Health System Performance Indicators Research Articles

Impact of early death recording on international comparison of acute myocardial infarction mortality – administrative hospital data study using the example of Germany and the United States

BackgroundIn-hospital mortality from acute myocardial infarction (AMI) is widely used in international comparisons as an indicator of health system performance. Because of the high risk of early death after AMI, international comparisons may be biased by differences in the recording of early death cases in hospital inpatient data. This study examined whether differences in the recording of early deaths affect international comparisons of AMI in-hospital mortality by using the example of Germany and the United States, and explored approaches to address this issue.MethodsThe German Diagnosis-Related Groups Statistics (DRG Statistics), the U.S. National Inpatient Sample (NIS) and the U.S. Nationwide Emergency Department Sample (NEDS) were analysed from 2014 to 2019. Cases with treatment for AMI were identified in German and U.S. inpatient data. AMI deaths occurring in the emergency department (ED) without inpatient admission were extracted from NEDS data. 30-day in-hospital mortality figures were calculated according to the OECD indicator definition (unlinked data) and modified by including ED deaths, or excluding all same-day cases.ResultsGerman age-and-sex standardized 30-day in-hospital mortality was substantially higher compared to the U.S. (in 2019, 7.3% vs. 4.6%). The ratio of German vs. U.S. mortality was 1.6. After inclusion of ED deaths in U.S. data this ratio declined to 1.4. Exclusion of same-day cases in German and U.S. data led to a similar ratio.ConclusionsWhile short-duration treatments due to early death are generally recorded in German inpatient data, in U.S. inpatient data those cases are partially missing. Excluding cases with short-duration treatment from the calculation of mortality indicators could be a feasible approach to account for differences in the recording of early deaths, that might be existent in other countries as well.

The centre for health informatics: a novel approach to accelerating the field of health data science

Precision Medicine and Precision Public Health are approaches to improve population health. Achieving these goals requires innovation in health informatics. The Centre for Health Informatics (CHI) within the Cumming School of Medicine (CSM) at the University of Calgary (UC), Canada, was created to respond to this need by fostering multidisciplinary collaborations, building capacity by recruiting and training outstanding faculty and students, and harnessing Alberta's rich health data to advance health informatics. To establish CHI as a health informatics leader, CHI has struck partnerships with stakeholders, including Alberta Health Services (AHS), Alberta Health (AH), and the Alberta Strategy for Patient-Oriented Research Unit (AbSPORU) among others. Through these close relationships, the CHI intake team facilitates access to Alberta's rich health data sources and educates researchers on the available health data in Alberta. The concept of a "One Stop Shop" for CSM and UC researchers encourages multidisciplinary collaboration, helps investigators access a wide range of datasets, and receive analytical support. Population-based data sets enable the development of methods to turn raw data into health information, improve health data collection, linkage, analysis, and quality, and applied studies creating clinical decision-support tools, prognostic tools, improved health surveillance methods, and health system performance indicators. CHI's ecosystem of diverse research expertise, cutting-edge technology, and embedded AHS analysts to support data access via a wide-ranging network of partnerships allows our provincial researchers, national and international collaborators tremendous opportunities for empirical research. It paves the way for implementing Precision Medicine in the real world.

Hospitalizations for conditions sensitive to primary care and sustainable development objectives

Hospitalizations for Primary Care Sensitive Conditions (ICSAP) are widely recognized as an indicator of health system performance. Considering that the evaluation of health practices is mandatory, monitoring these indicators becomes relevant, with a view to directing actions that can contribute to the Sustainable Development Goals. The objective of this study was to analyze the profile of ICSAP that occurred in the Federal District (DF) in the period from 2018 to 2022. This is an ecological time series study, using Hospital Admission Authorizations as a data source, via the Information System Hospital of the Unified Health System. Data collection was carried out in November 2022 and covered the period from 2018 to 2022. Descriptive statistical analysis was carried out. It was possible to identify the profile of ICSAP in DF. The elderly population and children aged 1 to 14 years were predominant, as well as diagnoses related to anemia, ear, nose and throat infections and asthma. The main causes of deaths and expenses were cerebrovascular diseases, heart failure and bacterial pneumonia.

