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Developing Quality Standards for the Hospital Management of Acute Stroke (QS for stroke)

Prof Anthony Rudd reading brain scans from a stroke patientiDSI has helped the Ministry of Health (MOH) develop the first set of evidence-informed clinical quality standards in Vietnam. They form part of wider efforts by the MOH to improve hospital care quality as Vietnam moves towards universal health coverage (UHC).

Stroke is the leading cause of death in Vietnam, with 230,000 cases annually accounting for 110,000 deaths and 1.7 disability-adjusted life years (DALYs) lost, and is estimated to cost the Vietnamese health system US$48m per year. Many complications are preventable using simple, inexpensive interventions, but many hospitals lack access to evidence-based standards of care due to workforce and capacity constraints. The MOH and the the Vietnam Health Economics Association (VHEA) requested iDSI practical support, in developing widely accepted and locally feasible standards of care, based on robust evidence and a nationally-owned process. The Rockefeller Foundation,  with its interest in supporting the transformation of health systems for UHC, provided funding support for the work.

Effective partnerships

NICE International and the Royal College of Physicians / NHS England together brought expertise in developing clinical quality indicators and delivering stroke service improvement in the UK and in LMICs worldwide. A multi-stakeholder Committee was convened, comprising MOH and provincial policymakers, stroke clinicians and hospital administrators across Vietnam. Through three workshops in Hanoi over 9 months, the Committee:

  • prioritised clinical areas with greatest potential for impact in Vietnam
  • identified relevant clinical recommendations from UK evidence-based guidelines
  • adapted these into quality statements with measurable indicators, appropriate to the Vietnamese context.

Stronger institutions

QS workshop small-group discussionsThe QS for Stroke brought together Vietnamese policymakers and stroke clinicians for the first time in a deliberative, evidence-informed process, with direct policy impact. The MOH has included quality standards among its hospital quality accreditation criteria, and is now funding pilot implementation of the QS for Stroke in several provinces through the World Bank North East and Red River Delta Regions Health System Support Project (NORRED). Vice Minister Prof Le Quang Cuong has also expressed his commitment to expand the development of quality standards in other disease areas.

Better decisions

The 15 standards emphasise low cost, high impact interventions, including prevention, joint working between disciplines around stroke units, early diagnosis, and early rehabilitation (mobilisation and swallowing checks).

Implementing the QS for Stroke will require significant investment. However, the best available evidence suggests that full implementation in all 1,050 acute hospitals could lead to estimated net savings of US$2.8m per year, primarily resulting from better care and referral processes, with associated reductions in lengths of stay.

Developing a Strategic Roadmap for HTA in Vietnam

Vietnamese hospital benefits planUnder the umbrella of the Rockefeller Foundation’s project on building a global agenda and institutional capacity for priority setting through HTA, HITAP and the Health Strategy and Policy Institute’s (HSPI) creation of a detailed two-year plan was the first step to establishing HTA research as a tool for policy-making in Vietnam. In discussion with the MOH, HSPI was assigned as the primary arm of the government in conducting HTA in the country. In April 2014, NICE International, HITAP, HSPI, and various stakeholders and policy-makers met to map out the rough framework of the plan, beginning with the preliminary selection of topics relevant to Vietnam’s current healthcare situation. During this initial meeting, HITAP researchers developed an assignment to guide the technical team including HSPI, Hanoi Medical University (HMU), Hanoi School of Public Health (HSPH), and VHEA, on the process of developing a set of selection criteria. Some articles related to health topics prioritization were suggested to the technical team as a primary document. And again in May, HITAP researchers had a face-to-face meeting with HSPI staff during the HTAsiaLink conference in Beijing to discuss the primary set of criteria which had been developed from literature reviews, how to select the criteria, how to use and define the criteria and scoring system, and HITAP’s experience on Thailand’s process for topic selection.

Subsequently, the technical team sent their first draft of the selection criteria set to HITAP for comments and suggestions. HITAP shared examples of topic nomination, evaluation, and conflict of interest declaration forms with the technical team and advised that they might use similar forms during their consultation workshop for purposes of transparency; and finally, the manual for selection criteria was completed in November 2014.

As a successfully functioning HTA organization, HITAP’s role is to provide HTA development oversight and make sure that the process is appropriate in the Vietnam context. As such, a two-day visit was conducted in June 11-12, 2014, and the agenda was focused on the first phase of the plan and involved developing criteria for topic selection, obtaining recommendations on HTA topics from stakeholders, and selecting 3-4 topics for further HTA research. On June 12, 2014, HITAP conducted a workshop on the methodology, the conduct, the economic evaluation models, estimating the health state preference, and costing for the chosen research topics.  These are, in particular, the following: using interferon and peg-interferon for treatment of chronic hepatitis C; using trastuzumab for treatment of HER-2+ breast cancer; and using MRI for non-specific diagnosis. Write-up and submission of the policy briefs and report manuscripts are set to be completed in June 2015, with the hope that they will become the first steps to HTA use in policy-making in Vietnam.

In conjunction with the national activities and to guarantee continuous growth, international efforts to support HTA introduction to Vietnam were also included in the plan, with HSPI’s membership in HTAsiaLink and continuous involvement in regional HTA meetings, such as the Asia Pacific Observatory (APO) meeting in November 2014. HSPI will also participate with HITAP and other HTA agencies in Asia in the Prince Mahidol Award Conference (PMAC) in 2015 as well as iDSI meetings and events.