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Study of Quality of Care in Public and Private Sectors

Research Symposium Quality of Healthcare in Sri Lanka

Hosted by SLMA, CMASL and IHP

30 August 2013

Study Organization

*Study Team –  Isurujith K Liyanage, Janaki Jayanthan, Nilmini Wijemanne, Sanil

de Alwis, Sarasi Amarasinghe, Indika Siriwardana, Shanti Dalpatadu, Prasanna Cooray, R P Rannan-Eliya

Study Objective –  To assess levels and differences in quality of care in public and

private medical sectors in Sri Lanka

Funding –  World Bank contract to IHP, IHP Public Interest Research Fund

Grant PIRF-2012-03, IDRC Grant 106439-003

Ethical Review –  Ethical review and clearance of study design and survey

instruments by IHP Ethical Review Committee (IHP ERC Approval Nos. 2012/006A, 2012/006B)

2

Outline

•  Study Organization •  Background •  Methodology •  Findings •  Conclusions

3

Background - Importance of measuring quality - Background on Sri Lanka

4

Why did we measure quality?

•  How to optimise the contribution of the private sector within Sri

Lanka’s mixed health system? –  Who they treat –  Relative costs –  Quality of care provided

•  Research questions –  Does clinical quality differ between the public and private sectors in

Sri Lanka –  Does interpersonal quality differ between the public and private

sectors in Sri Lanka

5

Concepts

What is quality? •  “The degree to which health services for individuals and

populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge.” –  Institute of Medicine 1991

Dimensions of quality (Donabedian 1980) •  Structure

–  Whether providers have correct inputs, equipment, training, etc. •  Process

–  Whether good practices are followed •  Outcomes

–  Impact of medical services on patients, including health outcomes and patient satisfaction

6

Measuring process quality

•  No widely accepted approach •  Methods differ

–  Developing countries: •  Single conditions •  Little relevance to Sri Lanka (tuberculosis, HIV, malaria)

–  Developed countries •  Broader methods (range of conditions)

7

Utilization of healthcare services CBSL CFS 2003/04

45%

55%

Outpatient

8

96%

4%

Inpatient

Key indicators of hospitals in Colombo, Gampaha, Galle (2011)

9

Sources: Management Development and Planning Unit (2011) and Institute for Health Policy (2013)

Category Hospitals Beds Admissions Inpatient spending per admission

n n n rupees

!"#$%&'()*+%,-$* ./ /01232 456'7%$$%)8 401/2.

!9%:-,;'()*+%,-$* 63 /1<2= 05/'7%$$%)8 231643

Inpatient quality of care

Comparison between public and private sectors

Methodology - Study design - Tracer indicators & inclusion criteria - Sampling

11

Study design – inpatient care Overview

•  Study object –  Process quality, i.e., what providers actually do

•  Approach –  Retrospective review of inpatient medical records –  Analysis of care using tracer conditions

12

Inpatient tracer conditions

Criteria for selection •  Conditions should be relatively frequent •  Feasible quality indicators should exist with support in literature

•  Should be representative of a range of conditions and patient populations

Tracer conditions (initial) 1.  Acute Myocardial Infarction (AMI) (1% of discharges) 2.  Acute Asthma (4% of discharges)

3.  Childbirth (6% of discharges)

13

Selecting quality indicators

•  Identified possible quality indicators –  Quality clearing houses –  Quality assessment agencies –  Studies: developed and developing countries –  Clinical guidelines

•  Review by panel of doctors

•  Subsequent review of RAND quality assessment tool –  Identification of additional tracer conditions and quality indicators –  Choice of method to aggregate quality indicators

14

Inpatient Quality Indicators 55 Quality Indicators

15

Condition

Asthma (7)

AMI (15)

Childbirth (10)

Other (TIA, Dengue, COPD,

Heart Failure, Pneumonia)

Resource Intensity

Low (12)

Medium (33)

High (4)

Drug prescribing

All drug prescribing

(36)

DVT prophylaxis

(9)

Surgical antibiotics

(4)

Clinical area

Assessment and investigations (10)

Management (39)

Outcome (6)

Inpatient quality indicators – examples

16

Indicator Condition Clinical area Resource intensity

Drug prescribing

Neonatal APGAR score recorded

Childbirth Assessment / Investigations

Low -

Prophylactic antibiotics given during LSCS

Childbirth Management Medium All drug prescribing, surgical antibioitics

Live discharge, AMI AMI Outcome - -

AMI patient underwent PCI / stenting

AMI Management High -

Oxygen saturation measured in acute asthma

Acute asthma Assessment / Investigations

High -

Sampling Distribution of sampled facilities

17

Colombo Gampaha Galle Total

Large 2 1 1 4Intermediate 2 1 1 4Obstetric 1 0 1 2Paediatric 1 0 0 1Other specialist 0 0 0 0

