quality measurement and public reporting of quality data in …€¦ · short version of the the...

Quality measurement and public reporting ofquality data in Swedish health care – a common

support structure for regions and national program areas

US Study group , October 16th 2019

Fredrik Westander, SALAR

Mailadress: [email protected]

Twitter: @Fwestander

mailto:[email protected]

Remember – Sweden is not just Stockholm and the larger cities, but also very much a rural countly, sparsely populated.

This week is the start week of the moose hunt period, in my part of Sweden (Värmland, half wayto Oslo). Most men who also can claim ownership of a piece of land, participate. The whitemoose is not common. Strange and magic to se such a large, white animal.

Content

• Swedish health and health care

• Kunskapsstyrningsmodellen: 21 Regions in a national collaborative

• Health care quality measurement – general conditions• Data sources, quality registries, public reporting traditions • The web site Health Care in Numbers – the main tool

• A health care data /quality data tour: • Comparing regions - health systems • National program groups; condition based quality reporting

• Policy perspectives - discussion

• Demo of Health Care in Numbers (if time)

My question to you: Large scale healthcare reform in US – is this a mission impossible?

What should be done?

Comments are invited – before we end.….

Swedish health

and health care

National system for knowledge-based management within healthcare__________________________________SWEDEN´S REGIONS IN COLLABORATION

Decentralised healthcareTax funded system with shared responsibility between national government and local authorities; financed by regional taxes plus state grants to

National levelLegislation, monitoring and education/training. National Board of Health and Welfare, Socialstyrelsen – crucial state agency

Regions (21)Healthcare, but also regional development and support to cultural activities and public transport

Municipalities (290)Social services; care of elderly and disabled people, schools and school health care, spatial planning and building, health and environmental protection, rescue services,

Larger healthcare regions (6)Geographic partnership, consolidate specialised care within the region and other collaborations, moreimportant in later years as collaboration between the 21 Regions is widening.

The six are: South, West, South-East, Uppsala-Örebro (Middle…), Stockholm-Gotland; Northern region

Costs: Health care cost as share of GDP. Stable share – in that sense wehave no explicit cost crisis in Sweden. Rise in 2011 due to change i OECD definition. But note – difficulties in recruiting nurses in latestyears, also GPs. Wages is on the rise. So – there is cost pressure.

Under pressure: Estimated yearly growth of health care need, 1980-2030. Drivers: Change in total population + change in age compositionof population. No estimate of other factors; general health etc.

Need growth is exceedingrise in tax incomes; lead to pressure for higher tax rates.

The number of persons aged 80 – w is expandingrapidly in the coming 10 years period.

Strong effect on social careneed (nursing homes etc), but also health care need, to a lesser extent.

2019

Private – public mix; 1-2 % of costs is private insurance”Socialized medicine”, but out of pocket payments is rule. Expansion of private providers since 1990s, mainly in primarycare. For profit or self employed; weak tradition of non profit providers. Private providers = about 12-13 % of total cost.

Perhaps 1-2 % of total health care costs is private insurance. About 600 000 persons is partly covered. Mostly youngerages. ”Add on” insurance; giving faster access to care. Not much knowledge of the content of private insurance.

Age distribution for persons with private health careinsurance

Blue bars – total population

Red bars – privately insured

Kunskapsstyrningsmodellen:

21 Regions in a national collaborative


Collaboration for a knowledge-based, equal and resource-efficient

healthcare

Knowledge-based management

Mats Bojestig, Chair of the National Steering Group, [email protected] Lawrence, National Coordinator, SALAR, [email protected]

New and evolving collaboration, just 1-2 years old. National support function placed at SALAR, integrated into the ”old SALAR” – the employersorganisation etc etc – partly a new role.




Knowledge-basedmanagement in practice

• We use the best available knowledge

• The visit (caregiver-patient) is followed up and analysed

• New knowledge is put into practice quickly

• Identify areas for improvement with the patient

Support patients and care givers to use best available knowledge

The patient as co-creatorShort version of the stated aims of the collaboration, expressedi terms of patient-caregiver interaction

Strong focus on quality improvementand equality in care and healthoutcomes.


