Quality indicators and healthcare
A first step to the evaluation of healthcare quality
Ana Cristina Barbosa Pereira,
Ana Rita de Sousa Vieira de Oliveira,
Ana Teresa Leite Fernandes Carapenha,
André de Jesus Magalhães Vinha,
Catarina Castro Vieira,
Eduardo Manuel Pinto Ferreira Silva Freitas,
João Manuel Dias Ferreira Rebelo,
Mariana Almeida Leite Gomes de Oliveira,
Nuno Filipe da Silva Ribeiro,
Paulo Renato Moreira Guedes,
Susete Marli Fonseca da Cruz,
Vitoriano Penhor José da Costa,
José Alberto Silva Freitas, PhD,
Class 10
ABSTRACT
The quality of health services is considered a serious public health problem since they influence a great part of the population. We can improve the quality of healthcare if we study the evolution of some indicators’ values (such as mortality, postponed surgeries or childbirth of caesarian operation). AIM: This paper aims to calculate the indicators’ values according to the proposed variables. METHODS: This is a retrospective and observational study that focused on data since 1999 until 2008 in a Portuguese central hospital. These data was treated with SPSS. To reach the initial aim, a syntax file (which contains a set of commands that is used to analyze the entire database and select the appropriate cases for each indicator) was needed. RESULTS: Regarding mortality, 4.0% of the patients died, having achieved the highest and lowest values in 1999 and 2004, respectively. Men had a higher rate of mortality, so as the +64 years-old group. The 0-14 age group had the lowest rate of mortality; the length of stay decreased from 2000 until 2003 and continued without significatively changes until 2008. These values resulted in a general mean of 8 days of internment; concerning postponed surgeries, 5% of all surgeries were postponed. 11% were for patient’s desire, 13% for contraindication and 76% for other reasons. CONCLUSION: Many conclusions can be drawn from mathematical and statistical results, since they do not carry any subjectivity which could justify some situations out of what would be considered “normal” for a particular hospital. Also, these indicators, by themselves, do not totally represent the performance of the hospital due to its complex organization in many services. Taking these facts into consideration, our study becomes only the initial step to the analysis of hospital healthcare.
KEY-WORDS: Quality of Healthcare, Quality Indicators, Patients, Performance Measurements, DRGs.
INTRODUCTION: BACKGROUND AND JUSTIFICATION
Quality is a concept widely used in our days when we want to evaluate a certain aspect. However, it is considerably difficult to find a universal definition that can be used and understood by everyone due to its subjectivity. As in all areas of interest, the quality in health is also a multidimensional concept and it includes not only the notion of clinical quality but also social, economical, ethical and physical aspects. [1] Taking this into account, it is easy to understand that the global quality of a health system is the average of the values assigned to each of the dimensions mentioned above.
