The below tables outline the types of health care services as well as delivery settings:

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1 Assuring Quality Health Care Delivery in Asia Introduction Guk-Hee Suh, PhD, MD, Chair, ISPOR Asia Consortium Health Service Providers (Clinicians) Committee, and Professor of Psychiatry, Hallym University College of Medicine, Hangang Sacred Heart Hospital, Seoul, South Korea Delivering quality health care includes using evidence-based efficient treatment, sound monitoring of patient treatment outcomes and an evaluation program to modify patient treatment. Basically it aims to keep safety of patients and raise the quality of life of patients. As always the issue is cost and access and quality, and often these issues are competing. Clinicians are asked to prevent disease at primary care levels but most diseases are progressing so there is a need for specialized care and chronic maintenance even through the use of long-term care facilities. As a universal rule, quality assurances are very, very important, and all practitioners and providers should see health care systems and treatments in this aspect. Human resources, along with health care institutions and pharmaceutical industry are key stakeholders in protecting this standard. Safeguards against over-prescribing, miscommunication, mismanaged patient / provider expectations, as well as misdiagnoses are essential for progress. The below tables outline the types of health care services as well as delivery settings: The ultimate aim for developing a quality assurance health care delivery system will be to maximize efficiency which will in turn free up more health resources and increase the access to care. Integration between the

2 different stakeholders, service providers and delivery settings will be essential to ensure that continuity of care isn t broken and positive outcomes are maximized. Mainland China Jiuhong Wu, PhD, Department of Pharmacy, 306 Hospital of PLA, Vice Chairman of Pharmacoeconomics Committee of Chinese Pharmaceutical Association, Beijing, China The growing ageing population is creating a new health care crisis in China. By 2050 it is estimated that there will be around 375 million elderly citizens. With this rise also comes a vast increase in the disease burden, particularly from non-communicable diseases. Chronic disease is becoming the major health burden in China. According to JAMA, the number of diabetes patients (in China) has increased from around 2.6% in 2002 to 11.6% in Regarding the treatment from hospital in China, there are several problems, such as, unbalanced distribution of hospital resources across areas, the large percentage of mild diseases treatment coming from first-class hospitals instead of clinical, and irrational use of medicine. Since majority of health care delivery occurs at hospitals, they have become overcrowded. And there is an unbalanced distribution of hospital resources across the country. The rational and efficient use of medicines is a major challenge, with the average annual use of antibiotic per capita more than 138 grams and 74% in patients, which represents over a twofold increase over three years. With the injection of Chinese medicine and other biological medicines, ancillary medicine use is very popular especially for cancer patients. There is high utilization of parenteral nutrition and intra-nutrition treatments as well. That being said, safety is very important. According to the CFDA national report, 690,000 case of ADR caused by abuse of medicines including 600 deaths occurred in Of that, 103,000 of ADR reports were attributed to Chinese medicine injection, which is very popular in China. The government cannot be faulted for lack of trying, as they have attempted to tighten the regulatory environment and safety protocols. But still, with limited success. The true success story can be found in antibiotic measurement. The Minister of Health has launched a special certification campaign, progress of which has been seen, for the clinical use of antibiotics from April The prescribing of antibiotics has decreased from 27% in 2006 to 15% in 2011,and it is still (keep) decreasing. Antibiotic use has dropped from 80 DDDs to 40 DDDs, bringing it closer to other country averaging of 20 DDDs. An area for significant improvement is in clinical pharmacy. In the US, there is a greater interest and supply of clinical pharmacists, but in China there are much less clinical pharmacists working in hospitals. Ideally, every big hospital needs to have five clinical pharmacists, but only a few of them in China can meet this standard. As an indicator of the lack of capacity, clinical pharmacist in China requires only a master s or bachelor s degree instead of PharmD training.

