Evaluation of Outcomes in Health

Evaluation of Outcomes in Health

Orla Hardiman MD,FRCPI, FAAN

Director of Neurology

Beaumont Hospital

Health Services in Ireland

Community Based services (Primary Care)General PractitonersPublic HealthClinical Professionals

Hospital Based services (Secondary Care)Consultants NCHDsNursingClinical Professionals

Combined care programmes

Deloitte &Touche Report

Deloitte & Touche Executive Summary

Current Measures of Efficiency(defined by Deloitte Touche report)

• …”high utilisation of capacity, and increased use of day surgery…”

• .Casemix

Measuring Health Service

• Mortality Data: Rates and causes of death

• % Spending of total GDP

• Health Status /Disease Status of Population

Death Rates in Ireland

Health Status of Population:Measurables

Notifiable Diseases/ Conditions

Primary care based data acquisitionNational databases

Cancer RegistryIntellectual Disability databaseNational Physical and Sensory Database

Quantitation of activity in secondary careActivity levels in acute hospitalsWaiting lists

Health Status Indicators ( Dept of Health Statistics)

• Infectious Diseases• New cancers• Inborn errors of metabolism• Low birth weight• Accidental Injuries• Alcohol consumption• Satisfaction rating

Health Indicators:Satisfaction Rating

(Eurostat)











Strategies to Adjust Provision of Care based on Available Statistics

• Health Strategy

• Cardiovascular Strategy

• Cancer Strategy

• Waiting List Initiative / National Treatment Purchase Fund (NTPF)

Equity of Access to Hospital Care

Waiting Lists: Caveats

• Partial Data

• Data based on “census-type” measures rather than “throughput-type” data

• Reliability of data not verified (frequent validation of lists required)

• Determinants for inclusion on waiting list, and rate of ascension to the top of the list not subject to audit

Martin defends hospital waiting lists

04 May 2004 22:30

The Minister for Health, Micheál Martin, has said that there has been a significant fall in hospital waiting lists.

Figures released by the National Treatment Purchase Fund this afternoon show that 37% of patients have now been

waiting between three and six months. The figures also indicate that 43% of patients have been

waiting between six and 12 months for surgery..

Assessment of Neurological Services as a Model of Health

Care Provision

What is a Neurological Condition?

• A condition that affects the brain, spine or muscle

• Can be roughly divided into 3 categories– Physically disabling– Non-Physically disabling– Loss of cognitive ability (Dementia)






Prevalence of Neurological Conditions in Ireland

• Approx 500,000 suffer from a neurological disorder in the Republic of Ireland

• Not notifiable

• No publicly funded national databases

• No curative treatment

• Not suitable for NTPF:

• Frequently undiagnosed : Poor access to relevant specialist

• Reliable data generated by investigators. No official data

5.75.75.7

4.85.3

4.7

4.1

2.02.0

1.41.6

2.32.31.9

0.0

1.0

2.0

3.0

4.0

5.0

6.0

1995 1996 1997 1998 1999 2000 2001

Year

Pe

r 1

00

,00

0 p

op

ula

tio

n

Prevalence rates

Incidence rates

Epidemiology of MND in Ireland

Frequency of Review by a Neurologist in Ireland

0%20%40%60%80%

100%

MS

MND

Measuring Neurological Services: Available Data

• Health Status /Disease Status of Population UNKNOWN

• % Spending of total GDP UNKNOWN

• Number of doctors per capita

• Waiting lists and Hospital Activity

Distribution of neurologists in Europe

8 100

18 400

21 200

21 300

23 200

23 900

29 100

33 100

35 600

38 500

177 000

333 300

25 800

0 400000

Ireland

UK

France

Sweden

Portugal

Switzerland

Netherlands

Luxembourg

Austria

Greece

Denmark

Norway

Italy

Population per neurologist

Distribution of neurologists in Europe

0 25 50 75 100 125

Ireland

UK

France

Sweden

Portugal

Switzerland

Netherlands

Luxembourg

Austria

Greece

Denmark

Norway

Italy

Neurologists per million population

Neurologists in Europe

Problems in Current System based on Waiting Lists

• Excessive reliance on unverified / inaccurate data, including waiting list data

• Minimal audit of waiting list management:– Equity

• Assumption that “outcome” is associated with “procedure” (usually surgical)

Problems with Current System based on Waiting Lists

• Absence audit data for non-surgical hospital-based clinical activity

• Absence of audit /efficiency monitoring data for out-patient services

• Absence of tools to measure outcomes for chronic conditions for which procedures are not indicated

• Absence of measurement tools to assess continuity of care between hospital and community services

• NO INCENTIVE TO PRACTICE EVIDENCE-BASED MEDICINE

Waiting Lists

In Patient Services to Neurology Beaumont Hospital 2003

0

20

40

60

80

100

120

140

Admissions

Admissions from A+E

Top Ten A&E Admissions

51

29 27

9 7 6 4 4 3 2

0

10

20

30

40

50

60

No

of

Ad

mis

sio

s

Readmission Rates

128

17

91

10

67

4

43

10

2413

0

20

40

60

80

100

120

140

Number of Admissions

Length of Stay for top 4 Diagnoses

8.7

14.3

1211

8.8

12

27.9

23.2

15.9

11

18.5

12.5

0

5

10

15

20

25

30

Mean length of Stay in Days

Epilepsy MS Stroke MND

Diagnosis

A&E

Transfers

Elective

How Do We Compare?Top 5 Dx, Beaumont and

Massachusetts General Hospital

Mean Length of Stay

02468

101214161820

Day

s MGH

Beaumont

Cost Analysis

17380

31284

20692

41452984

0

5000

10000

15000

20000

25000

30000

35000

Cost in €

Epilepsy Stroke MS MND CIDP

Cost Analysis for Year 2003 (Diagnositic Related only)

