Download Innovative Approaches to Building an Evidence Base

QUALITY OF CARE
IMPROVING CLINICAL PRACTICE:
Connecting Universal Coverage to
Better Health Outcomes
John Peabody MD, PhD, FACP
Professor, UCSF and UCLA
President, QURE Healthcare
World Bank Brown Bag Lunch – 17 September 2015
Contact: [email protected]
Please do not reproduce without permission
UCSF Institute for Global Health, Global Health Sciences
AGENDA
• Health policy instruments
− UHC
− Structure versus Process
• Quality of Care Delivery: Structure  Process 
Outcomes
• From Measuring to Changing Practice
• Implications and Summary
© QURE 2015
UHC is Increasing Access and Coverage
of Key Care Interventions
Global Tracer Indicators for UHC Coverage
SDG Goal 3.8:
Achieve UHC, including financial
risk protection, access to quality
essential health care
services and access to safe,
effective, quality and affordable
essential medicines and
vaccines for all
WB and WHO assistance on
UHC to over 100 countries
since 2010.
WHO and WB. Tracking universal health coverage: first global monitoring report.
Geneva: WHO, 2015
© QURE 2015
Policy Instruments are Improving Access
to Care Across Countries and Settings
• Policy levers and tools being implemented across countries
and conditions.
– Universal Health Coverage (2005)
– Program for Results (PforR) (2010)
– Results-based financing (RBF) (2008)
– UNAIDS 90/90/90 Initiative (2014)
– USAID Health systems strengthening (2009-10)
• Common aim is to increase access to health care services.
© QURE 2015
Example: RBF Improving Access vs. Quality
•
RBF: Cash or non-monetary transfer made after contractually predefined results
verified.
•
Objective: Improvements in Population Health Outcomes
–
•
•
Structure (e.g., UHC) and Process Interventions (e.g., P4P)
RBF improves access and structural quality indicators
–
Breaks Down Financial Barriers
–
Staffing, availability of essential drugs/medical equipment and supplies
Process interventions are more limited and have had less impact
–
Compliance to guidelines for service delivery (e.g., disinfection, high-risk screening, prescription of
supplements for pregnant women)
–
Functioning of monitoring and evaluation system (e.g., service registers, drug stock management
cards)
© QURE 2015
Better Access and Structural Quality Does
not Translate into Better Health Outcomes
Effect interventions to
increase access can be
measured in several
dimensions, e.g.:
• Content of care
• Biomarkers
• Cohort registration
• Risk adjusted outcomes.
Crude and effective coverage of hypertension
treatment across Mexican states, 2005–2006.
Evidence demonstrates that
just providing access does
not result in better outcomes.
Ng M, Fullman N, Dieleman JL, Flaxman AD, Murray CJL, et al. (2014) Effective Coverage: A Metric for Monitoring Universal
Health Coverage. PLoS Med 11(9): e1001730. doi:10.1371/journal.pmed.1001730
© QURE 2015
http://127.0.0.1:8081/ploscollections/article?id=info:doi/10.1371/journal.pmed.1001730
RBF Example: Policy Levers Widely Improves
One Structural Quality Measures
Access to an Institutional Delivery Done by a Skilled Birth
Attendant
Each bar
represents
a calendar
quarter of
RBF
implement
ation
Source: 2014 RBF Progress Report http://www.hritfreport.org/#chapter-3
© QURE 2015
Having Skilled Birth Attendants Does Not Mean That
They Are Skilled—Unless Someone Measures
Midwives attending a delivery misdiagnose 30%
Lacuna in Diagnosis2
% Missed
diagnosis
CPV case
Total misdiagnosis
rate
Cephalopelvic
disproportion
Postpartum
hemorrhage
Pre-eclampsia
29.8%
25.2%
33.0%
31.0%
• Providers who misdiagnosed a
simulated CPV vignette were more
likely to have patients w/ complications.
• Complicated patients more likely to be
sent to the hospital.