A study protocol for a predictive model to assess population-based avoidable hospitalization risk: Avoidable Hospitalization Population Risk Prediction Tool (AvHPoRT)

IntroductionAvoidable hospitalizations are considered preventable given effective and timely primary care management and are an important indicator of health system performance. The ability to predict avoidable hospitalizations at the population level represents a significant advantage for health system decision-makers that could facilitate proactive intervention for ambulatory care-sensitive conditions (ACSCs). The aim of this study is to develop and validate the Avoidable Hospitalization Population Risk Tool (AvHPoRT) that will predict the 5-year risk of first avoidable hospitalization for seven ACSCs using self-reported, routinely collected population health survey data.Methods and analysisThe derivation cohort will consist of respondents to the first 3 cycles (2000/01, 2003/04, 2005/06) of the Canadian Community Health Survey (CCHS) who are 18–74 years of age at survey administration and a hold-out data set will be used for external validation. Outcome information on avoidable hospitalizations for 5 years following the CCHS interview will be assessed through data linkage to the Discharge Database (1999/2000–2017/2018) for an estimated sample size of 394,600. Candidate predictor variables will include demographic characteristics, socioeconomic status, self-perceived health measures, health behaviors, chronic conditions, and area-based measures. Sex-specific algorithms will be developed using Weibull accelerated failure time survival models. The model will be validated both using split set cross-validation and external temporal validation split using cycles 2000–2006 compared to 2007–2012. We will assess measures of overall predictive performance (Nagelkerke R2), calibration (calibration plots), and discrimination (Harrell’s concordance statistic). Development of the model will be informed by the Transparent Reporting of a multivariable prediction model for Individual Prognosis or Diagnosis (TRIPOD) statement.Ethics and disseminationThis study was approved by the University of Toronto Research Ethics Board. The predictive algorithm and findings from this work will be disseminated at scientific meetings and in peer-reviewed publications.

Making development assistance work forAfrica: from aid-dependent disease control to the new public health order.

The Coronavirus disease (COVID-19) pandemic has revealed the fragility of pre-crisis African health systems, in which too little was invested over the past decades. Yet, development assistance for health (DAH) more than doubled between 2000 and 2020, raising questions about the role and effectiveness of DAH in triggering and sustaining health systems investments. This paper analyses the inter-regional variations and trends of DAH in Africa in relation to some key indicators of health system financing and service delivery performance, examining (1) the trends of DAH in the five regional economic communities of Africa since 2000; (2) the relationship between DAH spending and health system performance indicators and (3) the quantitative and qualitative dimensions of aid substitution for domestic financing, policy-making and accountability. Africa is diverse and the health financing picture has evolved differently in its subregions. DAH represents 10% of total spending in Africa in 2020, but DAH benefitted Southern Africa significantly more than other regions over the past two decades. Results in terms of progress towards universal health coverage (UHC) are slightly associated with DAH. Overall, DAH may also have substituted for public domestic funding and undermined the formation of sustainable UHC financing models. As the COVID-19 crisis hit, DAH did not increase at the country level. We conclude that the current architecture of official development assistance (ODA) is no longer fit for purpose. It requires urgent transformation to place countries at the centre of its use. Domestic financing of public health institutions should be at the core of African social contracts. We call for a deliberate reassessment of ODA modalities, repurposing DAH on what it could sustainably finance. Finally, we call for a new transparent framework to monitor DAH that captures its contribution to building institutions and systems.

