Health Quality Indicators, Value of Health:
Accounting for Quality Change
Aileen Simkins, Department of Health
Co-Director of the Atkinson Review
Context
• UK measurement of public service
healthcare output and productivity – Part 2
• Quality adjustments to series for healthcare
output described earlier by Chris Little
• Quality adjustments developed by DH; used
by ONS in Health Productivity article but not
in National Accounts
• Development programme
ONS Health Productivity Oct
2004
110
105
100
95
90
85
80
Output w ithout quality; inputs: drugs deflated by cost of all items; capital
services; missing years estimated as average of last 3 years
Output w ithout quality; inputs: drugs deflated by Paasche Price Index;
capital consumption; missing years estimated as previous year
1995 1996 1997 1998 1999 2000 2001 2002 2003
DH Press Release Oct 04
John Reid (Secretary of State for Health) says
“ it is absurd to measure NHS
output without taking account
of quality”
Quality as part of NHS
Output
• How many domains of quality?
– Health gain
– Patient experience
• What can we measure?
• How can we link quality measures to the NHS
output index?
• How should we weight different aspects of
quality?
• How valid is a partial story?
DH Work on Quality Adjusted
Output
• York/NIESR research commissioned 2004
• Parallel DH work during 2005
• DH paper Accounting for Quality Change
published Dec 2005, with research report
• Used in 2nd ONS Health Productivity article
Feb 2006
Accounting for Quality
Change
Average over last 5 years:
• Value of health
• Value weight for statins
• York/NIESR adjustment
• Patient experience*
• Blood pressure control *
• Heart attack survival
Total **
Quality adjusted output growth
1.5%
0.81%
0.17%
0.07%
0.05%
0.01%
2.68%
6.29%
ONS Health Productivity
2006
110
105
100
95
Output w ith quality and value of health; inputs: drugs deflated by cost of all
items; capital consumption, direct labour method
90
85
Output w ith quality and value of health; inputs: drugs deflated by Paasche
Price Index; capital services, indirect labour method
80
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
York/NIESR Research
0.17%
• Ideal method is value weighted output
index, not cost weighted activity index
• Algebra takes account of multiple aspects
of quality and their value to patients – e.g.
health gain (QALYs)
• Interim formula uses cost weights with
mortality after hospital treatment +
estimate for health gain if not dead
• Waiting time – interim formula measures
as deferred benefit (discounted)
Quality Adjusted Life Years
Health
Status
h=1
h
h* (t )
*
ho
ho (t )
t0
t1
Ideally we want to measure the area under the curve
Before and after measures are a reasonable
approximation (?)
t2
t3
Value Weight for Statins 0.81%
• Statin prescriptions rising fast (so positive
output growth in CWAI)
• Value per prescription, in QALYs, can be
shown to be greater than cost
• Work based on epidemiological research –
lives saved, less morbidity
• Value weight is £115 v cost £30 (assuming
£30,000 per QALY)
• So using value weight raises output growth
even further
Improving blood pressure
control 0.05%
• GP Contract Quality and Outcomes Framework
• First data set Sept 2005 – no time series yet
• QRESEARCH data on 400+ practices (3m patients)
– quarterly measures of many QOF indicators,
pre-contract
• Prevalence rates and comorbidity rates
• Examined data for blood pressure and cholesterol
control
Hypertension: blood pressure
control
Key results Jan 2002 – Oct
2004
CHD
Blood pressure control Jan 02
Blood pressure control Oct 04
Annual rate of increase
Hypertension
Blood pressure control Oct 01
Blood pressure control July 04
Annual rate of increase
60.4%
78.3%
10.4%
44.6%
63.0%
22.4%
Overall GP Quality
Adjustment
• Most patients (86%) don’t have CHD or
hypertension – assume no change in quality
• Patients with hypertension and/or CHD also
see GP for other illnesses – weight as
equally important as CHD/hypertension, no
change
• Patients with CHD need wider treatment than
blood pressure control – weight BP as 1/3
• Result: 1.1% a year for GMS as a whole
• Raises NHS output by 0.14% a year
Patient Experience 0.07%
• Survey programme set up NHS Plan 2000
• Operated by Healthcare Commission
• PSA target for national improvement in
measured patient experience
• Separate surveys for inpatients, outpatients,
primary care, A&E – with 2 data sets each
• Many questions; 5 domains
Patient Experience Data
Domains
Inpatient survey
access and waiting
safe, high quality co-ordinated care
better information, more choice
building closer relationships
clean, friendly, comfortable place to be
Aggregate
Outpatient survey
access and waiting
safe, high quality co-ordinated care
better information, more choice
building closer relationships
clean, friendly, comfortable place to be
Aggregate
2001/2
2002/3
Year
2003/4
82
64
67
83
78
74.8
83
65
68
83
78
75.1
83
66
68
83
77
75.4
b
b
b
b
b
b
a
a
a
a
a
b
-------
70
83
77
86
70
77.2
70
83
77
86
69
76.8
69
82
77
86
68
76.4
-------
Figures in bold are actual data points. Figures not in bold are estimates.
*: aggregate score calculated by taking average of first four domain scores.
a : domain score based on actual data pointss to be published
b : to be estimated / calculated when relevant data become available
‘--‘ : no survey carried out
‘n/a’ : domain not relevant for this survey
2004/5
2005/6
Value of Health 1.5%
• Biggest single element; used first for education
• Does not depend on NHS data – same every year
• Atkinson Report Principle C
‘account should be taken of the complementarity
between public and private output, allowing for
the increased real value of public services in an
economy with rising real GDP’
• E.g ‘rising real wage rates mean we attach a
higher valuation to days lost through sickness
absence’
Establishing the Principles
• UKCeMGA consultation paper Sept 2006
• Framework for quality adjustment – based on
Atkinson Report
• Arguments on public/private
complementarity – two way
• Effect depends on specific channels of
influence in each area of public spending
• DH will await outcome of consultation and
further clarity
DH Development Work
•
•
•
•
•
•
•
•
•
Aiming for AfQC 2 in winter 2006/7
Improvements on volume series (hospital, GP)
? Use ‘avoidable deaths’ instead of ’30 day mortality
Discussion of functional form – additive not
multiplicative, how to weight different domains
Wider, longer analysis of primary care clinical
outcomes
Re-analysis of patient experience
New quality indicators (e.g. discharge to normal
residence after stroke)
New value weight for smoking cessation
Progress on routine measurement of patient
reported outcomes
Value and Validity of Quality
Adjusted Output Measures
• Focus on attributable impact on outcomes
and quality change
• Data incomplete; biased towards areas of
attention / improvement
• Development work by DH – partial?
• Techniques new, untried, difficult
• UKCeMGA in position to set standards, lead
development work, assure independent view
• External consultation important – health
Nov 06 based on Dec 05 paper