Efficiency in Health Care - Cardiac Care in Sweden

1. Efficiency in Health Care - Cardiac Care in Sweden Rosita Claesson Wigand Project manager (MSc Economics, MPH)National Board of Health and Welfare (NBHW) Department of Statistics and Evaluation Unit for Performance Assessment Telephone : + 46 75 247 37 17E-mail: rosita.wigand@socialstyrelsen.se Nordic Case Mix Conference , Helsinki, June 4, 2010

2. Good Care National Strategy for Good Care N a t i o n e l l t Systematic reviews of evidence-based knowledge Prerequisites Monitoring and evaluation at national level: transparent and open comparisons Regulations, National guidelines and priorities • Regulation on systems for quality and patient safety • Patient Data Act • IT-based documentation • Health Data Registries • National Information Structure • National Terminology • National Indicators Monitoring and evaluation at local and regional levels Steering and systematic work of improvement at local and regional levels

3. National Guidelines • Evidence based reviews: effectiveness and cost effectiveness • Recommendations • priority 1 - 10 • ”not to do” • R&D • Indicators • Expected consequences of implementing the guideline (economic and organisational) • Different versions

4. Performance Assessment Framework - Good Care Effectiveness Safety Patient- centeredness Timeliness Equity Costs of Care Quality of Care Efficiency

5. Efficiency Efficiency Goal/ Desired Outcome Costs Outcome Processes Productivity

6. Objective to assess quality and analyse efficiency of cardiac care in Sweden

7. Methodology 45 process and outcome indicators Data sources: six quality registers patient register prescribed drug register cause of death register Data from 2007 or earlier. Costs (estimations) Data sources: DRGs cost per patient database prescribed drug register statistics, Swedish Association of Local Authorities and Regions (SALAR)

8. Assessment of Quality 45 process and outcome indicators: • General indicators (2) • Care and treatment at hospitals – coronary artery disease (7) • Pharmaceutical treatment - coronary artery disease (12) • Mortality and readmission - coronary artery disease (9) • Other - coronary artery disease (2) • Rhythm disorders (5) • Heart failure (5) • Valvular heart diseases and congential heart diseases (3)

9. Results - Quality • Per indicator: • background (choice of indicator, importance) • comments on results: development over time, geographical and gender differences • biases and interpretation issues • Figures depict data: • over time • country council/regional comparisons • hospital comparisons

10. Analysis of Efficiency How much cardiac care is consumed? What are the costs of cardiac care? Co-variation between costs and quality of cardiac care? What are the costs of not choosing cost-effective interventions/treatments? What are the costs of non-compliance with the National Guidelines? (Inefficient use of resources)

11. Consumption of cardiac care can only partly be described In-patient care (38/50 DRGs in MCD 5 defined as cardiac care: no of cases, total DRG-weight, number of hospital days, ALOS) Out-patient visits in specialised hospital care (physicians + surgery) Primary health care?

12. In-patient: Cases och total weight Intervention-based categories: No of cases Total DRG weight Medical 187 205 35 787 Invasive 24 944 41 817 Surgical 7 875 108 57 Others 5 413 3 800 Source: DRG/Patient Register

13. In-patient: cases och total weight Diseases in National Guidelines: cases, % total weight,% Coronary artery 46,2 44,5 Rhythm disorders 26,6 19,1 Heart failure 21,4 21,4 Valvular & congenital 2,9 9,7 heart diseases Other types 2,9 5,3 Total 100,0 100,0

14. Average Length of Stay 2007 2002 2002-2007,% 3,7 days 4,1 days -9,8% Note! Measure hospital days per ward! Says nothing about the ALOS per episode! Organisational aspects have changed over time!

15. Costs of cardiac care varied, but data on costs limited County council agreed accounting - functional levels: primary health care specialised somatic care specialised psychiatric care NOT possible to monitor costs of cardiac care or any other type of care for specific group of patients Cost Per Patient (KPP) for some hospitals!

16. Costs per case per hospital, KPP database Costs per case, Insertion or replacement of pacemaker (DRG 115B), 2007 SEK/case

17. => Estimated Costs per Case, Cardiac Care and Acute Myocardial Infarction (AMI) Care Costs per case, cardiac care and AMI care, 2007 cardiac care AMI care National SEK/case

18. Co-variation between costs and process quality? This is what we would want to do at hospital level if data on costs....... Costs per case (AMI care) and RIKS-HIA Quality Index (cardiac intensive care) , county councils with KPP, 2007 Score RIKS-HIA Quality Index, 2007 Regression line SEK/case

19. Co-variation between costs and outcome quality? What we would like to do if.... Costs per case, AMI care and Percentage of readmissions within 30 days, county councils with KPP, 2007 Percent Regression line SEK/case

20. Additional costs due to non-compliance with National Guidelines Patients with AMI 1998-20007 treated with low cost statins or high cost statins January- June 2008 Possible prescription of low cost statins Low cost statins High cost statins Percent

21. Additional costs due to inefficient use of resources Costs of statins for patients with AMI 1998-2007 Low cost statins High cost statins Percent

22. Efficiency in cardiac care? differences in quality exists differences in costs exists no obvious co-variation between costs and quality?But........... could use resources more efficiently for instance by prescribing low-cost (generic) drugs Efficiency potential.............

23. .........but which hospital/county council is the most efficient? Based on existing data it is not possible to determine which hospital/county council has the most efficient cardiac care!

24. Further developmental work Data on specialised out-patient care (not only physicians) and primary health care Costs per patient/case (based on unique patient identifier!) National health data registers and quality registers: coverage, outcome indicators (quality of life/health), case-mix

25. Thanks a million! More information: www.socialstyrelsen.se