Total 6 2 3 11

Large 3 1 0 4Intermediate / small 1 2 2 5Obstetric 1 0 0 1Paediatric 0 0 0 0Other specialist 0 0 0 0

Total 5 3 2 10

Sampled facilities

Public

Private

Hospital type

18

Geographic distribution of sampled providers

Gampaha

Colombo

Galle

19

Distribution of private hospitals, Sri Lanka 2012

Data collection and processing

Patient sampling •  Systematic sample of patient records from 2011 discharges •  Supplementary samples of tracer conditions

Data collection •  Data extraction and entry by pre-intern medical graduates using Apple

iPads. Drug name entry using pre-coded listing of brand and generic names.

Data analysis •  Diagnoses coded to ICD-10 by physician. •  All analysis using Stata 12.0.

20

Data collection and processing Quality and satisfaction scores

Adapted method used by RAND quality study (McGlynn et al)

•  Quality instance = each opportunity a patient could potentially receive recommended care

21

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Data collection and processing Quality scores

22

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FEN FIN

Findings - Inpatient quality of care

23

Characteristics of patient sample

24

Average age, yearsMale sex, %

Discharge diagnosesAsthma, %AMI, %Childbirth, %

Characteristic Public Sector (n = 2,523)

Private Sector (n = 1,815)

36.8 37.0 1.047.9 47.8 1.0

1.0 1.2 0.70.6 0.7 0.86.9 6.2 0.9

Weighted, standardizedStandardized p value

Average length of stay, days 3.6 3.0 0.1

63 68

89

69† 68

89

0

10

20

30

40

50

60

70

80

90

100

Asthma AMI Childbirth

Per

cent

age

of p

atie

nts

(%)

Quality by condition

Public Private

25 Condition Resource limitation Drug prescribing Clinical area

26

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@2-8+//

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!"# $%&'($ )'*)

!"#$%&'"()*+*,-,*$.

Condition Resource limitation Drug prescribing Clinical area

94**

58*

10

81

48

31**

0

10

20

30

40

50

60

70

80

90

100

Low Medium High

Per

cent

age

of p

atie

nts

(%)

Quality by resource limitation

Public Private


68*

0

68*

60

1

58

0

10

20

30

40

50

60

70

80

Drug indicators (all) DVT prophylaxis Perioperative antibiotics

Per

cent

age

of p

atie

nts

(%)

Drug prescribing

Public Private


Difference in scores by clinical area

29

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Condition Resource limitation Drug prescribing Clinical area

Quality scores by hospital size Is quality better in small/intermediate hospitals than large hospitals?

30

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Quality scores by hospital size and resource limitation

Difference in scores compared to large hospitals


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Conclusions

32

Key findings

Public vs. private •  Quality is fairly similar, although the public sector is slightly

better •  Private sector performs better in indicators that are resource

intensive

•  Smaller hospitals tend to do slightly better in both sectors in low resource intensity indicators

33

Outpatient quality of care and patient satisfaction

Comparison between public and private sectors

Study design - outpatient Overview

•  Study objects: Process quality and Patient Perceptions

•  Approach –  Observation of patient consultations

•  Analysis of care using tracer conditions

–  Exit interview of patient •  Patient satisfaction •  Socioeconomic background and ethnicity

35

Final conditions

•  Common conditions from Sri Lanka Primary Care Survey, 2000 •  Conditions with quality indicators used in other settings – India

study, RAND –  Cough

–  Diarrhoea

–  URTI & tonsillitis

–  Asthma

–  Hypertension

–  Diabetes

–  Pregnancy

36

Quality indicators 39 quality indicators

37

Condition Diarrhoea (7)

Cough (4)

Hypertension (7)

Diabetes (6)

Asthma (3)

Pregnancy (2)

Clinical Area

History (6)

Examination (7)

Investigations and Management (20)

Patient education (6)

Outpatient quality indicators – examples

38

Condition Indicator Type

Diarrhoea Patient asked about fever HistoryCough Physician performed a physical examination ExaminationDiabetes Physician gave dietary advice EducationOther Patients 65 years or older given < 5 drugs Assessment and management

Patient satisfaction

39


Technical (2)