Multivariate Relationships Between Health Outcomes and Health System Performance Indicators: An Integrated Factor Analysis With Canonical Correlations

ObjectivesThis study aimed to investigate the relationships between sets of variables related to health system performance indicators and health outcomes. MethodsThe relationships between a set of health outcomes and a set of health system performance indicators of a developing country were examined using multivariate statistical analysis techniques. A combinative strategy of explanatory factor analysis and the canonical correlation coefficient was used to define linear structural relationships between study variables. Province-based data were gathered from2 official statistical records of the Turkish Statistical Institute for the year 2019. Life expectancy at birth, infant mortality rate, and crude death rate were accepted as health outcome indicators. ResultsThe explanatory factor analysis indicated 2 independent variable groups, namely (1) health-related human resources and capacity and (2) health service utilization characteristics. The results of the canonical correlation analysis illustrated good performance to define sparse linear combinations of the 2 groups of variables. There existed strong positive correlations between health outcomes and health-related human resources and capacity indicators (rc = 0.83; P < .001) and health service utilization indicators (rc = 0.59; P < .001). ConclusionsThe results of this study support the view that there is a linear and strong positive relationship between health outcomes and health-related human resources and capacity indicators. Further studies will combine big data analytics with multivariate statistical analysis techniques by studying large health system performance data sets.

Digital Maturity as a Strategy for Advancing Patient Experience in US Hospitals.

Patient experience is globally recognized as an important indicator of health system performance, linked to health system quality and improving patient outcomes. Post COVID-19, health systems have embraced digital health and advanced digital transformation efforts; however, the relationship between digital health and patient experience outcomes is not well-documented. Using HCAHPS hospital survey data to measure patient experience, and HIMSS EMRAM Maturity Model data to measure digital maturity, a cross-sectional design using multivariate analyses examined the impact of digital maturity on patient experience in US hospitals. Our analysis shows that advanced digital maturity in US hospitals is associated with stronger patient experience outcomes, particularly relative to communication with nurses, doctors, and communication about medicines and therapies. The findings suggest that there are significant differences in patient experience associated with teaching versus nonteaching hospitals, urban versus rural hospitals. As hospitals advance and progress digital transformation initiatives, evidence to inform how transformation efforts can engage and advance patient experience will contribute to health system performance well into the future.

Development and Implementation of a Unified Care Model Performance Framework in the Yishun Zone Regional Population Health System

Background / Objective: Governance and Leadership Subsystem (GLS) of health systems governs but also directs Service Delivery Subsystem (SDS) transformation. Performance management (PM) is a key GLS activity. Coherent PM frameworks improve SDS governance, health system performance and ultimately population health outcomes.&#x0D; Yishun Health (YH) is an integrated care organization within National Healthcare Group (NHG) caring for 320,000 residents in northern Singapore as the Yishun Zone Regional Population Health System (YZ). YH designed and deployed the Unified Care Model (UCM) as future-state SDS model to integrate and transform its care/services with care partners. A redesigned PM framework going beyond disease-condition services, specialty-departments, and institutions-partners was required.&#x0D; Method: Population segmentation was achieved using NHG River-of-Life segmentation model, dividing YZ residents into four Lifelong Care segments (LLC) and one Episodic Care segment (EC). Employing UCM, LLC and EC were further sub-segmented into a cascade of ever smaller populations of unique care needs to envision future SDS needs/demand-supply matching in the form of integrated microsystems of care/services delivery.&#x0D; UCM Performance Framework (UCMPF) was conceptualized by adapting IHI’s Quadruple Aim as annual outcomes for LLC microsystems and Dartmouth’s Clinical Value Compass as 90-day outcomes for EC microsystems. Ability to govern integrated microsystems was then modelled using clinical logic models, enabling curation of input, process, and output indicators into domains of standardized care strategies i.e. “Horizontal Logic”. “Vertical Logic” was then employed to aggregate relevant LLC or EC microsystem input, process, output or outcome indicators up the cascade of UCM population segments and higher order systems to envision future-state GLS, such as i) person and need/demand centric mesosystems e.g. LLC and EC or a community geographically, or ii) provider-centred mesosystems e.g. site-based disease condition-services or program, specialty-departments, institution-partners, culminating ultimately in whole health system or macrosystem performance indicators. UCMPF dual logic enabled stakeholders to visualize interdependencies in whole system PM indicators and more coherently co-create performance indicators at all levels of YZ.&#x0D; &#x0D; &#x0D; Results: Exceeding 1,300 existing care/services indicators across disease condition-services or program, specialty-departments, institution-partners were discovered and systemically visualized using UCMPF in LLC and EC Indicator Menus, revealing how current care/services indicators impacted input, process, output and outcome of LLC and EC at different levels of the SDS. Numerous leadership conversations were conducted to envision future GLS activities using UCMPF, spawning many working level discussions, which continue to be ongoing between senior clinicians and administrators to prioritize indicators for PM. Technical definitions for prioritized indicators was also initiated to support informatics systems and enterprise data warehouse dashboard redesign. &#x0D; Discussion/Conclusion: UCMPF employs a systemic design and visualization approach to mitigate complexity in whole system PM. LLC and EC Menus reduce cognitive difficulty for stakeholders to relate their existing care/services measurement efforts with micro and mesosystem levels of the UCM and jumpstarts conversations whether existing care/services contribute or not towards YZ outcomes i.e. macrosystem. UCMPF therefore supports our ongoing care/services integration activity, and the co-creation of future GLS for YZ SDS is hypothesized to ultimately accelerate health system transformation towards better population health outcomes in YZ.&#x0D;

