How to commission for improving health outcomes: measuring quality along care pathways
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This slide set is the second of two looking at how Clinical Commissioning Groups (CCGs) can make the best use of measurement to support them to commission for improved outcomes. This set looks specifically at how commissioners can build up sets of measures along whole pathways of care.
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How to commission for improving health outcomes: measuring quality along care pathways
- 1. Measuring quality along care pathways Sarah Jonas, Clinical Fellow, The King’s Fund Veena Raleigh, Senior Fellow, The King’s Fund Catherine Foot, Senior Fellow , The King’s Fund James Mountford, Director of Clinical Quality, UCL Partners © The King’s Fund 2012 Slide 1
- 2. Rationale The NHS Commissioning Board will assess the performance of clinical commissioning groups (CCGs) on the basis of outcomes, as defined in the Commissioning Outcomes Framework This requires CCGs to monitor care processes and intermediate outcomes along the care pathways that drive those outcomes Measuring quality along pathways is especially important in the context of long-term conditions, that typically have many stages, requiring care over time and in different settings. The rising prevalence of long-term conditions is a growing challenge for the NHS Measuring quality along care pathways is therefore critical for enabling CCGs to monitor progress in improving outcomes © The King’s Fund 2012 Slide 2
- 3. 1. What we mean by measuring quality along care pathways © The King’s Fund 2012 Slide 3
- 4. Defining quality measurement along a care pathway Defined broadly as ‘a set of quality measures that together describe a care pathway for a particular population or group of patients’ Differs from ‘clinical pathways’, which generally refer to a standardised set of actions aiming to optimise care for a particular clinical problem, in line with evidence or guidelines © The King’s Fund 2012 Slide 4
- 5. 2. Reasons for measuring quality along care pathways © The King’s Fund 2012 Slide 5
- 6. The policy perspective › The NHS Outcomes Framework is complemented by outcomes frameworks for public health and social care › The NHS Outcomes Framework 2012/13 highlights the government’s intention to align outcomes across the three outcomes frameworks, with an emphasis on collaboration and integration › The Department of Health’s Information Strategy aims to: › promote inter-operability of information systems locally › encourage record linkage locally across different care settings › increase record linkage of national data sets by the Information Centre › make information available to drive integrated care across health and social care, within and between organisations ‘Information will move freely through the health and care system’ › These developments will support quality measurement along care pathways © The King’s Fund 2012 Slide 6
- 7. Developments in measuring quality Quality measurement has focused mainly on measuring isolated aspects of care in specific settings Stand-alone indicators do not assess quality holistically for patients with a given condition and are therefore inadequate for understanding and improving performance at a system level – especially for long-term conditions The growing prevalence of long-term conditions and increased need for integrated care has led the United Kingdom and many developed countries to move towards measuring quality along pathways © The King’s Fund 2012 Slide 7
- 8. Uses of measuring quality along care pathways Planning and developing health care services Improving the co-ordination and integration of care Improving the management of chronic conditions Improving the quality of care, including from a patient perspective Understanding how quality in one part of the health care system impacts on other health care services Lowering costs and improving productivity Commissioning care packages from a consortium of providers, or on the ‘accountable care organisation’ model, designed to provide integrated care © The King’s Fund 2012 Slide 8
- 9. 3. What to measure © The King’s Fund 2012 Slide 9
- 10. Example stages in a pathway Population health and wellbeing, health prevention and promotion (primary prevention) Diagnosis, referral and investigation Control of risk factors Treatment (primary/community/secondary care as appropriate) Recovery and rehabilitation Support and follow-up Secondary prevention Palliative and end-of-life care © The King’s Fund 2012 Slide 10
- 11. Example environments/care settings Population level Primary and community care Urgent, out-of-hours and emergency care Hospital care (emergency and planned) Tertiary and specialist care Mental health care Hospice and other palliative care Social care Domiciliary/home care © The King’s Fund 2012 Slide 11
