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DEFINING INDICATORS

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DEFINING INDICATORS Powered By Docstoc
					     MONITORING THE
  QUALITY OF CARE USING
   CLINICAL INDICATORS
                 Jan Mainz, MD, Ph.D.
Project Manager, The National Indicator Project, Denmark
   Associate Professor, University of Aarhus, Denmark

                   WWW.NIP.DK
                    DEFINITIONS
    • Indicators provide a quantitative basis for
      clinicians, providers, organisations and planners
      aiming to achieve improvement in care and the
      processes by which patient care is provided.
                                  (ISQua, Melbourne 1999)

    • Indicators are quantitative measures that can be
      used to monitor and evaluate the quality of
      important governance, management, clinical, and
      support functions that affect patient outcomes.
                                 (Joint Commission, 1990)

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      Jan Mainz, The National Indicator Project and Aarhus University
                     DEFINITIONS
    • Indicators should be explicit statements of desirable (or
      undesirable) structural, process or outcome dimensions.

    • They should be supported by either research that establishes
      the efficacy or effectiveness of the indicators by a formal
      process of obtaining experts consensus.

    • The tools for measurement should be tested and evaluated
      for reliability, validity and feasibility.

    • Results should be repeated in a format that maximizes the
      likelihood that the information can be interpreted and used
      in appropriate decision contexts.
                                                      (RAND, 1998)


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       Jan Mainz, The National Indicator Project and Aarhus University
                    DEFINITIONS
    • Indicators are measures that assess a particular
      health care process or outcome.
                    (European Medical Associations, 1992)

    • Indicators are measures of the clinical management
      and outcome of care and are objective measures of
      either the process or outcome of patient care in
      quantitative terms.
                                              (ACHS, 1993)



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      Jan Mainz, The National Indicator Project and Aarhus University
          USES OF INDICATORS
    • To document the quality of care
    • To make comparisons
       – Over time
       – Between places (e.g. hospitals)
    • To make judgements and priorities
       – e.g. choosing a hospital or surgery
       – e.g. organising medical care
    • To support accountability
    • To support quality improvement
    • Transparency for society

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      Jan Mainz, The National Indicator Project and Aarhus University
     SAME MEASURE CAN SERVE
        MUTIPLE PURPOSES
    • Physician
      - ”How am I doing?”
    • Patient
      - ”What are my chances?”
      - ”Which is the best hospital?”
      - ”Which is the best doctor?”
    • Society
      - ”What does it cost?”



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      Jan Mainz, The National Indicator Project and Aarhus University
              KEY CHALLENGE


    • Everyone wants measurement

    • No one wants to be measured




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      Jan Mainz, The National Indicator Project and Aarhus University
                      INDICATORS
    - Must be precisely defined i.e.

           • Be based on agreed definitions which can be uniformly
             implemented.
           • Have specificity
           • Be valid and reliable (validation and reliability testing)
           • Have discrimination ability
           • Be risk-adjusted to enable comparison
           • Relate to clearly identifiable events
           • Permit useful comparisons
           • Evaluation and review would incorporate changes over time



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       Jan Mainz, The National Indicator Project and Aarhus University
                       INDICATORS
    •   Significance
    •   Ownership reflected in the development and use
    •   Widely accepted
    •   Ease of data extraction
    •   Be interpreted in the light of socio-economic and
        cultural issues.
    •   Responsive
    •   Will not violate patient confidentiality
    •   Be cost effective
    •   Be public available

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        Jan Mainz, The National Indicator Project and Aarhus University
      INDICATORS ARE BASED ON:


     • Best evidence
       (cochrane, metaanalyses, RCT etc)


     • Consensus among health professionals




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       Jan Mainz, The National Indicator Project and Aarhus University
                              INDICATORS
     Can be categorised by
     •   Type of care
          –   Preventive
          –   Acute
          –   Chronic
     •   Function
          –   Screening
          –   Diagnosis
          –   Treatment
          –   Follow up
     •   Modality
          –   History
          –   Physical examination
          –   Laboratory/radiology study
          –   Medication
          –   Other interventions
     •   Generic or disease specific
     •   Rate-based or sentinel


