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Quality and Outcome Indicators for Acute Healthcare Services

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© Commonwealth of AustraliaISBN 0 644 37481 XFirst published March 1997This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no partymay be reproduced by any process without prior written permission from the Australian GovernmentPublishing Service. Requests <strong>and</strong> enquiries concerning reproduction <strong>and</strong> rights should be addressedto the Manager, Commonwealth In<strong>for</strong>maiton <strong>Services</strong>, Australian Government Publishing Service,GPO Box 84, Canberra ACT 2601Responsibiltiy <strong>for</strong> the content of this report remains with the authors. This report does not necessarilyreflect the views of the Commonwealth Department of Health <strong>and</strong> Family <strong>Services</strong>.Cover design by the Publications <strong>and</strong> Design (Public Affairs, Parliamentary <strong>and</strong> Access Branch)Commonwealth Department of Health <strong>and</strong> Family <strong>Services</strong>Produced by the Australian Government Publishing Service


2ContinuityDischarge PlanningCoordinationTechnical Proficiency -Appropriateness -These dimensions of care are reflected variably in currently available indicators. They include concepts ofquality that overlap (that is, there is some redundancy in this classification) <strong>and</strong> they are notcomprehensive (that is, there are important quality dimensions - such as equity <strong>and</strong> benevolence - whichare inadequately represented. These dimensions of care are conceptually complex <strong>and</strong> poorly translatedinto quantitative indicators. Consequently no feasible indicators of these dimensions were identified).We have proposed a number of attributes of quality of care indicators which provide a basis <strong>for</strong> assessing<strong>and</strong> deciding the potential utility of any putative indicator <strong>for</strong> a nationally consistent quality <strong>and</strong> outcomeindicator set. These attributes are:ATTRIBUTEReliabilityValidityENCOMPASSINGInternal consistencyTest/re-test stabilityInterrater reliabilityFace validityContent validityConstruct validityPredictive validitySensitivitySpecificityPredictive valueResponsiveness -Interpretability -SignificanceBurdenVulnerability toundesired effectsRelevanceCollection impostGamingDistortion of healthservice deliveryUtility -Availability ofalternate <strong>for</strong>msAmenity toindependent corroborationLanguage adaptedLiteracy adaptedCulturally adaptedAuditData SourceIt is frequently stated that the science of healthcare quality indicators is in its infancy. Certainly we foundthat good data on the attributes of proposed indicators <strong>and</strong> specific in<strong>for</strong>mation on their developmental


3rigour were frequently missing. Some indicators have no basis in science. Nonetheless, we foundsufficient evidence supporting quality of care indicators to suggest that an appropriate growth <strong>and</strong>development analogy would place quality indicators in early childhood, rather than infancy, with severalquality <strong>and</strong> outcome indicator programs having passed significant developmental milestones. Most existingquality <strong>and</strong> outcome indicators are imperfect. In the majority of indicators we examined there wasinsufficient in<strong>for</strong>mation available on indicator attributes to allow us to draw firm conclusions aboutindicator per<strong>for</strong>mance against all of our chosen attributes. We see the current generation of indicators asstepping stones to future better indicators. It will only be by their application in the health sector thatindicators will improve. Provided all those using current indicators are aware of their limitations <strong>and</strong>appropriately cautious in their interpretation, no harm will come from use of less than perfect per<strong>for</strong>mancemeasures. Existing - albeit imperfect - indicators do provide useful pointers to quality of care. If resultsof indicator data occasionally differ significantly from user expectations it may be necessary <strong>for</strong> thoseusing these tools to consider revising their underst<strong>and</strong>ing of the role of indicators in monitoring qualityrather than discarding these indicators <strong>and</strong> persisting with attempts to find “perfect” indicators.This report contains insights derived from an examination of how we <strong>and</strong> other western healthcare systemshave applied quality of care indicators. These experiences contain valuable lessons <strong>for</strong> those embarking onlarge scale quality monitoring in healthcare - particularly on how best to manage the introduction ofquality <strong>and</strong> outcome indicators to maximise their value as accountability tools, instruments guidingconsumer choice <strong>and</strong> facilitators of provider ef<strong>for</strong>ts to improve quality. One recurring imperativeidentified by our review is the requirement <strong>for</strong> a collaborative approach to indicator development <strong>and</strong> thesubsequent interpretation <strong>and</strong> dissemination of quality <strong>and</strong> outcome indicator data. Such collaborationmust embrace purchasers, providers <strong>and</strong> consumers of healthcare to see quality <strong>and</strong> outcome indicatorssuccessfully achieve their multiple goals.<strong>Quality</strong> of care indicators are constructed from data obtained from administrative databases, abstractedfrom medical records, reported by patients in response to structured survey or by some combination ofthese methods. Administrative databases are a relatively complete data source, although there aresignificant risks of inaccuracy if data are used <strong>for</strong> purposes other than those originally intended. Patientclassification <strong>and</strong> categorisation within existing coding systems mask patient differences of potentialimportance <strong>for</strong> quality <strong>and</strong> outcome indicator construction. In contrast to the low cost of indicator datafrom administrative databases, medical record abstraction is expensive. The in<strong>for</strong>mation present in recordsis inconsistent <strong>and</strong> frequently incomplete. Occasionally, the added expense of collection is justified by theclinical detail obtained by record review, although such abstraction cannot be a basis <strong>for</strong> core nationalindicators. Patient surveys are uniquely capable of providing valuable insights into the processes <strong>and</strong>outcomes of care <strong>and</strong> care acceptability. Although expensive, as indicator data sources go, patient surveyswill be essential <strong>for</strong> a worthwhile national quality monitoring program embracing consumer perspectiveson care delivery.The development of explicit guidelines <strong>for</strong> the care of particular clinical conditions has been a majorachievement of several international <strong>and</strong> national expert groups over recent years. The National Health<strong>and</strong> Medical Research Council (NHMRC) has undertaken initiatives to develop guidelines <strong>for</strong> national use,including areas targeted as national health priority areas. Clinical practice guidelines can readily beadapted to generate quality of care indicators <strong>for</strong> specific conditions or interventions.Following a review of existing indicators available <strong>for</strong> the identified key dimensions of quality of care inthe acute healthcare sector, <strong>and</strong> assessment of their relative strengths <strong>and</strong> weaknesses, we have made aseries of recommendations regarding the potential development of a quality <strong>and</strong> outcome indicator programnationally.


41.1 STRUCTURE OF A NATIONAL INDICATOR PROGRAM1.1.1 National quality <strong>and</strong> outcome indicators be developed as two complementary sets - a coreindicator set intended <strong>for</strong> long-term continuous collection <strong>and</strong> a series of indicator modulesfocused on periodic collection <strong>for</strong> a finite duration at a defined frequency.1.1.2 Core indicators focus on aspects of care that are common across conditions.1.1.3 Indicator modules be targeted to specific conditions, diseases, diagnoses or interventions<strong>and</strong> include a balanced portfolio of clinical indicators, health status, acceptability <strong>and</strong> costindicators. It is likely that most benefit <strong>for</strong> facility-level quality improvement in acutehealthcare will flow from energy devoted to such targeted quality of care indicator modules.1.1.4 Where possible, the development of indicator modules should commence in identifiednational health priority areas.1.1.5 Core indicator sets be based upon data from administrative databases or patient surveys.1.1.6 Indicator modules include hybrid data collection - including medical record sampling,review <strong>and</strong> data abstraction - to establish the cost benefit of more sophisticated indicatorconstruction methodologies in a national quality monitoring context.1.1.7 Indicator development programs be cooperative - involving all relevant agencies - <strong>and</strong>multidisciplinary.1.1.8 Appropriate sampling technique be used in indicator data acquisition wherever possible toincrease the complexity of data available <strong>for</strong> a given cost.1.1.9 A resource be developed to assist providers with indicator data collection, analysis,feedback <strong>and</strong> interpretation <strong>and</strong> with the potential to provide independent confirmation ofdata integrity.1.1.10 <strong>Indicators</strong> developed <strong>for</strong> national use include comprehensive operational definitions,preferably encoded within suitable software packages, to enhance data reliability.1.2 SUGGESTED INDICATORS FOR ADOPTION IN AUSTRALIAThere are no indicators with unequivocal <strong>and</strong> universal support as “gold st<strong>and</strong>ard” means ofmonitoring healthcare quality. Comparative studies of indicator per<strong>for</strong>mance in acute healthcare arerare <strong>and</strong> do not provide a basis <strong>for</strong> the unquestioned support of any individual quality of careindicator or indicator set in an Australian context. From the in<strong>for</strong>mation available on currentquality indicators we have selected a reasonable, basic set of indicators which we believe havesufficient evidence to support their probable utility. This evidence includes knowledge that thepremise underpinning the indicator is sound, that data collection is feasible (given current orreasonably anticipated future health services in<strong>for</strong>mation systems) <strong>and</strong> that the indicator would havepractical utility. The absence of compelling evidence to guide our choice of suggested indicatorsmeans that ultimately, those indicators recommended receive that recommendation based on anassessment by us of their overall worth - following our in-depth review of available in<strong>for</strong>mation onquality indicators. A balance has been sought between the size of the initial indicator set <strong>for</strong>adoption <strong>and</strong> the desire <strong>for</strong> comprehensive coverage of the quality of acute healthcare services.Over time a larger indicator library can be developed based upon local research, development <strong>and</strong>experience <strong>and</strong> a close linkage of our national indicator programs to international initiatives inquality indicators <strong>for</strong> acute healthcare.


51.2.1 Access- Elective surgery waiting times- Emergency Department waiting times- Waiting times in Emergency Department prior to emergency admission- Patient-based reports of elective surgery, Emergency Department <strong>and</strong> OutpatientDepartment waiting times <strong>and</strong> the acceptability of these waiting times to patients1.2.2 Efficiency- Cost per casemix adjusted separation1.2.3 Safety- <strong>Indicators</strong> of adherence to best practice guidelines <strong>for</strong> the processes of care or variationsin observed to predicted outcomes should be incorporated in indicator modules targetingparticular clinical circumstances. In view of the importance of cardiovascular disease,modules addressing interventions in patients with ischaemic heart disease (angioplasty,CABG, angiography <strong>and</strong> AMI) should be included in any initial module sets.1.2.4 Effectiveness- Generic health status (SF36 or SF12) be included in the core indicator set, examiningchange in health status about an acute episode of care.- Health status measures, either generic or condition-specific, be incorporated intoindicator modules targeting specific clinical circumstances.- Mortality rates, stratified with data available within administrative databases, becollected <strong>for</strong> key clinical conditions <strong>and</strong> compared to risk-adjusted mortality indicesdeveloped within indicator modules. Such analyses will establish the cost-benefit ofmore sophisticated risk-adjustment modelling in the context of a national qualitymonitoring program (commencing with angiography, CABG, angioplasty <strong>and</strong> AMI).- Unplanned readmission after inpatient treatment <strong>for</strong> asthma (paediatric <strong>and</strong> adultgroups).- Low <strong>and</strong> very low birthweight rates <strong>for</strong> infants.1.2.5 Continuity- Patient-based assessments using relevant modules from the Picker CommonwealthSurvey instrument.1.2.6 Acceptability- A national survey on the acceptability of care be based upon components of the PickerCommonwealth, Hospital Corporation of America <strong>and</strong> Royal College of Surgeonsinstruments.1.2.7 Technical Proficiency- Avoid putative generic indicators of facility-wide technical proficiency- Promote risk-adjusted technical proficiency indicators developed within indicatormodules addressing targeted clinical circumstances.1.2.8 Appropriateness- Use relative utilisation rates of targeted interventions as proxies <strong>for</strong> appropriateness.


6These recommended indicators are summarised on Page 8.The complexity underlying the process of trialing putative quality indicators should not beunderestimated. Even apparently simple indicators require in-depth analysis of competingoperational definitions <strong>and</strong> generation of an agreed, detailed operational definition (preferablysupported by written materials with computer software expansion, clarification <strong>and</strong> problem-solvingguides). This agreed operational definition is then to be rigorously <strong>and</strong> uni<strong>for</strong>mly applied in thefield. In the case of modular indicator sets, project teams with a range of relevant skills <strong>and</strong>experience should build balanced sets of indicators from existing available indicators or develop denovo indicators to address relevant per<strong>for</strong>mance measurement needs. Both classes of indicatorsshould be trialed in a collaborative, cooperative atmosphere <strong>and</strong> involve provider, purchaserregulator <strong>and</strong> consumer representation in the project teams. Pilot projects across interestedrepresentative facilities should precede any more widespread implementation to ensure that thenational indicator set, when launched, is valuable to all concerned <strong>and</strong> credible. Engaging existingdrivers of quality indicators in the trialing process (e.g. the States <strong>and</strong> Territories <strong>and</strong> TheAustralian Council on <strong>Healthcare</strong> St<strong>and</strong>ards Care Evaluation Program (ACHS CEP)) will beessential to ensure that common operational definitions <strong>for</strong> quality indicators are arrived at. Thiswill avoid the creation of competing, overlapping data collection requirements of healthcarefacilities - which could lead to inefficiencies, the disenfranchisement of providers <strong>and</strong> a drasticreduction in the reliability of indicator data.1.3 FUTURE DIRECTIONS FOR INDICATOR DEVELOPMENT1.3.1 Dimensions of care with particular needs <strong>for</strong> indicator development:- Unmet access needs- Allocative <strong>and</strong> technical efficiency- Acceptability- Continuity- Appropriateness- Indicator modules <strong>for</strong> vulnerable patient populations1.3.2 <strong>Quality</strong> of care <strong>and</strong> outcomes indicators <strong>for</strong> healthcare developed by multidisciplinarygroups should focus on producing balanced portfolios of indicators targeting particularconditions, diseases or interventions <strong>and</strong> reflecting many key dimensions of healthcarequality <strong>and</strong> the perspectives of purchasers, providers <strong>and</strong> patients.1.3.3 Most of the significant health concerns of Australians relate to chronic illnesses, where theper<strong>for</strong>mance of the integrated healthcare system is far more important than the per<strong>for</strong>manceof its isolated components. In the long term, quality <strong>and</strong> outcome indicator programs shouldaddress integrated healthcare system per<strong>for</strong>mance rather than retaining an acute healthcaresector focus. Measurement of the quality <strong>and</strong> outcomes offered by the care continuum willthen in<strong>for</strong>m the success of overall service delivery.1.3.4 Australia should develop centres of excellence pursuing quality of care indicator research<strong>and</strong> seek their inclusion in the WHO <strong>Quality</strong> Assurance Collaboration.Changes in the science of quality of care indicators <strong>and</strong> the science of medicine will require that quality<strong>and</strong> outcome indicator programs are dynamic, iterative programs attuned to advances in academic <strong>and</strong>


7clinical knowledge. Few indicators should there<strong>for</strong>e be built around m<strong>and</strong>ating changes in routineminimum data set collections. It is unlikely that we will ever see single indicators or small indicator setsthat work <strong>for</strong> all parties, at all times <strong>and</strong> <strong>for</strong> all purposes. Above all else, effective use of quality <strong>and</strong>outcome indicators requires knowledge of their limitations <strong>and</strong> intelligence, good-will <strong>and</strong> common sense intheir applications. Programs to “perfect” indicators must be complemented by educational campaigns toimprove the underst<strong>and</strong>ing of their use by all with an interest in monitoring healthcare quality.


8<strong>Indicators</strong> Recommended <strong>for</strong> Trialing in a Core National Set• Access- Elective surgery waiting times- Emergency Department waiting times- Waiting times in Emergency Department prior to Emergency admission- Patient-based reports of elective surgery, Emergency Department <strong>and</strong>Outpatient Department waiting times <strong>and</strong> the acceptability of these waitingtimes to patients• Efficiency- Cost per casemix adjusted separation• Effectiveness- Generic health status (SF36 or SF12)• Continuity- Patient-based assessments using relevant modules from the PickerCommonwealth survey instrument• Acceptability- A national survey based upon components of the Picker Commonwealth,Hospital Corporation of America <strong>and</strong> Royal College of Surgeons instruments• Appropriateness- Relative utilisation rates of targeted procedures<strong>Indicators</strong> Recommended <strong>for</strong> Trialing in Indicator Modules at a Defined Frequency<strong>and</strong> <strong>for</strong> a Finite DurationProjects should be promoted to develop indicator modules targeting particular clinicalcircumstances. These balanced sets of quality of care indicators should include a variety ofperspectives on the quality of care chosen from relevant dimensions of care such as:AccessEfficiencySafetyEffectivenessTechnicalProficiencyAppropriateness- Waiting times- Cost- Adherence to best practice guidelines- Observed to expected outcome ratios- Condition-specific health status or health-related quality of lifemeasures- Stratified mortality rates- Unplanned readmission rates (asthma)- Low <strong>and</strong> very low birthweight infants (obstetric care)- Risk-adjusted technical proficiency indicators- Condition/procedure-specific relative utilisation rates


92. INTRODUCTION2.1 The Aim of the ProjectThe National Hospital <strong>Outcome</strong>s Program (NHOP) commissioned this Project to critically review thestatus of Australian <strong>and</strong> overseas knowledge regarding the development <strong>and</strong> use of quality of care <strong>and</strong>health outcome indicators in acute care services. It specifically sought to identify those per<strong>for</strong>manceindicators that contribute to improvements in the quality <strong>and</strong> outcomes of care to in<strong>for</strong>m the developmentof a set of nationally consistent quality of care <strong>and</strong> health outcome indicators <strong>for</strong> acute healthcare servicesin Australia.The Project wished to:• Identify key issues surrounding the use of quality <strong>and</strong> outcome indicators in a national context• Identify key dimensions of quality of care <strong>for</strong> indicator development <strong>and</strong> implementation• Assess the usefulness of existing indicators <strong>for</strong> application in the Australian context• Advise on future directions <strong>for</strong> quality <strong>and</strong> outcome indicator developmentsThe research was to include commentary on hospital access, technical <strong>and</strong> allocative efficiency,effectiveness, appropriateness, nursing, change in health status, discharge planning <strong>and</strong> patient safetyindicators at a minimum. Health concerns of vulnerable patient groups, such as Aboriginals <strong>and</strong> TorresStrait Isl<strong>and</strong>er peoples, were to be addressed in the context of indicator utilisation. The Projectspecifically excluded replication of work undertaken within complementary projects.The Commonwealth, States <strong>and</strong> Territories in recent years have been putting substantial ef<strong>for</strong>ts intoimproving the cost efficiency of public hospitals. Health consumers are greatly concerned about thequality <strong>and</strong> outcomes of care, particularly in an environment of programs pursuing efficiencyimprovements. The Commonwealth, States <strong>and</strong> Territories are concerned that quality of care <strong>and</strong> healthoutcomes are at least maintained - <strong>and</strong> preferably improve - whilst efficiency gains are progressing. InSchedule I of the 1993-1998 Medicare Agreements, the Commonwealth, States <strong>and</strong> Territories agreed tothe development of national quality of care <strong>and</strong> health outcome indicators <strong>for</strong> hospitals. It is believedessential that mechanisms be developed to monitor quality of hospital care so that consumers <strong>and</strong>governments can be sure of the value of delivered care (i.e. the ratio of quality to cost) <strong>and</strong> providers ofcare are stimulated to pursue quality improvement within acute healthcare programs.The NHOP seeks to develop <strong>and</strong> implement per<strong>for</strong>mance indicators <strong>and</strong> determine st<strong>and</strong>ards of quality ofcare <strong>for</strong> Australian hospitals. It is a three year program to develop <strong>and</strong> trial workable indicators that canbe used to promote improvements in the quality of care <strong>and</strong> health outcomes in Australian hospitals. TheProject is to identify a manageable set of indicators that would primarily serve the accountabilityrequirements of a large purchaser of acute care services. This Project does not seek identification ofmicroindicators that might be relevant in the internal management of quality by acute care providers. TheProject is the first stage in the programmed development of a nationally consistent quality <strong>and</strong> outcomeindicator set <strong>and</strong> will provide a basis <strong>for</strong> future work to develop, refine <strong>and</strong> test indicator sets suitable <strong>for</strong>national application.Data <strong>for</strong> generation of quality <strong>and</strong> outcome indicators has either to be specifically created or obtained fromdata sources developed <strong>for</strong> other purposes. There has been a strong trend to manipulate existing datasources to produce quality indicators at low cost. As is discussed in detail later in this report (Section 5.4)there are considerable difficulties in the use of data <strong>for</strong> purposes other than those originally intended bydata gatherers. <strong>Indicators</strong> based solely around data from administrative databases will always be ofsomewhat limited utility. The longterm success of quality <strong>and</strong> outcome indicator programs will requirethat necessary data are identified <strong>and</strong> subsequent steps taken to obtain such data (be it routine collectionfrom all or sampling strategies targeting patient population subsets) rather than persevering with strategies


