Health Services Research (HSR)

Transcription

1 Health Services Research (HSR) Vijj Kasemsup, M.D., Ph.D. Department of Community Medicine Ramathibodi Hospital, Mahidol University Definition (1) Health services research... examines how people get access to health care, how much care costs, and what happens to patients as a result of this care. The main goals of health services research are to identify the most effective ways to organize, manage, finance, and deliver high quality care; reduce medical errors; and improve patient safety. (Agency for Healthcare Research and Quality, 2002 ) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions 1

2 Definition (2) Health services research... is the multidisciplinary field of scientific investigation that studies how social factors, financing systems, organizational structures and processes, health technologies, and personal behaviors affect access to health care, the quality and cost of health care, and ultimately our health and well being. Its research domains are individuals, families, organizations, institutions, communities, and populations. (Academy for Health Services Research and Health Policy, 2000) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions Definition (3) Health services research... is a multidisciplinary field of inquiry, both basic and applied, that examines the use, costs, quality, accessibility, delivery, organization, financing, and outcomes of health care services to increase knowledge and understanding of the structure, processes, and effects of health services for individuals and populations (IOM, 1995) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions 2

3 Definition (4) Health services research... is a field of inquiry that examines the roles of organization, finance, manpower, technology, and prevention in the provision of health care services, and their impact on utilization, cost, and quality of care. The field draws on many disciplines to address this breadth of research, including biostatistics, epidemiology, health economics, medicine, nursing, operations research, psychology, and medical sociology. (Steinwachs, 1991:10) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions Definition (5) Health services research... is a field of inquiry that examines the impact of the organization, financing, and management of health care services on the delivery, quality, cost, access to, and outcomes of such services. (Valentine, 1991) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions 3

4 Definition (6) Health services research... is the integration of epidemiologic, sociological, economic, and other analytic sciences in the study of health services. (Last, 1988:58) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions Definition (7) Health services research... is a recognized, multidisciplinary field...[with a focus on certain generic issues, such as] the organization and financing of medical care, utilization patterns, patient and provider relations, social and behavioral epidemiology, health information systems, and monitoring and evaluation of health services. (Marshall, 1985:381,382) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions 4

5 Definition (8) Health services research... is inquiry to produce knowledge about the structure, processes, or effects of personal health services. A study is classified as health services research if it satisfies two criteria: it deals with some features of the structure, processes, or effects of personal health services; At least one of the features is related to a conceptual framework other than that of contemporary applied biomedical science (IOM, 1979:14) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions Definition (9) Health services research... is concerned with problems in the organization, staffing, financing, utilization, and evaluation of health services..[it] subsumes both medical care and patient care research. It could well be termed "sociomedical" research. (Flook and Sanazaro, 1973:1) Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions 5

6 HSR: Selected Characteristics it lacks a widely adopted standard definition or conceptual structure, in part because of its markedly multidisciplinary nature; it is conducted in many different settings (e.g., academia, government, clinical health care settings); it has diverse purposes (e.g., empirical data collection, development of research instruments and methodologies, policy and operational decision making); Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions HSR: Selected Characteristics (2) it focuses on several different geographic levels (e.g., international, national, state, county) and on broad populations as well as specific population subgroups; it uses a particularly disparate set of theories, concepts, statistics, and devices and instruments derived from various disciplines; and it uses a wide range of time frames for data collection and analysis (e.g., historical, most current, future trends). (IOM, 1991:6) What is Health Services Research? Department of Health Services, School of Public Health, the University of Washington: research definitions 6

7 What is HSR? Health Services Research Components from the IOM Report, 1979 A focus on the health states of individuals or populations, or both; review or analysis of health systems, health interventions, and the factors that influence health states; a comprehensive set of variables involving health care techniques, practices, programs and policies; and combination and integration of these variables in many ways, frequently emphasizing the nonbiological aspects of health and medical care (IOM, 1991:8 Department of Health Services, School of Public Health, the University of Washington. What is Health Services Research? : research definitions the simplest terms of HSR The science/field of study that asks: What works? For whom? At what cost? Under what circumstances? AcademyHealth. What is HSR? 7

8 Why HSR Public attention and demands to address the well recognized, complex, and interdependent problems of US health care cost, quality, and access. The socioeconomic political debates about healthcare delivery in the United States have, if nothing else, made it clear that effective solutions must be based more on evidence than rhetoric. Why HSR (2) Adding to the urgency of HSR studies is the rapid transition underway toward delivery models based on population health, which are significantly affected by many confounding factors, of which the impact on specific cohorts in various settings is poorly understood. 8