- 12. NHS Outcomes Framework: domains Outcome domains Quality domains 1. Preventing premature death 2. Enhancing quality of life for people with Clinical long-term conditions effectiveness Commissioning 3. Helping recovery from ill-health and injury Outcomes Framework 4. Ensuring a positive experience of care Patient experience NICE quality 5. Treatment in a caring environment and standards Safety protection from avoidable harm © The King’s Fund 2012 Slide 12
- 13. 4. How to build sets of care pathway measures © The King’s Fund 2012 Slide 13
- 14. Three main routes to pathway measures Indicators from available national and/or local data sets can be selected and compiled to simulate a pathway Different sets of patient records can be linked together for analysis. This can be done locally, or centrally by linkage of national data sets by an authorised agency New data can be collected to fill the gaps in available data, to measure quality more comprehensively along pathways © The King’s Fund 2012 Slide 14
- 15. Bringing existing data sets together to simulate a pathway Existing data sets include: population-based data: eg, prevalence of risk factors, incidence/prevalence of disease, mortality data by cause of death, cancer registration data, use of primary and secondary care services, programme budgeting data primary care data: eg, Quality and Outcomes Framework, Hospital Episode Statistics (HES), prescribing, data in GP computer systems, screening , immunisation secondary care data: HES (data on inpatients, outpatients, A&E patients) mental health data: eg, Mental Health Minimum Data Set national clinical audit data: several data sets (held by the Information Centre and Healthcare Quality Improvement Programme) patient experience data: General Practice Patient Surveys, patient experience surveys in acute/mental health trusts etc patient-reported outcome measures (PROMs) data: currently available for four procedures: hip and knee replacement, hernia, cataract © The King’s Fund 2012 Slide 15
- 16. London Health programmes London Health Programmes have developed a series of pathway intelligence profiles for London PCTs (stroke) and local authorities (chronic obstructive pulmonary disease and maternity) The aim is to provide information to support policy-makers and commissioners to plan and deliver services, and for benchmarking to identify areas of strength and areas where improvement is needed © The King’s Fund 2012 Slide 16
- 17. COPD pathway profile: Southwark Key: England Key: Significantly better than England average Not significantly different from England average Significantly worse than England average No significance can be calculated Domain Local Local Lon Eng Eng Eng Indicator England Range Number Value Avg Avg Worst Best 1 Adults who smoke n/a 26.9 20.8 22.2 35.2 10.2 Factors Risk 2 Population aged 35yrs and over 129,423 45.3 49.6 56.2 70.4 37.8 3 Population aged 75yrs and over 12,278 4.3 5.6 7.8 16.0 3.4 4 COPD prevalence, recorded* 3,649 1.2 1.0 1.6 3.3 0.7 General Practice: 5 COPD prevalence, modelled 10,325 4.4 3.9 3.6 6.1 1.9 diagnosis 6 COPD prevalence, modelled v. recorded* 4.4 3.8 3.9 2.4 6.2 1.3 7 Asthma prevalence, recorded* 12,790 4.0 4.8 5.9 7.1 3.5 8 COPD diagnosis confirmed by post bronchodilator spirometry* 594 88.3 89.4 90.3 82.8 94.8 9 Exception rate for COPD indicators* 1,699 0.14 0.11 0.13 0.20 0.07 10 Adults with COPD who smoke General Practice: treatment 11 Patients with long-term conditions with smoking status recorded* 44,661 93.7 95.3 95.2 93.3 97.4 12 Patients with long-term conditions offered stop smoking advice* 8,736 92.0 92.7 92.8 88.7 96.7 13 Exception rate for smoking indicators* 511 0.89 0.77 0.71 1.40 0.36 14 Successful smoking quitters at 4 weeks, CO validated* 973 417 550 614 51 1,455 15 Prescribed nicotine replacement therapy (NRT)* 7,133 2,520 2,184 2,997 143 10,887 16 Prescribed varenicline* 3,961 1,400 984 1,704 275 5,221 17 Eligible COPD patients offered pulmonary rehabilitation 18 COPD patients with medical review in last 15 months* 2,710 85.7 89.6 89.9 80.7 93.9 Secondary Care 19 Length of stay, emergency inpatient COPD admissions* 3,230 5.9 6.7 6.8 9.6 3.2 20 Emergency admissions for COPD, overall* 559 3.3 1.9 1.8 4.9 0.9 21 Emergency admissions for COPD, COPD registered patients* 470 12.9 13.6 12.5 17.9 9.6 22 Emergency readmissions within 28 days, overall* 23 22.1 23.3 21.6 44.2 9.9 23 Emergency readmissions within 90 days, COPD admitted patients 131 41.6 40.2 33.9 63.8 7.5 Mortality & End 24 Deaths from COPD, all ages 291 38.9 25.4 26.2 48.7 11.9 of Life Care 25 Deaths from COPD, <75yrs 112 21.0 11.4 11.8 27.5 3.4 26 Years of life lost due to mortality from COPD 112 21.5 9.8 10.5 26.0 1.2 27 Deaths with any mention of respiratory disease as cause 1,694 37.9 35.1 33.9 41.1 25.7 28 Respiratory deaths at own residence 127 21.2 12.9 13.7 7.5 29.1 29 Cost of oxygen prescribing Source: NHS London Health Spend 30 Overall spend on obstructive airways disease* 3,690,000 10.7 10.9 13.1 24.5 6.4 n/a n/a 4.1 5.4 13.8 0.8 Programmes. © Crown 31 Primary care spend on obstructive airways disease* Copyright 2011. © TheSecondary care2012 on obstructive airways disease* 32 King’s Fund spend 3,586,000 11.9 6.8 7.6 16.4 1.8 Slide 17