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         Jan Mainz, The National Indicator Project and Aarhus University
             DEFINITIONS
     E.G NOSOCOMIAL INFECTIONS
     • Dirty: Operations in which a perforated viscus or pus is
       found.
     • Contaminated: Operations breaching the gastrointestinal,
       respiratory and genitourinary tracts, or in which a break in
       aseptic technique occurs and in traumatic wounds.
     • Clean: All other operations where the criteria set out in
       ’dirty’ and ’contaminated’ do not apply.
     • Wound infection: Any surgical wound from which purulent
       material drains or is obtained.
     • Hospital-acquired bacteraemia: A positive blood culture
       for inpatients who were afebrile on admission (i.e.
       temperatures less than 37,4°C) on blood collected 48h after
       admission.

                               – Reference: ACHS. J. Qual. Clin Practice 1997


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        Jan Mainz, The National Indicator Project and Aarhus University
           DATA FORMAT E.G
        NOSOCOMIAL INFECTIONS
     • Clean and contaminated wound infection
        – A) Numerator: The number of patients who develop wound infection
          from the fifth post-operative day after (i) clean surgery, (ii)
          contaminated surgery.

        – B) Denominator: The total number of patients undergoing (i) clean and
          (ii) contaminated surgery within the time period under study who have
          a post-operative length of stay of 5 or more days

     • Hospital-acquired bacteraemia
        – A) Numerator: Total number of patients who acquire bacteraemia as
          defined above.

        – B) Denominator: Total number of patients in hospital during the study
          period.

                                           – Reference: ACHS. J. Qual. Clin Practice 1997



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        Jan Mainz, The National Indicator Project and Aarhus University
     CONCEPTUAL FRAMEWORK
     Structural quality
        – assesses health system characteristics that affect the system’s
          ability to meet the health care needs of individual patients or a
          community (e.g. the nurse-to-bed ratio in a hospital)
     Process quality
        – assesses what the provider did for the patient and how well he or
          she did it (e.g. proper diagnostic approach to symptoms)
     Outcome quality
        – assesses the influence of the health care delivery process on the
          individual’s health (e.g. morbidity and mortality)




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        Jan Mainz, The National Indicator Project and Aarhus University
     EXAMPLES OF STRUCTURE
          INDICATORS
     • Numbers of specialists compared to other doctors

     • Access to specific technologies

     • Availability of specific units (e.g.. stroke units)

     • Clinical guidelines revised every 2nd year

     • Physiotherapists associated to specific units




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        Jan Mainz, The National Indicator Project and Aarhus University
         EXAMPLES OF PROCESS
             INDICATORS

     • Patients treated according to clinical guidelines

     • Patients with MI, who received thrombolyses

     • Door to needletime for MI patients

     • Breast cancer patients < 75 years, who got axillary resections

     • Waiting time for doctor contact for patients admitted acute



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        Jan Mainz, The National Indicator Project and Aarhus University
        OUTCOMES OF DISEASES
            (THE FIVE D’s)
     Death                    A bad outcome if untimely
     Disease                  A set of symptoms, physical signs and
                              laboratory abnormalities

     Discomfort               Symptoms such as pain, nausea, dyspnoea etc.

