Measuring, Reporting, and Rewarding Quality of Care in 5 Nations: 5 Policy Levers to Enhance Hospital Quality Accountability

Effect on hospital incentive payments and quality performance of a hospital pay for performance (P4P) programme in Belgium

BACKGROUND

Belgium initiated a hospital pay for performance (P4P) programme after a decade of fixed bonus budgets for "quality and safety contracts". This study examined the effect of P4P on hospital incentive payments, performance on quality measures, and the association between changes in quality performance and incentive payments over time.

METHODS

The Belgian government provided information on fixed bonus budgets in 2013-2017 and hospital incentive payments as well as hospital performance on quality measures for the P4P programmes in 2018-2020. Descriptive analyses were conducted to map the financial repercussion between the two systems. A difference-in-difference analysis evaluated the association between quality indicator performance and received incentive payments over time.

RESULTS

Data from 87 acute-care hospitals were analyzed. In the transition to a P4P programme, 29% of hospitals received lower incentive payments per bed. During the P4P years, quality performance scores increased yearly for 55% of hospitals and decreased yearly for 5% of hospitals. There was a significant larger drop in incentive payments for hospitals that scored above median with the start of the P4P programme.

CONCLUSIONS

The transition from fixed bonus budgets for quality efforts to a new incentive payment in a P4P programme has led to more hospitals being financially impacted, although the effect is marginal given the small P4P budget. Quality indicators seem to improve over the years, but this does not correlate with an increase in reward per bed for all hospitals due to the closed nature of the budget.

Who Benefits From Hip Arthroplasty or Knee Arthroplasty? Preoperative Patient-reported Outcome Thresholds Predict Meaningful Improvement

BACKGROUND

Hip arthroplasty (HA) and knee arthroplasty (KA) are high-volume procedures. However, there is a debate about the quality of indication; that is, whether surgery is truly indicated in all patients. Patient-reported outcome measures (PROMs) may be used to determine preoperative thresholds to differentiate patients who will likely benefit from surgery from those who will not.

QUESTIONS/PURPOSES

(1) What were the minimum clinically important differences (MCIDs) for three commonly used PROMs in a large population of patients undergoing HA or KA treated in a general orthopaedic practice? (2) Do patients who reach the MCID differ in important ways from those who do not? (3) What preoperative PROM score thresholds best distinguish patients who achieve a meaningful improvement 12 months postsurgery from those who do not? (4) Do patients with preoperative PROM scores below thresholds still experience gains after surgery?

METHODS

Between October 1, 2019, and December 31, 2020, 4182 patients undergoing HA and 3645 patients undergoing KA agreed to be part of the PROMoting Quality study and were hence included by study nurses in one of nine participating German hospitals. From a selected group of 1843 patients with HA and 1546 with KA, we derived MCIDs using the anchor-based change difference method to determine meaningful improvements. Second, we estimated which preoperative PROM score thresholds best distinguish patients who achieve an MCID from those who do not, using the preoperative PROM scores that maximized the Youden index. PROMs were Hip Disability and Osteoarthritis Outcome Score-Physical Function short form (HOOS-PS) (scored 0 to 100 points; lower indicates better health), Knee Injury and Osteoarthritis Outcome Score-Physical Function short form (KOOS-PS) (scored 0 to 100 points; lower indicates better health), EuroQol 5-Dimension 5-level (EQ-5D-5L) (scored -0.661 to 1 points; higher indicates better health), and a 10-point VAS for pain (perceived pain in the joint under consideration for surgery within the past 7 days) (scored 0 to 10 points; lower indicates better health). The performance of derived thresholds is reported using the Youden index, sensitivity, specificity, F1 score, geometric mean as a measure of central tendency, and area under the receiver operating characteristic curve.

RESULTS

MCIDs for the EQ-5D-5L were 0.2 for HA and 0.2 for KA, with a maximum of 1 point, where higher values represented better health-related quality of life. For the pain scale, they were -0.9 for HA and -0.7 for KA, of 10 points (maximum), where lower scores represent lower pain. For the HOOS-PS, the MCID was -10, and for the KOOS-PS it was -5 of 100 points, where lower scores represent better functioning. Patients who reached the MCID differed from patients who did not reach the MCID with respect to baseline PROM scores across the evaluated PROMs and for both HA and KA. Patients who reached an MCID versus those who did not also differed regarding other aspects including education and comorbidities, but this was not consistent across PROMs and arthroplasty type. Preoperative PROM score thresholds for HA were 0.7 for EQ-5D-5L (Youden index: 0.55), 42 for HOOS-PS (Youden index: 0.27), and 3.5 for the pain scale (Youden index: 0.47). For KA, the thresholds were 0.6 for EQ-5D-5L (Youden index: 0.57), 39 for KOOS-PS (Youden index: 0.25), and 6.5 for the pain scale (Youden index: 0.40). A higher Youden index for EQ-5D-5L than for the other PROMs indicates that the thresholds for EQ-5D-5L were better for distinguishing patients who reached a meaningful improvement from those who did not. Patients who did not reach the thresholds could still achieve MCIDs, especially for functionality and the pain scale.

CONCLUSION

We found that patients who experienced meaningful improvements (MCIDs) mainly differed from those who did not regarding their preoperative PROM scores. We further identified that patients undergoing HA or KA with a score above 0.7 or 0.6, respectively, on the EQ-5D-5L, below 42 or 39 on the HOOS-PS or KOOS-PS, or below 3.5 or 6.5 on a 10-point joint-specific pain scale presurgery had no meaningful benefit from surgery. The thresholds can support clinical decision-making. For example, when thresholds indicate that a meaningful improvement is not likely to be achieved after surgery, other treatment options may be prioritized. Although the thresholds can be used as support, patient preferences and medical expertise must supplement the decision. Future studies might evaluate the utility of using these thresholds in practice, examine how different thresholds can be combined as a multidimensional decision tool, and derive presurgery thresholds based on additional PROMs used in practice.