10attempting to build credible indicators entirely from existing computer database contents. At presentAustralian healthcare providers collect various data items - with no uni<strong>for</strong>m definitions applicable to manyapparently similar data (such as elective surgery waiting times). As requisite data points <strong>for</strong> qualitymonitoring are identified, national uni<strong>for</strong>m data definitions must be incorporated into the national datadictionary <strong>and</strong> mechanisms enacted to audit compliance with definition application in the field. Such aprospective approach to quality indicator data collection will undoubtedly increase the cost of indicatorcollection - but the consequent increase in the value of indicator data flowing from the prospectivedesignation <strong>and</strong> collection of reliable, relevant data will be more than commensurate.2.2 The Aim of this ReportIn this final report we convey, in a summary <strong>for</strong>mat, our opinions <strong>and</strong> recommendations regarding qualityof care <strong>and</strong> health outcome indicators <strong>for</strong> acute healthcare services. We seek to do this in an accessibleway, hence the report on these complex 1-1136 <strong>and</strong> at times controversial matters is relatively succinct.Those interested in more detailed analyses <strong>and</strong> commentaries will find these in the attached appendices tothis report or within the bibliography listing of in<strong>for</strong>mation sources.<strong>Quality</strong> <strong>and</strong> outcome indicators are of interest to many customer groups. These include:• Patients <strong>and</strong> their families• <strong>Healthcare</strong> professionals• Purchasers of healthcare• Regulators of healthcare• Health system employees• CommunitiesOccasionally, the needs <strong>and</strong> expectations of these groups regarding quality <strong>and</strong> outcome indicators do notalign, <strong>and</strong> sometimes these differences are substantial. Our report repeatedly places commentary <strong>and</strong>recommendations in a context of the intended use of derived indicator data. This report encompassesdiscussion of the history of per<strong>for</strong>mance indicators in acute healthcare, recommendations on keydimensions of quality of care requiring monitoring <strong>and</strong> the identification of pertinent issues aroundintroduction of a nationally consistent quality <strong>and</strong> outcome indicator set. It seeks to point out gapsbetween existing indicators <strong>and</strong> those desired by potential users. Knowledge of these gaps permitsprioritisation of subsequent research <strong>and</strong> development ef<strong>for</strong>ts.3. BACKGROUND3.1 History of Indicator DevelopmentHistorically, the responsibility <strong>for</strong> healthcare quality was thought to reside only with the medical <strong>and</strong>clinical care professions (the so-called “professional model” of accountability) 297 . Consumers <strong>and</strong>purchasers assumed that relatively uni<strong>for</strong>m quality of care existed across any given healthcare deliverysystem <strong>and</strong> that investigation <strong>and</strong> treatment approaches were relatively st<strong>and</strong>ard within that system of care.Several decades ago there was a move to make provider facilities accountable <strong>for</strong> care delivered withinthose facilities, which saw an increased emphasis on facility-level peer-review of per<strong>for</strong>mance regardingquality of care. Facility peer-review is essentially a strengthening of the professional model ofaccountability which typically fails to provide objective evidence on per<strong>for</strong>mance <strong>for</strong> external review.Concerns that existed regarding significant variations in quality of care <strong>and</strong> the nature of care deliveredwithin the acute healthcare sector coincided with interest in improving acute care efficiency <strong>and</strong> restrainingtotal expenditure on acute healthcare in several western communities 16-28 . Whilst the relative balancebetween consumerism <strong>and</strong> cost-control varied between communities, all have demonstrated a progressiveinterest in objective quality evaluation in healthcare. Consumers, purchasers, regulatory agencies,


11governments <strong>and</strong> providers increasingly seek to compare provider per<strong>for</strong>mance to address accountabilityrequirements, promote quality improvement <strong>and</strong> in<strong>for</strong>m consumer decisions.<strong>Quality</strong> of care <strong>and</strong> outcome indicators first appeared almost a century ago with proposals to monitor theimpact of hospital care by pioneers such as Florence Nightingale in the UK <strong>and</strong> Ernest Codman in theUSA. These proposals were not widely acceptable to healthcare professionals <strong>and</strong> the mechanics of largescale data collection were impractical, hence they were not embraced. <strong>Indicators</strong> resurfaced in the early1970s when the potential <strong>for</strong> improving quality by using measurement was rediscovered by socialscientists. In North America, groups that sought to systematically monitor acute healthcare quality(Professional St<strong>and</strong>ards Review Organisations) debuted in 1973 <strong>and</strong> began applying crude qualityindicators to the hospital sector. In the 1980s the availability of improved data management systems, theperceived impact of efficiency strategies such as prospective payment systems <strong>and</strong> Deming’s <strong>Quality</strong>Improvement principles rejuvenated interest in quality monitoring <strong>and</strong> saw a move from indicator usage <strong>for</strong>quality maintenance (quality assurance) to use <strong>for</strong> quality upgrading (quality improvement).In the mid 1980s programs were launched to evolve complete sets of quality <strong>and</strong> outcome indicators,rather than use of individual indicators on an ad-hoc basis. These indicator sets were designed to be partof comprehensive quality monitoring programs in hospitals (e.g. The Maryl<strong>and</strong> Hospital Association<strong>Quality</strong> Indicator Project; 1985 55,304,335 . The Joint Commission on Accreditation of <strong>Healthcare</strong>Organisations Indicator Measurement System; 1986 14 . ACHS CEP Clinical Indicator Program;1989 367,507,508 ). More recently the focus in healthcare monitoring has moved from acute healthcare qualityassessments, specific <strong>for</strong> an episode of care, to assessment of the per<strong>for</strong>mance of integrated healthcaresystem per<strong>for</strong>mance (e.g. The Consortium Research on <strong>Indicators</strong> of System Per<strong>for</strong>mance; 1990 300-303 .The Health Employers Data <strong>and</strong> In<strong>for</strong>mation Set; 1989 307 . The Clinical Accountability <strong>and</strong> SystemsPer<strong>for</strong>mance Evaluation <strong>Quality</strong> <strong>and</strong> <strong>Outcome</strong> Indicator Set; 1996) embracing review of the continuum ofcare. This move to a broader focus on healthcare provision is driven by the recognition that:• Chronic illnesses, in particular, do not have clearly defined start/stop points <strong>for</strong> per<strong>for</strong>manceassessment based on a single episode of care.• The quality of integration <strong>and</strong> coordination of care is as important as the quality of componentservices.• Per<strong>for</strong>mance indicators should reflect whether required care was delivered to communities requiringcare, not simply how well care was delivered to hospitalised individuals who have successfullyaccessed care.Initial quality indicators tended to address healthcare structures (such as the level of equipment <strong>and</strong> staff).Later, indicator ef<strong>for</strong>ts were directed at process measures (such as if care was delivered as planned) whenprocess management was recognised as the key to successful quality improvement 255 . In the late 1980s astrong emphasis on outcome indicators emerged - driven by Paul Elwood 649 <strong>and</strong> others - requiringsystematic evidence of the end result of healthcare interventions (such as the duration or quality of lifeachieved).Original indicator sets tended to focus on narrow aspects of healthcare delivery (such as technicalproficiency or outcomes as perceived by providers of care) 320,321 . More recently, indicator sets haveemphasised the importance of a balanced portfolio of indicators, encompassing clinical outcomes, theacceptability of care, functional health outcomes, critical process measures <strong>and</strong> cost of care delivery (suchas Hospitals Corporation of America’s “Value Compass” Indicator Sets) 492,930 .Typically, indicator development programs commence with an emphasis on hospital episode of carereview, because of the availability of data systems in hospital practice <strong>and</strong> an assumption that hospitalbasedepisodes of care represent critical moments in individual patients’ overall healthcare. Such hospitalbasedindicator measures should only represent the beginning of an integrated approach to comprehensivequality of care <strong>and</strong> outcome monitoring within a healthcare system.


12SUMMARY OF TRENDS IN INDICATOR USE• Autonomy → Peer Review → Facility Review → External Review• Structure → Process → <strong>Outcome</strong> Focus• Individual <strong>Indicators</strong> → Indicator Sets• R<strong>and</strong>om Indicator Development → Balanced Sets of <strong>Indicators</strong>• <strong>Quality</strong> Control → <strong>Quality</strong> Assurance → <strong>Quality</strong> Improvement Context3.2 TerminologyThis field of health services research is replete with examples of individuals using the identical term torepresent quite different underlying concepts <strong>and</strong> different terms to reflect a common theme. No universallexicon exists. There has been a relatively recent growth in interest in quality <strong>and</strong> outcome indicators <strong>and</strong>the appropriation of words from common usage to serve as descriptors <strong>for</strong> very specific quality <strong>and</strong>outcome concepts. We provide brief working definitions we have used <strong>for</strong> important terms appearing inthis report. (A more detailed glossary of some examples of what others believe to be the various preferreddefinitions of terms is contained in Appendix 1).Structure:comprises the characteristics of care or resources compiled todeliver care to the patient. It includes the physical facilities, the staff<strong>and</strong> the licensing <strong>and</strong> credentialling of healthcare providers <strong>and</strong>selected patient characteristics 297 .Process:refers to the actual delivery of care. The series of linked, often (butnot necessarily) sequential steps that convert an input into anoutput, cause some set of outcomes to occur, generate usefulknowledge or add value 315 .<strong>Outcome</strong>:the significant result or end product of care delivery, such asimproved survival, functional health status or quality of life 304 .Health <strong>Outcome</strong>:a change in the health of an individual or a group of people orpopulation which is attributable to an intervention or series ofinterventions 352,504 .Health Intervention:any action which is intended to improve someone’s health (orreduce the rate at which it deteriorates), whether the action is aimedat health promotion, disease prevention, early diagnosis, a clinicalintervention, counselling or social service support, educational orpreventive measures, a change in administrative or budgetaryresponsibilities, regulations relating to safety, the relief of poverty,better housing or whatever 352,504 .Measures: seek to directly quantify quality of care or health outcomes 352,504 .<strong>Indicators</strong>:statistics or other units of in<strong>for</strong>mation which reflect, directly orindirectly, the per<strong>for</strong>mance of the healthcare system in maintainingor increasing the well-being of its target population 352,504 .Generic Measures orare measures or indicators that can be applied to individuals in any<strong>Indicators</strong>:health condition 352,504 .Clinically Specific<strong>Indicators</strong> or Measures:Attribution:Association:are indicators or measures that relate to specific clinical conditionsor measures of function that may have particular significance <strong>for</strong>particular conditions 352,504 .a health outcome is attributable to an intervention if the interventionhas been shown in a rigorous scientific way to cause the change inhealth status 352,504 .a health outcome is associated with an intervention if the change inhealth status generally occurs following the intervention but has notbeen demonstrated through rigorous scientific study to cause thechange 352,504 .


13Health Status:an integrated indicator of health (i.e. well-being), typicallyincorporating biological function, physical <strong>and</strong> mental health, social<strong>and</strong> role functioning 505 .Health-related <strong>Quality</strong> of that component of quality of life related to the sense of health (i.e.Life:well-being) of the individual concerned 764 .Customer:the recipient of a service within healthcare or anyone who hasexpectations regarding healthcare delivery 339 .Consumer: the population of potential customers 339 .The differential application of “indicator” versus “measure” <strong>and</strong> “quality/outcome” versus “per<strong>for</strong>mance”was particularly noted in our review of the literature. Terms such as “quality indicator” <strong>and</strong> “qualitymeasure” or “outcome indicator” <strong>and</strong> “outcome per<strong>for</strong>mance indicator” are effectively usedinterchangeably by some - yet are regarded as substantially different by others.If indicators are identifiable markers which describe or relate to quality of care <strong>and</strong> measures arequantifiable dimensions of objects or functions then clearly there is a continuum between an identifiabledescriptor related to quality (i.e. an indicator) <strong>and</strong> a quantified marker of quality (i.e. a measure). It is amatter of opinion as to when an “accurate description” merges into “quantification” 333 .We have elected to use the term “indicator” <strong>for</strong> all instruments that estimate the extent to which qualityhealthcare services are delivered, believing the overall status of quality evaluation in healthcare warrantsuse of a term implying less precision in the inferential relationship between evaluation <strong>and</strong> quality of care333,341 . We acknowledge that all “quality indicators” are strictly-speaking “quality per<strong>for</strong>mance indicators”337 . They provide reflections on the care setting (structure) <strong>and</strong> on things providers do (processes) orachieve (outcomes) rather than judgements based upon these reflections. For brevity’s sake, <strong>and</strong> indeference to common usage, we have frequently applied the term “quality indicator” without reference tothe “per<strong>for</strong>mance” qualifier.4. METHODOLOGY FOR THE PROJECT4.1 Literature ReviewAll consultant members contributed to an initial bibliographic database search <strong>and</strong> h<strong>and</strong>search of relevantdata sources. One month into the six month consultancy the Centre <strong>for</strong> Health Program Evaluationmembers assumed primary responsibility <strong>for</strong> further literature review of indicators of access <strong>and</strong> efficiencywhile The Alfred <strong>Healthcare</strong> Group <strong>and</strong> Department of Epidemiology <strong>and</strong> Preventive Medicine, MonashUniversity, members continued the broad literature search <strong>for</strong> other identified key dimensions of quality ofcare (see 5.1 below). Further details of the literature search methodologies are contained in Appendix 2.In common with other researchers in this field, we found the literature search to be a relatively inefficient<strong>and</strong> ineffective tool <strong>for</strong> accessing the body of knowledge of healthcare quality indicator applications320,321,340 . This reflects poorly developed key-word identifiers <strong>for</strong> research in indicators (limiting thesuccess of computer-based data searches) <strong>and</strong> the spread of relevant literature across a broad range ofjournals (rendering h<strong>and</strong> searches of journals relatively inefficient). Additionally, much of the detailedknowledge surrounding quality <strong>and</strong> outcome indicators is not published in conventional <strong>for</strong>ms - but iscontained in commissioned consultancy reports, purchaser or regulatory bodies internal workingdocuments or within healthcare providers’ in<strong>for</strong>mation systems. At Project’s end, the computer-basedbibliographic search <strong>and</strong> the h<strong>and</strong>-search strategies produced relatively equivalent numbers of relevantcitations.


144.2 Expert ConsultationThe Project team (Appendix 3) allocated responsibilities <strong>for</strong> canvassing expert opinion to complement theknowledge of quality of care <strong>and</strong> health outcome indicators obtained from the literature review in thefollowing way:• The Centre <strong>for</strong> Health Program Evaluation consulted with a number of States <strong>and</strong> Territories relevantto access <strong>and</strong> efficiency indicators.• The Alfred <strong>Healthcare</strong> Group members consulted with the Commonwealth on related researchprograms <strong>and</strong> overseas consultation with acknowledged leaders in indicator development <strong>and</strong>implementation. This included site visits to centres of excellence in the United States <strong>and</strong> the UnitedKingdom (Appendix 4).• The Department of Epidemiology <strong>and</strong> Preventive Medicine consulted with academic research groupspursuing relevant research within Australia.• The Australasian Association <strong>for</strong> <strong>Quality</strong> in <strong>Healthcare</strong> consulted with State <strong>and</strong> Territorygovernments to ascertain the status of relevant indicator developments <strong>and</strong> experience withinAustralia.Taken together, these contacts with experts working in the field were extraordinarily productive, both inproviding textural details <strong>and</strong> balanced opinion frequently absent from published reports <strong>and</strong> in helpingidentify additional sources of relevant in<strong>for</strong>mation <strong>and</strong> mechanisms to access these sources. These expertconsultations were crucial in obtaining the operational details of many indicators <strong>and</strong> indicator sets - detailswhich frequently in<strong>for</strong>med our decisions regarding the ultimate utility of proposed indicators. Additionaldetails concerning these site visits are included in Appendix 5. We acknowledge the generosity of those whoshared their valuable time <strong>and</strong> accumulated wisdom with us over the six months of the consultancy <strong>and</strong>contributed to our decision-making processes.5. RESULTS FROM THE PROJECT5.1 Key Dimensions of <strong>Quality</strong>The definition of quality in healthcare remains a challenge 12 . As <strong>for</strong> all abstract concepts it is possibleto define healthcare quality equally correctly from a variety of perspectives. We believe no singleperspective or resultant definition to be inherently superior to others. Use of several definitions isboth possible <strong>and</strong> legitimate. We consider the following definitions contribute to a broadunderst<strong>and</strong>ing of what is meant by quality in healthcare.• The degree of excellence. OXFORD DICTIONARY• How closely the result of a medical service approaches the fundamental objectives ofprolonging life, relieving distress, restoring function <strong>and</strong> preventing disability. PAULLEMBCKE• Achieving <strong>and</strong> producing health <strong>and</strong> satisfaction. AVEDIS DONABEDIAN• Consistently meeting or exceeding in<strong>for</strong>med customers’ expectations. W.EDWARDS DEMING• The degree to which health services <strong>for</strong> individuals <strong>and</strong> populations increase the likelihood ofdesired health outcomes <strong>and</strong> are consistent with current professional knowledge. INSTITUTEOF MEDICINE


15Whilst there are multiple dimensions to healthcare quality, only some of these are currently amenable toquantification. Following a preliminary review of the available literature we agreed with our SteeringCommittee to address indicators in the following care dimensions:AccessDIMENSIONTimelinessENCOMPASSINGEfficiencyTechnical EfficiencyAllocative EfficiencySafety -EffectivenessEfficacyAcceptabilityConsumer PerceptionCustomer PerceptionSatisfactionRelevanceCultural AppropriatenessConsumer Involvement in Health <strong>Services</strong>ContinuityDischarge PlanningCoordinationTechnical Proficiency -Appropriateness -The working definitions <strong>for</strong> these designated dimensions of care are:Access:Efficiency:The capacity of individuals to obtain the same quality of service.Maximising benefits (or outcomes) <strong>for</strong> a given cost:♦♦Technical efficiency: the degree to which the least cost combination ofresource inputs occur in production of a particular service.Allocative efficiency: the degree to which maximum benefit (oroutcomes) are obtained from available resources.Safety:Effectiveness:Acceptability:Continuity:TechnicalProficiency:The extent to which potential risks were avoided <strong>and</strong> inadvertent harmminimised in care delivery processes.The degree to which an intervention produces measurable increases in survivalor improved quality of life (or improved outcomes) when applied in routinepractice.The degree to which the service meets or exceeds the expectations of in<strong>for</strong>medcustomers <strong>and</strong> consumers.The extent to which an individual episode of care is coordinated <strong>and</strong> integratedinto overall care provision.The extent to which the per<strong>for</strong>mance of interventions by healthcareprofessionals is consistent with contemporary st<strong>and</strong>ards <strong>and</strong> knowledge ofskills relevant to that intervention.


16Appropriateness:The extent to which potential benefits of an intervention exceed the risksinvolved.Some identified dimensions of quality (such as equity) are only partially represented in the above schema(access reflects some aspects of equity). Others (such as benevolence) see aspects represented withinseveral of our proposed dimensions of quality of care, but are still inadequately represented overall. Wechose not to include care dimensions <strong>for</strong> the purpose of this Project when initial review failed to identifyany feasible indicators likely to be applicable in any national indicator program. These oversights do notindicate that dimensions not incorporated into this review are less crucial than those featuring - rather theseidentified dimensions of quality of care are a reasonable starting point from which to begin building acomprehensive quality <strong>and</strong> outcome indicator set <strong>for</strong> acute healthcare services. This final choice ofdimensions of quality of care encompasses aspects of care relevant to patients, providers <strong>and</strong> purchasers.There is minimal overlap between individual dimensions <strong>and</strong> the coverage of aspects of quality iscomprehensive. Because of the importance of patient safety in acute healthcare, we have chosen toemphasise safety by its designation as a discrete dimension of care, despite considerable content overlapwith matters analysed in the dimensions of effectiveness, technical proficiency <strong>and</strong> appropriateness.5.2 Criteria <strong>for</strong> Assessing <strong>Indicators</strong><strong>Healthcare</strong> quality indicators need to be judged against criteria which indicate whether they are likely tofulfil their intended purposes. We chose the following assessment criteria:♦Reliability:The degree to which an indicator is free from r<strong>and</strong>om error, is reproducible (or stable) over time <strong>and</strong>shows interrater agreement at one point in time.This includes the concepts of:• Internal consistency• Test/retest stability• Interrater reliabilityReliability will be largely dependent on the adequacy of the operational definition <strong>for</strong> the indicator<strong>and</strong> the rigour of data collection, data analysis <strong>and</strong> data audit.♦Validity:Given the quality monitoring purpose <strong>for</strong> which it is intended, do inferences regarding quality ofcare based upon the indicator accurately reflect the quality of care delivery?Validity is a matter of degree <strong>and</strong> must be judged with an underst<strong>and</strong>ing of the intended applicationof an indicator (that is, is it valid <strong>for</strong> its intended purpose?).Judgements of validity are based upon review of:• Face validity: Does the indicator appear to relate to quality of care?• Content validity: How closely does the indicator relate to quality of care <strong>and</strong> how well arerelevant aspects of care quality covered by the indicator?• Construct validity: What relation does the indicator have to other measures of quality?• Predictive validity: How well does an indicator of good/poor care predict that good/poorcare was delivered?


