Developing health care

quality indicators for UHC

Yot Teerawattananon M.D., Ph.D.

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 What are quality indicators?
• Concise set of measurable indicators aimed at driving quality
improvement in a specific area of care
• Describe achievable best practice, not minimum standards
• Based on best available relevant evidence (robust national and
international clinical evidence)
• Aim to maximise impact in terms of:
• promoting cost-effective interventions
• reducing variation between different regions or population groups
• raising overall healthcare quality
• Developed through a collaborative process among stakeholders
e.g. MOH policymakers, health insurers, hospital managers,
clinicians …
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 Why do Thailand/Indonesia needs
quality indicators?
• UHC needs not only health service coverage but also quality— ‘effective
coverage’
• Paying providers based on ‘capitation’ or ‘case mix’ cannot guarantee
effective coverage
• Government needs justification for UHC investment
• UHC needs to link evidence to policy and practice to ensure impact
• They can be readily linked to audit, payment, accreditation, education

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 Case study of DM and HT screening
• A population-based screening was introduced to cope with an
increasing burden of NCDs
• All elderly aged > 60 years are eligible for a yearly screening free-of-
charge
• Providers are paid based on number of case screened only
Known HT DM screening
16%
Unknown HT 4%

This is a result of poor quality

Unknown normal of DM screening which is
BP 9% failed to inform screening
Known normal results to elderly population
BP
71%

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 What is Quality Outcome Framework
(QOF)?
• Introduced in UK (2004) and Thailand (2014)– voluntary
annual incentive scheme that rewards primary healthcare
providers for improving care (P4P)
• Consisting of different types of quality indicators
• To improve quality by linking income to quality targets for:
• Managing common diseases (asthma/diabetes)
• Implementing preventative measures (blood pressure checks)
• Targeting hard to reach / at risk groups (vaccinations and
screening)
• Increasing accountability of providers

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 Historical development of quality
outcome framework in Thailand
• Before 2009: budgets for improving quality of hospital-based
services
• From 2009-2013: on-top payment for primary care structural
elements, mainly human resources (e.g. increasing number
of nurses in health promotion hospitals)
• Since 2014 QOF program has been introduced. This is among
many measures to strengthen primary care

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 2014 QOF indicators in Thailand
Category 1 Indicators: Quality and performance of health
promotion and disease prevention (max. 400 points)
Central Indicators
1.1 The percentage of pregnant women receiving prenatal care for the first
time before 12 weeks (50 points).
1.2 Percentage of pregnant women receiving antenatal care 5 times (50
points).
1.3 Percentage of coverage of cervical cancer screening in women between
30-60 years within 5 years (50 points).
Category 2 Indicators: Quality and performance of primary
care services (max. 300 points)
Central indicators
2.1 Proportion of OP in primary care to total patients hospital patients (50
points).
2.2 % Hospital visit due to asthma (50 points).
2.3 % Hospital visit due to short-term complications of diabetes (50 points).
2.4 % Hospital visit due to short-term complications of hypertension (50
points).

Local indicators Local indicators

1.4 ..... 2.5 ......
1.5 ..... 2.6 ......
QOF 2014
Category 3 Indicators: Quality and performance of
organisational development and management ( max. 200 Category 4 Indicators: Quality and performance of services
points) targeted to local need (max. 100 points)
Central indicators
3.1 Percentage of people who have acces to a physician (25 points). Local indicators
3.2 Percentage of registered PCU (25 points). District and provincial committees collaboratively decide on local quality
indicators

Local indicators
3.3 ......
3.4 ......
 Evaluation of QOF by HITAP and UK
experts
• Delay in issuing the indicators before the
beginning of the fiscal year and poor
communication led to minimum changes
of providers’ behaviors
• Too many (local) indicators led to the lack
of focus and data entry burden
• No clear definition on each indicator
• No strong financial incentives to providers
• Lack of evidence support in many (local)
indicators (questionable in health impact)
• No feedback loop to providers

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 Recommendations for 2016 QOF
• Setting priority on focused areas for quality improvement
• Developing evidence-based indicators
• Making transparent and participatory process
• Having clear timeline and effective communication
mechanism to providers
• Improving quality of data and encouraging the use of data at
the local level

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 The development of quality indicators
• Performed by HITAP (a HTA agency) with the support by UK experts
• Under the Steering Committee consisting of representatives from MOPH,
NHSO, health professional association, local authorities and hospitals

Setting priority
Developing
of areas for Testing Selecting
evidence-based
quality indicators indicators
indicators
improvement

