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Evaluating Portuguese primary healthcare through Prevention Quality Indicators (PQIs ). Introdução à Medicina I/II Class 9 Adviser: Alberto Freitas. What are PQIs?. QIs Not definitive measures Use hospital discharge inpatient data Based on readily available data. PQIs

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Evaluating Portuguese primary healthcare through

Prevention Quality Indicators

(PQIs)

Introdução à Medicina I/II

Class 9

Adviser: Alberto Freitas

slide2

What are PQIs?

IntroMedI - class 9 - PQIs

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QIs

  • Not definitive measures
  • Use hospital discharge inpatient data
  • Based on readily available data

IntroMedI - class 9 - PQIs

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PQIs

  • Primary Healthcare
  • Ambulatory Care Sensitive Conditions
  • “avoidable hospitalization rates are a sensitive indicator for assessing quality of primary ambulatory care” (Niti et al, 2003)

Prevention starts here.

IntroMedI - class 9 - PQIs

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Source: Ansari Z. Laditka JN. Laditka SB. Access to Health Care and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care Res Rev. 2006; 63:719-742

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When were they first introduced?

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Studies of the kind in other countries

  • United States (Starfied et al.,1991, Sanderson et al., 2000, Kozak et al., 2001)
  • Australia (Ansari et al., 2003, 2006)
  • New Zealand (Sheerin et al., 2006)
  • Canada (Roos et al., 2005, Porter et al., 2007)
  • Singapore (Niti & Ng, 2003)
  • Spain (Sánchez et al., 2004)
  • Italy (Rizza et al., 2007)

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Source: Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; March 2007.

IntroMedI - class 9 - PQIs

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This kind of studies

  • evaluate the quality of the healthcare conditions
  • establish patterns
  • allow comparison with past and future works inside and outside the sampling area.

IntroMedI - class 9 - PQIs

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Key-words

  • Ambulatory Care
  • Primary Care
  • Quality of Healthcare
  • Portugal
  • Delivery of Healthcare
  • Prevention Quality Indicators

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Aim

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RESEARCH QUESTION

What is the status of the primary health care system in Portugal and how does it compare to past years and among its regions?

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AIMS

  • Assessment of the primary healthcare system quality, in an outpatient setting.
  • Compare different level 2 NUTS*, trends 2000-2005
  • Lay hypotheses for the observed differences.
  • *except for Azores and Madeira.

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ParticipantsandMethods

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PARTICIPANTS

  • 6199102 patients’ discharge data from national database (ACSS)
  • 94 Acute Care Public Hospitals (continent)

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DATA COLLECTION

  • Data collected from acute care hospital database
  • Variables of interest present in the database or calculated from others
  • INE (Instituto Nacional de Estatística) provides populational and other statistical data

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Division in NUTS II

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INCLUSION

  • Diagnosis according to PQI
  • EXCLUSION
  • Age <18
  • MDC = 14 or 15
  • Transferred from
  • Related non-evaluative conditions

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Source: Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; March 2007.

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INVALID

  • Address codes missing. non-existent or belonging to the Azores or Madeira.
  • Absurd age (below 0; over 150)
  • Undetermined Sex (3)

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STRATIFICATION

  • NUT II (Norte, Centro, Lisboa, Alentejo, Algarve)
  • Year (2000-2005)
  • Gender
  • Age (0-17; 18-24; 25-34; 35-44; 45-54; 55-64; 65-74; 75+)

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RESULTS OVERVIEW

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*

* Overall PQI = Sum of all PQIs except for 2 and 9

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Significant Associations

  • Life Quality
    • GIP per Capita
    • Life Expectancy at Birth
  • Healthcare Facilities
    • Number of Health Centers per 100.000 pop.
    • Medical visits per inhabitant
    • Number of doctors per 1000 pop.
  • Education
    • Literacy Index
    • Proportion of active population with minimum education (“3º Ciclo”)
    • Proportion of active population with secondary education or higher
  • Neonatal
    • Age of first pregnancy