- 18. Stroke pathway profile: Southwark Source: NHS London Health Programmes. © Crown Copyright 2011. © The King’s Fund 2012 Slide 18
- 19. The spine chart below shows how maternity data for this local authority compares with London and the rest of England. Your local authority’s results for each indicator are displayed as a circle. The average rate for England is shown by the black line in the centre of the chart. The range of results for all local authorities in England is shown as a grey bar. Green Maternity pathway profile: Southwark and red circles show differences from the England average. A green circle may still indicate an important public health problem. KEY Significantly better than the England average Significantly worse than the England average Significantly lower than the England average Significantly higher than the England average Not significantly different from the England average Significance not calculated. Data recording <50% - interpret with caution Local Local Lon Eng Eng Eng Dom ain Indicator England Range Num ber Value Avg Avg Worst Best 1 Women of childbearing age 74,400 25.9 23.6 20.1 29.7 9.5 Demography 2 Births 5,131 69.0 72.1 65.5 113.9 24.4 3 Total period fertility n/a 1.9 2.0 2.0 3.2 0.7 4 Births to women aged >35 1,356 26.4 24.9 20.1 41.6 7.7 5 Births to women aged >40 273 5.3 5.3 3.9 9.7 0.0 6 Teenage pregnancy 781 69.3 43.7 40.2 69.4 14.6 7 Early antenatal assessment*† 2,077 49.2 56.8 63.0 4.3 88.0 Antenatal 8 Early antenatal assessment recording* 4,221 92.6 68.6 67.7 0.3 99.3 care 9 Smoking during pregnancy* 217 4.9 6.5 13.5 32.5 3.1 10 Abortions (<10wks gestation)* 1,786 78.9 79.6 76.9 60.6 85.1 11 Inpatient admissions before delivery* 5,426 1.2 1.0 1.0 2.5 0.3 12 Births in NHS hospitals 4,827 94.1 96.6 97.0 99.4 65.7 13 Births at home or midwifery unit* 602 13.5 14.2 10.6 0.0 98.6 14 Unplanned transfer to hospital* 9 1.6 38.0 38.0 100.0 0.0 15 Inductions 926 16.7 15.2 17.2 37.5 0.2 16 Normal deliveries 2,780 59.4 58.5 61.4 45.9 76.3 17 Caesarean deliveries 1,277 27.3 26.7 24.0 38.9 11.8 18 Elective caesareans 377 8.1 9.9 9.6 19.4 4.9 Birth 19 Emergency/other caesareans 900 19.2 16.8 14.4 22.2 7.9 20 Vaginal birth after caesarean* 148 31.8 30.9 31.1 18.7 54.7 21 Midwives 180 38.5 31.3 31.5 15.2 80.9 22 Obs and Gynae consultants 18 3.9 2.8 2.6 0.2 7.9 23 Consultant: Midwife ratio n/a 10.0 11.2 12.1 187.2 7.0 24 1:1 care in labour 25 Multiple births 174 3.5 3.5 3.3 6.0 1.3 26 Premature births 638 14.0 12.4 12.3 63.6 0.0 27 Length of hospital stay after delivery 4,616 2.1 1.9 1.7 4.9 0.9 natal Post- care 28 Breastfeeding initiation* 4,025 90.5 86.3 73.6 39.0 92.3 29 Breastfeeding continuation* 3,457 75.3 64.1 45.7 19.2 83.1 30 Perinatal mortality (<7 days + stillbirth) 142 9.4 7.8 7.5 19.2 3.2 Outcomes 31 Neonatal mortality (<28 days) 56 3.7 3.0 3.1 19.2 0.0 32 Infant mortality (<1 year) 79 5.3 4.5 4.6 19.2 1.2 33 Low birth weight <2500g 424 8.3 7.8 7.3 11.5 3.9 34 Very low birth weight <1500g 85 1.7 1.6 1.4 3.3 0.0 Source: NHS London Health 35 Total maternity spend* 32,852,000 6,742 5868.3 5,483 9,955 2,389 Programmes. © Crown Spend Copyright 2011. © The King’s Fund Maternity spend primary care* 36 2012 - 0 255.6 392 0 2,010 Slide 19 37 Maternity spend secondary care* 32,852,000 6,742 5612.6 5,091 9,863 2,265
- 20. Data linkage Linkage across data sets can enable analyses that would not otherwise be possible. It is suitable for data sets comprised of individual patient records Linkage is often done using NHS number and/or other patient identifiers; the Information Strategy stipulates that all health and social care providers should record these to allow this Linkage is increasingly being undertaken with national data sets. Examples include: HES with ONS mortality records from death registration records HES with the patient-reported outcome measures data for selected procedures cancer registration data with HES data from national clinical audits such as Myocardial Ischaemia National Audit Project, to HES and ONS mortality records Information governance issues associated with linkage must be adequately addressed, and appropriate data protection safeguards put in place © The King’s Fund 2012 Slide 20
- 21. RAIDR: linking primary and secondary care Reporting Analysis and Intelligence Delivering Results (RAIDR) is a business intelligence tool for use by commissioners and practices in NHS North of Tyne and Durham and Darlington RAIDR links real-time primary care and secondary care data to enable analysis of patient care pathways and events for different conditions across different settings (eg, primary care, inpatient, outpatient, A&E). Comparative data is available by practice, and enables drilldown to individual patients RAIDR provides health care professionals in commissioning and primary care with a single portal for information that integrates multiple stand-alone data sources into graphical dashboards that users can drill down into for more information © The King’s Fund 2012 Slide 21