Collaboration for knowledge-based management

Micro system – care teams

Meso level – regional

Macro – national

Care teams, patients and support systems, operational managers

Health care management, health care region,

collaboration municipality

SALAR, responsibleauthorities

central government

The patients

The ideal:

Support for the microsystem, the care teams.

But also for Regions, and social care functions in municipalities


A learning system

Knowledgesupport

Leadership and support for

development

Support forfollow-up,

open comparisonand analysis

A cohesive systemfor knowledge based

management


24 national national program groups (NPGs) Condition based NPGs• Cancer diseases• Cardiovascular diseases• Dental care• Eye diseases• Infectious diseases• Diseases of the ears, nose and mouth• Musculoskeletal diseases• Diseases of the nervous system – stroke MS etc• Endocrine diseases – diabetes etc• Gastrointestinal diseases• Gynaecological diseases, pregnancy and childbirth• Lung and allergy diseases – COPD etc• Mental health• Rare diseases• Renal and urologic diseases• Skin diseases and sexually transmitted diseases

Functional/other NPGs• Emergency healthcare

• Elderly´s health

• Living habits

• Medical diagnostics

• National council for primary care

• Rehabilitation, habilitation and insurance medicine

• Childrens health

Members från alla 6 health care regions, mandate from 21 Regions. A national mandate.

National Program Groups (NPGs) – condition based. Each NPG couldappoint working groups – for example Sepsis, Claucoma, Heart Failure

Cancer diseases

Cardiovascular diseases

Dental care Eye diseasesInfectious diseases

Diseases of the ears, nose and

mouth

Musculoskeletal diseases

Diseases of the nervous system

Endocrine diseases -diabetes

Gastrointestinal diseases

Gynaecological diseases,

pregnancy and childbirth

Lung and allergy

diseasesMental health Rare diseases

Renal and urologic diseases

Skin diseases and sexually transmitted

diseases

Mandate – functions of NPGs

- Analyze-assess health care within its field

- Unfulfilled needs?

- Unwarranded geografical variation? Misuse of resources?

- Sub par quality? Patient safety issuses?

- Not enough meaningful data?

- Set drivers of change in motion

- National clinical guidelines (care programs, Vårdprogram, in Swedish)

- Quality standards to be followed

- If needed, propose expansion of resources/more efficient resource use

- Collect and use meaningful data, both locally and at national level

- Establish a model (indicators, targets) for follow up and benchmarking

Sepsis, Heart Failure is among more than perhaps 20-30 ongoingprojects since spring-summer 2019. All are initatives of the NPGs, approved by the national steering committé.


7 national theme based groups working in collaboration – support structure for NPGs

National collaboration groups

• Methods for knowledge support

• National quality registers

• Follow-up and analysis

• Pharmaceuticals/MedTech

• Research/Life Science

• Patient safety

• Structured healthcare information coding, informatics

National support function for follow-up, benchmarking and analysis

– two tracks

Regions – the 21 population based

entities

National Program Groups, NPGs -

Condition/diseasebased

National support strategies - follow up, analysis

• Publish available quality data – the site Health Care In Numbers, HCIN• Yearly report with national trends and regional comparisons• Reports with quality data per each NPO in HCIN (on going work)• Develop a wise structure of national health care databases

• Informatics, coding standards• Patient administrative data (”Billing data” )• Costs, waiting times, use of drugs, PREM-PROM etc• Explose new ways of data collection – close to a national data base for lab results

• Expand datasets – collect new, relevant data in accordance with the needsof NPGs

• Make data useful in everyday care….even decision support systems; a long way to go – perhaps?

