Managing COVID-19 within and across health systems: why we need performance intelligence to coordinate a global response

Background

The COVID-19 pandemic is a complex global public health crisis presenting clinical, organisational and system-wide challenges. Different research perspectives on health are needed in order to manage and monitor this crisis. Performance intelligence is an approach that emphasises the need for different research perspectives in supporting health systems’ decision-makers to determine policies based on well-informed choices. In this paper, we present the viewpoint of the Innovative Training Network for Healthcare Performance Intelligence Professionals (HealthPros) on how performance intelligence can be used during and after the COVID-19 pandemic.

Discussion

A lack of standardised information, paired with limited discussion and alignment between countries contribute to uncertainty in decision-making in all countries. Consequently, a plethora of different non-data-driven and uncoordinated approaches to address the outbreak are noted worldwide. Comparative health system research is needed to help countries shape their response models in social care, public health, primary care, hospital care and long-term care through the different phases of the pandemic. There is a need in each phase to compare context-specific bundles of measures where the impact on health outcomes can be modelled using targeted data and advanced statistical methods. Performance intelligence can be pursued to compare data, construct indicators and identify optimal strategies. Embracing a system perspective will allow countries to take coordinated strategic decisions while mitigating the risk of system collapse.A framework for the development and implementation of performance intelligence has been outlined by the HealthPros Network and is of pertinence. Health systems need better and more timely data to govern through a pandemic-induced transition period where tensions between care needs, demand and capacity are exceptionally high worldwide. Health systems are challenged to ensure essential levels of healthcare towards all patients, including those who need routine assistance.

Conclusion

Performance intelligence plays an essential role as part of a broader public health strategy in guiding the decisions of health system actors on the implementation of contextualised measures to tackle COVID-19 or any future epidemic as well as their effect on the health system at large. This should be based on commonly agreed-upon standardised data and fit-for-purpose indicators, making optimal use of existing health information infrastructures. The HealthPros Network can make a meaningful contribution.

Using routine data to benchmark quality and outcomes of diabetes care in the EU HEALTHPROS project

Background

The EU-funded Marie Curie project HEALTHPROS aims to foster a new generation of “Healthcare Performance Intelligence Professionals” through a cohesive stream of 13 doctoral projects (www.healthpros-h2020.eu). Over 48 months, researchers will investigate key levers of healthcare improvement in 7 different countries, using methods drawn from the diverse fields of biostatistics, medical informatics and health services research.

Objectives

To describe barriers and enablers in the conduction of two doctoral projects aimed at exploring the impact of personal risk factors and organizational arrangements on lower extremity amputations in diabetes, through the use of large-scale databases from England, Scotland, Denmark and Germany.

Results

The research plan included a systematic review, structured comparison of data sources, predictive modelling and software development for automated international comparisons. Barriers encountered by researchers were: knowledge and access to data sources from different countries, dealing with data protection rules and the ability to carry out international comparisons when individual records are not easily allowed to leave national boundaries. Enabling factors included: a targeted educational process for risk modelling in diabetes and a multidisciplinary support team to help doctoral students overcoming the above barriers across different sites. Further clinical insight and contextual knowledge of data systems in place at different locations were needed in addition to the statistical, epidemiological and technical skills initially foreseen by the program.

Conclusions

The success of studies within a general educational program on health systems performance may depend from the continued support of a multidisciplinary team helping students in their educational process as well as with the practicalities of their research. International comparisons using routine data may require prioritisation to meet the tight timelines of doctoral theses.

Key messages

Academic programs for international comparisons in health care may be hampered by different type of barriers including technical aspects, legal regulations and a range of contextual factors. The establishment of multidisciplinary support teams may be essential for training doctoral students aiming to conduct international comparisons using routine data.

