Methodological and statistical Methodological and statistical consulting to policy makers in consulting to policy makers in

health care financehealth care finance

Jules EllisJules Ellis

Radboud University NijmegenRadboud University Nijmegen

My styleMy style ListenListen

E.g. Stork managerE.g. Stork manager Determine who advise and who decidesDetermine who advise and who decides

Compare advice to studentsCompare advice to students Ask the substantive contextAsk the substantive context

People often start in abstract statistical termsPeople often start in abstract statistical terms (E.g. is X correlated to Y -> gender is related to aggression)(E.g. is X correlated to Y -> gender is related to aggression)

Change the questionChange the question To something that can be done (toolbox)To something that can be done (toolbox) To something that you think will be interesting for the client (E.g. To something that you think will be interesting for the client (E.g.

is group program correlated with well-being -> does a group is group program correlated with well-being -> does a group program influence well-being)program influence well-being)

Offer alternativesOffer alternatives E.g. PCA versus ADFE.g. PCA versus ADF

Be pragmaticBe pragmatic Time, moneyTime, money Prior concepts Prior concepts (e.g. clusters vs. factors groups vs scores)(e.g. clusters vs. factors groups vs scores) PrejudicePrejudice

There must be 7 clustersThere must be 7 clusters Dichotomization is good / badDichotomization is good / bad Nobody/ everybody is doing thisNobody/ everybody is doing this

Client Client mustmust understand it within available time understand it within available time Explain at right level (common sense)Explain at right level (common sense) WriteWrite

After consult (compare physician)After consult (compare physician) After analysisAfter analysis

EducateEducate

Organizational hierarchyOrganizational hierarchyDepartment

(VWS)

Accountancy (PWC)

Ass. Nursing Homes(Arcares)

Ass. Health Insurance Companies(ZN)

VLP CCC Prismant

I I

Tasks in the hierarchyTasks in the hierarchy

Cost Model

Costs; Efficiency; Best Practice Organizations

Care for clients Pay for care

Client Need Caring Time Quality of Care

Old cost modelOld cost model

Depends on Depends on locationlocation of client of clientNursing homes: € Nursing homes: € xx per client / day per client / dayAssisted Living Facilities (Caring homes): € Assisted Living Facilities (Caring homes): € yy

per client / dayper client / dayHome Health Care (Extramural care) € Home Health Care (Extramural care) € zz per per

client / dayclient / dayAdult Day Care ServicesAdult Day Care Services

Limitations of old cost modelLimitations of old cost model

Ignores client differences in needIgnores client differences in need Ignores overlap in client populationsIgnores overlap in client populationsEmphasis on somatic careEmphasis on somatic careSupply driven, not demand drivenSupply driven, not demand driven

Time lineTime line

Pilot: 10 homes (2000 clients)Pilot: 10 homes (2000 clients)Test: 100 homes, automatingTest: 100 homes, automatingBenchmark 1: 1000 homesBenchmark 1: 1000 homesBenchmark 2: 1000 homesBenchmark 2: 1000 homes

Assessment of client needsAssessment of client needs

Two central caring employees observe Two central caring employees observe client during two weeksclient during two weeks

Both fill in one questionnaire of 24 items Both fill in one questionnaire of 24 items about clientabout client

Two sum scores are computed:Two sum scores are computed:Sumlic: Somatic need for careSumlic: Somatic need for careSumpsy: Psycho-social problemsSumpsy: Psycho-social problems

Items for client needsItems for client needs1 Is in dressing / undressing 1 Is in dressing / undressing Not / A little / Not / A little /

Partially / Very Partially / Very much / Totally much / Totally dependentdependent

2 Is in movements2 Is in movements3 Is in eating or drinking3 Is in eating or drinking4 Is in the bathroom4 Is in the bathroom……

10 Is incontinent in urine or faeces10 Is incontinent in urine or faeces Never / Rarely / Never / Rarely / Sometimes / Often Sometimes / Often / Always/ Always

11 Is irritated 11 Is irritated 12 Has difficulties to remember12 Has difficulties to remember13 Shows restless behavior13 Shows restless behavior14 Is lonely14 Is lonely……24 Is aware about what happens around him/ 24 Is aware about what happens around him/ herher

Assessment of caring timeAssessment of caring time

Pilot: Observers make one round every 20 Pilot: Observers make one round every 20 minutes (-> chaos)minutes (-> chaos)

Later: Employees receive a handheld computerLater: Employees receive a handheld computer Beeps every 20 minutes, at random moment, Beeps every 20 minutes, at random moment,

whole week 16 hour / daywhole week 16 hour / day Employee records own behavior in one of 32 Employee records own behavior in one of 32

actions, + clientactions, + client Total caring time in various categories per client Total caring time in various categories per client

per day is estimated from thisper day is estimated from this

Items for caring timeItems for caring time Direct Client RelatedDirect Client Related

