Monitoring infections, complications and incidents, and registration of failure costs

1. 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

2. Envisioning health care quality in Hungary Examples: Surgical Site Infection Surveillance Pressure Ulcer Surveillance Breast Cancer Management

3. 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 HunHTAUnit of Health Economics and Health Technology Assessment

4. What was heard related to accountabilityduring 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.” HunHTAUnit of Health Economics and Health Technology Assessment

5. 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. HunHTAUnit of Health Economics and Health Technology Assessment

6. 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 HunHTAUnit of Health Economics and Health Technology Assessment

7. 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 HunHTAUnit of Health Economics and Health Technology Assessment

8. Methods • Surveillance Methodology • Hospitals in Europe Link for Infection Control through Surveillance (HELICS) • 1992/97 CDC definition of SSI • Hospital Selection:convenience sample • Procedures: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 HunHTAUnit of Health Economics and Health Technology Assessment

9. NNIS SSI Risk Index HunHTAUnit of Health Economics and Health Technology Assessment

10. Procedure-specific, Risk-Adjusted SSI Rates and NNIS Percentile Ranks HunHTAUnit of Health Economics and Health Technology Assessment

11. Procedure-specific, Risk-Adjusted SSI Rates and NNIS Percentile Ranks HunHTAUnit of Health Economics and Health Technology Assessment

12. 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 HunHTAUnit of Health Economics and Health Technology Assessment

13. 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 HunHTAUnit of Health Economics and Health Technology Assessment

14. 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 HunHTAUnit of Health Economics and Health Technology Assessment

15. The effectiveness and cost-effectiveness 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 - compliancebelow 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 HunHTAUnit of Health Economics and Health Technology Assessment

16. 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 HunHTAUnit of Health Economics and Health Technology Assessment

17. 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? HunHTAUnit of Health Economics and Health Technology Assessment

18. 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?) HunHTAUnit of Health Economics and Health Technology Assessment

19. 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. HunHTAUnit of Health Economics and Health Technology Assessment

20. 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. HunHTAUnit of Health Economics and Health Technology Assessment

21. 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. HunHTAUnit of Health Economics and Health Technology Assessment

22. 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 HunHTAUnit of Health Economics and Health Technology Assessment