Crossing the Global Quality Chasm Improving Health Care Worldwide (2018) / Chapter Skim
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4 The Current State of Global Health Care Quality
4 The Current State of Global Health Care Quality
Pages 129-168
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From page 129... ...
• Choosing existing indicators rather than investing heavily in developing new ones can allow health systems in low-resource settings to close the gap with high-resource settings in transparency and knowledge of performance. To improve the quality of health care globally, it is imperative first to be able to characterize and quantify the burden of low-quality care.
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From page 130... ...
We quantify the burden of low-quality care as an estimate of the deaths and disability resulting from unsafe and ineffective care for the proportion of the population that has attained actual coverage. In addition, we demonstrate the variability of person-centeredness across countries by documenting variations in patients' assessment of their health care interactions.
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was the best way to deliver the baby. Kwame relayed this request to the resident doctor, who agreed to perform the CS at 2:00 p.m.
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The baby, however, did not cry at birth, and the midwives started immediate resuscitation on the baby, later joined by the resident doctor, who had been informed of the situation by Kwame. After about 30 minutes, the resident doctor and one of the midwives rushed the baby to the neonatal intensive care unit (NICU)
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THE STATE OF QUALITY ACROSS DOMAINS For each domain of quality outlined in Chapter 1, the team of commissioned analysts defined a set of indicators corresponding to poor-quality care (detailed methods relating to each indicator are outlined in Appendix D)
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This review, which was conducted with the input of the WHO Committee on Research for Patient Safety, identified 23 topics pertaining to patient safety, including adverse events. From those 23 topics, six indicators composed of types of adverse events and hospital-acquired conditions were selected for measurement, in line with a previous review on the global burden of patient safety and taking into account the availability of data (Jha et al., 2013)
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of Deaths Adverse drug events 3.2 17,152,226 222,979 Falls 5.1 27,198,059 40,797 Ventilator-associated pneumonia 7.4 316,279 63,256 Decubitus ulcers 9.0 47,931,418 239,657 Catheter-associated urinary tract infections 0.9 27,187,770 1,631,266 Venous thromboembolisms 2.6 14,081,893 422,457 Overall 133,867,645 2,620,412 NOTES: Ventilator-associated pneumonia is applied to the intensive care unit (ICU) population on ventilators only; the rates for all other measures are applied to an estimate of total global hospitalizations, including ICUs (studies that are limited to the ICU population are excluded)
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and HIV. Deaths and years of life lived with disability (YLD)
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For TB in particular, more deaths and a greater burden of illness are attributable to the use of substandard and falsified medicines than to the failure to receive treatment among diagnosed patients. Work conducted to date by a selected few provides a strong foundation on which to call for improved tracking systems, technical innovation, and policy solutions.
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From page 138... ...
In addition, this estimate does not always consider instances in which condi TABLE 4-2 Conditions Represented in the Effectiveness Domain Communicable diseases • HIV/AIDS • Tuberculosis • Pneumonia • Diarrheal diseases Noncommunicable diseases • Cancer: lung cancer • Cardiovascular disease: acute myocardial infarction (AMI) , heart failure, and hypertension • Cerebrovascular disease: ischemic stroke and hemorrhagic stroke • Chronic obstructive pulmonary disease (COPD)
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From page 139... ...
mortality Diabetes Untreated diabetes among diagnosed patients Injury and trauma Excess mortality from trauma and injury Depression Untreated depression among those seeking care Anxiety Untreated anxiety among those seeking care Bipolar disorder Untreated bipolar disorder among those seeking care Schizophrenia Untreated schizophrenia among those seeking care Substance abuse Untreated substance abuse among those seeking care Maternal Mortality and Child Health Maternal mortality Mortality among women during birth who had a skilled birth attendant at delivery Neonatal mortality Mortality among neonates in the first month of life who had a skilled birth attendant at delivery tions were not appropriately diagnosed; accounting for misdiagnosis would increase the estimate of the burden. In certain cases, however, such as for pneumonia and diarrheal disease, the data represent care-seeking behavior among people with symptoms and were not limited to cases in which a diagnosis had already been made.
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TABLE 4-5 Deaths and Disability Resulting from Ineffective Care for Communicable Diseases in Low- and Middle-Income Countries, Annually (millions) Quality-Related Years of Life Lived Treatment Indicator Deaths with Disability HIV/AIDS 0.46 2.5 Diarrheal disease (under 5 years)
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, measured as the percentage of the population diagnosed and not treated annually, are presented in Table 4-6. Estimated annual deaths and disability resulting from ineffective care for NCDs are presented in Table 4-7.
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0.10 -- Heart failure 0.62 -- Ischemic stroke 0.18 -- Hemorrhagic stroke 0.02 -- Chronic obstructive pulmonary disease 1.0 -- (COPD) Injury and trauma 2.1 -- Diabetes mellitus -- 13.1 Depression -- 44.6 Anxiety -- 17.9 Bipolar disorder -- 3.3 Schizophrenia -- 5.0 Alcohol use disorder -- 4.2 Total 4.15 88.1 NOTE: See Table 4-6.