CLINICAL RELEVANCE

Preoperative PROM score thresholds in this study will support clinicians in decision-making through objective measures that can improve the quality of the recommendation for surgery.

Barriers and enablers to the implementation of patient-reported outcome and experience measures (PROMs/PREMs): protocol for an umbrella review

BACKGROUND

Patient-reported outcome and experience measures (PROMs and PREMs, respectively) are evidence-based, standardized questionnaires that can be used to capture patients' perspectives of their health and health care. While substantial investments have been made in the implementation of PROMs and PREMs, their use remains fragmented and limited in many settings. Analysis of multi-level barriers and enablers to the implementation of PROMs and PREMs has been hampered by the lack of use of state-of-the-art implementation science frameworks. This umbrella review aims to consolidate available evidence from existing quantitative, qualitative, and mixed-methods systematic and scoping reviews covering factors that influence the implementation of PROMs and PREMs in healthcare settings.

METHODS

An umbrella review of systematic and scoping reviews will be conducted following the guidelines of the Joanna Briggs Institute (JBI). Qualitative, quantitative, and mixed methods reviews of studies focusing on the implementation of PROMs and/or PREMs in all healthcare settings will be considered for inclusion. Eight bibliographical databases will be searched. All review steps will be conducted by two reviewers independently. Included reviews will be appraised and data will be extracted in four steps: (1) assessing the methodological quality of reviews using the JBI Critical Appraisal Checklist; (2) extracting data from included reviews; (3) theory-based coding of barriers and enablers using the Consolidated Framework for Implementation Research (CFIR) 2.0; and (4) identifying the barriers and enablers best supported by reviews using the Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approach. Findings will be presented in diagrammatic and tabular forms in a manner that aligns with the objective and scope of this umbrella review, along with a narrative summary.

DISCUSSION

This umbrella review of quantitative, qualitative, and mixed-methods systematic and scoping reviews will inform policymakers, researchers, managers, and clinicians regarding which factors hamper or enable the adoption and sustained use of PROMs and PREMs in healthcare settings, and the level of confidence in the evidence supporting these factors. Findings will orient the selection and adaptation of implementation strategies tailored to the factors identified.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42023421845.

Strengthening provider accountability: A scoping review of accountability/monitoring frameworks for quality of RMNCH care

Increasing health providers' accountability is an important element in improving quality of care (QoC) for reproductive, maternal, neonatal, and child health (RMNCH), so as to improve health outcomes of the population in many low- and middle-income countries (LMICs). Implemented RMNCH monitoring initiatives vary in their settings, methods of data collection, and indicators selected for monitoring. The purpose of this study is to evaluate the monitoring/accountability frameworks used by key global monitoring initiatives and provide insights for countries to develop context-customized indicators for RMNCH monitoring and accountability in middle-income countries. The authors conducted a scoping review of key global monitoring initiatives on their monitoring/accountability framework and associated indicators. Data was extracted into a spreadsheet template for analysis. Monitoring/accountability frameworks corresponding to the selected global RMNCH initiatives were described, analyzed, and then categorized the monitoring indicators used by the initiatives according to the type of indicators, quality domains, monitoring levels, and type of services. The results showed that all frameworks regarded developing quality indicators and their monitoring as important elements of accountability and emphasized the role of health systems blocks as inputs for QoC. The researchers demonstrated the importance of measuring quality through both condition-specific and general health system indicators. However, given the different purposes of global monitoring initiatives, the indicators they used varied. We found a lack of indicators measuring QoC of reproductive health. In terms of quality domains, the timeliness and efficiency of RMNCH services were neglected, as few of these indicators were selected for monitoring. Global monitoring initiatives provide valuable frameworks for countries to understand which key indicators need to be tracked to achieve global objectives and develop the foundation for their own accountability/monitoring systems. Gaps in quality indicator design and use emphasize countries need to build on what the global initiatives have achieved to systematically examine quality concerns, develop a tailored and effective accountability/monitoring framework, and improve population health.

Changing roles of health insurers in France, Germany, and the Netherlands: any lessons to learn from Bismarckian systems?

Bismarckian health systems are mainly governed by social health insurers, but their role, status, and power vary across countries and over time. We compare the role of health insurers in three distinct social health insurance systems in improving health systems' efficiency. In France, insurers work together as a single payer within a highly regulated context. Although this gives insurers substantial bargaining power, collective negotiations with providers are highly political and do not provide appropriate incentives for efficiency. Both Germany and the Netherlands have introduced competition among insurers to foster efficiency. However, the rationale of insurer competition in Germany is unclear because contracts are mostly concluded at a collective level and individual insurers have little power to influence health system efficiency. In the Netherlands, insurer competition is substantially more effective, but primarily focused on price and cost containment. In all three countries, the role of insurers has been transforming slowly to respond to common challenges of assuring care quality and continuity for an ageing population. To assure sustainability, they need to ensure that care providers cooperate with the same quality and efficiency objectives, but their capacity to do so has been limited by insufficient support to enforce public information on provider quality.