Disease Assessment:Measurables

• Survival rates• Symptoms, signs, disability measures

and complications of condition and treatment• Health Status and Quality of Life• Experiences of patients and their carers• Costs of use of resources

(UK Department of Health, 1992)

Preliminary Studies of Outcome for Neurological Conditions

Survival

Survival of Irish ALS patients according to the clinic type attended

• Median survival of ALS clinic patients = 677 days versus 448 days for general neurology clinic

• Beneficial effect persisted throughout follow-up: four year mortality rate decreased by 13.4% in the ALS clinic cohort

0

.2

.4

.6

.8

1

Cum

ulat

ive

surv

ival

0 250 500 750 1000 1250 1500 1750 2000 Time from diagnosis (days)

ALS clinic (n = 82)

General Neuro clinic (n = 262)

229 days

29.7%

10.7%13.4%

Treatment with Riluzole

0

.2

.4

.6

.8

1

Cu

mul

ativ

e s

urv

iva

l

0 1 2 3 4 5 6 Time (years)

Riluzole (n = 149)

No Riluzole (n = 97)

97)

Outcome Assessment: Management of Symptoms,

Signs, Complications

Outcome Evaluation: Clinical Signs and Disability Measures

• Generic Scales

• Disease Specific Scales

• Individualised Measures

Natural Course of Multiple Sclerosis

Relapses and Disability Total MRI-Lesion load MRI-Activity

Secondary ProgressiveRelapsing Remitting

First exacerbation

Clinical MS

Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA

Relapses and Disability Total MRI-Lesion load MRI-Activity

Secondary ProgressiveRelapsing Remitting

Adapted from McFarland et al., 52nd Annual Meeting American Academy of Neurology, May 2000, San Diego, USA

First exacerbation

Clinical MS

Beta Interferon therapy modifies the course of Multiple Sclerosis

SPMS delayed

EARLY TREATMENT

CIDP: Evaluation of Treatment Outcome

Individualised Measurement pre- and post- IVIg

Maximal Voluntary Isometric Contraction

(Quantitative Muscle Assessment)

MVIC Values Lower Limbs

0

5

10

15

20

25

30

35

40

45

HFLL HFLR KEXL KEXR KFLL KFLR ADFL ADFRMovement

Kgs

Pre Rx

PostRx

Medianfor age

Graph 4 : The patient was tested before and after treatment on 8 occasions (abscissa) and the change in muscle strength in 18 muscles was plotted (ordinate). Following the

fifth treatment the patient felt that his muscle strength had deteriorated (not shown) . The patient was treated with plasmapheresis (cycle 6). This failed to improve his muscle

strength. A further course of IVIg did not improve his clinical status (cycle 7) He was then treated with a CD 20 antibody (Rituximab). He did not require further IVIg infusion for 5

months. Re-introduction of IVIg infusions following treatment with Rituximab (cycle 8) led to an improvement in muscle strength

Effect of Rx on muscle strength

-15

-10

-5

0

5

10

15

20

cycles of treatment

Dif

fere

nc

e in

mu

sc

le

str

en

gth

pre

v p

os

t rx


• Survival rates• Symptoms, signs, disability measures

and complications• Health Status and Quality of Life• Experiences of patients and their carers• Costs of use of resources


Quality of Life: What does it mean?

Quality of Life

Health-related QoL

Health Status (ALSAQ5) v Functional Disability Scale

(ALSFRS)

alsfrs-r

50403020100

alsa

q5100

80

60

40

20

0

N=31, r = -0.78, significant at p = 0.01

Relationship between Quality of Life & Functional Disability

functional disablilty

3.02.52.01.51.0.50.0

qu

ality

of

life

100

80

60

40

20

0

disease

PPS

MS

MND


• Survival rates

• Symptoms,signs and complications

• Health Status and Quality of Life

• Experiences of patients and their carers

• Costs of use of resources


Cost Analysis

17380

31284

20692

41452984

0

5000

10000

15000

20000

25000

30000

35000

Cost in €

Epilepsy Stroke MS MND CIDP

Cost Analysis for Year 2003 (Diagnositic Related only)

Costs of Managing MND

Demography by Year

0

5

10

15

20

25

30

35

1996 1997 1998 1999 2000

Year

no. ofnew Patients

Male Limb

Male Bulbar

Female Bulbar

Female Limb

Prevalence per100,000 pop. over15years of age

Audit Costs IRL£ Patient care Transport

YEARNew

Equip. attendants of equip. Storage Totals1996 109,000 15,000 17,000 5,000 146,0001997 117,000 27,000 25,000 5,000 174,0001998 191,000 28,000 33,000 5,000 257,0001999 114,000 33,000 34,000 5,000 186,0002000 108,000 51,000 40,000 5,000 204,000

Equipment cost- Total/year

050,000

100,000150,000200,000250,000300,000350,000400,000

1996 1997 1998 1999 2000

Year

IRL£

Equipment Funding

050,000

100,000150,000200,000250,000

1996 1997 1998 1999 2000

Year

IRL£

IMNDA

National Lottery

Gov. Grant

How Can Evidence-Based Medicine Be Used to Change the Practice of Medicine in Ireland?

Quis custodiet ipsos custodes?

Proposed Structure of Health Service

Proposed Structure of Health Service

CONCLUSION

Documents

Evaluation of Outcomes in Health