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Significant Associations

  • Overall PQI
  • Acute PQI
  • Diabetes PQI

No significant associations found

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Diabetes short-termcomplication

  • Doctors (N)r=-0,70
  • Nurses (N) r=-0,81
  • Lit. Indexr=-0,67
  • Lifeexp. r=-0,61
  • Med. Visitsr=-0,59
  • Health Centres r=0,74
  • Hospital Distancer=0,76

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PerforatedAppendix

  • Pop. Densityr=-0,96
  • Med. Visitsr=-0,76
  • Doctors (N) r=-0,53
  • LifeExp.r=-0,43
  • Lit. Indexr=- 0,40
  • Hospital Distancer=0,37

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NONE

  • Med. Visits r= 0,71
  • Life Exp. r= 0,60
  • Sec. Education r= -0,36
  • Min. Education r= -0,35

Diabetes Long-termcomplication

COPD

  • Hospital Distance r= -0,53
  • Min. Education r= -0,39

Hypertension

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Doctors (N) r= -0,68

  • Lit. Index r= -0,68
  • Health Centres r= 0,70
  • Hospital Distance r= 0,56
  • Hospital Distance r= 0,78
  • Health Centres r= 0,73

CongestiveHeartFailure

Dehydration

Lit. Index r= -0,64

Life Exp. r= -0,40

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Sec. Education r= 0,49

  • Min. Education r= 0,52
  • GDP r= 0,37
  • Life Exp. r= -0,51
  • Med. Visits r= -0,51

Bacterial Pneumonia

UrinaryTractInfection

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GDP r= 0,54

  • Minim. Education r= 0,44
  • Sec. Education r =0,42

Hospital Distance r= 0,74

Health Centres r= 0,63

Minim. Education r= 0,33

  • Life Exp. r= -0,50
  • Lit. Index
  • r= -0,62

Angina withoutProcedure

Lower-extremetyamp. inDiabetics

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Uncontrolled Diabetes

Med. Visits r= 0,50

AdultAsthma

GDP r= 0,50

Min. Education r= 0,47

Sec. Education r =0,46

Lit. Index r= 0,38

Med. Visits r= -0,57

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LowBirthWeightper 100 neonates

GDP

r=0,70

Age 1st Pregnancy

r=0,64

Mean

Fig.6 Mean age of first child vs LBW Linear Regression

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Cost Analysis

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Discussion

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Prevention

  • There are differentlevelsofprevention
    • Preventingtheonsetofthecondition
    • Preventingtherampagedevelopmentofsymptoms; i.econtrolingthecondition

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Sources: INE, 2005; Cónim C. População e Desenvolvimento Humano- Uma Perspectiva de Quantificação -1970-1999; Marques JL, Martins JM, Castro EA. Análise input-output rectangular inter-regional - emissões de CO2 em Portugal e o protocolo de Quioto

Fig.9 Overall PQI per NUT II

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Self-PerceptionofHealth

Source: National Health Survey, 1999

Overall PQI

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PatientProfile

  • Male
  • Elderly (75 years old +)
  • Living in areas not densely populated

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Studies supporting this association:

Lockwood et al .Stress-associated preterm delivery: the role of corticotropin-releasing hormone.

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COPD

Hypertension

CHF

Asthma

COPD

Asthma

CHF

Hypertension

CHF

Diabetes

Hypertension

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Dehydration

Dehydration

Dry arid

BWk – arid, desert, cold arid

Mediteranean

Csb – warm temperature, summer dry,

warm summer

Csa – warm temperature, summer dry,

hot summer.