Using Comorbidity Statistical Modeling to Predict Inpatient Mortality: Insights Into the Burden on Hospitalized Patients

Background The expenditures of the United States for healthcare are the highest in the world. Assessment of inpatient disease classifications associated with death can provide useful information for risk stratification, outcome prediction, and comparative analyses to understand the most resource-intensive chronic illnesses. This project aims to adapt a comorbidity index model to the National Inpatient Sample (NIS) database of 2020 to predict one-year mortality for patients admitted with select International Classification of Diseases, 10th Edition (ICD-10) codes of diagnoses. Methodology A retrospective cohort study analyzed mortality with comorbidity using the Charlson comorbidity index model (CCI) in a sample population of an estimated 5,533,477 adult inpatients (individuals aged ≥18 years) obtained from the National Inpatient Database for 2020. A multivariate logistic regression model was constructed with in-hospital mortality as the outcome variable and identifying predictor variables as defined by the Clinical Classifications Software Refined Variables (CCSR) codes for selected ICD-10 diagnoses. Descriptive statistics and the base logistic regression analyses were conducted using SAS statistical software version 9.4 (SAS Institute, Cary, NC, USA). To avoid overpowering, a subsample (n = 100,000) was randomly selected from the original dataset. The initial CCI assigned weights to ICD-10 diagnoses based on the associated risk of death, and conditions with the greatest collective weights were included in a subsequent backward stepwise logistic regression model. Results The results of the base CCI regression analysis revealed 16 chronic conditions with P-values <0.20. Anemia (1,567,081, 28.32%), pulmonary disease (asthma, chronic obstructive pulmonary disease [COPD], pneumoconiosis; 1,210,892, 21.88%), and diabetes without complications (1,077,239, 19.47%) were the three most prevalent conditions associated with inpatient mortality. Results of the backward stepwise regression analysis revealed that severe liver disease/hepatic failure (adjusted odds ratio [aOR] 10.50; 95% confidence interval [CI] 10.40-10.59), acute myocardial infarction (aOR 2.85; 95% CI 2.83-2.87) and malnutrition (aOR 2.15, 95% CI 2.14-2.16) were three most important risk factors and had the highest impact on inpatient mortality (P-value <0.0001). The concordance statistic (c-statistic) or the area under the curve (AUC) for the final model was 0.752. Conclusions The CCI model proved to be a valuable approach in categorizing morbidity classifications associated with the greatest risk of death using a national sample of hospitalized patients in 2020. Study findings provide an objective approach to compare patient populations that bear important implications for healthcare system improvements, clinician treatment approaches, and ultimately decision decision-makers poised to influence advanced models of care and prevention strategies that limit disease progression and improve patient outcomes.

A composite measure for patient-reported outcomes in orthopedic care: design principles and validity checks

BACKGROUND

The complex, multidimensional nature of healthcare quality makes provider and treatment decisions based on quality difficult. Patient-reported outcome (PRO) measures can enhance patient centricity and involvement. The proliferation of PRO measures, however, requires a simplification to improve comprehensibility. Composite measures can simplify complex data without sacrificing the underlying information.

OBJECTIVE AND METHODS

We propose a five-step development approach to combine different PRO into one composite measure (PRO-CM): (i) theoretical framework and metric selection, (ii) initial data analysis, (iii) rescaling, (iv) weighting and aggregation, and (v) sensitivity and uncertainty analysis. We evaluate different rescaling, weighting, and aggregation methods by utilizing data of 3145 hip and 2605 knee replacement patients, to identify the most advantageous development approach for a PRO-CM that reflects quality variations from a patient perspective.

RESULTS

The comparison of different methods within steps (iii) and (iv) reveals the following methods as most advantageous: (iii) rescaling via z-score standardization and (iv) applying differential weights and additive aggregation. The resulting PRO-CM is most sensitive to variations in physical health. Changing weighting schemes impacts the PRO-CM most directly, while it proves more robust towards different rescaling and aggregation approaches.

CONCLUSION

Combining multiple PRO provides a holistic picture of patients' health improvement. The PRO-CM can enhance patient understanding and simplify reporting and monitoring of PRO. However, the development methodology of a PRO-CM needs to be justified and transparent to ensure that it is comprehensible and replicable. This is essential to address the well-known problems associated with composites, such as misinterpretation and lack of trust.

Introduction of quality indicators in German hospital capacity planning - Do results show an improvement in quality?

In Germany, the use of quality data to support hospital capacity planning was introduced in 2017. On behalf of the Federal Joint Committee, IQTIG suggested 11 quality indicators and developed a program on how to collect, evaluate and report data for the clinical areas gynaecological surgery, obstetrics and breast surgery. By analysing data from 2015 to 2021, effects of the introduction of the program on indicator results, statistical discrepancies and impact on care quality are examined. Effects on capacity planning are discussed. Since the program started, indicator results improved in all clinical areas, and statistical discrepancies and the number of assessments with insufficient quality decreased due to enhanced adherence to quality standards and data validity. Effects on capacity planning or the allocation of hospitals have not occurred. Thus, a change of the legal basis to allow a better link between quality and hospital planning is recommended. The approach to use quality data on hospital regulation in Germany is evolving. The current hospital reform in Germany also addresses other approaches to quality-based regulation. Already now, there have been clear improvements in specific indicators as well as lessons for quality assurance and its link to capacity planning provided by the program, which are also applicable to other countries.