Health care quality monotoring –general aspects

In comparison to other countries - good health care quality data available from Swedish registries (we think…)

• Personal/unique ID used in all vital registers – all citizens

• Mandatory Patient Register for out-/inpatient episodes of care

• Prescribed Drug Register for outpatient drugs

• Quality Registers - more/accurate clinical information, outcomes

• Mandatory Cancer register – all cases of cancer are included

• Cause of Death register, mandatory

• Combined use of these registers = powerful tool

Good data available, but also some obvious gaps: No good data on breastcancer screening, pneumonia vaccinations, high need-high cost patients; primary care data (until now); difficulties to combine data from different parts of the system (legal aspects, ex social care – health care) …

NQRs have long been and are of great importance to us - without them, a muchbleaker picture.

Health Care in Numbers is SALARS and the Regions go to place for health care data. Many data sources. Accessible. Text presentation. Often continous reporting (monthly-quarterly). All data is public.

PROM-PREM data, population surveys

Wait times in non acutecars

Productivity, casecosting, KPP

Quality registries

Cost per inhabitants

Patient safety data

NBHWs health data statistics

Prevalence and incidence of diseases

Costs per inhabitant

Health careconsumption

The purpose of public reporting & of Health Care in Numbers

• Support Regions in locating quality problems

• Comparisons could stimulate improvement• Use professional pride as a driving force

• ”Political pride” - learn from others, avoid being a ”low quality – outlier”

• Transparency – data to inform public debate, media coverage

• Continous access to ”real time” data/fresh data when possible

• Offer a one point entry to health care data in Sweden

Quality in the health care system. Remeber - we have good data JUST for some (vital) parts/aspects of care– yellow spots. Grey spots – some data, but not good enough. And also large black areas – aspects/areas where much less data is available: Complex quality aspects, multimorbidity. We need to be humble. Wecant measure ”everything”.

An eagles flight over the Swedish healthcare system –data/graphs extracted from Health Care in Numbers late autumn 2018 or in 2019

A health care data /quality data tour:

Comparing regions - health systems

Health care costs - productivity

Health care costs per inhabitants, 2012-2018. Needs adjusted. 25 000-29 000 SEK or about 2500-2900 USD.Rising, as GDP is rising. Variation between Regions. Not as large variation as in the US?

Difficult-demanding to analyze the causes of this variation. Is it due to wage levels, other costs, productivity or over-underuse, variation of clinical quality? Willingness to tax? Tax rates – Regions decide.

No obvious pattern: Stockholm is high cost, as is rural Regions in the northernpart.

KPP-läget september 2019

Landsting/region Somatik Psykiatri Primärvård

Blekinge

Gävleborg

Kronoberg

Norrbotten

Sörmland

Värmland

Västernorrland

Östergötland

Halland

Skåne

Västerbotten

Västra Götaland

Kalmar

Uppsala

Västmanland

Dalarna

Jönköping

Örebro Slutenvård

Stockholm

Jämtland-Härjedalen

Gotland

Samlas ej in Case Costing – Kostnad per Patient, KPP i Swedish.

Selt reported costs, irrespective of reimburesmentmodel.

Most Regions now use global budgets, some DRG-based models, and none use Fee for service models.

Green = participate

Yellow = planning to participate

Red = No plan

Specialised somatic care (Hospitals) Psychiatric carePrimary Care (GPs, district nurses etc in Sweden)

Productivity: Cost per DRG-point 2018, selection of hospitals.

In inpatient hospital care only. Costs related to volyme/treated patients, adjusted.

National Case Costing model and database; Cost Per Patient (visit, procedure, admission)

Low cost = high productivity.

St Görans hospital – long tradition ofhigh productivity; now a private hospital butalso as a Region Stockholm hospital they wereconsidered being an efficient hospital – sincethe 90s…

University Hospitals often ”expensive”?

Not a perfect mesure, but relevant. Variations in how diagnosis is chosen and registeredaffects the outcome.

Burden of disease, public health – smoking, alkohol use etc

10 leading causes of health loss in Sweden:

• Ischemic heart disease• Low back pain• Stroke• Headache disorders • Diabetes• COPD• Falls• Depressive disorders• Lung cancer

Does our data (useful data) match the burden of disease? To some extent…

Preventable diseases – to whatextent?

