HersenletselCongres

HersenletselCongres 2015

4-11-2015

Disclosure belangen sprekers

A4a - Presteren door prestatie-indicatoren: balanceren tussen hoop en twijfel Gerard Ribbers

(potentiële) belangenverstrengeling

geen

De betrokken relaties bij dit project zijn:

nvt

Sponsoring of onderzoeksgeld:

Hersenstichting, ZoNMW, KFA,

Honorarium of andere (financiële) vergoeding:

Geen

Aandeelhouder:

Geen

Andere relatie, namelijk:

Geen

De ‘transparantiedruk’ Vertrouwen Bewust kiezen Verantwoorden Verbeteren Prestatiecontracten Ranglijsten

kans

Geobserveerde uitkomsten

Rotterdam Neurorehabilitation Research

casemix

bias

onverklaard

kwaliteit

onverklaard

Over uitkomsten en kwaliteit


Over kwaliteit: Donabedian’s model


casemix

casemix Klinisch / ICF

Kwaliteit

PROM’s

proces uitkomst

Kosten etc

bias

bias

Kwaliteit

structuur



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casemix

structuur Kenmerken organisatie:

Faciliteiten, localisatie etc

Klinisch / ICF

proces uitkomst

Kenmerken van de zorg: Eindresultaat: Type behandeling, intensiteit, frequentie etc

PROM’s Kosten

Kwaliteit

Kwaliteit

casemix

Prestatie Indicatoren (extern)

Klinisch / ICF

proces uitkomst

Kenmerken van de zorg: Eindresultaat: Type behandeling, intensiteit, frequentie etc

PROM’s Kosten etc

Ontslagbestemming, Mobiliteit, etc

bias

Ontslagbestemming, Mobiliteit, etc

bias

structuur Kenmerken organisatie:

Faciliteiten, localisatie etc

etc

Kwaliteits Indicatoren (intern)


Donabedian’s model in de CVA keten: (interne) kwaliteitsindicatoren


Stroke: evidence based quality indicators







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Benchmarken: making complexity simple

• Zwaardere patiënten • Andere registratie (heropnames) • Trage CIZ • Lokale overheid • Zorgverzekeraar • Beschikbare ketenpartners • Regionale verschillen • …………..

bv gemiddelde opnameduur

bv gemiddelde opnameduur

Benchmarken: making complexity simple

bv aantal patiënten per jaar

bv aantal patiënten per jaar



Pas op met benchmarken Waarmee?: Uitkomst: ICF domeinen, (P)ROM’s, complicatie ratio’s, patienttevredenheid, heropnames, Proces: betrokkenheid partner, intensiteit, individuele of groepsbehandelingen Structuur: volume, faciliteiten, Case-mix variatie: ernst, co-morbiditeit, nationaliteit, Regionale verschillen: groot- vs kleinstedelijk, Wat benchmark je: organisaties, teams, individuele professionals Risico’s: blaming and shaming, datapoetsen, Reputatiemanagement boven kwaliteitsmanagement

Kwaliteits indicatoren: de bedenkingen Vaak niet gericht op wat de individuele patiënt belangrijk vindt Wordt er naar me geluisterd, word ik met respect behandeld, word ik begrepen? Vaak niet gericht op wat de individuele behandelaar belangrijk vindt Wordt mijn behandeling er beter van? Administratiedruk Draagvlak (para-)medici

Beschrijf de nachtwacht in 12 woorden. Reductie van de werkelijkheid



Patient reported outcomes (PROM’s)

Waardegedreven zorg

Subjectieve evaluatie Kwaliteit van leven

Patient health outcomes achieved Value

= Cost of delivering those outcomes


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Int Cons Health Outcome Measurement : value-based health care by defining global outcome standards Where we come from

ICHOM’s Sponsoring Partners*

PLATINUM

Our mission

Three organizations with the desire to unlock the potential of value-based health care founded ICHOM in 2012:

ICHOM is gaining the support of the health care community

GOLD Our mission Unlock the potential of valuebased health care by defining global Standard Sets of outcome measures that really matter to patients for the most relevant medical conditions and by driving adoption and reporting of these measures worldwide

ICHOM is a nonprofit ▪ Idealistic and ambitious goals ▪ Global focus ▪ Engages diverse stakeholders

Value

=

SILVER Cooper-Newell Foundation

BRONZE

Patient health outcomes achieved Cost of delivering those outcomes

COFOUNDERS *As of May 11, 2015 ICHOM Stroke

baseline characteristics to enable global comparisons Information on baseline characteristics is needed to make meaningful comparisons (adjust for case-mix)

Baseline characteristics

Patient initial conditions

Structure

Processes

e.g., Staff certification, facilities standards

e.g. Protocols/ guidelines

▪

Patient experience/ engagement

▪

Indicators

Copyright © 2015 by the International Consortium for Health Outcomes Measurement. All rights reserved.

