introdução à medicina i class 11 adviser: dr. armando teixeira pinto faculdade de medicina da...

Introdução à Medicina IClass 11Adviser: Dr. Armando Teixeira Pinto

Faculdade de Medicina da Universidade do PortoCurso de Mestrado Integrado em Medicina

2008/2009

Faculdade de Medicina da Universidade do Porto

Comparison and Evolution of Medical Care of Inpatients

with Acute Myocardial Infarction in Portuguese Public

Hospitals

Acute myocardial infarction (AMI – ICD9 410) is one of the major causes of death among Western civilization.

Such studies are not widespread among Portuguese institutions

Access to hospitals’ admnistrative data.

Introduction Background and Justification

Value

Understanding the general quality concerning the treatment of AMI in Portuguese Public Hospitals.

It may create the need for improvement.

Stimulating further analysis and future studies.

Providing a guide for general population.

Age-standardised death rates per 100,000 population from AMI, from 1972 to 2002, in

Portugal

0

20

40

60

80

100

120

140

160

180

200

1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Years

Nu

mb

er

of

De

ath

s

Acute Myocardial Infarction (AMI)

Medical term for heart attack.

Caused by the blockage of the coronary arteries which will lead to an insufficient blood suply to the heart muscle (myocardium).

Research Question and Aims

RESEARCH QUESTION What is the status of medical care system in

Portugal for AMI and how has it evolved throughout the years?

What is the geographical distribution of AMI incidence in mainland Portugal?

AIMS Compare different Portuguese areas according to

2 criteria Compare hospitals’ quality based on 2 criteria. Evaluate the improvements of medical care in

hospitals.

Participants and Methods

Sample

SampleAge and gender

65,3 %

34,7%

Median: 70,00

SampleGeographic distribution

2001

Relative frequency of admissions distribution

Fatality rate distribution

Distrito % (internments in total population)

Aveiro 0,074

Braga 0,074

Viseu 0,082

Leiria 0,085

Coimbra 0,089

Guarda 0,089

Vila Real 0,090

Porto 0,099

Santarém 0,099

Faro 0,101

Setúbal 0,104

Castelo Branco 0,110

Viana do Castelo 0,111

Portalegre 0,120

Lisboa 0,133

Bragança 0,136

Évora 0,143

Beja 0,144

Distrito %(fatalities in total population)


Aveiro 0,007

Braga 0,008

Coimbra 0,008

Leiria 0,010

Viseu 0,010

Porto 0,011

Faro 0,013

Setúbal 0,013

Vila Real 0,013

Beja 0,014

Santarém 0,014

Guarda 0,016

Bragança 0,017

Évora 0,019


Lisboa 0,022

Portalegre 0,025

SampleGeographic distribution

2007

Relative frequency of admissions distribution

Fatality rate distribution

Distrito % (internments in total population)

Vila Real 0,080

Braga 0,084

Aveiro 0,090

Viseu 0,093

Leiria 0,099

Santarém 0,109

Lisboa 0,112

Porto 0,114


Guarda 0,125

Coimbra 0,133

Setúbal 0,139

Faro 0,140

Bragança 0,165


Portalegre 0,168

Évora 0,172

Beja 0,173

Distrito % (fatalities in total population)

Vila Real 0,006

Braga 0,007

Leiria 0,009

Porto 0,009

Aveiro 0,010

Beja 0,010

Évora 0,012

Coimbra 0,013

Santarém 0,013

Viseu 0,013


Guarda 0,015

Faro 0,016

Lisboa 0,016

Portalegre 0,018

Setúbal 0,018

Bragança 0,021


SampleEvolution

Total number of admissions with AMI, fatality rate and median length of stay in the hospital, per year of admission

(total n= 91133)

Sample

Median: 7 days

Length of Stay Fatality/Survival rate

Fatalities Survivals

12,5 87,5


Study Design

Transversal and longitudinal Study

Data: from all Portuguese Public Hospitals, from 2000 to 2007.

Data Used

Comparison 2007

Evolution 2000-2007

Variables:

Number of admissions;

Lenght of Stay;

Fatality rate:

FR = Number of deaths caused by AMI Number of Admissions by AMI

Extract of the database’s codes


Data and Variables

Hospitals’ Classification

According to the newest hospital classification:

▪ Central hospitals– Including the main hospitals of the main regions in Portugal;

▪ Distrital hospitals– Including the main hospitals of secondary regions in Portugal;

▪ Level 1 distrital hospitals – Including the smallest hospitals.

