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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

Evaluating Portuguese primary healthcare through

Prevention Quality Indicators

(PQIs)

Introdução à Medicina I/II

Class 9

Adviser: Alberto Freitas


Evaluating portuguese primary healthcare through prevention quality indicators pqis

What are PQIs?

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • QIs

  • Not definitive measures

  • Use hospital discharge inpatient data

  • Based on readily available data

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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


Evaluating portuguese primary healthcare through prevention quality indicators pqis

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

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

When were they first introduced?

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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)

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

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


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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


Evaluating portuguese primary healthcare through prevention quality indicators pqis

Key-words

  • Ambulatory Care

  • Primary Care

  • Quality of Healthcare

  • Portugal

  • Delivery of Healthcare

  • Prevention Quality Indicators

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

Aim

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

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.

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

ParticipantsandMethods

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • PARTICIPANTS

  • 6199102 patients’ discharge data from national database (ACSS)

  • 94 Acute Care Public Hospitals (continent)

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • INCLUSION

  • Diagnosis according to PQI

  • EXCLUSION

  • Age <18

  • MDC = 14 or 15

  • Transferred from

  • Related non-evaluative conditions

IntroMedI - class 9 - PQIs





Evaluating portuguese primary healthcare through prevention quality indicators pqis

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


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • INVALID

  • Address codes missing. non-existent or belonging to the Azores or Madeira.

  • Absurd age (below 0; over 150)

  • Undetermined Sex (3)

IntroMedI - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

RESULTS OVERVIEW

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

*

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

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

Significant Associations

  • Overall PQI

  • Acute PQI

  • Diabetes PQI

No significant associations found

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • Life Exp. r= -0,51

  • Med. Visits r= -0,51

Bacterial Pneumonia

UrinaryTractInfection

IntroMedII - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • 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


Evaluating portuguese primary healthcare through prevention quality indicators pqis

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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

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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Evaluating portuguese primary healthcare through prevention quality indicators pqis

Cost Analysis

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

Discussion

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

  • Prevention

  • There are differentlevelsofprevention

    • Preventingtheonsetofthecondition

    • Preventingtherampagedevelopmentofsymptoms; i.econtrolingthecondition

IntroMedII - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

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

IntroMedII - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

Self-PerceptionofHealth

Source: National Health Survey, 1999

Overall PQI

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

PatientProfile

  • Male

  • Elderly (75 years old +)

  • Living in areas not densely populated

IntroMedII - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

Studies supporting this association:

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

IntroMedII - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

COPD

Hypertension

CHF

Asthma

COPD

Asthma

CHF

Hypertension

CHF

Diabetes

Hypertension

IntroMedII - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

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

IntroMedII - class 9 - PQIs


Evaluating portuguese primary healthcare through prevention quality indicators pqis

Spain

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Evaluating portuguese primary healthcare through prevention quality indicators pqis

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

  • IntroMedII - class 9 - PQIs


    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • 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.

    IntroMedII - class 9 - PQIs


    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • FutureResearch

    • Multivariateanalysisofcorrelations

    • Litoral/Interior Analysis

    • Widertimespan (PreandPost SNS restructuration)

    • Carefulanalysisofeconomical indexes andprevalenceofanalysedconditions

    • FurtherInternationalComparison

    IntroMedII - class 9 - PQIs



    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • 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.

    IntroMedI - class 9 - PQIs


    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • 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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    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • 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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    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • Pappas G, hospitalizations: potential for primary and public health initiatives in Canterbury, New Zealand. N Z Med J. 2003; 119(1236). 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

    IntroMedI - class 9 - PQIs


    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • 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

    IntroMedI - class 9 - PQIs


    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    • Software Saúde – Contas Globais 2001 [Internet].

    • 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/

    IntroMedII - class 9 - PQIs


    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    Protocol developed by: Saúde – Contas Globais 2001 [Internet].

    Ana Catarina Moura, mimed07028@med.up.pt

    Ana Margarida Oliveira, mimed07022@med.up.pt

    Bárbara Mendonça, mimed07248@med.up.pt

    Cláudia Pereira, mimed07173@med.up.pt

    Hélio Alves, mimed07223@med.up.pt

    João Miguel Rego, mimed07261@med.up.pt

    José Pedro Pinto, mimed07054@med.up.pt

    Maria Francisca Costa, mimed07093@med.up.pt

    Maria Guiomar Pinheiro, mimed07095@med.up.pt

    Nelson Couto, mimed07135@med.up.pt

    Ricardo Reis, mimed07115@med.up.pt

    José Alberto Silva Freitas, alberto@med.up.pt

    IntroMedI - class 9 - PQIs


    Evaluating portuguese primary healthcare through prevention quality indicators pqis

    Thank you for your time Saúde – Contas Globais 2001 [Internet].

    IntroMedI - class 9 - PQIs