- 22. RAIDR: Non-elective stroke admissions for atrial fibrillation patients © The King’s Fund 2012 Slide 22
- 23. NW London Integrated Care Programme The programme aims to provide integrated care to 750,000 diabetic and elderly patients Data from primary care, outpatients, A&E, inpatients, mental health, community services and social care is linked using NHS number; can be used by clinicians, providers and commissioners The programme builds capability for primary, community, hospital and social care services to work collaboratively to support people at home, so reducing unnecessary hospital stays Launched in 2011, it is clinically led by GPs, hospital doctors and community care professionals, and involves a partnership between NHS organisations, local authorities and charities. Boundaries between providers are lifted so they can work as a team, allowing patients to receive the right treatment, in the right place at the right time © The King’s Fund 2012 Slide 23
- 24. NW London ICP: performance dashboard Performance Management Metrics Financial Impact Operations ▪ Total number of emergency admissions ▪ Patients on care plan ▪ Total number of A&E attendances ▪ Adherence to care plan ▪ Total number of UCC attendances ▪ Average length of stay ▪ Total number of emergency inpatient days ▪ Quality of care planning ▪ Community nursing hours per patient ▪ Bed occupancy rate Quality Staff ▪ Number of acute re-admissions ▪ Attendance at multi-disciplinary groups ▪ Number of emergency admissions ▪ Staff satisfaction ▪ Control measures ▪ Team effectiveness ▪ Level of community, social and mental health care ▪ Skills and capabilities ▪ Reduction in long-term care ▪ Waiting lists for non-acute care ▪ Hard outcomes (including PROMs) ▪ Patient experience metrics (including PREMs) Quarterly audit = Scorecard © The King’s Fund 2012 = Quarterly audit Slide 24
- 25. Torbay Care Trust Torbay Care Trust brings together commissioning and provision of adult social care and community health services The Trust records NHS number for users of social care services and uses this to link health and social care records. It has linked hospital inpatient, outpatient and A&E records with community services activity and adult social care services. It is now linking with GP practice records also Integrating health and social care information sources enables individual patients, pathways or services, and the associated costs, to be tracked over time The information has been used to support patients at home and reduce hospital bed use, emergency bed days, delayed transfers of care and costly care home placements © The King’s Fund 2012 Slide 25
- 26. Collecting new data for constructing a care pathway Routinely available data sets are not always comprehensive enough to construct a profile of performance along a whole care pathway Data about acute episodes of care is often readily available, but information about performance at either end of the care pathway is less so Professionally led initiatives – national and local – can drive the collection of additional data as needed National clinical audits, such as those co-ordinated by the Healthcare Quality Improvement Partnership (HQIP), are examples of data sets developed by health care professionals © The King’s Fund 2012 Slide 26
- 27. 5. A case study from UCL Partners: London Cancer © The King’s Fund 2012 Slide 27
- 28. London Cancer London Cancer is an integrated cancer system for North Central & North East London and West Essex. It designs an integrated care pathway for each cancer, to drive improvements in patient experience and outcomes, with associated metrics on: clinical outcomes patient-reported outcomes patient experience Based on information about existing good practice, published guidance and local priorities, care pathway measures were developed in five phases: specialist clinical development consultation with patients engaging with commissioners bringing partners together from across the cancer community consolidation of the measures, specification of the definitions, and construction of a scorecard for each cancer pathway © The King’s Fund 2012 Slide 28
- 29. © The King’s Fund 2012 Slide 29
- 30. London Cancer Care pathway measures for brain and other central nervous system tumours Pathway stage Sample indicators Presentation Patients diagnosed on emergency presentation Patients seen <2 weeks of urgent referral Diagnostics Diagnostic surgery <14 days of diagnosis Treatment <31 days of decision to treat Multidisciplinary Patients finding it easy to contact their key worker team Treatment • surgery Complication rates, 30 day survival rates • radiotherapy Treatment delivered <45 minutes from home • chemotherapy Patients admitted as an emergency during course of treatment Follow-up Patients undergoing holistic needs assessment Survival 1, 2, 5 year survival rates End of life Patients who die in their preferred place of death System Patients and carers given clear information during pathway stages © The King’s Fund 2012 Slide 30
