TOWARDS HEALTH CARE PLANNING AND EVALUATION Professor Michael Clarke Dept of Epidemiology & Public...

TOWARDS HEALTHCARE PLANNING

ANDEVALUATION

Professor Michael ClarkeDept of Epidemiology &

Public Health

Are we doing the right thing? - evidence based medicine

To the right people? - appropriate care

Often enough - meeting needs

People have health care Needs

Health services are the responses to the

Needs

Good Quality Health services must be:

(i) effective

(ii) efficient

(iii)equitable

ie work for the lowest cost, and be

fairly distributed

A Taxonomy of NeedNeeds: Items of service, or resources,

felt to be required, either by consumers or providers…………………

Demands: …………….. which are applied for …….

Met (demands) ……….. provided and utilised …… (admissions, consultations)

Unmet (demands) …… and the request is rejected or, (more usually) cannot be met at that time

(waiting lists)

CONSUMERDEFINEDNEED

NEEDNEEDNEED

DEMAND

MET

DEM.UNMET

NEEDNEEDNEED

DEMAND

MET

DEM.UNMET

NEEDNEEDNEED

DEMAND

METDEM.

UNMET(UTILISATION)

PROVIDER DEFINED NEED

CONSUMERDEFINEDNEED

NEEDNEEDNEED

DEMAND

MET

DEM.UNMET

NEEDDEM.UNMET

DEMANDMET

CONSUMERDEFINEDNEED


NEEDNEEDNEED

DEMAND

MET

DEM.UNMET

NEEDNEEDNEED

DEMAND DEM.UNMET

CONSUMERDEFINEDNEED


INAPPROPRIATE / INEFFECTIVE CARE

UTILISATION

Examples of Inappropriate Care

UK

Approximate %

50 Coronary angiography and bypass surgery

in Trent

60 Cholecystectomies in North West Thames

USA

66 Carotid endarterectomies – 65+

25 Gastrointestinal endoscopies

25 Coronary angiographies

25-66 Coronary artery bypass

ops Brook, R.H. Brit. Med. J. (1994) 308,

218-9

Factors which influence Quality of health care

STRUCTURES(RESOURCES)

Capital FacilitiesHospitalsDoctors

SurgeriesAmbulances

Trained Personnel




SurgeriesAmbulances

Trained Personnel

PROCESSES(USE OF

RESOURCES)

ConsultationsProcedures

Admissions etc(Ethical

RelevantEffective

Socially acceptable)




SurgeriesAmbulances

Trained Personnel

PROCESSES(USE OF

RESOURCES)



RelevantEffective


OUTCOMES

DeathDisease

DisabilityDiscomfort

DissatisfactionDebt




SurgeriesAmbulances

Trained Personnel

PROCESSES(USE OF

RESOURCES)



RelevantEffective


OUTCOMES

DeathDisease

DisabilityDiscomfort

DissatisfactionDebt

CASE-MIXAge, severity of illness, co-morbidity, culture/language

Derived from Donabedian, A. Evaluating the Quality of Medical Care. Milb. Mem. Fund Quart. 44(3) Part2:116-323,

July 1963.

Q How do we know what are the best structures or processes?

A (i) Judgemental method ‘human rights’

avoidable factors in care Consensus Conferences

(ii) Comparative approach confounders

case mix differences

Case Study of theComparative Method

Paediatric Intensive Care

Provision of intensive care for childrenA geographically integrated service may now be achieved

A study comparing illness adjusted mortality for children living in the ‘Trent’ region, where paediatric intensive care provision is fragmented among 19 centres, with that in the two paediatric intensive care units in Victoria, Australia – which has similar size of child population and similar rate of admission to paediatric intensive care – showed both an excess mortality and a greater length of stay in Trent

Jane Ratcliffe, Consultant Paediatric Intensivist, Alder Hey Childrens Hospital, Liverpool

BMJ Editorial Vol. 316, 1547, 23 May 1998

Should paediatric intensive care be centralised? Trent versus

Victoria

Lancet (1997), 349, 1213-17

Gale Pearson, Frank Shann, Peter Barry, Julian Vyas, David Thomas, Colin Powell,

David Field

Population 1994 1996Total<16 years

4,781,000 913,700

5,121,238 975,000

Deaths aged 1 month to <15 yearsNumberRate per 100,000 < 15 years (+/- 95% ci)