Treatable diseases – Alzheimers; great burden, no real treatmentSource:

http://www.healthdata.org/

DALY – lost lifeyears and years with functional loss due to health problems – diseases

Most risk factors show a positive trend over time. Sometimes no good data – blood pressure, impaired kidney function in the population as a whole?

We live longer – which is eroding our pension system…

Vaccination, screening programmes

MPR-vaccination in kids - strong child healthtradition in Sweden since the 1930s (?).

MPR = Measles, mumps, rubella.

No good national data for mammography and influenza vaccinations among elderly –planning for this.

Health risk, personal habits:Self-reported daily smoking

10 % is daily smokers, falling steadily.

Variation between CCs and diminishingtrend – 7-12 %. (Note: broken X-axis)

Also population data for

• Obesity• Use of alcohol• Dental health• Psysical activity• Food intake – fruits, vegetables

Population health – self rated. Questionnaire. Response rate is falling – general trend. Also data per educational status (high, medium, low). Socio-economic variation more relevant than geographical.

Percentage persons with good general health, 73 % (left).

Percentage persons with loss of function due to mental health problems, 14% (right).

Health system efficiency, integrated care etc

• General ambition – strenghten primary care

• Support patients with chronic-long term conditions in out patient settings;

• Minimize early avoidable deaths

• Keep patients out of inpatient stays at hospitals

• Reduce avoidable care/use of ERs

• Reduce readmissions

• Minimize patients waiting in hospitals wards for places at nursing homes, return to own home

• Over-under use

Bed days per inhabitants.

Large variations – difficult to understand, to explain. Goodhealth or good health care?

Trend:Less use of in-hospital care. Falling number ofhospital beds. Shorter stays. More care in own home.

Sweden: Lowest number of acute care beds in OECD. 20 000 hospital beds, decreasing.

Well organized/resourceful social care function– nursing homes, support in own home etc

Readmission within 30 days– selected conditions, 65 years or older.

Variation 14-22; largervariation between hospitals.

We meause, but don’t usefor reimbursementpurposes.

Perhaps also relevant to study within 7 days

System level efficiency: Avoidable hospital care – admissions per 100 000 inhabitants.

Good primary/outpatient care could keep patients with certain conditions (heartfailure, COPD …) out of hospitals, to a degree.

Ready for discharge patients ; no further medical need – buttime spent in hospital, awaiting discharge.

A problem in many countries: Patients staying at hospital without strict medical need –just waiting to go home (withsupport) or to care home.

Reflect cooperation betweenhealth care and social caresector.

We measure time spent (ALOS) waiting in hospital, and also total amount/% of this unnecessaryhospital care.

Over- or underuse: Percentage of newborn babiesadmitted to neonatal care. Variation 6-15 procent. Due to”culture”, medical need, available capacity?

Variation ofresource use, health careconsumption –often large.

We need to use this data in betterways.

Patient experiences - PREM

• National patient surveys; bi annual• Primary care visits

• Emergency Room visits

• Hospital outpatient visits

• Hospital inpatient cara – admissions

• Huge volume of surveys, abt 200 000

• Response rate slowly falling, no about 50%. Implications?

• Soon also condition based surveys and PROMs – deliverys is pilot• 110 000 (all) pregnant women will be invited to answer 3 surveys – before,

just after and a period after the delivery. A new infrastructure – important.

Patient experiences and population trust in health care: 11 indicators A-J, all 21 Regions compared. Red colour = worse outcome compared to median.

