Sessio 3: Assessing and developing quality of care by utilizing electronic patient records and national register

Puheenjohtaja: Professori Tiina Laatikainen, Itä-Suomen yliopisto

12.30–12.35 Opening

3.1 Quality of care of type 2 diabetes patients with mental and memory disorders

12:35–12:50

Nazma Nazu, Katja Wikström, Marja-Leena Lamidi, Jaana Lindström, Hilkka Tirkkonen, Päivi Rautiainen, Tiina Laatikainen

Aims: The study assessed whether the treatment outcomes and process indicators differ among type 2 diabetes (T2D) patients with dementia, depression, and other mental disorders compared with those who have only T2D among the primary care patient cohort of T2D in North Karelia, Finland, from 2011-12 to 2015-16. 

Methods: Data from all diagnosed T2D patients living in North Karelia (n=10190) were collated retrospectively from regional electronic patient records. We assessed whether HbA1c and LDL were measured and managed according to the guidelines and if there were any difference in the long-term management of T2D among the patient with mental and memory disorders compared with patients having only T2D.

Results: In overall, the monitoring of HbA1c improved during the follow up among all disease groups (dementia 79% vs 83%, depression 78% vs 89%, other mental disorders 82% vs 89%, only T2D 78% vs 89%) and LDL monitoring also improved among all disease groups except dementia patients (dementia 53% vs 51%, depression 75% vs 83%, other mental disorders 74% vs 86%, only T2D 75% vs 86%). The HbA1c treatment targets were obtained by 75% of patients with only T2D and patients with mental disorders, dementia patients had the lowest control rates (64%) at baseline. During the follow-up the proportion of those achieving HbA1c target declined in all groups (dementia 64% vs 53%, depression 71% vs 60%, other mental disorders 75% vs 66%, only T2D 75% vs 66%), but most in those with dementia or depression. Differences between groups were also observed in achieving LDL targets. 

Conclusions: There is definite improvement observed in process indicators during the follow-up from 2012 to 2016, but ageing obviously influences the achievement of treatment targets. Changes differ among patients with mental and memory disorders and those having only T2D. Patients with depression need to be monitored and managed more effectively.


3.2 Impact of reduction in the reimbursement rate of antidiabetic medications on glycaemic control in Finnish patients with type 2 diabetes

12.50–13.05

Piia Lavikainen, Emma Aarnio, Kari Jalkanen, Hilkka Tirkkonen, Päivi Rautiainen, Tiina Laatikainen, Janne Martikainen

Aims: A new reimbursement scheme for non-insulin diabetes medications was implemented in Finland on January 1, 2017. The aim of the study was to evaluate the impact of this co-payment increase on glycaemic control among Finnish type 2 diabetes (T2D) patients. 

Materials and methods: Data on glycaemic control were collected with HbA1c measures from electronic patient records from primary health care in North-Karelia region, Finland, from patients with a diagnosed T2D in 2012. Average HbA1c levels were measured monthly 2 years before and after the policy change. Consumption of diabetes medications was measured with defined daily doses (DDDs) from the Prescription register. Interrupted time series design was applied to examine the effect of policy change on average HbA1c levels. 

Results: 10,204 participants had T2D diagnosis in 2012. Of them, 9294 patients were alive at January 1, 2015 and 8509 had at least one HbA1c measurement within 20152018. Mean age of the patients was 70.0 (SD 11.4) years and 53.0% were women. Average time since T2D diagnosis was 9.8 (SD 6.3) years. An estimated increase of 1.86 (95% confidence interval, CI, 0.333.39) mmol/mol in average HbA1c levels was detected at the time of the policy change. In subgroup analyses, strongest effects were detected among patients living in less highly educated areas (2.38 mmol/mol, 95% CI 0.754.02) and patients with T2D-coexisting diseases only in addition to T2D (2.35 mmol/mol, 95% CI 0.704.00). Meanwhile, consumption of diabetes medications decreased from 12,101 daily DDDs in 2016 to 11,485 in 2017. 