- 31. 6. Challenges to measuring along care pathways © The King’s Fund 2012 Slide 31
- 32. Challenges Data gaps remain Information governance must be robust when personal information moves across organisations or is used for record linkage Measurement across institutional boundaries requires acceptance of joint responsibility, attribution, accountability and new ways of working Focusing on particular conditions will not capture issues related to co-morbidities and multi-morbidities Development of care pathway measures will need to be an incremental process, determined by local priorities and data availability and information developments © The King’s Fund 2012 Slide 32
- 33. 7. Conclusions © The King’s Fund 2012 Slide 33
- 34. Conclusions Measuring quality along care pathways has the potential to improve quality and outcomes, and reduce costs – especially for patients with chronic conditions and multiple morbidities The development and use of quality measures along care pathways can also support CCGs in commissioning integrated care packages from a range of local providers CCGs will need to demonstrate that they are working with local partners to improve the continuity, co-ordination and integration of care across services and providers. Care pathway measures can help with this. Joint commissioning and health and wellbeing board strategies provide a basis for identifying priorities and taking this forward Currently available data sets offer considerable potential for such measurement Information developments in the pipeline – such as increased use of record linkage, wider availability of clinical audit data, improved information flows across providers and services, more data transparency – will improve the prospects for measuring quality along care pathways © The King’s Fund 2012 Slide 34
Hinweis der Redaktion
- This slide set is the second of two looking at how Clinical Commissioning Groups (CCGs) can make the best use of measurement to support them to commission for improved outcomes.The first slide set introduced general concepts about approaches to measurement in health care, the uses of structure, process and outcome indicators, and how to achieve a good mix of indicators for commissioning.This second slide set follows on from that, and looks specifically at how commissioners can build up sets of measures along whole pathways of care.
- As long-term and chronic conditions come to dominate the need for, and delivery of, health care, measurement at individual organisation level becomes increasingly inadequate as a marker of quality since these conditions require care that straddles several care organisations and settings.There are growing moves internationally towards a pathway approach to quality measurement, where sets of quality measures are compiled that jointly describe a whole pathway of care for a particular population or group of patients. There is also growing interest in this approach in this country.
- In this slide set, a care pathway is defined as the journey a patient with a particular condition follows through care. The condition could have several stages, and require care at various times and in various types of care settings, depending on the condition.This is different to ‘clinical pathways’, the term used to describe a recommended set of clinical processes as defined by the evidence or by clinical guidelines.
- Although there are three Outcomes Frameworks – for the NHS, Public Health and Social Care – the government recognises the importance of aligning outcomes across these frameworks and setting shared outcomes with shared accountability for delivery. Better outcomes will often be delivered through integrated services, especially for those with long-term conditions. The NHS Outcomes Framework for 2012/13 emphasises the need for alignment, collaboration and integration. Among the many aims of the Department of Health’s new Information Strategy is the use of information and linked care records to support integrated care. It sees the consistent application of nationally specified information standards, inter-operability of local information systems, and record linkage across services as the route to having fully linked records across health and social care. In addition to the many other benefits that could accrue when these proposals are fully realised, they could enhance the measurability of quality along pathways to support more informed commissioning and improvements in the delivery of care and outcomes.
- The approach to quality measurement hitherto of measuring individual aspects of care – for example, re-admission rates for stroke – is increasingly inadequate for an NHS coping more and more with the needs of patients with chronic and complex conditions. This has led to a growing move towards measuring quality along care pathways.
