Prevention Quality IndicatorsComparative evaluation of selected international

primary healthcare services using PQIs

21-05-2010

Unidade Curricular de Introdução à Medicina II

Head teacher : Altamiro da Costa-Pereira, MD, PhDSupervisors : Alberto Freitas, PhD and Ricardo Reis

Introduction“Of all the ways to face pathologies perhaps the

most important one is PREVENTION.” [1]

Healthcare system quality analysis:

AVOID unnecessary hospital admissions

SAVE time and resources

IMPROVE quality of life

...through analysis of PQIs.

[1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

Introduction“Of all the ways to face pathologies perhaps the

most important one is PREVENTION.” [1]

• Conditions for which good outpatient care can potentially prevent the need for hospitalization

• Or for which early intervention can prevent complications or more severe disease [2]

ACSCs

[1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf[2] Moura, A. C., A. M. Oliveira, et al. (2008). "[Evaluating Portuguese primary healthcare through Prevention Quality Indicators (PQIs)]." 35. Unpublished data.

PQI’s

Evaluate the quality of oupatient healthcare

Improvement of the healthcare

system

Included in QI’s

Created by AHRQ

Based on ACSC’s

PQI’s by AHRQ

PQI1: Diabetes

short term complication PQI2:

Perforated appendix

PQI3: Diabetes long-term

complication

PQI5: Chronic obstructive pulmonary

disease

PQI7: Hypertension

PQI8: Congestive heart failure

PQI9: Low Birth Weight

PQI10: Dehydration

PQI11: Bacterial

pneumonia

PQI12: Urinary tract

infection

PQI13: Angina

admission without

procedure

PQI14: Uncontrolled

Diabetes

PQI15: Adult Asthma

PQI16: Lower-extremity

amputation among

diabetics

PQI1: Diabetes short term complication

Using several PQIs, compare Portugal`s primary healthcare system with other countries.(USA, Italy, Spain and Singapore)

Aims

Participants & Methods

• Database with hospitalizations in

Portuguese mainland public hospitals

• 2000 - 2007

Portugal

All the following conditions

Participants & Methods

• Patients between 20-64 years-old admitted in

four Italian cities (Turin, Milan, Bologna, Rome)

• 2000 - 2007

Italy

PQI#3 Diabetes Long-term Complications Admission RatePQI#5 - Chronic Obstructive Pulmonary DiseasePQI#7 - Hypertension without proceduresPQI#8 - Congestive Heart Failure without proceduresPQI#13 - Angina without procedures

Participants & Methods

Angina AsthmaCellulitisCongestive heart failureCongestive pulmonar diseaseDehydrationDiabetesGastroenteritis Great evilHypertension

HypoglycemiaUrinary and kidney tract infectionsPneumoniaSevere ENT InfectionsImmunizable disordersConvulsionsPulmonary TuberculosisOther tuberculosisCongenital syphilis

Dental problemsIron deficiency anemiaNutritional deficiencyGrowth FailurePelvic inflammatory disease

• Patients between 0-44 years-old

admitted in public Spanish hospitals [3]

• January – December (2000)

[3] José Luis Alfonso, S., V. Joan Sentís, et al. (2004). "[Characteristics of avoidable hospitalization in Spain]." Med Clin (Barc) 122(17): 653-658.

Spain

• Nationwide data with

hospitalizations in Singapore [4]

• 1991 - 1998

Participants & Methods

•Asthma• Congestive heart failure•Chronic obstructive pulmonary diseases• Diabetes mellitus• Hypertension

Singapore

[4] 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.

Participants & MethodsUSA

• Patients over 18 years old

admitted in hospitals of USA

• Data calculated and made

available by AHRQ [1]

• 2004 - 2007

All 14 PQIs

[1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

Data retrieved from acute care hospital database

Variables of interest present in selected articles from other countries (Pubmed,INE…)

We retrieved articles from PubMed using the following query: "prevention quality indicators" OR "ambulatory care sensitive" OR

Data Collection

"avoidable hospitalizations" OR "avoidable hospitalization" OR "preventable hospitalization" OR "preventable hospitalizations" OR "PQI" OR "primary care quality" AND ”(country of interest)

To calculate, we used a syntax (it allows filter admittance for a given disease) for each indicator of each article and also data provided by AHRQ

After obtaining a certain frequency for each case we divide it by the entire population of Portugal which results on a quotient similar to PQI. For PQI 2 and PQI 9 the denominator is not related to the population.