     Disability               Impaired ability connected to usual
                              activities at home, work or in recreation

     Dissatisfaction          Emotional reactions to disease and its
                              care, such as sadness or anger



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         Jan Mainz, The National Indicator Project and Aarhus University
       EXAMPLES OF INTERMEDIATE
         OUTCOME INDICATORS


     • HbA1C for diabetics
     • Lipid profile for patients with hyperlipidemia
     • Numbers of lymph nodes removed at breast cancer
       surgery
     • Blood pressure for hypertensive patients



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       Jan Mainz, The National Indicator Project and Aarhus University
          OUTCOME INDICATORS

     •   Mortality
     •   Morbidity
     •   Functional status
     •   Health measurement status
     •   Work status
     •   Complications
     •   Quality of life
     •   Patient satisfaction



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         Jan Mainz, The National Indicator Project and Aarhus University
     THE OUTCOME OF CARE
     The Patient
     –   Demographic factors (age, sex, height)
     –   Lifestyle factors (smoking, alcohol, weight, diet, physical exercise)
     –   Psychosocial factors (social status, education)
     –   Compliance
+
    The Illness
     – Severity, prognosis
     – Comorbidity
+
    The Treatment (Prevention, diagnostics, care, rehabilitation, therapy and
    control)
     –   Competence
     –   Technical equipment
     –   Evidence based clinical practise
     –   Efficacy, accuracy
+
    The Organisation
     – Use of clinical guidelines
     – Cooperation
     – Delay


=   OUTCOME
                  PROBLEMS WITH
                   INDICATOR USE
     •   Inappropriate definitions
     •   Ranking instability
     •   Discriminative power
     •   Viewed as absolute measure of quality
     •   Lack of timely access
     •   Data incompleteness
     •   Lack of interest
     •   Lack of trust
     •   Lack of ownership


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         Jan Mainz, The National Indicator Project and Aarhus University
               DIMENSIONS OF
            THE QUALITY OF CARE

     • Quality of the technical care in terms of prevention,
       diagnostics, treatment and rehabilitation
     • Quality of the interpersonal relationship in terms of
       communication and information
     • Quality of the organisation of care in terms of
       continuity and coordination



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        Jan Mainz, The National Indicator Project and Aarhus University
      WHAT DO WE KNOW ABOUT THE
     QUALITY OF THE TECHNICAL CARE?

     • Lack of documentation about how major illnesses are treated
       in the health care system
     • Few goals regarding the technical quality
     • Lack of outcome assessment
     • Lack of resource evaluation
     • Persisting variations
     • No formal monitoring systems

     The principal quality problems and their
     prevalence and incidence are unknown


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        Jan Mainz, The National Indicator Project and Aarhus University
     THE NATIONAL INDICATOR PROJECT
          -a concerted action between:


     •   The Ministry of Health
     •   The National Board of Health
     •   The County Counsellors’ Association
     •   The Scientific Societies
     •   The Danish Medical Association
     •   The Danish Nursing Association
     •   The Danish Physiotherapist Association




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         Jan Mainz, The National Indicator Project and Aarhus University
     THE NATIONAL INDICATOR
          PROJECT AIMS:

     • Improving prevention, diagnostics, treatment and
       rehabilitation
     • Documentation for making priorities
     • Information for patients and consumers




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       Jan Mainz, The National Indicator Project and Aarhus University
     THE NATIONAL INDICATOR
            PROJECT
     • All major diseases are evaluated
     • Evidence based process and outcome indicators are derived by
       health professionals on national level
     • Health professionals and clinical epidemiologists are responsible for
       data-collection, analyses, evaluation and interpretation of results
     • Hospitals are compared at county and national and international
       levels
     • Audit activities are organised at county and national level
     • Improvements are initiated if necessary



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        Jan Mainz, The National Indicator Project and Aarhus University
              BASIC PRINCIPLES


     • Health professionals develop evidence based
       standards and indicators for all major diseases
     • Health professionals assess and interpret results
       before public release of data




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       Jan Mainz, The National Indicator Project and Aarhus University
     THE NATIONAL INDICATOR
            PROJECT


     • Established 2000
     • Developed 6 sets of indicators covering 96
       individual clinical indicators
     • Mandatory participation by all hospitals and
       relevant clinical departments in Denmark.



