EVALUATION OF THE EFFICIENCY OF MEDICAL ACTIVITY

1. Elena A. Abumuslimova Ph.D., Associate Professor Department of Public Health and Health Care, Northern-West State Medical University named after I.I. Mechnikov, Saint-Petersburg EVALUATION OF THE EFFICIENCY OF MEDICAL ACTIVITY

2. Evaluation of the efficiency of medical activity is a logical and explicit framework to health care workers, decision-makers, governments or society at large, to make choices on how best to use resources.

3. There is difference between "effect" and "efficiency" of medical activity. • The concept of "effect" means the result of the actions, consequences of effect of any reason. For example, spending the economic resources to treat the patient, the doctor receives recovery or improvement of the patient’s condition. • The term "efficiency" refers to the degree of achievement of results in relation to the inputs spending for the treatment. Evaluating the effectiveness shows how to use the material, human and financial resources in any medical method, intervention, treatment or prevention.

4. The concept of "effectiveness of medical care" shouldn’t be identified with general economic category, with the corresponding criterion in the sphere of material production. It is possible to have "zero" or even "negative" economic outcome in health care, even with the most skilled labor and the use of modern medical technology.

5. Theconceptofefficiencyisclosetothenotionofeffectiveness. • Effectivenessisgenerallyunderstoodasthedegreeofachievementofpositiveoutcomes, withoutregardtothecostoftheirimplementation. Fromthispointofview, theefficiencycanbedefinedastheeffectivenessinrelationtothecosts. Buthigheffectivenesscanbeachievedwiththeexcessiveeffortandexpensethatsharplylowerseconomicefficiency.

6. Efficiencyandeffectivenessofhealthcaremaybeindirectandinverserelationship. Thisisduetotheactionoftwogroupsoffactors: • 1. Theinfluenceonthetreatment’soutcomeoftheindividualityofapatient. Thusforthesametreatmentindifferentpatientsmaybeexpectedadifferentoutcomesandwhenthesameresultcanbeachievedwithdifferentcosts. • 2. Differentcriterionforevaluatingoftheeffectivenessofdifferentlevelsofcare. Byassigningapatientapotentandexpensivemedicinedoctorevaluatesthepositiveresultsasobtainedatminimumcost, whiletotalhospitalinputscanbehighandlowefficiency.

7. Effectiveness of general health care, its services and separate activities is measured as a set of criteria and indicators, each of them characterizes some aspect of the process of medical practice.

8. Theeffectivenessofthehealthcareindustryisexpressedbythecriteriaclosetomacroeconomicones: itsimpactonmaintainingandimprovingpublichealth, reducingthecostsofhealthandsocialcare, thecostsavingsinothersectorsoftheeconomy, anincreaseinthegrowthofnationalincome. • Theeffectivenessofpublichealthestablishmentswillbedeterminedbyasetofindicatorsapprovedbytherelevanthealthauthorities (morbidity, disability, demographicandothercriteria). • Theefficiencyoftheprivatehealthorganizationswillmostlybedefinedsuchamacroeconomicindicatorasthesizeoftheresultingprofits. • Theeffectivenessofthedoctorworkinginthemedicalestablishments, mainlywillbemeasuredbythestructureofoutcomesoftreatedpatients, thepositivedynamicsofthepatientsunderobservation, etc.

9. Directionsforestimationofefficiencyinpublichealthcare: • Byatypeofefficiency: medical, social, economic. • Byalevel: thelevelofthephysician, thelevelofworkunits, thelevelofhealthestablishment, thelevelofthehealthcareindustry, thelevelofthenationaleconomy. • Bystagesorsectionsofwork: thepreventivestageofthedisease, thetreatmentstage, therehabilitationstage.