9 Why HSR (3) Rigorous population based HSR studies provide many challenges, including the need to develop larger and more complex big data repositories that include the necessary social and biomedical covariates, as well as appropriate and sometimes novel biostatistical and informatics approaches for analysis of the questions under study. Why HSR (4) Variation in care (Dartmouth Atlas of Health care): Overuse, underuse, misuse factors behind Cost quality of care? Most needy patients get services? Geographical difference for the same surgical procedure (why) Same surgical procedure different outcomes (why) Difference in experience of the surgeon Difference in patient s conditions How to differentiate Inappropriate outcome indicators (composite index VS mortality or mortality VS patients reported outcomes) 9

10 HSR: Areas & Targets Disciplines need for HSR Multidisciplinary approach Biostatistics/Epidemiology Engineer Economics/Business/Law/Policy Sociology/Social Science/Humanity/Anthropology Behavior sciences/psychiatry Implementation Dissemination Comparative effectiveness Translational research (clinical to population/patientpopulation/basic population/translation to practice/translation to populations) 10

11 Methods & Designs for HSR Qualitative study to identify reason behind phenomena In depth interview, focus group discussion, & observations Descriptive study Cost of care quality of life/care Observational studies (population based using administrative data) Quality of care Access to care of different ethnic groups Forecast of future trends Quasi experimental (intervention with a control group) Experimental (Randomized controlled trial) Compare efficacy & effectiveness Economics evaluation Cost utility analysis Example of HSR(1) Nellans K, Walijee J F (2014). Health Services Research: Evolution and Application. Hand Clin 30;

12 Example of HSR(2) Nellans K, Walijee J F (2014). Health Services Research: Evolution and Application. Hand Clin 30; Example: Research on implementing PD first policy in Thailand Vijj Kasemsup, MD, Ph.D. 1 Piyatida Jeungsamarn, MD 2 Phatipa Sakthong, Ph.D Faculty of Medicine, Ramathibodi Hospital, Mahidol University 2. Banpaew Hospital 3. Faculty of Pharmaceutical Science, Chulalongkorn University 12

13 Background 1 Thailand is a country with 65 million population in 2009 Live expectancy at birth: 73.1 years 75.5 years in female and 70.7 years in male In 2002 Thailand had achieved universal coverage of healthcare for all citizens with 3 public insurance schemes CSMBS for government employee and dependants SHI for private sector employee UC scheme for the rest of the population The numbers of beneficiaires of the three public health insurance schemes in Thailand in 2007 (million) CSMBS, 6 SSS, 10 UC, 47 CSMBS SSS UC 13

14 Beneficiaries by income quintiles, 2004 Source: NSO HWS % 80% 60% 52% 49% 10% 17% 23% 40% 26% 31% 25% 20% 0% 11% 14% 25% 7% 4% 5% 1% CSMBS SSS UC Q1 (poorest) Q2 Q3 Q4 Q5 (the richest) 50% of UC members belong to poor 40 percentile of Thai population, while CSMBS and SHI are wealthier, 52% and 49% belong to the wealthiest quintile respectively Background 2 While beneficiaries of CSMBS and SHI had full access to RRT. Access to RRT by UC members therefore Relied on capacity to pay Resulted in financial catastrophe, indebtedness and impoverishment to household was a widespread phenomena until January 1, 2008 when the Cabinet decision to grant universal RRT to UC Scheme

15 Background 3 Dialysis services are expensive just to prolong life until a new kidney is transplanted Annual cost of treatment is very high: US$ 5,000 10,000 per patient per year in 2007 Thailand GNI per capita in 2007 was 7,880 PPP US$, or 3,400 US$. 29 Background 4 RRT had proven not to be cost effective Cost per QALY saved was 52,000 to 63,000 PPP US$. This is 6.6 to 7.99 times of GDP per capita Thailand GNI per capita in 2007 was 7,880 PPP US$, or 3,400 US$. Benchmark in Thailand for public investment in health, is <1 GNI per capita per QALY. 15

16 Background 5 However, RRT services May cause catastrophic spending and impoverish households Inequitable access to RRT across 3 public insurance schemes is unfair to the poorest Universal coverage of RRT results in a substantial budget increase for the government 31 Expected Numbers of ESRD Patients and Expected Expenditure of The New Policy Year CAPD (cases) HD (cases) KT (cases) Total expenditure (US$ million) , ,286 1, ,398 3,536 1, ,489 5,889 1, ,720 9,498 2, ,643 13,626 2, ,480 18,038 3, ,286 22,691 4, ,497 27,160 5, ,087 32,148 6,

