

External auditor: AlizaLukach

Israel National Institute for Health Policy Research

Advisory boards


Importance and relevance
Importance and Relevance Healthcare: Methodological Issues


Evidence moving target
Evidence – Moving Target Healthcare: Methodological Issues

HbA1c control

“Intensive therapy was stopped after a mean of 3.5 years due to increased mortality”The Action to Control Cardiovascular Risk in Diabetes Study Group N Engl J Med 2008; 358:2545-2559

.


Ability to quantify defining diabetes
Ability to Quantify – Defining Diabetes Healthcare: Methodological Issues

32


Reporting1
Reporting Healthcare: Methodological Issues

33


Quasi external audit
Quasi-external Audit Healthcare: Methodological Issues


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