Transcript Prevention Quality Indicators

Unidade Curricular de Introdução à Medicina II
Comparative evaluation of selected international
primary healthcare services using PQIs
21-05-2010
Head teacher : Altamiro da Costa-Pereira, MD, PhD
Supervisors : Alberto Freitas, PhD and Ricardo Reis
“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
“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]
[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 Unpublished data.
 Included in QI’s
Created by
AHRQ
Based on
ACSC’s
Evaluate the
quality of
oupatient
healthcare
Improvement of
the healthcare
system
PQI16: Lowerextremity
amputation
among
diabetics
PQI1:
Diabetes short
term
complication
PQI2:
Perforated
appendix
PQI3:
Diabetes
long-term
complication
PQI1: Diabetes
short term
complication
PQI15: Adult
Asthma
PQI5: Chronic
obstructive
pulmonary
disease
PQI14:
Uncontrolled
Diabetes
PQI’s by
AHRQ
PQI13: Angina
admission
without
procedure
PQI7:
Hypertension
PQI8:
Congestive
heart failure
PQI12: Urinary
tract infection
PQI11:
Bacterial
pneumonia
PQI9: Low
Birth Weight
PQI10:
Dehydration
(USA, Italy, Spain and Singapore)
Participants & Methods
Portugal
• Database with hospitalizations in
Portuguese mainland public hospitals
• 2000 - 2007
All the following conditions
Participants & Methods
Italy
• Patients between 20-64 years-old admitted in
four Italian cities (Turin, Milan, Bologna, Rome)
• 2000 - 2007
PQI#3 Diabetes Long-term
Complications Admission Rate
PQI#5 - Chronic Obstructive
Pulmonary Disease
PQI#7 - Hypertension without
procedures
PQI#8 - Congestive Heart
Failure without procedures
PQI#13 - Angina without
procedures
Spain
Participants & Methods
• Patients between 0-44 years-old
admitted in public Spanish hospitals [3]
• January – December (2000)
Angina
Asthma
Cellulitis
Congestive heart failure
Congestive pulmonar
disease
Dehydration
Diabetes
Gastroenteritis Great evil
Hypertension
Hypoglycemia
Urinary and kidney tract
infections
Pneumonia
Severe ENT Infections
Immunizable disorders
Convulsions
Pulmonary Tuberculosis
Other tuberculosis
Congenital syphilis
Dental problems
Iron deficiency anemia
Nutritional deficiency
Growth Failure
Pelvic inflammatory
disease
[3] José Luis Alfonso, S., V. Joan Sentís, et al. (2004). "[Characteristics of avoidable hospitalization in Spain]." Med Clin (Barc) 122(17): 653-658.
Participants & Methods
Singapore
• Nationwide data with
hospitalizations in Singapore [4]
• 1991 - 1998
•Asthma
• Congestive heart failure
•Chronic obstructive pulmonary diseases
• Diabetes mellitus
• Hypertension
[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 & Methods
USA
• Patients over 18 years old
admitted in hospitals of USA
All 14 PQIs
• Data calculated and made
available by AHRQ [1]
• 2004 - 2007
[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
"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.
Inclusion
By AHRQ [1] and other
sources (depending on
the studied country)
Based on Diagnoses
Codes ICD-9-CM
Different criteria for
different PQIs
Exclusion
Pregnancy
Childbirth
Puerperium
Newborn (or other
neonates)
Cases transferred from
other institutions. [1]
PQI specific
[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
USE
Articles with data of the selected countries
ADAPT
Portugal’s Methods and Data
Other Countries
COMPARE
Results: Graphics and Tables
Examples of Portuguese
Database (in SPSS)
Nº 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
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
[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
[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.
[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.
[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).
[8]
Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt
2004;122(17):653-8.
[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.

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

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
• 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.

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.
2.
3.
4.
5.
6.
7.
8.
9.
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
Moura, A. C., A. M. Oliveira, et al. (2008). "[Evaluating Portuguese primary
healthcare through Prevention Quality Indicators (PQIs)]." 35. Unpublished data.
José Luis Alfonso, S., V. Joan Sentís, et al. (2004). "[Characteristics of avoidable
hospitalization in Spain]." Med Clin (Barc) 122(17): 653-658.
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.
Ansari Z, Laditka JN, Laditka SB. Access to Healthcare and Hospitalization for
Ambulatory Care Sensitive Conditions. Med Care Res Rev. 2006; 63:719-42
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.
Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available
from: http://www.ine.pt
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 populationbased study in Italy. BMC Public Health. 2009;9(1):457.

Ana Sara Ferreira, [email protected]

Andreia Sofia Teixeira, [email protected]

Catarina Lombo, [email protected]

Diogo Milheiro, [email protected]

Diogo Teixeira, [email protected]

Henrique Teixeira, [email protected]

Inês Pessanha Silva, [email protected]

Mariana Magalhães, [email protected]

Miguel Coimbra, [email protected]

Pedro Carvalho, [email protected]

Paulo Lopes, [email protected]

Samuel Queirós, [email protected]

Tiago Barbosa, [email protected]
Thank you for your time…