Patient outcomes: the view from France

France has made a number of forays into collecting health outcomes data and now the time is right to turn pilot projects and regional initiatives into a coherent nationwide effort, according to high-level experts from government, academia and the health services.

There is an urgent need to break down silos between the myriad agencies with a role in healthcare and innovation, to enable this to happen, according to participants in a Healthy Measures event in Paris on 8 November.

While several rich databases have been developed, greater coordination is needed to unlock the full potential of the information they hold.

One of the key sources of data in France is an annual email survey of patient satisfaction (or not) with their experiences in French hospitals.

Between two and 10 weeks after discharge from hospital, patients receive an email from a national technical agency with a secure link to the questionnaire. The 61 questions take around 10 minutes to complete. If the recipient of the email takes no action, a reminder is sent.

Once the agency receives completed surveys, it feeds the data into a dynamic scoreboard which is updated every 48 hours. Hospitals can access the raw data, comments received from patients, details of the participation rate, and the detailed results behind its scoreboard performance.

“After two years of experimentation with between 150 and 200 hospitals, the system was launched on a compulsory basis in September 2015 and now covers 1,500 hospitals,” said Felix Faucon, an Inspector General, Inspection Générale des affaires sociales (Igas).

Strong response

Since the official launch last year, more than 615,000 patients have been invited to take the survey and over 110,000 have responded. The support of the national federation of patient associations helps to give visibility and credibility to the initiative, according to Faucon.

The big news will come later this year when satisfaction ratings will be published for the first time by the national health authority. “At the end of 2016, everyone will know the level of satisfaction in each hospital and learn where there is room for improvement,” Faucon said.

The database will only grow. The current survey targets people who have spent at least two days as an inpatient but authorities plan to extend this to patients who have stayed for just one night. The other major change that may be further over the horizon – and arguably the most significant – will be the addition of questions about patient perception of outcomes.

The existing questionnaire looks at various aspects of the patient experience – from hospital food quality to staff communications standards – but does not specifically probe for insights about how patients felt about the results of their treatment. “It’s difficult to do that due to the prevailing medical culture,” Faucon said. “So we need to wait but that may be a new frontier in future.”

Innovation nation

One of the biggest tasks for Jean-Yves Fagon, Delegate for Health Innovation at the French Ministry for Social Affairs and Health, is the implementation of new structures to accelerate the adoption of healthcare innovation. There is no shortage of official players with a role in fostering innovation, Fagon said, but this runs the risk of duplication and waste.

“The future of healthcare relies on innovation, so our system must adapt to new medical equipment and diagnostic technologies, as well as digital and connected devices, but we have far too many actors in this field,” he said. “One of my missions is to characterise the missions of each organisation, identify overlaps, and make the system more efficient and simplified.”

Greater effort is needed to evaluate digital technologies, Fagon said. “France has thousands of projects active in this area but no way to assess their value.”

Another hot topic is how to manage the wealth of data already stored in databases. As ever, the challenge is to ensure data security and privacy while opening up information to public and private entities.

“I have become more optimistic about succeeding in this area,” said Fagon. “Two years ago it was more difficult but there is a will now from all the main actors to give secured access to databases” However, he stressed that this data must be usable and that analysis should be restricted to genuine data experts.

As participants in the subsequent debate noted, much of the data collected in French databases measure processes rather than patient outcomes. For example, health insurers hold large volumes of unrefined data on morbidity and mortality, but this may not be useful in assessing PROMs. While the French regions are required to have a harmonised approach, greater cooperation at European level would also be essential to benchmarking France against its neighbours.