European Journal of Obstetrics & Gynecology and Reproductive Biology 171 (2013) 1–2
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Editorial
Perinatal quality indicators: yardsticks for quality of care, measures of population health
Population-based perinatal health indicators serve a useful purpose both for public health and for clinical care. When standards to account for reporting variations are applied, international comparisons can highlight progress toward public health goals and markers for quality perinatal care. Clinical and public health indicators require review on a periodic basis: in the United States the Healthy People indicators, first introduced as goals for the year 1990, are revised and updated decennially. Perinatal quality measures also require ongoing review [1]. The science underlying the development, utilization and evaluation clinical indicators for quality health care is not new: most researchers trace its evolution at least to the work of Donabedian beginning in the 1960s [2]. A scientific approach to indicator development, as outlined by Mainz [3], was the basis for the initial set of 10 core and 23 recommended perinatal health indicators for use in monitoring and evaluating maternal and neonatal health, demographics, and health care services across Europe [4]. Euro-Peristat has published several reports based on these indicators, the most recent report being published in May 2013 [5]. International comparisons of perinatal health tend to focus on measures of perinatal mortality and its components [6], as well as infant outcomes such as low birth weight and preterm birth. Recently in this Journal, Santos et al. [7] asked the question, ‘‘Should European perinatal indicators be revisited?’’ The question is rhetorical because evaluation, refinement and adjustment of indicators are implicit features of any process designed to monitor health outcomes or quality of care. The larger question is how best to ensure that all necessary information and perspectives are incorporated into a transparent process. Who are the stakeholders whose voices should be heard in such a process? Santos et al. identified potential respondents for their survey by selecting obstetrical and pediatric journals with high impact factors, and identifying authors with European affiliations and an available email address. This approach identified a large pool of potential respondents, among whom approximately 7% participated in on on-line survey. Researchers who publish in clinical journals represent an important form of expertise for assessing the utility and feasibility of indicators, but research of relevance to this topic also appears in social science, public health and prevention literature and occasionally in general health and medical journals. Other stakeholders should also be involved in the process of
DOI of original article: http://dx.doi.org/10.1016/j.ejogrb.2013.08.019 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.09.033
indicator development, including population health scientists, quality managers, perinatal epidemiologists, statisticians, ministry of health staff, and the public. Not all ideas concerning new perinatal indicators are feasible, especially across many nations, jurisdictions and systems for health care delivery. Casting a broad net, followed by careful consideration of existing and proposed indicators, can ensure that each measure serves its intended purpose. As noted in their letter in this issue of the Journal, the EuroPeristat program casts a broad net that includes the broadest constituencies possible in the development and evaluation of European perinatal quality indicators [8]. While Santos et al. [7] are to be commended for their interest in this process, the wellarticulated approach devised and implemented by the EuroPeristat team and its scientific committee ensures that perinatal indicators used are valid and reliable, measurable, produce comparable data, and are evidence-based. While some measures might be seen by some perinatal professionals as desirable, systems to capture the relevant inputs and quantitate the measure may not be in place. Given the need to collect comparable data using consistent definitions across 29 countries (each comprised of numerous hospitals and birthing centers with differing practice styles) indicators must be selected after careful deliberation. As one case in point, Santos et al. [7] identify severe neonatal morbidity among babies at high risk as one of the most relevant indicators. ‘High risk’ is a very subjective assessment. To be comparable across the Euro-Peristat countries, data on this indicator would require very detailed definitions, and most likely include an algorithm with numerous clinical inputs. Clinicians may also disagree as to the definition of ‘severe neonatal morbidity’. Perhaps a consensus might emerge around a clinical tool such as the Score for Neonatal Acute Physiology (SNAP) in one of its various permutations, but implementation across all facilities caring for newborn infants or those in neonatal intensive care might prove problematical [9]. It is difficult enough to ensure comparable data for perinatal indicators in widespread use since the mid-20th century, as recently demonstrated by Joseph et al. [6]. Perinatal indicators serve an important and useful purpose in focusing attention on trends and relative differences in health outcomes, population characteristics and perinatal services. Only when they are developed, monitored, evaluated and implemented using a comprehensive and scientific framework will the resulting data provide the basis for initiatives to improve the quality of care and outcomes for women and their pregnancies.