Conceptualizing patient-reported outcome measures for use within two Danish psychiatric clinical registries: description of an iterative co-creation process between patients and healthcare professionals

BACKGROUND

Denmark has national clinical indicator programs for adult patients diagnosed with depression and schizophrenia, respectively. Within each program, the responsible steering group (SG) decided to add some indicators based upon patient-reported outcome measures (PROMs).

AIMS

The primary aim was to describe the process of selecting PROMs and defining a national measurement concept for use in clinical practice and for indicator monitoring and the secondary aim s to collect patient recommendations for implementation.

METHODS

An interdisciplinary SG of healthcare professionals and a Patient Peer Board (PPB) representing both patient groups co-created the output in an iterative process. The work included literature search, PPB workshops, SG meetings, ratings of PROM topics and items, and a pilot. The PPB discussed the following: item relevance, mode of data collection, graphical format of the online PROMs, and display of results. Finally, requirements for PROM patient information were identified. Based upon input from the PPB, the SG selected the items and specified the measurement concept.

RESULTS

The PPB prioritized 20 of 53 suitable items and suggested alternative wording and answer categories. A pilot was performed and 19 items covering well-being, lack of well-being, impairment of functioning, and overall health were selected for clinical testing. The patients recommended concrete, unambiguous, easily understandable information and procedures for data collection and display of results.

CONCLUSIONS

The iterative co-creation process based upon a high degree of patient involvement resulted in a set of PROMs, a national measurement concept, and patient recommendations for implementation. The cooperation between patients and professionals was successful.

Quality of care for medical comorbidities among patients with and without schizophrenia

Introduction

The association between schizophrenia and quality of care for medical comorbidities in universal health care systems remains unclear.

Objectives

To elucidate whether equal access also implies equivalent and sufficient care.

Aims

To compare the quality of care for heart failure, diabetes and chronic obstructive pulmonary disease (COPD) among patients with and without schizophrenia in Denmark.

Methods

In a nationwide population-based cohort study, we used Danish national registries to estimate the risk of receiving guideline recommended disease-specific processes of care between 2004 and 2013.

Results

Compared to patients without schizophrenia, patients with schizophrenia had lower chance of receiving high overall quality of care (≥ 80% of recommended processes of care) for heart failure (Relative risk [RR] 0.67, 95% CI: 0.48-0.92), diabetes (RR 0.84, 95% CI: 0.79-0.89) and COPD (RR 0.82, 95% CI: 0.72-0.93) as well as lower chance of receiving individual disease-specific processes of care including treatment with beta-blockers (RR 0.87, 95% CI: 0.79-0.96) in heart failure care and measurement for albuminuria (RR 0.96, 95% CI: 0.93-0.99), eye examination at least every second year (RR 0.97, 95% CI: 0.94-0.99) and feet examination (RR 0.96, 95% CI: 0.93-0.99) in diabetes care. Diabetic patients with schizophrenia also had lower chance of receiving antihypertensive (RR 0.84, 95% CI: 0.73-0.96) and ACE/ATII inhibitors (RR 0.72, 95% CI: 0.55-0.94). In COPD care, patients with schizophrenia had lower chance of receiving LAMA/LABA medication (RR 0.92, 95% CI: 0.87-0.98), however, higher chance of treatment with non-invasive inhalation (RR 1.85, 95% CI: 1.61-2.12).

Conclusions

Quality of care for three medical comorbidities was suboptimal for patients with schizophrenia.

Disclosure of interest

The authors have not supplied their declaration of competing interest.

Towards actionable international comparisons of health system performance: expert revision of the OECD framework and quality indicators

OBJECTIVE

To review and update the conceptual framework, indicator content and research priorities of the Organisation for Economic Cooperation and Development's (OECD) Health Care Quality Indicators (HCQI) project, after a decade of collaborative work.

DESIGN

A structured assessment was carried out using a modified Delphi approach, followed by a consensus meeting, to assess the suite of HCQI for international comparisons, agree on revisions to the original framework and set priorities for research and development.

SETTING

International group of countries participating to OECD projects.

