Health System Performance Indicators Research Articles

Top “5 in 5” CNA responds to the National Expert Commission

In our last column (Villeneuve and Mildon 2013), we shared the topics of 11 project charters developed by the Canadian Nurses Association to respond to the nine-point Call to Action of the National Expert Commission (NEC 2012). The lead recommendation of the NEC was to move Canada’s ranking on five key population health and health system performance indicators into the “top five” internationally in five years. That recommendation by the NEC was intended to respond to Canada’s mediocre (and in some cases deteriorating) ranking on a number of influential, internationally comparable population health and health system performance indicators. Throughout the tenure of the NEC, its members were troubled by those outcomes when set against constantly rising healthcare spending. Its place as the first recommendation reflects the determination of the commissioners that nurses must join with others to lead efforts required to shift that paradox.

Understanding safety management system applicability in community sport

Despite recent interest in understanding the implementation context for sports injury prevention interventions, little research attention has been paid to the management structures and processes of community sporting organisations. This study developed expert consensus about the importance of Occupational Health and Safety (OHS) setting-related safety management system (SMS) principles and performance indicators in the context of Australian community sporting organizations, and the feasibility of these organisations meeting the requirements for the SMS performance indicators. Twenty-nine sports injury prevention, community sports administration and OHS SMS experts participated in a three-round online Delphi study by rating the importance of 64 SMS performance indicators categorised under the five principles of Commitment and Policy; Planning; Implementation; Measurement and Evaluation; and Review and Improvement. Overall, consensus agreement – define as rated ‘essential’ or ‘very important’ on a five-point scale by ⩾75% of the participants in Round 3 – was reached for 57 performance indicators. Ten (15%) performance indicators were rated as ‘very difficult’ or ‘relatively difficult’, and six (9%) were rated as ‘very easy’ or ‘relatively easy’ on a four-point scale, by ⩾75% of participants. This research suggests that the guiding principles and associated performance indicators that underpin OHS safety management systems in the workplace are very relevant and applicable to community sporting organisations in Australia. However, considerable work is required to build organisational capacity to be able to develop and implement meaningfully and useful SMSs to prevent sports injuries in the most common setting in which they occur.

Socioeconomic equity in amenable mortality in Finland 1992–2008

This study presents an approach to assess socioeconomic equity in the effectiveness of health services. As an indicator of health system performance we use amenable mortality which captures premature deaths that should not occur in the presence of effective and timely health care. Data on amenable deaths by income groups in Finland in 1992–2008 came from the National Causes of Death Register which was linked to sociodemographic data in population registers. We evaluate the extent of and trends in socioeconomic differences with two widely used inequity indices, the concentration index and the slope index of inequality, and also for different categories of amenable mortality. By categorizing conditions according to the level of intervention associated with the conditions it is possible to evaluate the effect of types of health interventions. Causes of death attributable to specialized and primary care interventions comprise the main groups. By this approach of decomposing equity in amenable mortality in Finland we detected major and increasing socioeconomic inequities and also greater inequity among deaths amenable to specialized health care interventions. Moreover, we saw that inequity increased at a faster pace among deaths amenable to specialized health care interventions yet primary health care interventions made a greater contribution to overall inequity. Although the overall rate of amenable mortality decreased notably during the follow-up, the time trends of socioeconomic differences in amenable health care indicate a substantial increase in inequities in health care in Finland.

Measuring NHS performance 1990–2009 using amenable mortality: interpret with care

The new performance framework for the NHS in England will assess how well health services are preventing people from dying prematurely, based on the concept of mortality amenable to healthcare. We ask how the different parts of the UK would be assessed had this measure been in use over the past two decades, a period that began with somewhat lower levels of health expenditure in England and Wales than in Scotland and Northern Ireland but which, after 1999, saw the gap closing. We assessed the change in age-standardized death rates in England and Wales, Northern Ireland and Scotland in two time periods: 1990-1999 and 1999-2009. Mortality data by five-year age group, sex and cause of death for the years 1990 to 2009 were analysed using age-standardized death rates from causes considered amenable to healthcare. The absolute change was assessed by fitting linear regression and the relative change was estimated as the average annual percent decline for the two periods. United Kingdom. Not applicable. Mortality from causes amenable to healthcare. Between 1990 and 1999 deaths amenable to medical care had been falling more slowly in England and Wales than in Scotland and Northern Ireland. However the rate of decline in England and Wales increased after 1999 when funding of the NHS there increased. Examination of individual causes of death reveals a complex picture, with some improvements, such as in breast cancer deaths, occurring simultaneously across the UK, reflecting changes in diagnosis and treatment that took place in each nation at the same time, while others varied. Amenable mortality is a useful indicator of health system performance but there are many methodological issues that must be taken into account when interpreting it once it is adopted for routine use in England.

Mortality amenable to health care in the United States: the roles of demographics and health systems performance.