Transforming Health Care Delivery towards Value-Based Health Care in Germany: A Delphi Survey among Stakeholders

Value-based healthcare (VBC) represents one strategy to meet growing challenges in healthcare systems. To date, VBC is not implemented broadly in the German healthcare system. A Delphi survey was conducted to explore stakeholders' perspectives on the relevance and feasibility of actions and practices related to the implementation of VBC in the German healthcare system. Panellists were selected using purposive sampling. Two iterative online survey rounds were conducted which were preceded by a literature search and semi-structured interviews. After two survey rounds, a consensus was reached on 95% of the items in terms of relevance and on 89% of the items regarding feasibility. The expert panels' responses were in favor of the presented actions and practices of VBC in 98% of items for which consensus was found (n = 101). Opposition was present regarding the relevance of health care being provided preferably in one location for each indication. Additionally, the panel considered inter-sectoral joint budgets contingent on treatment outcomes achieved as not feasible. When planning the next steps in moving towards a value-based healthcare system, policymakers should take into account this study's results on stakeholders' perceptions of the relative importance and feasibility of VBC components. This ensures that regulatory changes are aligned with stakeholder values, facilitating greater acceptance and more successful implementation.

Public Reporting Of Hospital Quality Measures Has Not Led To Overall Quality Improvement: Evidence From Germany

Hospital quality has been measured and made publicly available for decades in the US and for more than a decade in Germany, as part of an effort to help those countries achieve quality improvement. The German hospital market presents a unique opportunity to examine the relationship between public reporting and quality improvement in the absence of performance-linked payment incentives in a high-income country. We considered quality indicators from several important categories of health services provided in hospitals (hip, knee, obstetrics, neonatology, heart, neck artery surgery, pressure ulcers, and pneumonia), using structured hospital quality reports from the period 2012-19. Our findings support the idea that public reporting provides a quality benchmark and prevents the provision of very low quality health care services, suggesting that imposing financial punishment on low performers is not necessary and may hinder quality improvement and aggravate health disparities. Although hospitals' intrinsic motivation and market forces play roles in improving quality, they are not sufficient to maintain the quality of high-performing hospitals. Therefore, in addition to rewarding high-performing institutions, aligning quality incentives with the intrinsic professional values of clinical care may be useful in achieving quality improvement.

The use of patient-reported outcome and experience measures for health policy purposes: A scoping review in oncology

The systematic use of patient-reported measures (PRMs) [i.e., patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs)] is advocated as an effective way to improve care practices. However, whether PRMs can lead to the performance assessment of healthcare organisations (HCOs) through valid quality indicators (QIs) for national purposes (i.e., public reporting and paying for performance) is open to debate. This study undertakes a scoping review to examine the use of PRMs as QIs for health policy purposes and to identify the challenges faced in the emblematic case of oncology. According to PRISMA guidelines, published papers, websites and reports published by national and international initiatives were analysed using five online databases (Web of Science, Scopus, PubMed, JSTOR and Google Advanced Search), and then studied using the same keywords. We selected 61 articles and 19 websites/reports and identified 29 PREMs and 48 PROMs from 14 countries and two international initiatives that routinely used them as QIs for HCOs' comparisons. Four types of barriers to this specific use were identified relating to the definition of a standard set, scientific soundness, data collection, and the actionability of such measures. Despite current developments, different barriers still must be overcome before PRMs can be used for health policy purposes in oncology. Future research is needed to ensure that valid QIs related to PRMs are applied at a national level.

The Association between Bundled Payment Participation and Changes in Medical Episode Outcomes among High-Risk Patients

Background: Bundled payments for medical conditions are associated with stable quality and savings through shorter skilled nursing facility (SNF) length of stay. However, effects among clinically higher-risk patients remain unknown. Objective: To evaluate whether the association between participation in bundled payments for medical conditions and episode outcomes differed for clinically high-risk versus other patients. Design: Retrospective difference-in-differences analysis; Participants: 471,421 Medicare patients hospitalized at bundled payment and propensity-matched non-participating hospitals. Exposures were 5 measures of clinically high-risk groups: advanced age (>85 years old), high case-mix, disabled, frail, and prior institutional post-acute care provider utilization. Main Measures: Primary outcomes were SNF length of stay and 90-day unplanned readmissions. Secondary outcomes included quality, utilization, and spending measures. Key Results: SNF length of stay was differentially lower among frail patients (aDID −0.4 days versus non-frail patients, 95% CI −0.8 to −0.1 days), patients with advanced age (aDID −0.8 days versus younger patients, 95% CI −1.2 to −0.3 days), and those with prior institutional post-acute care provider utilization (aDID −1.1 days versus patients without prior utilization, 95% CI −1.6 to −0.6 days), compared to non-frail, younger, and patients without prior utilization, respectively. BPCI participation was also associated with differentially greater SNF LOS among disabled patients (aDID 0.8 days versus non-disabled patients, 95% CI 0.4 to 1.2 days, p < 0.001). Bundled payment participation was not associated with differential changes in readmissions in any high-risk group but was associated with changes in secondary outcomes for some groups. Conclusions: Changes under medical bundles affected, but did not indiscriminately apply to, high-risk patient groups.

Internal Operational Metrics and Center for Medicare and Medicaid Services Hospital Compare Quality Ratings

ABSTRACT

The Center for Medicare and Medicaid Services (CMS) has made several refinements to their model for calculating hospital quality star ratings (Hospital Compare) amidst criticism and evidence of bias against some institutions. We argue that the CMS model does align with important internal quality metrics and encourage a measured approach to redesign, potentially using categorizations or tiers, rather than a complete abandonment of the ratings system. We find that institutional characteristics (available resources, average severity of illness, and academic affiliation) are associated with internal quality metrics related to patient flow. Furthermore, regression results from the original and revised CMS star rating methodologies suggest that patient flow metrics (discharges before noon [p < .01] and weekend discharges [p < .001]) have a positive relationship with the Hospital Compare rating. Hospitals with better patient flow, as measured by higher levels of discharges before noon and weekend discharges, are associated with higher CMS quality ratings. These findings suggest that CMS star ratings do reflect key aspects of operational performance, specifically efforts to improve patient flow, but the ranking system should consider hospital characteristics that influence internal operations as we move toward a system capable of quality and price transparency for consumers.

