3. Creation of information systems that allow to grade the management [1] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June

4. In a general way… …measurement units to monitor and evaluate through comparison between different entities …are… Two main functions EvaluateDescribe [1] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June [2] Johantgen M, Elixhauser A, Bali JK, et al. Quality indicators using hospital discharge data: state and national applications. As many as one-fourth of hospital deaths might be preventable [2]

5. Efficiency Efficacy Effectiveness Cost-efficiency Comparability Availability Relevance Consistency Reliability [1] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June [3] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005 [4] Collopy B T. Clinical indicators in accreditation: an effective stimulus to improve patient care.

6. Purpose Entity being measured Dimension of quality Type of measure Intended audience [5] Eddy D M. Performance measurement: problems and solutions. 1998

7. Lack of technical means Input/Output measurement difficulties Availability of funding Employees lack of instruction Little dynamism from commissions responsible for executing indicators Inadequacies of information systems [1] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June [3] Correia L F. Indicadores de Desempenho Económico na Saúde. 2005 [5] Eddy D M. Performance measurement: problems and solutions. 1998

8. 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 [1] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June

9. Comparative quality reporting Public reporting Pay-for-performance Public reporting Pay-for-performance Comparative quality reporting

10. 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 Built from the diagnostic features and patients therapeutic profiles that explain the resource consumption in hospitals Tendency to rationalize the funds distribution process [7] Bentes M, Gonçalves M, Urbano J, Tranquada S. A utilização dos GDHs como instrumento de financiamento hospitalar.

11. We explicitly acknowledge limits of our ability to measure actual quality of care. The literature on quality of care clearly underscores the quality improvement implementation and Hospital Performance difficulty of measuring quality in a valid, reliable fashion. Each approach to assessing quality is subject to criticism, regardless of whether measures derive from discharge abstract databases or from patient chart abstracts. [8] Weiner B J, Alexander J A, Shortell S M, Baker L C, Becker M, Geppert J J. Quality of Care - Quality Improvement Implementation and Hospital Performance on Quality Indicators.

13. Norte Centro Lisboa Alentejo Algarve Região Autónoma dos Açores Região Autónoma da Madeira Compare the numbers from 2000 to 2007 Establish a comparison between the different areas of Portugal Evolution of the services quality and efficiency [9] Nomenclatura de Unidades Territoriais para fins estatísticos, Wikipédia, 2008 [10] 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.

15. 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 episode85,4 Ambulatory episode14,6 Database with inpatient episodes from 87 Portuguese public Hospitals between 2000 and 2007

16. Male 44,4 Female 55,6 1719,8 18 - 245,4 25 - 3412,6 35 - 449,3 45 - 549,3 55 - 6410,8 65 - 7414,2 7518,2 Alentejo4,9 Algarve3,7 Centro26,0 Lisboa26,5 Norte33,8 200012,1 200112,2 200212,4 200312,7 200412,6 200513,0 200612,5 200712,5 Total admissions: 7.768.467

17. Discharged patients Newborns Discharged patients Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Newborns Vaginal Delivery Unspecified surgical procedures Medical DRGs complications Exceptional admission episodes Surgical admission time Complication-free long-term admissions Readmissions Short-term inappropriate admissions Vaginal Delivery Unspecified surgical procedures Medical DRGs complications

18. o HOSP_ID o EPIS_ID o SEXO o BIRTH_WGT o HOSP_FROM o HOSP_TO o ADM_TIP o DSP o SAIDLAST o RESIDE o DDX1 o DDX2-DDX20 o SRG1-SRG20 o ENT1 o HOSP_ID o EPIS_ID o SEXO o BIRTH_WGT o HOSP_FROM o HOSP_TO o ADM_TIP o DSP o SAIDLAST o RESIDE o DDX1 o DDX2-DDX20 o SRG1-SRG20 o ENT1 o TOTDIAS o DRG o MDC o AGE o HOSP_DIST o HOSP_RESIDE o TOTDIAS o DRG o MDC o AGE o HOSP_DIST o HOSP_RESIDE ICD-9-CM code Portaria nr110-A/2007, January the 23rd of 2007attachments II e III [11] Ministério da Saúde. Diário da República [Internet]. 2007 January 23. Portaria n.º 110-A/2007 - 1.ª Série - N.º16 [12] Ministério da Saúde. I Série-A. Diário da República. 2002 Nov 5. [13] Newborn (infant) (liveborn) [Internet], ICD9 chrisendres

19. Beginning Creation of the variable of the lowest limit for each DRG Creation of the variable of the highest limit for each DRG Time < lowest limit YesNo Short-term episode Time > highest limit End YesNo Long-term excepcional episode Normal episode DRG Portaria nr110-A/2007 TOTDIAS DRG Portaria nr110-A/2007 [10] Ministério da Saúde. Diário da República [Internet]. 2007 January 23. Portaria n.º 110-A/2007 - 1.ª Série - N.º16

