PROGRESS ON HCQI RESEARCH AND DEVELOPMENT WORK Ian Brownwood, HCQI Project, OECD HCQI Expert Group Meeting 21 and 22 may 2015
R&D Agenda for 2014 Primary Care Indicators Avoidable Hospital Admission Indicators led by the United Kingdom Composite Indicator for Avoidable Hospital Admissions led by Canada Standardised Definition and Calculation of Lower Extremity Amputation Rates led by Italy Acute Care Indicators Hip Fracture Surgery within 48 Hours after Hospital Admission led by the Netherlands and Germany Mental Health Indicators International Suicide Indicators led by Denmark Excess Mortality from Serious Mental Illness led by the United Kingdom Cross-Cutting Themes Use of Health Care Quality Indicators in National and Regional Reports led by the Netherlands. In addition to this work, the HCQI secretariat has carried out ongoing development and refinement of other indicators with the HCQI set, including: Prescribing in primary care Patient safety.
2014-15 HCQI Data Collection Significant changes resulted from agreed outcomes of HCQI Expert Group meeting in Nov 2015 Changes reflected in guidelines and technical specification for the 2014-15 HCQI Data Collection Changes reviewed by lead countries Reflection on the R&D data from the 2014-15 HCQI Data Collection
PRIMARY CARE INDICATORS Ian Brownwood, HCQI Project, OECD HCQI Expert Group Meeting 21-22 May 2015
1. Avoidable Hospital Admissions Changes to indicator specifications: Multiple data records for the period of patient care from formal admission to formal discharge Treatment of transfers to both maximise identification and avoid double counting Exclude cases with obstetric diagnosis code in any diagnosis field where MDC assignment not possible
Changes to Indicator Specifications Compliance Multiple Records About 50% of countries have multiple records 100% of countries report using all records Exclusion of Transfers About 75% of countries excluded transfers Only about 50% of these countries were confident they only excluded double counting cases Assessment of impact of transfers warranted
Changes to Indicator Specifications Exclusion of Obstetric Cases About 70% of countries used the code list, with most of the countries confirming they used all diagnosis fields Impact Comparison of initial and updated 2011 rates Some countries have revised rates, notably Sweden and Canada (e.g. excludes only acute hospital transfers) Added value to robustness of data
1. Avoidable Hospital Admissions Use of Secondary Diagnosis for Diabetes: diabetes-related complication in PDx along with a diagnosis of diabetes in SDx list of agreed complications not available for HCQI data collection existing coding conventions (i.e. asterisk and dagger codes) HCQI data collection assessed alternative coding practices
Use of Secondary Diagnosis for Diabetes Diabetes admissions identified using SDx as a proportion admissions identified using PDx, 2013 40.0% 35.0% 30.0% 25.0% 20.0% 15.0% 10.0% 5.0% 0.0% Note: Luxembourg data excluded awaiting further validation
Use of Secondary Diagnosis for Diabetes Rate for some countries (e.g. Korea) is likely to be understated compared with other countries, given current coding practices
1. Avoidable Hospital Admissions Further R & D on Diabetes Indicator existing code pairs do not reflect all risk-outcome relationships for diabetes modest approach to exploring use of SDx in 20124-15 HCQI Data Collection was modest HCQI Bureau meeting (Feb 2015) members (Canada, Italy, UK, US) showed interest in further consideration of SDx use
Further R & D on Diabetes Indicator Expert teleconference in March 2015 involving Bureau members and invited clinical and coding experts in diabetes: Professor Massimo Massi Benedetti, Co-coordinator of BIRO and EUBIROD projects, Italy Naomi Holman, Head of Health Intelligence for Diabetes, National Cardiovascular Intelligence Network, Public Health England, United Kingdom Bob Young, Consultant Diabetologist and Clinical Lead for the National Diabetes Audit and the National Diabetes Information Service, United Kingdom Professor Patrick Romano, UC David School of Medicine, United States Yana Gurevich, Manager, Health Indicators and Client Support, Canadian Institute for Health Information (CIHI), Canada Alana Lane, Classifications Specialist, CIHI, Canada Janet Manuel, Classifications Specialist, CIHI, Canada