Individual Individual Client RelatedClient Related General daily life support (eat, General daily life support (eat,

wash, …)wash, …) Assistence in preparing food Assistence in preparing food

and/ or drinkand/ or drink Individual treatmentIndividual treatment Communication with familyCommunication with family Housekeeping for individualHousekeeping for individual Preserved actionsPreserved actions

CollectiveCollective Client Related Client Related Collective medicationCollective medication Collective treatmentCollective treatment House keeping for groupHouse keeping for group

Indirect Client RelatedIndirect Client Related Individual Client RelatedIndividual Client Related

Coordination for individualCoordination for individual

Collective Client RelatedCollective Client Related Coordination for individualCoordination for individual

Organization RelatedOrganization Related WaitingWaiting BreakBreak EducationEducation TravellingTravelling

Employee relatedEmployee related MissingMissing Personal timePersonal time

Time categoriesTime categories

Categories:Categories: Client relatedClient related

DirectDirect IndividualIndividual CollectiveCollective

IndirectIndirect IndividualIndividual CollectiveCollective

Organization relatedOrganization related Employee relatedEmployee related

Functions:Functions: Housekeeping Housekeeping

servicesservices Personal carePersonal care NursingNursing Supportive assistanceSupportive assistance Activating assistanceActivating assistance TreatmentTreatment

Other dataOther data

ClientsClients24 services24 servicesOn which days presentOn which days presentMembership of collective time groupsMembership of collective time groups

EmployeesEmployees35 35 professionsprofessionscontractscontractsOn which days presentOn which days present

Analysis schemeAnalysis scheme

Best Practice

Efficiency Quality

Output Costs

Client needs Caring time

Question 1:Question 1:Cluster the clients on basis of Cluster the clients on basis of

needsneeds7 or 87 or 8 clusters clustersHomogenous in Homogenous in timetime and and costcost Include psychological needsInclude psychological needsApplicable in Applicable in Nursing HomesNursing Homes and Assisted and Assisted

Living Facilities. Living Facilities. ““Recognizable”Recognizable”

Answer to question 1Answer to question 1

Select items on inter observer agreement, and Select items on inter observer agreement, and variance > 1variance > 1

Factor analysis on the items -> 2 factorsFactor analysis on the items -> 2 factors Define 2 subscales: somatic and psycho-social.Define 2 subscales: somatic and psycho-social. Reliability analysis (internal consistency)Reliability analysis (internal consistency) Divide the scores of each subscale in 4 quartiles Divide the scores of each subscale in 4 quartiles

(Light, Medium, Serious, Very serious)(Light, Medium, Serious, Very serious) Result: 4 x 4 = 16 groupsResult: 4 x 4 = 16 groups

Psychosocial problemsPsychosocial problems

LightLight(0-6)(0-6)

MediumMedium(7-18)(7-18)

SeriousSerious(19-31)(19-31)

Very Very seriousserious(32-56)(32-56)

Somatic Somatic care care needneed

Light (0-3)Light (0-3) II IIII IIIIII IVIV

Medium (4-13)Medium (4-13) VV VIVI VIIVII VIIIVIII

Serious (14-Serious (14-31)31) IXIX XX XIXI XIIXII

Very serious Very serious (32-40)(32-40) XIIIXIII XIVXIV XVXV XVIXVI

ReasonsReasons Cluster Cluster analysis -> only somatic factoranalysis -> only somatic factor We have already 7 groups for nursing homes alone, We have already 7 groups for nursing homes alone,

which were formed as 3 x 3 groups and combining some which were formed as 3 x 3 groups and combining some of these.of these.

The partition on the somatic axis should contain at least The partition on the somatic axis should contain at least these 3 groups (these 3 groups (to satisfy the nursing homesto satisfy the nursing homes) + another ) + another one to accomodate the Assisted Living Facilities. one to accomodate the Assisted Living Facilities.

Similarly for the psychosocial axis.Similarly for the psychosocial axis. So we need 4 x 4 groups to begin with -> 16 So we need 4 x 4 groups to begin with -> 16 typestypes Without time & cost data we cannot know how to Without time & cost data we cannot know how to

combine these groups and respect homogeity.combine these groups and respect homogeity. But perhaps we can combine some groups later.But perhaps we can combine some groups later.

First evaluationFirst evaluation

Initially accepted with reluctanceInitially accepted with reluctanceAs of 2006: There are still 16 client typesAs of 2006: There are still 16 client types It took years to accept thatIt took years to accept that

Question 2: Compute reference Question 2: Compute reference timestimes

Compute mean individual client time (ICT) Compute mean individual client time (ICT) for each client typefor each client type

The mean can be used in the cost model, The mean can be used in the cost model, e.g. to compute the total ICT that the e.g. to compute the total ICT that the home should deliver.home should deliver.

How reliable is this?How reliable is this?

First answer to Question 2First answer to Question 2

Using client types is an unnecessary loss of Using client types is an unnecessary loss of informationinformation

Conduct a multiple regression analysis, with Conduct a multiple regression analysis, with dependent variable = ICT, independent variables dependent variable = ICT, independent variables = somatic need, psychosocial need= somatic need, psychosocial need

Compute the predicted ICT score for each clientCompute the predicted ICT score for each client Take the mean of the predicted scores for each Take the mean of the predicted scores for each

home.home. This was not accepted: This was not accepted: Too difficult (3 Too difficult (3

parameters?!)parameters?!); there had to be groups.; there had to be groups.