Using Patient-Reported Outcome Measures to Evaluate Care for Patients With Inflammatory Chronic Rheumatic Disease

OBJECTIVES

Few countries integrate patient-reported outcome measures (PROMs) in routine performance assessment and those that do focus on elective surgery. This study addresses the challenges of using PROMs to evaluate care in chronic conditions. We set out a modeling strategy to assess the extent to which changes over time in self-reported health status by patients with inflammatory chronic rheumatic disease are related to their biological drug therapy and rheumatology center primarily responsible for their care.

METHODS

Using data from the Portuguese Register of Rheumatic Diseases, we assess health status using the Health Assessment Questionnaire-Disability Index for rheumatic patients receiving biological drugs between 2000 and 2017. We specify a fixed-effects model using the least squares dummy variables estimator.

RESULTS

Patients receiving infliximab or rituximab report lower health status than those on etanercept (the most common therapy) and patients in 4 of the 26 rheumatology centers report higher health status than those at other centers.

CONCLUSIONS

PROMs can be used for those with chronic conditions to provide the patient's perspective about the impact on their health status of the choice of drug therapy and care provider. Care for chronic patients might be improved if healthcare organizations monitor PROMs and engage in performance assessment initiatives on a routine basis.

Toward System-Wide Implementation of Patient-Reported Outcome Measures: A Framework for Countries, States, and Regions

OBJECTIVES

This study aimed to develop a framework facilitating (1) the maturity assessment of healthcare systems regarding patient-reported outcome measure (PROM) implementation and (2) the comparison of different healthcare systems' PROM implementation levels to guide discussions and derive lessons for regional, state-level, and national PROM initiatives.

METHODS

Guided by the grounded theory methodology, a PROM healthcare system implementation framework was developed following multiple steps. Based on interviews with 28 experts from 12 countries and a literature review, a framework was drafted and refined through 29 additional validation interviews.

RESULTS

The resulting framework comprises 5 implementation stages along 7 dimensions. Implementation stages range from "first experimentation" to "system-wide adoption and a vibrant ecosystem." The dimensions are grouped into patient-reported outcome (PRO) measurement and PRO utilization, the former with the dimensions "scope and condition coverage," "metric and process standardization," and "tools and information technology-based solutions" and the latter with "patient empowerment and clinical decision support," "reporting and quality improvement," and "rewarding and contracting." The "culture and stakeholder involvement" dimension connects both groups. Although a concerted implementation approach across dimensions can be observed in advanced countries, others show a more uneven adoption.

CONCLUSIONS

The framework and its preliminary application to different healthcare systems demonstrate (1) the importance of coherent progress across complementing dimensions and (2) the relevance of PROM integration across clinical specialties and care sectors to strengthen patient-centered care. Overall, the framework can facilitate dialogues between stakeholders to analyze the current PROM implementation status and strategies to advance it.

Defining minimum volume thresholds to increase quality of care: a new patient-oriented approach using mixed integer programming

A positive relationship between treatment volume and outcome quality has been demonstrated in the literature and is thus evident for a variety of procedures. Consequently, policy makers have tried to translate this so-called volume-outcome relationship into minimum volume regulation (MVR) to increase the quality of care-yet with limited success. Until today, the effect of strict MVR application remains unclear as outcome quality gains cannot be estimated adequately and restrictions to application such as patient travel time and utilization of remaining hospital capacity are not considered sufficiently. Accordingly, when defining MVR, its effectiveness cannot be assessed. Thus, we developed a mixed integer programming model to define minimum volume thresholds balancing utility in terms of outcome quality gain and feasibility in terms of restricted patient travel time and utilization of hospital capacity. We applied our model to the German hospital sector and to four surgical procedures. Results showed that effective MVR needs a minimum volume threshold of 125 treatments for cholecystectomy, of 45 and 25 treatments for colon and rectum resection, respectively, of 32 treatments for radical prostatectomy and of 60 treatments for total knee arthroplasty. Depending on procedure type and incidence as well as the procedure's complication rate, outcome quality gain ranged between 287 (radical prostatectomy) and 977 (colon resection) avoidable complications (11.7% and 11.9% of all complications). Ultimately, policy makers can use our model to leverage MVR's intended benefit: concentrating treatment delivery to improve the quality of care.

[Quality Variation in Switzerland: Analysis of Mammary Resections for Breast Cancer using the Quality Indicator of Breast Preservation]

AIM OF STUDY

The aim of the study was to investigate whether there are regional differences in the treatment results of elective mammary resections for breast cancer in Switzerland and, if so, whether a possible cause could be found in the hospital planning by the cantons.

METHODS

Using the Inpatient Quality Indicators (CH-IQI), the quality of outcomes was analysed at the level of the Swiss cantons and compared with the cantonal requirements for carrying out this treatment.

RESULTS

Cantonal differences became apparent both in the quality of results based on the quality indicator of breast preservation and in the level of detail of the requirements for structural and process quality.