17Un<strong>for</strong>tunately criterion validity (the degree to which an indicator is related to widely accepted validmeasures of quality) could not be included in our assessments as criterion measures <strong>for</strong> quality areunavailable in acute healthcare.Within validity determinations lies knowledge of quality indicator sensitivity, its “true positive” rate<strong>and</strong> specificity, its “true negative” rate.♦♦♦♦♦♦♦♦Responsiveness:How does the indicator change as quality of care changes? Is the indicator capable of detecting thesorts of differences in quality of care typically experienced in acute healthcare services?Interpretability:Does the indicator make sense? Does it communicate a consistent message to those who use it?Significance:Does the indicator reflect aspects of care that matter to users of the indicator <strong>and</strong> are relevant incurrent healthcare contexts?Burden:How difficult or costly is indicator data collection <strong>and</strong> indicator construction?Utility:Has the indicator been proven to be of value when used in acute healthcare (either <strong>for</strong>accountability, directing consumer decisions or quality improvement)?Vulnerability to Undesired Effects:What is the likelihood that use of the indicator would create perverse incentives <strong>for</strong> healthcareproviders (such as to corrupt indicator data or alter healthcare provision in undesirable ways)?Availability of Alternate Forms:Can the indicator be altered to allow its use in different target populations (e.g. those requiringlanguage or cultural adaptations)?Amenity to Independent Corroboration: Can indicator data be confirmed by others?These attributes of indicators were culled from several proposed assessment criteria panels 320,321,324 . Theyprovide a realistic basis upon which to judge indicator suitability <strong>for</strong> application in an Australian context.In the majority of cases examined we found insufficient in<strong>for</strong>mation upon indicator per<strong>for</strong>mance to enableus to make appropriate firm judgements regarding indicator per<strong>for</strong>mance against these desired attributes.Final judgements on the utility of indicators involved assessments of all available in<strong>for</strong>mation regardingindicators <strong>and</strong> the potential <strong>for</strong> local collection of requisite in<strong>for</strong>mation.5.3 Current Status of Indicator Development5.3.1 AustraliaThe major program <strong>for</strong> acute healthcare quality indicators underway in Australia is the ACHSCEP <strong>and</strong> specialist medical colleges conjoint development of clinical indicators 367,507,508 .Although this work was specifically excluded from our terms of reference, it is such a dominant<strong>for</strong>ce in indicator development that we believe some brief comments on its achievements thus farare appropriate. In 1996 there are seven indicator sets in use - with 16 clinical indicator setsplanned to be available <strong>for</strong> use within ACHS accreditation programs in 1997 (Appendix 6).These indicators have been cooperative developments between the ACHS <strong>and</strong> relevant medicalspecialty colleges <strong>and</strong> strongly reflect the perspectives of providers, with a heavy emphasis ontechnical proficiency. Although drawing upon overseas indicator developments, operational


18definitions <strong>for</strong> ACHS CEP indicators are sufficiently different from international definitions torender direct comparisons impossible. Their focus upon clinician involvement in the derivationof indicator data means that they frequently cannot be simply collected from routineadministrative databases <strong>and</strong> hence may not be easily applied as core indicators at a nationallevel. At present indicators are not risk-adjusted using patient level data, but are stratified on thebasis of provider-facility characteristics. Throughout their development there has been relativelylittle data made available on the methodologic rigour of indicators - with little current dataavailable on their reliability, validity <strong>and</strong> responsiveness. These are not necessarily criticisms ofthe AHCS CEP nor the contributions of specialist colleges to this clinical indicator program.Rather, they reflect the context within which the ACHS program has progressed <strong>and</strong>, inparticular, its stated aims to promote facility quality improvement <strong>and</strong> engage clinicians inmeasurement endeavours. It does mean that ACHS clinical indicators are not immediatelysuitable <strong>for</strong> transfer to a national quality of care <strong>and</strong> health outcome indicator program withoutclose scrutiny of their suitability <strong>for</strong> that purpose <strong>and</strong> subsequent <strong>for</strong>mal trials of theirapplication in such a context.Numerous other indicator initiatives have occurred within facilities, benchmarking projects, bestpractice programs <strong>and</strong> the Health Departments of States <strong>and</strong> Territories. These initiatives havelargely not attempted to generate the sort of high level indicators which would be of value in anational monitoring program. Rather, they looked at indicators suitable <strong>for</strong> the specific purposeat h<strong>and</strong>. We found quality of care issues dealt with by a broad range of interested parties(including a variety of departments <strong>and</strong> sections in governmental <strong>and</strong> regulatory bodies) <strong>and</strong> itproved difficult to access comprehensive in<strong>for</strong>mation on work in progress or recently completedindicator development work in the timeframe of the Project. Additionally, it appeared that someagencies were ambivalent about contributing to a developmental program <strong>for</strong> a nationallyconsistent set of quality <strong>and</strong> outcome indicators <strong>and</strong> may have tempered their contributions toour research in proportion to this ambivalence.Some examples of identified quality indicator applications include:Commonwealth The Commonwealth Department of Health <strong>and</strong> Family <strong>Services</strong> supports theACHS CEP clinical indicator program (see above). Within the Health <strong>Services</strong> <strong>Outcome</strong>sBranch it has groups looking at primarily patient safety, health models, consumer perspectiveson health, health outcomes policy, workplace change promotion <strong>and</strong> healthcare quality <strong>and</strong>outcomes. Recent key initiatives include the funding of a study addressing the reliability, validity<strong>and</strong> risk-adjustment issues around four so-called “hospital-wide quality of care indicators” (i.e.wound infection, nosocomial bacteraemia, unplanned return to theatre <strong>and</strong> emergencyreadmission).The Health Models Development Section supports an Ambulatory Care Data Working Groupwhich has recently proposed per<strong>for</strong>mance indicators <strong>for</strong> Ambulatory Care with a potentialrelevance <strong>for</strong> the acute healthcare sector. These are:♦♦♦♦♦♦Waiting times in Emergency Departments - based upon The Australian College ofEmergency Medicines five triage categories.Waiting times <strong>for</strong> admission to hospital from the Emergency Department.Cost per outpatient separation.Patient satisfaction.Waiting times <strong>for</strong> outpatients appointments.Waiting times in outpatients per attendance.At present these indicators have conceptual definitions, with operational definitions <strong>and</strong>subsequent field trials pending.


19The National Demonstration Hospital Program has identified per<strong>for</strong>mance indicators whichrequire development at three levels (program, project <strong>and</strong> hospital). To date, some 20 programlevel per<strong>for</strong>mance indicators have been advanced. They have crude operational definitionsprovided, which would be inadequate <strong>for</strong> routine applications. These indicators do not covermany of the significant dimensions of care quality (e.g. effectiveness, technical proficiency,safety) being restricted to access <strong>and</strong> efficiency indicators (as is the purpose of the program).They are:♦ Percentage of Category 1 patients waiting more than specified days.♦ Percentage of Category 2 patients waiting more than appropriate time.♦ What is the average excess wait (days) <strong>for</strong> patients classed as Category 1?♦ What is the average excess wait (days) <strong>for</strong> patients classed as Category 2?♦ By how many does the total waiting list number exceed appropriate levels in each category?♦ Trend in elective admissions from the waiting list this month.♦ Does the percentage change in all admissions exceed the percentage change in electiveadmissions?♦ Does the percentage change in admissions exceed the percentage change in annual funding?♦ Change in unplanned readmissions within 28 days.♦ Percentage of elective patients surveyed <strong>for</strong> satisfaction.♦ Level of overall elective patient satisfaction with total admission.♦ Is the waiting list at least equal to a month’s elective admissions?♦ Surgical patients treated per sessional hour per month.♦ Is operating room utilisation improving?♦ Percentage elective admissions on planned day of surgery.♦ Percentage of same-day surgical admissions.♦ Percentage of electives cancelled on planned day of surgery.♦ Patients treated per available bed per month.♦ Months since last audit based on direct patient survey.The Health Service <strong>Outcome</strong>s Branch, through the <strong>Quality</strong> <strong>and</strong> <strong>Outcome</strong>s Section, are funding atrial of an Integrated <strong>Quality</strong> Management Model which will involve, amongst a range ofactivities, the application of indicator sets within provider facilities. These will be developedaround the principle of the “Value Compass” (of Hospitals Corporation of America) 492 <strong>and</strong> willinvolve balanced indicator sets <strong>for</strong> specific clinical conditions incorporating indicators of clinicaloutcomes, functional health status, patient perception <strong>and</strong> cost. The actual indicator sets to beapplied are currently under development.The Commonwealth is engaged in developing numerous additional indicators, many of which arein areas outside acute health services. A complete list is included in Appendix 6.The Australian Institute of Health <strong>and</strong> Welfare play a pivotal role in the collection <strong>and</strong> analysisof current per<strong>for</strong>mance indicator data. They have been instrumental in establishing the interimpopulation norms <strong>for</strong> the SF-36, a functional health status questionnaire designed to measuregeneric aspects of health. They also have produced the First National Report on Health SectorPer<strong>for</strong>mance <strong>Indicators</strong> <strong>for</strong> the National Health Ministers’ Benchmarking Working Group. Thisinaugural report contains indicators relevant to quality as follows:♦♦♦♦♦♦Cost per casemix adjusted separation.Cost of treatment per outpatient.Inpatient average length of stay <strong>for</strong> top 20 AN-DRGs.Rate of emergency patient readmissions within 28 days.Rate of unplanned return to operating room.Patient satisfaction.


20♦♦♦♦♦♦Proportion of facilities accredited with ACHS.Waiting times <strong>for</strong> elective surgery.Accident <strong>and</strong> emergency waiting times.Outpatient waiting times.Variations in intervention rates.Separations per 1000 population.The authors of this report emphasise that consistent national data is currently unavailable <strong>for</strong>many of these indicators <strong>and</strong> caution - appropriately - that they be interpreted in light of thesemethodological deficiencies. These caveats notwithst<strong>and</strong>ing, it is likely that this initiative of TheAustralian Health Ministers’ Conference marks the first step on a journey to improvedper<strong>for</strong>mance indicators of increased relevance <strong>and</strong> utility.Victoria The Department of Health <strong>and</strong> Human <strong>Services</strong> (then Health <strong>and</strong> Community <strong>Services</strong>)completed a comprehensive review of quality activities in acute healthcare in 1995 - the resultsof which are contained in “A New Framework <strong>for</strong> <strong>Quality</strong> in Victoria’s Public Hospitals: FinalReport” 357,358 . This identifies several major quality <strong>and</strong> outcome indicator initiatives acrossVictoria sponsored by The Department of Health <strong>and</strong> Human <strong>Services</strong>:♦♦♦♦♦Monitoring of unplanned hospital readmissions.St<strong>and</strong>ard survey of patient satisfaction (based upon the Picker Commonwealth Instrument).A requirement <strong>for</strong> hospital quality plans.Subsidisation <strong>for</strong> participation in the ACHS hospital accreditation program.Monitoring of Emergency Department per<strong>for</strong>mance.Additional identified indicators included:• Percentage of private separations/facility.• Percentage of private bed days/facility.• Average available beds.• Average length of stay (by ANDRG).• Non-admitted patient occasions of service.• Separations/facility.• Same-day medical separations as percentage of all separations.• Non-same day emergency separations as percentage of all separations.• Non-same day elective separations as a percentage of all separations.• Nursing home type bed days <strong>and</strong> separations.• Regional separations as percentage of all separations.• Outside region non-tertiary separations as a percentage of all non-tertiary separations.• Non-tertiary separations from tertiary hospitals as percentage of all network non-tertiaryhospitals.• Tertiary separations from tertiary hospitals as percentage of all network tertiary hospitals.• Transfers between network campuses as a percentage of total separations.• Transfers to/from other networks as a percentage of total separations.South Australia Activities initiated through the Casemix <strong>and</strong> Clinical Costing Unit of the SouthAustralian Health Commission include:♦♦♦♦♦Emergency patient readmissions.Returns to theatre.Nosocomial infections.Health status assessment (SF36).Patient Satisfaction.


21♦♦♦♦♦♦Waiting times <strong>for</strong> elective surgery.Available bed days: Daily average.Cost per casemix adjusted separation.Cost per casemix treatment per patient.Inpatient average length of stay by DRG.Proportion of facilities accredited by ACHS.The South Australian Health Commission has also undertaken considerable research <strong>and</strong>development on utilisation review. This management tool particularly addresses issues aroundsite of care (such as appropriateness of admission) or intensity of care (such as numbers ofinvestigations per case). We regard utilisation review as an important facility managementinstrument with little application in any national quality <strong>and</strong> outcome indicator programaddressing acute hospital care <strong>and</strong> have not included review of this, or other utilisation reviewprotocols, within our review.Australian Capital Territory The Department of Health <strong>and</strong> Community Care identifiedevaluation of the SF36 health status survey as a relevant activity <strong>for</strong> quality <strong>and</strong> outcomeindicator development, occurring under the auspices of the Care Continuum <strong>and</strong> Health<strong>Outcome</strong>s Project. Additional developmental work is currently underway in:• Ambulatory care.• Palliative care.• Breast cancer.• Hospital-based cancer care.• Discharge planning.• Asthma.• Injury.• Orthopaedic rehabilitation domiciliary service.• Cardiac disease.Western Australia The Health Department of Western Australia indicated that a number ofper<strong>for</strong>mance measures had been applied in the past, although existing purchaser/providercontracts have not had any quality indicators reported. A sample of past per<strong>for</strong>mance measuresincluded:♦ Average cost per bed day.♦ Average cost per admission.♦ Average cost per non-inpatient occasion of service.♦ Average length of stay per admission.♦ Median wait time from hospital waiting list.♦ Percentage of clients satisfied with their hospital stay.♦ Overall satisfaction index.♦ Percentage of hospitals operating quality assurance programs.♦ Percentage of hospitals accredited.♦ Hospital acquired wound infection.♦ Apgar score of four or less at five minutes <strong>for</strong> newborns whose birthweight was at least 500grams.♦ Geographic variation in admission rates per 1000 population.Tasmania Under a “Health Goals <strong>and</strong> Targets <strong>for</strong> Tasmania” program, a process to identify keyhealth issues was commenced in May 1992. Currently there are no state-wide indicatorinitiatives, although Regional Business Plans have an agreed set of per<strong>for</strong>mance indicators -including some quality indicators - against which they report. These indicators include:


22♦ Emergency Department waiting times by triage code.♦ Outpatient waiting times by specialist area.♦ ACHS CEP hospital-wide medical indicators (nosocomial infection, unplanned return totheatre, post-operative pulmonary embolism <strong>and</strong> unplanned readmission).Northern Territory No state-wide indicator collection is currently occurring. Major providerfacilities (e.g. Royal Darwin Hospital) are collecting ACHS CEP hospital wide medicalindicators, including:♦ Unplanned return to the operating room.♦ Nosocomial infection.♦ Unplanned readmissions.Queensl<strong>and</strong> Queensl<strong>and</strong> Health have data available on:♦ Client satisfaction with Accident <strong>and</strong> Emergency Department care delivery.♦ Separation rates.♦ Cost of care delivery.They support pursuit of ACHS accreditation (<strong>and</strong> hence indirectly promote use of ACHS CEPclinical indicators). They noted a current inability to track <strong>and</strong> report elective surgery accesstimes because of limitations to existing in<strong>for</strong>mation systems. They identify ongoing projectsaround waiting lists, commercial key per<strong>for</strong>mance indicators, client services st<strong>and</strong>ards <strong>and</strong> bestpractice implementation.New South Wales The New South Wales Health Department has been reviewing the utility of anumber of ACHS hospital-wide medical indicators in quality assessment (including unplannedreadmission, unplanned return to theatre) <strong>and</strong> have an extensive developmental programaddressing issues surrounding the identification of nosocomial infection. In addition, routinemonitoring of elective surgery queuing times <strong>and</strong> emergency department waiting times isoccurring. Pilot patient satisfaction surveys have been per<strong>for</strong>med across NSW hospitals,including an emergency department survey.Specific indicators currently applied by New South Wales Health include:♦ Unplanned readmission to hospital or inpatient health service within 28 days of dischargefrom an inpatient health service where the original admission had been <strong>for</strong> an electiveprocedure.♦ Patients assessed in Outpatient Department within 1 month of referral.♦ Patient satisfaction with their access to in<strong>for</strong>mation.♦ GP satisfaction with their access to in<strong>for</strong>mation.♦ “Urgency 1 <strong>and</strong> 2” patients waiting longer than 1 month.♦ “Urgency 3” patients waiting longer than 6 months.♦ “Urgency 3” patients waiting longer than 12 months.♦ “Urgency 3” elective surgical patients given definite dates of admission with 12 weeks ofplanned procedure.♦ Elective surgical patients attending preadmission process.♦ Elective patient satisfaction with their waiting time <strong>for</strong> inpatient care.♦ Elective patients having their planned admission date brought <strong>for</strong>ward.♦ Elective patients admitted on day of procedure (selected).♦ Patients having an unplanned return to operating room.♦ Patients having a procedure as a “same day” patient (selected).♦ Patients discharged on anticipated date.


23♦ Patients in<strong>for</strong>med of their discharge date on admission.♦ Relative stay index <strong>for</strong> 5 elective surgical procedures.♦ Elective patients delayed (not self deferred).♦ Waiting time from Emergency Department arrival to be seen by medical officer (by triagecategory).♦ Emergency Department treatment time: from time seen by medical officer to admission toinpatient bed.It should be noted that existing State <strong>and</strong> Territory programs have paid little attention toascertaining the reliability <strong>and</strong> validity of indicator data provided to central indicator monitoringprograms. Typically, indicator data are used to aid policy implementation <strong>and</strong>/or to satisfyrudimentary accountability requirements. The only research <strong>and</strong> development activitiesidentified by the Project team primarily directed at acute care quality <strong>and</strong> outcome indicators isthe nosocomial infection indicator work underway within NSW 360 . Overall States <strong>and</strong>Territories are tending to promote ACHS-CEP hospital-wide medical indicators, rather th<strong>and</strong>eveloping de novo indicator programs, although the operational definitions <strong>for</strong> these indicatorsare frequently modified by individual States <strong>and</strong> Territories to suit the unique requirements oftheir data h<strong>and</strong>ling systems. As a result, even the in<strong>for</strong>mation available on apparently similarACHS CEP-based indicators may not be comparable between States <strong>and</strong> Territories.The State <strong>and</strong> Territory indicators have largely been selected from those in common usagenationally <strong>and</strong> internationally. Typically, they are readily available from routine data sources.Those indicators requiring additional data collection have frequently not yet been introduced intoroutine monitoring programs. Many comments on the lack of knowledge of the reliability <strong>and</strong>validity were made. Concerns were expressed frequently about lack of indicator risk adjustment.Although some limited evidence of the application of indicators in local quality improvementef<strong>for</strong>ts were reported, typically little was known of the utility of indicator data. Often thoseindicators in use <strong>for</strong> longer periods had more caveats <strong>and</strong> concerns regarding their usefulness -perhaps reflecting accumulated knowledge of their limitations with continued application (<strong>for</strong>example, many reported uncertainty regarding the value of the unplanned readmission indicator).5.3.2 North America The past two decades have seen an explosion of activity in quality <strong>and</strong>outcome indicator development <strong>and</strong> implementation in North America. The range of indicatorsapplied <strong>and</strong> the multitude of agencies developing <strong>and</strong> implementing indicator programs makes acomprehensive review of these activities a daunting task. We have elected to present briefsummaries of programs that illustrate seminal principles in indicator development, novelindicator strategies or competing views on indicator applications. Additional detail on NorthAmerican quality indicators is contained in Appendix 6.NATIONAL PROGRAMS/MULTISTATE PROGRAMS OF NOTE IN USA1. Joint Commission on Accreditation of Health Care Organisations (JCAHO)Indicator Measurement System (IM System)2. National Committee <strong>for</strong> <strong>Quality</strong> Assurance (NCQA)Health Employer Data <strong>and</strong> In<strong>for</strong>mation Set (HEDIS)3. Maryl<strong>and</strong> Hospitals Association (MHA) <strong>Quality</strong> Indicator Project (QIP)4. Consortium Research on <strong>Indicators</strong> of System Per<strong>for</strong>mance (CRISP)


