Dr Niek Klazinga (Head of the Health Care Quality Indicators Project in the OECD Health Division) spoke with the HARC network in December 2014 about current developments in performance measurement and reporting. HARC stands for the Hospital Alliance for Research Collaboration. HARC is a collaborative network of researchers, health managers, clinicians and policy makers based in NSW, Australia managed by the Sax Institute. HARC Forums bring members of the HARC network together to discuss the latest research and analysis about important issues facing our hospitals. For more information visit saxinstitute.org.au.

1. PERFORMANCE
REPORTING IN OECD
COUNTRIES
Niek Klazinga, HARC, Sydney December 2 2014

2. niek.klazinga@oecd.org

3. 3
Most recent Health Statistics OECD
Slow recovery in health spending in many countries after a period of
decline

4. Life expectancy at birth, 1970 and 2011 (or nearest year) Source: OECD
Health Statistics 2013, http://dx.doi.org/10.1787/health-data-en; World Bank for
non-OECD countries

6. • Quality of health care services is seen in the overall
context of health system performance, population
health and health system development.
• The performance of the health care system is one
of the determinants of population health alongside
non-medical determinants of health such as
behavioural and environmental factors
• In OECD reports quality has 3 components;
effectiveness, safety and person centeredness
• It is used alongside the domains access and
costs/expenditure and the cross cutting domains
efficiency and equity
Conceptual notions

7. This conceptual thinking is reflected in the framework used for
reporting statistics in OECD’s Health at a Glance

8. • The OECD Health Data Questionnaire collects data on a range of variables
related to health status, non-medical determinants of health, the
pharmaceutical market, waiting times, long-term care resources and
utilisation, and public and private health insurance coverage.
• The OECD/Eurostat/WHO-Europe Joint Questionnaire on Non-Monetary
Health Care Statistics collects data on health care resources (human and
technical) and health care activities.
• The OECD/Eurostat/WHO Joint Health Accounts Questionnaire collects
data on health expenditure by function, provider and financing scheme,
based on the System of Health Accounts.
• The OECD/Eurostat Purchasing Power Parity (PPP) Questionnaire collects
data on the prices of a selected set of health services and goods (for the
purpose of developing health-specific and economy-wide PPP indices).
• The OECD Health Care Quality Indicators Questionnaire collects data on
quality of care (including health outcomes and patient safety).
OECD Statistics