Interpersonal (6)

System (2)

Overall (1)

Sampling Distribution of sampled facilities

40

Colombo Gampaha Galle Total

Large 1 1 1 3Intermediate 2 1 1 4Obstetric 1 0 1 2Paediatric 1 0 0 1Other specialist 0 0 0 0

Total 5 2 3 10

General practitioners 27 25 14 66

Public

Private

Hospital typeSampled facilities

41

Geographic distribution of sampled providers

Gampaha

Colombo

Galle

Data collection and processing

Patient sampling •  Systematic sampling of patients waiting for consultation •  All patients asked to give consent

Data collection and analysis •  Patient symptoms and doctor diagnosis coded using ICPC

–  In field where possible –  Coding by physicians

42

Findings - Outpatient quality of care

43

Final sample

•  Small number of refusals •  No significant differences in age and sex in participants vs.

refusals

44

n % n %

Total number of patients approached 1,971 100.0 1,948 100.0

PartipicationParticipated 1,948 98.8 1,906 97.8 Refused 23 1.2 42 2.2

Patients approached for observation of consultation

(for PER)

Patients approached for exit survey of patient

satisifcation

Patient characteristics after standardization

45

Average age, yearsMale sex, %

Socioeconomic statusLower third, %Middle third, %Upper third, %

Characteristic Public Sector (n = 1,027)

Private Sector (n = 944)

32.2 32.1 1.035.2 35.3 1.0

29.1 14.1 0.042.2 38.8 0.428.6 47.1 0.0

Weighted, standardizedStandardized p value

Conditions of interestDiarrhoea, %Cough, %Hypertension, %Diabetes, %Asthma, %Pregnancy, %URTI and Tonsilitis, %Other, %

Length of consultation, min

1.9 2.5 0.720.8 23.8 0.56.8 6.4 0.95.3 3.0 0.32.9 5.1 0.25.9 0.7 0.316.5 26.4 0.060.3 58.5 0.8

3.1 7.8 0.0

78† 76†

68

34

59

49

31

59 66

72

55* 54 48

40

0

20

40

60

80

100

Diarrhoea Cough Hypertension Diabetes Asthma Pregnancy URTI and tonsilitis

Per

cent

age

of p

atie

nts

(%)

Quality by condition

Public Private

46 Condition Clinical Area Patient satisfaction

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Condition Clinical Area Patient satisfaction

Quality by clinical area

47

48

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Antidiarrhoeals - adsorbents, bulk forming medicine, anti-motility, antispasmodics

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49

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72

86**

72*

12

65 65 69

63 57**

65

0

20

40

60

80

100

History Examination Investigations and management

Education Overall

Per

cent

age

of p

atie

nts

(%)


Public Private


51

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0

20

40

60

80

100

120

Technical Interpersonal System Overall satisfaction

Per

cent

age

of p

atie

nts

(%)


Public Private


53

•  Comparison of public and private sectors –  Socioeconomic status –  Ethnicity

Process quality by socioeconomic status Difference in scores compared to the poorest tertile

54

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Patient satisfaction by socioeconomic status Difference in scores compared to the poorest tertile

55

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Process quality by ethnicity Difference in scores compared to Sinhala patients


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Patient satisfaction by ethnicity Difference in scores compared to Sinhala patients


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Conclusions

58

Key findings Outpatient

Public vs. private •  Overall quality, diagnosis and treatment is similar between the

two sectors

•  Patients in the private sector receive more –  Time from the physician –  Education and advice (independent of time from physician)

•  Patient satisfaction reflects this –  Overall satisfaction & satisfaction with technical aspects similar –  Satisfaction with interpersonal quality & systems quality better in

private sector

59

Key findings

•  Seems to be no large systematic differences between socioeconomic and ethnic groups

•  Socioeconomic groups –  Richer patients scoring less in examination, investigations and

management in public sector

•  Ethnic groups –  Tamil patients more satisfied with the public sector –  Moor patients more satisfied with the private sector

60

International comparisons

International comparisons

•  Limited •  Sources of comparison

–  Indian study (Das & Hammer, 2004) –  US study – RAND Quality Assessment Tool –  Australian study – RAND + others

62

100 100 100

16

84

70

97

37 28

33

18 9

0

20

40

60

80

100

120

Asked about fever Asked about vomiting Asked about stool Given oral rehydration solution

Per

cent

age

of p

atie

nts

(%)

Outpatient process quality – diarrhoea Comparison with India

Public Private India (Das & Hammer, 2004)