Further R & D on Diabetes Indicator Background paper: Intent of the indicator Existing coding conventions Implications for composite indicators Use of secondary diabetes codes Broad agreement on further R&D work
Further R & D on Diabetes Explores the use of secondary diagnosis fields based on existing code sets (e.g. Canada, UK, Australia) Caters for variations in coding practices by allowing use of both PDx and SDx fields Seeks to better understand coding practices of countries
Use of Secondary Diagnosis 2014-15 HCQI Data Collection: Proposed use of ICD 10 Chapter IX (Diseases of the Circulatory System) SDx Diabetes CHF and Hypertension Use of SDx has flow-on implications for planned composite indicator. Broader issues of dealing with comorbidity
CHF Avoidable Hospital Admissions CHF: Proportion of Total Admissions with a Diabetes Secondary Diagnosis, 2013 60% 50% 40% 30% 20% 10% 0% Finland Portugal Netherlands Slovenia Spain Canada Israel
Hypertension Avoidable Admissions Hypertension: Proportion of Total Admissions with a Diabetes Secondary Diagnosis, 2013 35% 30% 25% 20% 15% 10% 5% 0% Slovenia Netherlands Finland Portugal Canada Israel Spain
2. Composite Indicator Collect data on all 5 indicators with a view to publication of composite indicator in Health at a Glance 2015. Collection of supplementary data: in-hospital mortality coding depth, coding standards missing data
International Variation Lowest Rate (per 100,000) Highest Rate (per 100,000) Variation (2013) Variation (2011) Diabetes 44 370 8-fold 8-fold Asthma 10 117 11-fold 14-fold COPD 24 395 17-fold 16-fold Asthma + COPD 58 436 8-fold 8-fold CHF 74 548 7-fold 10-fold Hypertension 9 397 46-fold 374-fold CHF + Hypertension 128 834 7-fold 14-fold Overall Composite 380 1338 4-fold 4-fold
Mortality data Explore impact of excluding admissions where death occurred, given these admissions are likely not to be avoidable Over a third of countries did not provide data Downward impact on rates: Asthma (- 0.6%) Hypertension (- 1.6%) Diabetes (- 2.5%) COPD (- 4.1%) CHF (- 8.9%)
Impact of excluding mortality Difference between avoidable admission rate with and without inclusion of in-hospital deaths 18.0% 16.0% Average 14.0% 12.0% 10.0% 8.0% 6.0% 4.0% 2.0% 0.0% Asthma Hypertension Diabetes COPD CHF
Impact of excluding mortality CHF hospital admission in adults aged 15 and over, 2013 (or nearest year) per 100 000 population 600 Without excluding deaths Excluding deaths 500 400 300 200 100 0
Impact of excluding mortality International Variation With and Without Inclusion of In-hospital Deaths. Variation including deaths Variation excluding deaths Asthma 8.6-fold 8.6-fold COPD 5.5-fold 5.6-fold CHF 7.4-fold 7.6-fold Hypertension 46.3-fold 48.0-fold Diabetes 7.1-fold 7.1-fold
Coding Depth Number of secondary diagnosis fields in country datasets. Question referred to dataset capacity rather than actual use Third of countries = unlimited Some of these countries provided further insights (e.g. Denmark = 19, Finland = 3) Data revealed significant variation Confront with data on SDx from Patient Safety
Coding Depth Country No SDx Fields Canada 31 Czech Republic 4 Ireland 29 Italy 5 Korea 19 Luxembourg 3 Mexico 0 Netherlands 10 Norway 20 New Zealand 99 Poland 5 Slovenia 19 Spain 14 Switzerland 50
Coding Standards Coding variations specific coding standards or practices exist for conditions covered by the indicators About 70% of counties report they do not have standards Seven countries (Canada, Chile, Ireland, Mexico, New Zealand, Slovenia and Spain) provided information on their standards. Degree of convergence - use or adaption of Australian coding standards in 3 countries
Missing Indicators Only 4 countries reported not being able to provided data on all avoidable hospital admission indicators, with coding capacity (e.g. lack of procedure codes) issues being highlighted
Recommendations Further R&D Further assess impact of excluding transfers on avoidable admission rates Further explore use of secondary diagnosis in calculation of diabetes avoidable admissions include consideration of coding depth and coding standards and practices Assess overall capacity to report in-hospital mortality.
