Second Opinion: New hospital structures do not necessarily mean better health outcomes

Assigning Ireland’s 49 acute hospitals to six new groups will probably make a difference to patient outcomes. Unfortunately, with the exception of cancer, no one knows what these outcomes will be because there is no system in place to routinely record them.

Health outcomes refer to changes in the health status of individuals which can be attributed to an intervention or series of interventions. These changes can include better physical functioning such as the ability to carry groceries, climb a flight of stairs or walk a mile, or mental health functioning such as no longer feeling down in the dumps or worn out.

Health status should be measured before and after every medical procedure is carried out. There are hundreds of different tools available for measuring outcomes depending on the health problem and the intervention, which can be surgical, medical or therapy of one kind or another.

Outcomes are not routinely measured in Irish hospitals.


Convincing evidence
There is convincing international evidence that outcomes are better when patients are treated in units with high volumes of activity, appropriate numbers of specialist staff, and the right diagnostic and treatment facilities.

The Establishment of Hospital Groups as a transition to Independent Hospital Trusts report emphasises health outcomes: "all we do must be predicated on improving outcomes for patients"; "patient outcomes are the optimum"; and "best outcomes for patients are paramount".

Outcomes are referred to many times throughout the nearly 200-page report, yet there is not a single word about how these are measured now or will be measured in the future.

This is not to say that health professionals are not keeping notes as to how their patients are doing, just that, with the exception of cancer, there is no system in place to measure outcomes routinely, so that hospital outcomes can be compared and contrasted.

Outcomes written in patients’ notes are not analysed and made available to the public and future patients. Anyone going into an Irish hospital next week for a procedure does not know what outcomes to expect or which hospital is best.

Mortality and survival rates are often used as proxies for outcomes. This was the system favoured by Florence Nightingale during the Crimean war. Patients were classified as either alive or dead when discharged from hospital.

Nearly 200 years later Ireland has no system for collating acute hospital mortality figures. When a recent study found that Ireland has the fourth worst mortality-after-surgery rates among 28 European countries, expert spokespeople were unable to refute or clarify the findings because the planned Irish Audit of Surgical Mortality is not available yet.

The Lancet study examined 856 Irish hospital patients and identified 55 deaths following surgery. This study sample represents a tiny percentage of inpatients so the findings are unlikely to be accurate.

Detailed statistics
Apart from outcomes, everything that happens in Irish hospitals is measured. The Department of Health and Children collects detailed statistics, hospital by hospital, on beds available, bed occupancy, length of stay and so on.

The ESRI produces a report every year which describes everything except outcomes.

The 2011 Activity in Acute Public Hospitals report analyses in great detail, ages and sexes of those who availed of hospital services, when they were admitted and discharged, what the diagnosis was and how they were treated.

In 2011 almost 12,000 people were admitted for diabetes, nearly 8,000 for piles, 4,317 for tonsillectomy/
adenoidectomy, and 2,502 for varicose veins.

Hiqa has produced cost-effective analyses on several of these procedures: a tonsillectomy costs €3,261 for an inpatient and an inpatient varicose vein operation costs €3,800.

Unfortunately, apart from the consultants involved no one knows whether a person is better, worse or dead following their hospital treatment.

Measuring the Patient’s Experience of Hospital Services Hospital Inpatient Survey 2011, launched last week by the Irish Society for Quality and Safety in Healthcare, included some questions about health status. More than two-thirds of respondents reported a health status improvement after their inpatient procedure.

However, based on ESRI figures, an estimated 150,000 people thought their health status stayed the same or disimproved after their hospital procedure.

While the patient’s perspective is valuable information, it is no substitute for a system that routinely and objectively measures health outcomes for acute hospital activities.

Everyone admitted to an Irish hospital for a procedure is entitled to know what outcomes to expect and which hospitals have the best outcomes. The new structures offer little hope that this will happen any time soon.

Dr Jacky Jones is a former HSE regional manager of health promotion