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Mary Tran, MS
Director, QURE Healthcare
Outline
• Mission objectives
• Quality of Care Assessment
– Methodology
– Results
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Mission Objectives (September 2018)
• Obtain a sample assessment of the
quality of clinical care in Lao PDR:
Luang Prabang
• Assess vignettes as an effective
measurement tool to assist providers in
elevating their care and improving
patient outcomes nationwide
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Metholology
Improving the Quality of Healthcare
Satisfaction
Access Quality
Health
Structural Clinical
Outcomes
Inputs Practice
Patient
Process
Status
© QURE 2017
How Can You Measure and Improve Clinical
Practice: Clinical Performance and Value (CPV)
• Taking a history
• Conducting a physical
1• Measure: Physician cares for examination
patient vignettes, providing their • Ordering tests
responses to:
• Making a diagnosis
• Providing treatment
• Performance benchmarks
2• Feedback: Physician engaged to peers and to the
with customized feedback, evidence base
receiving information on: • Unneeded workup
• Personalized education
• Links to references
© QURE 2018 6.
5 sources of data used
1. Lao’s District Health Information System 2
2. Qualitative interviews with hospital and
district administrators
3. Provider Surveys
4. Facility Surveys
5. CPV Vignettes for hypertension, diabetes
mellitus and children’s diarrhea
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We Designed 3 CPV Patient Vignettes
Case Type Patient Presentation and Key Assessment Points
Mr. Bouphavanh, 52 years old, presents with unexpected weight loss
1. Recognize and institute cost-effective work-up of newly diagnosed diabetes and its
complications
2. Emphasize medical nutrition therapy as first-line treatment for newly diagnosed diabetes
Diabetes 3. Prescribe appropriate pharmacologic treatment for diabetes (metformin as first line)
4. Estimate and manage overall cardiovascular risk
5. Emphasize primary preventative care for patients with diabetes including screening,
vaccination and counseling
Mr. Kommandam, 66 years old, presents with shortness of breath
1. Recognize and initiate management of acute decompensated heart failure (HF)
Chronic including hospitalization;
Obstructive 2. Institute appropriate pharmacologic treatment for uncontrolled hypertension
Pulmonary 3. Recognize the patient has co-existing subclinical hypothyroidism
Disease 4. Estimate and manage overall cardiovascular risk
5. Emphasize primary preventative care for patients with COPD including screening,
vaccination and counseling
Keophothong, 5 years old, is brought in by his mother looking weak
1. Recognize severe dehydration in a child with diarrhea
2. Utilize cost-effective diagnostic tests to evaluate severity and etiology of diarrhea
Pediatric 3. Administer appropriate non-pharmacologic and pharmacologic treatment
Diarrhea for diarrhea with dehydration
4. Prescribe antibiotic therapy for a patient with acute gastroenteritis when necessary
5. Identify preventive strategies for diarrhea including those on sanitation, hygiene and
safe food practices
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57 Providers Across 6 Facilities in Luang
Prabang Completed the CPV Vignettes
Baseline Provider Characteristics
Number of Providers 57
Female 35 (61%)
Age 38.1+11.4
Provider Type
Advanced Nurse 1 (2%)
General Practice Physician 44 (77%)
Specialty Physician 4 (7%)
Did not State 7 (12%)
Facility (6)
Lao-Friend Hospital (Pediatrics) 10 (18%)
Luang Prabang Provincial Hospital 20 (35%)
Nan District Hospital 7 (12%)
Nambak District Hospital 8 (14%)
Ngoy District Hospital 5 (9%)
Xieng Ngeun District Hospital 7 (12%)
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Results
Overall Quality of Care Scores Varied, Showing a
Bell Shaped Distribution
CPV Score Distribution (n=57) Average Score:
44.0%±11.8%
30
10 (45%-65%)
5
0
0 10 20 30 40 50 60 70 80 90 100
Overall CPV Score
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Highest Scores in History and Physical; Most
Variation in Diagnosis and Treatment
Lao Mission 2: CPV Score by Domain (132 CPVs)
100%
80%
67%
60% 57% 48%
44% 43%
40%
30%
20%
0%
Total History Physical Workup Diagnosis Treatment
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Opportunity to Reduce Unneeded Testing,
Lower Costs and Improve Diagnostic Workup
Average No. of Unneeded Top 3 Unneeded Tests Ordered
Tests Ordered
Diabetes Diabetes
Sputum test (9)
0.8 2D echo/TTE (7)
HIV test (6)
Diarrhea Diarrhea
TB test (6)
0.3 HbA1c (3)
Blood typing (2)
Hypertension Hypertension
Abdominal ultrasound (6)
0.5 Sputum test (4)
Albumin (4)
Total Cases 37 48 47
Average Score 51.4% 39.2% 42.9%
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Provider Survey: What is high quality healthcare?
