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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