Quality indicators for health care providers in Hungary

Éva Belicza, Semmelweiss University ( Budapest )

Miklós Fehér, Hungarian Medical Chamber (Budapest )

121.chapter of the health care act deals with quality system of health care providers, it differentiates two quality systems, such as internal and external ones. It also says the introduction of internal quality system is mandatory for every health care institution.

Act on health careAct on health care

The tools and methods of internal quality system are set by

a guideline of the Ministry of Health. In this guideline the

quality indicators are defined as follows: a quantitative

index of events occurring in the course of health provision,

which can be used for measuring and evaluating the quality

of health provision, the health status of the population and

the system of providing health care.

In Hungary two working group were established for designing quality indicators, one in the National Health Insurance Fond another one in the Ministry of Health.

There are two main differences between this two working

groups. The number of indicators and the sources of data.

The ministry group set up more indicators and collected the

data from more sources, while the insurance group

collected the data from database required by reimbursement

system (DRG) only

The indicator groups of ministry:The indicator groups of ministry:

- general

- surgery

- nosocomic infections and antibiotic treatment

- paediatry

- oncology

- intensive treatment

- cardiology

- geriatry

- human policy

The general indicators:The general indicators:

- turn-over of patients per bed

- rate of changing admission diagnosis

- mortality rate

- rate of re-admissions

- average length of stay

- rate of discrepancy between the clinical and pathological diagnosis

- rate of autopsy

Surgical indicators:Surgical indicators:

- rate of surgical interventions

- rate of reoperations

- rate of endoscopic operations

- rate of very specific ( index ) operations

- mortality rate in the first 24 hours

- rate of non operated patient in the surgical

wards

Nosocomic infections and antibiotic treatment:Nosocomic infections and antibiotic treatment:

- rate of relevant antibiotic treatments

- rate of haemo-culture examinations

- rate of nosocomial infections

- rate of nosocomic pneumonias in connection with artificial respiration

- rate of sepsis in connection with intravascular catheterisation

- rate of hospital wound infections

- rate of antibiotic prophylaxis

- rate of intravenous catheterisations

- rate of antibiotic prophylaxis 30-120 minutes prior operation

- rate of antiseptic shavings

Pediatrics::

- frequency of Caesarean section

- infant mortality rate

- new-born mortality rate

- premature birth rate

- perinatal death rate

- rate of developmental anomalies

Oncology:

- rate of histological examinations of given type of tumours

- rate of tumours detected by screening

- death rate of patients with given type of tumours

- five years survival rate of patients with given type of tumour

Intensive therapy:Intensive therapy:

- rate of artificial breathing

- rate of primarily successful reanimations

- rate of artificial feedings

- rate of operated patients needed treatment in ICU

Cardiology:Cardiology:

- rate of AMI patients with thrombolytic treatment

- death rate of AMI patients in the first 24 hours

- overall death rate of AMI patients

- rate of AMI patients with PTCA

GeriatrGeriatricsics::

- death rate of admitted geriatric patients within one month

- emergence rate of bed shores for bedridden patients

- emergence rate of incontinence for geriatric patient in different

age groups

Human policy:Human policy:

- rate of licensed health

workers

- turn-over of personnel

Those are quite numerous indicators, measuring the quality on

different levels, such as level of ward, level of individual

institutions, and level of group of institutions, on national level

and on international level as well. The institutions were grouped

according their owner (universities, state, capital, county and

town self-governments) and according their geographical

localisation.

The NHIF working group has elaborated far less quality indicator yet, in four groups:

- AMI,

- rehabilitation wards,

- Caesarean section rate

- autopsy rate.

- death rate in different time-intervals,

- rate of different interventions (thrombolysis, PTCA, stent,

by-pass)

As far as possible risk adjustment was performed.

AMI indicators

16

30-day mortality rate of AMI cases 2000-2004, Hungary

20.96% 20.79% 20.23% 21.01%19.20%

0%

5%

10%

15%

20%

25%

2000 2001 2002 2003 2004

years

30

-da

y m

ort

alit

y r

ate

17

30-day mortality rate of AMI cases aggregated according to the number (more or less than 50) of cases cared in a hospital

(first provider) in a given year 2000-2004

23.97%

20.75% 20.68%18.76%

20.81%20.06%

25.34%26.02%

23.31%

28.23%

0%

5%

10%

15%

20%

25%

30%

2000 2001 2002 2003 2004

years

30-d

ay m

ort

alit

y ra

te

at least 50 cases per hospital in a year less than 50 cases per hospital in a year

18

30-day mortality rate of AMI cases according to the types of hospitals (first provider), 2000-2004

0%

5%

10%

15%

20%

25%

universities special institutes Budapest hospitals county hospitals municipal hospitals

types of hospitals

30-d

ay m

ort

alit

y ra

te

2000 2001 2002 2003 2004

- death rates in the ward and in the hospital

- transmission rate of patients

- rehabilitation personell rate

Rehabilitation wards indicators

- great debate on question of publicity, how to publish and whether to publish at all

- it came to an end by a compromise; the indicators were

published on the web unanimously using code-numbers

established for this single purpose only.

Publication

(publish or not to publish?)

Main statements on applying and publishing indicators*

● Indicators itself are not suitable for qualifying purposes

● Application of standards are not avoidable● Methodology of risk adjustment is not

unambiguous● Outcome results after discharge are not known● Indicators have to be given over for providers

instead of publish it openly

*Objective judgement of hospital care;dream or reality. É.Belicza, E.Takács

●Thank you for your attention!