1. 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

2. 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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4. 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

5. 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

6. 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)

7. "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

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

9. Care pathway &quality potentials

10. 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

11. 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)

12. 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

13. 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")

14. 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

15. 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")

16. 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

17. 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

18. 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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