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Introdução à Medicina II 2008/09 Turma 18. Alexandre Almendra Ana Cunha António Miranda Cristina Costa Gabriela Gonçalves Joana Esteves João Pedro Barreto Luísa Costa Mariana Carvalho Mónica Garrido Pedro Canão Pedro Valente Rita Costa Sara Braga Tiago Magalhães. INTRODUCTION. - PowerPoint PPT Presentation
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Alexandre AlmendraAna CunhaAntónio MirandaCristina CostaGabriela GonçalvesJoana EstevesJoão Pedro BarretoLuísa Costa
Mariana CarvalhoMónica Garrido Pedro CanãoPedro ValenteRita CostaSara BragaTiago Magalhães
♦ Need to evaluate management♠ Control the costs♥ Fulfill new requirements♣ Greater demandings
Creation of information systems that allow to grade the management
INDICATORS
INTR
ODU
CTION
[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June
INDICATORSINDICATORS
In a general way…
…“measurement units” to monitor and evaluate through comparison
between different entities
…are…
Two main functions
Evaluate Describe
INTR
ODU
CTION
[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June
INDICATORSINDICATORS
♠Efficiency ♥Efficacy♣Effectiveness♦Cost-efficiency♠Comparability
♦Availability♣Relevance♥Consistency♠Reliability
INTR
ODU
CTION
[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June
[4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005
PROBLEMS ASSOCIATEDPROBLEMS ASSOCIATED
♠ Lack of technical means♥ Input/Output measurement difficulties♣Availability of funding♦ Employee’s lack of instruction♠ Little dynamism from commissions
responsible for executing indicators♥ Inadequacies of information systems
INTR
ODU
CTION
[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June
[4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005
Facing an inefficient and non productive governmental management of public health systems
Construction of evaluation means for the efficiency and effectiveness levels of health systems
HEALTH INDICATORS
INTR
ODU
CTION
[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June
♠ Comparative quality reporting
♠ Public reporting ♠ Pay-for-performance
♣ Public reporting ♣ Pay-for-performance
♣ Comparative quality reporting
INTR
ODU
CTION
INTR
ODU
CTION
The financing of Health entities is based on Diagnosis Related Groups
(DRGs)
Sorting systems for patients in clinically coherent and
homogeneous groups – in a resource consumption point of view
Tendency to rationalize the funds’ distribution process
[5] Bentes M, Gonçalves M, Urbano J, Tranquada S. A utilização dos GDHs como instrumento de financiamento hospitalar. Revista Gestão Hospitalar. 1996 December-1997 January;33: 33-43.
RESEARCH QUESTIONRESEARCH QUESTION
• HOW CAN INDICATORS BE USED TO EVALUATE THE QUALITY OF HEALTHCARE PROVIDED TO IN-PATIENTS IN NATIONAL HOSPITALS?
• WHAT INFORMATION DO THEY PROVIDE ON SPECIFIC ASPECTS: ON PORTUGUESE HEALTH SERVICES PERFORMANCE?
• Norte• Norte• Centro• Centro• Lisboa • Lisboa • Alentejo• Alentejo• Algarve• Algarve• Região Autónoma dos Açores• Região Autónoma dos Açores• Região Autónoma da Madeira
OBJECTIVESOBJECTIVES
Establish a comparison between the different
areas of Portugal
Compare the numbers from 2000 to 2007
Evolution of the services’ quality and efficiency
[25] Nomenclatura de Unidades Territoriais para fins estatísticos , Wikipédia, 2008 [26] Parlamento Europeu, Conselho da União Europeia. Regulamento (CE) N.º 1059/2003 do Parlamento Europeu e do Conselo, relativo à instituição de uma Nomenclatura Comum das Unidades Territoriais Estatísticas (NUTS), Jornal Oficial da União Europeia. 2003 May 26.