• Costs:
• Complicated patients received more
hospital care; were more expensive.
• Mothers w/complications less likely
to return to work, and lost a
significant amount of income
(~1,000USD)
1Peabody
et al. 2014 Quality of care in Eastern Europe and Central Asia: Six country report
R et al. 2015 Misdiagnosis of obstetric cases by providers and the clinical and cost
consequences to patients in the Philippines. Forthcoming
2Shimkhada
© QURE 2015
Why Isn’t Access Enough? Quality Service is
the More Proximal Determinant to Outcomes
Access
Utilization
Structural Inputs
Factors that affect the
context in which care
is delivered
Quality
Clinical
Practice
Process
The sum of clinical actions
by providers that translate
inputs into outputs
Outcomes
Health Status
Patient &
Population
Effects of healthcare
on patients or
populations
Improvements in Quality Leads to Better Health in Months, not Years
© QURE 2015
Thinking in Global Health Is Shifting: Moving from
Access/Structural Inputs to Quality Services
In resource-poor settings:
•
Quality typically focused on access,
investments in equipment
•
An implicit assumption  scarcity of
qualified health providers and a lack of
infrastructure, equipment & access are
primary drivers of low-quality care
Missing from this debate is systematic
evidence on the quality of care that patients
actually receive when they enter a clinic.
- Jishnu Das et al, 2012
© QURE 2015
We Know that Quality Services (Process) Are
Poor… Everywhere
Enthusiasm growing for systematic assessment and international benchmarking
Distribution of Hospital Risk
Stand. Mortality Rate, 2006-8
• In Papua New Guinea, 69% of HCW
checked for 2 or fewer physical in patients
presenting with pneumonia.
• In Ghana, only 24% of HCW could
indicate correct treatment for malaria.
• In Pakistan, 56% of providers could
diagnose diarrhea.
• In India, only 6% of private practitioners
followed diagnostic standards for TB
management.
Beracochea et al, 1995; Thaver et al 1998; Achanta et al, 2013; OECD Health at a Glance:
Europe, 2012; CMS Medicare Hospital Quality Chartbook, 2010
© QURE 2015
Variance Of Quality Services—Defines the Quality
Problem: Shows What Improvement is Possible
Variation in procedure rates
(services) is an indicator of
healthcare quality
2013 Health Affairs study:
Cesarean Delivery Rates Vary 10X Among
US Hospitals; Reducing Variation May
Address Quality And Cost Issues
– Variation itself is
simultaneously clinically
helpful, harmful and costly
– Comparisons done properly
are powerful
Kozhimannil KB, Law MR, Virnig BA. Cesarean
Delivery Rates Vary Tenfold Among US
Hospitals; Reducing Variation May Address
Quality And Cost Issues. Health Aff (Millwood).
2013 Mar;32(3):527-35.
© QURE 2015
AGENDA
• Health policy instruments
• Quality of Care Delivery: Structure  Process
 Outcomes
• From Measuring to Changing Practice
• Implications and Summary
© QURE 2015
Different Perspectives on What Quality
Means: One Word, 20 Places to Start
•
Delivery Systems
– Access, utilization
– Public and/or private
•
Policy
– Regulations, incentives, mandates
– Organization
•
Structural/Inputs
– Facilities, equipment, supplies
•
Platform
– Public health
– Payment and insurance
•
“What Providers Do When
they See Patients is”:
• Influenced by policy
• Requires inputs
• Incented by platforms
• Provided by delivery
system
 Focused on the impact
on the patient
Patient
© QURE 2015
The Quality of Care Framework from DCP-3
Political
Factors
Institutional
Factors
2015--DCP3
Equity
Policy Levers:
Access:
Coverage, Benefits
Health Care
Access
1. Platform Level:
Aggregate System
Structure,
Systems, Human
Resources
2. Provider Level
Practice, Behavior
Process,
Clinical Care
Patient-level
Engagement, Behavior,
Adherence
Provider:
Clinical skill, adherence to guidelines,
diagnostic accuracy, communication
Health
Outcomes
3. Payment Systems
Environmental
Factors
Social/Cultural
Factors
© QURE 2015
Poor Quality Exists Across Developing Countries,
All Countries
5 Country Cross-National
Comparison
– Diarrheal disease
Percentiles
– Prenatal care, TB
95th
75th
50th
25th
5th
Mean
• Limited differences intercountry
China
El Salvador
India
Mexico
Philippines
Comparison of overall scores
across countries
• Wide variation within countries
• 30% vs 93%
Peabody JW, Florentino A Liu. ”A Cross-national comparison of quality of clinical care using
vignettes.” Health Policy and Planning. 2007 ; 22: 294-302.
