Quality and accessibility of Portuguese hospital services through 2000 to 2007 Course: Mestrado Integrado em Medicina Subject: Introdução à Medicina I

Quality and accessibility of Quality and accessibility of Portuguese hospital services Portuguese hospital services

through 2000 to 2007through 2000 to 2007

Course: Mestrado Integrado em Medicina

Subject: Introdução à Medicina I

Class 8

Teacher (adviser) Alberto Freitas

15th December 2008

Structure of the presentation

• Motivations

• Indicators

• Research Question and Aims

• Participants and Methods

• Expected Results

• References

Evaluate the state of Portuguese healthcare

Analyse its evolution through the past eight years (2000-2007)

Compare the activity and quality indicators among the different Portuguese regions.

Motivations of the study

Indicators

Importance• Mechanisms to assess quality and accessibility of hospitals

• Factors for accounting and financial directing

What are quality and activity/productivity indicators?

Indicators

Health care quality indicators

• Measures which contain relevant information concerning services conditions

• Reflect the health status of a population and help monitoring health conditions

Indicators

Activity/Productivity indicators

• Evaluate hospital performance

• Express the relation between applied resources and goals achieved

• Related with public access to healthcare services

Indicators

Indicators

Both quality and activity indicators are susceptible:• Actualization of evaluative parameters• Modification of their relevance in hospital assessment

Indicators are not fixed evaluative parameters!

Indicators Domain

Mortality Quality

Hospitalization time Quality and Activity/Productivity

Postponed surgeries Quality

Ambulatory episodes Activity/Productivity

Ambulatory surgeries Activity/Productivty

Births by Caeserean-section Activity/Productivity

Main diagnostics Quality

Surgical procedures, complications Quality

Indicators

• How have health indicators evolved, in Portugal, during the past 8 years, how is that reflected in the quality and accessibility of healthcare services an in which ways can they be improved?

Research Question and Aims

Research Question

Research Question and Aims

Participants and Methods

Study Participants

Target population:Portuguese continent population

Sampling Methods:No samples were taken from the dataset of

registers from private and public continental hospitals


Study Participants

Note: Analysis of only continent private and public hospitals recordsMadeira and the Azores archipelagos use a different system of classification

Inclusion and exclusion criteria: each indicator considers all registers, thus no need for criteria


Study Design

Descriptive – Indicators analysis will describe accessibility and quality parameters of hospitalsAnalytical – Less evident, only few relations are established between indicators

Observational – There was no intervention. Data was collected from observation of hospital’s registers

Longitudinal – The study consists of a data follow up through 2000 to 2007

Retrospective – Data was collected from registers in the pastProspective – Via the results obtained a future prospect of the healthcare system will be presented


Study Design

Secondary data – Data wasn’t specifically collected for this study


Data collection methods

Dataset provided by the Health Care System Central Administration (ACSS) containing all registers of public and private hospitals in the continent, from 2000 to 2007

Microsoft Office Excel:

• Graphics and tables

SPSS • Data filtering

(according to each indicator)

• Statistical calculations and graphics (Planned

Statistical Analysis)


Data collection methods

Variable description


Diagnosis Related Groups - DRG Classification system for patients admitted to

hospital

• Clinically coherent and homogenous groups• Consumption of resources



The International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM)

System of codes to diagnoses and procedures associated with hospital utilization

The ICD-9-CM consists of:• tabular list containing a numerical list of disease code numbers;• classification system for surgical, diagnostic, and therapeutic procedures


Variable descriptionThe International Classification of Diseases,

Ninth Revision, Clinical Modification (ICD-9-CM)


Variable descriptionHospital IDHospital Location – Allows an analysis of the various regions through the hospitals there located.

Both allow a regional analysis according to hospitals location – NUTS


Variable descriptionNomenclature of territorial units for statistics (NUTS)

Level II: 7 units, of which 5 in the continent.