Excluded episodes (ambulatory episodes):
♣ Planned admission♥ Release date equals admission date♠ Patients do not change hospitals♦ Patients do not leave against medical advice nor die
%
Inpatient episode 85,4
Ambulatory episode 14,6
METHODS AND R
ESOURC
ES
Database with inpatient episodes from 87 Portuguese public Hospitals between 2000 and 2007
MAIN CHARACTERISTICS OF INPATIENT DATABASEMAIN CHARACTERISTICS OF INPATIENT DATABASE
CHARACTERISTICS %Gender
Male 44,4
Female 55,6Age
≤ 17 19,818 - 24 5,425 - 34 12,635 - 44 9,345 - 54 9,355 - 64 10,865 - 74 14,2
≥75 18,2
METHODS AND R
ESOURC
ES
Nuts IIAlentejo 4,9Algarve 3,7Centro 26,0Lisboa 26,5Norte 33,8
Discharge Year
2000 12,12001 12,22002 12,42003 12,72004 12,62005 13,02006 12,52007 12,5
Total admissions: 7.768.467
ORIGINAL VARIABLESORIGINAL VARIABLES
◦ HOSP_ID◦ EPIS_ID◦ SEXO◦ DDX1-DDX20◦ SRG1-SRG20◦ DSP◦ BIRTH_WGT◦ ADM_TIP◦ HOSP_FROM
METHODS AND R
ESOURC
ES
◦ HOSP_TO◦ TOTDIAS◦ SAIDLAST◦ DRG◦ MDC◦ RESIDE◦ ENT1◦ HOSP_RESIDE◦ DISTANCIA
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions Newborns
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
INDICATORS
Common variables: cod_conc; nuts3; nuts2; ambulatorio; ano_de_alta;
ICD-9-CM code, Portaria nr110-A/2007,January the 23rd of 2007 and attachments II e III
METHODS AND R
ESOURC
ES
ACTIVITY/PRODUCTIONHEALTH CARE QUALITY
DISCHARGED PATIENTS
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions NEWBORNS
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
EXCEPTIONAL ADMISSION EPISODES
SURGICAL ADMISSION TIME COMPLICATION-FREE LONG-TERM ADMISSIONS
READMISSIONS SHORT-TERM INAPPROPRIATE ADMISSIONS
Newborns
VAGINAL DELIVERIES
UNSPECIFIED SURGICAL PROCEDURES
MEDICAL DRG’S COMPLICATIONS
DISCHARGED PATIENTS
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions Newborns
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
EXCEPTIONAL ADMISSION EPISODES
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions Newborns
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
SURGICAL ADMISSION TIME
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions Newborns
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
Surgical admission time
COMPLICATION-FREE LONG-TERM ADMISSIONS
Readmissions Short-term inappropriate admissions Newborns
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
READMISSIONS Short-term inappropriate admissions Newborns
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions SHORT-TERM INAPPROPRIATE ADMISSIONS Newborns
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions NEWBORNS
Vaginal Deliveries
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions Newborns
VAGINAL DELIVERIES
Unspecified surgical procedures
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions Newborns
Vaginal Deliveries
UNSPECIFIED SURGICAL PROCEDURES
Medical DRG’s complications
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions Short-term inappropriate admissions Newborns
Vaginal Deliveries
Unspecified surgical procedures
MEDICAL DRG’S COMPLICATIONS
Exceptional admission episodes Limiar_inf; Limiar_max; Tipo_episode Surgical admission time PRE_OP_days; POS_OP_days; Complication-free long-term admissions
limiarMax; cc_DDX1 cc_DDX20; Int_Sem_CC ; Int_Validos
Readmissions GDHexcepçao; DuracaoDaAlta; Readmissao; Grupos_Diagnostico
Newborns gr4500plus; trauma_na_clavicula; trauma_inespecifico; fetal_distress_during_labour; asfixia_severa; asfixia_inespecifica; prematuro; outras_condicoes_respiratorias_e_no_recem-nascido; respiratory_distress_sindrome; infeccoes_especificas_do_periodo_perinatal; hemorragia_fetal_e_neo-natal; breast_engourgement; problemas_de_pele_ou_temperatura; problemas_alimentares; drug_withdrawal
Vaginal Delivery totalpartos; partoscc; partosnormalUnspecified surgical procedures ProcCirurInespMedical DRG’s complications Drg_mp; ddx_sec_CC; Med_CC; filter_pneumovent;
filter_infectalgal; filter_ulcerpres; filter_MC
Discharged patients
Exceptional admission episodes
Surgical admission time
Complication-free long-term admissions
Readmissions
Short-term inappropriate admissions
Newborns
Vaginal deliveries
Unspecified surgical procedures
Medical drg’s complications
Which variables did we use to calculate these indicators?
