Avoidable admissions: Respiratory diseases
Chronic conditions like asthma and chronic obstructive pulmonary disease (COPD) are either preventable or manageable through proper prevention or primary care interventions. Proper management of these chronic conditions in primary care settings can reduce exacerbation and costly hospitalisation. Hospital admission rates serve as a proxy for primary care quality, so high admission rates may point to poor care co-ordination or care continuity. They may also indicate structural constraints such as the supply of family physicians (AHRQ, 2009; Starfield et al., 2005).
Avoidable admissions: Uncontrolled diabetes
Diabetes is one of the most significant non-communicable diseases globally, and is also a leading cause of mortality. In the United States for example, where there are an estimated 26 million diabetics, diabetes was a contributory factor to around 230 000 deaths in 2007. In Europe, an estimated 55 million people live with diabetes. Across the world, the population of diabetics is expected to rise from 285 million in 2010 to 438 million by 2030 (IDF, 2009) (see also Indicator 1.10, "Diabetes prevalence and incidence").
In-hospital mortality following acute myocardial infarction
Although coronary artery disease remains the leading cause of death in most industrialised countries, mortality rates have declined since the 1970s (see Indicator 1.3 "Mortality from heart disease and stroke"). Much of the reduction can be attributed to lower mortality from AMI, due to better treatment in the acute phase. Care for AMI has changed dramatically in recent decades, with the introduction of coronary care units in the 1960s (Khush et al., 2005) and with the advent of treatment aimed at rapidly restoring coronary blood flow in the 1980s (Gil et al., 1999). This success is all the more remarkable as data suggest that the incidence of AMI has not declined for most countries (Goldberg et al., 1999; Parikh et al., 2009). However, numerous studies have shown that a considerable proportion of AMI patients fail to receive evidence-based care (Eagle et al., 2005).
In-hospital mortality following stroke
Stroke and other cerebrovascular disease is the fourth most common cause of death in OECD countries, accounting for over 8% of all deaths on average (OECD, 2011a). Estimates suggest that it accounts for 2-4% of health care expenditure and also significant costs outside of the health care system due to its impact on disability (OECD, 2003a). In ischemic stroke, representing about 85% of cases, the blood supply to a part of the brain is interrupted, leading to a necrosis of the affected part, while in hemorrhagic stroke, the rupture of a blood vessel causes bleeding into the brain, usually causing more widespread damage.
Patient safety has recently become one of the most prominent issues in health policy, as increased evidence of a high rate of errors during the delivery of medical care has begun to undermine the trust that patients and policy makers have historically bestowed on the medical profession. As early as 1991, the landmark Harvard Medical Practice Study found that adverse events occur in 1 to 4% of all hospital admissions (Brennan et al., 1991). The US Institute of Medicine integrated the available evidence on medical errors and estimated that more people die from medical errors than from traffic injuries or breast cancer (Kohn et al., 2000). One recent Swedish study showed that over 12% of hospital admissions had adverse events, of which 70% were preventable, resulting in an increased length of stay of 6 days (Soop et al., 2009). The Council of the European Union adopted in 2009 a Recommendation on patient safety, including the prevention and control of healthcare associated infections (European Union, 2009).
Procedural or postoperative complications
Efforts to improve patient safety have sparked interest in reporting sentinel and adverse events arising from health care. Sentinel events are rare but dramatic incidents where medical errors may lead to tangible harm to patients. These, sometimes referred to as "never events", indicate failure of safeguards to protect patients during care delivery. Foreign body left in during procedure is such an occurrence that reflects serious process problems. The indicator captures errors relating to the failure to remove surgical instruments (i.e. needles, knife blades, gauze swabs) at the end of a procedure. The most common risk factors that might cause retained bodies after surgery are emergencies, unplanned changes in procedure, changes in the surgical team during the procedure and patient obesity (Gawande et al., 2003). Preventive measures include counting procedures, a methodical wound exploration and effective communication among the surgical team.
Unplanned hospital re-admissions for mental disorders
The burden of mental illness is substantial, accounting for between 3 and 16% of total expenditure on health across OECD countries. Severe disorders such as schizophrenia and bipolar disorder are among the top ten causes of years lost due to disability worldwide (WHO, 2008b).
Screening, survival and mortality for cervical cancer
Cervical cancer is preventable and curable if detected early. The main cause of cervical cancer, which accounts for approximately 95% of all cases, is sexual exposure to the human papilloma virus, HPV (IARC, 1995; Franco et al., 1999). Three indicators are presented to reflect variation in cervical cancer care across OECD countries: cervical cancer screening rates in women aged 20-69 years, five-year relative survival rates, and mortality rates.
Screening, survival and mortality for breast cancer
Breast cancer is the most prevalent form of cancer in women, accounting for almost 460 000 deaths worldwide in 2008 (WHO, 2011d). One in nine women will acquire breast cancer at some point in her life and one in thirty will die from the disease. There are a number of risk factors that increase a person’s chance of getting this disease such as age, family history of breast cancer, estrogen replacement therapy, alcohol use and others. Overall spending for breast cancer care typically amounts to about 0.5-0.6% of total health expenditure (OECD, 2003a). Variation in breast cancer care across OECD countries is indicated by mammography screening rates in women aged 50-69 years, relative survival rates, and mortality rates.
Survival and mortality for colorectal cancer
Colorectal cancer is the third most commonly diagnosed form of cancer worldwide, after lung and breast cancer, with approximately one million new cases diagnosed per year (Parkin et al., 2005). There are several factors that place certain individuals at increased risk for the disease, including age, the presence of polyps, ulcerative colitis, a diet high in fat, and genetic background. The disease is more common in the United States and Europe, and is rare in Asia. In Asian countries where people are gradually adopting western diets, such as Japan, the incidence of colorectal cancer is increasing (IARC, 2011). It is estimated that approximately 610 000 people worldwide died due to colorectal cancer in 2008 (WHO, 2011d). Total spending on the treatment of colorectal cancer in the United States is estimated to reach USD 14 billion per year (Mariotto et al., 2011). Two indicators are presented to reflect variation in outcomes for patients with colorectal cancer across OECD countries: five-year relative survival rates and mortality rates.
Childhood vaccination programmes
Childhood vaccination continues to be one of the most cost-effective health policy interventions. All OECD countries or, in some cases, sub-national jurisdictions have established vaccination programmes based on their interpretation of the risks and benefits of each vaccine. Coverage of these programmes can be considered as a quality of care indicator. Pertussis, measles and hepatitis B are taken here as examples as they represent in timing and frequency of vaccination the full spectrum of organisational challenges related to childhood vaccination.
Influenza vaccination for older people
Influenza is a common infectious disease worldwide and affects persons of all ages. For example, on average, between 5% and 20% of the population in the United States contracts influenza each year (CDC, 2009). Most people with the illness recover quickly, but elderly people and those with chronic medical conditions are at higher risk for complications and even death. Between 1979 and 2001, on average, influenza accounted for more than 200 000 hospitalisations and 36 000 deaths per year in the United States (CDC, 2009). The impact of influenza on the employed population is substantial, even though most influenza morbidity and mortality occurs among the elderly and those with chronic conditions (Keech et al., 1998). In Europe, influenza accounts for around 10% of sickness absence from work, while the cost of lost productivity in France and Germany has been estimated to be in the range of USD 9.3 billion to 14.1 billion per year (Szucs, 2004).
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