In spite of the subjectivity of the concept “quality”, it is important to establish terms of comparison in order to analyze the performance of health systems and its evolution, and thus improve the conditions of health services. Besides, we must not forget the constant search for healthcare by a more and more aged population, and also by more informed and demanding people.[2] After all, patient satisfaction is important as it may reflect the quality of the health care. However, “patient satisfaction or dissatisfaction is a complicated phenomenon that is linked to patients' expectations, health status, and personal characteristics, as well as health system characteristics”. [3]
Therefore, governments are increasingly introducing performance management systems to improve the quality and outcomes of healthcare. [4] Even though it is not an easy task, as it is impossible to find the perfect evaluation system, it must be accomplished with responsibility in order to develop the best methods. “Given the importance of healthcare, it seems inconceivable that we do not have excellent ways of evaluating how well we are doing”. [5]
To do so, many surveys were made to discover which quality aspects of a hospital performance must be analyzed, not only to improve the quality of hospital care but also to find out patients and doctors’ opinion about the relevance of the quality indicators that are included in hospital reports. [6]
One of the used case mix classification systems are Diagnosis Related Groups (DRGs) and, more specifically, indicators. [7]
DRGs are “a system for classifying patient care by relating common characteristics such as diagnosis, treatment, and age to an expected consumption of hospital resources and length of stay. Its purpose is to provide a framework for specifying case mix and to reduce hospital costs and reimbursements and it forms the cornerstone of the prospective payment system”. [8]
Every Portuguese hospital keeps a permanent database about their patients to classify them in DRGs, and that information is sent periodically to Administração Central do Sistema de Saúde (ACSS). It’s at ACSS that data is processed for cost calculation in order to make more accurate budgets. [9]
Indicators can be defined as measurement units that allow monitoring and evaluation of key variables of an organization through comparison with its corresponding internal and external referential. [10] So, indicators are empirical instruments that allow us to show the theorical dimension of a key variable. Specifically, healthcare indicators are measurements that reflect relevant information about different attributes, health dimensions and factors that influence health system performance. [11-12] With the information given by these instruments, governments can know how much money was spent and where it was used (normally prices per DRGs), as well as understand where it is needed. [13-14]
Then, there are some indicators that can provide us useful information about the performance of a hospital, such as mortality, length of stay, postponed surgeries, outpatient department episodes, outpatient surgery, childbirth of cesarean operation, principal diagnosis, and finally surgical proceedings (and complications). [15] All of these will be used as sources of data in our study.
We can see, by the examples of foreign countries, that the information given by these indicators is very useful, as well as the performance measurements. For instance, Australia has introduced a National Quality and Performance System (NQPS) with the purpose of establishing a higher performance, promote best practice, support under performance and sharpen the focus of healthcare institutions. [4] To accomplish those goals, about 52 indicators (National Performance Indicators-NPI) are analyzed. These indicators are concernedwith governance, prevention and early intervention access, integration and chronic diseases management.
In the USA, a study was done to evaluate if the 7 surgeries chosen as quality indicators by the Agency for Healthcare Research and Quality were performed frequently enough to identify hospitals with increased mortality rates. [16] To do that, a large number of data from different hospitals and from different gaps of time was used to turn possible the representation of all hospitals in the country. Analysing the results of this study, we easily understand that for only one surgery, the majority of hospitals exceed the minimum caseload and for the remainder just a small number of hospitals met the minimum caseload required.
So, using this indicator, we are assuming that one hospital with great results in this 7 surgeries is an excellent hospital but that might not be exactly true, because this hospital could have this results simply because his activity is very low in this kind of operations. This way, patients are falsely reassured that they are choosing a safe hospital basing their choice in this indicator.
The main conclusion of this study was that the policy makers should consider sample size in selecting the best quality measure for specific procedures, particularly when data is used for public reporting. [17-18] Otherwise, they run the risk of mislabelling hospitals and misinforming patients.
With the importance given by the Australian and American authorities, we can confirm the importance of having regular analyses to improve management policies. [19] We can also use these examples to avoid measurement errors.
In this study, we had access to specific information about a central hospital through a number of healthcare quality indicators. The aim of this project is to analyze these indicators (the ones referred above) and obtain information that may be useful in the future to study the evolution of the hospital healthcare.
RESEARCH QUESTION AND AIMS
The main question in this study is related to how the indicators evolved through the years in the chosen central hospital. According to this, our general purpose was the calculation of the indicators’ values concerning the proposed variables. Some specific aims can be also be referred, such as the examination of the quality of healthcare by analysing the evolution of mortality, postponed surgeries, surgical procedures, among others; the definition of an hospital’s activity and production by using the data related with indicators as, for instance, length of stay, outpatient episodes, outpatient surgery and childbirth of caesarean operation; and finally the use of main diagnosis to study the quality of the available data.
PARTICIPANTS AND METHODS
This study is observational and retrospective, as it is based on pre-existing data and focused on episodes from a Portuguese central hospital that occurred between 1999 and 2008. In this research we calculated and analyzed the indicators in agreement with the variable proposals.