9. 3
Overarching indicators
Helping people to recover from episodes of ill health or
following injury
3a Emergency admissions for acute conditions that should not usually require
hospital admission
3b i Emergency readmissions within 30 days of discharge from hospital
(PHOF 4.11*)
Improving outcomes from planned treatments
3.1 Total health gain as assessed by patients for elective procedures
i Physical Health-related procedures
ii Mental Health-related procedures
iii Recovery in Quality of life for patients with mental health problems
Preventing lower respiratory tract infections (LRTI) in children from
becoming serious
3.2 Emergency admissions for children with LRTI
Improving recovery from injuries and trauma
3.3 Survival from major trauma
Improving recovery from stroke
3.4 Proportion of stroke patients reporting an improvement in activity/lifestyle
on the Modified Rankin Scale at 6 months
Improving recovery from fragility fractures (Wording amended)
3.5 Proportion of patients with hip fractures recovering to their previous levels
of mobility/walking ability at i 30 and ii 120 days
Helping older people to recover their independence after illness or injury
3.6 i Proportion of older people (65 and over) who were still at home 91 days
after discharge from hospital into reablement / rehabilitation service
(ASCOF 2B[1]*)
ii Proportion offered rehabilitation following discharge from acute or
community hospital (ASCOF 2B[2]*)
Enhancing quality of life for people with long-term
conditions2
Overarching indicators
2 Health-related quality of life for people with long-term conditions (ASCOF
1A**)
Improvement
areasEnsuring people feel supported to manage their condition
2.1 Proportion of people feeling supported to manage their condition
Improving functional ability in people with long-term conditions
2.2 Employment of people with long-term conditions (ASCOF 1E** , PHOF
1.8*)
Reducing time spent in hospital by people with long-term conditions
2.3 i Unplanned hospitalisation for chronic ambulatory care sensitive
conditions
ii Unplanned hospitalisation for asthma, diabetes and epilepsy in under
19s
iii Alcohol-related hospital admissions (PHOF 2.18*)
Enhancing quality of life for carers
2.4 Health-related quality of life for carers (ASCOF 1D**)
Enhancing quality of life for people with mental illness
2.5 i Employment of people with mental illness (ASCOF 1F** & PHOF 1.8**)
ii Health related quality of life for people with mental health problems
Preventing people from dying prematurely1
Overarching indicators
1a Potential Years of Life Lost (PYLL) from causes considered amenable to
healthcare
i Adults ii Children and young people
1b Life expectancy at 75
i Males ii Females
1c Neonatal mortality and stillbirths
Improvement areas
Reducing premature death in people with mental illness
1.5 i Excess under 75 mortality rate in adults with serious mental illness
(PHOF 4.9*)
ii Excess under 75 mortality rate in adults with common mental illness
iii Mortality from suicide and injury of undetermined intent
(PHOF indicator 4.10**)
Reducing deaths in babies and young children
1.6 i Infant mortality (PHOF 4.1* )
ii (previously 1.6.iii) Five year survival from all cancers in children
Reducing premature mortality from the major causes of death
1.1 Under 75 mortality rate from cardiovascular disease (PHOF 4.4*)
1.2 Under 75 mortality rate from respiratory disease (PHOF 4.7*)
1.3 Under 75 mortality rate from liver disease (PHOF 4.6*)
1.4 Under 75 mortality rate from cancer (PHOF 4.5*)
i One- and ii Five-year survival from all cancers
iii One- and iv Five-year survival from breast, lung and colorectal cancer
v One- and vi Five-year survival at stage 1&2
Reducing premature death in people with a learning disability
1.7 Excess under 60 mortality rate in adults with a learning disability
4
Overarching indicators
Ensuring that people have a positive experience of care
4a Patient experience of primary care
i GP services
ii GP Out-of-hours services
iii NHS dental services
4b Patient experience of hospital care
4c Friends and family test
4d Patient experience characterised as poor or worse
Improvement areas
Improving people’s experience of outpatient care
4.1 Patient experience of outpatient services
Improving hospitals’ responsiveness to personal needs
4.2 Responsiveness to in-patients’ personal needs
Improving access to primary care services
4.4 Access to i GP services and ii NHS dental services
Improving women and their families’ experience of maternity services
4.5 Women’s experience of maternity services
Improving the experience of care for people at the end of their lives
4.6 Bereaved carers’ views on the quality of care in the last 3 months of life
Improving experience of healthcare for people with mental illness
4.7 Patient experience of community mental health services
Improving children and young people’s experience of healthcare
4.8 Children and young people’s experience of outpatient services
Improving people’s experience of accident and emergency services
4.3 Patient experience of A&E services
Improving people’s experience of integrated care
4.9 People’s experience of integrated care (ASCOF 3E**)
Reducing the incidence of avoidable harm
5.1 Deaths from venous thromboembolism (VTE) related events
5.2 Incidence of healthcare associated infection (HCAI)
i MRSA
ii C. difficile
5.3 Proportion of patients with category 2, 3 and 4 pressure ulcers
5.4 Hip fractures from falls during hospital care
Improving the safety of maternity services
5.5 Admission of full-term babies to neonatal care (Definition amended)
Treating and caring for people in a safe environment
and protecting them from avoidable harm5
Overarching indicators
5a (previously 5c) Deaths attributable to problems in healthcare
5b Severe harm attributable to problems in healthcare
Improvement areas
NHS Outcomes
Framework 2015/16
at a glance – DRAFT
Alignment with Adult Social Care Outcomes Framework
(ASCOF) and/or Public Health Outcomes Framework (PHOF)
* Indicator is shared
** Indicator is complementary
Indicators in italics are placeholders, pending development or
identification
Enhancing quality of life for people with dementia
2.6 i Estimated diagnosis rate for people with dementia (PHOF 4.16*)
ii A measure of the effectiveness of post-diagnosis care in sustaining
independence and improving quality of life (ASCOF 2F**)
Dental Health
2.8 i Decaying teeth
ii Under 10 tooth extractions in secondary care
Improvement Areas
Improving the culture of safety reporting
5.6 Patient safety incidents reported

10. Conceptual Framework Dutch Report on health
System performance
Zorgbalans 2014 | 10 september 2014
10

12. • The 3 domains of quality (effectiveness, safety and
person centeredness) are explored along 4 health
care system functions; staying healthy, getting
better, living with illness or disability and coping
with the end of life (IoM)
• The HCQI program started in 2002, the
framework was developed in 2004 and updated in
2013
• Quality Indicators have been reported on OECD
countries since 2005 (at present 55 indicators and
participation of 35 countries)
Conceptual notions in the Health Care
Quality Indicator program