© QURE 2015
Low Quality Service—
Disproportionately Affecting the Poor
Indonesia:
•
Mexico
•
Similar access to quality
for poor and affluent
women
•
Poorer women received
fewer prenatal services.
Afghanistan
•
•
Government clinics
Lower quality of care for
patients in poorer
neighborhoods
(composite index of
quality) (p>0.05).
\
•
Procedures self-reported by
providers, in government and
private facilities:
• Quality lower in poor compared
to wealthier areas. (p<0.05)
India
Gaps in aggregate measure of
Quality exist in basic care
• Quality (competence) of private
providers located in poorer areas
of the city significantly lower than
those in richer neighborhoods
Barber, Gertler and Harimurti. 2007. Differences in Access to High Quality Outpatient Care in Indonesia. Health Affairs 26(3): 352-366.
Barber, Bertozzi and Gertler. 2007. Variations in prenatal care quality for the rural poor in Mexico. Health Affairs. 26: 310-23.
Hansen et al. 2008. Determinants of primary care service in Afghanistan. Int J for Quality in Health Care. 20(6): 375-383.
Das J, Hammer J. Location, location, location: residence, wealth, and the quality of medical care in Delhi, India. Health Aff (Millwood). 2007 May-Jun;26(3):w338-51
©training
QURE
and Das J, Holla A, Das V, Mohanan M, Tabak D, Chan B. In urban and rural India, a standardized patient study showed low levels of provider
and 2015
huge
quality gaps. Health Aff (Millwood). 2012 Dec;31(12):2774-84.
Perceived Quality Affects Utilization
• Patients in Tanzania preferred to
travel to more distant facilities if
those facilities perceived to
provide higher quality care
Multivariable associations between participant and nearest health
facility characteristics and by-passer status for a populationbased sample of women from Kasulu District. Western Tanzania,
2007
(n=387)
– Availability of drugs, perceived
quality, trust were other
important reasons
• In Jamaica, quality was higher at
facilities with fewer drugs
From: Kruk et al, 2009
Kruk ME, Mbaruku G, McCord CW, Moran M, Rockers PC, Galea S. Bypassing primary care facilities
for childbirth: a population-based study in rural Tanzania. Health Policy Plan. 2009 Jul;24(4):279-88
Peabody J., Gertler P., Liebowitz A. The Policy Implications of Better Structure and Process on Birth © QURE 2015
Outcomes in Jamaica. Health Policy. 1998;43(1):1–13.
Studies Show that Physician Skill
Is Where Improvement is Needed
•
Das et al (2012): Correct
diagnosis only 8-18% the
time.
•
Achanta et al (2012):
Poor adherence to TB
guidelines (diagnostic
and treatment)
– E.g. only 6% of private
practitioners followed
diagnostic standards
in TB management
From Das et al. (2012)
Das J, Holla A, Das V, et al. In urban and rural India, a standardized patient study showed low levels of
provider training and huge quality gaps. Health Aff (Millwood). 2012 Dec;31(12):2774-84.
Achanta S, Jaju J, Kumar AM, et al, Tuberculosis management practices by private practitioners in © QURE 2015
Andhra Pradesh, India. PLoS One. 2013 Aug 13;8(8):e71119.