- Measuring quality across care pathways has many uses. It is critical for planning local health care services and for facilitating co-ordination and integration of care across multiple providers and care settings. This facilitates improvements in care quality, including from a patient perspective. It is also useful for tracking inter-dependencies in the health care system. For example, the quality of primary care for diabetes can impact on the use and outcomes of secondary care. In addition, it offers opportunities to identify cost savings and productivity improvements. Many cost-saving service improvements involve shifting care and intervention earlier in the patient pathway, such as preventive measures, improvements in primary and community care that result in fewer unplanned hospital admissions, or improving post-discharge follow-up to reduce re-admissions. Measurement along whole pathways is useful for identifying and acting on these sorts of improvement opportunities.It can also inform the commissioning of integrated care packages from a consortia of providers. Various forms – formal and informal – of organisational partnerships aiming for integrated care can use this approach to develop shared sets of quality measures.
- Fundamentally, pathway measures need to cover all key stages in the patient pathway. For each of these, they will also need to cover all three domains of quality, that is, effectiveness, safety and patient experience.This slide describes the stages in a pathway, from the initial stage of primary prevention, through diagnosis and referral to treatment, secondary prevention, support and follow-up, and end of life care. These stages will of course vary depending on the condition or patient group.
- In line with the stages identified in the previous slide, pathway measures will need to cover all associated environments or care settingsThese again will vary by condition, but are likely to span some of those listed here.
- Where possible within the constraints of data availability, measurement along pathways should capture the five domains in the NHS Outcomes Framework. In following this structure, CCGs will be able to link their measurement strategies to the overarching national framework for measuring outcomes improvement – which will also be reflected in the Commissioning Outcomes Framework. The five domains map to the three broad domains of quality – clinical effectiveness, patient experience and safety. These elements of quality apply in all care settings and cover aspects of care that matter to patients and impact on outcomes.The NICE quality standards, and associated measures, can inform the choice of indicators, and the Commissioning Outcomes Framework indicators should be included.Where relevant, the domains in the Public Health Outcomes Framework and Adult Social Care Outcomes Framework should also be taken into consideration.International quality frameworks, such as that of the US Institute of Medicine, also include other important dimensions such as timelines, access, equity and efficiency.
- Essentially, there are three broad approaches for measuring quality along pathways. Firstly, you can simply bring together indicators from available data sets that you judge make up the important and typical elements of the care pathway for a particular condition or group of patients and present the data together to profile the quality of local services at a community level. While it doesn’t enable the tracking of individual patients, it serves as a useful proxy, makes optimal use of available data sources and avoids adding to the burden and cost of new data collection. Secondly, data sets for different care settings or different databases can be linked using patient identifiers such as the NHS number. This offers possibilities for analysis not otherwise available – for example, linkage of inpatient and outpatient records, or linkage of health and social care records. This can be done locally by commissioners, and is also undertaken nationally by authorised agencies such as the Information Centre.Thirdly, new bespoke data is collected so that missing parts of the pathway can be captured. In each case, the choice of indicators selected for analysis should be guided by the involvement of patients and carers, and of clinicians, in order to ensure that the whole has legitimacy and ownership by these key stakeholders.
- Indicators typically cover discrete, stand-alone elements of the services provided to patients in particular care settings. In the absence of comprehensive, linked, cross-sectoral, patient-level data, using data sets in conjunction with each other to simulate a pathway provides an alternative. A basket of indicators for local communities from disparate data sources can be ‘stitched’ together to capture as many elements of care as possible, depending on the data sources available for particular pathways. This then makes it possible to examine the inter-relationships between these indicators at local level.This approach provides an ‘ecological’ perspective of the quality of care for particular conditions or patient groups in local health economies, and serves as a useful proxy for pathway data for individual patients.Some examples of the major national data sets are given here. It is noteworthy that the Information Strategy promotes the increasing use of record linkage across these data sets.
- A series of pathway intelligence profiles for stroke, chronic obstructive pulmonary disease and maternity have been developed by NHS London Health Programmes. These complement the health needs assessment toolkit designed to support London’s commissioners with their health intelligence requirements. These profiles can be used by commissioners to plan and deliver services, and to monitor quality along the care pathway. For further details, see:http://www.londonhp.nhs.uk/health-intelligence/
- Here, data for chronic obstructive pulmonary disease is shown for a London local authority, starting with population data, then moving into indicators on prevention, treatment (in both general practice and secondary care), final outcomes and costs. Looking at the data in this way, benchmarked against other local authorities and the England average and best, helps to show where performance might need particular focus in order to improve overall outcomes.