Recommendations Publication in Health at a Glance 2015 publish both overall composite and subcomposite charts for avoidable admission indicators. publish avoidable hospital indicator rates including in-hospital deaths
PROGRESS REPORTS ON HCQI DATA COLLECTION 2014-15: AVOIDABLE HOSPITAL ADMISSIONS Ian Brownwood, HCQI Project, OECD HCQI Expert Group Meeting 21-22 May 2015
Avoidable Hospital Admissions Update - since preparation of agenda paper: Iceland, UK, US provided data Italy, Mexico updated data on diabetes Data reflected in following charts Data source - Colombia reported data is not nationally representative subject to further validation Compliance - 13 countries did not exclude transfers and/or were not able to exclude only those transfers that would have resulted in double counting
Asthma Avoidable Admissions Asthma hospital admission in adults aged 15 and over, 2013 (or nearest year) per 100 000 population 120 100 80 60 40 20 0
Asthma Avoidable Admissions Indicator was published in Health at a Glance 2013 International variation = 11-fold (2011 = 14-fold) Rate in most countries decreased over past five years between 2008 and 2013 (or nearest years), except for Denmark (3.9% increase), Netherland (13% increase), Slovenia (6.4% increase) and Sweden (15.3% increase) Observed annual pattern or trend over previous five years is relatively consistent with these changes, except for Demark where a decreasing trend has been evident Only Mexico did not exclude all cases with a cystic fibrosis and anomalies of the respiratory system diagnosis code in any field Data received from 32 countries. Data for 3 countries presented using data from previous data collections (Australia, Germany, Hungary). Data will be updated if suitable data is received prior to publication deadline for Health at a Glance 2015 It is planned that data from all countries will be published, except for Colombia (subject to further validation)
COPD Avoidable Admissions COPD hospital admission in adults aged 15 and over, 2013 (or nearest year) per 100 000 population 450 400 350 300 250 200 150 100 50 0
COPD Avoidable Admissions Indicator was published in Health at a Glance 2013 International variation = 17-fold (2011 = 16-fold) Rate in most countries decreased over past five years between 2008 and 2013 (or nearest years), except for Canada (20.1%), France (+41.9%), Netherlands (+0.1%), Slovak Republic (+39.7%), Sweden (+17.4%) and Switzerland (+16.3%) Observed annual pattern or trend over previous five years is relatively consistent with these changes, except for Slovak Republic and Switzerland where a decreasing trend has been evident and Sweden where the rate has kept relatively steady Data received from 32 countries. Data for 3 countries is from previous data collections (Australia, Germany, Hungary). Data will be updated if suitable data is received prior to publication deadline for Health at a Glance 2015 It is planned that data from all countries will be published, except for Colombia (subject to further validation).
CHF Avoidable Admissions CHF hospital admission in adults aged 15 and over, 2013 (or nearest year) per 100 000 population 600 500 400 300 200 100 0
CHF Avoidable Admissions Indicator was not published in Health at a Glance 2013 International variation = 7-fold (2011 = 10-fold) Rate in most countries has decreased over the past five years between 2008 and 2013 (or nearest years), except for Canada (13.5%), Czech Republic (14.2%), Portugal (2.3%), Slovak Republic (5.6%), Slovenia (823.4%), Spain(9.2%), Sweden (13.9%) and Switzerland (0.6%). Significant increase in rate for Slovenia in 2013 is most likely attributable to a change in data reporting methodology. Observed annual pattern or trend over previous five years is relatively consistent with changes between 2008 and 2013, except for Canada and Portugal where a decreasing trend has been evident and Sweden where the rate has kept relatively steady. Rates for Canada and Sweden are consistent with a change in data reporting resulting from changes in the HCQI data specifications for 2014-15 (e.g. treatment of transfers). Only Mexico, Slovak Republic and Colombia did not exclude all cases with cardiac procedure codes. While Belgium, Czech Republic and Switzerland excluded all cases with cardiac procedure codes, they were not able to effectively map specified ICD-9-CM codes to the procedure classification in their country. Data received from 29 countries. Data for 4 countries is presented using earlier data from previous data collections (Australia, Germany, Hungary,, Latvia). Data will be updated if suitable data is received prior to the publication deadline for Health at a Glance 2015. It is planned that data from all countries will be published, except for Colombia (subject to further validation).
