Translating Clinical Guidelines into Performance Measurements Translating Clinical Guidelines into Performance Measurements. The challenge of being both relevant and feasible Anke Bramesfeld G-I-N 2016, Philadelphia

Disclaimer Disclosure of Interests (last 3 years): none Reporting my experience with developing quality assurance: Quality Assurance programme of the German health care system: Developing QA: Schizophrenia European Commission Initiative on Breast Cancer (ECIBC): Developing European QA scheme for breast cancer services

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Agenda What are Quality Assurance (QA) programmes about? Developing person/patient oriented QA: Care pathways & quality potentials Example: developing QA for Schizophrenia within the mandatory QA system of the German healthcare system Conclusions

What are Quality Assurance (QA) programmes about? Assess performance of different health services in a way that they can be compared longitudinally and between services Indicators (Peer)Audits

Purpose of QA Programs Patient choice Transparency Accountability Performance improvement Data for health policy and planning Purpose of QA Programs Bramesfeld et al. Mandatory National Quality Improvement Systems using indicators. Health Policy (accepted)

"What is quality of care": changes with perspective Guidelines (processes) Effectiveness in respect to priorities (outcomes) Efficiency Service Provider Patient Cost carrier German QA and EIBC both: Patient/person oriented

Developing person/patient oriented QA: Care pathways & quality potentials

Care pathway &quality potentials

Develop requirements/ indicators I. Collection of requirements /indicators Not meeting inclusion criteria II. Panel process Evaluate req./ind. for 1. Understandability, relevance 2. Technical feasibility Understandable, relevant and feasible Not understandable, relevant and feasible Meeting inclusion criteria III. Country/stakeholder consultation Req./ind. likely to be feasible in the respective health systems. IV. Pilot testing Schemes Current Guidelines Indicator Databases New Requirements/Indicators Literature Incl. patient Evident Distinguishes performance quality Actionable Incentive

Example: developing QA for Schizophrenia within the mandatory QA system of the German healthcare system Mandate by Federal Joint Committee 2012: Indicators for care for patients suffering Schizophrenia, schizotypal, delusional, and other non-mood psychotic disorders (DSM- 10 F.20)

Preconditions QA scheme is mandatory concerns: all psychiatric hospitals (500) + all outpatient centres/offices (2000) Only indicators Data sources available health insurance claims data (inpatient: diagnosis, days of admission, outpatient: diagnosis, physicians seen, medication prescribed) extra documentation in hospital care no extra documentation in outpatient care no patient survey Guideline available (2005): S3 Guideline Schizophrenia

1. Pharmacotherapy Guideline *: In the treatment of acute schizophrenic episode antipsychotics should be the treatment of first choice Quality potential? Distinguishes between good and bad treatment? What is acute? Patient preferences? What about other measures (Soteria)? Routine Data available? *S3 Leitlinie Schizophrenie 2005: Recommendation Grade A (evidence grade I a/Ib, “strong Recommendation")

2. Poly-Pharmacology in outpatient care Guideline*: In principle antipsychotics should not be combined. Quality Potential: 17% patients ICD-10 F2 in outpatient > 1 antipsychotics, (excluding clozapin)** Indicator: Antipsychotic combination therapy: all patients that receive more than three different antipsychotics for more than two quarters Assessable with routine data Focuses on the worst cases *S3 Leitlinie Schizophrenie 2005: Recommendation Grade C (evidence grade IV, “medium Recommendation") ** 2012 health insurance claims data, computation AQUA

3. Coercive Treatment Guideline: Measures such as restraint/seclusion should only be used in exceptional emergency, are to be documented and explained to the patient*. Quality Potential Patient priority No transparency, no data available on a regional/national basis Indicators: The number of patients exposed to restraint /seclusion The total time that patients are exposed to restraint /seclusion Number of patients receiving 1to1 care during restraint /seclusion *S3 Leitlinie Schizophrenie 2005: Recommendation Grade C (evidence grade IV, “medium Recommendation")

What is the Problem? Different perspective of guidelines (service provider) and quality assurance (patient oriented) Guidelines do not cover all processes that are relevant from a patient perspective Guidelines stick to the strength of evidence but not the strength of relevance from a patient perspective Guidelines do not necessarily work with quality potentials

ECIBC aims at crossing the gap between guidelines and QA scheme Voluntary European QA scheme for breast cancer services Person/ patient involvement Metho-dology European Breast Guidelines

Conclusions Be conscious of the perspective of quality of care that you take! Person/patient oriented QA: Orients at care pathway and quality potentials Includes person/patients in all processes Respects evidence from guidelines, but they are not the only source of reference Question: If guidelines would be more person/patient oriented, will more recommendations translate into performance measurements?

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