24JCAHO IM System: This quality <strong>and</strong> outcome indicator program has been under developmentsince 1985 14,138,144 . As at 1996 it consists of 33 indicators covering obstetrics, perioperativecare, cardiovascular, trauma, oncology, infection control, medication use <strong>and</strong> health carenetwork per<strong>for</strong>mance. In 1997, additional indicators <strong>for</strong> depressive disorders, long term care <strong>and</strong>home infusion therapy are planned <strong>for</strong> introduction.The JCAHO launched the IM System with a view to making it the pre-eminent indicator programin the USA - the use of which would eventually be m<strong>and</strong>atory <strong>for</strong> providers wishing to seekJCAHO accreditation 142 . There was considerable industry opposition to a clinical per<strong>for</strong>mancemonitoring system developed by a regulatory body. This opposition <strong>and</strong> the desire by JCAHO tom<strong>and</strong>ate IM System use broadly across the USA resulting in a rigorous developmental programwhich has actively sought in<strong>for</strong>mation regarding the reliability, validity <strong>and</strong> relevance ofindicators.The IM System has detailed operational definitions available <strong>for</strong> all indicators 142 (see example<strong>for</strong> nosocomial infection: Appendix 13) which help ensure data reliability. An extensiveresearch program, based around an initial (Alpha) testing <strong>for</strong> face validity <strong>and</strong> indicatorfeasibility is followed by a more exhaustive second phase (Beta testing) examination addressingreliability, validity <strong>and</strong> relevance issues. Whilst some tens of facilities participate in Alphatesting, surveys indicator data collection <strong>and</strong> on-site visits <strong>for</strong> several hundred facilities occur inBeta testing - providing firm data upon which to base judgements on indicator attributes.The IM System is based around a common software program which guides accurate datacollection <strong>and</strong> includes audit-checks <strong>for</strong> data reliability encoded in the software. A substantialresearch <strong>and</strong> development group <strong>and</strong> service infrastructure support indicator application byfacilities. Despite these features, it has enjoyed only modest penetration in the US market -reflecting competing indicator systems, concerns that the IM System is still developmental <strong>and</strong>resistance because of its origins in a regulatory body. In 1996 JCAHO elected to discontinue theplanned m<strong>and</strong>ating of IM Systems <strong>for</strong> the purposes of JCAHO accreditation, instead opting toreview <strong>and</strong> approve any indicator that fulfilled their criteria <strong>for</strong> methodological rigour. A call <strong>for</strong>indicators was made, inviting submission of any existing indicators or indicator sets to JCAHO<strong>for</strong> review by their expert panel. At completion of this review process, the JCAHO will publisha compendium of quality <strong>and</strong> outcome indicators which are deemed sufficiently wellcharacterised to meet their methodological rigour requirements <strong>and</strong> hence be approved <strong>for</strong> use infacilities seeking JCAHO accreditation. This compendium will offer a valuable entree to thestate-of-the-art in indicator science in North America (it is scheduled <strong>for</strong> release in the NorthernHemisphere Autumn 1996).The JCAHO IM System provides facilities with risk-adjusted 144 indicator data based uponpatient, not hospital, characteristics. Individual risk adjustment methodologies are designed <strong>for</strong>each indicator - typically using their database to generate “predicted” indicator rates with whichfacilities can compare their actual rates per indicator.NCQA: HEDIS HEDIS was designed to permit employers to judge the value of the healthcarethey are buying <strong>for</strong> their employees <strong>and</strong> to make health plans accountable <strong>for</strong> their per<strong>for</strong>mance307,313 . The NCQA - an accreditation body that focuses on health plans rather than hospitals <strong>and</strong>is the major player in this market - has developed the HEDIS measure set in three iterations (thusfar), i.e. HEDIS 1.0, HEDIS 2.0 <strong>and</strong> HEDIS 2.5. The HEDIS measures were a response to theproliferation of competing indicator systems amongst health plans which were typically notproducing comparable data. HEDIS was seen as providing a common language <strong>for</strong> guidingchoice of health plans. The measures were chosen by a Per<strong>for</strong>mance Assessment Committee(PAC), consisting of employers, NCQA <strong>and</strong> technical expertise representatives. To date, no dataare available on indicator/measure attributes, such as reliability or validity, although it is planned


25to collect such data <strong>for</strong> the HEDIS 3.0 measures currently under development. HEDIS 2.5includes more than 60 measures across the broad areas of:♦♦♦♦<strong>Quality</strong> of care.Member access <strong>and</strong> satisfaction.Membership <strong>and</strong> utilisation.Finance.The particular measures within each of these major areas were chosen on the basis of theirperceived relevance <strong>and</strong> value to the employer community, the reasonable ability of health plansto provide the requested data <strong>and</strong> their potential impact on improving health care delivery. Themeasures are a mix of population-based per<strong>for</strong>mance <strong>and</strong> episode of care per<strong>for</strong>mance indicators(see Appendix 6). Those specific <strong>for</strong> acute episodes of care could feasibly be adapted <strong>for</strong> use inacute healthcare in Australia. At present HEDIS data, although frequently stratified, are notrisk-adjusted. Relevant indicators in HEDIS 3.0 are proposed to be risk-adjusted using indicatorspecificmodels developed around patient level data. NCQA has also had a “Call <strong>for</strong> <strong>Indicators</strong>”in 1996, seeking indicators suitable <strong>for</strong> inclusion in HEDIS 3.0.MHA: QIP The oldest of the multifacility indicator monitoring programs, the MHA QIPprovides comparable indicator data on 10 inpatient quality <strong>and</strong> outcome indicators <strong>and</strong> 5ambulatory care indicators to over 1000 participating facilities in North America, Japan, Europe<strong>and</strong> the United Kingdom (Appendix 6). It is the largest single indicator monitoring program inexistence anywhere in acute healthcare. The Project seeks to educate participants in the use ofquality indicator data <strong>for</strong> quality improvement. The MHA QIP guarantees confidentiality <strong>for</strong> allparticipant facilities. It does not risk-adjust data, primarily because of a belief that it isunnecessary as indicators are intended only <strong>for</strong> facility quality endeavours <strong>and</strong> not comparativejudgement by others. <strong>Indicators</strong> have available data on reliability, validity <strong>and</strong> relevance -collected over their 10 years of experience with indicator use. The software provided to facilitatedata collection contains data reliability checks. There are several documented case-studiesavailable which demonstrate favourable strategies developed in response to initial indicator datareview (such as a progressive reduction in absolute rates <strong>and</strong> the extent of variation betweencentres <strong>for</strong> Caesarean section in New Hampshire).CRISP This is a voluntary collaborative program administered from The Henry Ford HealthSystem in Detroit. Eighteen integrated healthcare systems participate in a research programwhich aims to identify preferred indicators of healthcare delivery per<strong>for</strong>mance. <strong>Indicators</strong> aredivided by category:♦♦♦♦♦♦♦♦♦♦♦Population health.Community benefit.<strong>Quality</strong> of care.Episode prevention.Episode characteristics.Satisfaction.Efficiency.Capacity.Financial per<strong>for</strong>mance.Research.Education.At present, indicators lie in two tiers, the first representing indicators of established reliability,validity <strong>and</strong> utility <strong>and</strong> the second tier a group of developmental indicators 300,301,302,303 (seeAppendix 6 <strong>for</strong> further detail). CRISP uses risk adjustment to increase the comparability ofper<strong>for</strong>mance indicators across the systems. The risk adjustment models are developed <strong>for</strong> each


26indicator <strong>and</strong> based on patient level data, typically demographic descriptors (e.g. age, sex,race/ethnicity, educational attainment). CRISP maintains all indicator data as confidentialcommunications - arguing that, at present, the data lie within a research program, are notsufficiently well characterised <strong>for</strong> further release <strong>and</strong> failure to protect participant confidentialitywould compromise the ultimate development of credible indicators suitable <strong>for</strong> public release.There are several other noteworthy examples of quality <strong>and</strong> outcome indicator applications inNorth America. They include:CONQUEST Computer needs-oriented quality measurement evaluation system (CONQUEST)is a system of interlocking databases summarising in<strong>for</strong>mation on approximately 1200 clinicalper<strong>for</strong>mance measures used by public <strong>and</strong> private sector organisations to examine technicalquality of clinical care. Developed as a collaboration between the Centre <strong>for</strong> <strong>Quality</strong> of CareResearch <strong>and</strong> Education at the Harvard School of Public Health (in Boston) <strong>and</strong> the Centre <strong>for</strong>Health Policy Studies (in Colombia) it is essentially a typology of clinical per<strong>for</strong>mance measureswhich allows identification of measures on the basis of characteristics or properties of thesemeasures. This software is based upon a research project commissioned by the Agency <strong>for</strong>Health Care Policy <strong>and</strong> Research (AHCPR) in 1994. It can be used to search <strong>for</strong> measuresunder:• Name.• Rigour of development.• Organisation type developed <strong>for</strong>.• Intended use.• Extent of use.• Practicality.• Clinical event.• Age of patient.• Care needs.• Care setting.• Process/outcome.• Data source.• Sampling frame.• Stratification method.• Time window.• Allowance <strong>for</strong> patient factors in scoring.• Comparative st<strong>and</strong>ards.• Display of results.Its widespread availability (anticipated <strong>for</strong> mid-1996) to health service researchers should speedaccess to in<strong>for</strong>mation on existing indicators <strong>and</strong> indicator sets.FACCT: The newly established Foundation <strong>for</strong> Accountability plans to endorse qualityindicators, advocate their widespread use by providers <strong>and</strong> promote consumer use of endorsedindicators. They have developed criteria <strong>for</strong> assessing per<strong>for</strong>mance indicators <strong>for</strong> use byconsumers (Guidebook <strong>for</strong> Per<strong>for</strong>mance Measurement) <strong>and</strong> are likely to contribute significantlyto the adoption of indicators by health plans <strong>and</strong> acute care users across America.Veterans’ Affairs: The US Department of Veterans Affairs has an active research programencompassing a range of studies on the use of process <strong>and</strong> outcome indicators in healthcare, therelationships between selected process measures <strong>and</strong> observed outcomes, the reliability <strong>and</strong>validity of particular indicators <strong>and</strong> the application of patient-based measures of health status,process <strong>and</strong> outcome in per<strong>for</strong>mance assessment. They have refined risk-adjustment


27methodologies <strong>for</strong> use in veterans populations <strong>and</strong> developed instruments to facilitate technicalproficiency assessments. The VA per<strong>for</strong>m much of the detailed methodological researchnecessary to ensure that indicators are appropriately used <strong>for</strong> quality monitoring in their acute<strong>and</strong> integrated healthcare systems.Clevel<strong>and</strong> Health <strong>Quality</strong> Choice: This exemplary program was the first healthcare marketre<strong>for</strong>m plan of its kind in the USA which brought business, providers, physicians <strong>and</strong> expertisein quality measurement together in a voluntary collaborative ef<strong>for</strong>t to measure <strong>and</strong> improve thequality <strong>and</strong> af<strong>for</strong>dability of healthcare services. It commenced in 1989. It has developed its ownindicators to measure <strong>and</strong> compare the quality of selected services at participating hospitals inthe Greater Clevel<strong>and</strong> area. It evaluates four service areas:• Surgery: e.g. Total hip replacement• General Medicine: e.g. Pneumonia treatment• Intensive Care: e.g. Respiratory failure• Obstetrics <strong>and</strong> Gynaecology e.g. ChildbirthIt reports utilisation, in-hospital mortality, length of stay <strong>and</strong> patient satisfaction across a rangeof high volume or high cost interventions (see detail: Appendix 6). All data is risk-adjusted,using the <strong>Acute</strong> Physiology <strong>and</strong> Chronic Health Evaluation (APACHE III) System of adjustment<strong>for</strong> intensive care patients <strong>and</strong> a customised, patient-level risk adjustment system <strong>for</strong> noncriticallyill populations. The quality indicator data is first validated by a stringent reviewprocess involving independent experts, the CHQC <strong>and</strong> providers. Following the confirmation ofdata reliability <strong>and</strong> validity it is released publicly. The initial development <strong>and</strong> confirmation ofdata credibility prior to public indicator data release required a three year cooperative program.Semi-annual consumer reports are now published which provide indicator data <strong>and</strong> guidancewith interpretation. A summary <strong>for</strong>mat is available to the public. Because of the complexity ofthe complete set of data <strong>and</strong> the sensitivity associated with the interpretation of the 300 page pluscomprehensive report, it is m<strong>and</strong>atory to attend a half day training workshop in appropriate useof the data be<strong>for</strong>e being provided access to the comprehensive report. This program,components of which has been replicated in various guises across North America, contains anumber of cardinal features which have determined its success, including rigorous developmentof credible measures <strong>and</strong> the cooperative development program involving providers <strong>and</strong>purchasers.New York <strong>and</strong> Pennsylvania States: These States collect, calculate <strong>and</strong> publish in<strong>for</strong>mation onquality of care obtained from m<strong>and</strong>ated hospital discharge data sets. They report risk-adjustedmortality <strong>for</strong> Coronary Artery Bypass Grafting (CABG), major morbidity, length of stay,charges <strong>and</strong> physician-specific CABG mortality. These have been controversial programs, attimes appearing confrontational. There is no evidence that consumers’ or providers’ behaviourshave changed favourably as a consequence of public release of this data. Initial reports ofimproved patient outcomes with CABG proved to be due to conscious or unconsciousmanipulation of contributed data to favourably realign risk-adjusted mortality prediction. Thecosts of wide-scale data collection <strong>for</strong> the risk-adjustment methodologies used - <strong>and</strong> <strong>for</strong> systemsto audit data reliability - are considerable.HCFA’s Mortality Analyses: In 1986 the Health Care Financing Administration (HCFA)released via the media risk-adjusted overall mortality data <strong>for</strong> US hospitals treating Medicarepatients. For several subsequent years, HCFA continued to release these outcomes data asputative quality indicators, despite concerns about the accuracy of administrative databasesunderpinning indicator construction <strong>and</strong> the detail of the risk-adjustment models used to predictwhether quality of care fell within likely acceptable bounds. Considerable energy <strong>and</strong> expensewere devoted to identifying the deficiencies of this attempt at public accountability. EventuallyHCFA itself ceased publication of such indicator data when internal review failed to demonstrate


28that mortality categorisation of quality of care aligned with independent determinations of carequality (i.e. the approach was invalid). In many respects this experiment is a model <strong>for</strong> how notto introduce putative quality of care <strong>and</strong> health outcome indicators.HCFA’s Health Care <strong>Quality</strong> Improvement Initiative: As part of a new focus on qualityimprovement, HCFA’s HCQII is seeking to improve the mainstream of care, rather than relyingon identifying isolated apparent error. The initiative seeks to get doctors <strong>and</strong> hospitals involvedin the analysis of treatment patterns <strong>and</strong> promote improvement through adherence to bestpractice processes. The initiatives see HCFA, doctors, hospitals <strong>and</strong> specialty societies worktogether to develop indicators of quality of care. HCFA then facilitate data collection, analysis<strong>and</strong> confidential feedback to providers <strong>and</strong> promote use of the data <strong>for</strong> internal qualityimprovement <strong>and</strong> benchmarking activities.An example of this program, focused on care of patients with myocardial infarction, saw 26proposed quality of care indicators refined to 12 final quality indicators (see Appendix 6 <strong>for</strong>detail). These indicators reflect the provider focus of these activities. They are largely measuresof technical proficiency based upon acknowledged guidelines <strong>for</strong> the management of acutemyocardial infarction. The approach taken by HCQII has much to recommend it <strong>and</strong> reflects therealisation by HCFA that its previous unilateral approach to quality monitoring, in<strong>for</strong>mingconsumers <strong>and</strong> accountability (see HCFA Mortality Analysis - above) was unsuccessful.Health Care Report Cards: We have identified three dozen or so Health Care Report Cards,released to the public in the USA in recent years (predominantly post 1993). They contain avariety of putative quality <strong>and</strong> outcome indicators (see Appendix 6). Typically, there is no detailas to the operational definition <strong>for</strong> presented indicators nor <strong>for</strong> data reliability or validity. Giventhe “<strong>for</strong> profit” status of many groups generating these self-reports of per<strong>for</strong>mance, it issignificant that none of the reports contain data independently audited <strong>for</strong> accuracy. It is open todebate how valuable the contained in<strong>for</strong>mation is to healthcare consumers - as the targetaudience <strong>for</strong> these initial attempts at consumer reports was frequently healthcare purchasers,rather than the direct recipients of service delivery.5.3.3 United KingdomThe predominant focus of activities in the UK has been the rein<strong>for</strong>cing <strong>and</strong> st<strong>and</strong>ardisation ofClinical Audit <strong>and</strong> an aligning of indicators of quality <strong>and</strong> outcomes of care with the NHSPatient Charter. The UK has been at the <strong>for</strong>efront of the evolution of so-called “Evidence-BasedMedicine” <strong>and</strong> are currently active in designing quality <strong>and</strong> outcome indicators within thiscontext. There has been relatively little in the way of comprehensive national quality <strong>and</strong>outcome indicator programs to date - although a report from the Clinical Accountability <strong>and</strong>System Per<strong>for</strong>mance Evaluation (CASPE) Research Group to the Department of Health(anticipated <strong>for</strong> the European summer, 1996) will identify quality <strong>and</strong> outcome indicators <strong>for</strong> tencommon health conditions (including asthma, diabetes, heart failure, bladder outlet obstruction,childbirth, back pain, hypertension, ischaemic heart disease <strong>and</strong> menorrhagia) that span theinterests <strong>and</strong> perspectives of patients, providers <strong>and</strong> purchasers of health. Many of theseindicators will have data on reliability <strong>and</strong> validity based upon field-testing over the past threeyears. It is unclear at present what use the Department of Health will make of these indicators.They are targeted at assessment of an integrated healthcare system, rather than hospitals, but arelikely to include indicators of relevance to acute healthcare.The National Health System (NHS) so-called “League Tables” have been published <strong>for</strong> severalyears - encompassing a range of indicator data including waiting times <strong>and</strong> overall mortality.The data is not risk-adjusted <strong>and</strong> is not audited. There is no evidence that it has materiallyaltered provider behaviour with regard to care delivery. Several academic departments <strong>and</strong>research consortia are active in the development, characterisation <strong>and</strong> promotion of health status<strong>and</strong> quality of life assessment instruments (e.g. The London H<strong>and</strong>icap Scale). Whilstcontributing much to the characterisation of such instruments, there is little evidence of attempts


29to systematically introduce these outcome measures into current practice on a wide scale. Recentchanges in funding of acute healthcare, with enhancement of the purchaser/provider split (socalled),are seeing increasing sophistication in contractual arrangements between those fundingcare <strong>and</strong> those delivering care. Based upon the examples made available to us, there was littleevidence of sophistication in quality per<strong>for</strong>mance indicators within these contracts with mostemphasis on volume <strong>and</strong> cost. Those indicators used were “conventional” (e.g. patientsatisfaction; wound infection). Accreditation of acute hospitals is a relatively recent concept inthe UK. The King’s Fund Organisational Audit Unit is the predominant <strong>for</strong>ce in accreditation.They currently adopt a st<strong>and</strong>ards-based approach, not dissimilar to the ACHS prior toimplementation of the Charter <strong>for</strong> Change. There are no requirements <strong>for</strong> the routine applicationof quality of care indicators <strong>for</strong> the purposes of accreditation.In the absence of a systematic national approach to quality <strong>and</strong> outcome indicators, the NHS hasfunded a regional trial of the feasibility of UK hospitals’ participation in the MHA QIP. Thistrial of participation, coordinated from Newcastle University, has been judged a success by thoseinvolved. It is currently being exp<strong>and</strong>ed to involve more facilities. It provides an interestingmodel <strong>for</strong> “instant” access to an established quality indicator program, providing comparativedata <strong>for</strong> quality improvement at a relatively modest cost. Such an approach may prove attractiveto individual hospitals or hospital groups in Australia, although the confidentiality requirementsof MHA QIP would preclude its use as a substitute <strong>for</strong> a national monitoring program.5.3.4 EuropeMost European countries are involved in active, large-scale quality monitoring programs. Themajority are based on cooperative, quality improvement focused activities (such as the WorldHealth Organisational confidential indicator feedback programs in diabetes care, hypertension<strong>and</strong> dental care). In large part, these programs are similar to initiatives described <strong>for</strong> NorthAmerica <strong>and</strong> are using indicators that are conceptually similar, although operational definitionstend to be unique as they are tailored <strong>for</strong> local practice patterns <strong>and</strong> in<strong>for</strong>mation systems.Exemplary programs identified include:♦♦♦WHO collaborative demonstration project: This has established quality <strong>and</strong> outcomeindicators <strong>for</strong> common conditions (e.g. diabetes mellitus <strong>and</strong> dental caries) <strong>and</strong> fed-backconfidential reports to individual clinicians on their own per<strong>for</strong>mance vis-a-vis theseindicators (e.g. retinopathy screening <strong>for</strong> diabetes or caries rates <strong>for</strong> dental care). Linked toeducational programs based around benchmark processes of care (identified through theseprograms), these programs have seen a progressive <strong>and</strong> substantive improvement in auditedoutcomes.Establishing <strong>Quality</strong> Improvement in <strong>Healthcare</strong> in Spain: Over the past 10 years theMinistry of <strong>Healthcare</strong> <strong>and</strong> Consumer Affairs in Spain has been promoting a program tointroduce routine per<strong>for</strong>mance measurement <strong>and</strong> the utilisation of measured per<strong>for</strong>mance <strong>for</strong>improvement. This program has focused on ensuring that data collected to construct qualityindicators is reliable <strong>and</strong> continues to work to develop appropriate risk-adjustment modelsbased on patient-level data. Initial confidential data collection <strong>and</strong> validation was followedby collaborative public release of conventional indicator data (e.g. mortality; queuingtimes).Norway’s Contract <strong>for</strong> <strong>Quality</strong>: Norway has established explicit access targets <strong>for</strong>healthcare providers based upon designated medical or surgical conditions. These targetsstate access st<strong>and</strong>ards (e.g. waiting times <strong>for</strong> elective surgery or ambulatory specialtyreview by condition) but do not as yet stipulate outcome targets.


