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Measuring the Quality of Healthcare

The Connection between Structure, Process, and Outcomes of Care, Using the Example of Myocardial Infarction Treatment in Germany

  • Review Article
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Disease Management & Health Outcomes

Abstract

Recently, enormous efforts to measure the quality of healthcare have been made to attain information on ways to improve the quality of healthcare. However, this area of research is still at an early stage of development and more research is required. This article outlines a framework by which the quality of healthcare can be analyzed on the basis of the three quality dimensions introduced by Donabedian. The article then goes on to test the validity of this (theoretical) framework within an empirical analysis.

Because of increasing financial shortages within health systems, this article focuses on the treatment of myocardial infarction, which is one of the costliest and most prevalent diseases. This approach establishes a link between medical and economic problems. The variables for structure quality (i.e. number of cardiologists, number of catheterization facilities) were sourced and evaluated from the ‘Herzberichte der Jahrgänge’ (‘heart reports’) compiled by Bruckenberger for the period 1994–2004 for the 16 German federal states. Data from the Federation of Quality Assurance (BQS) were used for the evaluation of process quality (i.e. adequacy of indication for coronary angiography). Finally, administrative data from the German Federal Statistical office for 1994–2004 were used to determine the variables of outcome quality (i.e. standardized mortality rate due to myocardial infarction, potential years of life lost <70 years due to myocardial infarction).

Three hypotheses were tested using panel data: (i) a better structure and/or process quality increases the probability of getting a better outcome quality for the clinical picture under observation; (ii) by employing additional input factors (such as additional catheterization facilities), the probability of getting a good outcome quality is increased; and (iii) in addition to structure quality and process quality, factors lying outside of the sphere of influence of the health system have an additional influence on outcome quality (marginal gains would decrease in this case). Three models were used to test these hypotheses using fixed effects estimation.

The empirical analysis produced three results. First, the analysis confirms the predicted causality between the different dimensions of quality of care for the German federal states. Notably, the number of catheterization facilities has a highly significant positive influence on the outcome quality. Second, support is found for decreasing marginal gain of inputs. Third, a good structure and a good process quality alone cannot guarantee good outcome quality. However, the analysis also showed that, in addition to healthcare provided, there are other determinants that also affect the outcome quality of healthcare. Further empirical investigation regarding the influence of these factors on the outcome dimension could elaborate on our findings and deliver additional insights.

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References

  1. World Health Organization. The world health report 2002: reducing risks, promoting healthy life. Geneva: WHO, 2002

    Google Scholar 

  2. Organization for Economic Coordination and Development. A disease based comparison of health systems: what is best and at what cost? Paris: OECD, 2003

    Google Scholar 

  3. Organization for Economic Coordination and Development. Health care quality indicators project. Paris: OECD, 2006

  4. Donabedian A. The definition of quality and approaches to its assessment. Ann Arbor (MI): Health Administration Press, 1980

    Google Scholar 

  5. Müller-Nordhorn J, Rossnagel K, Mey W, et al. Regional variation and time trends in mortality from ischaemic heart disease: East and West Germany 10 years after reunification. J Epidemiol Health 2004; 58: 481–5

    Article  Google Scholar 

  6. Gesundheitsberichterstattung des Bundes (2006) [online]. Available from URL: http://www.gbe-bund.de/ [Accessed 2006 Nov 17]

  7. Schoen C, Osborn R, Huynh PT, et al. Taking the pulse of health care systems: experiences of patients with health problems in six countries. Health Aff 2005 Nov 3: W5-509-W5-525 [online]. Available from URL: http://www.content.healthaffairs.org/cgi/content/full/hlthaff.w5.509/dc1 [Accessed 2007 Jul 26]

  8. Sauerland D. Gesundheitspolitik in Deutschland. 2nd rev. ed. Gütersloh: Verlag Bertelsmann-Stiftung, 2003

    Google Scholar 

  9. Donaldson MS. Measuring the quality of health care: a statement by the National Roundtable on Health Care Quality. Washington, DC: National Roundtable on Health Care Quality, 1999

    Google Scholar 

  10. Weaver WD. Time to thrombolytic treatment: factors affecting delay and their influence on outcome. J Am Coll Cardiol 1995; 25: 3–9

    Article  Google Scholar 

  11. Goldberg RJ, Yarzebski J, Gore JM, et al. Decade-long trends and factors associated with time to hospital presentation in patients with acute myocardial infarction: the Worcester Heart Attack study. Arch Intern Med 2000; 160: 3217–23

    Article  PubMed  CAS  Google Scholar 

  12. Goldberg RJ, Steg PG, Sadiq I, et al. Extent of, and factors associated with, delay to hospital presentation in patients with acute coronary disease (the GRACE registry). Am J Cardiol 2002; 89: 791–6

    Article  PubMed  Google Scholar 

  13. Hamm CW. Leitlinien zur Therapie des akuten koronaren Syndroms mit ST-Hebungen. Zeitschr Kardiol 2004; 93: 324–41

    Article  CAS  Google Scholar 

  14. Van de Werf F, Ardissino D, Betriu A, et al. Management of acute myocardial infarction in patients presenting with ST-segment elevation: the task force on the management of acute myocardial infarction of the European Society of Cardiology. Eur Heart J 2003; 24: 28–66

