Evaluation of Outcomes in Health

1. Evaluation of Outcomes in Health Orla Hardiman MD,FRCPI, FAAN Director of Neurology Beaumont Hospital

2. Health Services in Ireland Community Based services (Primary Care) General Practitoners Public Health Clinical Professionals Hospital Based services (Secondary Care) Consultants NCHDs Nursing Clinical Professionals Combined care programmes

5. Deloitte &Touche Report

6. Deloitte & Touche Executive Summary

7. Current Measures of Efficiency(defined by Deloitte Touche report) • …”high utilisation of capacity, and increased use of day surgery…” • .Casemix

8. Measuring Health Service • Mortality Data: Rates and causes of death • % Spending of total GDP • Health Status /Disease Status of Population

9. Death Rates in Ireland

11. Health Status of Population:Measurables Notifiable Diseases/ Conditions Primary care based data acquisition National databases Cancer Registry Intellectual Disability database National Physical and Sensory Database Quantitation of activity in secondary care Activity levels in acute hospitals Waiting lists

12. Health Status Indicators ( Dept of Health Statistics) • Infectious Diseases • New cancers • Inborn errors of metabolism • Low birth weight • Accidental Injuries • Alcohol consumption • Satisfaction rating

13. Health Indicators:Satisfaction Rating (Eurostat)

14. Health Status of Population:Measurables Notifiable Diseases/ Conditions Primary care based data acquisition National databases Cancer Registry Intellectual Disability database National Physical and Sensory Database Quantitation of activity in secondary care Activity levels in acute hospitals Waiting lists

16. Health Status of Population:Measurables Notifiable Diseases/ Conditions Primary care based data acquisition National databases Cancer Registry Intellectual Disability database National Physical and Sensory Database Quantitation of activity in secondary care Activity levels in acute hospitals Waiting lists

18. Strategies to Adjust Provision of Care based on Available Statistics • Health Strategy • Cardiovascular Strategy • Cancer Strategy • Waiting List Initiative / National Treatment Purchase Fund (NTPF)

20. Equity of Access to Hospital Care

21. Waiting Lists: Caveats • Partial Data • Data based on “census-type” measures rather than “throughput-type” data • Reliability of data not verified (frequent validation of lists required) • Determinants for inclusion on waiting list, and rate of ascension to the top of the list not subject to audit

22. Martin defends hospital waiting lists04 May 2004 22:30 The Minister for Health, Micheál Martin, has said that there has been a significant fall in hospital waiting lists. Figures released by the National Treatment Purchase Fund this afternoon show that 37% of patients have now been waiting between three and six months. The figures also indicate that 43% of patients have been waiting between six and 12 months for surgery..

23. Assessment of Neurological Services as a Model of Health Care Provision

24. What is a Neurological Condition? • A condition that affects the brain, spine or muscle • Can be roughly divided into 3 categories • Physically disabling • Non-Physically disabling • Loss of cognitive ability (Dementia)

25. Health Status of Population:Measurables Notifiable Diseases/ Conditions Primary care based data acquisition National databases Cancer Registry Intellectual Disability database National Physical and Sensory Database Quantitation of activity in secondary care Activity levels in acute hospitals Waiting lists

26. Prevalence of Neurological Conditions in Ireland • Approx 500,000 suffer from a neurological disorder in the Republic of Ireland • Not notifiable • No publicly funded national databases • No curative treatment • Not suitable for NTPF: • Frequently undiagnosed : Poor access to relevant specialist • Reliable data generated by investigators. No official data

27. Epidemiology of MND in Ireland

28. Frequency of Review by a Neurologist in Ireland

29. Measuring Neurological Services: Available Data • Health Status /Disease Status of Population UNKNOWN • % Spending of total GDP UNKNOWN • Number of doctors per capita • Waiting lists and Hospital Activity

30. Neurologists in Europe

31. Problems in Current System based on Waiting Lists • Excessive reliance on unverified / inaccurate data, including waiting list data • Minimal audit of waiting list management: • Equity • Assumption that “outcome” is associated with “procedure” (usually surgical)

32. Problems with Current System based on Waiting Lists • Absence audit data for non-surgical hospital-based clinical activity • Absence of audit /efficiency monitoring data for out-patient services • Absence of tools to measure outcomes for chronic conditions for which procedures are not indicated • Absence of measurement tools to assess continuity of care between hospital and community services • NO INCENTIVE TO PRACTICE EVIDENCE-BASED MEDICINE

33. Waiting Lists

34. In Patient Services to Neurology Beaumont Hospital 2003

35. Admissions from A+E

36. Readmission Rates

37. Length of Stay for top 4 Diagnoses

38. How Do We Compare?Top 5 Dx, Beaumont and Massachusetts General Hospital

39. Cost Analysis

40. Disease Assessment:Measurables • Survival rates • Symptoms, signs, disability measures and complications of condition and treatment • Health Status and Quality of Life • Experiences of patients and their carers • Costs of use of resources (UK Department of Health, 1992)

41. Preliminary Studies of Outcome for Neurological Conditions

42. Survival

43. 13.4% Survival of Irish ALS patients according to the clinic type attended • Median survival of ALS clinic patients = 677 days versus 448 days for general neurology clinic • Beneficial effect persisted throughout follow-up: four year mortality rate decreased by 13.4% in the ALS clinic cohort 29.7% 229 days 10.7%

44. Treatment with Riluzole

45. Outcome Assessment: Management of Symptoms, Signs, Complications

46. Outcome Evaluation: Clinical Signs and Disability Measures • Generic Scales • Disease Specific Scales • Individualised Measures

47. First exacerbation Clinical MS Natural Course of Multiple Sclerosis Relapses and Disability Total MRI-Lesion load MRI-Activity Relapsing Remitting Secondary Progressive Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA

48. SPMS delayed Beta Interferon therapy modifies the course of Multiple Sclerosis Relapses and Disability Total MRI-Lesion load MRI-Activity Relapsing Remitting Secondary Progressive EARLY TREATMENT First exacerbation Clinical MS Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA

49. CIDP: Evaluation of Treatment Outcome Individualised Measurement pre- and post- IVIg

50. Maximal Voluntary Isometric Contraction (Quantitative Muscle Assessment)