Monitoring and analysing in primary health care in Norway

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1 Monitoring and analysing in primary health care in Norway
Jan Magne Linnsund Senioradvisor dpt. Primary Health Care Norwegian Directorate of Health NDPHS

2 GDP per capita and total health expenditure per capita 2005 in US dollar (OECD 2007)
GDP – gross domestic product = brutto nasjonalprodukt NDPHS

3 Health expenditure per capita 2013 in US dollar (OECD 2015)
NDPHS

4 Much is not necessarily better than less !!
Although I am not fond of being the messenger of the message, it is no research in the world that can document that to pour in money automatically improves quality Kristin Clemet, norwegian conservative politician;born in 1957 Selv om jeg ikke er noe glad for å være budbringer av budskapet, så finnes det ikke noen forskning i hele verden som kan dokumentere at det å pøse på med penger automatisk gir bedre kvalitet. NDPHS

5 Health status - OECD 2015 The number in the cell indicates
Indicator Life expectancy at birth - Men Life expectancy at birth - Women Life expectancy at 65 - Men * Life expectancy at 65 - Women * Mortality from cardiovascular diseases ** Australia 8 7 3 Austria 18 13 16 26 Belgium 22 19 23 14 15 Canada 17 10 5 Chile 27 28 Czech Rep. 29 30 31 Denmark 21 25 Estonia 32 Finland 20 9 24 France 2 Germany Greece 11 Hungary 33 34 Iceland Ireland Israel Italy 4 Japan 1 6 Korea Luxembourg 12 Mexico Netherlands New Zealand Norway Poland Portugal Slovak Rep. Slovenia Spain Sweden Switzerland Turkey United Kingdom United States The number in the cell indicates the position of each country NDPHS

6 Norwegian health services has high quality in an international perspective
Nevertheless, there are undesirable variations in our health ervices National guidelines and and quality indicators are tools to promote desired practises Undesirable incidents happens that we must learn from and it is a need for greater transparency on such issues The debate of prioritization has been more about the specialist health care than primary health care and it is a goal that priorities should be: More unified and coordinated Integrated in management and practice at all levels NDPHS

7 Guidelines in primary health care – too much?
Results from an investigation of 22 primary doctors offices in UK: 855 different guidelines (68 cm height and 28 kg weight) 75 % were about clinical issues Mengden retningslinjer på et allmennlegekontor skyldes blant annet påtrykk fra legemiddelkonsulenter som reiser rundt, men mange allmennleger lager også sine egne både individuelt og for legekontoret NDPHS

8 Background 2010: Framework for a national quality indicator system in primary- and specialist helath service 2012: New legislation on municipal health and care services: «Norwegian Health Directorate should develop, convey and maintain national quality indicators as a tool for management and quality of service, and as a basis for patients to protect their rights." Historien på 1-2-3: Stor politisk interesse for området. De eldste kvalitetsindikatorene vi har går tilbake til tidlig 2000-tall. I 2010 utarbeidet utga helsedirektoratet en rapport om Rammeverk for et nasjonalt kvalitetsindikatorsystem i primær og spesialisthelsetjenesten, basert på en rapport fra kunnskapssenteret. Det ble etablert en gruppe i Helsedirektoratet, og da ansvaret ble lovpålagt i 2012, ble det etablert et eget sekretariat. 2013 fikk vi egen publiseringsløsning på helsenorge Den politiske interessen rundt kvalitetsindikatorer er stor. I 2013 kom en egen melding om kvalitet og pasientsikkerhet i helse og omsorgstjenesten. I 2014 leverte den første av det de har varslet at skal bli en årlig melding til stortinget om kvalitet og pasientsikkerhet. Her inngår kvalitetsindikatorene som en viktig kilde, sammen med flere andre. 2012: Stortingsmelding 9 ( ). En innbygger – en journal 2013: Stortingsmelding 10 ( ). God kvalitet – trygge tjenester 2014: Stortingsmelding 11 (2014 – 2015). Kvalitet og pasientsikkerhet 2013 NDPHS