RESULTSRESULTS
b) Establish a comparison between the different
areas of Portugal
a) Compare the numbers from 2000 to 2007
RESULTS
A) COMPARISON BETWEEN YEARSA) COMPARISON BETWEEN YEARSR
ESULTS
2000(%) 2001(%) 2002(%) 2003(%) 2004(%) 2005(%) 2006(%) 2007(%)
Exceptional admission episodes
Short-term episode 19,2 19,4 19,7 19,8 19,8 20,3 19,7 19,8
Long-term exceptional episode
2,4 2,1 1,9 1,7 1,6 1,5 1,5 1,5
Complication-free long-term admissions 1) 1,3 1,3 1,0 0,8 0,8 0,6 0,5 0,6
Readmissions 45,8 45,5 46,0 45,9 45,9 46,3 45,8 44,4
Newborns 1,04 1,08 1,15 1,15 1,08 1,06 1,04 1,02
Vaginal Delivery Complications free 75,5 76,4 71,3 74,8 73,9 76,7 72,9 73,5
With complications 24,5 23,6 28,7 25,2 26,1 23,3 27,1 26,5
Unspecified surgical procedures 13,4 12,6 12,3 13,0 12,6 12,4 11,7 11,8
Medical DRG’s complications 10,5 11,3 12,4 12,5 12,2 14,0 13,1 13,91)Calculated from a 1 % sample
2000 2001 2002 2003 2004 2005 2006 2007
1.04
1.08
1.15 1.15
1.081.06
1.041.02
Newborn's problems per cent
2000 2001 2002 2003 2004 2005 2006 2007
24,5%
23,6%
28,7%
25,2%
26,1%
23,3%
27,1%
26,5%
Variações de partos vaginais com complicações
2000 2001 2002 2003 2004 2005 2006 200710.5
11
11.5
12
12.5
13
13.5
14
Variation of Specified and Non-specified Surgical Procedures per year
Non-specified Surgical Procedures
Specified Surgical Procedures
Per
cen
t
2000 2001 2002 2003 2004 2005 2006 2007
10.5%
11.3%
12.4% 12.5%12.2%
14.0%
13.1%
13.9%
Variation of Medical DRG's with CC over the Years
B) COMPARISON BETWEEN NUTS IIB) COMPARISON BETWEEN NUTS IIR
ESULTS
1)Calculated from a 1 % sample
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)
Exceptional admission episodes
Short-term episode 16,6 18,3 18,6 21,3 19,8
Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6
Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8
Readmissions 78,6 77,6 75,3 76,7 75,3
Newborns 1,1 1,1 1,5 1,2 1,3
Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5
With complications 14,0 11,7 28,8 26,5 26,5
Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5
Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9
REFERENCESREFERENCES
[1] Entidade Reguladora da Saúde. Relatório da Actividade Reguladora de 2007 [Internet]. Porto: 2008 August [accessed 2008 October 30]. Available from http://www.ers.pt/actividades/relatorio-de-actividades/Relatorio%20Actividade%20 Reguladora%202007.pdf/ view.[2] Ministério da Saúde. Diário da República [Internet]. 2007 January 23 [accessed 2008 October 30]. Portaria n.º 110-A/2007 - 1.ª Série - N.º16. Available from http://dre.pt/pdf1sdip/2007/01/01601/00020124.PDF.[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June [accessed 2008 October 27]; N.º3. Available from www.netautarquia.pt /noticias/Confer Forum.htm. [4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005 December [accessed 2008 October 27]. Available from http://www.iqs.pt/pdf/ Dezembro-2005/13-16-20.pdf. [5] Bentes M, Gonçalves M, Urbano J, Tranquada S. A utilização dos GDHs como instrumento de financiamento hospitalar. Revista Gestão Hospitalar. 1996 December-1997 January;33: 33-43.[6] Eddy D M. Performance measurement: problems and solutions. PubMed [Internet]. 1998 July-August [accessed 2008 October 27]; 17(4):7-25. Available from http://www.ncbi.nlm.nih.gov/pubmed/9691542?ordinalpos=8&itool= EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum.[7] Freeman T, Using performance indicators to improve health care quality in the public sector: a review of the literature. PubMed [Internet]. 2002 May [accessed 2008 October 27]; 15(2):126-37. Available from http://www.ncbi.nlm.nih.gov/ pubmed/12028801.[8] Collopy B T. Clinical indicators in accreditation: an effective stimulus to improve patient care. PubMed [Internet]. 2000 June [accessed 2008 October 27]; 12(3):211-6. Available from http://www.ncbi.nlm.nih.gov/pubmed/10894192?ordinalpos=4&itool=EntrezSystem2. PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum. [9] Thomson R G, Lally J. Performance management at the crossroads in the NHS: don't go into the red. PubMed Central [Internet]. 