Comparison

Sample used for comparison

Comparison

By type of hospital

Number of admissions

Fatality / Survival Rates

Length of stay

Central hospitals Fatality rate Length of stay

Distrital hospitals Fatality rate Length of stay

Level 1 distrital hospitals Fatality rate Length of stay

Comparisonby type of hospital

Distribution according to hospital typeFrequency %

Central hospitals 4719 40,0

Distrital hospitals 6834 57,9

Level 1 distrital hospitals 250 2,1

Fatality rate

Fatality and survival ratesFrequency %

Central hospitalsFatalities 516 10,9

Survival 4203 89,1

Distrital hospitalsFatalities 766 11,2

Survival 6068 88,8

Level 1 distrital hospitals

Fatalities 47 18,8

Survival 203 81,2

Length of Stay


Length of stay distribution (days)

Median Min Max

Central hospitals 6,00 0 203

Distrital hospitals 7,00 0 119

Level 1 distrital hospitals 7,00 0 71

Total 7,00 0 203

Central Hospitals (N=4 719)ranking

Top 5 hospitals with lowest fatality rate

Hospital code


Fatality

N (%)

1 20 758 47 6,2

2 26 431 31 7,2

3 74 423 32 7,6

4 7 505 47 9,3

5 90 408 40 9,8

Bottom 5 hospitals with highest fatality rate

Hospital code


Fatality

N (%)

9 25 281 36 12,8

10 45 144 21 14,6

11 16 441 73 16,6

12 50 309 58 18,8

13 32 65 19 29,2

Top 5 hospitals with lowest length of stay

Hospital code Number of admissions

Length of stay (days)

Median Percentile 25

Percentile 75

1 50 309 4 3 7

2 45 144 4 0 11

3 7 505 5 3 7

4 96 342 5 4 8

5 74 423 6 4 9

Bottom 5 hospitals with highest length of stay




Percentile 75

9 90 408 6 4 9

10 32 65 7 2 16

11 25 281 7 4 13

12 20 758 7 5 12

13 87 97 7 5 12

Distrital Hospitals (N=6 834)ranking


Hospital code


Fatality

N (%)

1 79 54 2 3,7

2 55 234 11 4,7

3 67 255 15 5,9

4 71 68 4 5,9

5 77 232 14 6,0

Bottom 5 hospitals with highest fatality rate

Hospital code


Fatality

N (%)

32 19 125 23 18,4

33 37 73 14 19,2

34 4 14 3 21,4

35 56 13 3 23,1

36 31 141 42 29,8





Percentile 75

1 81 114 2 0 11

2 8 504 4 3 6

3 92 192 5 2 9

4 36 433 5 4 10

5 77 232 6 4 9

Bottom 5 hospitals with highest length of stay




Percentile 75

32 75 59 9 5 14

33 37 73 10 6 14

34 31 141 11 5 17

35 44 187 12 7 16

36 79 54 12 7 18

Level 1 Distrital Hospitals (N=250)ranking


Hospital code


Fatality

N (%)

1 47 61 4 6,6

2 58 27 3 11,1

3 29 96 19 19,8

4 3 12 3 25

5 82 23 8 34,8


Hospital code



Median Percentile 25 Percentile 75

1 3 12 4 1 12

2 82 23 5 2 11

3 58 27 6 5 9

4 29 96 8 4 13

5 47 61 8 6 11

EVOLUTION

0

20

40

60

80

100

120

140

160

180

200

1972 1974 1976 1978 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002

Years

Nu

mb

er

of

De

ath

s

Evolution

The evolution of fatality rates and median length of stay throughout the years, for central, distrital and level 1 distrital hospitals

---- Median length of stay___ Fatality rate

Discussion

EVOLUTION Regarding the fatality rate:

▪ No significant variation was observed for distrital and central hospitals. A slight increase was observed for type 1 distrital hospitals.

▪ These results should not be linearly associated to a decrease in the quality of medical care provided as various factors could be related to this (ex: older population).

Regarding the length of stay:▪ a very slight decrease was observed, more evident between the years of

2000 and 2002 and between 2004 and 2006. ▪ This can be connected to structural and organizational modifications in

SNS hospitals, like the introduction of “Hospitais SA” in 2002 and “Hospitais EPE” in 2004.

Discussion

COMPARISON As expected, there were significant differences

between the three types of hospitals.

Admittance of an association between lower fatality rate and lower length of stay.

Possible indicators in the quality of care provided.

DiscussionLimitations

Information relative to the year 2007 (some changes may have occured since).

Possible information bias in the database.

No information ab0ut procedures.

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References

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