Health Quality Indicators, Value of Health: Accounting for Quality Change

Aileen Simkins, Department of HealthCo-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

80

85

90

95

100

105

110

1995 1996 1997 1998 1999 2000 2001 2002 2003

Output w ithout quality; inputs: drugs deflated by cost of all items; capitalservices; 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

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 1.5%• Value weight for statins 0.81%• York/NIESR adjustment 0.17%• Patient experience* 0.07%• Blood pressure control * 0.05%• Heart attack survival 0.01%Total ** 2.68% Quality adjusted output growth 6.29%

ONS Health Productivity 2006

80

85

90

95

100

105

110

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Output w ith quality and value of health; inputs: drugs deflated by cost of allitems; capital consumption, direct labour method

Output w ith quality and value of health; inputs: drugs deflated by PaaschePrice Index; capital services, indirect labour method

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

t0 t1 t2 t3

Health Status

h=1

()oht

*()ht*h

oh

Ideally we want to measure the area under the curveBefore and after measures are a reasonable approximation (?)

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 60.4%

Blood pressure control Oct 04 78.3%

Annual rate of increase 10.4%

Hypertension

Blood pressure control Oct 01 44.6%

Blood pressure control July 04 63.0%

Annual rate of increase 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 Year 2001/2 2002/3 2003/4 2004/5 2005/6

Inpatient survey access and waiting 82 83 83 b a safe, high quality co-ordinated care 64 65 66 b a better information, more choice 67 68 68 b a building closer relationships 83 83 83 b a clean, friendly, comfortable place to be 78 78 77 b a Aggregate 74.8 75.1 75.4 b b

Outpatient survey access and waiting -- 70 70 69 -- safe, high quality co-ordinated care -- 83 83 82 -- better information, more choice -- 77 77 77 -- building closer relationships -- 86 86 86 -- clean, friendly, comfortable place to be -- 70 69 68 -- Aggregate -- 77.2 76.8 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

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