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Editorial / European Journal of Obstetrics & Gynecology and Reproductive Biology 171 (2013) 1–2
References [1] Main EK. New perinatal quality measures from the National Quality Forum, the Joint Commission and the Leapfrog Group. Curr Opin Obstet Gynecol 2009;21: 532–40. [2] Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44:166–206. [3] Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 2003;15:523–30. [4] Zeitlin J, Wildman K, Breart G, et al. Selecting an indicator set for monitoring and evaluating perinatal health in Europe: criteria, methods and results from the PERISTAT project. Eur J Obstet Gynecol Reprod Biol 2003;111:S5–14. [5] Euro-Peristat Project with SCPE and EUROCAT. European perinatal health report: health and care of pregnant women and babies in Europe in 2010; May 2013, Available at: http://www.europeristat.com/images/European%20 Perinatal%20Health%20Report_2010.pdf. [6] Joseph KS, Liu S, Rouleau J, et al. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System Influence of definition based versus pragmatic birth registration on international comparisons of perinatal and infant mortality: population based retrospective study. Br Med J 2012;344:e746. [7] Santos JV, Correia C, Cabral F, Bernardes J, Costa-Pereira A, Freitas A. Should European perinatal indicators be revisited? Eur J Obstet Gynecol Reprod Biol 2013;170:85–9.
[8] Zeitlin J, Mohangoo A, Macfarlane A, et al., the Euro-Peristat Scientific Committee. Building a European perinatal health information system: plurality, innovation and realism. Eur J Obstet Gynecol Reprod Biol 2013;171:193–4. [9] Dammann O, Shah B, Naples M, et al., ELGAN Study Investigators. Interinstitutional variation in prediction of death by SNAP-II and SNAPPE-II among extremely preterm infants. Pediatrics 2009;124:e1001–06.
Russell S. Kirby* Department of Community and Family Health, College of Public Health, University of South Florida, United States *Correspondence to: Department of Community and Family Health, University of South Florida College of Public Health, 13201 Bruce B. Downs Boulevard, MDC56, Tampa, FL 33612, United States. Tel.: +1 813 396 2347 E-mail address: [email protected] (R.S. Kirby)
Contents lists available at ScienceDirect
European Journal of Obstetrics & Gynecology and Reproductive Biology journal homepage: www.elsevier.com/locate/ejogrb
Editorial
Perinatal quality indicators: yardsticks for quality of care, measures of population health
Population-based perinatal health indicators serve a useful purpose both for public health and for clinical care. When standards to account for reporting variations are applied, international comparisons can highlight progress toward public health goals and markers for quality perinatal care. Clinical and public health indicators require review on a periodic basis: in the United States the Healthy People indicators, first introduced as goals for the year 1990, are revised and updated decennially. Perinatal quality measures also require ongoing review [1]. The science underlying the development, utilization and evaluation clinical indicators for quality health care is not new: most researchers trace its evolution at least to the work of Donabedian beginning in the 1960s [2]. A scientific approach to indicator development, as outlined by Mainz [3], was the basis for the initial set of 10 core and 23 recommended perinatal health indicators for use in monitoring and evaluating maternal and neonatal health, demographics, and health care services across Europe [4]. Euro-Peristat has published several reports based on these indicators, the most recent report being published in May 2013 [5]. International comparisons of perinatal health tend to focus on measures of perinatal mortality and its components [6], as well as infant outcomes such as low birth weight and preterm birth. Recently in this Journal, Santos et al. [7] asked the question, ‘‘Should European perinatal indicators be revisited?’’ The question is rhetorical because evaluation, refinement and adjustment of indicators are implicit features of any process designed to monitor health outcomes or quality of care. The larger question is how best to ensure that all necessary information and perspectives are incorporated into a transparent process. Who are the stakeholders whose voices should be heard in such a process? Santos et al. identified potential respondents for their survey by selecting obstetrical and pediatric journals with high impact factors, and identifying authors with European affiliations and an available email address. This approach identified a large pool of potential respondents, among whom approximately 7% participated in on on-line survey. Researchers who publish in clinical journals represent an important form of expertise for assessing the utility and feasibility of indicators, but research of relevance to this topic also appears in social science, public health and prevention literature and occasionally in general health and medical journals. Other stakeholders should also be involved in the process of