- These examples demonstrate how commissioners can use currently available indicators to gain a profile of the quality of care in the local community. The indicators span the pathway from primary prevention, through various stages of health care, to final outcomes.The examples also illustrate the lack of routinely available data for some stages in the pathway and dimensions of care. This constraint will apply to pathway indicators for other population groups and conditions also. Furthermore, data availability is not uniform, with more data available for some stages (for example primary and hospital care) and dimensions of care than for others. However, the drive towards increased use of data from the national clinical audits, as announced in the Information Strategy, will help to address many data gaps. Although these examples are limited to health care data, social care indicators could be added in as appropriate.
- The example of maternity illustrates that care pathway indicators can also be useful in contexts other than long-term conditions.
- The second approach to making the most of available data for measuring quality along pathwaysis to link different data sets together. This can significantly enhance the utility of the separate data sets. Data linkage is only possible for data sets comprising individual patient records – rather than those (such as the Quality and Outcomes Framework and prescribing data) that are aggregated.Although a variety of approaches have been used to date to link records, the NHS number will become the norm for record linkage, as set out in the Department of Health’s Information Strategy – in which data linkage plays a prominent role, in particular for promoting integrated care.There are some important examples of linkage at a national level. For example, Linking Hospital Episode Statistics (HES) with Office for National Statistics (ONS) mortality death records enables deaths after discharge from hospital to be tracked – as with the new Summary Hospital-level Mortality Indicator (SHMI). Linkage of HES with Patient Reported Outcome Measures (PROMs) enables comparison of clinical outcomes with patient feedback about their health status. Linking cancer registration data with HES, to enable analysis of cancer outcomes in relation to patients’ use of hospital cancer services.Because data linkage involves the use of patient identifiers, information governance issues must be adequately addressed when linkage is undertaken locally.
- This example shows how primary care and secondary care data can be linked to understand how patients are using services. Reporting Analysis and Intelligence Delivering Results (RAIDR) covers commissioners and practices in NHS North of Tyne. This project provides real-time data via monthly secondary uses service (SUS) updates linked with direct uploads from GP computer systems, to enable analysis of hospital admissions by practice and condition. It enables drilldown to individual patients, and cross-checking of diagnosis between practice and SUS records. The information is presented in graphical dashboards, and allows users to navigate, select and drill down to gain intelligence in a variety of ways, from high level trends to detailed patient level data.RAIDR provides health care professionals in commissioning and primary care with a single portal for information that integrates multiple standalone data sources. Further details are available at:http://www.raidr.co.uk/RAIDRleafletv8.pdf
- This graph illustrates the prevalence of atrial fibrillation against admission rates for stroke for GP practices in Newcastle. Practices/CCGs using this sort of data can identify differences in admission rates for a given prevalence rate, and explore further what the reasons may be and how they can be tackled. Such information, obtained by linking data from primary and secondary care, can be used to reduce admission rates for different conditions, thereby saving the costs of unnecessary admissions. Many more dimensions of this type of analysis become possible with linked data, spanning different care settings. The GP Extraction Service (GPES), due to go live later in 2012, will for the first time provide a mechanism for extracting data from general practices in England. GPES offers an exceptional opportunity for linking data from general practice with secondary care records on a national basis.
- In this project, using NHS number, data is routinely extracted and linked across a variety of local health care settings and a social care database. The system covers complex elderly and diabetic patients, and can be expanded to include other long-term conditions. Such systems enable health and social care professionals across care settings to see all relevant information about a patient’s care and history, to inform risk assessment, clinical decision-making and delivery of care to recognised standards. At a system level, it enables analysis of overall trends and variations.The business case for this system aims to recoup initial outlay (on IT systems and training) within two years, primarily by reduced admissions and unnecessary duplication of tests.Key to the effectiveness of any information system is its users – clinicians and managers, as well as patients – to ensure the system delivers usable information, while also mitigating patient confidentiality or other concerns. This system was co-designed by clinical end-users within the context of an integrated care pilot in which financial and other incentives are aligned for GPs to avoid admission.
- This slide shows the metrics used for monitoring various dimensions of the performance of the project.
- Torbay Care Trust is an exemplar in the linkage of health and social care records. Using NHS number, ithas linked inpatient, outpatient and A&E records with community services activity (such as community hospital, intermediate care and nursing) and incorporated adult social care services (such as care home placements, domiciliary care and day services). The trust is now moving to include GP practice records also. This has enabled it to produce a comprehensive profile of the health and social care usage of its residents. The linkage enables tracking of services according to age, diagnosis, area, GP practice, pathways etc. and over time. Patients can be tracked according to any criteria (such as those living in care homes or nearing end of life) and all this activity is costed. The IT platform allows clinicians, managers and commissioners to understand the totality of services that patients need and are receiving. The results are apparent in reduced use of inpatient and residential care, and associated costs. Torbay’s model is in line with that described in The Department of Health’s Information Strategy, whereby NHS number is used for comprehensive linkage of health and social care records at a local level. Next, we’ll look at the third way of measuring along pathways – new measurement to follow up or track back along a pathway.