305.4 Data Sources <strong>for</strong> Indicator ConstructionThere are essentially four means of obtaining data <strong>for</strong> indicator construction:a) Administrative Databasesb) Medical Recordsc) Patient Surveysd) Hybrid Methods (i.e. more than one of the above).5.4.1 Administrative DatabasesLarge databases established <strong>for</strong> other purposes (e.g. billing; risk management; utilisation review;costing) are increasingly able to be linked together <strong>and</strong>/or applied to quite different purposes,such as quality indicator construction. There are inherent dangers in using data obtained <strong>for</strong> onepurpose in a different context, largely centred on data accuracy. Typically, data items perceivedto be of little direct relevance to the primary intent of data collection (e.g. comorbidity recordedin some billing databases) are poorly collected <strong>and</strong> hence inaccurate. These inaccuracies tend toresolve over time when it is appreciated that these data have an important secondary purpose -albeit of little relevance to the primary purpose of data collection.More serious limitations of administrative database are their lack of clinical detail relevant toquality indicator construction. This absence of significant clinical detail (e.g. history <strong>and</strong>examination findings, investigation results <strong>and</strong> a full intervention profile) severely limit theirusefulness <strong>for</strong> construction of clinically relevant indicators. Common coding systems (such asAN-DRG <strong>and</strong> ICD9-CM) frequently group conditions <strong>and</strong> interventions which do not logicallybelong together <strong>for</strong> process or outcome analyses - <strong>and</strong> it is not possible to “unbundle” thesedisparate groups after their numerical codes have been allocated. Administrative databases tendto offer more complete data at considerably less expense than alternative data sources. Untilcomprehensive, compatible clinical databases are developed around computerised medicalrecords, indicators derived from administrative databases will remain attractive, low-cost options<strong>for</strong> those implementing large-scale quality <strong>and</strong> outcome monitoring programs.5.4.2 Medical RecordsExisting paper medical records are a rich source of narrative detail on an individual episode ofcare. They are, however, frequently incomplete data sources <strong>and</strong> inherently of variable content<strong>and</strong> quality. The need <strong>for</strong> trained data abstracters makes data derived from medical recordsexpensive. Differences between the content of different medical record systems may hamperbroad-based monitoring programs - although knowledge of the need to identify particularin<strong>for</strong>mation within the medical record <strong>for</strong> subsequent quality monitoring ef<strong>for</strong>ts would be likelyto drive st<strong>and</strong>ardisation of entry of these data points nationally.5.4.3 Patient SurveysPatient surveys provide vital in<strong>for</strong>mation about the acceptability of care delivery, reports ofexperiences with the processes of care <strong>and</strong> health status <strong>and</strong> quality of life, patients’ healthbehaviours <strong>and</strong> intervention-specific outcomes. In recent years it has been established thatpatients provide accurate <strong>and</strong> reliable estimates of all these aspects of care - with the onlydemonstrated limitation being in reports of resource utilisation (where they consistentlyunderestimate utilisation rates in most reported survey comparisons). Although relativelyexpensive to administer, patient surveys provide invaluable in<strong>for</strong>mation that cannot be obtainedfrom any other source. Traditional written surveys are increasingly complemented or replacedby verbal (usually telephone) surveys or computer-aided surveys. There is also a trend to theamalgamation of components of specific-purpose surveys to create omnibus measures,generating data on several different domains of quality of care. These might include:


31• Patient details (e.g. age/sex/self reported diagnosis)• Description of processes of care (e.g. waiting times, communication, dischargeplanning)• Functional health status (e.g. SF36) or health related quality of life• Acceptability of care (e.g. satisfaction)• <strong>Outcome</strong>s of care (e.g. visual acuity after cataract extraction).Hybrid methods combine the advantages, <strong>and</strong> the disadvantages, of the above methods. Inparticular, they sum the cost burdens, <strong>and</strong> typically should be avoided unless the clinicalcircumstance dem<strong>and</strong>s the complexity <strong>for</strong> credible analysis, thereby justifying the added cost.Many indicators would more readily be derived if requisite data were m<strong>and</strong>ated in universalminimum data set requirements. However, many quality <strong>and</strong> outcome indicators may only berelevant <strong>for</strong> a relatively short period of time, as advances in medical care result in newper<strong>for</strong>mance indicators, supplanting previous indicators (such as in heart attack, where time tothrombolytic therapy has replaced use of anticoagulant drugs). Most indicators should be builtaround samples of care. Only when indicators are deemed robust, useful <strong>and</strong> likely to provedurable in the longterm, should there be consideration of revising minimum data sets solely <strong>for</strong>indicator construction. Although much useful in<strong>for</strong>mation exists within Australian minimumdatasets at present, quality <strong>and</strong> outcome indicators should not be restricted to all conceivablepermutations <strong>and</strong> combinations of existing data within administrative databases. Usefulindicators will require extending data collection into medical record abstraction <strong>and</strong> patientsurveys, with very occasional need to modify the uni<strong>for</strong>m data set, most probably to obtainrelevant risk-adjustment in<strong>for</strong>mation. Existing administrative coding systems (AN-DRG <strong>and</strong>ICD classifications) may require alterations to enable easy quality <strong>and</strong> outcome indicatorconstruction.Future revisions of these categorisation systems should seek input from those engaged in qualitymonitoring within hospitals to maximise any potential <strong>for</strong> routine indicator construction withminimisation of duplication of ef<strong>for</strong>t.5.5 Examples of <strong>Indicators</strong> by Dimensions of <strong>Quality</strong>This section of the results discusses a range of the specific indicators identified by us over the course ofthis Project. As already indicated, there are literally several thous<strong>and</strong> indicators in use (or proposed <strong>for</strong>use) worldwide. It is not practical - <strong>and</strong> we believe it undesirable - to discuss each of these severalthous<strong>and</strong> indicators serially, with comments on their indicator attributes. Rather, we will discuss measuresthat have some promise as future indicators in a nationally consistent quality <strong>and</strong> outcome indicator set<strong>and</strong> will illustrate, by example, indicators which failed to impress our reviewers - highlighting the specificcriteria with which substantive deficiencies were identified. More detailed discussion of each dimension isprovided within Appendices 11 <strong>and</strong> 12.5.5.1 Access♦Waiting TimesMany quality monitoring programs use the concept of waiting time as the principal index ofaccess to care. Hence, waiting times are recorded <strong>for</strong>:: elective surgery...* by urgency category* by procedure* by specialty


32: outpatient appointments* by urgency category* by specialty: emergency departments* by urgency category: emergency admission: outpatient waiting time at episode of careThe use of any of these queuing indicators in initial national indicator sets would requirethat adequate data sources exist or could reasonably be anticipated being brought intoexistence over a short timeframe. Waiting times are typically recorded by providers <strong>and</strong>varying operational definitions (e.g. of waiting time, urgency categorisation) render manyindicators of apparently similar concepts non-comparable.There has been a move to st<strong>and</strong>ardise these operational definitions <strong>and</strong> to monitor queuingtime from the decision to deliver care to actual care delivery (sometimes called “decision toincision” time) to avoid gaming of queuing indicators <strong>and</strong> allow independent audit of actualper<strong>for</strong>mance.There have also been moves to stratify conditions in some relationship to need <strong>for</strong>healthcare. This is either on the basis of perceived global urgency (as is common practice,in various <strong>for</strong>ms, in Australia currently) or specific diagnostic groupings (as is the case inseveral Sc<strong>and</strong>inavian countries currently). Global urgency measures leave the decisionregarding the need <strong>for</strong> care with clinicians providing care. Narrow diagnosticcategorisation, although superficially attractive, would still require clinical judgement abouturgency <strong>and</strong> could provide incentives to shift diagnostic classification to suit queuingtargets. The necessity to retain urgency categorisation <strong>and</strong> add detailed categorisation wouldmake queuing data management difficult. Consensus on target waiting times within eachcategory <strong>and</strong> between categories may be difficult to obtain in provider communities, assingle procedures such as coronary artery disease requiring CABG may be eitherurgent/semi-urgent or non-urgent depending on the clinical circumstance on the patient.The use of patient-reported waiting times <strong>and</strong> judgements on the acceptability of reportedwaiting times are commonplace in North America <strong>and</strong> Europe. They accurately reflectindependently observed waiting times <strong>and</strong> are not subject to gaming by providers.Satisfaction with waiting times from the consumer perspective is relevant - <strong>and</strong> of particularvalue when interpreted in the light of the actual wait time. Satisfaction is largely dependentupon consumer expectations - which are moulded by numerous patient, provider <strong>and</strong>societal influences. Patients are more likely to report the total waiting time (i.e. time fromdecision to treat to receipt of treatment) than provider-based indicators such as those fromdecision time to the time of allocation of a booking <strong>for</strong> the procedure.Refinements of waiting time indicators include:• Clearance time: the time that would be required to clear the current waiting listusing current hospital elective surgery throughput estimates.• Proportion of patients admitted after waiting inappropriately.(See also discussion on Commonwealth access <strong>and</strong> efficiency indicators - within 5.3.1 -<strong>for</strong> additional refinements proposed by the National Demonstration Hospitals Program)


33An indirect indicator of access - patient emergency department walkouts after triage - hasbeen proposed as a useful indicator of emergency care access. Although influenced bywaiting time, several patient-related factors strongly impact upon absolute walkout rates(e.g. presence of psychiatric illness <strong>and</strong>/or substance abuse). Although a useful facilitylevelindicator <strong>for</strong> monitoring trends over time, we cannot recommend it <strong>for</strong> nationalapplication in the absence of suitable risk-adjustment <strong>for</strong> casemix. The experience of theMaryl<strong>and</strong> Hospitals Association with this indicator supports our view - with widelydiscrepant “walkout” rates between inner urban <strong>and</strong> other community facilities which havebeen relatively fixed <strong>for</strong> given facilities with particular geographic <strong>and</strong> casemix profilesover lengthy time intervals.♦Preventable Admissions/Avoidable DeathsThese are excellent indicators of the adequacy of primary care although at best indirectindicators of access to appropriate acute care services. They have a real role in assessingquality in an integrated healthcare system. However, the inability to dissect failures inprimary care delivery from any index of acute care access render them of limited value injudging quality of acute care services. Comparisons between regions or facilities wouldalso require knowledge of the relative prevalence of the index conditions in the servicedpopulation. As future indicators of overall health sector per<strong>for</strong>mance they are stronglysupported, but they are not of value as acute healthcare quality indicators.♦Condition Specific UtilisationThere have been attempts at inferring access to care based upon the relative utilisation ofapparently clinically related interventions/conditions. Although offering useful insights onclinical care patterns, these are of limited value as access indicators.e.g.Access to acute hospital care <strong>for</strong> ischaemic heart disease measured by the ratio ofIHD admission to IHD death.COMMENT: This would be confounded by severity of illness <strong>and</strong> quality of care <strong>and</strong>would tell little of access but much about the appropriateness of accessed care,although desired indicator rates are unknown.e.g.Access to CABG measured by rates of CABG compared with rates of angiography.COMMENT: This utilisation statistic would infer more about clinical practicepatterns regarding the appropriateness of these interventions than access.♦Geographic Access MeasuresAlthough some complex models exist to define geographic access to care, these are usuallyderived to justify policy decisions regarding relocation of services or guide future planningof service profiles. Most studies of consumers identify time to service delivery as crucial -rather than distance - with a hierarchy of acceptable times based upon the level ofsophistication <strong>and</strong> complexity of care required. Assumptions about transportation modelsinherent in most geographic access models (e.g. public transport versus private vehicle;motor vehicle versus air ambulance) further limit their practical value as access measures inacute healthcare.


34♦Stratified Utilisation DataKnowledge of the age, sex, ethnic background <strong>and</strong> social class of those receiving acute careservices, coupled with knowledge of disease prevalence in these population strata, enableinferences about relative access of care. Such analyses are particularly valuable as pointersto groups who have needs <strong>for</strong> care but fail to access care. Linking of such utilisation rateindicator data to population health needs data (such as from the Australian Bureau ofStatistics Health Status <strong>and</strong> Health-Related Behaviour Survey) would be a mechanism bywhich indicator data could assist decision-making on access.Utilisation (e.g. discharge rate per 1000 population; average length of stay) can becompared within populations without knowledge of prevailing disease patterns as indices ofattained/achieved access. Such measures in an Australian context probably tell more aboutappropriateness of care than access, as rationing of particular interventions is rarelybelieved to be preventing receipt of appropriate care.♦Unmet NeedThese survey methodologies seek out patient reports of conditions warranting acute care(e.g. chest pain) <strong>and</strong> establish what care was sought <strong>and</strong> provided. The survey methods areexpensive <strong>and</strong> only applicable on larger population samples. They do, however, produceaccurate statistics on how successfully potential needs <strong>for</strong> care are matched by patterns ofexisting care delivery.♦Ambulance Bypass5.5.2 EfficiencyThis indicator has been applied in some jurisdictions as an index of access to emergencyservices. Our majority opinion is that this indicator has too many limitations to warrantinclusion in a national indicator program. It reflects access to services <strong>for</strong> a very smallpatient population judged to be not critically ill (i.e. patients using ambulance transport tohospital deemed non-time-critical by ambulance officers) <strong>and</strong> is amenable to gaming (as thedecision to declare an emergency department on bypass is arbitrary <strong>and</strong> based solely on thesubjective judgement of an emergency physician).Technical Efficiency♦Cost/Activity RatiosThis most common technique <strong>for</strong> measuring the technical efficiency of hospitals essentiallyanalyses the ratio of cost to some index of activity (i.e. quantity of delivered care). Theseindicators include:• Cost per Casemix adjusted separation• Cost of treatment per outpatient episode• Comparative average length of stay (ALOS).Whilst conceptually simple, costing data that is accurate, reliable <strong>and</strong> comparable is notreadily available in most healthcare systems - <strong>and</strong> is certainly currently not available withinAustralian hospitals. It would appear preferable to commence with simple measures ofefficiency <strong>and</strong> ensure that data used to construct these are accurate, reliable <strong>and</strong> comparablebe<strong>for</strong>e progressing to more complex measures. Data on ALOS are more readily available<strong>and</strong> potentially reliable. Their use as efficiency measures assumes that DRG outputs areequal in health outcome terms <strong>and</strong> that close relationships exist between cost <strong>and</strong> ALOS -


35assumptions that may not be reasonable given condition <strong>and</strong> severity differences withinadministrative database patient populations based on AN-DRG <strong>and</strong> ICD9-CMclassifications <strong>and</strong> differences in inpatient bed utilisation patterns such as those betweenurban <strong>and</strong> rural providers. Data on cost-per-casemix adjusted separation are currentlyprobably less accurate <strong>and</strong> considerably less comparable than ALOS data. Use of thisindicator will undoubtedly motivate improvements to data quality. At present we believecost data on outpatient episodes of care is likely to be so inaccurate (by virtue of the verylimited application of in<strong>for</strong>mation technology in outpatient costing) as to warrant avoidingrecommending its widespread use as a quality indicator in the short-term.♦Cost Frontier Estimation (or Production Frontier Estimation)These complex techniques, such as Data Envelopment Analysis, take account of themultiple inputs (such as labour, use of capital) <strong>and</strong> outputs (such as inpatient <strong>and</strong> outpatientservices, teaching, research) that are identified in acute healthcare. They involve modellingof inputs <strong>and</strong> outputs to generate weighted sums of inputs <strong>and</strong> outputs. The results of thismodelling can only be used to compare similar types of healthcare providers 368-402 . Thearbitrary allocation of weights to given inputs or outputs allow skewing of any modeltowards/against a significantly different service provision pattern (<strong>for</strong> example, if hospitalsdo not provide some services, weighting of these outputs appropriately in the model couldresult in apparently efficient or inefficient per<strong>for</strong>mance by comparison with a facilityproviding that service). Like all sophisticated mathematical models they depend heavily onthe precision of the manipulated original data points 403-404 . As indicated above, theaccuracy <strong>and</strong> comparability of currently available input <strong>and</strong> output data in Australianhealthcare would indicate that cost frontier estimates (such as Data Envelopment Analysis)are not realistic options <strong>for</strong> efficiency monitoring nationally at the present time.Allocative Efficiency♦The Oregon ExperimentThis well-publicised experiment in priority setting in healthcare produced a <strong>Quality</strong>Adjusted Life Year (QALY) league table based upon comparative cost-utility analyses.Although the approach is generally considered to have merit, it is compromised by the grosssimplifications in the costing of health interventions, the limited scope of services coveredby the model <strong>and</strong> the way QALYs were measured 407-411 .The requirement <strong>for</strong> marginal analysis as distinct from average analysis was ignored in theexperiment. Rankings of health interventions were based on average cost-utility ofinterventions, without due recognition that at the margin, cost-effectiveness will vary withpatient population, size of program <strong>and</strong> specific program characteristics.♦Program Budgeting with Marginal Analysis (PBMA)The PBMA approach has been developed by the Health Economics Research Unit inAberdeen <strong>and</strong> is being trialed by the NSW Health Department, through the Centre <strong>for</strong>Health Economics Research <strong>and</strong> Education 350,406 .The model focuses on the marginal levels of health gains <strong>and</strong> health losses associated withparticular healthcare interventions. In these terms priority is given to exp<strong>and</strong>ing programswhere the resultant health gains would be greatest, with a reduction in health services orprograms where the losses are minimal. With some modifications this approach has thepotential to be applied to the acute health sector.