13. Matrix Dimensions: Quality
Effectiveness
• Achieving
desirable
outcomes, given
the correct
provision of
evidence-based
health care
services to all
who could benefit
Safety
• System has the
right structures,
renders services
and attains
results in ways
that prevent harm
to the user,
provider, or
environment
Responsiveness/
Patient
centeredness
• System actually
functions by
placing the
patient/user at
the center of its
delivery of health
care

14. • Infectious Diseases: vaccination rates children and flu-
vaccination elderly
• Acute Care: 30-day case fatality rates AMI and Stroke
• Primary Care: hospital admission rates for chronic conditions
(diabetes, asthma/COPD, Chronic Heart Failure) and
prescribing rates antibiotics
• Cancer Care: screening, mortality and 5-year survival rates
• Mental Health: Excess Mortality persons with Severe Mental
Health problems
• Patient Safety Indicators (PSI’s)
• Patient Experiences (respect, autonomy, communication)
Types of Health Care Quality Indicators

15. An
evolving
view of
outcomes
Rationale, examples of measures and data sources
From
Deaths
• Mortality and life-expectancy: classical parameters to measure health systems
outcomes
• Look at outcome from a public health perspective
• Need good death registries as an information source
To
Diseases
• Prevalence and incidence of diseases are classical parameters to assess morbidity of
diseases in a country
• Related outcome measures try to capture the reduction in morbidity and the
outcomes of specific diseases (e.g. QALYs, SF36)
• Medical/clinical perspective is the dominant way of operationalizing outcome
measures. Outcome measurement is dependent on clinical registries (such as on
cancer and diabetes).
• Linking to costs (value) at system level (burden of diseases studies) and for specific
services and interventions (cost-effectiveness studies)
To
Disability
• Many chronic diseases come with long term disabilities and outcomes should also
address the way a health system deals with disabilities
• At system level DALY (Disability Adjusted Life Expectancy) most well-known
measure; at health services level various instruments available to assess disabilities
and their outcomes (e.g. inter RAI initiative)
• Administrative data-bases and surveys are the main data source
To
Discomfort
• Increasingly outcomes experienced by citizens/patients seen as an important
outcome
• PROMS (patient reported outcomes) mainly tested for clinical procedures and
treatments and still under development for chronic conditions ; EQ5D a more
generic measure used.
• PREMs with some limited international validation of instruments (CAHPS, Picker)

16. • Death registries
• Clinical Registries (cancer, diabetes)
• Administrative Data-Bases
• (Electronic) Health Records
• Surveys
• Key factor is the capacity for data-linkage
Data Sources for OECD’s HCQI

17. Hospital
in-patient
data
Primary
care data
Cancer
registry
data
Prescription
medicines data
Mortality
data
Formal
long-term
care data
Patient
experiences
survey data
Mental
hospital
in-patient
data
Population
health survey
data
Population
census or
registry data
Australia No No No No Yes No No No No No
Belgium Yes Yes Yes Yes Yes nr Nr No No nr
Canada Yes na nr na nr nr Na Nr nr nr
Denmark Yes Yes Yes Yes Yes na No Yes No Yes
France nr No No No No nr No Nr No No
Finland Yes na Yes Yes Yes Yes No Yes No Yes
Germany No No No No No No Na Na No No
Israel Yes No Yes No Yes Yes No Yes No Yes
Japan No No na No nr nr Nr Nr nr nr
Korea Yes Yes Yes Yes Yes Yes No Yes No No
Malta Yes No Yes na Yes No Na No No No
Norway Yes No Yes No Yes No No No Yes Yes
Poland No No No No No No No No No No
Portugal No Yes nr Yes nr nr Nr No nr nr
Singapore Yes na Yes No Yes Yes No No Yes No
Sweden Yes na Yes Yes Yes na No Yes Yes nr
Switzerland No na na na No No Na No No No
United Kingdom Yes No Yes No Yes No No No No No
United States Yes No Yes Yes Yes No Yes No Yes Yes
Total Yes 12 4 11 7 12 4 1 5 4 4
National record linkage projects are used for regular health care quality
monitoring Source: OECD HCQI Questionnaire, Secondary Use of Health
Data, 2011/12