Indicators can be subdivided in various categories. Initially, in order to achieve our specific aims, we divided the eight indicators to be studied (mortality, length of stay, postponed surgeries, outpatient department episodes, outpatient surgery, childbirth of cesarean operation, main diagnosis and complications related to surgical procedures) in three categories related to different fields in performance measurement: quality of the care, productivity of the hospital and quality of the data.
The indicators and the corresponding field are presented in Table 1.
Indicator / FieldMortality / Quality of the care
Length of stay / Productivity of the hospital;
Quality of the care
Postponed surgeries / Quality of the care
Outpatient episodes / Productivity of the hospital
Outpatient surgeries / Productivity of the hospital
Childbirth of cesarean operation / Productivity of the hospital
Main diagnosis / Quality of the data
Complications related to surgical procedures / Quality of the care
Table 1 – List of the indicators approached in the study
Mortality is an indicator with dubious quality (death as a result does not necessarily mean problems in the provided healthcare). However, it has important advantages: the concept of death is objective and does not allow subjective interpretations and big differences are not expected in registration of obits in hospitals. [20-21]
Length of stay is an indicator that can be easily interpreted. For each DRG are established minimum and maximum limits length of stay, that allow the identification of irregular situations. This indicator and the quality of care have been studied it seems to exist a direct relationship between both of them. [22-23]
The number of postponed surgeries is an indicator which consists in a retrospective evaluation of cancellations of scheduled elective and urgent operations, considering the reason for the adjournment. The reasons are normally related with the lack of medical clearance and patient preparation, the lack or failure of instruments or patient’s desire. [24]
Outpatient department episodes are inserted in the area of activity and production. In fact, its main purpose is to calculate the number of outpatient department episodes to estimate the evolution of the hospital’s performance and patient’s satisfaction. [25] Important sources of data to estimate this indicator are DRGs. [26]
Outpatient surgery compares the number of outpatient surgeries with the number of programmed surgeries. Typically, in this type of surgeries, the recovery phase is transferred to the home environment. For this reason, the clinical practice has little opportunity to observe the patient's post-operative course. If we relate these numbers with the satisfaction of the patient, the comparison between each method of operation is very important to obtain information about reasonable measures for improvement. [27] When a reliable method is reached, it is applied as a repetitive process in the provision of highly predictable and reproducible surgical services, as benefit to the evolution of healthcare quality. [28]
Childbirth of cesarean operation is expressed by the relation between childbirth of cesarean surgery and the total number of childbirths. Studies demonstrate that the number of cesareans has increased through the years in many countries all over the world in a significant way, but there is not a consensus about the limits of delivery rates, which are still debated frequently because of the risks that cesareans still carry. [29-30] This indicator does not provide information about the reason for undergoing caesarean section, and includes cesarean sections that were performed without a clinical indication as well as those that were medically indicated. Various studies were made in order to conclude which is the most advantageous kind of labor and which offers a best obstetric care: vaginal breech delivery or caesarean section. [31] Still, we can admit that “offering a trial of vaginal breech delivery to well-counseled strictly selected patients remains an appropriate option”. [32]
Main diagnosis is a variable that can decisively affect the course of the illness. It depends on the formation and experience of the doctor, the availability of technological resources and it also depends on the time of permanence in the hospital. [33] By evaluating the quality and the results of the diagnosis and converting that data into numbers we can relate this indicator with others, such as the length of stay or mortality. It is calculated in percentage or simply in numbers, and it expresses the quality of the data.
Complications related to surgical procedures are powerful indicators. Although some of them cannot be avoided, a high number of complications after surgery could be associated with bad clinical practice or deficient health care quality in hospitals.
These indicators are calculated by applying the SPSS which stands for Statistical Package for the Social Sciences, a software program used in statistical analysis [34]. To calculate the indicators, a syntax file was needed. The syntax file contains a set of commands that is used to analyze the entire database and select the appropriate cases for each indicator.