Accumulating, Hard to Obtain Evidence: Higher
Quality Service Means Better Outcomes
Quality integral to decreasing
postoperative complications?
•
•
Surgeons asked to representative
videotape performing a laparoscopic
gastric bypass.
Each videotape rated 1 to 5 on
various domains of technical skill
RESULTS
•
The bottom quartile of surgical skill, was
associated with higher complication rates
(14.5% vs. 5.2%, P<0.001) and higher
mortality (0.26% vs. 0.05%, P=0.01).
•
The lowest quartile of skill was also associated
with longer operations (137 minutes vs. 98
minutes, P<0.001) and higher rates of
reoperation (3.4% vs. 1.6%, P=0.01) and
readmission (6.3% vs. 2.7%) (P<0.001).
If We Could Change Practice
and Raise Quality, Would
Complications Go Down?
Birkmeyer JD, Finks JF, O’Reilly A, et al. Surgical skill and complication rates after bariatric
surgery. N Engl J Med. 2013;369:1434–42.
© QURE 2015
AGENDA
• Health policy instruments
• Quality of Care Delivery: Structure  Process 
Outcomes
• From Measuring to Changing Practice
• Implications and Summary
© QURE 2015
Bridging the Gap Between Measuring
Practice and Actually Changing Practice
Starts with Measurement:
4 key requirements for
measurements to impact outcomes
1.1
Transparency and feedback
–
2.2
Timely
–
3.3
Measurement that can be acted on (e.g. clinical decision
making with feedback, training) early-on
Repeatable/serial
–
4.4
To the provider, decision-makers
Measurement that is done over time to identify trends,
improvement
Actionable
–
Measurement that can be put into policy action,
intervention
–
Affordable
“…it's hard to
improve, and to
demonstrate
what's best,
unless everyone
does it the same
way”
-Brent James, MD,,
Intermountain Healthcare
© QURE 2012
2015
Current Methods for Measuring Quality Are
Not up to the Task of Changing Behavior
1. Patient Exit Interviews
• Self-reported status;
response bias; anchoring
bias
2. Formal Testing-Licensing
• Single best answer
questions; gaming
3. Scenarios
• Knowledge focused, Effort
level higher
4. Direct Observations
• Hawthorne effect
5. Medical Chart
Abstraction
• The current
standard, inaccurate
and time consuming
6. Standardized Patient
• The gold standard
but hard to
reproduce
© QURE 2015
Medical Chart Abstraction is Problematic
Chart abstraction
- Analyzing individual doctor’s charts
- Requires trained abstractor
- Messy and prone to false positives
- Doesn’t account for case-mix
- Time consuming
- Retrospective
To change behavior we want a measure that is:
1.
Valid, reliable and consistent determination of actual clinical
practice
2.
Case mix adjusted so comparisons among physicians and
disparate sites and health care systems can be made
3.
Example of a doctor’s chart
Inexpensive and can be used for repeated measures
© QURE 2015
Actor/Standardized Patients Measuring Quality
Standardized
patients can
capture
physician
practice
variation, and
are an
alternative to
direct
observation
(DO)
Researchers in Indonesia, India and
Tanzania posed as patients across a
variety of conditions (child diarrhea,
pregnant woman with pre-eclampsia)
Overall quality was
shown to be low: for a
diarrhea case, only
18-58% of necessary
care was provided
across the 3 countries
Doctors in Tanzania
completed less than
24% of essential
“checklist” items for
malaria
Das, J & Gertler PJ. Variations In Practice Quality In Five Low-Income Countries: A
Conceptual Overview. Health Aff. May 2007: 26(3):W296-309.
© QURE 2015
From an Actor Patient…
To a “Virtual Patient”
Actor Patients Taught us that a Virtual Patient (VP):
– Needs to be a standardized patient
• Case mix adjusted
– Can be done anywhere on anyone
• Paper or Plastic
– Match clinical setting, provide phased
disclosures to evaluate judgment and not just
knowledge
– Valid, reliable and consistent determination of
actual clinical practice
– Inexpensive
© QURE 2015
CPV Vignette Provides a Standard Measure
of Practice
• CPV virtual patient presents
with symptoms in the hospital,
ED or any outpatient setting.