PARTICIPANTS

Members of the OECD HCQI expert group.

RESULTS

A reference matrix, based on a revised performance framework, was used to map and assess all seventy HCQI routinely calculated by the OECD expert group. A total of 21 indicators were agreed to be excluded, due to the following concerns: (i) relevance, (ii) international comparability, particularly where heterogeneous coding practices might induce bias, (iii) feasibility, when the number of countries able to report was limited and the added value did not justify sustained effort and (iv) actionability, for indicators that were unlikely to improve on the basis of targeted policy interventions.

CONCLUSIONS

The revised OECD framework for HCQI represents a new milestone of a long-standing international collaboration among a group of countries committed to building common ground for performance measurement. The expert group believes that the continuation of this work is paramount to provide decision makers with a validated toolbox to directly act on quality improvement strategies.

How should medication errors be defined? Development and test of a definition

Aims: Definitions of medication errors vary widely in the literature, and prevalence from 2–75% in part because of this lack of consensus. Thus, clarification of the concept is urgently needed. The objective was to develop a clear-cut definition of medication errors and specify relevant error types in the medication process. Methods: Based on existing taxonomy and through a modified Delphi-process consensus of definition and error types were reached among Danish experts appointed by 13 healthcare organisations and the project group. The experts prioritised five definitions of medication errors and score the relevance of 76 error types. Based on explicit criteria, the project group settled non-consensus cases. Results: The panel consisted of 12 physicians, seven pharmacists, and six nurses. Consensus was reached for the definition “An error in the stages of the medication process – ordering, dispensing, administering and monitoring the effect – causing harm or implying a risk of harming the patient”. Moreover, consensus for 60 of 76 error types was achieved. Applied to a historic dataset the definition reduced the number of medication errors from 34% to 7%. Conclusions: Experts deemed a definition using harm or risk of harm as cut-off point as the most appropriate in Danish hospital settings. In addition, they agreed on a list of 60 error types covering the medication process. Interestingly, a substantial lower occurrence of medication errors was found when applied to historic data. The definition is in accordance with international taxonomy, thus is assumed to be applicable to modern healthcare settings abroad.

Cystic fibrosis in 65- and 67-year-old siblings. Clinical feature and nasal potential difference measurement in patients with genotypes F508del and 2789+5G-->A

Cystic fibrosis (CF) is a recessive genetic disease caused by defects of the cystic fibrosis trans-membrane regulator (CFTR) gene with a median survival of less than 35 years. This work reports on the oldest living German siblings with CF. Besides clinical history, CF genotype and nasal potential difference (NPD) measurement results, the remarkably high exercise activity of the siblings is discussed as a disease-modifying factor. Both male patients have an overall mild pulmonary manifestation. They have suffered from abdominal symptoms since their early childhood, including recurrent pancreatitis and diffuse symptoms leading to partial gastric resection. They were diagnosed as having CF with positive sweat tests at the advanced ages of 45 and 43 years, respectively. Later on genotyping revealed compound heterozygosity for F508del and 2789+5G-->A. Using NPD we demonstrated a CF-typical inhibition of the NPD by the Na channel blocker amiloride, although in both siblings the remaining CFTR function and alternate chloride channel function were detected during superfusion of the nasal epithelium with isoproterenol and ATP. Long-term survival with CF is basically influenced by the CFTR genotype. The patients' genotype was discussed as a mild one with remaining CFTR function. We demonstrated this residual CFTR function in both siblings using NPD. Additionally the siblings' continuous healthy lifestyle and their engagement in a remarkably high level of exercise activities from early childhood to the present possibly have an important effect on the long-term outcome of CF as disease-modifying factors. In this regard this report can encourage CF patients to maintain a high level of physical activity in their daily lives.

Evaluation of the quality of venous leg ulcer care given in a multidisciplinary specialist centre

OBJECTIVE

To determine the quality of venous leg ulcer care given in a multidisciplinary, specialist wound-healing centre and to identify problem areas that might affect it.