Spatial methods for measuring access to health care.

Access to health care is a universal human right and key indicator of health system performance. Spatial access encompasses geographic factors mediating with the accessibility and availability of health services. Equity of health service access is a global issue, which includes access to the specialized nursing workforce. Nursing research applying spatial methods is in its infancy. Given the use of spatial methods in health research is a rapidly developing field, it is timely to provide guidance to inspire greater application in cardiovascular research. Therefore, the objective of this methods paper is to provide an overview of spatial analysis methods to measure the accessibility and availability of health services, when to consider applying spatial methods, and steps to consider for application in cardiovascular nursing research.

Breast cancer survival in Mexico between 2007 and 2016 in women without social security: a retrospective cohort study

Essential indicators of health system performance for breast cancer are lacking in Mexico. We estimated survival and clinical stage distribution for women without social insurance who were treated under a health financing scheme that covered 60% of the Mexican population. We conducted a retrospective cohort study cross-linking reimbursement claims for 56,847 women treated for breast cancer between 2007 and 2016 to a mortality registry. We estimated overall- and clinical stage-specific survival and breast cancer survival according to patient age, state of residence, marginalization, type of treatment facility, and patient volume of the treatment facility. We also explored the distribution of clinical stage according to age, year of treatment initiation, and state where the woman was treated. We used log-rank tests and estimated 95% CIs to compare differences between patient groups. Median age was 52 years (interquartile range [IQR] 45, 61) (Sixty five percent patients (36,731/56,847) had advanced disease at treatment initiation. Five-year overall survival was 72.2% (95% CI 71.7, 72.6). For early disease (excluding stage 0), 5-year overall survival was 89.0% (95% CI 88.4, 89.5), for locally advanced disease 69.9% (95% CI 69.0, 70.2) and for metastatic 36.9% (95% CI 35.4, 38.4). Clinical stage at treatment initiation and breast cancer survival remained unchanged in the period analyzed. Clinical stage and survival differed across age groups, state of residence, and type of facility where women received treatment. In the absence of population-based cancer registries, medical claims data may be efficiently leveraged to estimate essential cancer-related performance indicators. The authors received no financial support for this research.