- Bespoke data collections can bridge gaps in routinely available national data sets, and offer additional scope for analysis. There are good examples – such as the national clinical audits – of primarily professionally-led initiatives to create pathway-based measures. The case study of London Cancer that follows uses a combination of both bespoke data collection and national data to drive local quality improvement, an initiative led by clinicians.However, bespoke data collections can add to the cost and burden of collecting data, and take time to establish.
- A case study of work currently underway through academic health science centre UCL Partners offers insights into some of the issues we have raised and how measures along pathways can be developed collaboratively across a local health economy.
- UCL Partners brings together providers from across the health community, academia and the voluntary sector in the development of London Cancer, an Integrated Cancer System for North Central & North East London and West Essex. Its aim is to drive improvements in outcomes and experience for its patients.London Cancer’s is designing – with patients and clinicians – an integrated care pathway for each cancer, with associated metrics covering a range of outcomes. Some measures are common for all cancers, others are specific to a particular pathway. For specific tumour types, London Cancer has used information about existing good practice, published guidance and priority areas locally to inform metric development. The development of pathway measures has five phases: Specialist clinical development – bringing together local experts to define what good care looks like and how to measure it. Asking patients the same questions, and distilling the outputs provided by the membership of regional Cancer Partnership Groups to the things that matter to patients. Engaging with commissioners to identify commissioning metrics that link to whole pathway principles and align with the improvement goals of providers.Bringing partners from across the cancer community – patients and patient support groups, primary care, cancer specialists – to workshops to review and finalise the list of metrics.Consolidating the measures into a scorecard for each cancer pathway.
- London has a very heterogeneous population, as this deprivation map shows. Earlier presentation of cancer results in a much higher likelihood of surviving to one year following diagnosis. One-year survival is used as a proxy measure for stage of diagnosis. These maps show that late presentation of cancer remains a major challenge in deprived areas within London Cancer.
- Work with clinicians and service users generated a number of metrics on brain and central nervous system cancers which can be used by the Integrated Cancer System through its Brain/CNS Cancer Pathway Board to measure how good services are in the system, whether patients’ needs are being met, and compliance with best clinical practice. This slide shows a subset of the metrics. The aim is for the indicators to be reported for providers in London Cancer from 2012. Some measures have also been adopted by commissioners for cancer locally, so indicators will be shared with them to agreed submission deadlines. The intention is to make the data available to patients and the public once it has been validated.
- While there are clear benefits and opportunities, there are also some challenges in measuring quality along pathways, which it is important to be aware of.Data gaps will constrain the measurement of quality along pathways. Examples are: data on risk factor and disease prevalence may be unavailable for local areas, data on primary and community care is patchy and incomplete, data is often not available for non-NHS providers. Data protection and patient confidentiality must be safeguarded. Using indicator sets that transcend organisational boundaries can raise issues of attribution and accountability that are less clear than when measuring performance for discrete organisational units. While some organisations may readily engage in initiatives to improve the performance of the health economy as a whole, others may seek only to optimise their own performance. Payment systems such as Payment by Results and Commissioning for Quality and Innovation (CQUIN) reinforce these challenges, especially when targets are missed. Measurement across organisations to facilitate joint working requires a different approach to that of performance management in organisations operating in isolation. Cross-organisational initiatives require a leadership and management style focusing on a systemic approach that fosters relationships between organisations and creates a shared vision of quality.Pathway measures for particular conditions are unsuitable for the growing number of patients with multiple conditions and co-morbidities. Initiatives that look at pathway measures for complex patients such as frail elderly patients can address this by developing clusters of measures reflecting the complexity of the patient mix rather than a linear care pathway that might be more suited to acute disorders.
- In this slide set, we have outlined how measuring quality along care pathways can serve the needs of both commissioners and patients, by supporting improvements in quality, outcomes, cost-effectiveness and the provision of co-ordinated and integrated care. It can also support CCGs in their commissioning activities and joint working with local partners. Although we have given a limited range of examples here of how data has been used for measuring quality along pathways, many other examples of good practice in this area are available. The data available to CCGs also has much potential for further development for use in these ways.Information developments underway, in the pipeline, and as envisaged in the Information Strategy, will further enhance the possibilities for measuring quality along care pathways. The application of such approaches to measuring quality should be a priority for CCGs, especially in the context of tackling the needs of increasing numbers of patients with long-term conditions.