Large-Scale Evaluation of Quality of Care in 6 Countries of Eastern Europe and Central Asia Using Clinical Performance and Value Vignettes

John W Peabody; Lisa DeMaria; Owen Smith; Angela Hoth; Edmond Dragoti; Jeff Luck

doi:10.9745/GHSP-D-17-00044

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FIGURE
Mean CPV Vignette Scores by Country and Condition
Abbreviations: CPV, Clinical Performance and Value; NCD, noncommunicable disease.
*Russia measured quality of care only for NCDs.

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TABLE 1.

Population and Health Characteristics of the ECA Countries Included in the Quality of Care Study, 2013^a

	Albania	Armenia	Georgia	Kazakhstan	Kirov Province, Russia^b	Tajikistan
Population	3,173,000	2,977,000	4,341,000	16,441,000	1,315,003	8,208,000
World Bank income group	Upper middle	Lower middle	Lower middle	Upper middle	High (Russia)	Low
% of population living in urban areas	53%	63%	53%	53%	74% (Russia)	27%
Life expectancy at birth	73 male 76 female	67 male 75 female	71 male 78 female	63 male 73 female	64 male 76 female	68 male 70 female
Total expenditure on health as % of GDP (2012)	6.0%	4.5%	9.2%	4.2%	6.3% (Russia)	5.8%
No. of physicians per 1,000 population	1.2	3.8	4.8	4.1	4.7	2.1
Neonatal mortality (deaths per 1,000 live births)	7	8	8	8	5	21
Maternal mortality (deaths per 100,000 live births) (2013)	21	29	41	26	24 (Russia)	44
Adult risk factors
Tobacco smoking (2011)	26%	22%	27%	24%	40% (Russia)	N/A
High blood pressure (2008)	37%	42%	43%	35%	38% (Russia)	31%
Obesity (2008)	21%	24%	22%	24%	27% (Russia)	9%
% of total deaths due to NCDs, all ages, both sexes (2013)	89%	92%	93%	84%	86% (Russia)	62%
% of total deaths due to cardiovascular disease, all ages, both sexes (2013)	59%	54%	69%	54%	60% (Russia)	38%

Abbreviations: ECA, Eastern Europe and Central Asia; GDP, Gross Domestic Product; NCDs, noncommunicable diseases; UNICEF, United Nations Children's Fund; WHO, World Health Organization.
Sources: Albania, WHO (http://www.who.int/countries/alb/en/); Armenia, WHO (http://www.who.int/countries/arm/en/); Georgia, WHO (http://www.who.int/countries/geo/en/); Kazakhstan, WHO (http://www.who.int/countries/kaz/en/); Russia, Knoema World Data Atlas (http://knoema.com/atlas/Russian-Federation/Kirov-Region/Population); Tajikistan, WHO (http://www.who.int/countries/tjk/en/); and neonatal mortality for all countries, UNICEF (http://data.unicef.org).
↵^a 2013 data unless otherwise specified.
↵^b Data for Kirov Province only, unless otherwise specified.

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TABLE 2.

Variation of Mean CPV Vignette Scores (%) for Neonatal Care Conditions, By Country

	Neonatal Pneumonia				Birth Asphyxia
	Mean	25th Percentile	75th Percentile	Difference Between 25th and 75th Percentiles	Mean	25th Percentile	75th Percentile	Difference Between 25th and 75th Percentiles
All Countries	61.7	51.7	75.0	23.3	53.6	42.3	65.1	22.8
Albania	57.8	47.5	72.5	25.0	48.1	38.0	57.5	19.5
Armenia	65.3	55.8	77.5	21.7	57.0	47.5	70.0	22.5
Georgia	65.9	57.5	77.5	20.0	60.4	47.5	72.5	25.0
Kazakhstan	68.0	60.0	77.5	17.5	56.9	44.6	70.5	25.9
Kirov, Russia	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Tajikistan	52.6	42.5	65.0	22.5	47.7	37.5	59.9	22.4

Abbreviation: CPV, Clinical Performance and Value.

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TABLE 3

Variation of Mean CPV Vignette Scores (%) for Postpartum Hemorrhage, By Country and Type of Clinician

	Physicians				Midwives
	Mean	25th Percentile	75th Percentile	Difference Between 25th and 75th Percentiles	Mean	25th Percentile	75th Percentile	Difference Between 25th and 75th Percentiles
All Countries	63.5	52.9	75.2	22.3	55.1	43.6	67.1	23.5
Albania	55.6	47.5	63.1	15.6	47.4	35.0	59.4	24.4
Armenia	61.1	52.3	70.6	18.3	47.4	34.9	59.5	24.6
Georgia	67.4	56.3	77.5	21.2	54.2	44.5	63.8	19.3
Kazakhstan	69.9	61.5	79.4	17.9	64.3	56.1	74.8	18.7
Kirov, Russia	N/A	N/A	N/A	N/A	N/A	N/A	N/A	N/A
Tajikistan	59.5	48.7	72.6	23.9	59.6	48.9	71.4	22.5

Abbreviation: CPV, Clinical Performance and Value.

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TABLE 4.