Health System Quality and Performance Indicators for Evaluating Home Care Programming: A Scoping Review

A systematic scoping review of health system Performance and Quality Indicators (PQI) related literature for evaluating publicly funded home care programming was conducted. Through the scoping review we identify PQIs, map these based on quadrants of the Institute for Healthcare Improvement’s (IHI) Quadruple Aim, classify these PQIs under general “areas of focus” categories, and present recommendations for use. We selected all articles that identified, referenced, proposed, and/or described at least 1 PQI to measure home care service programming. Minimum inclusion criteria were a description of 1 or more PQIs designed to evaluate and/or measure home care programming, outcomes of home care clients and/or caregivers, or overall system impacts of home care service provision. The review identified 3,475 citations. A review of the abstracts led to the retrieval of 510 full-text articles for assessment of which 105 articles were selected for detailed review and extraction of identified PQIs. Of the 105 identified articles a total of 829 unique PQIs were gathered. Based on the IHI Quadruple Aim, 661 unique measures were identified as Clinical Outcome, 35 as Healthcare Provider Satisfaction, 99 Patient Experience, and 34 in the Financial/Sustainability quadrants. Many patient outcome specific PQIs exist, followed by patient experience measures. Very few PQIs exist in the financial or healthcare provider experience quadrants. The lack of indicators across all the IHI Quadruple Aim quadrants is an opportunity for further development supporting home care quality oversight.

Impact of community health interventions on maternal and child health indicators in the upper east region of Ghana

BackgroundThis paper reports on results of a health system strengthening implementation research initiative conducted the Upper East Region of northern Ghana. Transformative interventions to accelerate and strengthen the health delivery were implemented that included empowering community leaders and members to actively participate in health delivery, strengthening the referral systems through the provision of community transport systems, providing basic medical equipment to community clinics, and improving the skills of critical health staff through training.MethodsA mixed method design was used to evaluate the impact of the interventions. A quantitative evaluation employed a flexible research design to test the effects of various component activities of the project. To assess impact, a pre-versus–post randomized cluster survey design was used. Qualitative research was conducted with focus group data and individual in depth interviews to gauge the views of various stakeholders associated with the implementation process.ResultsAfter intervention, significant improvements in key maternal and child health indicators such as antenatal and postnatal care coverage were observed and increases in the proportion of deliveries occurring in health facilities and assisted by skilled health personnel relative to pre-intervention conditions. There was also increased uptake of oral rehydration salts (ORS) for treatment of childhood diarrhoea, as well as marked reductions in the incidence of upper respiratory infections (URI).ConclusionsA pre-and post-evaluation of impact suggests that the programme had a strong positive impact on the functioning of primary health care. Findings are consistent with the proposition that the coverage and content of the Ghana Community-based Health Planning and Services programme was improved by program interventions and induced discernable changes in key indicators of health system performance.

Level of Satisfaction Towards Healthcare Services in Patients Attending Psychiatry Outpatient Department of a Tertiary Care Hospital in Eastern India.

Patients' satisfaction with healthcare services contributes to their compliance with the treatment and thus impacts their health. Therefore, patient satisfaction is increasingly being used as an indicator of health system performance in a country. Though several studies have been reported from different parts of India, most did not include psychiatric patients. This study assessed the level of satisfaction of psychiatric outpatients and its association with socio-demographic, hospital-related, and treatment-related variables. This cross-sectional study assessed 152 patients attending psychiatry outpatient department (OPD) of a tertiary care hospital. Treatment-related satisfaction was measured using the Short Assessment of Patient Satisfaction (SAPS) scale, and variables not related to treatment were assessed using Likert scales. Most participants were satisfied with the overall cleanliness of the hospital (82.9%), the useable condition of toilets (73%), and waiting time in the OPD ticket counter, doctor's room, and pharmacy. More than 80% were pleased with the OPD staff's behavior and working efficiency. In the seven dimensions of the SAPS scale, satisfaction level was variable. Overall satisfaction with the care received in the hospital was 60.5%. The level of patient satisfaction is good in psychiatry OPD services of our hospital, and it depends on treatment-independent variables also. So, liaison between the medical- and non-medical-management teams is crucial to augment patient satisfaction.