• The provider cares for a
variety of clinical cases (>200)
as they would in their practice
• Provider goes through the 5
clinical domains every
provider does when they see
a patient:
– Taking a history
– Conducting a
physical examination
– Ordering tests
– Making a diagnosis
– Providing treatment
© QURE 2015
CPV’s Vignettes Have Been Validated to Measure
Actual Practice
Validated CPVs Do Not Overestimate Actual Service Quality
Standardized Patients
80
70
Correct %
60
7368
63
69
65
62
7373
64
76
7068
50
73
65
59
Vignettes
Charts
40
CPV® vignettes:
30
• Superior to chart
abstraction (CA)
20
• Close to standard
patients (SP)
10
0
All Diseases
COPD
Diabetes
Vascular
Disease
Depression
• More practical and
less expensive than
both SP and CA
Peabody JW, Luck J, Glassman P, Jain S, Spell M and Hansen J. “A Prospective Multi-Site
Evaluation of Vignettes: Validating an Innovative Method for Measuring the Quality of
Physician Practice.” Annals of Internal Medicine. Vol. 141(10):771-80, November 2004.
© QURE 2015
28
Serially Implementation of CPV®
Measurement and Feedback
Desired Results
Observed
QURE develops cases
targeting high priority needs
Case Writing
CPV® vignettes
Feedback
Report Out
Practice Change
© QURE 2015
CPV® Vignette Global Applications
Over 20,000 CPV®
vignettes have been
completed worldwide
• 30 countries
There are more than
200 CPV clinical
conditions ranging
from Asthma to
Zoonosis.
Vignettes used to address different
service problem areas:
• RBF policy impact (e.g. practice change
in Africa)
• Guideline adherence for treatment (e.g.
WHO);
• Overuse of diagnostics (e.g. CT imaging
in China);
• Ensure right diagnoses (e.g., early
referral of High Risk OB);
• Cross national studies (e.g. monitoring
quality of care progress)
© QURE 2015
Quality of Care in Eastern Europe and
Central Asia (ECA-6)
• Countries in this region face
twin burden of disease:
– Problems of low-middle-income
countries, such as poor maternal
and neonatal care
– Problems of industrial countries,
such as heart attack and cardiovascular risk factors
• 10 CPVs designed to capture
quality of care and clinical
challenges and areas of need in
ECA-6 countries
CPV Disease Areas:
Non-communicable Disease
Acute Myocardial Infarction
Multiple Risk Factors
Neonatal Care
Birth Asphyxia
Neonatal Pneumonia
Obstetrics
Postpartum hemorrhage
© QURE 2015
CPV’s Scale Up Quality Measurement: Recent
Experience in a WB Multi-country Study
Using CPVs, The World Bank undertook the largest crossnational evaluation of the quality of care
• A total of 1,039 facilities, 2,855
physicians, 306 midwives
• Albania, Armenia, Georgia, Kazakhstan,
Russia, and Tajikistan
• Goals:
– Establish a benchmark and track impact
trends
– Motivate best practices
– Guides policy
© QURE 2015
There Are Major Deficits in Quality (just a
few findings of many)
•
In asphyxia, >50% of providers fail
to check for an open airway.
•
Universally poor across all country
Failure to Check for a Patent
Airway in Birth Aphyxia
100%
80%
60%
40%
20%
0%
•
In some countries the diagnosis of
an MI (heart attack) is missed >50%
of the time
•
Highly variable between country
Missed Acute MI Diagnosis
80%
70%
60%
50%
40%
30%
20%
10%
0%
© QURE 2015
(Too many) Examples of Deficits in
Quality Processes
•
Aspirin is affordable and available,
but not used >40% of the time in 5
countries
•
Cardiovascular disease and diabetes
account for the highest burden of
global illness
•
In Russia, use is high (good)
•
Cholesterol-lowering drugs and blood
pressure lowering drugs are not used
correctly >60% of the time.
