International Consortium for Health Outcomes Measurement ICHOM and the Older Person Standard Set 22nd September 2016 Agenda Why is outcome measurement important? The Working Group process The Older Person Standard Set Questions The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 2 How do we define a health outcome? “Outcomes are the results people care about most when seeking treatment, including functional improvement and the ability to live normal, productive lives.” – ICHOM The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 3 Outcomes are the 'real world' results that matter to patients For example: prostate cancer Patient initial conditions Protocols/ guidelines e.g., Staff certification, facilities standards Structure Processes PSA Gleason Score Surgical margin (…) Indicators Survival Continence Erectile function (…) (Health) outcomes The Older Person Standard Set Patient experience/ engagement Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 4 This is why measuring and reporting meaningful outcomes matters Comparing outcomes of prostate cancer care …may obscure large differences in outcomes that matter most to patients Focussing on mortality alone… % 100
94.0
94.0
95.0
90
80
75.5
80.0
70
60
50.0
50
43.3
40
34.7
30
20
6.5
10
0
5 year survival 1 yr incontinence Germany Sweden 1 yr severe erectile dysfunction Best-­‐in-­‐class: Martini Klinik Swedish data rough estimates from graphs; Source: National quality report for the year of diagnosis 2012 from the National Prostate Cancer Register (NPCR) Sweden, Martini Klinik, BARMER GEK Report Krankenhaus 2012, Patient-­‐reported outcomes (EORTC-­‐PSM), 1 year after treatment, 2010 The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 5 Variation in health outcomes is a worldwide problem 2x variation in 30-­‐day mortality rate from heart attack in US hospitals 4x variation in bypass surgery mortality in the UK hospitals 5x Variation of major obstetrical complications among US hospitals 9x variation in complication rates from radical prostatectomies in the Dutch hospitals 18x variation in reoperation rates after hip surgery in German hospitals 20x variation in mortality after colon cancer surgery in Swedish hospitals 36x variation in capsule complications after cataract surgery in Swedish hospitals But, for outcomes that matter most to patients – improvement in their symptoms, functioning, and well-­‐being – this only begins to describe the magnitude of the problem. The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 6 We need standardisation so that we can meaningfully and reliably compare the same outcomes Comparing apples with oranges is a lot harder than…. …comparing apples with apples Measuring different outcomes in different ways makes it impossible to meaningfully compare The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 7 Agenda Why is outcome measurement important? The Working Group process The Older Person Standard Set Questions The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 8 ICHOM was formed as a non-­‐profit catalyst to drive the industry towards value-­‐based health care Our mission: Unlock the potential of value-­‐based health care by defining global Standard Sets of outcome measures that really matter to patients and by driving adoption and reporting of these measures worldwide The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 9 Within our strategic agenda, value-­‐based health care begins with defining the standards Define Standards Benchmark on outcomes1 Establish outcomes transparency VBHC Measure outcomes Collaborate to improve value Develop value-­‐based payment models Core mission of ICHOM Enabler role The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 10 For all conditions and population areas we must first ask the following questions Step 1 Step 2 Step 3 Is this work needed? What is the condition or population of focus? Is it feasible to identify measureable outcomes within the area of focus and what work has been done already? Let’s now apply this to the Older Person Standard Set The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 11 Step 1 Is this work needed? ‘Reduction in emergency admissions’1 ‘Reduction in length of admission’1 The outcomes we routinely focus on for older people are process measures and not always outcomes that matter to older persons 1NHS Outcomes Framework 2016 to 2017 available at https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/513157/NHSOF_at_a_glance.pdf The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 12 Increasing ageing populations are highly likely to increase healthcare costs Step 1 Growth in activity over last 20 years in UK, by age group, 1989/90 – 2009/10 310% % 189% 63% 63% Non-­‐elective ordinary admissions 0 – 64 yrs 197% 71% Elective ordinary admissions 64-­‐84 yrs 85+ yrs Source: The King’s Fund, Ageing Population, Figures obtained through correspondence with the Department of Health http://www.kingsfund.org.uk/time-­‐to-­‐think-­‐differently/trends/demography/ageing-­‐