9 Scientifically justified
Requirements and objectives for national indicators of quality Frameworks and resources, expertise, available equipment, records Ex. Has hospitals stroke unites? Requirements: Momentous Scientifically justified Useful Feasible Published regularly Structure indicators Activities in patient care Ex. diagnostics, waiting time for further examination and treatment Process indikctors Complications Patient satisfaction Health benefit Survival Readmission Results indicators NDPHS

10 Published at Helsenorge.no
Hva er det nasjonale kvalitetsindikatorsystemet? Sett av måltall, indikatorer som publiseres på helsenorge.no Viser trender over tid, og sammenlikning på tvers av kommuner, fylker og nasjonalt (behandlingssteder, HF og RHF). I dag har vi 74 kvalitetsindikatorer, og målet er å utvide med fler. Ofte er vi mer interessert i å se på flere indikatorer i fellesskap enn en enkeltindikator for å si noe om kvaliteten. En kvalitetsindikator er ikke en fasit med to streker under, men må tolkes som et indirekte mål eller pekepinn. Kilde til å stille de riktige spørsmålene, og jobbe med løpende kvalitetsforbedring. Published at Helsenorge.no Per last publishing 25.aug 2016: national quality indicators; mostly within specialist care and hospitals!! “A quality indicator is an indirect measure, an idea, which says something about the quality of the area being measured.”  NDPHS

11 Some of the quality indicators within the specialist service in Norway
General indicators: : • Discharge report sent to GP within 7 days • Patients located in a corridor (1,4%) • Average waitingtime • Postponement of planned operations • Patients' experiences with hospital • 30-day overall survival after hospitalization • Hospital Infections • Re-admissions of elderly patients Fracture colli femoris: Operation within 48 hours 30 days survival Cancer: • Started treatment for colon cancer within 20 workdays • Started treatment for lung cancer within 20 workdays • Started treatment for breast cancer within 20 workdays • 5 years survival colon cancer • 5 years survival rectum cancer • 5 years survival lung cancer • 5 years survival breast cancer • 5 years survival prostatic cancer NDPHS

12 Some examples Discharge report from hospitals
In the country as a whole; in ,0 % of the discharge reports was sent from the hospital within 1 day and 80,8 % within 7 days. Heart lung rescue done by the population In 2015 had present people started Heart-lung-rescue before the ambulance arrived in 74,6 % of the cases nationwide NDPHS

13 Patients in nursing homes with medical consultation last 12 mnd.
NDPHS

14 Doctors’s time for residents in nursing homes
Doctor hours per resident per week NDPHS

15 Waitingtime for health and care services in the municipalities; last four – ready for publishing 25. aug. 2016 National indicatores of quality Waitingtime 0-15 days * 16-30 days * 31 days or more * Waitingtime for daily activities 83,2% 6,2 % 10,6 % Waitingtime for home nursing care 95,9 % 1,6 % 2,5 % Waitingtime for supportive contact 84,8 % 6,6 % 8,6 % Waitingtime for nursing home 90,0 % 4,4 % 5,7 % *The numbers shows the national average in 2015. NDPHS

16 KPR shall safeguard stakeholders need for information
For diskusjon Animert slide KPR shall safeguard stakeholders need for information KPR = Municipality Patient Register Information about activities and results from the health and care service Patient and user Service and organization Professional and quality development in the health and care service… Health condition and service needs Patient- and usercontact Research and innovation Treatment and follow-up Capacity, expertise and resources En konseptuell løsningsskisse regnes som den øverste løsningsskisse som benyttes for å formidle informasjon om interessentgrupper og aktører Ønsket funksjonalitet (uttrykt som informasjonsbehov og fremstilling av informasjon) bestanddeler av løsningen aktører (profesjoner, fagområder, roller) Skissen benyttes også til å vise avhengigheter til andre initiativer og systemløsninger som blir berørt av KPR. Knyttes til aktuelle Stortingsmeldinger og oppdragsbrev. Results and consequenes Collaboration Samhandling (pasientforløp) The exercise of authority and management to ensure good, comprehensive and equitable distributed healthcare