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       Jan Mainz, The National Indicator Project and Aarhus University
                           DISEASES

     •   Stroke
     •   Hip fracture
     •   Schizophrenia
     •   Acute surgery
     •   Heart failure
     •   Lung cancer




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         Jan Mainz, The National Indicator Project and Aarhus University
                        INDICATORS

                                    Stroke
     •   Stroke patients treated at stroke units
     •   Medical secondary prophylactic treatment
     •   CT/MR scan
     •   Patients assessed by physiotherapist
     •   Patients assessed by occupational therapist
     •   Assessment of nutritional status
     •   Mortality at 30 days, 3,6 and 12 months
     •   Discharge destination




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         Jan Mainz, The National Indicator Project and Aarhus University
           CLINICAL INDICATORS STROKE I
     Indicator      Indicator       Type       Standard Time       Evidenc   Prognostic
     concept                                                       e         factors
     Organisation   Proportion of    Process   90%     <24h          A      Age, sex,
     of treatment   patients                            after                previous
                    treated/                            admissio             stroke, TCI,
                    rehabilitated in                    n                    HA, DM,
                    stroke units                                             previous MI,
                                                                             alcohol,
                                                                             tobacco, social
                                                                             status




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             Jan Mainz, The National Indicator Project and Aarhus University
          CLINICAL INDICATORS STROKE II
     Indicator       Indicator        Type      Standard Time       Evidenc   Prognostic
     concept                                                        e         factors
     Secondary       Proportion of    Process    95%    <48h          A      Age, sex,
     prophylactic    patients                            after                previous
     treatment       treated with                        admissio             stroke, TCI,
                     trombocyte                          n                    HA, DM,
                     inhibitor                                                previous MI,
                                                                              alcohol,
                                                                              tobacco, social
                                                                              status
                     Proportion of    Process    60%    <14           A      Age, sex,
                     patients                            days                 previous
                     treated with                                             stroke, TCI,
                     anticoagulants                                           HA, DM,
                                                                              previous MI,
                                                                              alcohol,
                                                                              tobacco, social
                                                                              status
     Diagnostics     Proportion of Process    90% <24h           C           Age, sex,
                     patients who                     after                   previous
             Jan     undergo a                        admissio
                    Mainz, The National Indicator Project and Aarhus          stroke,
                                                                           UniversityTCI,
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         CLINICAL INDICATORS STROKE III
     Indicator       Indicator        Type      Standard Time       Evidenc   Prognostic
     concept                                                        e         factors
     Assessment      Proportion of    Process    90%    < 24h        C       Age, sex,
     by a            patients                            after                previous
     physiotherapi   assessed by a                       admissio             stroke, TCI,
     st              physiotherapis                      n                    HA, DM,
                     t                                                        previous MI,
                                                                              alcohol,
                                                                              tobacco, social
                                                                              status

     Assessment      Proportion of    Process    90%    < 24h        C       Age, sex,
     by an           patients                            after                previous
     occupational    assessed by                         admissio             stroke, TCI,
     therapist       an                                  n                    HA, DM,
                     occupational                                             previous MI,
                     therapist                                                alcohol,
                                                                              tobacco, social
                                                                              status


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             Jan Mainz, The National Indicator Project and Aarhus University
          CLINICAL INDICATORS STROKE IV
     Indicator         Indicator       Type      Standard Time           Evidenc   Prognostic
     concept                                                             e         factors
     Assessment        Proportion of   Process    90%       <24h          C       Age, sex,
     of nutritional    patients who                          after                 previous
     status            have their                            admissio              stroke, TCI,
                       nutritional                           n                     HA, DM,
                       status                                                      previous MI,
                       evaluated                                                   alcohol,
                                                                                   tobacco, social
                                                                                   status
     Mortality         30 days and 3, Outcom     30 days     30 days       C       Age, sex,
                       6, 12 months   e          mortality   and 3, 6,             previous
                       mortality                 < 20%       12                    stroke, TCI,
                                                             months                HA, DM,
                                                             after                 previous MI,
                                                             stroke                alcohol,
                                                                                   tobacco, social
                                                                                   status
     Destination       Proportion of Outcom < 30%       At          C             Age, sex,
     after             patients who  e        are       discharg                  previous
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             Jan
     discharge        Mainz, The National Indicator Project and Aarhus
                       are                    discharge e and 3                UniversityTCI,
                                                                                  stroke,
                       INDICATORS
                              Schizophrenics