Wet all seasons:

Dfa – snow, fully humid, hot summer ;

Dfb – snow, fully humid, warm summer

Humid subtropical:

Cfa – warm temperature, flly humid, hot summer

Dry semiarid

BSk – arid, steppe, cold arid

BSh – arid, steppe, hot arid

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Spain

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Study Limitations

  • Socioeconomic factors:
      • gender
      • age
      • Income
  • Propensity to seek care according to perceived health needs
  • Hospital bed availability
  • Regular source of care or continuity of care
  • Differences in healthcare service (Public/Private healthcare; Insurances)
  • Coding Issues
  • Lack in Epidemiological Studies (or inconsistent)
  • Intra-regional variations

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Conclusions

  • From 55 years old on:
    • There is a clear increase in avoidable hospitalizations
    • Males present higher avoidable hospitalizations rates
  • Differences among years are not significant
  • Norte presents the best quality/cost ratio
  • Portugal shows a more efficient primary healthcare system than USA or Spain.
  • Some heterogeneity among regions points to uneven primary healthcare supply
  • Further study is required to evaluate yearly trends and precise factors which influence PQ.

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FutureResearch

  • Multivariateanalysisofcorrelations
  • Litoral/Interior Analysis
  • Widertimespan (PreandPost SNS restructuration)
  • Carefulanalysisofeconomical indexes andprevalenceofanalysedconditions
  • FurtherInternationalComparison

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REFERENCES

  • PQI Info
  • Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Version 3.1. Rockville (MD): Agency for Healthcare Research and Quality; March 2007.
  • Farquhar, M. AHRQ Quality Indicators [slides]. Rockville (MD): Agency for Healthcare Research and Quality; 2005. 20 slides colour.
  • General Questions about the AHRQ QIs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; July 2004 [cited 2007 Oct 31]. Available from: http://www.qualityindicators.ahrq.gov/general_faq.htm
  • AHRQ Prevention Quality Indicators Overview [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; July 2004 [cited 2007 Oct 31]. Available from: http://www.qualityindicators.ahrq.gov/pqi_overview.htm
  • Agency for Healthcare Research and Quality. Prevention Quality Indicators: Technical Specifications. Version 3.2. Rockville (MD): AHRQ; March 2008.

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Related Articles

  • Ansari Z, Laditka JN, Laditka SB. Access to Healthcare and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care Res Rev. 2006; 63:719-42
  • Billings J, Zeitel L, Lukomnick J, Carey TS, Blank AE, Newman L. Impact of socioeconomic status on hospital use in New York City. Health Aff (Millwood). 1993; 2:162-9.
  • Starfield B. Primary care and health: a cross-national comparison. JAMA. 1991; 266:2268-71.
  • Sanderson C, Dixon J. Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care. J Health Serv Res Policy. 2000, 5:222-30.
  • Kozak LJ, Hall MJ, Owings MF. Trends in Avoidable Hospitalizations, 1980-1998. Health Aff. 2001; 2 (20): 225-32.
  • Casanova C, Starfield B. Hospitalizations of children and access to primary care: a cross-national comparison. Int J Health Serv. 1995; 25:283-94.
  • Ansari Z, Barbetti T, Carson NJ, Auckland MJ, Cicuttini F: The Victorian ambulatory care sensitive conditions study: rural and urban perspectives. SozPraventivmed. 2003; 48:33-43.

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Sheerin I, Allen G, Henare M, Craig K. Avoidable hospitalizations: potential for primary and public health initiatives in Canterbury, New Zealand. N Z Med J. 2003; 119(1236).

  • Roos LL, Walld R, Uhanova J, Bond R: Physician visits, hospitalizations, and socioeconomic status: ambulatory care sensitive conditions in a Canadian setting. Health Serv Res. 2005, 40:1167-85.
  • Porter J, Herring J, Lacroix J, Levinton C. Avoidable Admissions and Repeat Admissions: What Do They Tell Us? Healthc Q. 2007, 10:26-28.
  • Niti M, Ng TP. Avoidable hospitalization rates in Singapore, 1991-1998: assessing trends and inequities of quality primary care, J Epidemiol Community Health. 2003; 57: 17-22.
  • Rizza P, Bianco A, Pavia M, Angelillo IF. Preventable hospitalization and access to primary healthcare in an area of Southern Italy. BMC Health Serv Res. 2007; 7:134.
  • Sanchez JLA, Vilalta JS, Perepérez SB, Martínez IM. Characteristics of avoidable hospitalization in Spain. Med Clin (Barc). 2004; 122(17):653-8.
  • Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA. 1992; 268:2388-94.

