gms | German Medical Science

Background: As quality in healthcare is not directly measurable, quality indicators serve as a tool for operationalizing quality of care [1]. They are used as quantitative measures of the complex process of health care, mainly to measure the process and outcome quality of patient treatment for important events like stroke or myocardial infarction [2].

In Austria as in many other countries quality management based on routinely collected data is well established for the hospital sector [3]. However, guideline-conformant continuity of care after hospital discharge is equally important for patient safety. Unfortunately, cross-sector indicators that also consider outpatient treatments are rare [4].

The aim of the presented project was to develop and evaluate methods for implementing cross-sector quality indicators by means of Austrian claims data. Acute coronary syndrome (ACS) was used as tracer.

Methods: Population-based data was provided by the Main Association of Austrian Social Security Institutions. The anonymised data mainly included hospital discharge diagnoses (ICD-10 codes) and dispensed drugs of patients with ACS between 2011 and 2015.

Indicators measuring process and outcome quality on patient level were determined by cardiologists in collaboration with computer experts and statisticians regarding subject-specific guidelines and feasibility.

Indicators were defined as adherence to specific recommendations contained in guidelines typically over a 12-months observation period, and were evaluated by describing average adherence. Patient-level risk factors for non-adherence were determined by logistic and Poisson regression, which were also used to evaluate gender-and-age-adjusted geospatial differences. Impact of adherence on mortality, readmission and hospital days was evaluated by means of landmarked Cox and Poisson regression.

Results: Six indicators were specified by the cardiologists: Anti-platelet therapy, statin therapy, beta blocker therapy, ACE inhibitors therapy, cardiac rehabilitation, and echocardiography and cardioverter-defibrillator implant.

The cohort comprised 45.148 patients with a median age of 69. For all indicators, except statin therapy, our study indicated low adherence (10-35%) to the guidelines after ACS. The highest deviations were found within the first month after the ACS event. Throughout all indicators adherence is associated with a risk reduction for fatal events and hospital stays.

Conclusion: The use of claims data has well known limitations. In our study especially missing clinical data (e.g. weight) and over-the-counter drugs (e.g. ASS) not only weakened the evaluation (e.g. underestimation of adherence) results but also hindered the precise specification of indicators.

Nevertheless, results of outcomes analyses are promising. Awareness in terms of adherence to the guidelines should be promoted. Our evaluations may serve as basis for discussions in regional quality circles. The methods developed can be used as template for other medical areas.

Further development will also focus on standardisation of the process of indicator specification, the enhancement of the statistical risk adjustment and the use of a standardised data model like OMOP.

We thank G. Endel from the Main Association of Austrian Social Security Institutions for financial support, F. Fuchs for medical input, M. Robausch for providing data and F. Katsch and M. Todorovic for data preparation.

The authors declare that they have no competing interests.

The authors declare that a positive ethics committee vote has been obtained.