METHOD

The case records of 90 consecutive patients with venous leg ulcers, diagnosed and treated at the Copenhagen Wound Healing Centre, Denmark, were retrospectively audited by a Scandinavian cross-sectional and multidisciplinary expert panel. Quality of care was audited in each case using implicit criteria. The experts then formulated key recommendations for good clinical practice for patients with venous leg ulcers.

RESULTS

Quality of care was satisfactory in 74 patients (82%). The one-year healing rate was 77% (69/90), with a three-month recurrence rate of 12% (11/90). Identified problem areas included the lack of systematic assessment of patients' suitability for surgery; lack of systematic, duplex-verified diagnoses of venous aetiology; and the lack of systematic examination of distal arterial pressure. The recommendations include the need for venous diagnosis, differential diagnosis, compression therapy, surgery, systemic treatment, access to venous leg ulcer care and better communication.

CONCLUSION

The quality of venous leg ulcer care given in this multidisciplinary centre was satisfactory.

Randomised controlled trial of a shared care programme for newly referred cancer patients: bridging the gap between general practice and hospital

OBJECTIVE

To determine the effect of a shared care programme on the attitudes of newly referred cancer patients towards the healthcare system and their health related quality of life and performance status, and to assess patients' reports on contacts with their general practitioner (GP).

SETTING

Department of Oncology at Aarhus University Hospital and general practices.

DESIGN

Randomised controlled trial in which patients completed questionnaires at three time points. The shared care programme included transfer of knowledge from the oncologist to the GP, improved communication between the parties, and active patient involvement.

PARTICIPANTS

248 consecutive cancer patients recently referred to the department.

MAIN OUTCOME MEASURES

Patients' attitudes towards the healthcare services, their health related quality of life, performance status, and reports on contacts with their GPs.

RESULTS

The shared care programme had a positive effect on patient evaluation of cooperation between the primary and secondary healthcare sectors. The effect was particularly significant in men and in younger patients (18-49 years) who felt they received more care from the GP and were left less in limbo. Young patients in the intervention group rated the GP's knowledge of disease and treatment significantly higher than young patients in the control group. The number of contacts with the GP was significantly higher in the intervention group. The EORTC quality of life questionnaire and performance status showed no significant differences between the two groups.

CONCLUSIONS

An intersectoral shared care programme in which GPs and patients are actively involved has a positive influence on patients' attitudes towards the healthcare system. Young patients and men particularly benefit from the programme.

[Early results of ultrasound based calculation of broadband ultrasound attenuation and speed of sound in children and adolescents suffering from asthma]

PURPOSE

To determine broadband ultrasound attenuation (BUA) and speed of sound (SOS) on the os caicis in asthmatic children. To correlate these findings with sex, age, weight and height, topical steroid intake, and asthma severity grade (ASG).

PATIENTS AND METHODS

178 children (ASG 1 - 3)/(98 m, 80 f; mean age 11.9 +/- 3.1 y) were consecutively chosen from 4/00 to 9/01. Children with any other chronic disease were excluded. BUA and SOS were measured using SAHARA (Hologic lnc. Waltham, USA). Regional normative BUA and SOS data of 3 299 children (obtained with the same system), were used to calculate age-, weight- and height-matched standard-deviation-scores (SDS) for both sexes. Asthma severity grade and steroidal intake were determined. The highest topical steroid dosage was 500 micro g Fluticasone or 800 micro g Budesonide per day.

RESULTS

10/178 children were small and 7/178 tall per age (5.6 %/3.9 %), 11/178 children were light (6.2 %) and 9 heavy per age (5.0 %). 19 and 45 children had reduced BUA and SOS values, respectively. The following rates of reduced values were observed: girls: BUA 15.0 % (12/80), SOS 25.0 % (20/80); boys: BUA 7.1 %, SOS 25.5 % (7/98 and 25/98). Sexual differences were not significant. Reduced SOS-values were associated with higher severity and occurred significantly more frequent at children under steroidal intake (0.09 vs. 0.25 [BUA] and - 0.37 vs. - 0.07 [SOS]).