63

89

27

82 80

24

74

17

7

20

0

20

40

60

80

100

Asked about fever Asked about chest pain Asked about expectoration

Per

cent

age

of p

atie

nts

(%)

Outpatient process quality – cough Comparison with India

Public Private India (Das & Hammer, 2004)

64

International comparisons Conclusions

Sri Lanka’s performance compared to: •  India

–  Sri Lanka performs better

•  US –  Sri Lanka performs similarly in inpatient and outpatient –  caveat – we are mainly looking at indicators with low resource

intensity

•  Australia – awaiting –  Australia’s quality study results were similar to the US

65

Concluding Thoughts

Research Symposium Quality of Healthcare in Sri Lanka

Hosted by SLMA, CMASL and IHP

30 July 2013

Health outcomes – Sri Lanka comparative performance

20

Source: Unpublished analysis by Institute for Health Policy commissioned by the Rockefeller Foundation as input for the Foundation’s ongoing “Good Health at Low Cost 2010” study.

Figure 4: Health outcomes against income, relative country performance, Sri Lanka and other Asia-Pacific nations

Explanations

65. Evidently, controlling for its levels of income, education, nutrition and sanitation, Sri Lanka continues to perform far better than average in terms of health outcomes. An increasing body of evidence indicates that this exceptional performance is directly linked to the superior performance of both curative and preventive health services delivery in the island and the extensive provision of health services (Caldwell et al. 1989; De Silva et al. 2001; Rannan-Eliya and Sikurajapathy 2009). So this achievement must be largely credited to the government’s healthcare policies, which have fostered universal access to basic healthcare services since the 1930s.

66. These low mortality outcomes are the result of rapid and continuous improvements over half a century (Meegama 1986). In the past, there has been academic debate about whether Sri Lanka’s achievements were merely the consequence of a very rapid initial decline, and how good its subsequent performance was (Aturupane, Glewwe, and Isenman 1994). However, from the late 1970s onwards, and again in the 1990s, the rate of decline in IMR has accelerated. This is exceptional, since during most of this latter period Sri Lanka experienced almost continual internal conflict and declining numbers of physicians. The acceleration in the reduction of the IMR can also be contrasted with the experience with the other developing country that liberalized its economy in the late 1970s – China, which has seen stagnating health indicators, despite much faster growth in incomes. The distinct divergence in performance of Sri Lanka from that of China can largely be explained by the

China

China

ChinaIndia India

India

Indonesia

Indonesia

Indonesia

Japan

Japan

Japan

Korea

Korea

KoreaMalaysia

Malaysia

Malaysia

PhilippinesPhilippines

Philippines

Singapore

Singapore

Singapore

Thailand

Thailand

Thailand

Vietnam Vietnam

Sri Lanka

Sri Lanka Sri Lanka

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1960 1990 2006

GH

ALI

Inde

x

67

0.9

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1.8

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4.3

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10.5

13.0

13.4

0 2 4 6 8 10 12 14 16

Papua New Guinea

Solomon Islands

China

Viet Nam

Thailand

Fiji

Brunei Darussalam

Malaysia

New Zealand

Sri Lanka

Asia-17

Mongolia

Macao

Australia

OECD

Singapore

Hong Kong

Korea

Japan

Consultations with physicians per capita

36

38

60

75

79

89

102

107

109

113

120

125

137

140

145

162

163

228

234

254

0 50 100 150 200 250 300

Papua New Guinea

Bangladesh

China

Solomon Islands

Macao

Fiji

Singapore

Japan

Malaysia

Brunei Darussalam

Viet Nam

Asia-18

Thailand

New Zealand

OECD

Korea

Australia

Mongolia

Hong Kong

Sri Lanka

Hospital discharges per 1000 capita

Health services utilization, Sri Lanka and regional countries

68

Source: IHP-OECD AP HaG 2010 Database

Utilization of healthcare services, 2003

45%

55%

Outpatient

69

96%

4%

Inpatient

Concluding Thoughts on Sri Lanka’s Mix •  To a large extent achieves comparable clinical quality across

income levels –  Except expensive services for the better off –  Segregation is largely achieved through differences in interpersonal

quality •  But

–  Improving quality overall probably does need to address interpersonal quality

•  Important for patient perception •  Related to better management of NCDs

•  Quality in public sector –  Largely constrained by resource/funding levels –  Private sector cannot provide that better quality at comparable cost

levels, so improvements in system quality will depend on increased public financing

70

study of quality of care in public and private sectors - ihp · study of quality of care in public...

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