Conclusions: Increase of co-payment level increased the average HbA1c level among T2D patients from North-Karelia region, Finland. This may be explained by the decreased consumption of diabetes medications between 2016 and 2017. Special attention should be allocated to glycaemic control of patients from lowest income groups and with T2D-coexisting diseases.


3.3 Case Jyte. From measuring quality to systematic quality improvement

13.05–13.20

Aapo Tahkola, Päivi Korhonen, Hannu Kautiainen, Teemu Niiranen, Pekka Mäntyselkä

Hoidon laadun mittaaminen on noussut viime vuosina vahvasti keskusteluun. Terveydenhuollon tietoaineistoista aletaan hiljalleen saada käyttöön jatkuvasti päivittyvää, kattavaa laatutietoa. Myös perusterveydenhuollossa ollaan viimeinkin siirtymässä pelkkien kustannusten, lähetteiden ja jonotusaikojen mittaamisesta kohti kokonaisvaltaisempaa hoidon laadun ja vaikuttavuuden mittaamista.  Pelkkä laadun mittaaminen ei kuitenkaan välttämättä itsessään vielä muuta mitään. Me terveydenhuollon ammattilaiset olemme aivan liian kiireisiä siihen. Jatkuvaan ja tuloksekkaaseen hoidon laadun parantamiseen tarvitaan hyvää ajattelua, selkeä suunnitelma, pätevät laatumittarit, pysyvä rakenne ja paljon systemaattista kehittämistyötä. 

Jyväskylän yhteistoiminta-alueen terveyskeskuksessa (Jyte) on rakennettu pysyvää jatkuvan laadun parantamisen mallia vuodesta 2015. Sen keskeisiä elementtejä ovat Jyten Laatupankki sekä Jyten avosairaanhoidon laatutyöryhmä.  Jyten Laatupankki on automaattisesti päivittyvä hoidon laadun seurantajärjestelmä, joka hyödyntää potilastietojärjestelmästä saatavaa tietoa. Laatutietoja voidaan tarkastella koko organisaation tasolla, terveysasemakohtaisesti ja tietyiltä osin myös ammattilaiskohtaisesti. Laatupankkia hyödynnetään laatutavoitteiden asettamisessa ja sen laatuindikaattoreiden avulla seurataan laatutavoitteisiin pääsyä.  Jyten Avosairaanhoidon Laatutyöryhmän muodostaa lääkäri-hoitaja työpari jokaiselta JYTE:n kahdeksalta terveysasemalta. Ryhmän toimintaa johtaa ja koordinoi kehittäjälääkäri yhdessä kehittäjäsairaanhoitajan kanssa. Joka tammikuussa Laatutyöryhmä käy läpi edellisen vuoden tulokset sekä valitsee 1-3 motivoivaa laatutavoitetta alkaneelle vuodelle. Tavoitteet ovat kiistatta terveyshyötyä lisääviä, selkeästi mitattavia ja sellaisia, joihin myös johto voi vahvasti sitoutua. Lisäksi Laatutyöryhmä ehdottaa parhaaksi näkemiään keinoja tavoitteisiin pääsyyn. Johtoryhmän käsiteltyä ja hyväksyttyä tavoitteet ja keinot, Laatutyöryhmän tehtävänä on loppuvuoden aikana jalkauttaa tavoitteet ja toiminnan muutos terveysasemille siten, että valittuihin tavoitteisiin päästään.

Kehitelty malli näyttää mahdollistavan vaikuttavan ja tuloksellisen laatutyön perusterveydenhuollossa. Esimerkiksi vuonna 2016 sepelvaltimotautia sairastavista Jyten avosairaanhoidon potilaista LDL-tavoitteen (<1,8 mmol/l) oli saavuttanut 39% potilaista (n=927). Vuoden 2017 loppuun mennessä tavoitteessa oli 44% potilaista (n=1150). Vuonna 2016 Jyten varfariini-hoidetuista potilaista 51% (n=1694) oli mitattu TTR-% (Time in therapeutic range) hoitotasapainomittaus. Vuonna 2018 TTR-% oli mitattu 82% (n=1721) potilaista. Huonossa hoitotasapainossa (TTR<60%) olevien varfariini-potilaiden osuus vuonna 2016 oli 16% (n=362), kun vuonna 2018 se oli enää 10% (n=186). Keskimääräinen TTR-% vuonna 2016 oli 77% ja vuonna 2018 81%.