CONCLUSION

Following our results an increase incidence of reduced speed of sound occurs in asthmatic children which is attributed to asthma severity and seems to be negatively influenced even by topically applied low dose steroids. This could be attributed to a steroid induced collagen synthesis deficiency followed by a reduced bone elasticity. Further studies, especially using a longitudinal study design are required to verify these findings.

[Communication and information in the Danish health services. Laws, regulations and rules for patients and personnel in the Danish health services]

This article describes communication and information between patients and health staff in the Danish Health Service. A number of laws, regulations, rights, and rules have been passed, and in 1998 a new law came into effect concerning patients' rights in the health service. This law protects the rights of patients and provides the health staff with guidelines on communication and information to patients. An analysis of the law is given here. Each profession in the health service has its own regulations and ethic rules. These regulations and rules are reviewed with respect to communication and information in the Danish Health Service.

[Measurement of quality of care and the "soft values" at a pediatric department]

INTRODUCTION

Medical care must be provided in accordance with high professional standards and patients' needs and priorities.

MATERIALS AND METHODS

In this study, interviews with parents and focus group interviews with the health care staff (doctors and nurses) were conducted in order to set quality standards and define related indicators for emergency admittance to a paediatric department. According to the standards, the quality of care was measured with the indicators developed. One hundred and fifty episodes of care were assessed by questionnaires covering parent satisfaction, registration of waiting times, and investigation of case records.

RESULTS

In 17% of the episodes, there were waiting times of more than 2 hours before seeing a doctor. Various quality problems were identified. Thirty-one medical standards of the episodes of care were assessed in a structured audit process. The results of the clinical audit showed that some standards were met only in 50% of the episodes.

DISCUSSION

Quality development must be implemented on a documented basis. Improvements have been implemented according to the results.

[The significance of a reminder and physician's motivation for the response rate of a questionnaire survey in general practice]

The use of a mailed reminder to improve the response rate in a questionnaire survey was analysed in a general practice multicentre survey in Denmark, Norway, and the Netherlands. In total 14 general practitioners (GP's) handed out the questionnaire to 650 adult patients. A randomized sample of the patients who did not respond after three weeks received a reminder including a new questionnaire. In the group that received a reminder the response rate was significantly higher compared with the group that did not (79% vs. 62%). In Denmark, two of the four participating GP's were specially motivated. The response rate for these GP's was significantly higher compared to the normally motivated GP's (91% vs. 71%). Specially motivated GP's can increase the response rate and thereby minimise the effect of the reminder.

[How do practitioners evaluate the newly introduced system of substituting prescriptions?]

AIMS

In 1997 a new prescription system was introduced in the Danish health care system. The pharmacist must now substitute a prescribed drug with a cheaper version, either generic (G-substitution) or original (O-substitution) unless the general practitioner (GP) indicates that substitution is not allowed. The purpose of this study was to obtain the GPs' views on the system and evaluate the problems related to the system.

METHODS

The study was based on questionnaires to GPs developed via qualitative interviews with the GPs and afterwards pilot tested.

RESULTS

Out of 300 GPs the response rate was 80%. The study showed that 61% of the GPs were dissatisfied with the system and thought that it should be removed. There were several reasons for this: the system was incomprehensible, the introduction and information about the system was insufficient and the extra workload was too heavy. All the GPs agreed that analogue substitution (substitution between drugs with the same effect obtained by different means) was medically unjustifiable and should not be introduced.

[How do pharmacists evaluate the newly introduced system of substituting prescriptions?]