Indicator Calculation

By AHRQ [1] and other sources (depending on the studied country)

Based on Diagnoses Codes ICD-9-CM

Different criteria for different PQIs

Inclusion

Pregnancy

Childbirth

Puerperium

Newborn (or other neonates)

Cases transferred from other institutions. [1]

PQI specific

Exclusion

[1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

Criteria

Study Design

COMPARE

Results: Graphics and Tables

ADAPTPortugal’s Methods and Data Other Countries

USE

Articles with data of the selected countries

Data management

Examples of Portuguese Database (in SPSS)

Results…

Portugal 2000-2007Nº per 100000 inhabitants

PQI’s 1 to 8 (except PQIs 4 and 6)[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt

Portugal 2000-2007

Nº per 100000 inhabitants

PQI’s 10 to 16

[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt

Portugal 2000-2007

[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt[1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Oct 27]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

USA vs Portugal

[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt[5] Rizza P, Bianco A, Pavia M, Angelillo I. Preventable hospitalization and access to primary health care in an area of Southern Italy. BMC Health Services Research. 2007;7(1):134.[9] Agabiti N, Pirani M, Schifano P, Cesaroni G, Davoli M, Bisanti L, et al. Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy. BMC Public Health. 2009;9(1):457.

Portugal vs Italy

[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt[3] José Luis Alfonso S, Joan Sentís V, Sergio Blasco P, Isabel Martínez M. [Characteristics of avoidable hospitalization in Spain]. Med Clin (Barc). 2004;122(17):653-8.

Portugal vs Spain

[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt[3] José Luis Alfonso S, Joan Sentís V, Sergio Blasco P, Isabel Martínez M. [Characteristics of avoidable hospitalization in Spain]. Med Clin (Barc). 2004;122(17):653-8.

Portugal vs Spain

[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt[4] Niti M, Ng TP. Avoidable hospitalization rates in Singapore, 1991–1998: assessing trends and inequities of quality in primary care. Journal of Epidemiology and Community Health. 2003 January 2003;57(1):17-22.

Portugal vs Singapore

DiscussionDiscussion

DiscussionDiscussion Italy vs Portugal

• Higher rates in Italy in all of the five conditions compared.

• Worse food habits might be a reason, due to a diet rich in lipids, carbohydrates, fats and vegetable oils. [8]

• Therefore, cultural, social and economical disparities are, among other factors, na explanation for the results obtained [8].

[8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt

DiscussionDiscussion Singapore vs. Portugal

Portugal has for Chronic Obstructive Pulmonary disease, Diabetes Mellitus and Hypertension higher rates, explained by:• Environmental issues• Cultural issues

Singapore presents higher rates for:• Asthma (climate)• Congestive heart failure (diet enriched in lipids)

Comparison between these two countries is not reliable as this two countries have great cultural, economical and social disparities and the results for Singapore match the year 1998, as Portuguese results match the year 2000.

USA vs Portugal

DiscussionDiscussion• USA hospitalization rates are higher than in Portuguese ones except PQI 13 and 14, which are related with angina and diabetes, respectively.

WHY?• USA is more developed than us and therefore:• greater pollution;• greater racial disparities;• greater obesity;• other conditions that may lead to

higher rates of unnecessary hospitalizations.

• However PQI 13 and 14 may be explained by our diet, which is often exaggerated in quantity and impoverished in quality.

DiscussionDiscussion Spain vs Portugal • In the comparison made with Spain,

we found that in the 24 conditions faced Portugal has, in eight of them, higher rates.

• This is one of the most reliable of our comparisons because Portugal and Spain have cultural and ethnical similarities due to geographical proximity (same pollution values, same food habits, etc).

• Overall, we may infer that spain’s prevention system is worst than ours

1. Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

2. Moura, A. C., A. M. Oliveira, et al. (2008). "[Evaluating Portuguese primary healthcare through Prevention Quality Indicators (PQIs)]." 35. Unpublished data.

3. José Luis Alfonso, S., V. Joan Sentís, et al. (2004). "[Characteristics of avoidable hospitalization in Spain]." Med Clin (Barc) 122(17): 653-658.

4. 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.

5. 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.

6. Ansari Z, Laditka JN, Laditka SB. Access to Healthcare and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care Res Rev. 2006; 63:719-42

7. Alfradique, M. E., P. d. F. Bonolo, et al. (2009). "Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP - Brasil)." Cadernos de Saúde Pública 25: 1337-1349.

8. Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt

9. Agabiti N, Pirani M, Schifano P, Cesaroni G, Davoli M, Bisanti L, et al. Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy. BMC Public Health. 2009;9(1):457.

References

Ana Sara Ferreira, mimed09219@med.up.pt

Andreia Sofia Teixeira, mimed09242@med.up.pt

Catarina Lombo, mimed09237@med.up.pt

Diogo Milheiro, mimed09049@med.up.pt

Diogo Teixeira, mimed09046@med.up.pt

Henrique Teixeira, mimed09042@med.up.pt

Inês Pessanha Silva, mimed09059@med.up.pt

Mariana Magalhães, mimed09100@med.up.pt

Miguel Coimbra, mimed09120@med.up.p

Pedro Carvalho, mimed09135@med.up.pt

Paulo Lopes, mimed09250@med.up.pt

Samuel Queirós, mimed09150@med.up.pt

Tiago Barbosa, mimed09188@med.up.pt

Class 10

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