Association between children's health-related quality of life, healthcare costs and socioeconomic position: Results from a longitudinal Australian-based study

BackgroundEquity in healthcare service access and use are national goals and principal indicators of health system performance. Whilst it is important to understand how healthcare costs, socioeconomic position (SEP), and children's well-being are associated, limited literature explores how these covary. AimsTo explore the associations between families' SEP and (1) children's health-related quality of life (HRQoL) from 4 to 13 years; and (2) healthcare costs from 0 to 13 years; as well as (3) contributing factors that influence children's HRQoL and healthcare costs. MethodsData were drawn from the Longitudinal Study of Australian Children (LSAC). We used the parent-reported Pediatric Quality of Life Inventory 4.0 to measure children's HRQoL from 4 to 13 years. Healthcare costs to government from 0 to 13 years were measured using the government administrative data (Medicare) which includes records of both medical and pharmaceutical service utilisation. We used a composite of income, parental education, and occupation to measure SEP. We used linear and mixed effects modelling to explore associations between families' SEP and children's HRQoL or government healthcare costs, including the effects of predictors for these associations. Analyses were weighted and accounted for the survey design. ResultsCompared to children from high SEP families, those from low SEP families had lower HRQoL (from age 6–13 years, p = 0.001) and their families incurred higher government healthcare costs (from birth to 13 years). This association was confirmed using the mixed effects model (p = 0.054). Child special healthcare needs, being a single-parent or having parental stress were related to poorer children's HRQoL and higher government healthcare costs. Living in regional and remote areas was related to lower government healthcare costs. ConclusionUp to 13 years of age, children with low SEP used more health services but had lower HRQoL than those from high SEP families. These findings highlight a need to support children from low SEP families to improve their health and wellbeing.

Development of national framework for health status and health system performance indicators in Saudi Arabia

BackgroundThe global shift to value-based care has highlighted the necessity for performance measurement in healthcare. While the implementation may be incomplete, governments and providers have been moving towards value-based models of care delivery, funding and performance measurement. ObjectivesThe purpose of this report is to illustrate the steps taken in designing the framework in Kingdom of Saudi Arabia (KSA), using a 4-step approach: Key Input Analysis, Hierarchy Design, Indicator Analysis and Selection, and Indicator Profile Development. Furthermore, it presents a comprehensive view of the indicators collected to measure performance at the level of the Health System and Health Status in KSA and highlights main patient concerns, thus providing an overview of a new, unified national framework. MethodsThe methodology entailed examined the following components’ remits and roles, reporting mechanisms and channels, and performance indicators across all pertinent National Health agencies (NHA), by conducting a SWOT analysis of each of the components across the ecosystem. Engagement with the Steering Committee members was achieved through research and interviews. ResultsA total of 109 indicators were identified, of which 51 were Health Status Indicator Profiles and 58 Health System Indicators. The indicator profiles were developed with consideration of the KSA context in terms of the healthcare ecosystem as it stands today. The findings of this report, alongside the best practices arising from the benchmarking, will be key inputs into the design of the National Framework. ConclusionThe regulatory entity has set out to establish a National Framework, which aims to unify performance measurement in KSA from both health system and public health perspectives across all sectors providing healthcare services, based on a list of prioritized KPIs and their complete profiles, outlining the formulae, key responsibilities, and reporting mechanisms pertaining to each one.

MSR116 Multivariate Associations between Health Outcomes and Health System Performance Indicators: An Integrated Factor Analysis with Canonical Correlations

Multivariate statistical analysis techniques are helpful to identify associations between multidimensional health system performance indicators. This study is designed to explore the interrelationships between a set of health outcomes and a set of health system performance indicators.

Use of linked data to assess the impact of including out-of-hospital deaths on 30-day in-hospital mortality indicators: a retrospective cohort study.