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However, many international partners, including the Organisation for Economic TABLE 4-8 Quality-Related Deaths Resulting from Ineffective Care for Maternal and Child Health in Low- and Middle-Income Countries, Annually Indicator Quality-Related Deaths Neonatal mortality (attended) 462,131 Maternal mortality (attended)
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. This review was supplemented by a systematic review of the published literature to identify any publications on additional survey tools or data sources (often with smaller sample sizes, limited to one geographic area, etc.)
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Timeliness Lack of timely care can negatively affect patients emotionally and physically, in addition to increasing treatment costs. Timely care refers to care that is provided promptly, and minimizes waiting times and potentially harmful delays for both patients and providers (IOM, 2001)
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SOURCES: Systematic review of the literature in low- and middle-income countries, Service Provision Assessment & Commonwealth Fund International Health Policy Survey (see the discussion of methodology in Appendix D)
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Examples include the International Development Bank's (IDB's) Public Opinion Health Policy Survey; the OECD Health Care Quality Indicator Project; and the Service Provision Assessment component of the DHS, which collects data on problems with health facility wait time for 10 countries, with an average satisfaction rate of 67 percent.
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Difference between deaths in LMICs and high-income countries. a This number was revised after the prepublication release.
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Across all conditions, the mortality rate attributable to ineffective care in high-income countries is lower than that in LMICs. The greatest difference in mortality rates across the two groups of countries is for heart failure, for which inpatient mortality differs by 9 percentage points.
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In China, that number is 51 percent. Key Findings of Studies on Unnecessary Antibiotics Using Standardized Patients Correct Diagnosis and No.
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FIGURE 4-34-3 Variation in mortality rates for ineffective care, low- and middle-income versus FIGURE high-income countries. NOTE: AMI = acute myocardial infarction; COPD = chronic obstructive pulmonary disease; HIC = high-income country; HIV = human immunodeficiency virus; LMIC = low- and middle income country.
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, whereas ineffective care for communicable diseases included in this study accounts for 0.8 million deaths. The majority of YLD due to poor-quality care were incurred by the population living with mental illnesses (79.1 million years)
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, only 50 percent of low income countries have breast cancer screening programs or guidelines at the pri mary health care level, compared with 95 percent of high-income countries (WHO, 2015a)
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NOTE: AMI = acute myocardial infarction; COPD = chronic obstructive pulmonary disorder; HIV = human immunodeficiency virus. SOURCE: Institute for Health Metrics and Evaluation, Appendix D
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Where available, data were obtained from national or international databases. Where there was no available database for indicators of interest, estimates were obtained by carrying out systematic reviews of the peerreviewed published literature over the past decade.
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Figure 4-5 illustrates the geographic representation of the published literature from which safety estimates for five of the six indicators (excluding catheter-associated urinary tract infections) were obtained, while Table 4-11 details this distribution by condition for selected countries.
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Grey color in the map indicates regions where data were not available for analysis.
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Model Lung cancer mortality 139 World Bank DataBank, WHO GHO, IHME
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TRACKING PROGRESS IN QUALITY: WHERE ARE THE METRICS? Health care quality is multifaceted and difficult to measure, but its measurement is essential nonetheless.
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(OECD, 2017a) : • patient experiences with ambulatory care, • prescribing in primary care, • avoidable hospital admissions, • diabetes care, • mortality following ischemic stroke, • mortality following acute myocardial infarction, • hospital mortality rates, • waiting times for hip fracture surgery, • surgical complications, • obstetric trauma, • care for people with mental health disorders, • screening, survival, and mortality for breast cancer, • survival and mortality for colorectal cancer, • survival and mortality for leukemia in children, and • vaccinations.
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International Consortium for Health Outcomes Measurement The International Consortium for Health Outcomes Measurement (ICHOM) was founded in 2012 to address the challenges of variability in measurement and definitions of what matters most to patients across different countries.
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SUMMARY AND RECOMMENDATION Health care today in all settings and all nations suffers from high levels of poor quality in many dimensions. This global quality chasm prevents patients and communities from reaping the potential benefits of effective care.
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• Health care leaders should prioritize patient-reported outcome measures and patient-reported experience measures as well as health outcome metrics for assessing quality whenever possible. • Governments and organizations should track metrics frequently to assess performance and improvement over time.
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2015. Cervical cancer screening in developing countries at a crossroad: Emerging technologies and policy choices.
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2018. Health care quality indicators -- responsiveness and patient experiences.
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(14,680–25,767) NOTE: Variance, or high and low estimates, is informed by variation in estimated incidence, mortality, and age for the underlying indicators (which are presented throughout this chapter)
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Communicable (low and high range (low and high range Years of Life Lived Disease estimates) estimates)
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(473,307–612,030) NOTE: As in Annex Tables 4-1 and 4-2, variance, or high and low estimates, is informed by variation in the underlying indicators presented throughout this chapter.
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