10. Directionsforestimationofefficiencyinpublichealthcare: • Volumeofwork: theeffectivenessoftreatmentandpreventivemeasures, theeffectivenessofmedical-socialprograms. • Accordingtothemethodofmeasurementresults: byestimationareductionofalossofresources; becountingthesavingofresources; anadditionalresult, theintegratedindexwhichtakesintoaccountalltheresults. • Accordingtothecost: costofpubliclabor; totalratioofcostsoflivingandsociallabor. • Bytypesoffactors: standardindicatorsofpopulationhealth; indicatorsoflaborcosts, costparameters.

11. Unlike other sectors of the economy the results of therapeutic measures in health care are analyzed from the standpoint of the three types of efficiency: social, medical and economic. The most priorities of which are medical and social efficiency. Without taking into account medical and social efficiency economic efficiency can’t be determined. There is a relationship and interdependence between these three types of efficiency.

12. Medicalefficiency • there is degree of achievement of objectives for the prevention, diagnosis, treatment and rehabilitation of diseases.

13. Medicalefficiency • Medicaleffectivenessisevaluatedonseverallevels. • Onthelevelofonespecificpatientmedicalefficiencyishealingorimprovementofhealth, recoveryoflostfunctionsofspecificorgansandsystems. • Onthelevelofthehealthfacilitiesandpublichealthindustryingeneralmedicaleffectivenessismeasuredbymanyspecificindicators: shareofrecoveredpatients, thereductionofcasesoftransitiontothechronicformofthedisease, reducingthefrequencyofmorbidityamongthepopulation, etc.

14. Medicalefficiency

15. Medical efficiency reflects the extent of achievement of aims in diagnostic and treatment of diseases in the context of quality criteria, adequacy and effectiveness. Medical intervention may be more effective if the scientific level and their implementation provide the best result of health care at the lowest cost of all resources. But even under ideal quality of medical work the main goal for this activity – person’s health - can be don't achieved.

16. Socialefficiency • is the extent of achievement of social results.

17. Socialefficiency • Thiskindofefficiencyinhealthcareisalsoassessedattwolevels: • atthelevelofaspecificpatient: hisreturntoworkandanactivesociallife, satisfactionwithqualityofmedicalaid; • atthelevelofthepublichealthindustry: increasingofthelifeexpectancyofthepopulation, reducingcriteriaofmortalityanddisability, satisfactionofsocietywithqualityofmedicalaidsystemasawhole.

18. Socialefficiency

19. Economicalefficiencyofhealthcare • is the economic effect of the medical establishments activity correlating with the amount of money spent on public health care.

20. Assessing the benefits and costs, economic analysis can compare various medical programs, technologies, services aimed at qualitatively similar results, but obtained with different efficiencies. • Health care specific feature is that often the medical therapeutic and preventive measures can be economically unfavorable, but the medical and social effects demand their carrying out. Thus the organization of health care action for older people with chronic and degenerative diseases, patients with mental problem, etc. has the apparent positive medical and social effectiveness but on the other hand economic effect will be negative.

21. Medical and social effects are achieved by using modern medicine, intensive care - the man's life is saved, but he/ she can become disabled and lose the opportunity to engage in socially useful work. • However the cost effectiveness in the health care don't determines the choice of certain therapeutic measures. But the criteria of economic efficiency along with medical and social efficiency can help in prioritizing of certain medical activities in conditions of limited resources.

22. Themainobjectivesofeconomicanalysisinpublichealtharecomparinghealthcostswiththelevelofsocialandeconomicsociety’slossesfrommorbidityandmortality. Thenextaimisreceivingeconomicaleffectbyimprovingpublichealth. Generallyimprovingpublichealthacceleratesthedevelopmentofsocialproductionandthegrowthofnationalincomeandwelfare. • Cost-effectivenessisassociatedwiththesearchforthemosteconomicaluseofavailableresources. Thiscriterionisanecessaryelementintheassessmentofthefunctioninghealthcaresystemasawhole, itscertaindepartmentsandagencies, aswellaseconomicfeasibilityofmeasuresfortheprotectionofhealthofpopulation.

23. Economic efficiency in health care is considered in two ways: • at the first, for compare the effectiveness of using of different types of resources, • secondly, in terms of evaluating of influence of public health on the development of social production in general.

