From information to improvement: evidence from UK & US 27 April 2010 Gwyn Bevan.
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Transcript of From information to improvement: evidence from UK & US 27 April 2010 Gwyn Bevan.
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From information to improvement: evidence from UK & US
27 April 2010Gwyn Bevan
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Information improvement
Three pathways & evidence from US Change Selection Reputation
Evidence from UK Questions
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Selection & Change
ResultsAware of differences
Knowledge about performance
Consumers able to choose
Knowledge about process & results
Management &Professionals Implement change
Motivation
Adapted from Berwick et al. 2003
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Evidence from two systematic reviews Limited evidence
Industry of performance assessment Rigorous evalution
Cardiac Surgery Reporting System (CSRS) 6 other US systems
Change Weak evidence
Selection No evidence providers respond to threat
of patients using information as consumers
Ineffective in US likely to work in UK?
Sources: Marshall et al (2000) & Fung et al (2008)
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CSRS (2001): CABG outliers good & poor outcomes
Source: http://www.health.state.ny.us/statistics/diseases/cardiovascular/
RAMR Rates
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The Clinton’s selection pathway (2001 CSRS data available)
sudden onset of chest pains & shortness of breath (September 2004) small hospital near home cardiologists @
Westchester Medical Center
quadruple bypass @ Columbia-Presbyterian
Source:http://www.nytimes.com/2004/09/06/health/06hosp.html?scp=1&sq=Clinton%20Surgery%20Puts%20Attention%20on%20Death%20Rate&st=cse
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CSRS (2001): CABG outliers good & poor outcomes
Source: http://www.health.state.ny.us/statistics/diseases/cardiovascular/
RAMR Rates
Columbia Presbyterian
Westchester Medical Center
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CSRS: pathways
Change mediocre / below-average performance:
failed to use rich performance data Selection
outliers with good / poor performance: no changes in market share
Reputation outliers with poor performance: ‘naming &
shaming’ galvanised to improve
Source: Chassin (2002)
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3rd Pathway: Reputation Characteristics
i. rankingii. published: widely
disseminatediii. easily
understood: performance good or poor?
iv. future report: performance improved?
Paradox information not
used by patients to switch from poor to good hospitals
managers of poor hospitals respond to repair perceived damage to public reputation not market share
Sources: Hibbard et al. (2003, 2005)
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Controlled experiment in Wisconsin
Change Selection Reputation
public-report
private-report
no-report
Summary indices adverse events Deaths & complications) General: surgery / nonsurgery Specific: cardiac, maternity, & hip/knee
System characteristics Ranking, easily understood, followed up
Source: Hibbard et al. (2003, 2005)
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Wisconsin: pathways
Change: Private report little effort to improve quality
Selection: Public report no anticipated changes in market share no actual changes in market share
Reputation: Public report significantly greater efforts to improve
quality because of concerns over reputational damage
Source: Hibbard et al. (2003, 2005)
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Information improvement
Three pathways & evidence from the US
Evidence from UK Changing policy mix in England Natural experiment Evidence
Questions
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Changing policy mix in England
1997-99: Selection Change ‘internal market’ ‘third way’
2000-02: Reputation star ratings (2001 – 05)
2002 - : Reputation & Selection Reputation: star ratings healthcheck
(2006) Selection: FTs & ISTCs, PbR, patient
choice, & World Class Commissioning
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UK’s natural experiment
Change Reputation SelectionEngland•1991-97•1997-99•2000-02•2002 -
Devolved countries•1999 -
Reward failure
Abolish p/p split
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England: Selection Change1997 manifesto pledge waiting lists
Numbers waiting elective admissions (England) (‘000s)
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Star rating: Reputation ‘naming & shaming’ zero stars
‘devastating …hit right down to the workforce – whereas bad reports usually hit senior management upwards …nurses demanding changing rooms .. because being accosted in streets’
Source: Mannion et al (2005)
2001:the dirty dozen
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England: Change Reputation
Numbers waiting elective admissions (England) (‘000s)
Star ratings published
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Funding of UK’s natural experiment
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Natural experiment: Change & Reputation
No/‘000 waiting > 6 months for elective hospital admission
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Natural experiment: Change & Reputation
Source: Connolly et al (2010) Funding and Performance of Healthcare Systems in the Four Countries of the UK before and after Devolution. The Nuffield Trust.