DOI of original article: http://dx.doi.org/10.1016/j.ejogrb.2013.08.019 0301-2115/$ – see front matter ß 2013 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ejogrb.2013.09.033
indicator development, including population health scientists, quality managers, perinatal epidemiologists, statisticians, ministry of health staff, and the public. Not all ideas concerning new perinatal indicators are feasible, especially across many nations, jurisdictions and systems for health care delivery. Casting a broad net, followed by careful consideration of existing and proposed indicators, can ensure that each measure serves its intended purpose. As noted in their letter in this issue of the Journal, the EuroPeristat program casts a broad net that includes the broadest constituencies possible in the development and evaluation of European perinatal quality indicators [8]. While Santos et al. [7] are to be commended for their interest in this process, the wellarticulated approach devised and implemented by the EuroPeristat team and its scientific committee ensures that perinatal indicators used are valid and reliable, measurable, produce comparable data, and are evidence-based. While some measures might be seen by some perinatal professionals as desirable, systems to capture the relevant inputs and quantitate the measure may not be in place. Given the need to collect comparable data using consistent definitions across 29 countries (each comprised of numerous hospitals and birthing centers with differing practice styles) indicators must be selected after careful deliberation. As one case in point, Santos et al. [7] identify severe neonatal morbidity among babies at high risk as one of the most relevant indicators. ‘High risk’ is a very subjective assessment. To be comparable across the Euro-Peristat countries, data on this indicator would require very detailed definitions, and most likely include an algorithm with numerous clinical inputs. Clinicians may also disagree as to the definition of ‘severe neonatal morbidity’. Perhaps a consensus might emerge around a clinical tool such as the Score for Neonatal Acute Physiology (SNAP) in one of its various permutations, but implementation across all facilities caring for newborn infants or those in neonatal intensive care might prove problematical [9]. It is difficult enough to ensure comparable data for perinatal indicators in widespread use since the mid-20th century, as recently demonstrated by Joseph et al. [6]. Perinatal indicators serve an important and useful purpose in focusing attention on trends and relative differences in health outcomes, population characteristics and perinatal services. Only when they are developed, monitored, evaluated and implemented using a comprehensive and scientific framework will the resulting data provide the basis for initiatives to improve the quality of care and outcomes for women and their pregnancies.
2
Editorial / European Journal of Obstetrics & Gynecology and Reproductive Biology 171 (2013) 1–2
References [1] Main EK. New perinatal quality measures from the National Quality Forum, the Joint Commission and the Leapfrog Group. Curr Opin Obstet Gynecol 2009;21: 532–40. [2] Donabedian A. Evaluating the quality of medical care. Milbank Mem Fund Q 1966;44:166–206. [3] Mainz J. Defining and classifying clinical indicators for quality improvement. Int J Qual Health Care 2003;15:523–30. [4] Zeitlin J, Wildman K, Breart G, et al. Selecting an indicator set for monitoring and evaluating perinatal health in Europe: criteria, methods and results from the PERISTAT project. Eur J Obstet Gynecol Reprod Biol 2003;111:S5–14. [5] Euro-Peristat Project with SCPE and EUROCAT. European perinatal health report: health and care of pregnant women and babies in Europe in 2010; May 2013, Available at: http://www.europeristat.com/images/European%20 Perinatal%20Health%20Report_2010.pdf. [6] Joseph KS, Liu S, Rouleau J, et al. Fetal and Infant Health Study Group of the Canadian Perinatal Surveillance System Influence of definition based versus pragmatic birth registration on international comparisons of perinatal and infant mortality: population based retrospective study. Br Med J 2012;344:e746. [7] Santos JV, Correia C, Cabral F, Bernardes J, Costa-Pereira A, Freitas A. Should European perinatal indicators be revisited? Eur J Obstet Gynecol Reprod Biol 2013;170:85–9.
[8] Zeitlin J, Mohangoo A, Macfarlane A, et al., the Euro-Peristat Scientific Committee. Building a European perinatal health information system: plurality, innovation and realism. Eur J Obstet Gynecol Reprod Biol 2013;171:193–4. [9] Dammann O, Shah B, Naples M, et al., ELGAN Study Investigators. Interinstitutional variation in prediction of death by SNAP-II and SNAPPE-II among extremely preterm infants. Pediatrics 2009;124:e1001–06.
Russell S. Kirby* Department of Community and Family Health, College of Public Health, University of South Florida, United States *Correspondence to: Department of Community and Family Health, University of South Florida College of Public Health, 13201 Bruce B. Downs Boulevard, MDC56, Tampa, FL 33612, United States. Tel.: +1 813 396 2347 E-mail address: [email protected] (R.S. Kirby)