24. Methodologicalapproachesindeterminingofthecost-effectivenessofhealthcareisbasedprimarilyondeterminingofthecostofthespecialtypesofmedicalcareandepidemiologicalserviceandtheamountofdamagecausedbyvariousdiseases. Costparametersofmedicalcarearetheinitialpointsforcomparingthecostsofmedicalaidandeconomiceffectinevaluationoftheeconomiceffectivenessofhealthcare.

25. Economiceffect •   - is prevented economic damage, that is the damage was prevented as a result of the complex medical measures.

26. Therearealsodirectandindirecteconomiceffects. • Thedirecteconomiceffectisgotduetoimprovedmethodsororganizationofanymedicalactivityleadingtoitscheaper.E.g.,introductionofnewformsoforganizationofworkforhealthworkersandusingofnewformsofmedicalaid (departmentofnursing, onedayhospital, hospitalathome, dayhospitalcare) leadtosavingsofbedsfund. Usingofcheaperandmoreeffectivemethodsofdiagnosisandtreatmentallowreducingthecostofpatient’streatmentandcostperbed-day. • Indirecteconomiceffectisaresultofmedicalandsocialeffectsleadingtoareductionofcoststhroughthesavingsofresourcesspentonatreatmentofdiseasesandreducingeconomiclossesduetopopulation’sdisabilityanddeath.

27. Thereareactualandexpectedeconomiceffect. Whenplanninganactivitywearedealingwiththeexpectedeffects. Inaretrospectiveevaluationoftheresultswecalculateactualeffect.

28. Therearealsodirectandindirecteconomiclosses. • Directeconomiclosses- arethedirectcostsfortreatment, prevention, sanitary-epidemiologicalservice, scientificresearchanddevelopment, trainingofmedicalpersonnel, paymentofbenefitsfortemporaryincapacityanddisabilitypensions. • Indirecteconomicdamage- istheeconomiclossesassociatedwiththereductionofproductivityofwork, non-producedproductsandareductionofthenationalincomeleveloftheeconomyasaresultofillness, disabilityorprematuredeath.

29. Themostnoticeableeconomicdamageamongtheworkingpopulationisduetothetemporaryorpermanentdisability. Anemployeeunabletoworkisn’tinvolvedintheproductionofthesocialproductandthesocietyspendsonhe/ sheitsresourcesintheformofgrants, pensions, medicalaid, educationofdisablepeopleduetothere-qualificationandallkindsofsocialbenefits.

30. If a disabled person retains a partial capacity to work and continues to work by profession or on the job is paid at least the same salary, then economical damages of society will be smaller, since they do not include losses related to non-production of new value. • If as a result of partial disability patient moves to a work with lower salary it can be assumed that producing by him/ her national income for the certain year is reduced compared to the previous value of national income he/she was produced. This difference of reducing correlates with a share of reducing of an annual salary. Disability is detrimental to society as a whole and the patient’s family. This damage is manifested in for a number of years since determining of a disability up to restore of a workability, retirement or death.

31. Theanalysisofthetotalcostofthedisease • - characterizedbythetotalvalueofthecostsincurredbythesociety, specifichealthestablishment, familyinconnectionwithprovidingofalldiagnosticandtreatmentactivitiesduringthetreatmentofthedisease. • Ctcd=Cdc+ Cic, • Ctcd– coefficient of total cost of diseases • Cdc– coefficient of direct cost • Cic– coefficient of indirect cost

32. Directcosts- thesearethecostsofmedicalactivitieswhicharedirectlyrelatedtopatient'scare. Theseinclude: thecostsofdiagnostic, treatmentandpreventivemeasures, handlingandprocedures, thecostofmedicines, patient’sfeedandfeesfortheuseofmedicalequipmentandbuildings, etc. • Indirectcostsarechargesthatarenotdirectlyrelatedtothetherapeuticprocess, butcreatetheconditionsforit. Indirectcosts, asarule, constitutethelargestpartofthecostsoforganization, buttheyarenotrelatedwiththetreatment'sprocessdirectly. Thesetypesofexpensesarerelatedtotheuseofserviceunits (communityfacilities, transports, informationsystems, communicationservices, etc.).