population The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 13 What is the area of focus? The prevalence of frailty can vary from 4.9-­‐27.3% globally and there is no global definition of ‘old’ Step 2 Spain 27.3% Italy 23% Greece 14.7% Netherlands 11.3% Sweden 8.6% UK 8.1% Ireland 6% Western Europe Korea 7.8% Taiwan 4.9% North America Asia USA 6.9% Prevalence of Frailty by the Fried Scale in Community-­‐dwelling adults 65 years and older of the Nationally represented population Source: Choi et al 2015, Global Prevalence of Physical Frailty by Fried's Criteria in Community-­‐Dwelling Elderly With National Population-­‐Based Surveys The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 14 There are a number of existing efforts to measure the outcomes of older persons around the world and outcome tools have been developed Step 3 English Longitudinal Study of Ageing (ELSA) Intermediate Care Audit Electronic Frailty Index (eFI) and local frailty registers Canadian Longitudinal Study on Aging The Health & Retirement Study (HRS) Mexican Health and Aging Study (MHAS) The Irish Longitudinal Study on Ageing (TILDA) Dublin Mid Leinster Minimum Dataset for Older People in Care Settings Puerto Rican Elderly: Health conditions (PREHCO) Costa Rican Study of Longevity and Healthy Aging Mijnkwaliteitvanleven.nl, Netherlands The Older Persons and Informal Caregivers Survey Minimal Dataset’s (TOPICS-­‐MDS) National Care for the Elderly Programme (NCEP) Survey of Health, Ageing and Retirement in Europe (SHARE) China Health and Retirement Longitudinal Study (CHARLs) Korean Longitudinal Study of Ageing (KLoSA) Japanese Study of Ageing and Retirement (JSTAR) Taiwan Longitudinal Study on Aging (TLSA) Italian Longitudinal Study on Ageing (ILSA) Longitudinal Ageing Study in India (LASI) Brazilian Longitudinal Study of Ageing and Wellbeing The Older Person Standard Set The Swedish National Study on Aging and Care in Kungsholmen (SNAC-­‐K) Other multi center efforts: •  WHO Study on global ageing and adult health (SAGE) – China, Ghana, India, Mexico, Russian Federation, South Africa Dynamic Analyses to Optimise Ageing (combining 9 datasets and surveys) Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 15 Agenda Why is outcome measurement important? The Working Group process The Older Person Standard Set Questions The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 16 The Older Person Standard Set was developed by a Working Group representing 11 countries Samir Sinha, University of Toronto Donna Haslehurst, Older person Joanne Lynn, Altarum Institute Julie Bynum, The Dartmouth Institute Karen Bandeen-­‐
Roche, Johns Hopkins Jay Banerjee Chair, NHS Asan Akpan, Research Fellow NHS John Young, NHS England Gill Turner, NHS, BGS Diane Bell, COBIC Arnold Fertig, Cambridge CCG Barbara Batty, Oxford CCG Jenny Shand, UCLPartners David Bramley, NHS England Helen Lyndon, NHS England Tom Gentry, Age UK Ruth Isden, Age UK Jonathon Hope, NHS England Anne Ekdahl, Karolinksa Institute Mike Martin University of Zurich Liang-­‐Kung Chen, Taipei Veterans General Hospital George Yi, Formal caregiver and Yuan Ze University Claudia Bausewein, Munich University Hospital Nienke de Vries, Radboud University Nijmegen Medical Centre Francesco Mattace Raso, Erasmus Marleen Harkes, Havenziekenhuis Sheila Shaibu, University of Botswana Diana Rodriguez Hurtado, Universidad Peruana Cayeto Heredia The Older Person Standard Set Ian Cameron, University of Sydney Cathie Sherrington, University of Sydney Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 17 The Older Person Standard Set is supported by evidence, patient input and open review July 17th Working Group Process Literature input Working Group Launch Scope October 9th November 5th December 22nd January 25th February 22nd Call 1 Outcome domains Call 2 Outcome definitions Call 3 Outcome wrap-­‐up Call 4 Case-­‐mix domains Call 5 Case-­‐mix definitions March 22nd Call 6 Std. Set & publication wrap-­‐up April 26th Call 7 Review & transition to implementation May 18th Standard Set Launch Research & propose scope Literature review of outcome domains and definitions Patient input External Input The Older Person Standard Set Patient focus group Review of risk factor domains and definitions Further validation Open review period Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 18 Our selection of outcome domains is guided by the value-­‐
based healthcare framework The focus of the Working Group is to recommend a minimum set of outcomes for evaluating healthcare ▪  We are seeking to balance a comprehensive view of measurement with a feasible recommendation ▪  The goal is to enable outcome measurement in routine clinical practice to ü  Improve decision making between providers and patients ü  Facilitate quality improvement ü  Allow for benchmarking across organizations ▪ 
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Selected outcomes should… What is a health outcome? The Older Person Standard Set • 
Represent the end results of care, not the process of care Be important to older persons and their families Be feasible to capture Be sensitive over time to change Be modifiable with quality improvement efforts Outcomes are the results people care about most when seeking treatment, including functional improvement Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 19 The ICHOM Standard Set for Older Persons Scope This is set is recommended for an older population, however there is no globally agreed definition on what age this is. As a guideline, the Working Group recommend measuring outcomes for a population which, on average, is in the last 10 years of life based on average life expectancy at age 60 Sponsored by: The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 20 The ICHOM Standard Set for Older Persons Polypharmacy : •  Adverse outcomes •  Total number of prescribed medications •  Patient reported question on whether the patient believes the medication makes them worse Falls : •  Total no of falls •  Falls resulting in any fracture •  Falls resulting in hospital admission •  Falls resulting in any professional medical attention The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 21 The ICHOM Standard Set for Older Persons The UCLA 3-­‐item Loneliness Scale: • 