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baseline characteristics to enable global comparisons Information on baseline characteristics is needed to make meaningful comparisons (adjust for case-mix)

Capture the initial state of the patient before treatment to allow adjustment for differences in patient populations across providers For example: ▪ Demographics ▪ Baseline health status ▪ Prior treatments

Baseline characteristics

Patient initial conditions

Structure e.g., Staff certification, facilities standards

Processes e.g. Protocols/ guidelines

Capture the initial state of the patient before treatment to allow adjustment for differences in patient populations across providers For example: ▪ Demographics ▪ Baseline health status ▪ Prior treatments

▪

Patient experience/ engagement

▪

Indicators

e.g., x-ray, lab results

e.g., x-ray, lab results

Defined by working group

Defined by working group

(Health) outcomes

(Health) outcomes

ICHOM Stroke Working Group

ICHOM Standard Sets covering 70% of the disease burden by 2017

Stephanie Gethin, Aneurin Bevan Health Board, Newport Maxine Power, Salford Royal Hospitals, Salford Charlie Davie, University College London Hospitals, London

Bo Norrving, Swedish National Quality Register,

Eric Smith, University of Calgary/American Heart Association, Calgary, AB Frank Silver, Canadian Stroke Consortium, Toronto, ON Patrice Lindsay, World Stroke Organization, ON

Lund

Liping Liu, Neurology and Stroke Center, Beijing

4 conditions

2013

12 conditions

24 conditions

40 conditions

50+ conditions

2014

2015

2016

2017

Gerard Ribbers, Erasmus Medical Center, Rotterdam Sheila Martins, Brazilian Stroke Society

70% Share of disease burden in industrialized countries 37%

57%

Lee Schwamm, MGH/Harvard Medical School, Boston, MA Joel Salinas, MGH/Harvard Medical School, Boston, MA Mary George, Centers for Disease Control and Prevention, Atlanta,

45%

GA

9% 2013

2014

2015

2016

2017

Adam Kelly, University of Rochester Medical Center, NY Linda Williams, VA stroke quality improvement, Indianapolis, IN Teri Ackerson*, American Heart Association Louise Morgan, American Heart Association, NJ

Julie Bernhardt, The Florey Institute of Neuroscience and Mental Health, Melbourne *Patient/carer representative

Parkinson's Disease Deck - GENEVA.ppt


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Teleconferences and surveys used for discussion and democratic decision making, ensuring credibility of final product

The full list of risk adjustment variables included in the Stroke Standard Set Risk adjustment variable

Modified Delphi process followed; 2/3rds majority threshold for making decisions

Demographic factors

Stroke type and severity

Vascular and systemic

Treatment/care variables

20141203_Stroke_Call#4.pptx


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Age Sex Ethnicity Living location Living alone Prestroke functional status Stroke type Stroke severity Duration of symptoms Prior Stroke Prior TIA Prior MI Coronary artery disease Atrial fibrillation Diabetes mellitus Hypertension Hyperlipidemia Smoking status Alcohol use (> 1 drink/day) Length of hospital stay Diagnostic evidence base Rehabilitation Discharge destination Comfort care (optional item) IV Thrombolytic therapy Thrombectomy Hemicraniectomy

ICHOM Stroke

Measures Date of birth Sex at birth Country specific reporting Pre and 90 days post stroke Pre and 90 days post stroke Mobility, Toileting and Dressing IS; ICH; TIA NIHSS & Level of Consciousness < 1h; 1h - 1 day; > 1 day; UTD Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Y/N Date of admission & discharge Clinical alone; Clinical + MRI; Clinical + CT Dedicated rehabilitation during acute or post acute care Discharge following acute care hospitalization International definition and timing TBD Patient received IV Thrombolytic therapy Patient underwent Thrombectomy Patient underwent Hemicraniectomy