36PBMA requires health service providers or funders to classify their services into programstreams be<strong>for</strong>e evaluating where the gains <strong>and</strong> losses might lie.The use of this technique <strong>for</strong> management <strong>and</strong> decision-making purposes must be supportedby consistent <strong>and</strong> reliable evidence on both the likely costs <strong>and</strong> outcomes of varioustreatments or interventions to enable priorities to be set with confidence. This model can bemore readily applied to a single sector of the healthcare system (such as the hospital sector)than the other allocative efficiency models currently being tested in Australia.♦Purchaser-Provider SplitThe “Purchaser-Provider” <strong>and</strong> “Managed Competition” models of health service funding<strong>and</strong> delivery have been designed to promote both allocative <strong>and</strong> technical efficiency. In bothof these models there is a separation of the purchasers <strong>and</strong> the providers of healthcare, with,in the pure model, the purchaser being responsible <strong>for</strong> the total health care of a communityor constituency, receiving commensurate funds <strong>for</strong> the purchase of services on behalf oftheir community 348,405 . A small number of countries have moved towards such a healthfunding system, including Britain <strong>and</strong> New Zeal<strong>and</strong>. The possible relevance to Australiahas been extensively debated in Australia 412,413 . Importantly, any “purchaser-provider”system requires advice to the purchaser, on how to select between competing healthinterventions. Logically, purchasers would need quality indicators to guide their purchasingchoice. Evidence available from existing programs suggests that initial decisions werealmost exclusively based upon cost <strong>and</strong> an assurance of quality. Such programs arecurrently seeking realistic indicators of quality of care which they could subsequently use tosupplant “cost-only” decision-making. Our enquiries found little evidence of sophisticationin their quality indicator utilisation to date. These models of health service funding <strong>and</strong>delivery require, <strong>and</strong> are well placed, to make use of a rigorous approach to priority setting.A number of health economists in Australia have recommended the purchaser/providerframework as a means <strong>for</strong> achieving optimal resource allocation <strong>for</strong> health promotion, incombination with the adoption of a rigorous approach to priority setting (e.g. using modelssuch as the disease-based framework <strong>for</strong> priority setting by Segal <strong>and</strong> Richardson 348 ).♦Guidelines <strong>for</strong> Listing of Drugs on the Pharmaceutical Benefits Schedule (PBS)In Australia in 1993 the Commonwealth Government developed in its health planningframework the systematic use of economic analysis to in<strong>for</strong>m pharmaceutical resourceallocation decisions, be<strong>for</strong>e the listing of drugs on the Pharmaceutical Benefits Schedule(PBS). Economic appraisal (cost-minimisation analysis, cost-effectiveness or cost-utilityanalysis), must be undertaken by pharmaceutical companies in support of the listings ofnew drugs on the PBS. Guidelines <strong>for</strong> the industry on preparation of submissions to thePBS have been developed, the most recent being updated in November 1995 414 . Theeconomic analyses are submitted to the Pharmaceutical Benefits Advisory Committee(PBAC) <strong>for</strong> evaluation prior to approval <strong>for</strong> listing on the PBS.Comparative cost-effectiveness (or cost-utility analysis) provides the framework withinwhich the inclusion or exclusion of new drugs to the PBS is made. However, this approach,like many of the models <strong>for</strong> priority setting does have limitations. In this example, practicalproblems associated with the definition of evidence <strong>and</strong> the limited choice of comparatorslimit its usefulness as a model <strong>for</strong> priority setting.The PBS Guidelines provide <strong>for</strong> the comparison of drug <strong>and</strong> non-drug approaches tomanagement, <strong>and</strong> thus potentially extend priority setting beyond pharmaceuticals. If thePBAC were to seek economic analysis of classes of drugs, <strong>and</strong> a comparison with non-drug


37approaches to management, this would extend substantially the scope of interventionscovered.♦Macro Economic Evaluation Model (MEEM)The MEEM approach is being developed by the Health Economics Unit of the Centre <strong>for</strong>Health Program Evaluation at Monash University 415 . This approach is designed <strong>for</strong> diseaseimpact costing, <strong>and</strong> resource allocation in health promotion <strong>and</strong> illness prevention. TheMEEM is essentially the construction of a ranking index from a systematic analysis ofavailable databases allowing the evolution of a broad-based framework <strong>for</strong> priority setting.Its component parts (disease impact assessments, life expectancy analysis, <strong>and</strong> projectappraisal) can also be used <strong>for</strong> descriptive analysis, including issues of equity <strong>and</strong> needsassessment. The underlying rationale of MEEM is that judgements about priorities <strong>for</strong>illness prevention <strong>and</strong> health promotion should be guided by in<strong>for</strong>mation on: the publichealth significance of health problems (measured by a range of indicators, including cost ofillness); the theoretical preventability (efficacy) <strong>and</strong> practical preventability (effectiveness)of the health problems; <strong>and</strong> the relative cost-effectiveness (efficiency) of individualpreventive measures aimed at achieving the potential <strong>for</strong> prevention.The MEEM model has limited applicability to the acute sector, as its primary focus is onillness prevention <strong>and</strong> health promotion. However, the disease costing component of themodel does provide a very comprehensive estimation of the annual hospital cost of treatingparticular diseases (based on ICD-9 classifications) in Australia. This may be of someinterest to the Commonwealth in helping to gain an underst<strong>and</strong>ing of the public hospitalexpenditure on particular disease categories.♦Disease-based Framework <strong>for</strong> Priority SettingThe Centre <strong>for</strong> Health Program Evaluation has developed a further approach to resourcepriority setting, designed to cover the entire health sector, based on the principles ofallocative efficiency, with disease groupings as the context <strong>for</strong> analysis 348,405 . The model iscurrently being implemented in relation to non-insulin dependent diabetes mellitus, withsupport from the Public Health Section of the Department of Health <strong>and</strong> Community<strong>Services</strong>, Victoria 402 .While the theoretical prerequisites <strong>for</strong> allocative efficiency can be defined, implementationof the above models is problematical. The measurement of marginal costs <strong>and</strong> benefits isdifficult <strong>and</strong> the magnitude of the research task <strong>for</strong> health sector-wide allocative efficiencyis daunting. The aim of the models of allocative efficiency is to link healthcare inputs(dollars) to healthcare outcomes (such as quality adjusted life years - QALYS) in such away that different services <strong>and</strong> treatments can be compared on a common basis - using <strong>for</strong>example a measure of outcome, the QALY, as a generic outcome indicator. Priority settingthen allows decision makers to choose between healthcare services which produce thegreatest outcome (QALY) per unit of input (dollars). A recent review of outputmeasurement <strong>for</strong> resource allocation decisions in healthcare discusses the uses <strong>and</strong>limitation of such an approach 416 .There are a number of practical problems with these approaches <strong>and</strong> their applicability tothe hospital sector. Firstly, most of the models require a large investment of resources <strong>for</strong>measuring <strong>and</strong> analysing the costs <strong>and</strong> outcomes associated with the full range of allpossible healthcare interventions. Secondly, most of the models take a societal perspective(that is, they are concerned with the costs <strong>and</strong> outcomes of all members of the community -patients, funders etc) <strong>and</strong> do not confine their measurement to one sector of healthcare (e.g.


385.5.3 Safetya hospital). In addition, restricting the outcome measure to a single health delivery systemmay generate distortions <strong>and</strong> cost shifting.A further issue is that little attention has been paid to developing a single outcome measure(or measures) to capture the extent to which hospitals or healthcare systems achieveallocative efficiency.♦Incident Reporting SystemsThe reporting, categorisation <strong>and</strong> subsequent utilisation of in<strong>for</strong>mation on incidents (that is,events which had the potential to produce injury or did in fact produce injury) in safetypromotion within hospitals has enormous potential <strong>for</strong> improving safety margins in acutehealthcare 42-47,50,73-75,114,129,134,135,150-153 . Anonymous incident reporting offers a relatively lowcost, sensitive index of safety per<strong>for</strong>mance with qualitative detail which can direct safetyimprovement endeavours 9,10 . The expansion of the successful anaesthesia/intensive careincident monitoring program across acute care services (in an initiative of The AustralianPatient Safety Foundation funded by the Commonwealth) should provide importantconfirmation of the utility of such incident monitoring approaches. The use of externallyreported adverse event or incident reports which rely upon the self-identification of error -which include identifying in<strong>for</strong>mation - cannot be supported as a quality of care indicator,as such identified incident reporting systems would create perverse incentives <strong>for</strong> providersto either not detect or report incidents. The bulk of evidence suggests that the majority ofincidents are currently unreported in conventional hospital practice 42,47,50,73,74,111 . It wouldbe undesirable to create any indicator of per<strong>for</strong>mance which magnified this incidentawareness blindspot, by creating an incentive to under-report incidents to meet externallyapplied st<strong>and</strong>ards or thresholds of incident reporting.♦Adverse Event MonitoringVarious Adverse Event (that is, reports of injury as a consequence of a medical interventionor failure to intervene appropriately) monitoring systems have been proposed, based eitherupon administrative databases or medical record review. These events must be clearly dueto the intervention rather than primary illness or be preventable if good care was given <strong>and</strong>patient preferences regarding risk taking must be known be<strong>for</strong>e tradeoffs between risks <strong>for</strong>different outcomes may occur.Administrative database software systems use algorithms to flag adverse outcomes whichmay reflect quality of care problems 54,89,93,99,137,150,151 . Because existing common codingsystems (e.g. AN-DRG <strong>and</strong> ICD9-CM) do not reliably indicate when an event occurredduring an episode of care, such computer-based screens identify a mixture of events presentat the time of hospitalisation <strong>and</strong> events occurring during hospitalisation. They are thuscurrently relatively crude indicators of adverse events due to hospitalisation. Futureimprovements in coding <strong>for</strong> administrative databases (such as stipulation of pre-existent <strong>and</strong>hospital-related events by placing events in time sequence <strong>and</strong> improved codes <strong>for</strong>intervention complications) <strong>and</strong> improvements in software algorithms to detect <strong>and</strong> weight arange of potential intervention-related adverse events may see future algorithms <strong>for</strong>administrative database safety screens fulfil their potential as patient safety indicators.Medical record review - seeking evidence of adverse events - may be undertaken at r<strong>and</strong>omor on records identified following an initial “screen” <strong>for</strong> features suggestive of an adverseevent (such as the presence of an unplanned return to the operating room) 1,47,50,63,69,114,135,145 .Such preliminary screens may involve use of manual record review <strong>for</strong> criteria flagging


39records <strong>for</strong> expert review or use of computer-based screens of administrative database codesto detect records warranting focused review. Reviewed records are assessed using eitherexplicit criteria <strong>for</strong> quality of care or implicit (expert opinion) determine to review if anadverse event has occurred <strong>and</strong> if patient safety has been compromised unacceptably. Suchadverse event reviews have been associated over time with a decline in detected adverseevents, rein<strong>for</strong>cing the application of medical record-based adverse event screening <strong>for</strong>safety improvement 185 .Record review <strong>for</strong> adverse events <strong>and</strong> quality of care analysis had been the major tool usedby the Peer Review Organisations (PROs) in the USA until recently. PROs are independentcontractors to US government purchasers whose charter is quality of care oversight. Formany years, implicit review of medical records (identified <strong>for</strong> review by specificoccurrences), <strong>for</strong>med the basis of PROs quality assessments. However, analysis of theinterrater reliability of implicit review in these circumstances suggests that there was poorconcordance between independent reviews. In addition, provider defensiveness againstexternal review of the processes of care has limited the improvement utility of PRO adverseevent review. Both these factors have led to a decision to broaden quality PRO initiativesbeyond these medical record reviews (e.g. HCFA’s HQII: see above) <strong>and</strong>, many StatePRO’s have discontinued such external record reviews because of poor cost-effectiveness127,294 .5.5.4 EffectivenessConceptually, any external quality <strong>and</strong> outcome indicator program based on adverse eventdetection in the medical record has a potential to modify the nature of that record. Routineexternal adverse event detection programs could create incentives <strong>for</strong> non-recording ofmatters relevant to adverse events. Thus, whilst internal promotions of adverse eventscrutiny based on medical record review as one component of facility-based patient safetyinitiatives are applauded - they cannot be advocated as useful in any national quality <strong>and</strong>outcome monitoring scheme. Promoting patient safety will require a layering of strategies,including the development <strong>and</strong> local implementation of practice guidelines, facilityaccreditation, staff credentialling <strong>and</strong> hospital-based improvement programs to detect,interpret <strong>and</strong> respond to safety concerns. Safety is the dimension of quality of care wheremost responsibility must rest with providers. External review indicators risk masking safetyproblems, rather than promoting remedies. Accountability <strong>for</strong> facility-wide safety must beprovided by accreditation programs which incorporate a focus on safety issues rather thanexternal generic safety indicator programs.Targeted safety indicators can be constructed <strong>for</strong> specific conditions or interventions muchmore successfully than generic indicators of safety across facilities. Such indicators shouldbe included in modular indicator sets relevant to diagnoses/conditions/interventions ofinterest (see 7.1 below) <strong>and</strong> should be reported to reviewing bodies which include relevantprofessional colleges <strong>and</strong> specialist societies to help guarantee full <strong>and</strong> frank eventreporting. These indicators typically relate adherence to best practice processes of care(such as time to delivery of thrombolytic therapy in patients with acute myocardialinfarction) or report adverse outcomes (such as procedure specific complications or death).As the risks of intervention are often proportional to the severity of patient illness - <strong>and</strong> notinfrequently to the anticipated benefits of the intervention - such indicators requireadjustment <strong>for</strong> patient factors (such as severity of illness <strong>and</strong> treatment preferences) be<strong>for</strong>ethey can reasonably be used to monitor safety per<strong>for</strong>mance.<strong>Indicators</strong> of effectiveness are essentially either of outcomes of care or outcome-proxies (whichare output measures or process measures known to be related to subsequent health outcomes).<strong>Outcome</strong>s can be defined either by providers or patients.


40♦Provider-Assessed <strong>Outcome</strong>sMortality: <strong>Acute</strong> care systems typically look at intrahospital mortality as one indicator ofhealth outcome 7,35,38,85,86,92,131,153,208 . When possible, linkage of data systems to enablereporting of mortality within longer timeframes (30 days/60 days) perhaps provides a moreaccurate indication of the impact of an episode of care on overall health <strong>and</strong> avoids biascreated by premature discharge or interfacility transfer 92,116,119,131 . The interpretation ofmortality requires knowledge of the anticipated outcome in the absence of the intervention<strong>and</strong> of the best achievable outcome with that intervention. For use as a quality of careindicator, it is important that variations in care quality translate into mortality variations. Inmany situations there are deficits in our knowledge of process-outcome links - <strong>and</strong>currently, mortality rates are not widely accepted as credible quality indicators 131,133,138,156 .They are, however, easy to measure <strong>and</strong> intuitively attractive, if the issues of adjusting <strong>for</strong>illness severity can be resolved (see 6.2 below). Global mortality indices provide riskadjustmenthurdles that may well be insuperable given the inadequacies of current modelling<strong>and</strong> the costs of collecting the necessary clinical detail <strong>for</strong> analysis 156 . Mortality withinstratified population groups (e.g. diagnosis or intervention) could be readily collected <strong>for</strong>some conditions. There is the potential <strong>for</strong> relative mortality per<strong>for</strong>mance to be a crediblequality of care indicator if it proves that population strata contain a relatively uni<strong>for</strong>m mixof case-severity. This would minimise the need <strong>for</strong> collection of additional risk-adjustmentdata 13,138,141 .Morbidity: There have been a number of models which aggregate intrahospital morbidity tocontribute to an index of outcome. These have been described under the Patient Safetydimension (see 5.5.3 above).Clinical <strong>Outcome</strong>s: Various clinician/provider-assessed indices of physical <strong>and</strong>psychological function fall into a range of measures frequently labelled as “clinicaloutcomes” 31,779,1005 . These are often laboratory, medical imaging or physiological measureswhich are used as proxy measures <strong>for</strong> increased longevity or improvement in quality of lifeby clinicians.For example:• Range of joint movement at a defined time after total joint replacement.• Coronary artery patency after coronary angioplasty.• Reduction in tumour size in cancer therapy.• Fall in white blood cell count in treatment of leukaemia.• Exercise tolerance after CABG.The relationships between these measures <strong>and</strong> genuine outcomes (i.e. survival <strong>and</strong> quality oflife) are variable <strong>and</strong> sometimes tenuous 55,146,148,149 . These proxy measures are, however,easily quantified <strong>and</strong> provide useful short-term feedback to clinicians regarding the apparentsuccess of interventions. They are more or less specific <strong>for</strong>interventions/diagnoses/conditions <strong>and</strong> should <strong>for</strong>m part of balanced indicator setsdeveloped <strong>for</strong> key targeted clinical circumstances (see 7.1 below). At present, mostindicators are built around immediate <strong>and</strong> short-term measures which capture changes invariables related to health status within an episode of care. Mechanisms need to bedeveloped to routinely record clinical outcomes at relevant more remote time points if thetargeted condition warrants such longer-term indicators of clinical outcomes (<strong>for</strong> example,the 12 month infection rate <strong>for</strong> total joint replacement or 12 month coronary artery patencyrates following coronary artery angioplasty) 148,149 .


41♦Patient Assessed <strong>Outcome</strong>sPatient-based reports of outcomes of healthcare: These have a number of strengths <strong>and</strong>limitations. Obtaining comparable in<strong>for</strong>mation directly from patients (typically bystructured survey) enables the analysis of short-term <strong>and</strong> long-term outcomes of care fromthe patient’s perspective 207,291,306,310,320,321,1061,1071 . These outcomes may include reactions tothe intervention itself (pain, swelling, incapacity <strong>and</strong> so on) as well as longer term changesin symptoms <strong>and</strong> function. Detailed in<strong>for</strong>mation can be obtained on the extent to whichspecific functional impairments or symptoms changed <strong>for</strong> the better or worse aftersurgery/interventions. Patient-reported data are relevant, but not all-inclusive 291 . Theycomplement clinical observations <strong>and</strong> tests while providing comprehensive <strong>and</strong> reliable dataon perceptual dimensions of health outcomes. Patient-reported outcomes are particularlyappropriate when the indication <strong>for</strong> an intervention is primarily improving function orrelieving symptoms. Patient-reported outcomes tend to integrate all processes of care <strong>and</strong>their consequences. They may suffer from incorrect attribution of outcomes tointerventions, but over a range of conditions they have proven largely reliable <strong>and</strong> valid (bycomparison with other parallel outcome assessments) 291,306,1061,1071 . Survey instrumentsexist <strong>for</strong> a variety of interventions (such as cataract surgery) <strong>and</strong> chronic conditions (suchas hypertension, arthritis, asthma <strong>and</strong> bronchitis, low back pain <strong>and</strong> diabetes) <strong>and</strong> more areunder development by the AHCPR-funded Patient <strong>Outcome</strong> Research Teams (PORTS)317,491,494<strong>for</strong>:• Hip fracture repair <strong>and</strong> osteoarthritis.• Prevention of low birth-weight infants.• Benign prostatic hypertrophy <strong>and</strong> localised prostate cancer.• Pneumonia.• Back pain.• Biliary tract disease.• Ischaemic heart disease.• Schizophrenia.• Secondary <strong>and</strong> tertiary stroke prevention.• <strong>Acute</strong> myocardial infarction.• Cataract.• Childbirth.• Diabetes.Health status measures: are st<strong>and</strong>ardised instruments to quantify functional health statusfrom patient reports 662,649,652,780,806,899,1071,1104,1105,1106,1110,1130 . They typically divide healthfunction into domains (such as physical, emotional, psychological, social <strong>and</strong> role functions)<strong>and</strong> are either generic (that is, applicable to all) or specific <strong>for</strong> a targeted population(condition/diagnosis/intervention/age group). The science underpinning validation of theseindicators of health status has advanced significantly over the past decade 1104-1106 . Manyhealth status instruments are now well characterised, with detail of their per<strong>for</strong>mance in arange of populations <strong>and</strong> particular health states known. They are responsive tointerventions aimed at improving healthcare <strong>and</strong> the significance of measured changes infunctional status is increasingly understood 1011,1048,1063,1110,1130,1134 . Interventions <strong>for</strong> acutedepression, heart valve replacement, treatment <strong>for</strong> chronic arthritis, total knee replacement,total hip replacement <strong>and</strong> cardiac revascularisation in ischaemic heart disease are amongstthe growing list of conditions in which the delivery of medical services have been shown toimpact positively on health status as measured by the Short-Form 36 (SF36) instrument572,576,665,669,798,809,863,931,951,968,11041106 . This health status measure has the most data available onits use in acute healthcare, both within Australia <strong>and</strong> internationally. The Short Form 36(SF36) is a generic measure of health status that can be used to assess health changefollowing an acute episode of care 1106 . Recent demonstrations that health status prior to an


425.5.5 Acceptabilityepisode of care is reliably reported retrospectively by patients would enable single surveyspost episode of care to detect the impact of care 192 . The availability of shorter surveyinstruments such as the SF36 related Short Form 12 (SF12), will facilitate the incorporationof health status quantification into broader, omnibus surveys of patients’ experiences ofhealth <strong>and</strong> healthcare 490 . The Medical <strong>Outcome</strong>s Trust in Boston has established aScientific Advisory Committee to review <strong>and</strong> endorse health status instruments. It is likelythat instruments endorsed by this body will increasingly become the health status instrumentst<strong>and</strong>ards within healthcare quality <strong>and</strong> outcomes indicator programs.Health-related <strong>Quality</strong> of Life (HRQOL): These are instruments which encompass aspectsof functional health status <strong>and</strong> patients’ reports of the impact of their health on theirenjoyment of life 659,663,670,671,1027,1085 . Rather than representing a discrete measurementmethodology distinct from health status, the two approaches offer a continuum, withfunctional health status more focused on self-reports of what one can or cannot do <strong>and</strong>HRQOL more reflecting assessments of how health impacts the enjoyment of life. A largeliterature base on HRQOL instruments exists206 . There are both generic <strong>and</strong>disease/condition specific HRQOL instruments. There is consensus that they are of value inhealth services research, although it would be our view that current HRQOL instrumentsare insufficiently characterised to recommend their widespread application in large scaleacute healthcare outcome indicator programs. Further developments in HRQOLinstruments may well allow such applications in the near future.This report was not to address many of the complex issues surrounding acceptability of caregiven that a major report on the role of patient satisfaction surveys in a national approach tohospital quality management has recently been completed <strong>for</strong> the Commonwealth which canvasesthe issues around the reporting of consumers’ experiences <strong>and</strong> assessments of quality of care 188 .Patient satisfaction is known to be associated with better results from healthcare interventions(such as better compliance with preventative care/medications) <strong>and</strong> improved functional healthstatus 198 . Although there is still much to learn about how best to obtain feedback from patientsabout their needs <strong>and</strong> wants <strong>and</strong> how best to use this knowledge to drive improvement processes,the current state of knowledge allows application of proven instruments whilst furtherdevelopmental programs proceed. Provider generated instruments such as those of the HospitalCorporation of America (HCA) or the Royal College of Surgeons (RCS), <strong>and</strong> patient-focusedinstruments such as the Picker-Commonwealth survey, could easily be adapted to provide initialreference data on the level of acceptability of a range of processes <strong>and</strong> outcomes of acutehealthcare. The Picker-Commonwealth instrument has been applied in the USA, Canada, theUK, Australia <strong>and</strong> Europe - <strong>and</strong> thus offers an additional benefit of potential internationalcomparisons of healthcare acceptability.5.5.6 Continuity♦<strong>Indicators</strong> of ProcessAt a facility level, it is common to seek evidence that appropriate discharge planning <strong>and</strong>care integration steps have been instituted as part of quality monitoring. External reportingof compliance with such process measures would be unreliable as a quality of care indicatoras such self-reports of compliance with discharge planning processes would be open togaming <strong>and</strong> not amenable to independent audit <strong>for</strong> confirmation of data integrity.