Background:The Canadian Institute for Health Information (CIHI) annually reports on health system performance indicators, including various 30-day in-hospital mortality rates. We aimed to assess the impact of including out-of-hospital deaths on 3 CIHI indicators: 30-day acute myocardial infarction (AMI) in-hospital mortality, 30-day stroke in-hospital mortality and hospital deaths following major surgery.Methods:We followed national cohorts of patients admitted to hospital in 1 of 9 Canadian provinces for AMI, stroke and major surgery for 30-day all-cause mortality in 2 fiscal years (2011/12 and 2016/17). We calculated descriptive statistics to characterize the cohorts. The CIHI Discharge Database was linked with the Canadian Vital Statistics Death Database using a probabilistic algorithm to identify out-of-hospital deaths. We calculated absolute numbers, relative proportions and 30-day mortality rates for in-hospital, out-of-hospital and all deaths. We compared results between fiscal years.Results:We found that hospital admissions increased between fiscal years for each indicator; however, cohort characteristics remained consistent. In 2016/17, the number of out-of-hospital deaths that occurred was 325 for AMI, 545 for stroke and 820 for major surgery. The relative proportions of out-of-hospital deaths ranged from 12.3% for AMI to 14.9% for major surgery in 2016/17 (an increase from 10.6% and 13.1%, respectively, from 2011/12). In-hospital mortality rates improved over time for all 3 indicators, while out-of-hospital mortality rates remained consistent between fiscal years at 0.8% for AMI, 1.9%–2.0% for stroke and 0.2%–0.3% for major surgery.Interpretation:Improvements between fiscal years were attributable to reductions in in-hospital mortality, rather than deaths occurring outside of hospitals. Trends over time were the same for each indicator irrespective of whether in-hospital mortality or all deaths were measured.

The Devil Is in the Data: Can Regional Variation in Amenable Mortality Help to Understand Changes in Health System Performance in Poland?

The contribution of health systems to health is commonly assessed using levels of amenable mortality. Few such studies exist for Poland, with analyses of within-the-country patterns being particularly scarce. The aim of this paper is to analyse differences in amenable mortality levels and trends across Poland’s regions using the most recent data and to gain a more nuanced understanding of these differences and possible reasons behind them. This can inform future health policy decisions, particularly when it comes to efforts to improve health system performance. We used national and regional mortality data to construct amenable mortality rates between 2002 and 2019. We found that the initially observed decline in amenable mortality stagnated between 2014 and 2019, something not seen elsewhere in Europe. The main driver behind this trend is the change in ischemic heart disease (IHD) mortality. However, we also found that there is a systematic underreporting of IHD as a cause of death in Poland in favour of heart failure, which makes analysis of health system performance using amenable mortality as an indicator less reliable. We also found substantial geographical differences in amenable mortality levels and trends across Poland, which ranged from −3.3% to +8.1% across the regions in 2014–2019. These are much bigger than variations in total mortality trends, ranging from −1.5% to −0.2% in the same period, which suggests that quality of care across regions varies substantially, although some of this effect is also a coding artefact. This means that interpretation of health system performance indicators is not straightforward and may prevent implementation of policies that are needed to improve population health.

Common Features of Selection Processes of Health System Performance Indicators in Primary Healthcare: A Systematic Review.

Health system performance indicators are widely used to assess primary healthcare (PHC) performance. Despite the numerous tools and some convergence on indicator criteria, there is not a clear understanding of the common features of indicator selection processes. We aimed to review the literature to identify papers that document indicator selection processes for health system performance indicators in PHC. We searched the online databases Scopus, Medline, and CINAHL, as well as the grey literature, without time restrictions, initially on July 31, 2019 followed by an update November 13, 2020. Empirical studies or reports were included if they described the selection of health system performance indicators or frameworks, that included PHC indicators. A combination of the process focussed research question and qualitative analysis meant a quality appraisal tool or assessment of bias could not meaningfully be applied to assess individual studies. We undertook an inductive analysis based on potential indicator selection processes criteria, drawn from health system performance indicator appraisal tools reported in the literature. We identified 16 503 records of which 28 were included in the review. Most studies used a descriptive case study design. We found no consistent variations between indicator selection processes of health systems of high income and low- or lower-middle income countries. Identified common features of selection processes for indicators in PHC include literature review or adaption of an existing framework as an initial step; a consensus building process with stakeholders; structuring indicators into categories; and indicator criteria focusing on validity and feasibility. The evidence around field testing with utility and consideration of reporting burden was less clear. Our findings highlight several characteristics of health system indicator selection processes. These features provide the groundwork to better understand how to value indicator selection processes in PHC.