No. Characteristics % (n=57)
1 Evidence based/Effective treatment 19%
2 Good health/no illness 19%
3 Preventive and primary care 18%
4 Better outcomes 16%
5 Patient centered 11%
6 Accessible/comprehensive 11%
7 Good reception 9%
8 Good medical history 9%
9 Right diagnosis 9%
10 Good hygiene and sanitation 5%
11 Modern equipment/technology 4%
12 5G1S 4%
13 Quick recovery 4%
14 Specialty referrals 2%
15 Sufficient staff 2%
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16 Ethical 2% 15
Provider Survey: What are the top barriers to
providing high quality healthcare?
No. Characteristics % (n=57)
1 Lack of provider education 46%
2 Having necessary equipment 42%
3 Low patient cooperation 19%
4 Low patient education 14%
5 Access to medicines 12%
6 Lack of guidelines 11%
7 Language barriers 11%
8 Patient ethnic beliefs 7%
9 Staffing shortage 7%
10 Too many patients to see 5%
11 Access to remote areas 4%
12 Prevention 4%
13 Lab skills 4%
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14 Self-preservation 2% 16
We Also Completed 15 interviews with
District or Hospital Administrators
• Administrative and clinical stakeholders believe that improving skillsets of
providers is of primary importance to improving the quality of healthcare in Lao.
This ranked higher than obtaining healthcare equipment and resources in
discussions - “What good is having equipment if our doctors don’t know how to
use it?”
• District and Provincial hospitals offering only some ad hoc continuing medical
education. Provincial and District hospital administrators report rotating
providers quarterly or semi-annually through courses funded by the provincial
budget.
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Thank You
Questions?
Comments?
Appendix
CPVs have an Extensive Peer-Reviewed
Clinical Validation Record in the Literature
.
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Process is Most Proximal to Better
Outcomes
• Process measures are under our • Outcomes are affected by
control factors outside of health care
• Some providers deliver better clinical delivery
care than others • Outcome measures offer no
• Changing clinical behaviors is possible insight on how to improve
with good data and a gentle touch patient care
Diabetes HTN
Blood sugar
screening/testing rates Blood pressure screening rates
© QURE 2018
Drill Down: Diarrhea Care
Caring for Keophothong, 5
• 100% (n=37) identified the primary diagnosis (acute gastroenteritis), BUT
only one identified the specific etiology of the disease (Vibrio cholerae)
• More positively, 86% of providers ordered oral rehydration solution for the
patient
• Once the patient was stabilized and able to be discharged home, 62% of
providers offered appropriate preventive care services in the form of
counseling on good feeding practice, proper hygiene, food handling, etc.
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Drill Down: Hypertension Care
Caring for Mr. Kommandam, 66
• Only 21% (n=47), ordered the necessary diagnostic 2D
echocardiogram and only 31.9% performed a neuro exam
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Drill Down: Diabetes Care
Caring for Mr. Bouphavanh, 52
• Great workup: 92% (n=48) ordered either a fasting or random blood
sugar for this patient and nine providers ordering an HbA1c test
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