Regioner A B C D E F G H I J

Stockholm 81,4 58,4 65,1 58,3 62,4 79,8 79,9 90,2 89,0 85,9

Uppsala 82,3 65,1 72,3 61,4 64,7 81,0 79,6 90,0 86,2 85,7

Sörmland 82,2 57,3 60,2 59,2 63,8 80,8 79,8 87,4 83,9 87,7

Östergötland 82,1 68,2 75,0 58,5 60,4 77,2 83,0 89,9 89,2 88,6

Jönköpings län 87,3 74,3 76,0 66,8 55,2 82,0 84,4 90,7 89,6 87,0

Kronoberg 83,5 67,3 71,6 61,9 66,9 82,2 86,7 89,9 88,4 87,6

Kalmar län 87,3 72,3 78,8 67,7 60,2 82,1 87,3 91,4 91,2 88,5

Gotland 83,5 65,4 77,0 56,0 73,5 76,8 88,3 90,4 92,6 88,4

Blekinge 81,0 58,1 64,0 58,0 60,0 76,4 74,1 90,3 88,0 87,4

Skåne 80,1 57,7 65,8 55,8 62,2 79,0 81,5 89,6 87,0 86,8

Halland 86,3 68,0 74,4 68,3 63,3 84,4 83,9 92,1 89,0 89,7

Västra Götaland 79,0 57,4 65,3 53,4 64,7 77,4 81,7 89,5 85,8 85,8

Värmland 79,0 59,7 67,2 53,4 64,6 78,1 81,7 89,5 88,8 86,6

Örebro län 84,2 68,1 76,8 57,8 63,3 76,6 86,0 89,4 89,8 87,4

Västmanland 83,3 63,7 71,0 56,3 64,4 75,7 83,2 89,9 87,2 82,7

Dalarna 81,2 61,7 70,5 61,3 61,5 78,8 88,4 90,8 90,2 85,6

Gävleborg 82,2 54,7 57,0 60,9 61,1 80,1 81,8 89,1 85,8 87,6

Västernorrland 78,9 51,2 55,7 54,8 62,5 77,8 87,0 89,7 88,2 84,2

Jämtland Härjedalen 81,8 59,6 66,5 62,0 70,9 83,5 87,2 89,5 89,9 86,8

Västerbotten 82,4 67,6 73,4 62,3 73,7 81,2 88,0 89,7 90,6 85,7

Norrbotten 76,7 54,0 61,7 56,0 59,3 78,0 88,5 88,4 89,4 86,6

Riket 81,4 60,7 67,5 58,2 63,1 79,5 82,8 89,9 88,0 86,7

A Tillgång til l den hälso- och sjukvård man behöver,

%

B Förtroende för sjukvården i sin helhet, %

C Förtroende för sjukhus, %

D Förtroende för vård- eller hälsocentral, %

E Förtroende för 1177 Vårdguiden via telefon, %

F Positivt helhetsintryck hos patienter som besökt

en primärvårdsmottagning, index

G Positivt helhetsintryck hos patienter som besökt

en akutmottagning, index

H Positivt helhetsintryck hos patienter som besökt en

öppenvårdsmottagning på sjukhus, index

I Positivt helhetsintryck hos patienter som

varit inlagd på sjukhus, index

J Positivt helhetsintryck hos patienter standardiserat

vårdförlopp cancer, index

Patient experiences, PREM.

Opinions about hospital out-patient visit. 90 % is happy with the visit, all in all.

Patients seem to be happy. Small differences betweenRegions. OK?

But….

National Patient Survey. Result for All in all satisfaction with visit. All 1200 primarycare centers in Sweden, sorted by Regions. Small variation betweens CCs, but largevariation between centers. Data most useful at local levels of health care

Wait times – access to care in time

• 15 years tradition: wait times database, national wait time guarantees

• Non acute, non chronic care most often

• Wait times to first visit /new health care problem• Primary care• Hospital visits• ERs at hospitals (hours)

• Wait times to surgery – specifik operations

• Later years: Focus on cancer wait times• Date for well founded suspicion – start specialist diagnostics - time to

treatment/no treatment (no cancer)

Wait times.

Percentage ot patients treated within target of90 days efter decision to operate. Selection ofRegions

Slightly downwards trend. Much politicaldebate, considered a major problem by many.

Comprehensive data collection.

Patient safety

Patient safety: Use of WHO check list for safe surgery – 76% Source: Quality register covering most large operations in Sweden. Upward trend, more hospitals participate over time.

Regions; third quarter of 2019.

Use of WHO checklist – safe surgery.

Region Sörmlands threehospitals with op theaters

Nyköpings Hospital over time.