CONCLUSION

The quality of treatment in Switzerland can hardly be compared in a transparent manner; interpreting the available quality information is demanding and hardly possible for patients. In order to reduce the quality differences shown, hospital planning should be intercantonal, as is the case in highly specialised medicine.

Comparing the dangers of a stay in English and German hospitals for high-need patients

OBJECTIVE

To estimate the risk of an avoidable adverse event for high-need patients in England and Germany and the causal impact that has on outcomes.

DATA SOURCES

We use administrative, secondary data for all hospital inpatients in 2018. Patient records for the English National Health Service are provided by the Hospital Episode Statistics database and for the German health care system accessed through the Research Data Center of the Federal Statistical Office.

STUDY DESIGN

We calculated rates of three hospital-acquired adverse events and their causal impact on mortality and length of stay through propensity score matching and estimation of average treatment effects.

DATA COLLECTION/EXTRACTION METHODS

Patients were identified based on diagnoses codes and translated Patient Safety Indicators developed by the Agency for Healthcare Research and Quality.

PRINCIPAL FINDINGS

For the average hospital stay, the risk of an adverse event was 5.37% in the English National Health Service and 3.26% in the German health care system. High-need patients are more likely to experience an adverse event, driven by hospital-acquired infections (2.06%-4.45%), adverse drug reactions (2.37%-2.49%), and pressure ulcers (2.25%-0.45%). Adverse event risk is particularly high for patients with advancing illnesses (10.50%-27.11%) and the frail elderly (17.75%-28.19%). Compared to the counterfactual, high-need patients with an adverse event are more likely to die during their hospital stay and experience a longer length of stay.

CONCLUSIONS

High-need patients are particularly vulnerable with an adverse event risking further deterioration of health status and adding resource use. Our results indicate the need to assess the costs and benefits of a hospital stay, particularly when care could be provided in settings considered less hazardous.

On the correlation between outcome indicators and the structure and process indicators used to proxy them in public health care reporting

Hospital quality indicators provide valuable insights for quality improvement, empower patients to choose providers, and have become a cornerstone of value-based payment. As outcome indicators are cumbersome and expensive to measure, many health systems have relied on proxy indicators, such as structure and process indicators. In this paper, we assess the extent to which publicly reported structure and process indicators are correlated with outcome indicators, to determine if these provide useful signals to inform the public about the outcomes. Quality indicators for three conditions (breast and colorectal cancer, and hip replacement surgery) for Dutch hospitals (2011-2018) were collected. Structure and process indicators were compared to condition-specific outcome indicators and in-hospital mortality ratios in a between-hospital comparison (cross-sectional and between-effects models) and in within-hospital comparison (fixed-effects models). Systematic association could not be observed for any of the models. Both positive and negative signs were observed where negative associations were to be expected. Despite sufficient statistical power, the share of significant correlations was small [mean share: 13.2% (cross-sectional); 26.3% (between-effects); 13.2% (fixed-effects)]. These findings persisted in stratified analyses by type of hospital and in models using a multivariate approach. We conclude that, in the context of compulsory public reporting, structure and process indicators are not correlated with outcome indicators, neither in between-hospital comparisons nor in within-hospital comparisons. While structure and process indicators remain valuable for internal quality improvement, they are unsuitable as signals for informing the public about hospital differences in health outcomes.

The future of hospital quality of care policy: A multi-stakeholder discrete choice experiment in Flanders, Belgium

BACKGROUND

Collaboration between policymakers, patients and healthcare workers in hospital quality of care policy setting can improve the integration of new initiatives. The aim of this study was to quantify preferences for various characteristics of a future quality policy in a broad group of stakeholders.

MATERIALS AND METHODS

450 policymakers, clinicians, nurses, patient representatives and hospital board members in Flanders (Belgium) participated in five discrete choice experiments (DCE) on quality control, quality improvement, inspection, patient incidents and transparency. For each DCE, various attributes and levels were defined from a literature review and interviews with 12 international quality and patient safety experts.

RESULTS

For the attributes with the highest relative importance, participants exhibited a strong preference for quality control by an independent national organization and coordination of quality improvement initiatives at the level of hospital networks. The individual hospital was chosen over the government for setting up an action plan following patient complaints. Respondents also strongly preferred mandatory reporting of severe patient incidents and transparency by publicly reporting quality indicators at the hospital level.

CONCLUSIONS

A future quality model should focus on a multicomponent approach with external quality control, improvement actions on hospital network level and public transparency. DCEs provide an opportunity to incorporate the attitudes and views for individual components of a new policy recommendation.

Qualitätstransparenz in der stationären Krankenhausversorgung der Schweiz

Qualitätstransparenz ist eine entscheidende Grundlage für den Abbau von Informationsasymmetrien im Gesundheitswesen. Doch welche Informationen zur stationären, akutsomatischen Versorgung sind in der Schweiz vorhanden, wie können diese genutzt werden und welche Folgen ergeben sich daraus? Für diese Fragestellungen wird ein Review des Datenangebots vorgenommen, systematisch aufbereitet sowie Stärken und Schwächen aufgezeigt. Auf dieser Grundlage sowie internationalen Vergleichen folgen gesundheitspolitische Empfehlungen für eine Verbesserung der aktuellen Bedingungen. Die Studie zeigt auf, dass Qualitätstransparenz in der Schweiz trotz des bereits im Jahr 2011 vereinbarten nationalen Qualitätsvertrags nur begrenzt gegeben ist. Dies erschwert die Stärkung eines Qualitätswettbewerbs, die informierte Entscheidung über die Krankenhauswahl von Patienten sowie das selektive Kontrahieren. Eine Weiterentwicklung der in der Schweiz verfügbaren Daten und Messinstrumente in Krankenhäusern ist daher angezeigt und bedarf einer priorisierten Umsetzung.