    Article  PubMed  Google Scholar 

  15. Müller-Nordhorn J. Regionale Trends in der kardiovaskulären Mortalität: Bedeutung für das Versorgungsmanagement von Patienten mit Herz-KreislaufErkrankungen 2005 [online]. Available from URL: http://edoc.hu-berlin.de/habilitationen/mueller-nordhorn-jacqueline-2005-01-17/HTML/ [Accessed 2007 Feb 17]

  16. Euroaspire I and II Group. Clinical reality of coronary prevention guidelines: a comparison of Euroaspire I and II in nine countries. Lancet 2001; 357: 995–1001

    Article  Google Scholar 

  17. Bruckenberger E. Herzberichte der Jahrgänge 1994–2004 [online]. Available from URL: http://www.herzberichte.de [Accessed 2007 Jul 26]

  18. Bundesgeschäftsstelle für Qualitätssicherung. BQS-Qualitätsreport 2003: qualität sichtbar machen. Düsseldorf: BQS, 2003

    Google Scholar 

  19. Bundesgeschäftsstelle für Qualitätssicherung. BQS-Qualitätsreport 2004: qualität sichtbar machen. Düsseldorf: BQS, 2004

    Google Scholar 

  20. Landesgeschäftsstellen für Qualitätssicherung (2003, 2004) [online]. Available from URL: http://www.bqs-online.com/public/leistungen/exqual/qualbund/landesgesch [Accessed 2007 Feb 17]

  21. Bundesgeschäftsstelle für Qualitätssicherung (2006) [online]. Available from URL: http://www.bqs.outcome.de [Accessed 2007 Mar 15]

  22. Statistisches Bundesamt Deutschland (2006) [online]. Available from URL: https://www-genesis.destatis.de/genesis/online/xml;jsessionid=A0CECF887EA45B1FB24CEE7AFE56A9E1.tc3?operation=startseite&titel=HISTORY_START [Accessed 2007 Mar 17]

  23. Health reporting (2006) [online]. Available from URL: http://www.gbe-bund.de/ [Accessed 2007 Mar 17]

  24. Bundesgeschäftsstelle für Qualitätssicherung (2004) [online]. Available from URL: http://www.bqs-qualitaetsindikatoren.de/2004/ergebnisse/leistungsbereiche/ptca/indikatoren/5/rationale [Accessed 2007 Feb 17]

  25. Bashore TM. ACC/Society for Cardiac Angiography and Interventions clinical expert consensus document on cardiac catheterization laboratory standards. J Am Coll Cardiol 2001; 37: 2170–214

    Article  PubMed  CAS  Google Scholar 

  26. James PD, Manuel DG, Mao Y. Avoidable mortality across Canada from 1975–1999. BMC Public Health 2006; 6: 137

    Article  PubMed  Google Scholar 

  27. Nolte E, McKee M. Does healthcare save lives? Avoidable mortality revisited. London: The Nuffield Trust, 2004

    Google Scholar 

  28. Wooldridge JM. Econometric analysis of cross-section and panel data. Cambridge (MA): Mit Press, 2002

    Google Scholar 

  29. Greene WH. Econometric analysis. Upper Saddle River (NJ): Prentice Hall, 2000

    Google Scholar 

  30. Breyer F, Zweifel P, Kifmann M. Gesundheitsökonomie. 4th rev. ed. Berlin u.a.O: Springer-Verlag, 2003

    Google Scholar 

  31. Morris RW, Whincup PH, Lape FC, et al. Geographic variation in incidence of coronary heart disease in Britain: the contribution of established risk factors. Heart 2001; 86: 277–83

    Article  PubMed  CAS  Google Scholar 

  32. Tunstall-Pedoe H, Vanuzzo D, Hobbs M, et al. Estimation of contribution of changes in coronary care to improving survival, event rates, and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000; 355: 688–700

    Article  PubMed  CAS  Google Scholar 

  33. Kuulasmaa K, Tunstall-Pedoe H, Dobson A, et al. Estimation of contribution of changes in classic risk factors to trends in coronary-event rates across the WHO MONICA Project populations. Lancet 2000; 355: 675–87

    Article  PubMed  CAS  Google Scholar 

  34. Dockery DW, Pope CA 3rd, Xu X, et al. An association with air pollution and mortality in six U.S. cities. N Engl J Med 1993; 329: 1753–9

    Article  PubMed  CAS  Google Scholar 

  35. Willich SN, Müller-Nordhorn J, Kulig M, et al. Regional variations in mortality from cardiovascular diseases in Germany. Dtsch Ärztebl 1999; 96: A483–8

    Google Scholar 

  36. Marti B, Rickenbach M, Keil U, et al. Variation in coronary risk factor levels of men and women between the German-speaking MONICA centres. Revue ds’Épidémiologie et de Santé Publique 1990; 38: 479–86