Second answer to Question 2Second answer to Question 2

Use answer 1 but change the Use answer 1 but change the presentationpresentation a littlea little

Compute the predicted ICT score for each Compute the predicted ICT score for each clientclient

Compute the mean of the predicted scores Compute the mean of the predicted scores for each client type in each homefor each client type in each home

Compute the mean in each homeCompute the mean in each home

exampleexample

All homesAll homes

(y’ = 2x)(y’ = 2x)

This homeThis home

TypeType SomaticSomatic ICTICT ICT’ICT’ SomaticSomatic ICTICT ICT’ICT’

II 55 88 1010 66 88 1212

IIII 1010 2222 2020 99 2222 1818

IIIIII 1515 3030 3030 1616 3030 3232

IVIV 2020 4242 4040 2222 4242 4444

VV 2525 4848 5050 2727 4848 5454

MeanMean 1515 3030 3030 1616 3030 3232

First evaluationFirst evaluation Sceptical first, embraced the idea laterSceptical first, embraced the idea later Reliability of estimatesReliability of estimates More consistent outputMore consistent output

Employees in nursing homes typically argue that their Employees in nursing homes typically argue that their client type X is a little more serious than in other client type X is a little more serious than in other homeshomes

Reply: Indeed, and therefore we didn’t use the mean Reply: Indeed, and therefore we didn’t use the mean time of other homes but corrected it.time of other homes but corrected it.

Negative beta-weightNegative beta-weight of psychosocial problems of psychosocial problems Assistance needed in further researchAssistance needed in further research Assistance needed automationAssistance needed automation

Question 3: How reliable are the Question 3: How reliable are the time measurements?time measurements?

TIME

AC

TIO

N

11 00 00 11 11 00 00 11 11 11

= 153 min

t = 6 * 20 min

x = 6, n = 10, p = 0.6

Existing answerExisting answer

Why this formula? (the method was Why this formula? (the method was bought)bought)

Sometimes extreme large n needed. Sometimes extreme large n needed. Why?Why?

How many weeks observation are How many weeks observation are needed?needed?

p

nppityunreliabil

/)1(96.1

Answer to question 3Answer to question 3

Make a distinction between absolute unreliability Make a distinction between absolute unreliability (AU) and relative unreliablity (RU)(AU) and relative unreliablity (RU)

Require only that AU is small.Require only that AU is small. For example, if t = 1 For example, if t = 1 0.5 minute, then RU = 0.5 minute, then RU =

50% but AU = 30 sec (who cares)?50% but AU = 30 sec (who cares)? The average time can be reliable even though The average time can be reliable even though

the composing times are unreliable.the composing times are unreliable. Distinguish also other forms of unreliability Distinguish also other forms of unreliability

(sampling of clients, homes, weeks)(sampling of clients, homes, weeks)

(Details)(Details)

Note that t = pT, where T is the total Note that t = pT, where T is the total observation period (fixed).observation period (fixed).

AU(p) = 0.5 length of confidence interval AU(p) = 0.5 length of confidence interval for pfor p

RU(p) = AU/pRU(p) = AU/pAU(t) = AU(p)*TAU(t) = AU(p)*TRU(t) = RU(t)RU(t) = RU(t)

First evaluationFirst evaluation

Relevant people understood and accepted Relevant people understood and accepted the idea immediately (the idea immediately (why?)why?)

One week of observation would be enough One week of observation would be enough if if every week is the sameevery week is the same

Helped to convince nursing homesHelped to convince nursing homes

The aftermathThe aftermath

ElectionsElectionsSector wide model (including Sector wide model (including

handicapped, psychatric patients, etc.)handicapped, psychatric patients, etc.)Association of nursing homes refused to Association of nursing homes refused to

make the data available to othersmake the data available to othersPWC -> KPMG, VLP -> ? , CCC -> PWC -> KPMG, VLP -> ? , CCC -> 16 Client types -> 9 Care Heaviness 16 Client types -> 9 Care Heaviness

ProfilesProfilesReference times -> Indication timesReference times -> Indication times

ConclusionsConclusions

Prior concepts and prejudices are Prior concepts and prejudices are persistentpersistent

Large deviations from this will be rejectedLarge deviations from this will be rejectedSmall deviations are accepted if they are Small deviations are accepted if they are

explained at explained at common sensecommon sense level levelWrite it down with relevant examplesWrite it down with relevant examples ““A good method is a method that makes A good method is a method that makes

my life easier”?my life easier”?

Methodological and statistical Methodological and statistical consulting to policy makers in health consulting to policy makers in health

care financecare finance

Comments byComments by Marieke Timmerman, Marieke Timmerman,

University of Groningen,University of Groningen,

The NetherlandsThe Netherlands