43♦<strong>Indicators</strong> of <strong>Outcome</strong>The success of endeavours to ensure a care continuum may be judged by surveying thosemost intimately involved in care processes. Patients <strong>and</strong> their families are the principalexperts on care continuity, with primary care physicians <strong>and</strong> other community-basedhealthcare providers secondary resources 261,337 . Surveys of these participant groups willreadily in<strong>for</strong>m how well integrated an acute episode of care appeared to those involved <strong>and</strong>provide descriptive commentary on the success of processes in place to optimise continuityof care. Modules on discharge planning <strong>and</strong> communication regarding ongoing care exist inseveral existing survey instruments 188 . Continuity indicators are prime examples of theusefulness of patient reports on care processes <strong>and</strong> outcomes in quality of care indicatorsets.5.5.7 Technical Proficiency♦Observed versus Predicted <strong>Outcome</strong>s AnalysisMany indicators of technical proficiency are based upon some permutation of observed topredicted outcome ratios. Predicted outcomes are based upon historical norms, bestpractice targets, arbitrary st<strong>and</strong>ards or models of anticipated median outcomes built onrelevant patient level data on existing clinical practice profiles. Observed outcomes arecompared to predicted, <strong>and</strong> where significant variation is identified it is inferred that thesevariations are related to variations in technical proficiency 6,7,13,16,83,85,93,131,132,133,156 .For example:• Myocardial infarction rates following coronary angioplasty• Stroke rates follow carotid endarterectomy• Anastomotic dehiscence rates following bowel anastomosesAll comparisons of observed-to-predicted outcomes are critically dependent on knowledgeof a link between technical proficiency <strong>and</strong> outcome <strong>and</strong> the validity of the estimatedfrequency of the predicted outcome of interest. In both these domains the current science ofquality monitoring has significant limitations (see especially 6.2 below). Unequivocalinferences about quality/technical proficiency can rarely be made on the basis ofobserved/predicted outcomes data, although they provide a practical stepping-stone toimproved proficiency measurement 140,143 .♦Compliance with Guidelines <strong>for</strong> CareThere is a growing body of guidelines <strong>for</strong> care delivery in particular conditions. Potentiallythese stipulate what should be done, how it should be done, when it should be done <strong>and</strong>indicate the likely outcomes if good care (as defined by the guideline) is delivered.<strong>Indicators</strong> of technical proficiency targeted to particular conditions/interventions can bedeveloped based around these guidelines. There are now comprehensive methodologiesavailable to help translate clinical practice guidelines into instruments to evaluate quality ofcare 189 . The HCFA Cooperative Cardiovascular Project, within its HQII program,provides an example of how existing care guidelines can be converted into quality process<strong>and</strong> outcome indicators (see Appendix 6 <strong>for</strong> additional detail) 127 . As many guidelines arebased upon evidence - or at worse expert consensus - they <strong>for</strong>m an important foundation <strong>for</strong>quality indicator development, hastening indicator development <strong>and</strong> reducing the risk ofgenerating indicators of limited relevance.


445.5.8 Appropriateness♦Case-by-Case Comparison with Expert CliniciansTraditional approaches to appropriateness evaluation see comparison of each individualepisode of care to expert opinion on appropriate care - typically by reference to consensuscriteria on what constitutes appropriate care (e.g. the clinical circumstances in whichinterventions are warranted given knowledge of the relative risks <strong>and</strong> benefits) 20,21,25,39-41,52,67 . This clinician perspective is subject to criticism if doubt exists about the evidencesupporting applied criteria <strong>for</strong> appropriateness - although within given providercommunities there is a reasonable concordance of opinion on the appropriateness of targetedinterventions21,39-41,67 . These case-by-case reviews are sufficiently imperfect <strong>and</strong>impractical <strong>for</strong> use in any national indicator program as to be discounted <strong>for</strong> this purpose 53 .♦Inferences Based on Variation in UtilisationA more practical approach to large scale monitoring of appropriateness of care is theanalysis of comparative utilisation statistics 22-24,33,37,92,110,112 . Relative rates of application ofa particular intervention provide in<strong>for</strong>mation suggesting potential overuse (if rates areinexplicably high) or problems with access to care (if rates are inexplicably low). The useof utilisation rates as proxies <strong>for</strong> appropriateness is dependent upon the assumption thatpotential access is relatively uni<strong>for</strong>m - as would be the case <strong>for</strong> many medical interventionswithin urban Australia. Data stratification (such as by age, sex or ethnicity) allowsidentification of areas of potential inappropriate intervention or access difficulty inparticular vulnerable subgroups. Utilisation best reflects appropriateness when theprevalence of the relevant condition in the serviced population is known <strong>and</strong> can <strong>for</strong>m thedenominator in the utilisation rate equation (that is, a rate of intervention/1000 in populationat risk of needing intervention) 116,1003 . Although imperfect appropriateness indicators, suchutilisation rates are available at low cost <strong>and</strong> would provide interesting comparativein<strong>for</strong>mation <strong>for</strong> Australian populations.N.B.It should be noted that “appropriateness” is used in several ways in health servicesresearch. Its use as a dimension of quality in this report is restricted to the assessment ofnet benefit versus risk (that is, was an intervention worth doing). It does not encompassthe site of the intervention (which we would see primarily as an efficiency issue), nor theappropriateness from the patient’s perspective (which we have encompassed within thedimensions of acceptability <strong>and</strong> effectiveness).5.5.9 Other DimensionsThe original Project brief asked <strong>for</strong> specific comment on health status, discharge planning <strong>and</strong>nursing indicators. Health status measures are tools used to monitor effectiveness - <strong>and</strong> arediscussed within this context (see 5.5.4 above). Discharge planning constitutes one aspect ofcoordination of the continuum of care <strong>and</strong> is addressed within this context (see 5.5.6 above).After reviewing an extensive body of in<strong>for</strong>mation on indicators of nursing 171-178,209-261,285-290,323 ,we elected to treat all dimensions of care as indicators of integrated care delivery by all relevantclinical professionals. We thus include nursing contributions to care <strong>and</strong> those of other involvedhealthcare professionals within indicators <strong>for</strong> all identified care dimensions (see Appendix 7 <strong>for</strong>additional detail).


456. Discussion6.1 Rationale <strong>for</strong> a Nationally Consistent <strong>Quality</strong> <strong>and</strong> <strong>Outcome</strong> Indicator ProgramNational indicator programs would seek to provide:• Accountability by providers.• In<strong>for</strong>mation to guide consumer decisions.• Incentives <strong>for</strong> quality improvement.They would achieve these aims without imposing an unacceptable collection burden on providers, atreasonable cost to the community <strong>and</strong> without creating incentives <strong>for</strong> undesirable behaviour by providers(such as gaming of data or inappropriate skewing of service delivery profiles). An ability to comparequality <strong>and</strong> outcomes data, confident that the same indicator instrument was being applied in a consistentfashion across facilities, should stimulate national benchmarking activities. As indicators are expensive todevelop, a move to a nationally consistent set could conceivably reduce the net cost of indicatordevelopment - by allowing the routine application of well-characterised instruments broadly acrossAustralia. Inevitably, national indicators will lead to a prioritisation of quality improvement ef<strong>for</strong>ts - ashas occurred elsewhere following widespread application of specific quality of care indicators. Thisinfluence on provider behaviours could be used to direct their attention to national health goals <strong>and</strong> targets.National indicator sets should encompass aspects of quality of healthcare services of relevance to patients,providers <strong>and</strong> purchasers of care. Such a balanced, comprehensive approach to monitoring dimensions ofhealthcare quality is necessary to avoid unintended <strong>and</strong> undesired consequences which might arise fromskewing of a system’s per<strong>for</strong>mance to produced favourable results in narrow segments of monitoredservice delivery. We believe indicators spanning the dimensions of care identified as pivotal by this report(i.e. access, efficiency, safety, effectiveness, acceptability, continuity, technical proficiency <strong>and</strong>appropriateness) would provide a firm basis <strong>for</strong> a successful, coordinated national indicator program witha balance between comprehensive coverage <strong>and</strong> feasibility.The cost of indicator collection would be substantial - but would constitute a small proportion of overallhealth expenditure. Judgements on the value of indicator monitoring are varied - but input frompurchasers, providers <strong>and</strong> consumers must be integrated be<strong>for</strong>e final value decisions are reached. Anyintroduction of national quality of care indicators must be accompanied by parallel projects to demonstratethe per<strong>for</strong>mance of the indicators themselves against reasonable expectations regarding indicatorattributes. This current review has highlighted that many indicators have been developed <strong>and</strong> applied inthe workplace with little or no evidence of attributes such as reliability or validity <strong>and</strong> no systematicprocesses to monitor responsiveness, burden, interpretability or utility. Throughout the western worldthere is a progressive move to large-scale monitoring of healthcare - in part because of a need to monitorthe healthcare industry because of its importance economically <strong>and</strong> in part a desire to in<strong>for</strong>m consumers<strong>and</strong> drive improvement ef<strong>for</strong>ts. Within Australia, many States are moving to collect quality <strong>and</strong> outcomeindicator data. There would be little sense in collecting disparate data at a State <strong>and</strong> Territory level, ifagreement on indicator sets would allow national comparison at a minimal marginal cost. Whatever <strong>for</strong>mfinal national indicator programs adopt, systematic tracking of the attributes of individual indicators <strong>and</strong>indicator sets will better characterise quality indicators <strong>and</strong> support decision-making regarding qualityindicator applications. Future reviews similar to this would then find evidence available upon which tobase firm judgements on the value of indicator programs <strong>and</strong> analyse attributes of their component parts.One of the enduring debates around quality <strong>and</strong> outcome indicator collection concerns the compatibility ofindicators <strong>for</strong> internal quality improvement, external accountability functions <strong>and</strong> in<strong>for</strong>ming consumerchoice. There is no consensus on the ability of a single indicator to serve these functions. Some argue thatthese functions are inherently incompatible, with accountability programs inherently “unsafe”environments <strong>for</strong> healthcare providers, in contrast to the “safe” environment required <strong>for</strong> successful qualityimprovement programs. Whilst agreeing with the need <strong>for</strong> both activities, these experts opine that externalindicator programs will never enhance local quality enhancements - <strong>and</strong> at worse may detract from them.


46Others argue that it is the behaviour of those participating in indicator programs which determines theircongruence <strong>for</strong> accountability <strong>and</strong> quality improvement purposes. It will be essential that education (ofproviders <strong>and</strong> those receiving indicator data) <strong>and</strong> a collaborative development of credible indicatorsunderpins any national indicator implementation in Australia. Although there are stark examples offailures in indicator applications (such as HCFA - <strong>and</strong> others - release of inadequately risk-adjustedfacility mortality data), there are equally examples of successful dual-usage indicator programs (such asthe Clevel<strong>and</strong> Health <strong>Quality</strong> Choice), suggesting that the optimism of those supporting compatibility ofthese uses of some selected quality of care indicators is justified.The introduction of a nationally consistent quality <strong>and</strong> outcome indicator program would undoubtedly beassociated with changes in practice, as have occurred elsewhere 12,304,339 . The rationale <strong>for</strong> these changes inpractice <strong>and</strong> their relationship to indicator usage per se have never been systematically analysed. Whilst itwould be hoped that the availability of indicator data <strong>and</strong> the ability to benchmark per<strong>for</strong>mance motivatedquality improvement effects which resulted in improved processes <strong>and</strong> outcomes (such as a reduction inCaesarean section rates or readmission rates) these changes may have resulted from a halo effect of qualitymonitoring or indeed have occurred because of unrelated changes in health service delivery. In the leastdesirable circumstance, quality indicators may drive data manipulation exercises such that apparentimprovements merely represent the quality monitoring equivalent of “creative accounting”. As isemphasised throughout this report, the likely health service delivery consequences of a national qualityindicator program will be inextricably linked to the context of indicator development <strong>and</strong> use.6.2 Risk AdjustmentAt present we believe that none of the available severity adjustment systems reviewed are clearly superiorto others. There are a number of recent enlightening reviews of this subject 34,35,71,131,133,141,144,154,156,778 .They agree to the value of adjusting indicator data <strong>for</strong> patient characteristics so that the process oroutcome indicators better reflect the quality of delivered care <strong>and</strong> not factors unrelated to care quality (socalled“confounding factors”). Ideal risk adjustment systems incorporate a range of modifiers related tothe patient’s suitability <strong>for</strong> application of care processes (such as allergy to recommend treatment options)<strong>and</strong> their intrinsic vulnerability <strong>for</strong> a given outcome (such as the specific condition afflicting the patient,the severity of that disease, the presence of other medical conditions <strong>and</strong> patient’s overall physical,psychological, emotional <strong>and</strong> social resources). Following ideal risk adjustment, any remaining differencesin indicator rates would directly reflect differences only in the quality of care provided.Ideal risk adjustment methodologies do not currently exist. There is evidence that the more in<strong>for</strong>mationavailable <strong>for</strong> risk adjustment, the better the resulting model - although the gain in predictive abilities ofrisk-adjustment models (their ultimate validation) is not directly proportional to the quantity of data pointsprovided <strong>for</strong> modelling 293,329 . The principal question posed is there<strong>for</strong>e whether the gain in comparativeprecision warrants the costs of data collection <strong>and</strong> risk adjustment. Providers typically are not responsiveto unadjusted indicator data 141 . Credibility with providers is an important motivation <strong>for</strong> risk adjustment.It is crucial that the limitations of adjusted or unadjusted indicator data are known to all who use the data<strong>and</strong> that they act on the data accordingly. Serious problems arise if crude or incompletely risk-adjustedindicator data are acted upon as if they mean precisely what they may seem to mean (<strong>for</strong> example, ifoverall hospital mortality rates are reported as quality indicators <strong>and</strong> specialist cancer hospitals providingpalliative care services with high mortality rates are sanctioned).More sophisticated risk-adjustment models not only use more factors <strong>for</strong> adjustment, they also attempt tocompensate <strong>for</strong> known problems with data (<strong>for</strong> example, they seek in<strong>for</strong>mation from medical recordsrather than administrative databases to ensure accurate patient profiling) 156 . Better models avoid maskingdifferences in process or outcome that could potentially reflect differences in quality of care (<strong>for</strong> example,if ethnic minorities systematically received poorer quality of care - adjusting <strong>for</strong> ethnicity would concealthat aspect of relative per<strong>for</strong>mance) 320,324 .


47An alternative to patient-level risk adjustment is facility-level adjustment 293 . We believe this approachrisks the masking of systematic differences in care delivery between facilities <strong>and</strong> is not desirable. Nomajor respected risk-adjustment system studied included such facility-level adjustment in its modelling.Stratification of patient populations provides a relatively simple means of attempting to correct <strong>for</strong> patientleveldifferences impacting on process or outcome indicator data. The premise underpinning stratificationis that the identified groups (strata) are either homogeneous or that they may be treated as such <strong>for</strong>comparative purposes because any patient-level differences average out across the groups compared.These strata/groups may reflect primary diagnosis, disease severity, age or sex, or some combination ofsuch factors. When used successfully stratification allows indicator comparisons at low cost - providedthe data <strong>for</strong> stratification are routinely available in administrative databases.Stratification may be the only practical approach to addressing the monitoring of quality of care <strong>and</strong> healthoutcomes in vulnerable patient groups, such as Aboriginal <strong>and</strong> Torres Strait Isl<strong>and</strong>er peoples. Providedin<strong>for</strong>mation permitting stratification is readily available within data sets (such as indicators ofAboriginality or postcodes as a proxy <strong>for</strong> socio-economic class) it would be possible to reviewcomparative indicator data in those deemed potentially vulnerable. Indicator rate comparisons wouldsuggest areas of inequity in service delivery warranting further scrutiny.<strong>Quality</strong> indicators have been subjected to various levels of risk adjustment. Any single indicator reviewed<strong>for</strong> this report has been presented in <strong>for</strong>mats ranging from unadjusted facility or practitioner-level data todata reflecting risk-adjustment <strong>for</strong> 30 or more potential confounding variables. Expert opinion differs onthe utility of risk-adjustment <strong>and</strong> in particular its cost-effectiveness. There is no evidence to categoricallydecide the value of risk adjusting clinical indicators - although there is consensus that risk adjustmentimproves provider acceptance of indicator data <strong>and</strong> significantly alters apparent comparative per<strong>for</strong>manceof up to 30% of individual facilities. Each indicator requires the development of a unique risk adjustmentmodel based upon local experience of indicator <strong>and</strong> confounder data. Risk adjustment models do notsuccessfully “transport” from one healthcare environment to another - presumably because many apparentconfounders are in fact proxy measures of patient characteristics which act as valid proxies only in adefined patient population. The need to develop risk adjustment models <strong>for</strong> those indicators in the nationalindicator set will depend on the intended use of indicator data. It is probable that raw <strong>and</strong> adjusted orstratified indicator data will be required <strong>for</strong> most of the proposed indicators. The development of locallyrelevant risk adjustment models should <strong>for</strong>m an integral part of the construction of detailed operationaldefinitions <strong>for</strong> each indicator to be trialled as part of a putative national indicator set. Guidance on datacollection requirements necessary to adjust <strong>for</strong> confounding influences will initially be based around expertlocal opinion <strong>and</strong> the experience of others in risk-adjusting quality indicators in healthcare103,106,118,144,156,302,328,342 .6.3 Characteristics of a Successful National <strong>Quality</strong> <strong>and</strong> <strong>Outcome</strong> Indicator ProgramWe believe a successful national indicator program will require several key characteristics. It will be:• Comprehensive: A sufficient breadth of indicators will be used to guarantee that a range ofdimensions of care <strong>for</strong> common, relevant conditions are encompassed within the program.• Collaborative: The program will evolve with the active participation of all interested parties pursuinga common goal of attaining a credible indicator set which can satisfy accountability requirements,guide consumer-choice <strong>and</strong> promote quality improvement.• Consumer-focused: Indicator programs must embrace consumer involvement in the identification ofareas of care delivery warranting monitoring <strong>and</strong> in the design, implementation, interpretation <strong>and</strong>feedback on indicators of quality of care <strong>and</strong> outcomes.• Current: National indicator sets will need to be updated regularly to keep abreast of developments inthe science of quality of care monitoring <strong>and</strong> the science of medical care delivery.


48• Cost-efficient: Wherever practical, indicators should utilise existing data <strong>for</strong> indicator construction,making incremental changes to routine databases as the needs <strong>for</strong> additional data points are identifiedby appropriate research <strong>and</strong> field trials.Such a national indicator program would then be credible to all concerned <strong>and</strong> be of value in guidingpurchasing decisions, integral to facility quality improvement programs <strong>and</strong> in<strong>for</strong>m consumers’ healthcaredecisions. Achievement of these desired goals within the framework of a national indicator program willrequire more than agreement to a nationally consistent indicator set. Assistance with data collection, theinterpretation of statistical analyses, benchmarking, the design <strong>and</strong> implementation of improvementprojects <strong>and</strong> coordination of collaborative projects with other facilities will require the availability ofresources beyond those currently seen in most Australian healthcare facilities. To ensure that in<strong>for</strong>mationsharing on acute healthcare per<strong>for</strong>mance enhances local quality improvement ef<strong>for</strong>ts, provideraccountability <strong>and</strong> consumer choice, it will be necessary to exp<strong>and</strong> the community of professionalscommitted to quality <strong>and</strong> working collaboratively with hospitals to translate the potential benefits ofquality <strong>and</strong> outcome monitoring into achieved gains.The provision of this human resource <strong>and</strong> logistical support is an absolute requirement <strong>for</strong> the success ofthe national indicator program. A number of options exist <strong>for</strong> how this resource might be provided.Existing government, professional or regulatory agencies could be delegated responsibility <strong>for</strong> some or allof these functions. Alternatively, such functions could be concentrated within a group focusing on qualityissues in healthcare (such as those centres of excellence proposed in the final report of the Task<strong>for</strong>ce on<strong>Quality</strong> in Australian <strong>Healthcare</strong>). The use of some existing agencies to provide the program support mayraise concerns about potential <strong>for</strong> apparent conflicts of interest. St<strong>and</strong>-alone, quality-focused agenciesmight be deemed an unwanted additional complexity <strong>and</strong> expense. A USA model worthy of review in thissetting is the HCFA <strong>Quality</strong> Improvement Initiative. HCFA contracts out these support functions <strong>for</strong> thisquality monitoring project, which are provided by dedicated groups (typically set up by existing agenciesas independent entities with the purpose of enhancing improvement ef<strong>for</strong>ts).7. RECOMMENDATIONS7.1 Structure of a National Indicator ProgramThe development of a nationally consistent set of quality of care <strong>and</strong> health outcome indicators will be aniterative process, with more in common with a research <strong>and</strong> development program than with the workplaceimplementation of an established technology. If it is agreed that a variety of interests are best served bythe availability nationally of credible comparative in<strong>for</strong>mation on the per<strong>for</strong>mance of acute healthcareservices, there is the need to begin with the best available feasible indicators <strong>and</strong> progressively improve<strong>and</strong> supplement these, rather than deferring all action because of the absence of perfect indicators.We recommend:7.1.1 National quality <strong>and</strong> outcome indicators be developed as two complementary indicator sets:A core indicator set, intended <strong>for</strong> continuing collection <strong>and</strong> a series of indicator modulescontaining indicator sets intended <strong>for</strong> collection at a defined frequency <strong>for</strong> a finite duration.7.1.2 The core indicator set should focus on generic aspects of care - including access, efficiency<strong>and</strong> acceptability of care.7.1.3 The indicator modules be targeted to specific conditions, diseases, diagnoses or interventions<strong>and</strong> include a balanced array of indicators encompassing clinical indicators, health statusindicators, acceptability indicators <strong>and</strong> efficiency/cost indicators.