    CAS  Google Scholar 

  37. Heinemann LA, Garbe E, Classen E, et al. Trends in cardiovascular risk factors in East Germany: three independent population studies as part of the project MONICA East Germany. Dtsch Med Wochenschr 1998; 123: 889–95

    Article  PubMed  CAS  Google Scholar 

  38. Thefeld W, Stolzenberg H, Bellach BM. German national health interview and examination survey: response, composition of participants, and analysis of nonrespondents. Gesundheitswesen 1999; 61: 57–61

    Google Scholar 

  39. Heinemann LA, Greiser EM. Blood pressure, hypertension, and other risk factors in East and West Germany. Ann Epidemiol 1993; 3: 90–5

    Google Scholar 

  40. Hoffmeister H, Bellach BM. Die Gesundheit der Deutschen. Berlin: RKI-Heft, 1995: 7

    Google Scholar 

  41. Thiel C, Heinemann L. Nutritional behaviour differences in Germany. Rev Environ Health 1996; 11: 35–40

    Article  PubMed  CAS  Google Scholar 

  42. Winkler G, Holtz H, Döring A. Comparison of food intakes of selected populations in former East and West Germany: results from the MONICA Projects Erfurt and Augsburg. Ann Nutr Metab 1992; 36: 219–34

    Article  PubMed  CAS  Google Scholar 

  43. Winkler G, Brasche S, Döring A, et al. Dietary intake of middle-aged men from an East and a West German city after the German reunification: do differences still exist? Eur J Clin Nutr 1998; 52: 98–103

    Article  PubMed  CAS  Google Scholar 

  44. Umweltbundesamt. Umweltdaten Deutschland. Berlin: Umweltbundesamt, 2002

    Google Scholar 

  45. ZVFK. Zentrum für Versorgungsforschung (2006) [online]. Available from URL: http://www.versorgungsforschung.de [Accessed 2007 Mar 10]

  46. Ärztekammer Berlin. Die neuesten trends zum herzinfarkt Ergebnis-Symposium des Berliner Herzinfarktregisters am 17.11.2004 [editorial, online]. Available from URL: http://www.herzinfarktregister.de/verein/presse.htm [Accessed 2007 Mar 10]

  47. Hays RB, Veith C, Evans R. The determinants of quality in procedural rural medical care. Rural Remote Health 2005; 5: 473

    PubMed  Google Scholar 

  48. Morfeld M, Wirtz M. Methods in health services research: the example of the evaluation of the German disease management programmes. Bundesgesundheitsblatt Gesundheitsforschung Gesundheltsschutz 2006; 49: 120–9

    Article  CAS  Google Scholar 

  49. Verband der Angestellten Krankenkassen/Arbeiter-Ersatzkassen-Verband (2004), Geneinsame Presseerklärung der Krankenkassenverbände in Nordrhein und der Kassenärztlichen Vereinigung Nordrhein [online]. Available from URL: http://www.vdak.de/lven/nrw/presse/presseerklaerungen/presseerklaerungen_archiv/20040702gem/index.htm [Accessed 2007 Jul 26]

  50. Tunstall-Pedoe H, Kuulasmaa K, Mahonen M, et al. Contribution of trends in survival and coronary events rates to changes in coronary heart disease mortality: 10-years result from 37 WHO MONICA Project populations. Lancet 1999; 353: 1547–57

    Article  PubMed  CAS  Google Scholar 

  51. Perleth M, et al. Cardiac catheterization in Germany: diffusion and utilization from 1984 to 1996. Int J Technol Assess Health Care 1999; 15: 756–66

    PubMed  CAS  Google Scholar 

  52. Euroaspire Study Group. Euroaspire: a European Society of Cardiology survey of secondary prevention of coronary heart disease. Principal results (European Action on Secondary Prevention through Intervention to Reduce Events). Eur Heart J 1997; 18: 1569–82

    Article  Google Scholar 

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Acknowledgements

The author wishes to thank Dirk Sauerland (WHL Graduate School of Business and Economics) and Eberhard v. Hodenberg (Heart Institute Lahr/Baden, Germany), Eva Ludwig (WHL Graduate School of Business and Economics), Christoph Schwierz (RWI Essen), and several anonymous reviewers for their helpful comments and constructive criticism. An earlier version of the paper was presented at the 6th European Conference on Health Economics (ECHE), 2006 July 6–9, Budapest. Any remaining errors are the author’s own.

No sources of funding were used to assist in the conduct of this analysis. The author has no conflicts of interest that are directly relevant to the content of this paper.

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  1. Chair of Health Economics and Institutional Economics, WHL Graduate School of Business and Economics, Hohbergweg 15-17, 77933, Lahr, Germany

    Ansgar Wübker (Graduate Assistant)

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Correspondence to Ansgar Wübker.

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Wübker, A. Measuring the Quality of Healthcare. Dis-Manage-Health-Outcomes 15, 225–238 (2007). https://doi.org/10.2165/00115677-200715040-00004

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