The impact of quality on hospital choice. Which information affects patients' behavior for colorectal resection or knee replacement?

Quality competition among hospitals, induced by patients freely choosing their hospital in a price regulated market, can only be realized if quality differences between hospitals are transparent, understandable, and thus influence patients' hospital choice. We use data from ~145,000 German patients and ~ 900 hospitals for colorectal resections and knee replacements to investigate whether patients value quality and specialization when choosing their hospital. Using a random utility choice model, we estimate patients' marginal utilities, willingness to travel and change in hospital demand for quality improvements. Patients respond to service quality and specialization and thus, quality competition seems to be present. Colorectal resection patients are willing to travel longer for more specialized hospitals (+9% for procedure volume, +9% for certification). Knee replacement patients travel longer for hospitals with better service quality (+6%) and higher procedure volume (+12%). However, clinical quality indicators, often difficult to access and interpret, barely play a role in patients' hospital choice. Furthermore, we find that competition on quality for colorectal resection is rather local, whereas for knee replacement we observe regional competition patterns.

Divergent notions of "quality" in healthcare policy implementation: a framing perspective

PURPOSE

This paper examines how "quality" was framed in the design and implementation of a policy to reform hospital funding and associated care delivery. The aims of the study were: (1) To describe how government policy-makers who designed the policy and managers and clinicians who implemented the policy framed the concept of "quality" and (2) To explore how frames of quality and the framing process may have influenced policy implementation.

DESIGN/METHODOLOGY/APPROACH

The authors conducted a secondary analysis of data from a qualitative case study involving semi-structured interviews with 45 purposefully selected key informants involved in the design and implementation of the quality-based procedures policy in Ontario, Canada. The authors used framing theory to inform coding and analysis.

FINDINGS

The authors found that policy designers perpetuated a broader frame of quality than implementers who held more narrow frames of quality. Frame divergence was further characterized by how informants framed the relationship between clinical and financial domains of quality. Several environmental and organizational factors influenced how quality was framed by implementers.

ORIGINALITY/VALUE

As health systems around the world increasingly implement new models of governance and financing to strengthen quality of care, there is a need to consider how "quality" is framed in the context of these policies and with what effect. This is the first framing analysis of "quality" in health policy.

Rate of Preventable Mortality in Hospitalized Patients: a Systematic Review and Meta-analysis

BACKGROUND

The number of preventable inpatient deaths in the USA is commonly estimated as between 44,000 and 98,000 deaths annually. Because many inpatient deaths are believed to be preventable, mortality rates are used for quality measures and reimbursement. We aimed to estimate the proportion of inpatient deaths that are preventable.

METHODS

A systematic literature search of Medline, Embase, Web of Science, and the Cochrane Library through April 8, 2019, was conducted. We included case series of adult patients who died in the hospital and were reviewed by physicians to determine if the death was preventable. Two reviewers independently performed data extraction and study quality assessment. The proportion of preventable deaths from individual studies was pooled using a random-effects model.

RESULTS

Sixteen studies met inclusion criteria. Eight studies of consecutive or randomly selected cohorts including 12,503 deaths were pooled. The pooled rate of preventable mortality was 3.1% (95% CI 2.2-4.1%). Two studies also reported rates of preventable mortality limited to patients expected to live longer than 3 months, ranging from 0.5 to 1.0%. In the USA, these estimates correspond to approximately 22,165 preventable deaths annually and 7150 deaths for patients with greater than 3-month life expectancy.

DISCUSSION

The number of deaths due to medical error is lower than previously reported and the majority occur in patients with less than 3-month life expectancy. The vast majority of hospital deaths are due to underlying disease. Our results have implications for the use of hospital mortality rates for quality reporting and reimbursement.

STUDY REGISTRATION

PROSPERO registration number CRD42018095140.

Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study

OBJECTIVE

To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use.

DESIGN

Quasi-experimental difference-in-differences analysis.

SETTING

US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals.

PARTICIPANTS

238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals.

MAIN OUTCOME MEASURES

Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply.

RESULTS

In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points).

CONCLUSIONS

In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

The use of digitally collected patient-reported outcome measures for newly operated patients with total knee and hip replacements to improve post-treatment recovery: study protocol for a randomized controlled trial

Background

The number of total knee replacements (TKRs) and total hip replacements (THRs) has been increasing noticeably in high-income countries, such as Germany. In particular, the number of revisions is expected to rise because of higher life expectancy and procedures performed on younger patients, impacting the budgets of health-care systems. Quality transparency is the basis of holistic patient pathway optimization. Nevertheless, a nation-wide cross-sectoral assessment of quality from a patient perspective does not yet exist. Several studies have shown that the use of patient-reported outcome measures (PROMs) is effective for measuring quality and monitoring post-treatment recovery. For the first time in Germany, we test whether early detection of critical recovery paths using PROMs after TKR/THR improves the quality of care in a cost-effective way and can be recommended for implementation into standard care.

Methods/design

The study is a two-arm multi-center patient-level randomized controlled trial. Patients from nine hospitals are included in the study. Patient-centered questionnaires are employed to regularly measure digitized PROMs of TKR/THR patients from the time of hospital admission until 12 months post-discharge. An expert consortium has defined PROM alert thresholds at 1, 3, and 6 months to signal critical recovery paths after TKR/THR. An algorithm alerts study assistants if patients are not recovering in line with expected recovery paths. The study assistants contact patients and their physicians to investigate and, if needed, adjust the post-treatment protocol. When sickness funds’ claims data are added, the cost-effectiveness of the intervention can be analyzed.