Patient safety. Percentage patients admitted to hospital without access to ordinary ward/bed. 5,9 % of all patients. Worrying, long term trend.

Below - monthly data, all 70 hospitals. Colorful, chaotic.

Patient safety. Vaginal tears of category 3 and 4, in vaginal deliverys. Latest: 1,7 %Hotly debated in Sweden – but now at least there is a positiv trend. 50 % less women affected compared to 2014. Note: Data up to third quarter 2018 (July-Sept). This could be a genuine effect of a focussed effort at many hospitals.

We have quarterlydata for a numberof large qualityregisters:

Heart attackStrokeDiabetesICU-carePalliative careCancer

Hospital acquired infections, rates – Regions, Fall 2018, variation 1-10 %, Riket/Sweden = 4,6%

Not registry based data, but EHR-based. Ex post study of selection ofpatients/EHRs.

Rewiev of EHRs - perhaps to labourintensive?

Reliable results - is the method goodenough?

No strong trend over time .

A health care data /quality data tour:

National Program Groups; condition based quality monitoring

Diabetes

General

• National guidelines – SoS/National Board of Health &B Welfare

• Targets, expressed through indicators – quality measurement

• Quality Register – National Diabetes Register, NDR • Impressive, only QR in primary care with almost complete coverage

• Tradition of setting national standards, support improvement

• Transparent public reporting – per each primary care central

• Tradi

• 100 % of hospital-based diabetes centers

• > 90% of primary care/general practice centers, about1200

• Covers about 90% of all individuals with diabetes in Sweden

• Direct transfer of relevant patient data (via EHR-extractingsoftware)

• Results per center and Region are public and easy to access

• Funding

• Swedish Association of Local Authorities and Regions

• Region Western Sweden

NDR, National Diabetes Registry

Number of patients in NDR10 million inhabitants, < 5% diabetes prevalence. 2018 about 450 000 patients registered every year

Diabetes. Percentage of patients with BP less than the treatment goal 140/85 –note that 2015 almost all patients are included, which was not the case in 1996. Probably a relative success – but still a long way to go.

5-year risk for cardiovascular disease, NDR risk model. Patients with type 1 diabetes at specialist clinic, age 30 – 65 by country

A good (even if calculated) outcome measure.

Based on levels of HbA1c, blood pressure, lipid levels etc.

Results for each Region. Västerbotten – topposition.

NDRs risk model couldalso be used for individualpatients – decision support

National Diabetes Register

A performance dashboardfor region Dalarna, primarycare.

12 indicators; red and green scores (compared to Sweden results).

Blood pressure, foot/eyeexams, blood glucose levels, smoking status, psysicalactivity etc

Results accessible on the web for all; even per primarycare center.

Transparency! But also – ofcourse – difficulties for the general public to interpret quality data.

Patient profiles in NDR – a tool for empowering patients

SWEDISH NATIONAL

DIABETES REGISTER

Patients can log in to theirpersonal accounts at NDR and watch their profiles

Health risks – blood pressure in persons with diabetes typ 2.

Percentage persons reachingtreatment target (<140/85 mmHg).

Green line = national target from Socialstyrelsen.

One-two Regions is close.

We have no national register for blood pressure follow up in the general population, but for somedisease groups, thus – secondaryprevention:

• Diabetes• Stroke• Myorcardial infarction• Renal disease• Etc

Diabetes care – goal fulfillment 2018

A

Blodsocker (HbA1c ≤ 70 mmol/mol) vid diabetes

– primärvård, %

B

Blodsocker (HbA1c ≤ 70 mmol/mol) vid diabetes

typ 1 – medicinklinik, %

C

Blodtryck < 140/85 mmHg vid diabetes –

primärvård, %

D

Blodtryck < 140/85 mmHg vid diabetes typ 1 –

medicinklinik, %

E Fotundersökning vid diabetes – primärvård, %

F

Fotundersökning vid diabetes typ 1 –

medicinklinik, %

G Icke-rökare vid diabetes – primärvård, %

H Icke-rökare vid diabetes typ 1 – medicinklinik, %

Landsting/regioner A B C D E F G H

Stockholm 89,5 78,8 55,2 73,2 86,7 85,6 85,1 87,9

Uppsala 89,2 80,8 54,1 73,5 96,2 91,2 87,2 87,4

Sörmland 89,3 77,0 56,3 77,3 94,1 92,5 88,7 88,5

Östergötland 89,3 79,1 64,7 81,4 90,6 96,5 89,0 90,1

Jönköping 89,7 76,2 56,4 78,3 93,7 92,9 89,8 92,3

Kronoberg 89,1 80,2 54,0 72,6 92,2 88,8 87,8 91,4

Kalmar 90,9 79,9 51,1 68,8 87,4 89,0

Gotland 90,4 85,3 50,9 73,4 86,1 97,0 88,2 86,7

Blekinge 89,6 83,1 47,2 75,9 94,0 96,1 87,9 89,7

Skåne 90,1 78,2 49,8 73,1 84,4 93,1 86,2 87,2

Halland 93,3 84,7 56,7 77,4 87,4 91,5 88,2 89,6

Västra Götaland 89,8 82,8 55,6 77,5 85,5 85,1 86,6 91,0

Värmland 89,0 78,2 54,5 75,1 73,8 87,0 94,4 90,0

Örebro 91,8 83,8 57,0 74,0 95,5 85,7 87,4 92,1

Västmanland 90,7 79,9 53,7 74,4 89,1 95,8 87,2 87,2

Dalarna 90,7 79,5 54,9 73,7 90,7 88,8 87,6 89,2

Gävleborg 88,2 78,4 53,7 73,5 85,4 76,6 86,7 91,7

Västernorrland 89,5 83,4 55,5 65,5 92,9 96,2 89,2 92,6

Jämtland Härjedalen 91,2 82,2 52,5 71,4 96,6 96,0 88,3 92,1

Västerbotten 92,4 76,7 60,5 73,2 80,6 84,6 91,5 95,4

Norrbotten 87,1 76,0 53,5 72,2 82,6 89,8 86,3 89,1

Målnivå utgiven av

Socialstyrelsen 90,0 80,0 65,0 90,0 99,0 99,0 95,0 95,0

Ambitious goals…results in a sad

overall impression of diabetes quality.

A-H – common process and outcome

indicators. BP, Glucose, Foot exam,

smoking.

Extra: Sweden vs Intermountain HC – diabetes quality, 2012

Five indicators from IHCsbundle.

IHC had a somewhat bettertotal resultat, but Sweden included a larger proportion ofall diabetes patients and hadless missing values…so, perhaps inconclusive?

But one conclusion is bothrelevant and notable, for bothsystems: Few patients reach all goals.

8.0

9.4

11.7

11.8

12.1

12.6

12.7

12.7

13.1

14.1

14.2

14.7

15.0

15.9

16.0

16.1

16.8

16.9

17.8

21.3

24.8

26.5

0.0 5.0 10.0 15.0 20.0 25.0 30.0

Region Skåne

Västmanland

Örebro

Östergötland

Värmland

Stockholm

Gävleborg

Uppsala

Gotland

SWEDEN

Västerbotten

Västernorrland

Kalmar

Blekinge

Dalarna

Jönköping

Norrbotten

Sörmland

Västra Götaland

Halland

Jämtland

Kronoberg

IHC diabetes bundle for regions in Sweden - % patients fulfilling all five requirements, 2012.

IH 16,6 %

The bundle model is settinghigh standards, demanding.

When we study one goal-indicator at a time, resultslook better – but the bundlemodel is adding knowedge to our assessment of diabetes care.

Muscoloskeletal diseases

• National Guidelines for arthritis

• Good Quality Registries – also for fractures, in later years• Hip arthroplasty

• Knee

• Hip fractures

• Arthritis in knee and hip, primary care/psyhiotherapy

• started 1979• 100% coverage• 98-99% completeness• web based 1999• public reporting 1999 • PROMs since 2002• lowest reported reop frequency

(in world history?)

