Service delivery and health care improvement in Georgia

Thoughts from a recent case study

Dr. Francoise CluzeauSenior AdviserNICE International

Quality improvement (QI) at the heart of health care reforms

• EBM clinical guidelines and Quality Standards , if appropriately implemented can be effective levers for:

– performance management schemes

– inform regulatory initiatives at national or regional levels

– investment decisions to identify best value interventions in high priority diseases and conditions

• To work they need – Clear strategic direction– Engagement from governments, health insurers, providers

• Underpinned by– reliable information system– Regular and robust monitoring

QI in Georgia• Georgian Health Sector Development Project aims at

improving the equitable coverage and utilization of quality health care services

• Legislation article 16, b/1;• MOLHSA: the National Council on Elaboration, Evaluation

and Establishment of the national clinical practice recommendations (guidelines) and disease management standards. – multidisciplinary committee chaired by Deputy Health Minister– has approved over 80 guidelines 40 being developed– guidelines developed by professional associations, based on

guidelines from other countries, often funded by donor agencies

• Coordinating team based at MoLHSA

Collaboration with NICE International

• NICE International provided technical assistance to the MOLHSA to strengthen its existing framework for production and implementation of guidelines in Georgia: – building local technical capacity– adapting an existing NICE CPG in a high priority area, to the

Georgian setting – helping develop implementation support tools to increase the

uptake of evidence-informed standards in day-to-day policy and practice in Georgia

– Developing a Georgian policy document for producing CPG and Quality standards framework based on the experience from the project

• Twelve months project funded by the World Bank

The project• Training

– systematic reviewing– Introduction to health economics– Guideline development

Pilot adaptation– topic selection (stroke)– setting questions relevant to Georgia, reviewing NICE

recommendations, undertaking new reviews, updating evidence, making recommendations

– Selecting high priority recommendations for implementation and developing standards

– carrying out a cost impact for some recommendations for implementation

Key features of the project

• Guideline adapted by multidisciplinary group (professionals and patients) chaired by stroke expert, peer reviewed by international expert

• MoLHSA full involvement– MoLHSA technical and administrative team to

support the guideline group– the Guidelines Council reviewed and approved final

products• Involvement of policy makers

– Policy workshop in Tbilisi• Health insurance, providers, MoLHSA reviewed quality

standards

Why stroke? stroke case fatality (%)

Feigin et al, Lancet Neurol 2003;2:43-53; Mihalka et al, Stroke 2001;32:2227-2231; Feigin et al, Stroke 2005;26:924-929; Airian et al, Eur J Neurol 2004;11(suppl 2)15; Tsiskaridze et al, Stroke 2004;35:2523-2528; Kulesh et a, Zh Nevr I Psych. 2007.

28.1

34.8

35.4

40.4

30.6

23.3

21.4Middle dev. countries

Ujgorod, Ukraine (2001)

Novosibirsk (1992)

Russia (2001)

Russia (2003)

Tbilisi (2003)

Grodno, Belarus (2003)

Problems with stroke management in Georgia

• Lack of information on stroke signs at population level

• Inappropriate pre-hospital management /Delayed hospitalization

• No stroke units and stroke teams

• Imaging only available daytime

• No evidence-based national guideline

• Lack of evidence-based interventions

– Excessive use of drugs of no proven effectiveness

– Inappropriate use of anticoagulants• Unjustified high neurosurgical interventions for intracerebral

hemorrhage • Late mobilization and rehabilitation of stroke patients

Goals for 2015 (for all European countries)

• Continuum of care provided for all stroke patients

• Emergency transportation (< 3 hr) and treatment in stroke units (goal – decrease case fatality to 20% or less)

• 70% of post-stroke persons should be functionally independent in 3 months after stroke (adequate rehabilitation for all patients)

• Adequate secondary prevention accessible for all patients

• Each country shall develop stroke management quality assessment system and implement it in practice (clinical audit)

Outcomes from the MOLHSA-NICE project

A Georgian stroke guideline (for hospitals), adapted from an international guideline, based on evidence tailored for Georgian practice

– a full document with evidence– a quick reference Guide for use by health professionals caring

for stroke patients– a guide written for stroke patients and their carers– Quality standards for 5 high priority and easy to implement

recommendations targeting key areas of clinical performance improvement

– A cost impact of key recommendations (with high costs or potential savings)

– A technical & process manual for developing guidelines in Georgia

• Plan to establish a stroke unit in a large hospital in Tbilisi• Guidelines do not improve practice by themselves. Need

to implement other selected high priority recommendations and quality standards to ensure improvement in stroke care in hospital

o multistakeholder pilot project in few hospitals (urban and regional)

o Explore accredidation measures and P4P with support from MoLHSA, insurers and providers

• Use results and learning from pilot to inform strategy for QI programme in other disease areas

What next?

Further thoughts

• Clinical guidelines & standards = one vehicle for driving QI

• Explore accreditation and clinical audit

• Education: fellowship programs with professional associations, Continuous Medical education (CME)

• Use the contractual system to drive QI, using EBM standards, guidelines and other QI vehicles

• Use and enhance existing national guidelines structure (MoLHSA and Guidelines Council) for prioritising guidelines topic and assessing quality of products

• Governance, who monitors QI and regulates?

• Ensure information infrastructure is in place for data collection and uptake monitoring