Hypertension Avoidable Admissions Hypertension hospital admission in adults aged 15 and over, 2013 (or nearest year) per 100 000 population 450 400 350 300 250 200 150 100 50 0
Hypertension Avoidable Admissions Indicator was not published in Health at a Glance 2013 International variation = 46-fold (2011 = 374-fold). Rate in most countries decreased over past five years between 2008 and 2013 (or nearest years), except for Israel (3.4%), Netherlands (7.8%), Portugal (15.6%), Slovak Republic (0.1%) and Slovenia (848.9%). Significant increase in rate for Slovenia in 2013 most likely attributable to a change in data reporting methodology. Observed annual pattern or trend over previous five years is relatively consistent with the changes between 2008 and 2013, except for Slovak Republic and Israel where a decreasing trend has been evident, Mexico where an increasing trend has been evident and Czech Republic where the rate has kept relatively steady. Only Mexico, Slovak Republic and Colombia did not exclude all cases with cardiac procedure codes. While Belgium, Czech Republic and Switzerland excluded all cases with cardiac procedure codes, they were not able to effectively map the specified ICD-9-CM codes to the procedure classification in their country. Data received from 29 countries. Data for 4 countries has been presented using data from previous data collections (Australia, Germany, Hungary, Latvia). This data will be updated if suitable data is received prior to the publication deadline for Health at a Glance 2015. It is planned that data from all countries will be published, except for Colombia (subject to further validation).
Diabetes Avoidable Admissions Diabetes hospital admission in adults aged 15 and over, 2013 (or nearest year) per 100 000 population 500 450 400 350 300 250 200 150 100 50 0
Diabetes Avoidable Admissions Indicator was published in Health at a Glance 2013 Combines the uncontrolled diabetes without complication, diabetes short-term complications and diabetes long-term complications indicators. International variation = 8-fold (2011 = 8-fold) Rate in most countries has decreased over past five years between 2008 and 2013 (or nearest years), except for France (717.4%), Netherlands (13.6%), New Zealand (17%), Poland (18.0%) Singapore (63.9%) and Slovenia (50.1%). Observed annual pattern or trend over the previous five years is relatively consistent with the changes between 2008 and 2013, except for France where a decreasing trend has been evident and Slovenia, Spain and Switzerland where the rate has kept relatively steady. Over 40% of countries using ICD 10 or equivalent classification reported not being able to effectively distinguish between uncontrolled and controlled diabetes. 5 countries reported use of ICD-9-CM. Data was received from 28 countries by the 15 April 2015 for this indicator. Data for six countries has been presented using earlier data from previous data collections (Australia, Germany, Hungary, Iceland, United Kingdom and United States. This data will be updated if suitable data is received prior to the publication deadline for Health at a Glance 2015. It is planned that data from all countries will be published, except for Italy, Mexico and Colombia (subject to further validation).
HEALTH AT A GLANCE 2015 AVOIDABLE HOSPITAL ADMISSIONS
Recommendations Avoidable Hospital Admissions: Overall composite indicator (including Diabetes, Asthma, COPD, CHF and Hypertension) Respirator sub-composite (Asthma and COPD) Cardiovascular sub-composite (CHF and Hypertension) Diabetes Indicators Diabetes hospital admission Lower extremity amputation indicators Prescribing in primary care (diabetics)?
Overall Composite Avoidable Hospital Admissions for Selected Chronic Conditions, 2013 (or nearest year) Age-sex standardised rates per 100,000 1600 Asthma and COPD CHF and Hypertension Diabetes 1400 1200 1000 800 600 400 200 0
Composite for Respiratory Conditions Avoidable Hospital Admissions for Selected Respiratory Conditions, 2013 (or nearest year) Age-sex standardised rates per 100,000 500 450 400 350 300 250 200 150 100 50 0 Asthma COPD
Composite for Cardiovascular Conditions Avoidable Hospital Admissions for Selected Cardiovascular Conditions, 2013 (or nearest year) Age-sex standardised rates per 100,000 900 800 700 600 500 400 300 200 100 0 CHF Hypertension
Diabetes Diabetes Avoidable Hospital Admissions Conditions, 2013 (or nearest year) Age-sex standardised rates per 100,000 500 450 400 350 300 250 200 150 100 50 0
HEALTH AT A GLANCE 2015 DIABETES LOWER EXTREMITY MAJOR AMPUTATION
Diabetes Lower Extremity Amputation Total Population per 100 000 population Admission-based diabetes lower extremity amputation, 2013 (or nearest year) 16 14 12 10 8 6 4 2 0
Diabetes Lower Extremity Amputation Estimated Diabetes Population Diabetes Major Lower Extremity Amputations Rate (Estimated Diabetic Population), 2013 (or nearest year)