North

Centre

Alentejo

Algarve

Lisbon

Azores

MadeiraLevel III: 30 units, of which 28 in the continent

Level I: 3 units, of which 1 is the continent



Gender – Division into two groups of analysis: men and women

Age – Stratification based on age

Birth Weight – Obstetrics services

Days of hospital stay – Hospitalization Time

Discharge date – Year division of each indicator essential to evaluate the evolution of indicators


Planned statistical analysisSPSS for Windows

All Indicators:• Frequencies • Percentages

Hospitalization Time:• Means

• Percentiles• Median

SPSS for Windows and Microsoft Office Excel

GraphicsTables


Examples of applied Methods

Amb. Ep. Tot.Ep. Amb.%2000 733 19572 3,752001 959 20004 4,792002 1206 20277 5,952003 1503 21066 7,132004 1827 21295 8,582005 1840 21282 8,65

Evolution of the ratio between number of ambulatory procedures and total number of

procedures, from 2000 to 2005



62 274831

11331722

1002

0

500

1000

1500

2000

frequency

<18 18-44 45-64 65-74 75-84 85+

age

Mortality by age group

27542270

5024

0100020003000400050006000

frequency

male female total

gender

Mortality by gender

Surgery

15%

85%

Ambulatory Surgeries

Surgeries whichrequirehospitalization



•V3000 = Single lb in hospital w/o cs•650 = Normal delivery

• 43401 = Cere thrombosis w/ inrct •V3001 = single lb in hospital w cs

•486= Pneumonia, organism unspecified •55090 = Inguinal hernia, without mention of obstruction or gangrene

•V581= Encounter for chemotherapy and immunotherapy for neoplastic conditions•36610= Senile cataract, unspecified

•4280 = Congestive heart failure, unspecified•4549 = Asymptomatic varicose veins

Main diagnostic

Frequency

Percentage

Valid Percent

age Cumulative Percentage

4549 1112 0,9 0,9 81

43401 1125 0,9 0,9 81,9

4280 1147 0,9 0,9 82,8

336610 1347 1,1 1,1 83,9

V581 1452 1,2 1,2 85,1

55090 1625 1,3 1,3 86,4

486 2182 1,8 1,8 88,1

V3001 3143 2,5 2,5 90,7

650 3410 2,8 2,8 93,5

V3000 8086 6,5 6,5 100



DRG-14

DRG-39

DRG-89

DRG-127

DRG-162

DRG-359

DRG-371

DRG-373

DRG-390

DRG-391

2000 3,19% 0,71% 2,42% 1,70% 0,64% 1,13% 2,04% 3,03% 0,87% 3,35%

2001 2,98% 0,60% 2,40% 1,72% 0,51% 1,12% 2,76% 2,51% 0,78% 2,90%

2002 3,67% 0,62% 2,49% 1,64% 0,55% 1,08% 1,83% 2,73% 0,79% 3,03%

2003 3,29% 0,45% 2,47% 1,75% 0,50% 1,04% 1,64% 2,56% 0,94% 2,85%

2004 3,36% 0,44% 3,12% 1,86% 0,47% 0,94% 1,77% 2,75% 0,75% 2,87%

2005 3,36% 0,49% 3,93% 1,80% 0,39% 0,77% 1,68% 2,26% 0,82% 2,76%

Hospitalization Time – Percentage of hospitalization time of the 10 most frequent indicators in overall hospitalization time from 2000 to 2005

Ambulatory Episodes and Ambulatory Surgeries – Number of ambulatory episodes tends to rise but its still low

Hospitalization time – Tendency of diminishing hospitalization episodes and the mean of time of stay

Mortality – Greater mortality in rural regions; elderly group likely to have a greater incidence

Expected Results

Main Expectations – Indicators

Expected Results

• Quality and Accessibility to Portuguese hospitals are expected to improve during the years in analysis.

• Likelihood of disparity between rural and urban regions: rural regions present worst indicators values.

Main Expectations

Expected Results

LimitationsResults from 2% of the ACSS dataset

Articles and other information concerning indicators

Expected Results

Full ACSS dataset may present results that differ:• Sample is very small• Sample offers no coverage off all years (only 2000 to 2005)

Expected Results

Limitations

Hospital quality and accessibility also depends on:• Population lifestyle• Financing and logistical support

Thus indicators may not reflect the truth about the healthcare system

• Increase of knowledge and understanding of the Portuguese health system:– Quality characteristics– Accessibility characteristics

Expected Results

Future implications

• Suggestions of improvements according to the results obtained

– Healthcare services impact• Improved resources management

– Economic impact• Target financing to needed medical areas

– Social impact• Improvement of quality of life

Expected Results

Future implications

• Portugal• Public and private hospitals• Quality indicators• Organization and administration

KeywordsKeywords

1. Freeman T. Using performance indicators to improve health care quality in the public sector: a review of the literature. Health Services Management Reseach. 2002 May;15(2):126-37.

2. Olímpio J, Nogueira V, Bittar. Produtividade em hospitais de acordo com alguns indicadores hospitalares. Revista de Saúde Pública. 1996 February;30(1) .