49Examples of the type of indicators contained within such condition-specific modules areprovided at the end of this section. It is emphasised that these are listed to explain theconcept of indicator modules <strong>and</strong> that <strong>for</strong>mal development of indicator modules <strong>for</strong> trialingrequires expert local input (see 7.1.5).7.1.4 The core indicator set be based around in<strong>for</strong>mation derived from administrative databases(because of cost efficiency) or patient surveys (because of the high value of patient-basedin<strong>for</strong>mation).7.1.5 The indicator modules targeting a particular clinical circumstance be based on hybrid datacollection <strong>and</strong> include in their function a <strong>for</strong>mal assessment of the contribution of additionaldata points obtained from medical record data abstraction to the utility of indicator data.7.1.6 Indicator modules targeting particular clinical circumstances be developed as cooperativeactivities between government, regulatory bodies, providers, specialist <strong>and</strong> professionalcolleges <strong>and</strong> societies, consumers <strong>and</strong> those with expertise in indicator application. Theseprograms could be based at centres with expertise in data h<strong>and</strong>ling (such as AIHW) butshould include active participation of professional groups who will enhance the peercredibility of quality monitoring <strong>and</strong> help ensure that accurate data are transmitted <strong>for</strong>analysis.7.1.7 Wherever possible sample techniques be used to obtain detailed representative data ratherthan attempting routine data collection from all episodes of care. This will increase thecomplexity of available data whilst controlling costs.7.1.8 As part of a national indicator development program a resource be developed to assistfacilities with indicator data collection <strong>and</strong> interpretation <strong>and</strong> provide independentconfirmation of data integrity.7.1.9 Indicator programs should develop comprehensive operational definitions <strong>for</strong> indicators toenhance data reliability, preferably including software programs with inbuilt data reliabilitychecks.Examples of Condition-Specific<strong>Quality</strong> <strong>and</strong> <strong>Outcome</strong> Indicator ModulesCoronary Artery Bypass Grafting4-8 indicators chosen from:• Unplanned return to operating room• Inhospital mortality• 5 year mortality• Change in health status (at 6 or 12 months)• Secondary prevention strategies• Health related quality of life at 3 months• Underst<strong>and</strong>ing by patient of indication <strong>for</strong> CABG• Average length of stay• Satisfaction with inpatient episode of care• Other process or outcome indicators


50Myocardial Infarction4-8 indicators chosen from:• Compliance with Best Practice Guideline <strong>for</strong> Care- Time to revascularisation attempt (either thrombolysis or angioplasty)- Inhospital survival- Health status at 3 months- Administration of appropriate medicationsü Beta Blockersü Aspirinü ACE Inhibitors• Myocardial function at 12 months• Survival at 5 years• Risk factor education success• Risk factor intervention rates• Return to previous activity index• Satisfaction with inpatient episode of care• Length of stay• Cost of care• Other process or outcome indicators7.2 Suggested <strong>Indicators</strong> <strong>for</strong> Trial in AustraliaIt is a difficult judgement to support particular quality <strong>and</strong> outcome indicators without detailed knowledgeof the intended use of these indicators. As we have repeatedly stated, the determination of the adequacy ofan indicator is not categorical (that is, indicators are not either adequate or inadequate, good or bad),rather, indicator validity <strong>and</strong> utility lie upon a continuum with final adjudication on their relative adequacyrequiring knowledge of the context <strong>for</strong> per<strong>for</strong>mance measurement. Our recommendations assume acollaborative, iterative, developmental program <strong>for</strong> progressing towards a nationally consistent set ofquality of care <strong>and</strong> health outcome indicators.We have found little in<strong>for</strong>mation available on indicator attributes which would guide dogmatic choices ofindicators <strong>for</strong> our recommendations. The majority of putative quality <strong>and</strong> outcome indicators have no dataon their per<strong>for</strong>mance. The available data would suggest that many indicators are of some value - with fewst<strong>and</strong>ing out as examples dem<strong>and</strong>ing inclusion in quality monitoring programs. The recommendationsbelow are based upon our judgements regarding indicators of potential value, cognisant of existing <strong>and</strong>feasible short-term data availability. Our assessments of these indicators against the indicator attributeprofile is included in Appendix 6 - which also encompasses notation of identified indicators which havesufficient in<strong>for</strong>mation available to suggest that they also could be adapted <strong>for</strong> use in an Australian context<strong>and</strong> examples of indicators with significant shortcomings when judged against these criteria.♦Access7.2.1 Existing elective surgery waiting times be refined to a common operational definition whichencompasses a uni<strong>for</strong>m categorisation of urgency. Waiting time should be the time from thedecision to intervene to intervention, to reduce incentives <strong>for</strong> provider manipulation of data.Derivative measures, such as clearance times, help with interpretation of waiting/queuingtimes <strong>and</strong> should be continued.7.2.2 Following successful implementation of an indicator of uni<strong>for</strong>m waiting time <strong>for</strong> electivesurgery, consideration be given to stratification of queuing time by specialty in addition to


51urgency <strong>for</strong> core use in indicator sets or by intervention/procedure within modular setstargeting particular clinical circumstances.7.2.3 Emergency Department waiting times - stratified by triage category.7.2.4 Waiting times in Emergency Department prior to inpatient admission.7.2.5 Patient surveys be undertaken to derive reported elective surgery waiting times, EmergencyDepartment waiting times, time in Emergency Department awaiting admission, outpatientwaiting times (<strong>for</strong> appointment) <strong>and</strong> outpatient waiting time <strong>for</strong> particular attendances.This in<strong>for</strong>mation could be stratified by patient-reported urgency of care <strong>and</strong> the specialtyproviding service <strong>and</strong> the acceptability of reported queuing times recorded.♦Efficiency7.2.6 The continued development of cost/casemix adjusted separation be supported to resolveoperational definition <strong>and</strong> reliability issues be<strong>for</strong>e proceeding to consider more complex,high level technical efficiency indicators.7.2.7 No indicators of allocative efficiency are currently suitable <strong>for</strong> trialing.♦Safety7.2.8 No indicators of patient safety are currently suitable <strong>for</strong> trialing in the core indicator set.Progression of implementation of comprehensive, anonymous incident reporting systemsare seen as the optimal national strategy <strong>for</strong> monitoring safety in hospitals. All reviewedgeneric safety indicators were considered either conceptually flawed or liable to createundesirable incentives to bias the identification <strong>and</strong> reporting of safety concerns.7.2.9 Targeted safety indicators should be included in relevant modules of indicators focusedupon defined clinical circumstance. These will typically reflect adherence to best practiceguidelines or some variation on observed to predicted adverse outcome monitoring <strong>and</strong>could best be initially developed <strong>for</strong> interventions <strong>for</strong> ischaemic heart disease(angiography, CABG, angioplasty <strong>and</strong> AMI).♦Effectiveness7.2.10 Generic health status measures (the SF36 or SF12) be part of omnibus surveys (see 5.4.3)administered to recent recipients of care <strong>and</strong> these health status reports be compared toself-reported health on admission as indicators of care effectiveness <strong>for</strong> use in the coreindicator set.7.2.11 Health status measures (SF36 or SF12 as generic measures or other validated conditionspecific measures relevant to the targeted clinical circumstances) be included in thebalanced indicator sets developed <strong>for</strong> indicator modules addressing particular conditions,diagnoses, diseases or interventions.7.2.12 Mortality rates <strong>for</strong> selected clinical conditions, diseases, procedures or interventions becollected - stratified by readily available administrative data - <strong>and</strong> apparent quality of careper<strong>for</strong>mance be compared to more sophisticated health outcome indicators based uponrisk-adjusted mortality developed within targeted modules of indicators addressing theseprocedures. This would provide in<strong>for</strong>mation as to how significantly complex riskadjustmentalters apparent comparative per<strong>for</strong>mance <strong>and</strong> will guide judgements on the


52long term utility, in an Australian acute healthcare context, of these approaches tooutcomes monitoring.7.2.13 Unplanned readmission following index admission <strong>for</strong> asthma - stratified by age (0-19 <strong>and</strong>20-49) provides a valid indicator of the effectiveness of the overall asthma care plan <strong>and</strong>its revision or rein<strong>for</strong>cement during the initial hospital admission. Unplanned readmissionis, we believe, likely to be restricted in use in future to such condition specific applicationsrather than continuing as a generic hospital-wide medical indicator - although finaldecisions on its generic utility must await the results of studies underway under theauspices of the National Hospital <strong>Outcome</strong>s Program.7.2.14 Low (less than 2500 grams) <strong>and</strong> very low (less than 1500 grams) birthweight rates bemonitored. Although difficulties with attribution of outcome to facility-level quality ofcare are encountered with this indicator, at a population level it provides oversight of theadequacy of maternity care <strong>and</strong> examination of stratified results may yield evidence ofcomposite healthcare system quality problems (including aspects of access <strong>and</strong>effectiveness). Hospitals providing childbirth care have a crucial role to play in thepromotion or direct provision of adequate maternal antenatal care <strong>and</strong> in advocacy <strong>for</strong>social support <strong>for</strong> pregnant women. Thus, whilst this indicator reflects much more thanfacility-level per<strong>for</strong>mance during an inpatient episode of care, it is not an unreasonableindex of the broader success of healthcare providers in the management of antenatal care.♦Continuity7.2.15 Patient-based assessment: Surveys of patients’ perceptions of care should includeassessments of the success of discharge planning <strong>and</strong> integration of care based upon themodules currently within the Picker Commonwealth survey. In circumstances wherepatients themselves are unable to provide such feedback, the in<strong>for</strong>mation should beobtained from their carers.♦Acceptability7.2.16 Acceptability: We believe that a national survey program based upon r<strong>and</strong>om sampling ofrecent acute care patients using instruments built upon well validated surveys - such as thePicker Commonwealth survey, the Hospitals Corporation of America survey <strong>and</strong> theRoyal College of Surgeons surveys - is the appropriate action in the short term.7.2.17 Needs: A national program to better identify the needs of Australian consumers, inparticular vulnerable subgroups such as Aboriginals <strong>and</strong> Torres Strait Isl<strong>and</strong>ers, shouldbe implemented. This in<strong>for</strong>mation should be the basis <strong>for</strong> refinements of the nationalsatisfaction survey instrument.7.2.18 Contemporaneous reporting of process <strong>and</strong> outcome in<strong>for</strong>mation: Whenever practicable,surveys of acceptability should be linked to simultaneous patient reporting of theirperceptions of processes <strong>and</strong> outcomes of care.♦Technical Proficiency7.2.19 Targeted technical proficiency indicators: The major thrust <strong>for</strong> indicators of technicalproficiency should be within the modular indicator sets focusing upon specific clinicalconditions, diagnoses, diseases or interventions. These should be appropriately riskadjustedprocess indicators built upon accepted care guidelines or outcome indicators builtupon observed to predicted morbidity or mortality ratios (where the frequency of themonitored outcome is sufficiently high to avoid masking of quality of care issues by


53anticipated r<strong>and</strong>om variation). Initial modules should be built around cardiovasculardisease interventions. Later modules could examine conditions such as the care ofdepression, the management of newly diagnosed cancer or cataract extraction - asexamples of common conditions with a serious health impact, which have effectivetreatments <strong>and</strong> per<strong>for</strong>mance indicators available.♦Appropriateness7.2.20 Case by case analysis of appropriateness of care: The limitations of this analytictechnique, its cost <strong>and</strong> its influence on a collaborative development of external indicatorprograms render it unsuitable <strong>for</strong> a national indicator program. Such individualappropriateness reviews should be encouraged within provider facilities.7.2.21 Utilisation as a proxy appropriateness indicator: It would be valuable to analysepopulation- based differences in interventions believed to have significant unexplainedvariation in utilisation as indirect indicators of appropriateness of care. Where reliabledata on the population-based incidence of primary disease processes is available, suchutilisation data would prove more valuable in judgements of apparent comparativeappropriateness <strong>and</strong> might direct more focused review of a representative sample ofindividual cases <strong>for</strong> analysis of individual case appropriateness. Conditions to consider<strong>for</strong> such utilisation review include:• Cardiac catheterisation.• Coronary artery bypass grafting.• Angioplasty (PTCA).• Cholecystectomy.• Hysterectomy.• Laminectomy.• Caesarean Section (primary).• Vaginal birth after primary Caesarean Section.• Prostatectomy.7.3 Future Directions in Indicator Development7.3.1 Dimensions of care quality needing indicator developmentWhilst an argument can be made that all areas of quality <strong>and</strong> outcome indicators requiresubstantial research <strong>and</strong> development, we believe there to be a particular need <strong>for</strong> indicators thatreflect:♦♦Unmet access: Most existing hospital access indicators deal with characteristics of thosewho have succeeded in achieving access to our acute healthcare services. Betterin<strong>for</strong>mation is required on consumer health needs. This requires in<strong>for</strong>mation about thosewho fail to access healthcare to better in<strong>for</strong>m judgements on equity of healthcare services.Such indicators will require population-based surveys seeking evidence of likely need <strong>and</strong>the health system’s response to that need.Allocative efficiency: Much needs to be done to refine instruments <strong>for</strong> allocativeefficiency that more accurately reflect the balance between consumers’ needs <strong>and</strong> evidencethat services can meet those needs <strong>and</strong> offered care influence health outcomes - rather thanmodels mirroring directions of health policy. This will require improved in<strong>for</strong>mation onconsumer needs <strong>and</strong> an explicit linkage of this in<strong>for</strong>mation to evidence of existing capacityto address these needs (including evidence of effectiveness such as that provided by theCochrane Centre Collaborations).


54♦♦♦Acceptability: There is a particular need <strong>for</strong> better instruments to monitor the culturalappropriateness of care <strong>and</strong> the perceptions of vulnerable subgroups receiving care (suchas Aboriginals <strong>and</strong> Torres Strait Isl<strong>and</strong>ers).Continuity: Feasibility studies addressing the methodologies <strong>for</strong> obtaining relevantfeedback from representative, community-based healthcare professionals on the success ofintegration of acute healthcare services into the care continuum should be supported.Appropriateness: Research should be pursued into methods <strong>for</strong> linking patient-basedperceptions of the outcomes of care <strong>and</strong> preferences regarding the weighting of indications<strong>for</strong> care delivery (based upon patient perception of need <strong>for</strong> care) to provider assessmentsof the risks <strong>and</strong> benefits of care delivery. Initial studies should focus on commonconditions with evidence that patient election regarding care is a significant issue (e.g.treatment <strong>for</strong> benign prostatic hypertrophy <strong>and</strong> primary breast cancer).There are important dimensions of quality of care which are inadequately represented in ourproposed framework <strong>for</strong> per<strong>for</strong>mance measurement. Equity is only partly encompassed by accessmeasures, benevolence is incompletely represented in indicators of effectiveness <strong>and</strong> acceptability<strong>and</strong> the ethics of care delivery essentially unrepresented. These, <strong>and</strong> other, care dimensions areimportant. If it were feasible to develop quality indicators that better reflect these more complex<strong>and</strong> value-laden aspects of healthcare it would clearly be desirable. It is our opinion that thelikelihood of developing credible, quantitative indices of these more complex dimensions of care islow <strong>and</strong> that <strong>for</strong> the <strong>for</strong>eseeable future most research <strong>and</strong> development ef<strong>for</strong>ts in quality indicatordevelopment in acute healthcare would usefully be focused within the framework offered by ourdimensions of care quality.7.3.2 Indicator Development Strategies:♦We strongly recommend that future national indicator development be addressed bymultidisciplinary groups <strong>and</strong> be directed towards specific clinical circumstances with aview to the evolution of balanced sets of indicators (i.e. reflecting clinical indicators,patient functional health outcomes <strong>and</strong> HRQOL, the acceptability of care <strong>and</strong> cost of care)rather than exhaustive sets of indicators addressing a relatively narrow range ofdimensions of the quality of care delivery processes or achieved health outcomes.Australian quality <strong>and</strong> outcome indicator development should be more closely linked tointernational developments in health services research. Wherever possible, we should seekto build upon the knowledge established by others in much larger population bases <strong>and</strong>adapt putative indicators <strong>for</strong> local utilisation trials rather than building all quality of careindicators “from the ground up”. Linking our acute healthcare indicators more closely tointernational indicators would allow <strong>for</strong> more international comparisons - which webelieve will be increasingly relevant in health services as in benchmarking per<strong>for</strong>mance inother major national industries. The trialing of such derivative indicators would alsoallow our intellectual <strong>and</strong> fiscal resources to concentrate upon indicators reflectingnuances of healthcare delivery that are uniquely Australian <strong>and</strong> may speed thedevelopment of indicators of relevance to health issues or consumer groups currentlypoorly served by existing quality of care <strong>and</strong> health outcome indicators.♦We strongly recommend that work be supported to develop an indicator module whichspecifically addresses the health concerns of vulnerable patient groups, in particularAboriginal <strong>and</strong> Torres Strait Isl<strong>and</strong>er peoples. Together with stratification of indicatordata, this approach would strengthen knowledge of current gaps in service delivery <strong>and</strong>assist in monitoring of the impact of strategies to enhance care of vulnerable subgroups.


55♦Australia should seek to identify centres of excellence to link into the WHO <strong>Quality</strong>Assurance Collaboration Centre, to promote interfaces between clinical practice <strong>and</strong>academic developments in quality of care indicators.7.3.3 Integrated Health System Per<strong>for</strong>mance Assessment:♦♦National quality <strong>and</strong> outcome indicators should increasingly focus on integrated healthservice delivery rather than the per<strong>for</strong>mance of individual sectors such as acute care.Most of the major health concerns of Australians relate to chronic illnesses, where theper<strong>for</strong>mance of the integrated system of care is far more important than the per<strong>for</strong>manceof its isolated components. Patients turn to the healthcare services seeking adequate care<strong>and</strong> hoping <strong>for</strong> good overall outcomes. With chronic illnesses (such as hypertension,ischaemic heart disease, diabetes, arthritis <strong>and</strong> cancer) the overall success of interventionsmust sum the inputs of health promotion, preventative care, early detection programs <strong>and</strong>episodes of care in community <strong>and</strong> hospital sectors. Analyses of per<strong>for</strong>mance must judgewhether appropriate care has been delivered (e.g. education about risk reduction,screening <strong>for</strong> early disease, risk factor identification <strong>and</strong> therapeutic intervention) notwhere that care was delivered. Many of the best indicators of quality of care are suchglobal measures of per<strong>for</strong>mance (such as have patients been advised about relevantlifestyle changes, has blood pressure or cholesterol-level been checked, has adequacy ofdiabetes control <strong>and</strong> diabetes self-education been implemented, have necessary vaccinesbeen administered in a timely fashion).Any move to an integrated per<strong>for</strong>mance monitoring would require both the adoption of aunique identifier which respected the privacy <strong>and</strong> confidentiality needs of patients <strong>and</strong> thecooperation of the myriad of agencies - both at government <strong>and</strong> regulatory levels - whichoversight our compartmentalised health system. Such a move towards a more holisticper<strong>for</strong>mance appraisal may seem impractical given current realities, but the common goalof improving the value of healthcare, by raising the quality of care <strong>and</strong> lowering ormaintaining costs, will not be realised until such a global perspective on health servicesper<strong>for</strong>mance is adopted.


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