100
Getting Better: Improving Health System Outcomes in Europe and Central Asia
Hard evidence on the quality of care in ECA countries remains limited, with some exceptions (Peabody et al. 2007; Hill, Chitashvili, and Trevitt 2012). Available information suggests that both the clinical process and the patient outcomes are suboptimal. For example, as indicated in the previous section, hypertension is under control in only about 10 percent of those with high blood pressure in many ECA countries. This common condition is relatively easy to treat with widely available and affordable drugs. Although the causes extend well beyond the clinical setting, one important reason is the low quality of care in the management of this major cardiovascular risk in ECA. To generate more systematic evidence on the topic for this report, a provider survey was conducted in five countries in the region: Albania, Armenia, Georgia, Russia (Kirov oblast), and Tajikistan. To provide context, it started with the structural aspect of quality by looking at the availability of key inputs for the diagnosis and treatment of common noncommunicable diseases and at maternal and neonatal conditions at the primary and secondary levels and found deficiencies of essential equipment and lab services that are most pronounced for primary care. For example, in Armenia, Georgia, and Tajikistan, primary-care facilities had less than one-third of the essential equipment and basic lab services required for the management of these common conditions. The main focus of the survey was the clinical process dimension of the quality of care using the approach of clinical performance and value (CPV) vignettes (Peabody et al. 2004). This method attempts to mimic a clinical encounter by presenting health workers with a hypothetical but realistic standardized patient scenario and asks openended questions across five domains: patient history, physical exam, ordering tests, diagnosis, and treatment. New information is revealed as the vignette unfolds so that each successive component can be assessed irrespective of previous responses. The objective is to measure provider knowledge as a proxy of the clinical process aspect of quality. The approach has been validated and used in a variety of settings (Peabody et al. 2000). In keeping with this chapter’s emphasis on cardiovascular disease and neonatal conditions, the survey used selected tracer conditions to evaluate the competency of health workers in three areas: cardiovascular disease (a patient with multiple risk factors and another with signs of a heart attack), neonatology (birth asphyxia and pneumonia), and obstetrics (postpartum hemorrhage). The results reveal significant shortcomings in quality of care. The average CPV score was 58 out of a maximum score of 100 (figure 3.13). In most countries, physicians’ performance is somewhat lower for cardiovascular disease, especially for a patient with multiple risk factors,
GB.indb 100
22/05/13 7:29 PM