This article examines associations of socio-demographic and health-care indicators, and the statistic 'mortality amenable to health care' (amenable mortality) across the US states. There is over two-fold variation in amenable mortality, strongly associated with the percentages of state populations that are poor or black. Controlling for poverty and race with bi- and multi-variate analyses, several indicators of health system performance, such as hospital readmission rates and preventive care for diabetics, are significantly associated with amenable mortality. A significant crude association of 'uninsurance' and amenable mortality rates is no longer statistically significant when poverty and race are controlled. Overall, there appear to be opportunities for states to focus on specific modifiable health system performance indicators. Comparative rates of amenable mortality should be useful for estimating potential gains in population health from delivering more timely and effective care and for tracking the health outcomes of efforts to improve health system performance.

Modelling the dynamics of a public health care system: evidence from time-series data

The English National Health Service (NHS) was established in 1948, and has therefore yielded some long time series data on health system performance. Waiting time for inpatient care have been a persistent policy concern since the creation of the NHS. After developing a simple theoretical framework of the dynamic interaction between key indicators of health system performance, we investigate empirically the relationship between hospital activity, waiting time and population characteristics using aggregate time-series data for the NHS over the period 1952 to 2003. Structural Vector Autoregression (S-VAR) suggests that in the long run: higher activity is associated with lower waiting times (elasticity = −0.9); an increase in the elderly population is associated with higher waiting time (elasticity = 1.3). In the short run, higher lagged waiting time leads to higher activity (elasticity = 0.12). We also find that shocks in waiting times are countered by higher activity, so the effect is only temporary.

Avoidable mortality in the Russian regions

The current trends of avoidable mortality, which is an integral indicator of health system performance, were analyzed. The paper discusses the regional heterogeneity of levels and trends in avoidable mortality in the Russian Federation. Also, it contains the analysis of impact of the financial costs of public health on avoidable mortality in regions with different levels of economic development. The last 20-years period was studied, which includes a stage of crisis as well as a social recovery phase. The official data of the State Statistics Committee were analyzed. In Russia, all death cases are registered in accordance to the international classification ICD-10. Special computer program summarizes death cases from preventable causes, and calculates the standardized rates for the population aged from 5 to 64 years. The old European standard of population age structure is used. Estimates of avoidable mortality were made in accordance with the European approach, under which avoidable mortality accumulates deaths of persons aged from 5 to 64 years due to 34 causes and 4 classes of causes. These 38 causes are divided into 3 groups according to three levels of diseases prevention. The level of avoidable mortality in the different regions varies up to 8 times. That is comparable to the difference between Russia and the countries of European Union in 1994. This gap is due to the coexistence of different stages of epidemiological development among the regions in Russia. When death rates increased, it is shown that mortality from causes which are preventable by measures of primary and tertiary prevention increased to a greater extent than mortality from the causes which depend from measures of secondary prevention. Therein, the largest growth of observed mortality was due to low quality of medical care in case of males (group 3), and due to causes which are preventable by measures of primary prevention in case of females (group 1). When mortality was reduced, the rates of change for causes in groups 1 and 3 were approximately the same for both sexes. Avoidable mortality due to late detection of malignant tumors (group 2) has been changed the least. Preventable component defines over 80% of the regional differences in death rates. In 2009, the level of avoidable mortality differed more than fourfold among different regions of the Russia. Similarly, the difference in the level of unavoidable mortality was 1.3-fold and 1.7-fold, for males and females respectively. Proportion of deaths from preventable causes in the total sum of death cases varies from 40% till 75%. Funding for comprehensive programs of public health to a greater extent stimulates the reduction in mortality from preventable causes of the first group. Mortality connected with quality of medical care is more determined by socio-political situation in the country than by regional health care expenses. Based on these results, it is concluded that the action plans to reduce mortality in Russia must have a strong regional specificity, different targets and indicators. Using the proportion of preventable causes, it is possible to separate the regions into groups with different ratios of death determinants, which, therefore, require different approaches to reduce mortality.

Making Health System Performance Measurement Useful to Policy Makers: Aligning Strategies, Measurement and Local Health System Accountability in Ontario

This study examined the experience of the Ontario Ministry of Health and Long-Term Care in enhancing its stewardship and performance management role by developing a health system strategy map and a strategy-based scorecard through a process of policy reviews and expert consultations, and linking them to accountability agreements. An evaluation of the implementation and of the effects of the policy intervention has been carried out through direct policy observation over three years, document analysis, interviews with decision-makers and systematic discussion of findings with other authors and external reviewers. Cascading strategies at health and local health system levels were identified, and a core set of health system and local health system performance indicators was selected and incorporated into accountability agreements with the Local Health Integration Networks. despite the persistence of such challenges as measurement limitations and lack of systematic linkage to decision-making processes, these activities helped to strengthen substantially the ministry's performance management function.