% waiting list < 13 weeks for hospital admission (March 2008)
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Natural experiment: Change & Reputation
No/‘000 waiting > 3 months GP 1st outpatient appointment
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2003
35
45
55
65
75
85
England: Change Reputation
Change Reputation
% Ambulance response times to life-threatening emergencies < 8 minutes (Target 75%)
Source: Bevan & Hamblin (2009)
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Natural experiment: Change & Reputation
Star ratings published
Target
Source: Bevan & Hamblin (2009)
% Ambulance response times to life-threatening emergencies < 8 minutes
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Barber (2007) Instruction to Deliver
Awful adequate Command & control
public not satisfied have to keep flogging the
system
Adequate good / great quasi market & consumer
choice innovation from self-
sustaining systems
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The impact of the NHS market: An overview of the literature*
No good evidence reforms produced beneficial outcomes classical economic theory predicts of markets provider responsiveness to patients &
purchasers large-scale cost reduction innovation in service provision
NHS incurs transaction costs of market without benefits
* Brereton & Vasoodaven (2010) http://www.civitas.org.uk/nhs/download/Civitas_LiteratureReview_NHS_market_Feb10.pdf
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System reform package & commmissioning
No
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Questions
Change Devolution worse performance in
devolved countries? Selection
Purchaser / provider split? ‘World Class Commissioning’? Patient choice?
Reputation Executive democratic accountabilty?
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References Audit Commission & Healthcare Commission. Is the
treatment is working? <http://www.audit-commission.gov.uk/reports/NATIONAL-REPORT.asp?CategoryID=&ProdID=9F8B7F6A-214D-4165-BE65-716315270A82&fromREPORTSANDDATA=NATIONAL-REPORT>
Auditor General for Wales (2005) NHS waiting times in Wales. Volume 2 - Tackling the problem. <http://www.wao.gov.uk/reportsandpublications/2005.asp>
Bevan (2006) Setting Targets for Health Care Performance: lessons from a case study of the English NHS. National Institute Economic Review, 197, 67-79.
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References Bevan (2010) Approaches and impacts of different systems of
assessing hospital performance. Journal of Comparative Policy Analysis, 2010, 12(1 & 2): 33 – 56
Bevan & Hamblin (2009) Hitting and missing targets by ambulance services for emergency calls: impacts of different systems of performance measurement within the UK. Journal of the Royal Statistical Society (A), 172(1):1-30.
Bevan & Hood (2006) Have targets improved performance in the English NHS? British Medical Journal, 332, 419-422.
Bevan & Hood (2006) What’s Measured is What Matters: Targets and Gaming in the English Public Health Care System. Public Administration 84, 3, 517-38.
Chassin (2002) Achieving and sustaining improved quality: Lessons from New York State and cardiac surgery. Health Affairs, 21(4), 40-51.
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References Fung et al (2008) Systematic review: The evidence that
publishing patient care performance data improves quality of care. Annals of Internal Medicine, 148, 111-123.
Hibbard (2008) What can we say about the impact of public reporting? Inconsistent execution yields variable results. Annals of Internal Medicine, 148, 160 - 161.
Hibbard et al (2003) Does publicizing hospital performance stimulate quality improvement efforts? Health Affairs, 22 (2), 84-94.
Hibbard et al (2005) Hospital performance reports: impact on quality, market share, and reputation. Health Affairs, 24(4), 1150-60.
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References
House of Commons Health Committee (2010) Commissioning. (Fourth Report of Session 2009–10, Volume I) HC 268-I. London: The Stationery Office Limited. < http://www.parliament.the-stationery-office.co.uk/pa/cm200910/cmselect/cmhealth/268/26802.htm>
Mannion et al (2005) Impact of star performance ratings in English acute hospital organisations. Journal of Health Services Research & Policy, 10 (1), 18–24.
Mannion & Goddard (2001) Impact of published clinical outcomes data: case study in NHS hospital organisations. BMJ, 323, 260 – 263.
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References
Mannion & Goddard (2003) Public disclosure of comparative clinical performance data: lessons from the Scottish experience. Journal of Evaluation in Clinical Practice, 9 (2), 277–286
Marshall et al (2000) The Public release of performance data: What do we expect to gain? A review of the evidence. Journal of the American Medical Association, 283(14), 1866-1874.