33. Costminimizationanalyses (CMA)allowscomparativeanalysisoftwoormoreinterventionshavingthesametherapeuticeffectandsafety, butdifferenteconomiccosts (forinstance, asimplesurgeryinoutpatientorinpatientconditions).

34. Cost-effectivenessanalyses (CEA) isfundamentalintheclinical-economicanalysis. Itreflectsthecoststoaonecuredpatient (perunitofeffect). • Costeffectivenessanalysisshowstheamountyouhavetospendtogettheuniteffect. Costeffectivenesscoefficientallowstocomparedifferentmethodsoftreatingdiseases, leadingtotheachievementofcommongoals (e.g. reductionofmortality).

35. The main demand for the use of cost-effectivness analyses is the presence of the same units of measurement of the effect: • the years of life saved; • preventing deaths; • prevention of disability; • the number of cured patients; • the number of prevented complications etc.

36. Integralgainefficiency - basedontheprincipleofeffectiveapproachofcare’sanalysesandreflectsthedegreeofachievementofspecificresultsincertaincosts. Thiscoefficientdependsprimarilyonthechoiceofmedicaltechnologiesandtheirapplication, thatisonthequalityofmedicalcare. • Underthespecificresultsindependingontheestimatedobjectrefersindicatorsofacondition’sdynamicofthepatient, changingspecifichealthparametersofcertaincontingent (e.g. movingfromonedispensarygrouptoanotherinassessingclinicalexamination, customersatisfaction, whichcanbebothpatientandhealthcareworkerwhohasappointedanystudy).

37. Cost-utilityanalysis (QUA) allowstoevaluatetheresultsoftheinterventionintermsof "utility" fromthepointofviewofthehealthcareconsumer (e.g. improvementqualityoflife). Themostoftenusedintegralindexof "qualityadjustedlifeyears » (QALY). • Itisunacceptableinhealthcaretoconsidereconomicefficiencyinisolationfrommedicalactivities. Andevenmore, theonlyeffectivemedicinethatprovidesagoodclinicaleffectandbringsthepatienttothe "utility" of 1.00, i.e. toastateofabsolutehealth. "Utility" isexpressedbyaconventionalunitasa "gaininlifeyears" or "preventdeath."

38. Cost-utility ratio is considering the "utility" as a measure of results. In monetary terms the results are calculated as the cost per unit of "utility" or costs "for a year of healthy life taking into account health status» (QALY). • The analysis of a cost-utility it is estimation not only the achievement of certain clinical outcomes but the opinion of the patient about health condition’s progress in terms of their “utility”, i.e. it is taken into account patient’s preference in choosing of a method of treatment and its outcome.

39. Quality of life • The term quality of life (QOL) references the general well-being of individuals and societies. The term is used in a wide range of contexts, including the fields of international development, healthcare, and politics. • Quality of life should not be confused with the concept of standard of living, which is based primarily on income. Instead, standard indicators of the quality of life include not only wealth and employment, but also the built environment, physical and mental health, education, recreation and leisure time, and social belonging.

40. When the phrase is used in reference to medicine and healthcare as Health Related Quality of Life (HRQoL), it refers to how the individual’s wellbeing may be impacted over time by a disease, a disability, or a disorder.

41. The current concept of HRQoL acknowledges that subjects put their actual situation in relation to their personal expectation. • The latter can vary over time, and react to external influences such as length and severity of illness, family support, etc. As with any situation involving multiple perspectives, patients' and physicians' rating of the same objective situation have been found to differ significantly.

42. Consequently, HRQoL is now usually assessed using patient questionnaires. These are often multidimensional and cover physical, social, emotional, cognitive, work- or role-related, and possibly spiritual aspects as well as a wide variety of disease related symptoms, therapy induced side effects, and even the financial impact of medical conditions.