100%
80%
60%
40%
20%
0%
Failure to use Apirin for Acute
MI
Failure to use Statins and
Anti-hypertensives
100%
50%
0%
statins
anti-hypertensives
© QURE 2015
Can We Improve Quality Using Serial CPV
Measurement? Evidence from 2 Sites
Round 1
Round 2
Round 3
© QURE 2015
Can Quality Be Improved Using CPVs in LMIC’s?
QIDS: A National Policy Study from the Philippines
Bonuses Could be Earned for
Higher CPV Scores
Data Source
Round 1 and 2; Intervention A, C
• Linked patients with physician
quality, measured by CPV
Data Collection
• Difference-in-difference models
assessed the impact of Bonus on
many health outcomes:
Model
– hemoglobin, GSRH, CRP,
wasting, and stunting,
• Controlled for patient
characteristics, such as age,
mother’s education, income,
condition, and length of stay
Patient exits (biomarkers, anthropometrics)
Logit (Yit) = α0 + α1Ni + β0Ti + β1NiTi + ΣθjXjit
+ Uit
Yit = Health measure of ith individual in
survey round t
N = dummy variable for intervention site
T = dummy variable for post-intervention
period
X = patient and household characteristics
(age, illness, severity, household income)
© QURE 2015
36
QIDS Research Design
• Randomization at the District Level
• Multi-level Design
• Longitudinal Follow-up
Sites
Baseline Data
Randomize
Change Policy
Follow-up on Data
Insurance
30 District Hospitals
Round One Data
Bonus
Round Two
Data
6,000 Children
Control
37
© QURE 2015
Physicians with Higher CPV Vignette Scores Had
Patients with Better Outcomes
•
Quality improved by an average of 9.7% in the CPV Vignette linked P4P
Intervention arm (p<.001)
•
Health Outcomes in the Intervention: Reductions in wasting or reported health
status (GSRH) at discharge and 4-10 week follow-up
Difference-in-Difference
Improvement in
Round 2 vs Round 1
Wasting
General Self
Reported Health (at
least good)
At time of discharge
-6.5 percentage pts *
9.1 percentage pts **
At 8 wk follow-up
-11.8 percentage pts **
11.8 percentage pts **
Rate of improvement
(discharge to 8 wks)
-15.2 percentage pts **
9.5 percentage pts **
*p<0.10, **p<0.001
Peabody, John W., Riti Shimkhada, Stella Quimbo, Orville Solon, Xylee Javier, and
Charles McCulloch. The impact of performance incentives on child health outcomes:
results from a cluster randomized controlled trial in the Philippines. Health Policy and
Planning. Health Policy Plan. (2014) 29 (5): 615-621.
© QURE 2015
Philippine QIDS: Quality Improvements Were
Sustained Over Time
82%
Access
Bonus
Control
2003/4
2008
2013
80%
5 years a er the end
of the study, quality
scores are s ll high
in the interven on
groups and the
original cohort of
doctors
78%
76%
74%
72%
70%
68%
66%
64%
62%
Base
Round2
Round3
Round4
Round5
Round6
Round7
Round 17 Round 17
old
new
New
Original
group of
physicians
The QIDS Study in 2013
group of
physicians
Quality measurement creates:
A new culture of self-awareness and continual improvement
Launch
Continual measurements
Transformation
Culture change
Quimbo S, Wagner N, Florentino J, Solon O , and Peabody J. Do Health Reforms
To Improve Quality Have Long-term Effects? Results of a Follow-up on a
Randomized Policy Experiment in the Philippines . Health Economics, 2014.
Publication pending.
© QURE 2015
AGENDA
• Health policy instruments
• Quality of Care Delivery: Structure  Process 
Outcomes
• From Measuring to Changing Practice
• Implications and Summary
© QURE 2015
Our Discussions on Quality Have
Advanced in DCP-3
•
We think less about structural measures and more about the clinician - how does
his/her practice compare to the evidence base?
