European Collaboration for Healthcare Optimization An international project on healthcare performance. ECHO has set about the task of bringing together patient-level data from Austria, Denmark, England, Portugal, Slovenia and Spain, making them comparable. ECHO is expanding the usual approach in healthcare performance international comparison, by adding the variation framework.

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ECHO –
European Collaboration for Healthcare Optimization
An international project on healthcare performance
Enrique Bernal-Delgado, Sandra García-Armesto
Julián Librero, Natalia Martínez, Cristobal Baixauli,
Manolo Ridao, and Miriam Seral
on behalf of the ECHO consortium

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The concept
• ECHO has set about the task of bringing together patient-level data
from Austria, Denmark, England, Portugal, Slovenia and Spain,
making them comparable.
• ECHO is expanding the usual approach in healthcare performance
international comparison, by adding the variation framework
• The value-attribute informs on whether exposure/quality reaches an
acceptable level using a reference-value. The variation-attribute signals
whether the differences observed across territories/providers are
unwarranted and systematic.
• Performance dimensions: utilization, equitable access to effective care,
quality, and efficiency, in terms of opportunity costs, and provider-level
efficiency.
• Healthcare areas or hospital providers will be flagged as over- or under
performers – not a diagnostic tool but a screening tool

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Geographic-perspective Hospital-perspective
1. Effective care (hip fracture,
colectomy in colorectal cancer,
breast surgery in breast cancer,
etc)
2. Uncertain benefit/harm
balance in “non-average”
patients (CABG, knee
replacement, etc.)
3. Doubtful/ lower value care
and opportunity costs
(tonsillectomy, spinal fusion,
prostatectomy, etc.)
1. In-hospital case fatality rates
for a condition (admissions with
principal diagnosis of acute
myocardial infarction, ischemic
stroke);
2. In-hospital case fatality rates
after a procedure (in hospital
mortality after CABG, PCI, non-
ruptured abdominal aortic
aneurysm, hip replacement)
3. Patient safety event rates
(Trauma after vaginal delivery
with and without instrumentation,
Catheter-related infection,
Pulmonary Thromboembolism or
Deep venous thrombosis,
Postoperative sepsis)

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Some key issues in ECHO’s international comparisons
• Building a homogeneous knowledge infrastructure
– 250 million discharges (universe of hospitalizations since 2002 to
2009) plus ECHO indicators, plus contextual info
• Developing crosswalks across different languages
– ICD 9th ICD10th
– ICD 9th NOMESCO ACHI OPCS LEISTUNG-KATALOGUE-BMG
• Treating size (volume) heterogeneity across units of
analysis
– Comparable geographic units
– Controlling extra-heterogeneity
• Making patients and populations comparable by
pooling all eligible cases and …
– Age-sex standardization or Risk adjustment

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Some messages from ECHO performance
assessment
Utilization of effective procedures
Equity
Quality
Efficiency

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Utilization of effective procedures
Case-study: unwarranted variation in the use of PCI

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PCI
Rate 32.9 22.9 19.7 47.9 20.1
RV5-95 1.95 3.4 3.8 2.4 3.2
EB 0.03 0.26 0.1 0.26 0.24

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PCI in Slovenia and Portugal

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Equity
Case-study: income “effect” in hip replacement

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England vs Spain: hip replacement
0
5
10
15
2002 2003 2004 2005 2006 2007 2008 2009
0
5
10
15
20
25
30
35
2002 2003 2004 2005 2006 2007 2008 2009
Q1' Q2' Q3' Q4' Q5'

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Quality
Case study: mortality after CABG –
pooled 26,000 patients from England and Spain

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Spain to England adjusted mortality
OR = 1.5 [CI95% (1.1 to 2.03)]
Logit Multilevel: Fixed: age, sex, comorbidity, emergency Random: hospital

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Efficiency

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• Measuring hospital efficiency using SFA: a comparative
analysis of hospitals in Europe – Ceu Mateus
• Variation in length of stay and in-patient mortality for AMI
patients in Europe – Karen Bloor
• How to make comparable healthcare areas across European
countries – Terkel Christiansen
• Using geo analysis to enhance allocative efficiency:
opportunity costs of lower value care – Sandra García-
Armesto

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