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Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially Avoidable Hospitalization inequalities in rates between US socioeconomic groups. Am J Public Health. 1997; 87:811-6.

  • Booth GL, Hux JE. Relationship Between Avoidable Hospitalizations for Diabetes Mellitus and Income Level. Arch Intern Med. 2003; 163:101-6.
  • Data Sources
  • Administração Central do Sistema de Saúde, IP (ACSS). www.acss.min-saude.pt
  • Statistics Portugal [Internet]. Lisbon: INE. 1864- [cited 2008 Mar 30]. http://www.ine.pt
  • Regulation (EC) No 1059/2003 of the European Parliament and of the Council of 26 May 2003 on the establishment of a common classification of territorial units for statistics (NUTS) (Official Journal L 154, 21/06/2003)
  • Departamento de Gestão Financeira. Serviço Nacional de Saúde – Contas Globais 2000 [Internet]. IGIF; 2002 Sep [cited 2008 Apr 19]. 192p. Available from: http://www.acss.min-saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2000.pdf

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Departamento de Gestão Financeira. Serviço Nacional de Saúde – Contas Globais 2001 [Internet]. IGIF; 2003 Nov [cited 2008 Apr 19]. 171p. Available from: http://www.acss.min-saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2001.pdf

  • Departamento de Consolidação e Controlo de Gestão do SNS. Serviço Nacional de Saúde – Contas Globais 2002 [Internet]. IGIF; 2004 Apr [cited 2008 Apr 19]. 237p. Available from: http://www.acss.min-saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2002.pdf
  • Departamento de Consolidação e Controlo de Gestão do SNS. Serviço Nacional de Saúde – Contas Globais 2003 [Internet]. Lisbon: Instituto de Gestão Informática e Financeira da Saúde; 2005 Apr [cited 2008 Apr 19]. 223p. Available from: http://www.acss.min-saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2003.pdf
  • Departamento de Consolidação e Controlo de Gestão do SNS. Serviço Nacional de Saúde – Contas Globais 2004 [Internet]. Lisbon: Instituto de Gestão Informática e Financeira da Saúde; 2006 Mar [cited 2008 Apr 19]. 187p. Available from: http://www.acss.min-saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2004.pdf

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Software

  • SPSS for Windows, Rel. 15.0.0 2006. Chicago (IL): SPSS Inc.
  • Microsoft Frontpage 2003, Rel. 11.5516.8202. USA: Microsoft Corporation.
  • International Data
  • Health, UnitedStates, 2007 ;U.S. DepartmentofHealthandHumanServices; Centers for DiseaseControlandPrevention; NationalCenter for HealthStatistics
  • WorldHealthOrganization. Availablefrom:www.who.int/en
  • M. C. Peel, B. L. Finlayson, and T. A. McMahon. UpdatedworldmapoftheKoppen-Geigerclimateclassification
  • National Diabetes Statistics. Availablefrom: diabetes.niddk.nih.gov/dm/pubs/statistics/
  • U.S. CensusBureau. Availablefrom:www.census.gov/

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Protocol developed by:

Ana Catarina Moura, [email protected]

Ana Margarida Oliveira, [email protected]

Bárbara Mendonça, [email protected]

Cláudia Pereira, [email protected]

Hélio Alves, [email protected]

João Miguel Rego, [email protected]

José Pedro Pinto, [email protected]

Maria Francisca Costa, [email protected]

Maria Guiomar Pinheiro, [email protected]

Nelson Couto, [email protected]

Ricardo Reis, [email protected]

José Alberto Silva Freitas, [email protected]

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Thank you for your time

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