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 Priority areas for quality improvement
NCDs Five criteria were selected from the
review for priority setting
Maternal and child health 1) burden of condition,
2) seriousness of the quality,
Bedridden chronic illness 3) feasibility of quality assessment,
4) availability of clinical practice
guideline(s),
Antibiotic use 5) the extent to which area is in line
with national policy.
Asthma/COPD

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Developing evidence-based indicators
• Review of clinical studies to identify key surrogate indicators
that link to desirable health outcomes/impact
• Review of international and national clinical practice
guidelines

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Indicator code Indicator statement
HT1(PCU) Percentage of individuals aged 35 and above who received a screening for hypertension in the last 3 years

HT2 (PCU) Percentage of individuals with blood pressure 140/90 mmHg and above who were referred to a physician within 1 month

HT3 (PCU) Percentage of hypertensive patients who could control their blood pressure
DM1 (PCU) Percentage of individuals aged 35 and above who received a screening for DM using random or fasting capillary blood
glucose in the last 3 years
DM2 (PCU) Percentage of individuals with capillary blood glucose of 126 mg/dl and above who received fasting venous plasma glucose
test within 1 month
DM3 (PCU) Percentage of DM patients who could control their blood glucose
CVD1 (PCU) Percentage of individuals aged 35-70 who receive CVD risk assessment using Thai CV risk score

MCH1 (PCU) Percentage of pregnant women who received antenatal care (ANC) for the first time before 12 weeks

MCH2 (PCU) Percentage of pregnant women with hypertension who were referred to a physician

MCH3 (CUP) Percentage of pregnant women with anemia in 1st trimester whose Hct are in normal range in the 3rd trimester

MCH4 (CUP) Percentage of postpartum women with anemia during pregnancy whose Hct are in normal range at 3 months after delivery

MCH5 (PCU) Percentages of full-term infants aged between 0-1 years whose weight for age or weight for height or height for age falls
below 5 percentile or 95 percentile and above who are referred to doctors.
 Indicator codes Indicator statements
BR1 (PCU) PCUs can produce a register of bed ridden patients
BR2 (PCU) Percentage of bed ridden patients who were visited by family care team
RUA1 (PCU) Percentage of antibiotics prescription for patients diagnosed with upper respiratory tract
infections (URI)
RUA2 (PCU) Percentage of antibiotic prescription for patients diagnosed with acute gastroenteritis (AGE)

ASTH1 (PCU) The PCUs can produce a register of patients with asthma
ASTH2 (PCU) Percentage of asthma patients who received health education and counseling
ASTH3 (PCU) Percentage of asthma patients who were examined with a peak expiratory flow meter
ASTH4 (PCU) Percentage of asthma patients who are assessed by an Asthma Control Test
ASTH5 (PCU) Percentage of asthma patients who could not control asthmatic symptoms referring to a
physician
ASTH6 (PCU) Percentage of asthma patients with asthmatic exacerbation admitting to emergency
department
COPD1 (PCU) The PCUs can produce a register of patients with COPD
COPD2 (PCU) Percentage of COPD patients who are currently smoking receiving advises on smoking
cessation
 Testing (piloting) indicators
• Performed in 35 health promotion hospitals and district
hospitals in 3 provinces
• Duration: 3 months
• Measures
• Availability of routine data
• Acceptability of providers
• Time spent in collecting data

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 Availability of data for each indicator

group Data availability indicator

1 data are available in the 43 folder database HT1, HT2, HT3, DM1, DM3, MCH1, MCH2, MCH5,
and extraction rules could be applied RUA1, RUA2

2 variables exist in the 43 folder database but DM2, MCH3, MCH4, Asthma1, Asthma2, Asthma6,
staff did not enter data COPD1, COPD2

3 there are no variables in the 43 folder BR1, BR2, Asthma3, Asthma4, Asthma5, CVD1

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 Acceptability of indicators by
providers
Acceptability rate Indicator code
1. ≥ 70% HT1, DM1, HT2, DM2, HT3, DM3, MCH2,
MCH3, MCH5, BR1, BR2, Asthma1,
Asthma3, Asthma4, COPD1, COPD2
Concern
Time frame, target population,
indicator description, out of provider’s
control, indicator exception

2. 60-69% MCH1, RUA1, RUA2 Unintended pregnancy, out of

provider’s control

3. 50-59% Asthma2, Asthma6 Capacity at PCUs

4. <50% CVD1, MCH4, Asthma5 Capacity, time frame, target population
 Workload associated with developed indicators
BR 2