     •   Assessment of Side-effects of The Psychotic drugs
     •   Family Intervention
     •   Psycho - education
     •   Pharmacological Treatment
     •   Continuity of Contacts to The Health Care System
     •   Psychosis – relapse
     •   Functional Status




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         Jan Mainz, The National Indicator Project and Aarhus University
                      CLINICAL INDICATORS
                        SCHIZOPHRENIA I
     Indicator     Indicator            Type     Standa   Time          Eviden   Prognostic
     concept                                     rd                     ce       factors
     Diagnostics   Proportion of        Proces   90%     - discharge     D      Age, sex,
                   patients who are     s                 - once a               social status,
                   diagnosed for                          year                   abuse,
                   1.                                                            duration of
                   psychopathology                                               untreated
                                                                                 psychosis
                   2. cognitive         Proces           - discharge     B      Age, sex,
                   functions            s         75%     - once a               social status,
                                                          year                   abuse,
                                                                                 duration of
                                                                                 untreated
                                                                                 psychosis


                   3. need for social   Proces           - discharge     D     Age, sex,
                   support              s         80%     - once a              social status,
                                                          year                  abuse,
                                                                                duration of
                                                                                untreated
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             Jan Mainz, The National Indicator Project and Aarhus          University
                                                                                psychosis
      CLINICAL INDICATORS SCHIZOPHRENIA II
     Indicator      Indicator          Type     Standa   Time     Evidenc Prognostic
     concept                                    rd                e       factors
     Side effects   Proportion of      Proces           Once a     B      Age, sex,
                    patients who       s         80%     year              social status,
                    have registered                                        abuse,
                    side effects                                           duration of
                    - neurologically                                       untreated
                    - weight                                               psychosis
                    - cardiovascular
                    - libido
     Family         Proportion of      Proces           Once a     A      Age, sex,
     intervention   families who are   s         70%     year              social status,
                    offered family                                         abuse,
                    intervention                                           duration of
                                                                           untreated
                                                                           psychosis
     Psycho         Proportion of      Proces           Once a     A     Age, sex,
     education      patients who are   s         90%     year             social status,
                    offered psycho                                        abuse,
                    education                                             duration of
                                                                          untreated
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             Jan Mainz, The National Indicator Project and Aarhus    University
                                                                          psychosis
     CLINICAL INDICATORS SCHIZOPHRENIA III
     Indicator        Indicator             Type     Standa   Time     Eviden   Prognostic
     concept                                         rd                ce       factors
     Pharmacolog      Proportion of         Proces           Once a     A      Age, sex,
     ical treatment   patients who are      s        90%      year              social status,
                      given anti-                                               abuse,
                      psychotic                                                 duration of
                      treatment                                                 untreated
                      (conventional/                                            psychosis
                      2nd generation)
     Contact          Proportion of         Proces           Once a     A      Age, sex,
                      patients who are      s         75%     year              social status,
                      in contact with the                                       abuse,
                      health care                                               duration of
                      system                                                    untreated
                                                                                psychosis
     Psychopathol Proportion of     Outco                    Once a     C      Age, sex,
     ogy          patients who have me                40%     year              social status,
                  relapse                                                       abuse,
                                                                                duration of
                                                                                untreated
                                                                                psychosis

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               Jan Mainz, The National Indicator Project and Aarhus University
      CLINICAL INDICATORS SCHIZOPHRENIA IV
     Indicator     Indicator         Type    Standa   Time     Eviden   Prognostic
     concept                                 rd                ce       factors
     GAF           Proportion of     Outco           Once a     C      Age, sex,
     Function      patients with a   me      85%      year              social status,
                   GAF-Function                                         abuse,
                   score ≤ 40                                           duration of
                                                                        untreated
                                                                        psychosis




