QUALITY AND POPULATION George Rubin, Michael Frommer and Johanna Westbrook, Epidemiology and Health Services Evaluation Branch, NSW Health Department This article is based on a presentation by George Rubin at the Workshop on Quality Assurance of the International Society for Quality Assurance in Health Care at the Howard Florey Institute, Melbourne, Victoria, March 27, 1993. rom the catwalks of healthcare fashion, outcomes research emerges as the star of the show. While the benefits of clinical activity have motivated doctors for generations, the new imperative is to combine these with the consumerist agenda - in effect, to put professional standards into consumer values." These glittering lines from a recent Lancet editorial herald new directions in health care. Meantime, governments and health organisations strive to better assess, in health terms, the effectiveness of resources devoted to health services. Each year in Australia we spend around $32 billion. What do we achieve in terms of improving the health status and wellbeing of the population? Could these resources be allocated in a different way to obtain greater health benefits? While we have become preoccupied with improving the quality of care there is a major gap in the way we are going about this. The World Health Organisation (WHO) defines quality as improving the outcome of all health care in terms of health, functional ability, patient wellbeing and consumer satisfaction. The quality assurance process deals with three elements - structure, process and outcome. A health outcome is a change in the health of an individual or population which is attributable to interventions. The deficiency that we want to draw to your attention is a failure to link outcomes on the one hand with structure and process on the other. Most quality assurance activities have focused on only structure or process standards, with no clear relation to outcome. Indeed, whether these activities improve health benefits remains unclear and there is a growing recognition that many health interventions have not been evaluated and their effectiveness is not known. Moreover, quality is not just about obtaining the best outcomes regardless of the cost of the structure and process needed to do this. Health resources are most appropriately used for interventions which provide the best value for money. We have the methods to make this link between outcomes arid the quality of health interventions. We have been using epidemiologic methods for a long time to describe and analyse health-related phenomena in populations. They have enormous potential in quality assurance to quantify how the structure and process of health interventions relates to their outcomes. Epidemiology should underpin the key elements of health service management: • information analysis and policy formulation; • planning and program development; • program delivery; and • evaluation. Epidemiology has been going through a long, slow transition from its historic association with the old style of public health (communicable diseases, rats and drains) to the realisation that it is crucial to good decision making in health and hence to good health services management. assurance requires a reorientation of thinking in five key directions. 1. Implement an outcomes focus in health systems We are beginning to make good progress on this in Australia. The Commonwealth has introduced health outcomes into the Medicare agreements. States will be required to contribute to the development of outcomes-based accountability systems. The National Health and Medical Research Council (NHMRC) has established a Quality of Care Committee to enhance this process and develop mechanisms for establishing appropriate practice guidelines. NSW has a Health Outcomes Program. Under this program epidemiologists are working with clinicians, consumers, managers and health economists. The starting point is to ask what is the purpose of a particular clinical or public health service and then to agree on measurable health outcome indicators that fit with the explicit purpose of the service. The next steps are to establish data systems to collect, monitor and feed back information on the indicators, and for health service providers to use this information to improve the structure, process and outcomes of their services. How do we make all this happen? In NSW we will shortly announce a series of demonstration projects which exemplify this sequence in cardiovascular disease, critical care, asthma, diabetes, immuruisation and Aboriginal health. This leads me to the second direction. 2. Incorporate outcome measures into population health planning Measurable health outcome objectives should increasingly be included in health department and local health service plans. This is already happening to a greater or lesser extent in NSW, Victoria, Tasmania and Western Australia. In NSW, where increasing emphasis on outcome measurement is apparent, the corporate plan is used as the basis for performance agreements between the area chief executives and the Director-General. Incentives to adopt outcomes approaches at the service level and involving consumers will undoubtedly increase as local information systems improve. 3. Foster links with health economics Earlier the issue of value for money was raised. As well as indicators we need information on the resources involved in achieving the outcomes. In the lineup of people involved in the NSW outcomes program have been included health economists. A central plank in our outcomes approach is to involve health economists at the beginning of the process. 4. Improve information systems Current developments in information tecimology provide a seamless information capture mechanism extending from points of clinical contact to aggregated data at the hospital, area and Statewide level. The developments will enable us to effect the link between health interventions and their outcomes at the service and population levels. Examples of information systems with these capacities already exist. Under the NSW Quality Assurance Program clinicians are developing local PC-based outcome monitoring systems to improve their services in asthma, cardiovascular disease and obstetric care. To get epidemiology into the mainstream of quality VoI.4/No.12 137