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Clinical data

Overview of outcomes and measures in Standard Set Category

Outcomes

Acute complications

Symptomatic intracranial hemorrhage

Survival and disease control

Overall survival

Discharge

Administrative Patient reported

Timeline: stroke

90 days

Disease recurrence Smoking cessation Patient reported health status Cognitive and Psychiatric functioning Non-motor functioning

Global cognitive function Mood Pain and other unpleasant sensations Fatigue +

Ability to return to usual activities +

Self care and grooming

Social functioning General health status Health related QOL

T0

Discharge*

PROMIS-10 PROMIS-10

90 days post admission for index event**

1 year post index event

2 years 3 years 4 years 5 years post index post index post index post index event event event event

Recommended

PROMIS-10 Single question

Mobility Motor functioning

PROMIS-10

PROMIS-10 & Single question

*

PROMIS-10 & mRS**

Dressing & Toiletting

Dressing & Toiletting

T0 Entrance into outcome tracking system for Stroke Baseline characteristics / Risk adjustment variables Clinician reported

Feeding

Single question Single question

PROMs (patient reported outcome measures) - discharge assessment

Ability to communicate Social participation Patient reported general health status

Single question Single question

PROMs (patient reported outcome measures) - 90 days full battery assessment

Global patient reported health-rel. QOL

PROMIS-10

Survival

PROMIS-10 PROMIS-10

* Discharge or 7 days, whichever comes first ** 90 days post admission + 30 days window (90 to 120 days post index event)

* Captured with single item questions on mobility, dressing & toileting +Also captured ICHOM Stroke Copyrightphase © 2015 byof theStandard International Set Consortium for Health Outcomes Measurement. All rights reserved. as measure for pre-stroke functional 27 status **Simplified mRS questionnaire (smRSq) is included as comparison tool in roll-out

Praktijkervaring

•

•

Voorbeelden van vraagstukken: meetplan CVA

Terugdringen van missing values • Draagvlak clinici • IT infrastructuur Betrokkenheid van het management • Kwaliteitsjaarverslag • Beleidsevaluatie



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Voorbeelden van vraagstukken: meetplan CVA

Donabedian: een poging ….

Practice variation in the structure of stroke rehabilitation in four rehabilitation centres in the Netherlands “Pain and negative emotion have an adverse effect on rehabilitation outcome in stroke patients in addition to age, severity of stroke and functional status.”


Interne (kwaliteits-) kenmerken

Opname/ontslag gerelateerd: Behandeling gerelateerd: Patientbetrokkenheid: Faciliteiten:

9 verschillen op 14 items 20 verschillen op 24 items 1 verschil op 4 items 4 verschillen op 4 items


Profits

Iris F Groeneveld, Jorit JL Meesters, Henk J Arwert, Nienke Roux, Gerard M Ribbers, Coen AM van Bennekom, Paulien H Goossens, Thea PM Vliet Vlieland In Press: J Rehabil Med


Dutch Net-QuRe Dutch Neurotraumatology Quality Registry Prof dr Wilco C Peul, Leiden UMC Prof dr Gerard M Ribbers, Erasmus MC


Conclusie I Transparantie over de resultaten van de patiëntenzorg is vanzelfsprekend. Openheid over prestaties is iets anders dan openbaarheid van alle zorginformatie. Indicatoren zijn alleen betekenisvol als ze voortkomen uit specifieke doelen en stuurvragen.



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4-11-2015


1. de behandeling van de betreffende patiënt te verbeteren, 2. de kwaliteit van zorg voor alle patiënten te verbeteren, 3. de cliënt de ondersteunen bij de keuze tussen zorgaanbieders, 4. zorginkopers te ondersteunen bij het inkopen van doelmatige zorg, 5. de Inspectie voor de Gezondheidszorg te ondersteunen bij het toezichthouden



1. de behandeling van de betreffende patiënt te verbeteren, 2. de kwaliteit van zorg voor alle patiënten te verbeteren, 3. de cliënt de ondersteunen bij de keuze tussen zorgaanbieders, 4. zorginkopers te ondersteunen bij het inkopen van doelmatige zorg, 5. de Inspectie voor de Gezondheidszorg te ondersteunen bij het toezichthouden


[email protected]



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HersenletselCongres

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