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             Jan Mainz, The National Indicator Project and Aarhus University
                        INDICATORS
                               Lung Cancer
     •   Survival
     •   Delays in Diagnosis and Treatment
     •   Staging (Classification)
     •   Treatment and Resection (Appropriateness)
     •   Admission Time the last 3 months before Death
     •   Supporting Ambulatory Psychological Contact (Palliative
         Care)




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         Jan Mainz, The National Indicator Project and Aarhus University
          CLINICAL INDICATORS LUNG CANCER I
     Indicator        Indicator         Type     Standard             Time       Eviden   Prognos
     concept                                                                     ce       tic
                                                                                          factors
     Survival         Proportion of     Outcom Overall>98%            30 days      B      Heart
     after            patients are      e      Lobectomy>98%          after               disease,
     surgery          alive 30 days            Resection>99%          surgery             COLD
                      after surgery            Pneumectomy>96
                      (NSCLC)                  % Eksplorative
                                               thoracotomy >
                                               99%
     Survival         Proportion of     Outcom 1 year: 30%            1,2,5        B      Stage,
     NSCLC            diagnosed         e      2 year: 15 %           year                age, sex,
                      patients who             5 year: 10%            after               histo-
                      are alive after                                 admissio            pathology
                      1, 2, 5 years                                   n
     Delay            Proportion of     Proces   Patients should be   Discharg     B
                      patients with     s        diagnosed < 4        e
                      appropriate                weeks after
                      waiting time               admission
                      Proportion of Proces Patients should be Discharg             B
                      patients with s       treated < 14 days e
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                Jan   Mainz, The National Indicator Project and Aarhus
                      appropriate           after being                          University
         CLINICAL INDICATORS LUNG CANCER II
     Indicator    Indicator       Type     Standard            Time       Eviden   Prognos
     concept                                                              ce       tic
                                                                                   factors
     Staging      Proportion of   Proces   60%                Discharg     B
                  patients with   s        consistency         e
                  consistency              between cTNM
                  between                  and pTNM
                  cTNM and                 90% of patients
                  pTNM                     are cTNM
                                           assessed
     Treatment    Proportion of   Proces   Treatment rate:    Discharg     B      Histo-
                  patients, who   s        70%                 e                   pathology
                  are treated                                                      , age

     Resection    Proportion of   Proces   Resectionsrate:    Discharg     B      Histo-
                  patients, who   s        25%                 e                   pathology
                  are resected                                                     , age


     Admittance    Proportion of Proces 80% are admitted At death           C      Age
     time 3        patients with s       24 days
            Jan an admission
     months prior Mainz, The National Indicator Project and Aarhus        University
42
         CLINICAL INDICATORS LUNG CANCER IV

     Indicator      Indicator         Type     Standard             Time       Eviden   Prognos
     concept                                                                   ce       tic
                                                                                        factors


     Supportive     a. Proportion     Proces   a. All who are       At death     D
     consultation   of patients in    s        discharged without
                    palliative care            an offer of
                    who are                    treatment are
                    offered a                  offered a
                    supportive                 supportive
                    consultation               consultation
                    b. Proportion              b.75% of patients
                    of patients                accept a
                    who accept a               supportive
                    supportive                 consultation
                    consultation




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             Jan Mainz, The National Indicator Project and Aarhus University
                        INDICATORS
                                 Hip Fracture

     •   Risk Assessment of Nutritional Status
     •   Pain Intensity at Mobilisation at 5th Post Operative Day
     •   Functional Status at 5th Post Operative Day
     •   ADL: Functional Recovery
     •   Discharge Destination
     •   Reoperative by Different Types of Fractures
     •   Mortality at 30 Days, 4, 6, 12 months