In 1997 a new prescription system was introduced in the Danish health care system. The pharmacist must now substitute a prescription with a cheaper version of the drug (either generic or original) unless the prescribing doctor indicates that substitution is not allowed in the specific case. The purpose of this study was to evaluate problems of the system and obtain the pharmacists' views on the system. The study was based on questionnaires to a representative sample of 75 pharmacists (a quarter of Denmark's pharmacists). The response rate was 72%. Half of the pharmacists were dissatisfied with the system, which primarily was due to the excessive workload imposed. In spite of this, about half the pharmacists wanted the system to be continued, because the overall purpose of finding the cheapest drug for the patient is good. Nearly all pharmacists thought that analogue substitution (substitution between drugs with the same overall effects but obtained by different means) should not be introduced.

[How do patients evaluate the newly introduced system of substituting prescriptions?]

In 1997 a new prescription system was introduced in Denmark. The pharmacist must now substitute the prescribed drug with a cheaper version either by a generic prescription (G-substitution) or by an original prescription (O-substitution) unless the prescribing doctor indicates that substitution is not allowed in the specific case. The purpose of this study was to obtain the patients' view on the new prescription system and to identify any related problems. The investigation was based on structured interviews. The interview guide was designed as a questionnaire, which was validated and tested before use. The response rate was 82%. The study showed that 84% of the patients were satisfied with the system and 85% of the patients thought that it should continue. Eighty-three percent of the patients had tried another version of the substituted medicine earlier. Out of these, 6% had experienced more side-effects from the substituted medicine, and 10% felt that the substituted medicine had a weaker effect. There was one case of erroneous medical treatment as a consequence of the substitution system. Only few problems such as more side-effects or less effect of the substituted medicine was experienced by the patients. It can be concluded that the patients in general are satisfied with the new prescription system.

Patients in Europe evaluate general practice care: an international comparison

BACKGROUND

Patients' evaluations can be used to improve health care and compare general practice in different health systems.

AIM

To identify aspects of general practice that are generally evaluated positively by patients and to compare opinions of patients in different European countries on actual care provision.

METHOD

An internationally-validated questionnaire was distributed to and completed by patients in 10 European countries. A stratified sample of 36 practices per country, with at least 1080 patients per country, was included. A set of 23 validated questions on evaluations of different aspects of care was used, as well as questions on age, sex, overall health status, and frequency of visiting the GP.

RESULTS

The patient sample included 17,391 patients in 10 different countries; the average response rate was 79% (range = 67% to 89%). In general, patients visiting their general practitioner (GP) were very positive about the care provided. For most of the 23 selected aspects of care more than 80% viewed care as good or excellent; in particular, keeping records confidential, GP listening to patients, time during consultations, and quick services in case of urgent problems were evaluated positively. Patients were relatively negative about organisational aspects of care. The evaluations in different countries were largely similar, with some interesting differences; for instance, service and organisational aspects were evaluated more positively in fee-for-service health systems.

CONCLUSIONS

Patients in Europe are positive about general practice but improvements in practice management in some countries are requested. More research is needed to study the complex field of differences in expectations and evaluations between countries with different health systems.

[Communication between general practitioners and hospitals]

The study was partly based on a retrospective analysis of 408 hospital referrals and 261 discharge summary letters and partly on interviews with chief physicians/surgeons and general practitioners. The level of information in hospital referrals: patient history 87%, objective findings 94%, social medicine 31%, plan/expectations 21%. The diagnostic applicability of patient history/objective findings was 95% and social medicine 70%. The discharge summary letter was received 2-3 days after hospital discharge in 17% cases. In the discharge letters information about medication was described in 41%, information given to patient/relatives in 9%. When discharge summary letters from departments of internal medicine and surgery were compared the level of informations from departments of internal medicine to departments of surgery was superior e.g. descriptions of medication (62% against 26%), date of control (34% against 24%) and information to patient/relatives (12% against 5%). The conclusion was that the level of information and the diagnostic applicability showed variation with regard to quality. General practitioners and hospitals must develop guidelines for hospital referrals and discharge summary letters in order to improve the patient's course.