 

3.4 Healthcare professionals - expectations of a diabetes care performance management system in pre-implementation phase

13.20–13.35

Iiris Hörhammer, Juulia Jäppinen, Miika Linna, Hilkka Tirkkonen, Päivi Rautiainen, Petri Kivinen, Katariina Silander

Follow-up of health outcomes and resource use, and benchmarking between providers can support decisions to improve effectiveness and cost-efficiency of care. Despite healthcare professionals crucial role in operational change and performance information use, limited knowledge of how performance monitoring systems are accepted and used by this group exists. To address this gap, we studied diabetes care professionals attitudes towards performance evaluation and their expectations of a performance monitoring system in the pre-implementation phase in Siun sote, a Finnish social and healthcare district serving a population of c. 170 000.  Half of the professionals treating patients with diabetes, and their supervisors (n=86/170, 51%) responded to a survey. In addition, semi-structured interviews were carried out (n=11) to gain deeper understanding of the barriers and facilitators for performance management.  Over 90% reported interest in the cost of care and the association between cost and health outcomes. Professionals also rated their role in performance improvement quite high (average 4.0 on a scale 1-5).

The new performance monitoring system is believed to support and enhance the use of quality information in clinical care and management decisions, and the implementation of the new system has strong support in the region. The doubts, however, concern allocation of resources to the use of the system, and the development and sustaining of formal processes for the collective use of the information.  In order to fulfil the positive expectations of the clinicians, strong managerial support and leadership are needed. In addition to technical support, assessment and improvement of data comparability is essential, as well as setting formal processes for performance information interpretation and implementation of changes suggested by the information. Good implementation practices identified in information systems research will be discussed.


3.5 Individual and area-level factors associated with ambulatory care sensitive conditions in Finland

13.35–13.50

Markku Satokangas, Martti Arffman, Alastair Leyland, Ilmo Keskimäki

Background Geographic variation is common in ambulatory care sensitive conditions (ACSCs)  used as a proxy indicator for primary care quality. Its use is debated as it is more strongly associated with individual socioeconomic position (SEP) and health status than factors related to primary care. While most earlier studies have been cross-sectional, this study aims to observe if these associations change over time. Finland offers a good possibility for this due to its extensive registers and unexplained over time convergence of geographic variation in ACSC.  Methods This observational study obtained ACSCs in 2011-2017 from the Finnish Hospital Discharge Register and divided them into subgroups of acute, chronic and vaccine-preventable causes. In these subgroups we analysed geographic variations with a three-level multilevel poisson regression model  individuals, health centre areas (HC) and hospital districts (HD)  and estimated the proportion of the variance at each level explained by individual SEP and comorbidities, as well as both primary care and hospital supply and spatial access at three time points.

Results In the preliminary results of the baseline geographic variation in total ACSCs in 2011-2013  the model with age and sex  the variance between HDs was nearly twice that between HCs. Individual SEP and comorbidities explained 46% of the variance between HDs and 29% between HCs; and area-level proportion of ACSC periods in primary care inpatient wards a further 12% and 5%. This evened out the unexplained variance between HDs and HCs.  Conclusions Geographic variation in ACSCs was more pronounced in hospital districts than in the smaller health centre areas. The excess variance between HDs was explained by individual SEP and comorbidities as well as by use of primary care inpatient wards. Our findings suggest that not only hospital bed supply, but also the national structure of hospital services affects ACSCs. This challenges international ACSC comparisons.

 

13.50–14.00 Closing remarks