17 Why do we need KPR ? Too little comprehensive knowledge of health and care services in the municipalities. Good experience with having a national patient registry for specialist services (NPR from 2007) that provides information which is including management, statistics and research. Along with NPR will KPR could give a comprehensive picture of the patient's situation and needs and how health services meet and solve these across administrative levels. KPR will give municipalities the basis for better and more efficient planning and management of resources and activities within the health and care services. KPR will provide a knowledge base and create better conditions for quality improvement and patient safety work. Provide data for research, health analysis and innovation. OECD har påpekt at det er et svart hull i kunnskapen om primærhelsetjenesten i Norge, her ligger vi dårligere an enn mange sammenlignbare land, og land vi vanligvis ikke tenker på å sammenligne oss med som Portugal og Israel.

18 OECD and Norway – and NDPHS
OECD has pointed out that there is a “black hole” in the knowledge of primary health care in Norway. In this field Norway are poorer than many comparable countries - and countries we usually do not think of comparing ourselves with that Portugal and Israel Common indicators to manage to compare or - let the thousand flowers bloom!? NDPHS

19 KPR will be developed incrementally
KUHR - Control and payment of health reimbursement funksjonalitet IPLOS - Individual-based care and nursing registry Data from all service areas within primary care available Coordinated with “One resident – one journal”, a huge national project with a prestigious goal: a common electronic patient journal Establish a common reporting directly from the service Develop technical solution with automated data capture Strength analysis capabilities Expanding with new data from multiple services More data from GP’s and nursing and care Services like dental health, health clinics for children and school health Build upon current data KUHR IPLOS From 2017? OBS! Dette veikartet er en tidlig utkast for diskusjon internt i programmet. Hensikten med denne utkast er å legge fram hovedretningen i målbildet og gir en pekepinn til temaer som målbildearbeidet skal utrede for beslutning i Programstyret. Denne «trappetrinn» plan har bevisst utelatt informasjon om varighet og innsatsfaktor pr trinn. Disse vil detaljeres underveis som del av målbildearbeidet og øvrige tiltak fra de andre prosjekter. Veikartet lagt fram på dette tidspunktet er også ment å indikere ambisjonsnivået dvs hva som er programmets mandat og budsjettrammer vs hva som skal gjennomføres i linjen. Veikartet etableres på bakgrunn av flere parametre – blant annet avhengigheter til andre initiativer, finansiering, anskaffelsestekniske forhold, prioriteringer fra myndighetene osv. En trinnvis plan kan også vises som en «spindelvev» - der leveransesporene er tydeligere og tidsaksen (faser) vises i et visuelt format som er lett å kommunisere. En spindelvevs-model vil brukes for å beslutte en realiseringsstrategi og konkretisere en masterplan. En masterplan beskriver aktiviteter, bemanning/kompetanse, leveranser osv. KPR 1.0 KPR 2.0 KPR 3.0 KPR 4.0 tid

20 SKIL Centre for Quality Improvement in Medical Practices
Norwegian Medical Association (NMA)

21 AIMs Implement Quality Improvement (QI) in medical practices
Cooperate with authorities Cooperate with research institutions

22 SKIL’s MAIN THEMES Medication Review Better Antibiotics Prescription
Started November 2015, about 220 doctors have joined so far Better Antibiotics Prescription Starting January 2017 Coordinated Care for Multimorbid Patients Starting 2017/2018

23 AGGREGATED DATA PATIENTS WITH 4+ MEDICATIONS WHERE MEDICATION REVIEW HAS BEEN DONE AND DOCUMENTED LAST 12 MONTHS

24 I can’t get no NDPHS

25 Cost of satisfaction Arch Intern med/vol 172 (no 5) Mar 12, 2012
Medical Expenditure Panel Survey ; en prospectiv cohort study; total - N = Use of health services Total costs and expenses for drugs Mortality High degrees of patient satisfaction was associated with: Lower use of emergency department Higher use of general practitioner Larger total health expenditure Greater spending on drugs Higher mortality Satisfaction – a doubled-edged sword? NDPHS