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         Jan Mainz, The National Indicator Project and Aarhus University
            CLINICAL INDICATORS HIP FRACTURE I
     Indicator      Indicator        Type      Standard       Time          Evide   Prognostic
     concept                                                                nce     factors
     Assessmen      Proportion of    Process      90%        BMI on the      A     Comorbidity
     t of           patients who                              2nd
     nutritional    have their                                postoperati
     state          nutritional                               ve day
                    state
                    evaluated

     Pain           Proportion of    Outcom    85% has a      At Timed        C     Age, sex,
                    patients who     e         VAS score <    “Up and               senile
                    have a VAS                 4 in a Timed   Go” test on           dementia,
                    score < 4 in a             “Up and Go”    the 5th               acute
                    Timed “Up                  test           postoperati           confusion
                    and Go” test                              ve day
                    on the 5th
                    postoperative
                    day
     Ability to     Proportion of Outcom     50%      With pain     B   Physical
     walk           patients who  e                    VAS score         activity, senile
                    have a Timed                       on the 5th        dementia
                    “Up and Go”                        postoperati
              Jan   score < 30                         ve day
                    Mainz, The National Indicator Project and Aarhus University
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         CLINICAL INDICATORS HIP FRACTURE II

     Indicator   Indicator         Type     Standard     Time           Evide    Prognostic
     concept                                                            nce      factors
     ADL         Proportion of     Outcom   1. 50%       1. FRS at        B      Senile
                 patients who      e        have a       admittance              dementia, low
                 regain their               total FRS                            ADL score
                 ADL function               > 95                                 before fracture,
                                            before                               balance
                                            fracture
                                            2. 50%       2. BADL on
                                            have a       the
                                            BADL >       5th
                                            22 on the    postoperativ
                                            5th          e day
                                            postoperat
                                            ive day


                                            3. 50%     3. FRS after
                                            have a     4 months if
                                            total FRS  possible
                                            > 65 after
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             Jan Mainz, The      National Indicator Project and Aarhus
                                            4 months                          University
        CLINICAL INDICATORS HIP FRACTURE III

     Indicator     Indicator         Type     Standard         Time           Eviden   Prognosti
     concept                                                                  ce       c factors
     Mortality     Mortality after   Outcom   Mortality-rate   After 30         B      Comorbidit
                   30 days and       e        (SMR) <1,7       days, and               y, age, sex
                   after 4, 6, 12                              after 4, 6,
                   months                                      12 months
                                                               continuously

     Discharge     Proportion of     Outcom   80% are       After 4             B
     destination   patients who      e        discharged to months and
                   are                        home          continuously
                   discharged to
                   home/nursing
                   home or
                   equivalent




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             Jan Mainz, The National Indicator Project and Aarhus University
             PHASE 1:
     COMMENCEMENT OF THE TASK


     • Selection of group participants

     • Classification of concepts, definitions and limitations

     • Organising the work in the group. Creation of smaller
       working subgroups and delegation of projects to
       individual group participants




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       Jan Mainz, The National Indicator Project and Aarhus University
      PHASE 2: OVERVIEW OF EXCISTING
        KNOWLEDGE AND PRACTICE
     • Presentation of knowledge and documentation
       from literature and meta analyses

     • Consensus about existing knowledge, practice
       and conclusions

     • Determination of the clinical epidemiological
       task



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       Jan Mainz, The National Indicator Project and Aarhus University
       PHASE 3: DETERMINATION OF
       PROFESSIONAL INDICATORS
     • Determination of professional indicators based
       on existing professional and clinical
       epidemiological knowledge

     • Decisions about data collection. Inclusion
       criteria. Exclusion criteria.

     • Determination of interpretation (how to read
       data, limination and acceptable tolerances)

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       Jan Mainz, The National Indicator Project and Aarhus University
      PHASE 4: DATA COLLECTION
     • The data collection should be supported by clinical
       epidemiologists

     • Data from medical records, questionnaires, clinical
       databases, registers should be used




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       Jan Mainz, The National Indicator Project and Aarhus University
          CLINICAL DATABASES


     • A register, that contains specific clinical indicators,
       which can describe the quality of care for a specific
       patient group.