Variation of Mean CPV Vignette Scores (%) for Noncommunicable Disease Conditions, By Country

	CPV Vignette Condition
	Acute Myocardial Infarction				Multiple NCD Risk Factors
	Mean	25th Percentile	75th Percentile	Difference Between 25th and 75th Percentiles	Mean	25th Percentile	75th Percentile	Difference Between 25th and 75th Percentiles
All Countries	61.1	48.8	74.7	25.9	56.0	44.9	67.1	22.2
Albania	46.7	36.2	57.3	21.1	45.5	37.0	53.1	16.1
Armenia	62.7	53.3	73.9	20.6	56.1	44.3	67.1	22.8
Georgia	65.0	54.0	76.6	22.6	56.3	47.1	67.0	19.9
Kazakhstan	66.7	55.8	78.7	22.9	61.0	53.0	69.6	16.6
Kirov, Russia	75.3	65.1	84.5	19.4	67.8	62.3	72.5	10.2
Tajikistan	49.2	38.3	58.1	19.8	44.0	35.6	54.3	18.7

Abbreviations: CPV, Clinical Performance and Value; NCD, noncommunicable disease.

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TABLE 5.

Average CPV Vignette Scores (%), by Clinician Specialty and CPV Vignette Condition

	CPV Vignette Condition
	Multiple NCD Risk Factors (n=1,034)	Acute Myocardial Infarction (n=1,027)	Neonatal Pneumonia (n=733)	Birth Asphyxia (n=641)	Postpartum Hemorrhage (n=628)
	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)	Mean (SD)
All physicians
General practice (n=633)	53.9 (15.7)	57.3 (17.4)	59.0 (18.2)	48.5 (16.9)	54.9 (14.8)
Pediatricians (n=1,005)	–	–	63.2 (16.9)	56.2 (16.7)	–
Internal medicine (n=910)	58.7 (15.7)	66.2 (15.8)	56.5 (15.2)	45.4 (13.5)	60.3 (18.5)
Cardiologists (n=270)	55.9 (15.0)	69.2 (14.5)	–	–	–
OB/GYN (n=637)	–	–	51.7 (16.2)	54.1 (16.0)	64.0 (15.4)
Other physicians (n=45)	53.7 (16.2)	53.4 (17.9)	52.7 (12.4)	41.9 (17.3)	49.5 (6.9)
Midwives (n=353)	–	–	–	–	55.1 (17.0)

Abbreviations: CPV, Clinical Performance and Value; NCD, noncommunicable disease; OB/GYN, obstetricians/gynecologists; SD, standard deviation.

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TABLE 6.

Health Care Structural Quality Factors by Country and Facility Type

	Country and Facility Type
	Albania		Armenia		Georgia		Kazakhstan		Kirov, Russia		Tajikistan
	Total	Hospital	Total	Hospital	Total	Hospital	Total	Hospital	Total	Hospital	Total	Hospital
Average catchment	29,555	78,204	15,649	38,300	13,225	39,569	N/A	N/A	14,105	17,565	50,693	119,048
Average no. of full-time physicians	24	60	22	52	32	76	N/A	N/A	35	48	36	61
Average no. of full-time nurses	38	104	50	132	30	83	N/A	N/A	119	174	84	207
Infrastructure items
Controls/operates pharmacy (%)	45%	92%	95%	100%	49%	100%	N/A	N/A	30%	42%	17%	37%
Owns transportation (%)	33%	100%	46%	83%	26%	69%	N/A	N/A	86%	96%	43%	72%
Medical equipment and supplies in working condition (% out of 54 items)	35%	60%	48%	75%	40%	72%	N/A	N/A	43%	56%	34%	53%
Laboratory tests available (% out of 35 items)	45%	58%	59%	73%	70%	72%	N/A	N/A	75%	77%	54%	60%
Medications in stock (% out of 43 items)	35%	52%	42%	54%	18%	45%	N/A	N/A	10%	15%	28%	44%
No. of ambulances with defibrillators	20.8	27.2	1.1	1.5	1.4	1.8	N/A	N/A	1.2	1.3	0.4	0.6
No. of computers in working condition	5.8	18.2	5.6	14.6	9.4	23.8	N/A	N/A	27.3	37.6	2.6	6.7
Operational items
Committees/bodies at the facility
Quality assurance/review committee	15%	31%	59%	94%	27%	63%	N/A	N/A	44%	60%	27%	46%
Morbidity and mortality conference or committee	12%	33%	30%	67%	18%	57%	N/A	N/A	48%	65%	52%	93%
Infection control committee	11%	36%	33%	60%	22%	59%	N/A	N/A	40%	53%	56%	76%
Pharmacy or therapeutics committee	16%	81%	56%	81%	16%	47%	N/A	N/A	9%	11%	10%	17%
Written guidelines for treatment and management of various conditions (% out of 18)	58%	60%	66%	60%	55%	44%	N/A	N/A	79%	81%	34%	36%
Able to pull patient chart based on name (%)	77%	72%	98%	98%	55%	65%	N/A	N/A	34%	40%	48%	52%
Have system to track patients who require chronic care but miss follow-up (%)	39%	21%	58%	29%	46%	45%	N/A	N/A	86%	83%	68%	46%