3 In conclusion, the true advancement of Health care serves in China can only be achieved by change in policy. For example, a payment model that reflects the value and outcomes will be necessary to combat waste and irrational deployment of resources in the payment of health care. Pharmacoeconomics and Health Outcomes Research will play an integral role in determining how these future mechanisms will be shaped. Israel Nicky Liebermann, MD, Head, Medicine Community Division, Clalit Health Services, Tel Aviv, Israel As a background, Israel has a population of a little more than 8 million inhabitants, and possesses a national obligatory health insurance system which started in There are four health plans that are both insurer and providers and the funding is by capitation based on age, sex, and periphery. The life expectancy is the fourth in the world, and Israel has one of the best health systems in the OECD (Organization for Economic Co-Operation and Development). The attrition rate is less than 1% between the health funds and more than 90% are happy or very happy with their health plan. Clalit is the largest health plan in Israel with 54% of the market share, and more than 4.2 million insured with an over-representation of the sick, poor, and elderly. There are more than 2,000 community clinics everywhere in Israel including child health centers, women s health centers, large consultant medicine clinics, more than 3,000 primary care physicians and 2,000 nurses. There are over 14 hospitals, including general, children, psychiatric and geriatric, and all are based on electronic information where a computerized system maintains the health data. With more than 42,000 employees, Clalit maintains a budget of around $5 billion. They also have their own pharmacies, laboratories, medical imaging institutes and 17 research centers. As a full health insurance provider, they provide primary, secondary, and tertiary care in a unified framework. Since attrition between health providers is low in Israel and patients are covered their entire life, Clalit has long term incentives for better health outcomes. A key emphasis lies in innovation and data. Data is centralized in a data warehouse that stores inpatient and outpatient data. They have coverage in all the community clinics and hospitals including data like smoking, smoking cessation, BMI, blood pressure measures, laboratories, pharmacies, imaging, social data, demographic data, costs, and chronic disease registries. Possessing data for a full lifespan, idetect, geo-coded EMR-based data exists on more than 4 million people and Clalit makes policy decisions based on analyzing this data. The primary concept is prediction, prevention, and as personalized treatment as possible. The data analysis is done at Clalit s Health Quarter. They identify the population at risk and build the policy decision support systems, thereby passing the information to the primary physicians through education. Researchers and managers follow the interventions and share the results with the teams, adjusting the intervention in course. Education is the main engine: education to the nurses, dieticians, and pharmacies increases the support to the physicians. Education improves the skills and motivation for the primary physicians, helps the people with the chronic diseases and

4 especially diabetes, and gives a better awareness of lifestyle choices in the general population. So there is an aim for early diagnosing, compliance, and prevention. As a case we may consider diabetes. In 1995 and 1996, there were no accepted guidelines. The treatment was only conducted by specialists in hospitals. There was a restriction on tests and drugs and there was minimal knowledge in the community. Thus the Clalit Diabetes Program was initiated which later became a national program. It was based on a quality circle centering on gathering data, analyzing the problem, planning the intervention, and implementing treatment. The cycle continually repeats until progress has been achieved. It was finally declared that diabetes should rest in the hands of the primary physicians and that was the main issue. Following suit, a diabetes patient registry was established, and initiative was taken to empower and educate the diabetic patients. Patient education was achieved through videos, brochures, websites and workshops in Hebrew, Arabic, and Russian (Israel has a lot of Russian immigrants). The program had to be adapted ethnically to fit into different cultural paradigms. Following implementation, monitoring and control was conducting via program quality indicators following the patients feedback to primary teams primary teams including dieticians, nurses, and physicians together. A special achievement in this program was that it was the first in the world to write special comprehensive guidelines for the treatment of chronic wounds and diabetic wounds and later to introduce new wound therapy technologies, like vacuum macrophages, and the Tele-Care nurse home unit for chronic wounds that visits the patients at home via computer. Patients could get consultation from the specialist and be administered the treatment at the patient s home. Insulin dispensary was initiated at the level of the primary physician. There was also a campaign starting with pre-diabetes, identifying and treating pre-diabetes with drugs, dieting, and lifestyle. The whole program looked at pre-diabetes identification, education, and treatment by testing the high risk patient groups, intensive gestational diabetes screening, education, and treatment, controlling diabetes, lipids, and hypertension, bariatric surgery to suitable patients given free of charge. And all these factors were combined in the computerized system for continuous quality improvement. The financial impact was that the cost of the diabetic patient was lowered by about a third. And diabetic patients are considered the most expensive population. There was also an adoption of an aggressive medical policy in identifying and treating gestational diabetes which is one of the sources of Type 2 diabetes in adults. So what were the results? The amount of patients with hemoglobin A1c more than 9 was lowered from about 40% of the patients to about 12% and increased patients with a hemoglobin A1c of less than 7 to 55%. About 75% of the patients are controlled with LDL below 130 mg%,

5 and 60% with an LDL of less than 100 mg%. Additionally, there was a reduction in the number of amputations in the diabetic patients by 26%. Astonishingly, in 2008 there was also a reduction in PCIs by 18% and in CABGs by 22% sustained since then. Then what happens in hospitals? All Clalit hospitals pass accreditation assessment by the JCI of the United States every three years. And all action in the hospitals are measured by quality indicators like length of stay in the emergency room, the time from admission to starting an antibiotic treatment or a procedure, the percentage of postoperative operations, the percentage of post-procedure complications, adequacy of treatment to guidelines like post myocardial infarction treatment, community-acquired infections, ICU care and so on. And, of course, they measure the patient and family satisfaction. All Clalit new technology adoption passes a thorough quality assurance and quality control process and usually it s implemented through a testing period registry. There is a pharmacovigilance department to monitor all ADRs and physician messages received. You probably all remember Vioxx - It wasn t allowed it to be sold in Clalit from the beginning. And after a long debate with MSD, it was allowed to be prescribed only by specialists in internal medicine and rheumatology and not by other physicians. And again the disease registries are based on disease management and guided care models. This article was taken from News Across Asia Volume 3 Number 4

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