18. Asthma admissions

19. Antibiotics use

20. 20
6.4
3.4
2.3
9.1
4.3
2.7
6.3
3.9
2.7
6.5
3.8
2.8
7
4.1
3.3
5.9
5.3
3.4
5.5
4.3
3.4
8.4
5.6
3.8
10.1
6.3
3.8
7.2
4.7
3.9
5.9
4.7
3.9
10.6
6.8
4.2
7.8
4
4.4
9.2
6.4
4.5
10.2
7
4.7
10.5
8.3
5.2
9.5
6.7
5.4
11.6
9.9
8.4
10.4
9.7
9.3
05
1015
D
N
K
N
O
R
SW
E
N
ZL
AU
S
C
AN
ITA
FIN
IR
L
ISR
U
SA
C
ZE
LU
X
N
LD
AU
T
PR
T
ESP
BEL
SG
P
2000, 2005 and 2011 (or nearest year)
AMI Case-Fatality (admission-based)
2000 2005 2011

21. Excess mortality from schizophrenia, 2006 and
2011 (or nearest year)
3.6 3.5
5.8
8.5
5.0
6.3
7.9
3.6
3.8
4.1
5.6
5.9 6.0
6.8
8.8
0
1
2
3
4
5
6
7
8
9
10
Korea Slovenia Denmark OECD (7) New Zealand Finland Israel Sweden
Ratio 2006 2011
Source: OECD Health Statistics 2013 , http://dx.doi.org/10.1787/health-data-en.

22. Postoperative pulmonary embolism or deep vein
thrombosis in adults, 2011 (or nearest year)
356
136
268
278
589
668
90
416
452
301
246
541
888
367
354
554
1294
454
n.a.
802
1759
107
264
307
315
409
421
426
432
500
557
591
603
664
701
768
783
795
812
865
1144
1207
0 500 1000 1500 2000
Belgium
Portugal
Spain
Poland ¹
Israel
Germany
Denmark
Italy ¹
Switzerland
United States
Finland ¹
OECD (20)
Canada
Norway
Sweden
Ireland
New Zealand
United Kingdom
France
Slovenia
Australia
Rates per 100 000 hospital discharges
Hip and knee replacement All surgeries
Source: OECD Health Statistics 2013 , http://dx.doi.org/10.1787/health-data-en.

23. R&D in OECD’s HCQI program 2014
• Enhancing international comparability of indicators on
potential preventable hospital admissions (UK)
• Working towards a compound indicator on potential
preventable hospital admissions (Canada)
• Indicators on amputation rates in patients with diabetes
(Italy)
• Indicators on operation within 48h for patients with a hip
fracture (Netherlands/Germany)
• Excess Mortality in Mental Health (UK)
• Indicators on Suicide (Denmark)
• Patient Safety Indicators (France)
• Indicators based on prescription data (OECD)
• Indicators on patient experiences (OECD)

24. OECD Agenda for Health Care Quality Indicators 2015/16
• Focus on the use of OECD’s HCQI’s in national and regional
health system performance reports
• R&D work on Hospital Performance:
• Comparison of frameworks
• Inventory of Indicators used
• Overview of ways of public reporting
• Analyses of types of use of hospital performance indicators
• Describing spread of hospital performance within countries
• Building on Hospital performance work in previous European
research projects (ECHO, EuroHope, BIRO ….)
• Continue working on strengthening the information
infrastructure in OECD countries

25. Hospitals quality performance in care of AMI
patients on empirical Bayes estimates of random
coefficients
Stockholm 8.04.2014 EUROHOPE project

26. Reporting on Hospital Performance:
Canada

28. Success: effective use of information
(without financial incentives) in Israel
Asthma
Care
•Control
medication
•Influenza
vaccination
Cancer
screening
Breast
cancer
Colon
cancer
Immunisations
for older adults
Influenza
vaccination
Pneumococcal
vaccination
Child and
adolescent
health
Anemia
screening
(infants)
BMI
assessment
(adolescents)
Cardiovascular
health
Primaryprevention
•Cholesterol assessment
•Weightassessment
•Blood pressure
assessment
Care
•Use of LDL modifiers
•Use of ACEI/ARB
•Use of beta blockers
Effectivenessof care
•Cholesterol
assessment for
cardiac patients
Diabetes
Care
•Glycemic control
•Cholesterol
assessment
•Eye care
•Kidney care
•Immunisations
•Blood pressure
assessment
•Weightassessment
Effectivenessof
care
•Glycemic control
•Cholesterol
management
•Blood pressure
management
Israel Quality Indicators in Community
Healthcare

29. niek.klazinga@oecd.org