2000 [accessed 2008 October 27]; 9: 201-202. Available from http://www.pubmedcentral.nih.gov/ picrender.fcgi?artid =1743551&blobtype=pdf.[10] Agency for Healthcare Research and Quality (AHRQ). AHRQ Summary Statement on Comparative Hospital Public Reporting [Internet]. United States of America: Health and Human Services. [accessed 2008 October 27]. Available from: http://www.qualityindicators.ahrq.gov/news/AHRQSummaryStatement. pdf. [11] Kondro W. The joys of quality indicators. Canadian Medical Association Journal. 2008 January 15; 178(2): 142-143. [12] Shojania K G, Forster A J. Hospital mortality: when failure is not a good measure of success. Canadian Medical Association Journal. 2008 July 15; 179(2): 153-157.[13] Machado M C S. O Plano Nacional da Saúde 2004-2010 [Internet]. Portugal (PT): Alto Comissariado da Saúde. [accessed 2008 October 27]. Available from http://www.acs.min-saude.pt/pns/pt/.[14] Geraedts M, Schwartze D, Molzahn T. Hospital quality reports in Germany: patien and physician opinion of the reported quality indicators. Canadian Medical Association Journal. 2007 September 28; 7: 157.[15] Galvin R S. Are performance measures relevant?. Health Affairs. 1998 July-August; 29-31.[16] McGlynn E A. Selecting common measures of quality and system performance. Medical Care. 2003 January; 41(1 Suppl):I39-47.[17]Thomson R, Taber S, Lally J, Kazandjian V. UK Quality Indicator Project (UK QIP) and the UK independent health care sector: a new development. International Journal for Quality in Health Care. 2004 April; 16 Suppl:i51-i56.
REFERENCESREFERENCES
[18] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de 2006. Grupos de Diagnósticos Homogéneos. 2006.[19] Thomas J, Paranjothy S, Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press; 2001.[20] Faúndes A, Pádua K S, Osis M J D, Cecatti J G, Sousa M H. Brazilian women and physicians' viewpoints on their preferred route of delivery. Revista de Saúde Pública. 2004; 38(4):488-94.[21] Reynolds A, Ayres-de-Campos D, Costa M A, Santos C, Campos I, Montenegro N, Influence of three organisational measures on the cesarean. Acta Médica Portuguesa. 2004; 17:193-198.[22] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de 2003. Grupos de Diagnósticos Homogéneos. 2005 Mar.[23] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de 2004. Grupos de Diagnósticos Homogéneos. 2005 Sep.[24] Instituto de Gestão Informática e Financeira da Saúde, Ministério da Saúde. Relatório Nacional de 2005. Grupos de Diagnósticos Homogéneos. 2006 Aug.[25] Nomenclatura de Unidades Territoriais para fins estatísticos [Internet], Wikipédia, 2008 Dec 13 [accessed 2008 Dec 16]. Available from: http://pt.wikipedia.org/wiki/NUTS.[26] Parlamento Europeu, Conselho da União Europeia. Regulamento (CE) N.º 1059/2003 do Parlamento Europeu e do Conselho, relativo à instituição de uma Nomenclatura Comum das Unidades Territoriais Estatísticas (NUTS). Jornal Oficial da União Europeia. 2003 May 26.[27] Ministério da Saúde. I Série-A. Diário da República. 2002 Nov 5.[28]Pereira A C, Pinto A T, Parry G, Vieira P, Azevedo L F, Martins C, Vieira A, Desenhos de estudos [Internet]. Universidade do Porto, Serviço de Bioestatística e Informática Médica [accessed 2008 Dec 16]. Available from: http://stat2.med.up.pt/cursop/main.php3?capitulo=desenhos_estudo& numero=1&titulo=Desenhos+de+estudo.[29] Alto Comissariado da Saúde - Ministério da Saúde. Indicadores e Metas do PNS [Internet]. 2008 [accessed 2008 Dec 10]. Available from: http://195.22.11.132/websig/acsv2/gui/index.php? par=acs&lang=PRT#.[30] Sistema Nacional de Saúde. Indicadores de Desempenho 2004 – 2006 [Internet]. [acessed 2008 Dec 14]. Available from: http://www.portugal.gov.pt/NR/rdonlyres/A03A04DB-7EE1-43D6-8B69-2FE9118D43D9/0/Indicadores_SNS_2006.pdf.