26829.3

(26.0–33.0)

31232.0

(28.6-35.7)

ONS Population Data for Trent 1994 &1996

• population increase due to boundary changes – 1996 includes Grimsby & Scunthorpe• 1994 – 28% deaths <15 years occur in PICU’s (74 deaths)

Trent Victoria

Population Total <16 yrsDeaths 1 month – 16 yrs Number Rate/100,000<16

4,2000,000 913,700

266 (100%) 29.1

4,500,000 1,011,000

257 (100%) 25.4

PICU Admissions No. per year Per 1000 <16 Deaths in ICU Deaths per 1000 ICU admissions

1014 1.22 74 (28%)

73

1194 1.18 60 (23%)

50

PICU Admissions No. per year per 1000 <16 Deaths in ICU Deaths per 1000 ICU admissions

1414 1.55 74 (28%) 52

1194 1.18 60(23%) 50

Trent Victoria

PICU Admissions No. per year Per 1000 <16 Deaths in ICU Deaths per 1000 ICU admissions

1014 1.22 74 (28%)

73

1194 1.18 60 (23%)

50

Next Steps

1. Undertake Prospective Study – as initial step in developing a continuing

evaluation of P.I.C.

2. Establish a simple Enquiry into all Paediatric

Mortality in Trent

When Comparing Health Care Systems

BEWARE !1. Population errors

2. Cases missed, not admitted (unmet need)

3. Differences in case definitions, admissions policies

4. Counting people or admissions

5. Differences in case mix

Q How do we know what are the best structures or processes?

A (i) Judgemental method ‘human rights’

avoidable factors in care consensus Conferences

(ii) Comparative approach confounders

case mix differences

(iii) Experimental (RCTs) Methods

Continuum of increasing evidence

Explore relevant theory to ensure best choice of intervention Strategic design issues

Pre-clinical

Theory



Identify the intervention, and the underlying mechanisms by which they will influence outcomes.

Phase IPre-clinical

Theory

Modelling




Phase IPre-clinical

Design a feasible protocol for comparing the intervention to an appropriate alternative

Phase II

Theory

Modelling

Exploratory Trial




Phase IPre-clinical


Phase II

Compare a fully defined intervention to an appropriate alternative that is an adequate control

Phase III

Theory

Modelling

Exploratory Trial

Definitive RCT




Phase IPre-clinical


Phase II

Compare a fully defined intervention to an appropriate alternative that is an adequate control

Determine whether others can reliably replicate your intervention and results in uncontrolledsettings over the long tern

Phase III Phase IV

Theory

Modelling

Exploratory Trial

Definitive RCT

Long-term Implementation

RCTs can be simple or complex

(i) a) drugs

b) appliances - simple

(ii) a) management e.g. length of stay

b) personnel e.g. nurse practitioner

(iii) Preventive services - complex

e.g. screening programmes

SUMMARY1. Evaluation is essential if we are to get the

best “bang for the buck”

2. Evaluation of health services needs the best quality clinical science

3. Best clinical science includes patient outcomes from a variety of perspectives, measured over the longer term

PHASE IV TRIALSPostmarketing surveillance-

Long term safetyThe yellow card system

Promotional activityChanging prescribing

behaviour

PROGRAMME EVALUATION

Long-term monitoringDissemination ofResearch findings

Health gain

PHARMACEUTICALRESEARCHPRECLINICAL

-pharmacology, animal toxicityPHASE 1 TRIALS

Clinical pharmacology and toxicityDrug metabolism and bioavailability

Healthy volunteers

HEALTH SERVICERESEARCH

BASIC LABORATORY SCIENCE

CLINICAL SCIENCEService Innovation

PHASE II TRIALSInitial treatment studies onsmall numbers of patients

PHASE III TRIALSLarge scale randomised trials

comparing a standard treatmentwith a new treatment

EXPLANATORY TRIALS

PRAGMATIC TRIALSEconomic assessment

Patient compliancePatient satisfaction

TOWARDS HEALTH CARE PLANNING AND EVALUATION Professor Michael Clarke Dept of Epidemiology & Public...

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