BR 1

MCH 1

MCH 2

MCH 3

COPD 2

COPD 1

MCH 4

Asthma 2

MCH 5

Asthma 6
indicator

Asthma 1

Asthma 5

DM 3

HT 2

DM 1

Asthma 3

HT 1

RUA 1

HT 3

RUA 2

DM 2

Asthma 4

CVD 1

-00 20 40 60 80 100 120

service delivery Data Entry
Time spent (minutes/case)

Physician Staff Physician Staff

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 Selecting indicators by Steering
Committee

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Indicator code Indicator statement
HT1(PCU) Percentage of individuals aged 35 and above who received a screening for hypertension in the last 3 years

HT2 (PCU) Percentage of individuals with blood pressure 140/90 mmHg and above who were referred to a physician within 1 month

HT3 (PCU) Percentage of hypertensive patients who could control their blood pressure
DM1 (PCU) Percentage of individuals aged 35 and above who received a screening for DM using random or fasting capillary blood
glucose in the last 3 years
DM2 (PCU) Percentage of individuals with capillary blood glucose of 126 mg/dl and above who received fasting venous plasma glucose
test within 1 month
DM3 (PCU) Percentage of DM patients who could control their blood glucose
CVD1 (PCU) Percentage of individuals aged 35-70 who receive CVD risk assessment using Thai CV risk score

MCH1 (PCU) Percentage of pregnant women who received antenatal care (ANC) for the first time before 12 weeks

MCH2 (PCU) Percentage of pregnant women with hypertension who were referred to a physician

MCH3 (CUP) Percentage of pregnant women with anemia in 1st trimester whose Hct are in normal range in the 3rd trimester

MCH4 (CUP) Percentage of postpartum women with anemia during pregnancy whose Hct are in normal range at 3 months after delivery

MCH5 (PCU) Percentages of full-term infants aged between 0-1 years whose weight for age or weight for height or height for age falls
below 5 percentile or 95 percentile and above who are referred to doctors.
 Indicator codes Indicator statements
BR1 (PCU) PCUs can produce a register of bed ridden patients
BR2 (PCU) Percentage of bed ridden patients who were visited by family care team
RUA1 (PCU) Percentage of antibiotics prescription for patients diagnosed with upper respiratory tract
infections (URI)
RUA2 (PCU) Percentage of antibiotic prescription for patients diagnosed with acute gastroenteritis (AGE)

ASTH1 (PCU) The PCUs can produce a register of patients with asthma
ASTH2 (PCU) Percentage of asthma patients who received health education and counseling
ASTH3 (PCU) Percentage of asthma patients who were examined with a peak expiratory flow meter
ASTH4 (PCU) Percentage of asthma patients who are assessed by an Asthma Control Test
ASTH5 (PCU) Percentage of asthma patients who could not control asthmatic symptoms referring to a
physician
ASTH6 (PCU) Percentage of asthma patients with asthmatic exacerbation admitting to emergency
department
COPD1 (PCU) The PCUs can produce a register of patients with COPD
COPD2 (PCU) Percentage of COPD patients who are currently smoking receiving advises on smoking
cessation
 Recommendations
• Create infrastructure and measure baseline performance
• Make payments large enough to be meaningful and small
enough not to distort priorities
• Re-calibrate incentives so that they remain challenging but
attainable
• Monitor patient outcomes & unintended consequences

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 Lessons learnt
• Use technical support and robust/transparent process
• Involve physicians – value of testing & piloting
• Start with a small number of indicators
• Quality indicators including structure, process and proxy
outcomes
• Importance of timeliness for policy implementation

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 QOF makes a difference: UK’s
experience
• Has shaped clinical practice, driven up quality, helps deliver consistent care
• Improved data collection ; increasingly used to help benchmark
performance
• Improved process of care – Practices (Doctors, nurses etc) do things better
• Numerous indicators successfully embedded in clinical behaviour and are
no longer required
 Has QOF improved outcomes?
• Intermediate/proxy outcomes? – yes for some (blood pressure and cholesterol)
(Langdown and Peckham 2013)
• Decrease in emergency admissions for incentivised conditions (Harrison et al. 2014, BMJ)
• Clinical outcomes? – unclear
• Strong evidence of initially improved health outcomes for a limited number of
conditions but fell to the pre-existing trend; “due to its focus on process-based
indicators...” (Langdown et al. 2014, J Pub Health)
• Some evidence that the poorest performing practices have improved the most with
narrowing of inequalities in care (Gillam et al. 2012, Annals Fam Med)
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