THE ECHO PERFORMANCE MODEL
1. ECHO performance framework
ECHO performance measurement framework is inspired in the well-accepted OECD health systems performance conceptualisation. Applied to a particular domain of interest, ECHO focuses specifically on utilization of effective care, equity in access, quality and safety, and efficiency.
A set of around 68 performance indicators, actually an adaptation and validation of those developed by different initiatives – AHRQ quality measures, OECD Healthcare Quality Indicators Program and Atlas VPM project – allows ECHO to operationalize those performance dimensions.
On the other hand, ECHO adopts two different methodological approaches; the first is based on a geographical perspective and accounts for the population’s exposure to health care; the second, hospital-specific, accounts for the patient’s experience in a particular provider.
While the former draws out evidence on equitable access to effective care, uneven exposure to ineffective care, and high (low) opportunity costs associated to the place where populations live, the latter elicits differences in quality of care, safety and technical efficiency that might be attributed to the providers where patients are treated.
ECHO methodological approaches:
Finally, the ECHO measurement framework seeks to provide two informative attributes for each performance indicator: the value and the variation. The value-attribute informs on whether performance reaches an acceptable level using a conventional benchmark. The variation-attribute signals whether the differences observed across territories or providers are systematic -as opposed to random.
2. How ECHO indicators inform performance
ECHO indicators operate differently depending on whether the perspective is geographic or hospital-specific, and also depending on the nature of the type of care under study.
The geographic perspective looks at how exposed to health services are populations living in each of the policy meaningful areas in a country (MAREs) and, how the exposure varies within a country and across countries.
The interpretation differs depending on whether the exposure is to evidence-based effective care, or to services with unclear benefit-harm balance in non-eligible patients or to lower-value care. Let’s see how value and variation operate:
a) In the case of effective care rates are expected to be similar to the burden of disease in a particular area.
Variation in effective care would tend to be small, as small as differences in epidemiology (e.g. variation in colectomy in colorectal cancer should be similar to the variation in colorectal cancer). Thus, high variation might be interpreted as a signal of inequitable access in those areas with low rates.
b) In the case of care with uncertain benefit-harm balance in non-eligible patients, areas with high rates might signal populations over-exposed to unnecessary (if not harmful) care once differences in need and/or burden of disease are controlled. On the contrary, low rates, might point out to underexposure once differences in need and/or burden of disease are adjusted.
In this case, variation will tend to be larger than the differences in epidemiology (e.g. PCI variation would be larger than variation in the burden of ischemic disease). If so, variation might signal both underuse and overuse: underuse will be possible when access barriers are in place (e.g. ability to pay, time to door, economic gradient, ignorance about the relative benefit, etc.), while overuse will be likely in the presence of “do-more” incentives (e.g. fee for service payment schemes).
c) In the case of lower-value care, the lower the exposure the better. On the contrary, the higher the rate the higher the unnecessary exposure for the population to ineffective or less effective care, and the higher the opportunity costs.
Variation in these cases tends to be the largest, irrespective of the variation in epidemiology (e.g. radical prostatectomy in low risk prostate cancer vs. low-risk prostate cancer incidence variation) and strongly sensitive to supply factors – surgical signature phenomenon, learning cascades, fee-for-service payment schemes, etc.
HOSPITAL SPECIFIC INDICATORS
ECHO hospital specific indicators are representing the risk for a patient to experience an outcome just because he or she was treated in a particular hospital. All ECHO hospital-specific indicators are negative outcomes; then, high incidence rates are interpreted as poor quality (high probability of negative outcome); on the contrary, the lower the incidence in a hospital, the better its quality.
The interest of the variation-attribute in the hospital specific indicators lays on determining the part of the variance that could be amenable to the hospital of treatment once patient differences are ruled out – the larger the variance the more likely the results are amenable to the hospital of treatment.
3. Benchmarking in ECHO
An essential element in the ECHO performance measurement framework is the construction of benchmarks.
Given the advantage of the availability of individual-patient data in a single database, and the allocation of each hospital admission into a geographic area (place of residence) or into a hospital of treatment, ECHO is able to construct robust in-country and cross-country benchmarks.
In the case of the geographic analyses, the benchmark is determined by estimating the expected number of cases in a geographic area, either using a population of reference (direct standardisation) or the age-sex specific rates in the standard population (indirect standardisation). When the interest is in the national benchmark the standard of reference is the national “population”, while the ECHO population is used when the interest is in the international comparison.
In the case of hospital-specific analyses, the expected number of cases is estimated using logit-type multilevel analyses. When the interest is in national benchmarking the models use all the patients and hospitals in a specific country; in turn, international benchmarks are estimated using the whole sample of patients and hospitals in ECHO.
ECHO Atlases usually report performance indicators with both national and international benchmarks. But, ECHO allows benchmarking between pairs of countries, as well. This allows country A be compared with the best country within the ECHO sample, providing a sort of aspirational reference for each indicator.