Maternal near-miss and mortality associated with hypertensive disorders of pregnancy remote from term: a multicenter observational study in Ghana

BACKGROUNDMaternal death rates remain high in many low- and middle-income countries. Hypertensive disorders of pregnancy account for 18% of maternal mortality in Ghana. The maternal near-miss approach was designed to evaluate severe (acute) complications in pregnancy, which is useful to detect potential areas for clinical care improvement.OBJECTIVEThis study aimed (1) to determine the incidence of severe maternal complications, maternal near-miss cases, and mortality cases associated with hypertensive disorders of pregnancy remote from term and (2) to assess the health system's performance indicators for the management of hypertensive disorders of pregnancy remote from term in middle-income country referral hospitals.STUDY DESIGNThis study was nested in the ongoing Severe Preeclampsia adverse Outcome Triage study, a multicenter observational cohort study, and included women recruited from December 1, 2017, to May 31, 2020, from 5 referral hospitals in Ghana. Women aged >16 years, admitted to the hospital with hypertensive disorders of pregnancy, with gestational age between 26 and 34 weeks were eligible. Near miss was defined according to the World Health Organization and sub-Saharan African near-miss criteria. Descriptive statistics of pregnancy and maternal and perinatal outcomes up to 6 weeks after delivery of women with severe maternal outcomes were presented for maternal deaths and maternal near-miss casigurees and compared with that of women without severe maternal outcomes. The health system's maternal and perinatal performance indicators were calculated.RESULTSOverall, 447 women with hypertensive disorders of pregnancy were included in the analyses with a mean maternal age of 32 (±5.8) years and mean gestational age at recruitment of 30.5 (±2.4) weeks. Of these patients, 46 (10%) had gestational hypertension, 338 (76%) had preeclampsia, and 63 (14%) had eclampsia. There were 148 near-miss cases (33.1%) and 12 maternal deaths (2.7%). Severe maternal outcomes constituted complications from severe preeclampsia (80/160 [50%]) and eclampsia (63/160 [39.4%]). Concerning organ dysfunction, hematologic and respiratory dysfunctions constituted 59/160 [38.6%] and 23/160 [14.8%] respectively. Nearly all women had a cesarean delivery (347/447 [84%] and 140/160 [93%] in the severe maternal outcome group) and delivered prematurely (83%, with 178/379 [93%] at <32 weeks of gestation). Stillbirth and neonatal deaths occurred in 63 of 455 women (14%) and 81 of 392 women (19%), respectively, constituting a stillbirth ratio of 161 per 1000 live births and neonatal mortality rate of 207 per 1000 live births as there were 392 live births in this cohort. Overall, the intensive care unit admission rate was 12.7% (n=52/409); moreover, 45 of 52 women (86.5%) admitted to the intensive care unit had severe maternal outcomes. The maternal death ratio was 3100 per 100,000 live births, the maternal near-miss–to–mortality ratio was 12.3, and the mortality index was 8%.CONCLUSIONMaternal near miss and maternal and perinatal mortalities were common in women with hypertensive disorders of pregnancy remote from term in referral hospitals in Ghana. Providing appropriate patient-centered and multidisciplinary quality care for these women is crucial in improving pregnancy outcomes. Context-tailored interventions should be considered in the clinical management of complications associated with hypertensive disorders of pregnancy in resource-limited settings. Further research on interventions to improve timely referral and reduce in-hospital delays in care provision is recommended to facilitate emergency care services for women with hypertensive emergencies.