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How to Help French Patients Find Their Way Through the Healthcare System?

How to Help French Patients Find Their Way Through the Healthcare System?
 Laure Millet
Fellow - Healthcare

Institut Montaigne publishes today the report Système de santé : soyez consultés ! ("Healthcare System: be Consulted!") on quality indicators relevant for patients, in the French healthcare system. The objective of these indicators is to make available to patients the information they need on quality and safety of care, so as to enable them to orient themselves within the healthcare system, measure the medical service provided by an institution on the basis of criteria established by patients, and compare the quality of care provided by institutions.

What information do patients have now to judge the quality of care provided to them? Do they really have the possibility to compare medical care with one another, whether it is administered in a hospital or in the city, and on the basis of which criteria? In France, the quality of care is assessed through processes and available resources rather than real results. Indeed, there is no consideration of clinical outcomes (Clinical Reported Outcomes Measures, CROMs), such as relapse rates, hospital mortality or readmission rates, for example, nor outcomes measured and reported by the patient (Patient Reported Outcomes Measures, PROMs), such as elements related to their quality of life.

    66 % of French respondents feel that it is difficult today to obtain information on the quality of care in health institutions...

    However, these outcome indicators (clinical and quality of life) are essential in assessing the quality of care and useful both for the patient and for medical teams so that they can compare their practices and make progress. Like other patients, French patients want to be able to compare healthcare facilities on the basis of criteria that are important to them. According to a survey conducted by Kantar for Institut Montaigne, 66 % of French respondents feel that it is difficult today to obtain information on the quality of care in health institutionsand 59 % feel that it is difficult to choose a medical facility (hospital, clinic, etc.).

    To help patients choose a care facility according to their expectations, it is necessary to measure and evaluate the management of a given disease as well as the good medical practices carried out by an institution or a doctor. Quality indicators are relevant tools to achieve this objective and provide the information French citizens need.

    How is the quality of care measured in France?

    In France, the High Healthcare Authority (Haute Autorité de Santé or HAS) is responsible for developing quality indicators for our health system. It also collects the near-majority of the measures of these indicators, i.e. about fifty indicators of quality and safety of care, divided into two categories.

    These indicators developed in France have two major limitations

    • they are process-related indicators and indicators measuring patient experience and satisfaction following a hospital stay (PREMs) and not outcome indicators focusing on patients' functional score or quality of life (PROMs) and patients' clinical status (CROMs);
    • patients’ associations have been weakly included in the choice of quality and safety of care indicators developed by the Haute Autorité de Santé. While patients’ associations have been allowed since September 2017 to contribute to the evaluation of medicines and medical devices for reimbursement within the HAS, they still have a limited presence in the development of quality indicators, the latter therefore do not reflect indicator measures that matter to patients. 

    According to the Kantar survey,   However, there are no tools to measure such information in France.

    Who are the right students in this field?

    Unlike France, which measures indicators based on the assessment of compliance with processes and not on the outcomes of care provided, foreign initiatives and assessment systems focus more on clinical outcomes and outcomes reported by individuals in terms of quality of life.

    In the United Kingdom, the collection of outcome indicators by the National Health Service (NHS), the equivalent of Assurance Maladie in France, is mandatory for four targeted diseases: knee surgery, hip surgery, varicose vein surgery and hernia. 100% of the results collected are published online (My NHS and NHS Choice) and enable English citizens to make informed choices about their hospitals and healthcare professionals based on many quality indicators. The NHS Choice database is very popular and counts 48 million visits per month, thus responding to a real demand (in comparison, the French Health Insurance site "" counted about five million separate visitors per month in 2016).

      In the Netherlands, the Dutch Surgical Colorectal Audit (DSCA) was founded in 2009 at the initiative of the doctors of the Association of Surgeons of the Netherlands, to assess and improve the quality and good practice of hospital care in the case of colorectal cancer. The observed hospital participation rate in this registry was 100 %. Building on this success, the Netherlands Institute of Clinical Audit (DICA) was established in 2011 with the objective of developing and coordinating other national outcome registers covering several diseases. 21 registries have since been created, including for breast cancer, upper gastrointestinal cancer and lung surgery.

      ...and 59 % feel that it is difficult to choose a medical facility (hospital, clinic, etc.).

      As part of this study, Institut Montaigne conducted several workshops with six patient’s associations in the following therapeutic areas: Crohn's disease, colorectal cancer, bipolar disorders, chronic renal diseases, diabetes and hemophilia. Based on quality indicators defined at the international level by clinicians, patient’s associations and public bodies, those present at these workshops identified the indicators they felt were important. These were then submitted by survey to the members (patients, relatives and caregivers) of each association in order to validate the indicators most relevant to them. In total, more than 300 people were involved in the process.

      Our ten propositions to accelerate the deployment of results indicators in France

      Institut Montaigne puts forward ten proposals for the definition, production, publication and use of outcome indicators that matter to patients, in France. Our ambition is to define, by 2022, outcome indicators that are relevant to patients for 80% of care.

      First step: define the outcome indicators that are important to patients  

      • Proposal 1: create a multidisciplinary task force dedicated to defining performance indicators and steering the roadmap, based on indicators developed at the international level.

        In order to define outcome indicators (PROMs and PREMs), a working group should be mobilized at ministerial level bringing together stakeholders and experts to define and validate sets of outcome indicators in nine medical care, thus covering 80 % of care by 2022.

      Second step: production of performance indicators 

      • Proposal 2: systematize the collection of clinical outcome indicators from practitioners and health facilities.

        The collection of clinical outcome indicators should be systematized among healthcare teams, building on existing information systems and developing their capacities, initially through pilot initiatives.
      • Proposal 3: collect outcome indicators from all individuals concerned in the targeted diseases.

        Give the French Health Insurance (Assurance Maladie) the responsibility of collecting outcome indicators from patients. It is the most relevant actor because of the relationship it already has with patients and its mastery of health data.

      Third step: publication of performance indicators 

      • Proposal 4: make 100 % of the performance indicators defined by the task force transparent and accessible through a public website.

        All the performance indicators defined by the task force and considered important to patient’s associations must be accessible through a public website so that all stakeholders can use them for analysis, publication or ranking purposes.
      • Proposal 5: allow health facilities to adjust the level of transparency of their indicators during a transitional period.

        The collection, use and publication of data is a shift for our healthcare system. This must be gradually deployed and supported to promote ownership of these practices by stakeholders, primarily institutions and clinicians.

      Fourth step: use of outcome indicators to improve the quality and performance of the healthcare system  

      • Proposal 6: integrate outcome indicators into the licensing regimes for care activities and certification.

        A minimum level of quality in health care facilities must be defined per pathology and based on the analysis of outcome indicators in order to optimise the safety of care.
      • Proposal 7: build quality improvement programs based on performance indicators.

        Outcome indicators that are important to patients should be used to identify quality improvement programs within health care facilities.
      • Proposal 8: use outcome indicators to improve evaluation and relevance of care.

        The choice of treatments and management methods must be guided by an analysis of the data from the outcome indicators in order to optimise the relevance of the care provided to patients.

      Fifth step: application of outcome indicators in remuneration mechanisms for healthcare system actors

      • Proposal 9: increase the share of quality-based remuneration in the incomes of doctors and health care institutions.

        Outcome indicators that matter to patients and defined by the task force should be gradually integrated into the remuneration mechanisms of health care institutions and practitioners.
      • Proposal 10: use outcome indicators to restore a minimum level of quality requirement.

        For pathologies that are paid per episode of care, optimizing the use of outcome indicators will prevent a deterioration in the quality of care and will benefit medical teams by providing them with additional remuneration.
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