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        Jan Mainz, The National Indicator Project and Aarhus University
      PHASE 5: DATA ANALYSES


     • Analyses, evaluation, interpretation

     • Professional discussions of processed data results




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       Jan Mainz, The National Indicator Project and Aarhus University
     INTERPRETATIONS OF FINDINGS
     If differences are assessed in a clinical course
     there are different levels of explanation:

     • Bias due to selection of patients or bias in data
       collection

     • Confounding (different prognostic factors between
       groups)

     • Random variations

     • There is a difference
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        Jan Mainz, The National Indicator Project and Aarhus University
      PHASE 6: REFLECTIONS AND
           DESCRIPTIONS
     • Reflections about cause-and effects. Connections
       between these and conclusions based on data
       and cause analysis

     • Creations of reports to hospital quality
       committees

     • Feed back to professionals

     • Implementing quality improvement

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       Jan Mainz, The National Indicator Project and Aarhus University
     PUBLIC ACCESS TO DATA
     Data are released to the public at:


                 - National     level
                 - County level
                 - Hospital level
                 - Clinical unit level

     Data on individual doctor level will not be released


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     Jan Mainz, The National Indicator Project and Aarhus University
            COMMUNICABILITY


     • Data must be transformed into meaningful and
       useful information, reportable in a relevant manner
       to all stakeholders

     • Feedback required on a regular basis for
       behavioural change




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       Jan Mainz, The National Indicator Project and Aarhus University
                   PERSPECTIVES
     • Research
     • CME
     • Quality development
       - Clinical guidelines
       - Patients pathways
       - Audit




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       Jan Mainz, The National Indicator Project and Aarhus University
                        INDICATORS
     • Are strategic markers monitoring aspects of the quality of care
     • Measure the extent to which set targets are achieved
     • The surveillance of health care quality is impossible without the use
       of relevant indicators
     • Should be valid (measure exactly what we want to measure)
     • Should be sensitive (reflect correctly changes occurring given the
       situation)
     • Should be specific (to avoid the measurement of changes arising
       from external factors not related to the objectives and targets)
     • Should be evidence based

     The use of indicators should be followed by professional assessment,
       evaluation and interpretation

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        Jan Mainz, The National Indicator Project and Aarhus University
                 PERSPECTIVES

     THE EUROPEAN INDICATOR
              PROJECT
           under the flag of
         The European Union
                 and
               ESQH
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     Jan Mainz, The National Indicator Project and Aarhus University
      The European Indicator Project
              PRINCIPLES

     • Health professionals develop evidence based
       standards and indicators for all major
       diseases
     • One or two indicators for specific diseases
       shoul be developed
     • Health professionals assess and interpret
       results before public release of data


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       Jan Mainz, The National Indicator Project and Aarhus University
      The European Indicator Project
                 AIM

     • Improving prevention, diagnostics,
       treatment and rehabilitation
     • Documentation for making priorities
     • Information for patients and
       consumers
     • International benchmarking


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      Jan Mainz, The National Indicator Project and Aarhus University
       The European Indicator Project
             ORGANISATION
     • All interested European countries would be able to
       participate
     • Representatives from each country establish a steering
       committee
     • International and national fundings should finance the
       project
     • Important diseases are identified which would be relevant
       for international comparisons
     • The project should be conducted within a limited time
       period (e.g. 3 years)
     • The project should be evaluated in order to decide whether
       it would be feasible to continue the project

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       Jan Mainz, The National Indicator Project and Aarhus University
      ”I am called eccentric for saying in public that hospitals, if
      they wish to be sure of improvement, must find out what their
      results are. Must analyze their results to find their strong and
      weak points. Must compare their results with those of other
      hospitals…
      Such opinions will not be eccentric a few years hence.”
                                  E.A. Codman, MD, 1917.




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     Jan Mainz, The National Indicator Project and Aarhus University
            In God we trust –

     everybody else has to bring data



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