Discussion

The study is expected to deliver an important contribution to test PROMs as an intervention tool and examine the determinants of high-quality endoprosthetic care. Depending on a positive and cost-effective impact, the goal is to transfer the study design into standard care. During the trial design phase, several insights have been discovered, and there were opportunities for efficient digital monitoring limited by existing legacy care models. Digitalization in hospital processes and the implementation of digital tools still represent challenges for hospital personnel and patients. Furthermore, data privacy regulations and the separation between the in- and outpatient sector are roadblocks to effectively monitor and assess quality along the full patient pathway.

Trial registration

German Clinical Trials Register: DRKS00019916. Registered November 26, 2019 – retrospectively registered.

Predictors of online accountability practices in US hospitals: An exploratory investigation

The purpose of this research paper is to explore variations in online accountability practices in US hospitals and determine the factors that are associated with higher levels of online accountability practices. This project employed a quantitative content analysis of 240 US hospital websites. Additionally, secondary data were obtained from the American Hospital Association and the American Hospital Directory. The results show that the external environment somewhat impacted hospitals' online accountability practices, with hospital volume (measured through the number of annual admissions) as an unquestionable predictor. Another key finding is that some of the governance forms impacted online accountability practices. Particularly, hospitals with private ownership structures tended to disclose less accountability information in an online environment, compared with their public and nonprofit counterparts. The financial situation of hospitals did not have any significant impact on overall online accountability practices but was influencing performance disclosure practices. Online accountability studies have not been conducted in a health care setting. This research theoretically relates online accountability practices to organizational characteristics (such as size, volume, financial performance, system affiliation, ownership, and rurality). Knowledge of the online accountability landscape might benefit future policy decisions on accountability models.

Headline indicators for monitoring the performance of health systems: findings from the european Health Systems_Indicator (euHS_I) survey

Background

Cross-country comparisons of health system performance have become increasingly important. Clear evidence is needed on the prioritization of health system performance assessment (HSPA) indicators. Selected “leading” or “headline” HSPA indicators may provide early warnings of policy impacts. The goal of this paper is to propose a set of headline indicators to frame and describe health system performance.

Methods

We identified overlaps and gaps in the availability of reported indicators by looking at HSPA initiatives in Member States (MSs) of the European Union (EU), the European Commission as well as international institutions (e.g. OECD, WHO-EUR). On that basis, we conducted a two-stage online survey, the european Health System_Indicator (euHS_I) survey. The survey sought to elicit preferences from a wide range of HSPA experts on i) the most relevant HSPA domain(s), i.e. access, efficiency, quality of care, equity, for a specific indicator, and ii) the importance of indicators regarding their information content, i.e. headline, operational, explanatory. Frequency analysis was performed.

Results

We identified 2168 health and health system indicators listed in 43 relevant initiatives. After adjusting for overlaps, a total of 361 indicators were assessed by 28 experts in the 1st stage of the survey. In the 2nd stage, a more balanced set of 95 indicators was constructed and assessed by 72 experts from 22 EU MSs and 3 non-EU countries. In the domain access experts assessed share of population covered by health insurance as the top headline indicator. In the domain efficiency, the highest rank was given to Total health care expenditure by all financing agents, and in the domain quality of care to rate of hospital-acquired infections. Percentage of households experiencing high levels/catastrophic of out-of-pocket health expenditures results as the top headline indicator for domain equity.

Conclusions

HSPA indicators from different initiatives largely overlap and public health indicators dominate over health systems aspects. The survey allowed to quantify overlaps and gaps in HSPA indicators, their expert allocation to domain areas and establishment of an informed hierarchy structure. Yet, results show that more multidisciplinary work is needed to ensure the availability of accurate efficiency indicators which are comparable across countries.

Electronic supplementary material

The online version of this article (10.1186/s13690-018-0278-0) contains supplementary material, which is available to authorized users.

Statutory health insurance in Germany: a health system shaped by 135 years of solidarity, self-governance, and competition

Bismarck's Health Insurance Act of 1883 established the first social health insurance system in the world. The German statutory health insurance system was built on the defining principles of solidarity and self-governance, and these principles have remained at the core of its continuous development for 135 years. A gradual expansion of population and benefits coverage has led to what is, in 2017, universal health coverage with a generous benefits package. Self-governance was initially applied mainly to the payers (the sickness funds) but was extended in 1913 to cover relations between sickness funds and doctors, which in turn led to the right for insured individuals to freely choose their health-care providers. In 1993, the freedom to choose one's sickness fund was formally introduced, and reforms that encourage competition and a strengthened market orientation have gradually gained importance in the past 25 years; these reforms were designed and implemented to protect the principles of solidarity and self-governance. In 2004, self-governance was strengthened through the establishment of the Federal Joint Committee, a major payer-provider structure given the task of defining uniform rules for access to and distribution of health care, benefits coverage, coordination of care across sectors, quality, and efficiency. Under the oversight of the Federal Joint Committee, payer and provider associations have ensured good access to high-quality health care without substantial shortages or waiting times. Self-governance has, however, led to an oversupply of pharmaceutical products, an excess in the number of inpatient cases and hospital stays, and problems with delivering continuity of care across sectoral boundaries. The German health insurance system is not as cost-effective as in some of Germany's neighbouring countries, which, given present expenditure levels, indicates a need to improve efficiency and value for patients.