17 Background 6 Cabinet Resolution, October 2007 Universal RRT for UC scheme In light of cost ineffectiveness and long term huge fiscal obligations for the government But no coverage causes catastrophic and impoverishment to even middle income households Inequitable access across insurance schemes using public money Despite options on rationing provided by IHPP, the cabinet explicitly decided against rationing but provided universal RRT to all UC members 33 Background 7 Concerning about efficiency of the system (potential cost saving), transportation cost for patients, and impacts of shortages of nurses in public sectors The new PD first policy fully supports: peritoneal dialysis (PD) kidney transplantation (KT) 17

18 Implementing PD first policy 1 Only 23 main public hospitals in Thailand participated during the first year of the PD first policy. Also 20 PD patients has been limited in 80% of the participating hospitals. Many questions about the viability of the program came from professional groups. Implementing PD first policy 2 Distributing PD solution is a major problem: Policy makers asked distributors to send PD solution to health centers instead of patients homes. Some patients didn t have money to rent a truck to pick up the solution. 18

19 Implementing PD first policy 3 Quality of the PD connector and packaging Many providers complained about the difference of a connector of a PD bag from the India plant wasn t similar to the connector from Singapore. Packaging of PD solution was changed from 6 bags per package to 8 bags per package which increase weight of each package and may cause damage to the bags inside. Implementing PD first policy 4 Implantation methods of peritoneal catheter: Bedside by nephrologists In operation room by surgeons Brake in time: 14 days brake in time No brake in time after an implantation of the catheter. 19

20 Implementing PD first policy 5 Training and home care are the keys for success of the PD first program, but imposes substantial burdens on PD nurses. A PD solution company has been providing vital support for those two activities in half of the participating hospitals. However, National Health Security Office (NHSO), Thailand, has tried to build hospital abilities in those two activities by establishing PD networking and training programs. Results of the PD first policy 6 Since the inception, the number of patients has been gradually increasing to more than 1,100 cases in 2009 in 23 participating hospitals in the first phase. Participating hospitals in PD first policy has gone up from 23 in 2008 to 109 in 2009 the total number of registered PD patients are 3,

21 Survival and Complications A study that followed up 114 PD patients for a year with the mean follow up of 243 days showed that: PD survival: 86.1% Patients survival: 91.2% Peritonitis: 20.7 months per episode Utility of PD patients in the study EQ-5D NS 0.68±0.29 (range: ) 1 st interview 2 nd interview 0.72±0.31 (range: ) VAS * 0.66±0.26 (range: ) 0.74±0.19 (range: ) NS = No significant * P <

22 Cost of PD care (in US$) OR Break in Training Nor Visit Un Vis it Ex Visit Adm รวม Labor drugs ,286 Lab other patients , total , ,658.5 Total , US$ = 34 Baht Cost of PD care (%) Or Break in Training Nor Visit Un Visit Ex Visit Adm รวม Labor 1.1% 0.6% 7.7% 2.6% 0.4% 0.3% 0.0% 12.5% drugs 2.2% 0.0% 2.3% 32.4% 0.6% 0.3% 10.5% 48.4% Lab 2.2% 0.0% 0.0% 4.1% 0.4% 0.1% 2.1% 8.8% other 3.6% 0.7% 2.3% 0.8% 0.2% 0.1% 5.1% 12.7% patients 4.6% 1.2% 3.4% 2.5% 0.5% 0.3% 5.0% 17.6% total 13.7% 2.5% 15.7% 42.3% 2.0% 1.1% 22.7% 100.0% Total 31.9% 68.1% 100% 22

23 Cost of PD care/year (in US$) In the 1 st year Subsequent years Hospital cost of PD care 2, , PD Solution and Erythropoietin Total 7, US$ = 34 Baht Conclusion for the first year of PD first policy Despite several obstacles, the implementation of PD first policy in Thailand has been gradually improving. Quality of life of patients is comparable to international standard. Patients survival should closely be followed as it is a key outcome indicators. Even though, cost of PD per patients is acceptable (slightly higher than expected) but it should be better to compare financial burden of patients who received PD or hemodialysis. 23

24 , Health Services Research: in conclusion Aspects of health services research: delivery of care management of health services assessment of healthcare needs measurement of outcomes allocation of healthcare resources evaluation of different health markets and health services organizations international comparative analysis of health systems health economics and the impact of health policies and regulations. BMC Health Services Research. About BMC Health Services Research HSR (Stanford): in conclusion Health services research is concerned with the organization, financing, delivery and outcomes of health care. Students learn to address complex health care problems with a working knowledge of biostatics, business, economics, engineering, epidemiology, ethics, medicine, psychology, public policy, law and sociology. Its primary activities include: Research and analysis of health care delivery and medical interventions, with the aim of providing higher quality, more efficient and less expensive medical care to populations. Health Services Research Division, Department of Health Research and Policy, Stanford School of Medicine 24