3. Barros PP, Sena C. Quanto maior melhor? Redimensionamento e economias de escala em três hospitais portugueses. 1998 November.

4. Travassos C, Carvalho de Noronha J, Martins M. Mortalidade hospitalar como indicador de qualidade: uma revisão. Ciência & Saúde Coletiva.1999;4(2):367-381.

5. Grenier-Sennelier C, Corriol C, Daucourt V, Michel P, Minvielle E. Développement d’indicateurs de qualité au sein des établissements de santé: le project COMPAQH. Revue d'Epidémiologie et de Santé Publique. 2005 September;53: 130.

6. Mahapatra P , Berman P. Using hospital activity indicators to evaluate performance in Andhra pradesh, India. The International Journal of Health Planning and Management. 2006 September;9(2):199-211

References

References

7. MEDSTATWEB. Serviço de Bioestatística e Informática Médica. Faculdade de Medicina da Universidade do Porto [cited 2008 December 15]. Available from: http://stat2.med.up.pt/cursop/index.html

8. Mimwiki.med.up.pt: Informatica médica [Internet]. [cited 2008 December 15]. Available from: http://mimwiki.med.up.pt/index.php/Os GDhs em Portugal#Os GDHs em Portugal

9. Cdc.gov: Centers for Disease Control and Prevention [Internet]. [cited 2008 December 15]. Available from: http://www.cdc.gov/nhcs/about/otheract/icd9/abticd9.htm

10. Dgeep.mts.gov.pt: Diário da República [Internet]. [cited 2008 December 15]. Available from: http://www.dgeep.mtss.gov.pt/apresentacao/legislacaopdfs/dl244_02.pdf

11. Eur-lex.europa.eu. [Internet]. [cited 2008 December 15]. Available from: http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2007:039:0001:01:PT:HTML

12. Rangrez RA, Tabish SA, Bukhari IA, Deva SW, Pandit NA, Wani RA, Department of Hospital Administration, Sher-I-Kashmir, In Institute of Medical Sciences, Srinagar. Role of Ambulatory Care in a Teaching Hospital. JK-Practitioner. 2005; 12(1):48-50

References

13. Birkmeyer JD, Siewers AE, Finlayson EVA, Stukel TA, Lucas FL, Batista I, Welch HG, Wennberg DE. Hospital Volume and Surgical Mortality in the United States. The New England Journal of Medicine. 2002 April 11; 346(15):1128-1137.

14. Nawal LM, Bhat DK, Gandhi SR, Nguyen C, Weidenbacher-Hoper VL, Lipsky MS. A comparison of quality of care indicators in urban acute care hospitals and rural critical access hospitals in the United States. International journal for quality in health care. 2007 June ;19(3):141-9.

15. Lynnus Peng, Assistant Clinical Professor. Outpatient Surgery Page [Internet]. University of California at Irvine, Department of Anesthesiology, St Jude Medical Center; [updated 200 November 1; cited 2008 December 15]. Available from: http://www.emedicinehealth.com/outpatient_surgery/page2_em.htm

16. Tracy KJ, Craig EH, Scott DG. Ambulatory Surgery: Next-Generation Strategies for Physicians and Hospitals. Healthcare Financial Management. 2000 January.

17. Jarrett P, Ogg TW. The British Association of Day Surgery: the early years. The Journal of One-Day Surgery;14(3):62-63.

18. Dimick JB, Welch HG, Birkmeyer JD. Surgical Mortality as an Indicator of Hospital Quality.

JAMA. 2004 August 18; 292(7)

References

Ana Cláudia Matos Ribeiro [email protected]

Ana Rita Pereira Eluetério Silva [email protected]

Carolina Sobrinho Ribeiro [email protected]

Diogo Costa Branco [email protected]

Diogo do Fundo Raposo [email protected]

Ivo Pedro Costa Gomes [email protected]

João Filipe Pedrosa Bernardes joaofbernardes@hotmail,com

José Vitor Reis Lopes Gonçalves [email protected]

Oscar Ricardo Cerqueira Ramos [email protected]

Maria Leonor Taboas Simões [email protected]

Natália Sofia de Sousa Silva [email protected]

Pedro Miguel Aparício Chorão [email protected]

Sofia Maia Teixeira [email protected]

Tânia Sofia Gomes Esteves [email protected]

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Quality and accessibility of Portuguese hospital services through 2000 to 2007 Course: Mestrado Integrado em Medicina Subject: Introdução à Medicina I