Fig. 4 Survivorship curves (with 95% confidence intervals) for total hip arthroplasty implants in the United States, Sweden, and Norway.

Kurtz S. M. et.al. J Bone Joint Surg 2007:89:144-151

saving 1 billion SEK in 7 yearscompared to revision rate in USA

”Surviving” implants, not surviving patients – to be noted.

High quality care saves usmoney – this is a way ofshowing the benefits ofQuality Registers.

Outcomes per clinic –reported every year in printed report.

8 quality indicators, in comparison with the national average.

In total about 100 clinics

Huge expansion of hip replacements & good results (survival rates) – but 1 in 10 patients is unsure about outcome or disappointed after 1 year

How to find the patients with less chances of success – beforesurgery? Predict outcomes? Decision support system under way - a tool for dialogue with patients

Primary total hip replacement 1968-2017 - volume

Guidelines, arthritis: Patients should participate in a ”hip school” before decision about hip operation (same for knee).

Psysiotherapists organize.

Evaluate the need, keep function; postpone first operation as long as possible; revisions (2nd op) oftenworse results.

Slow but steady progress.

Over- and underuse? Knee arthroplasty per inhabitants. Standard procedure – still variation. Obesity could be a factor.

Cardiovascular disease - heart disease

• Guidelines since 15 years

• Good QRs – Swedeheart among them, a flagship QR

• Strong research tradition;

Incidence and deaths in heart attack – per 100 000 inhabitants. Strong, pervasive trend. Same pattern for stroke.

Regions. Incidence of heartattack. Age- and sex adjusted.

Quite big differences betweentop-bottom Regions.

Reflecting differences in healthin general, socio-economicvariation.

In general good data for incidence in well defineddiseases – due to mandatorynational patient register, PAR.


1990

2017

28-day case fatality (% deaths within 28 days) –AMI/heart attack

Sweden’s 21 health care regions, 1990 and 2017

Age & sex standardised

A success story, but….


Hospitals. Proportion of heart attack patients reaching 4 out of 4 prevention goals:

• Systolic blood pressure < 140 mmHg • LDL-cholesterol <1.8 mmol/L (≥ 50 %

reduction from baseline, or apoB < 0.8 g/L) • No daily smoking• Participation in a physical exercise program at

the 2nd follow-up)

…but there is more to do. Secondary prevention moreand more important.

Goal fulfilment of national targets. Time to treatmentafter arrival at hospital in heartattack, percentage patients within the timelimits. Green line = target , 90 %

Targets exists for a growing groupof indicators from Socialstyrelsen.

The target setting procedure takesplace when national guidelines areproduced.

Also Quality Registers set targets.

Neurological diseases – Stroke

• Guidelines since at least 15 years

• QR – Riksstroke, one of the flagship registries

• Good data on acute care, drug use for secondary prevention • Long term rehabilitation – less good/no data

Antocoagulants after stroke and atrial fibrillation.

Selection of hospitals; data upto Q3 2018.

Stroke preventing treatment. Great success over the last years.

Important guality aspect i national guidelines.

Many hospitals reaches the target level 70 %.

End note

5 year survival in breast cancer – a result of a conscious effort: Clinical care programs, national guidelines, relevant highquality data, a quality register and active monitoring of results. + Determined clinicians and teams.

End note: This is the preferred outcomeof the new system for knowledge basedhealth care management in Sweden: Stable, ongoing progress, less variation over time.

Policy aspects – discussion

• Focus on provider (clinical) quality vs population health/prevention?

• Ranking of healtcare systems/providers – pros and cons?

• Judge/evaluate or support improvement?

• Process vs outcome indicators?

• Data quality – how strict criteria? • We are ”liberals” – we publish even when data quality is close to low…

• Simple or nuanced (case mix adjustment etc) presentation?

• From ex post follow up & monitoring to decision support?

• What have we learnt in Sweden – with 10 -15 years of experience from performance measurement and public reporting?

quality measurement and public reporting of quality data in …€¦ · short version of the the...

Documents