•
We spend less time arguing over which measures to use and…
•
More time focused on improving clinical
care practice and patient outcomes
•
Think about how quality affects demand
•
Go beyond what is done and think about
how clinical information is synthesized
ty
Quali
– How does clinician make judgments,
diagnosis?
•
Active engage policy around the costs of
quality, its cost effectiveness and tradeoffs
igm
parad
Action,
Impact
Improvement,
Judgment,
Diagnosis
Definitions,
measurement
© QURE 2015
Policy Interventions that Might Improve Quality—With
Measurement—There Are Lots to Choose From
Policy Interventions that Can
Improve Quality of Care
Access
Universal
coverage,
Non-physician
providers,
Facilities, Benefit
expansion, CCTs
Clinical Practice Organization
Quality of Care
Measurement and
Feedback
Education, Licensing-certification,
Continuous Quality
Improvement/PDSA, CME,
Organization change/supervision,
Accreditation & administrative
regulation,
Clinical Practice Incentives
Quality Interventions Possibly the best
opportunity to quickly improve outcomes?
RBF, P4P, Volume of Care, Peer
review, Legal mandates, Public–private
quality-based competition
Peabody J.W, Taguiwalo M.M, Robalino D.A, et al. Improving the Quality of Care in Developing
Countries. In: Jamison DT, Breman JG, Measham AR, et al., editors. Disease Control Priorities in
© QURE 2015
Developing Countries. 2nd edition. Washington (DC): World Bank; 2006. Chapter 70.
Potential for Impact of Quality on
MDG/SDGs is Enormous
• Evidence from the Philippines shows that increasing
quality by just 10% can save 15,000-20,000 lives for the
under 5 population.
• Impact can be even greater as burden from chronic, noncommunicable disease continues to grow:
– Recent estimates total 764.8 million years of living
with disability
– 24 of 25 top causes of YLD are chronic diseases,
highly dependent of quality of care
Source: Global Burden of Disease Study 2013 Collaborators. Global, regional, and
national incidence, prevalence, and years lived with disability for 301 acute and
chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the
Global Burden of Disease Study 2013. Lancet. June 2015
© QURE 2015
More Research on Policy and Quality Impact Is
Needed
Cochrane Review, 2012 of
P4P in LIMC (Witter et al)
-
9 studies (only)
-
Some positive findings
(randomized studies, such as
Basinga et al 2011)
-
Authors conclude more robust
and comprehensive studies
needed
-
Effects depend on interaction
of several variables, such as
design of the intervention
(e.g. who receives payments,
magnitude, quality
measurement)
Basinga et al, 2011. Lancet:
Randomized study of performance incentives in Rwanda
Witter S, Fretheim A, Kessy FL, Lindahl AK. Paying for performance to improve the delivery of health interventions in
low- and middle-income countries. Cochrane Database Syst Rev. 2012 Feb 15;2:CD007899.
Basinga P, Gertler PJ, Binagwaho A, et al. Effect on maternal and child health services in Rwanda of©payment
QURE to
2015
primary health-care providers for performance: an impact evaluation. The Lancet 2011;377:1421-8.
Summary and Implications
1. Quality (Process of Care) is poor and
varied
2. Access and Structural elements of
quality have improved recently but
limited impact on health outcomes
3. Improving Quality of Care Services
requires Measurement and Feedback
to the provider
1. A few different
measurement tools are
available
2. Multiple Policy levers are
available
3. More research at national
scale is needed
-
Did the clinician make the right diagnosis,
did they decide to operate or not, did they
give the correct medicine?
4. Focus on impact, and
comparative effectiveness
-
Look for high impact health outcomes: e.g.
pediatrics, obstetrics, surgical
complications, avoidance of downstream
costs
5. Expect Quick Results
© QURE 2015
Thank you