Hidden waiting times of elective surgery

To the editor, Performance measurement is now an essential part of health services management, with a proliferation of performance indicators over the last 10 years. As a result, evidence must continue to guide and inform their ongoing use [1]. Long waiting times are frequently portrayed by the media and governments as indicators of poor health system performance. However, given that waiting lists are primarily created to support internal management and clinical decision making, care should be exercised when using them as indicators of performance [2]. With this in mind, Brasted should be congratulated on his novel and elegant paper “Ultrasound waiting lists: queue or extended capacity?”[3], as it represents a valuable contribution to the current literature on waiting lists and performance measurement. Diagnostic imaging, like elective surgery, is a limited resource, with demand usually exceeding supply. However, as Brasted points out, the literature on waiting times for diagnostic imaging is limited compared to that for elective surgery. A fundamental limitation with many elective surgical waiting lists is that they fail to disclose the ‘hidden’ waits prior to elective surgery. For instance, before being added to a waiting list, patients must wait to see a general practitioner for a referral, and then must wait for an appointment with a surgeon before waiting to access pathology and radiology services. To date, little is known about the relationship between waiting times for diagnostic imaging and waiting times for elective surgery. Therefore, Brasted’s attempts to characterize and model the supply and demand of diagnostic imaging services will greatly assist in the planning and management of both diagnostic imaging services and elective surgery. Ultimately though, waiting lists cannot expose definitive truths about the quality or safety of health services because that is not their primary purpose. Instead, they are tools to prompt and guide additional inquiry and investigation. This is true of surgical waiting lists as it is of waiting lists for ultrasound. This must be recognised by politicians, patients, health professionals and policymakers [4]. In this regard, Brasted’s paper is seminal.

States Show Wide Discrepancies in Quality of Health Care for US Children

THE QUALITY OF HEALTH CARE SYStems for children differs widely across the United States, according to a report released May 28. The report, US Variations In Child Health System Performance: A State Scorecard (available at http://www .commonwealthfund.org/publications /publications_show.htm?doc_id= 687113), ranks the states based on 13 indicators of child health system performance, grouped into 5 categories: access, quality, costs, equity, and potential of the state’s children to lead healthy lives. The report, issued by the Commonwealth Fund, a private foundation that supports independent research on health care issues, compared the care systems of all 50 states and the District of Columbia. The researchers argued that if all states reached benchmarks achieved in the top-performing states, an additional 4.6 million children would have health insurance; 11.8 million more children would get their recommended annual medical and dental checkups; 1.6 million fewer children would be at risk for developmental delays; and almost 800 000 more children would be up to date on their vaccines. In general, states in the Northeast and the upper Midwest performed better than those in the South and West. The top 3 states were Iowa, Vermont, and Maine. Oklahoma was the lowest ranked, followed by Florida and Mississippi. The report was issued with the changing political landscape in mind, said report coauthor Edward Schor, MD, a Commonwealth Fund vice president who heads the organization’s Child Development and Preventive Care program. “There’s going to be a new administration next year which gives us an opportunity to raise awareness of some of the issues,” Schor said. Although child health care tends to be a state function, the federal government plays a role through the funding of

Waiting lists: waiting for the evidence!

On 26 February 2008, Victorian State Opposition Leader Ted Baillieu described as a "blow out" the increase in average elective surgery waiting times from 202 days in September 2007 to 235 days in February 2008. Likewise, the Australian Medical Association is concerned that 800 000 Australians will leave private health insurance now that the federal government has increased the income threshold for the Medicare levy. They warn of "further pressure" on public hospital waiting lists. Public hospital waiting lists are frequently used for political point scoring and are portrayed by the media and politicians as indicators of health system performance. Alarmingly, governments often develop policies in response. This paper presents the current evidence to see whether waiting lists are valid indicators of health system performance and presents some advice for policymakers.

Keeping mental health reform on course: selecting indicators of mental health system performance.

Mental health reform was introduced as a public-sector policy response to identified deficiencies in the mental health services system. The reform agenda, which is underway in most provinces/territories, calls for greater accountability to mental health consumers, their families, and other stakeholders. This paper summarizes the major policy goals (which are the cornerstones of mental health reform) and suggests a series of high-level indicators to assess performance toward achieving these goals. Issues in the selection and measurement of performance indicators as markers of key goals are discussed. The proposed indicator set, while not a comprehensive framework, can provide a multi-dimensional appraisal of mental health system performance and help keep reform on course.

Access to health care. A conceptual framework and its relevance to health care planning.

Despite some serious past efforts to clarify its multiple dimensions and meanings, access to health care has remained a rather elusive concept, hampering the work of health care policymakers and professionals as they endeavor to effect meaningful health care reform. This article provides perhaps the most detailed clarification of the access concept, especially the crucial linkages among the various access dimensions, and presents a comprehensive conceptual framework for evaluation and planning activities as they relate to people's access to health care services. The proposed conceptual model recognizes access as the outcome of a process involving the interplay between the characteristics of the health care service system and of potential users in a specified area, and moderated by health care related public policy and planning efforts. An elaborate typology of access, incorporating four pairs of access dimensions, is also derived. This atomization of the concept allows us to focus on specific aspects of the access to health care problem, and to develop precise outcome indicators of health system performance for evaluative purposes. Further, it enables the access concept and its pertinent dimensions to be put into proper perspective when assessing the health care access situation in a specific national or regional context. The relevance of the proposed access model and the typology to health care planning in general, and to spatial planning of health care service systems in particular, is also discussed.