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How often do you feel lonely? How often do you feel you lack companionship? How often do you feel left out? How often do you feel isolated from others? Do you have as much social contact as you’d like?’ ADLs, pain, mood and emotional health: •  SF-­‐36 •  Gait speed Autonomy and control: •  Adult Social Care Outcomes Toolkit (ASCOT) The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 22 The ICHOM Standard Set for Older Persons Participation and decision making : •  Confidence in ability to cope with own health problems •  Confidence in role as participant in care •  Confidence in healthcare professionals •  Experience of having been treated with dignity and respect •  Coordination of care Carer burden using the 4-­‐item Zarit Burden Interview (ZBI): •  Do you feel that because of your relative that you don’t have enough time for yourself •  Do you feel stressed between caring for your relative and trying to meet other responsibilities (work, home)? •  Do you feel strained when you are around your relative •  Do you feel uncertain about what to do about your relative? The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 23 The ICHOM Standard Set for Older Persons Survival and place of death: All cause survival No of admissions No of readmissions Length of stay Discharged to place of choice •  Preferred place of death •  Was the place of death as preferred • 
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Frailty: •  Canadian Study on Health & Ageing Clinical Frailty Scale The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 24 The Standard Set includes baseline data to assess outcomes and perform risk adjustment for comparability Risk adjustment factors The Older Person Standard Set Demographic risk adjustment factors Baseline clinical risk adjustment factors Age Frailty stage Sex Inappropriate medication use Ethnicity Cognitive impairment Level of education Comorbidities Living status and location Activities of daily living function Smoking status Total number of medications prescribed Alcohol use Hearing or vision impairment Body mass index Level of care received Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 25 The Working Group recommended regular data collection: the following timelines are examples of when data could be collected The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 26 We have completed 21 Standard Sets, covering 45% of the disease burden as defined by WHO • 
By 2017, more will be in development Congenital hand and upper limb •  Chronic kidney disease •  Adult overall health malformation •  Facial palsy •  Hypertension* •  Diabetes •  Oral health •  Inflammatory arthritis •  Mental health *Focused on low and middle income countries The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 27 Watch this short video to get a more personal view of the Working Group experience http://vimeo.com/
111976337 The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 28 Agenda Why is outcome measurement important? The Working Group process The Older Person Standard Set Implementation Questions
The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 29 We have developed two models to support implementation Implementation Community • 
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Communities of providers working together to implement a Standard Set. Meet over video conference every 4-­‐6 weeks for 6-­‐8 months. ICHOM facilitates the teleconferences. Each teleconference has three parts: •  Update on progress and discussion around challenges •  ICHOM provides key knowledge e.g. IT solutions •  Plan action items. The Older Person Standard Set Capacity Building • 
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High touch support for a single provider. Combination of teleconferences and site visits spread over a 6-­‐8 month period. ICHOM provides key knowledge from experience of implementation across the world. At end of programme ability to independently scale to implementing multiple sets across across organisation. Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 30 Strong global demand to measure and compare outcomes Institutions and registries around the world are already measuring or implementing ICHOM Standard Sets 32 Countries 400 Organizations 13 National Registries The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 31 We are currently developing a global benchmarking program – The GLOBE Program Objectives of Global Comparisons project Pool health outcomes data from 10-­‐15 leading provider organizations – 2 conditions for pilot (Hip/Knee Osteoarthritis and Cataract). Risk-­‐adjust raw data and organize comparisons on key indicators ▪  Particular focus on patient-­‐reported outcomes Provide individual – and confidential – reporting to participating organizations Identify the “best-­‐in-­‐class” and publish about their performance Sample output – Hip and Knee Case mix complexity (risk-­‐
adjusted) Case-­‐mix average Complexity = 1.0 Worse Acute complications Readmissions
Knee functioning
Patient-­‐
reported health status -­‐ 0 + -­‐ 0 + -­‐ 0 + -­‐ 0 + Work status
Time to recovery
Health-related QoL
Overall satisfaction
Disease progression Better Mortality
Knee pain
Other organization The Older Person Standard Set 0.6 Need for surgery
Reoperation or revision
Your organizations World average (for participants) Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 32 Agenda Why is outcome measurement important? The Working Group process The Older Person Standard Set Implementation Questions
The Older Person Standard Set Copyright © 2016 by the International Consortium for Health Outcomes Measurement. All rights reserved. 33