20. a) Comparison between years b) Comparison between regions c) Hyphothesis of other studies

21. 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample 20002001200220032004200520062007 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample Short-term episode 0,6% Long-term exceptional episode 1% Long-term exceptional episode 1% REASONS: Financing system encourage length of stay reduction Reduce number of beds [5] Shortage of personnel [5] Reduction in admissions caused by bed shortage [5] Both relatives and patients may gain a great deal of pleasure [14] REASONS: Financing system encourage length of stay reduction Reduce number of beds [5] Shortage of personnel [5] Reduction in admissions caused by bed shortage [5] Both relatives and patients may gain a great deal of pleasure [14] [5] Eddy D M. Performance measurement: problems and solutions. 1998 [14] Thomson R, Taber S, Lally J, Kazandjan V. UK Quality Indicator Project® (UK QIP) and the UK independent health care sector: a new development.

22. 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1)Data from 1% sample 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample General readmission rate of 5,5% Matches the 5-29% set as reference in other articles [15-17] [15] Tierney A J, Worth A. Review: Readmission of elderly patients to hospital. [16] Victir C R, Vetter N J. The early readmission of the elderly to hospital. [17] Thomas J W, Holloway J J. Investigating early readmission as an indicator for quality of care studies..

23. 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample

24. Respiratory distress syndrome is the most common cause of respiratory failure and mortality [18] The incidence and severity of RDS can be reduced by measures like maternal antenatal steroid treatment [19] [18] Fidanovski D, Milev V, Saikovski A, Hristovski A, Sofiianova A, Koiic L, Kimovska M. Mortality risk factors in premature infants with respiratory distress syndrome treated by mechanical ventilation. [19] Harms K, Herting E, Kron M, Schill M, Schiffmann H.Importance of pre- and perinatal risk factors in respiratory distress syndrome of premature infants. A logical regression analysis of 1100 cases.

25. However this increase is also related to the tremendous strides made by neonatologists and the resulting increased willingness of obstetricians to deliver preterm babies from hostile intrauterine environments [26]. [20] Steer P. The epidemiology of preterm labour. [21] Goldenberg R L, Culhane J F, Iams J D, Romero R. Epidemiology and causes of preterm birth. [22] Martius J A, Steck T, Oehler M J, Wukf K H. Risk factors associated with preterm (<37+0 weeks) and early preterm birth (<32+0 weeks): univariate and multivariate analysis of 106 345 singleton births from the 1994 statewide perinatal survey of Bavaria. [23] Gardner M O, Goldenberg R L, Cliver S P, Tucker J M, Nelsin K G, Copper R L. The origin and outcome 1994 of preterm twin pregnancies. [24] Goldenberg R L, Hauth J C, Andrews W W. Intrauterine infection and preterm delivery. [25] Vitamin. Keep Em Cooking [Internet]. 2009 [26] Huddleston J F, Sanchez J F, Sanchez-Ramos L, Huddleston K W. Acute management of preterm labor

26. 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample An increase in vaginal deliveries with complications wasnt expected having in mind the improvement in health care [27]. [27] Simon N V, Heaps K P, Chodroff C H. Improving the processes of care and outcomes in obstetrics/gynecology.

27. Normal deliveriesComplicated deliveries Weekdays Count 29753299815 % within day of week 74,925,1 Weekend Count 9725733864 % within day of week 74,225,8 Variation of vaginal deliveries between weekdays and weekends In Portugal this association is statistically significant (p< 0,05) Hospitals should work toward increasing the robustness of safeguards on weekends [28]. [28] Bendavid E, Kaganova Y, Needleman J, Gruenberg L, Weissman J S. Complication rates on weekends and weekdays in US hospitals

28. 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample 20002001200220032004200520062007 Exceptional admission episodes Short-term episode19,219,419,719,8 20,319,719,8 Long-term exceptional episode2,392,111,921,681,611,541,521,49 Readmissions4,985,315,485,475,635,655,705,59 Newborns problems1,041,081,15 1,081,061,041,02 Short-term inappropriate admissions Surgical DRG 4,414,685,095,736,156,056,406,32 Medical DRG1,701,361,331,170,970,950,901,55 Vaginal DeliveryWith complications23,624,126,025,424,425,626,327,6 Unspecified surgical procedures0,830,770,740,760,750,710,690,74 Medical DRGs complications 1) 15,817,318,418,317,719,619,420,2 Variation of overall indicators from 2000 to 2007 (percentages) 1) Data from 1% sample

29. AlentejoAlgarveCentroLisboaNorte Exceptional admission episodes Short-term episode16,618,318,621,319,8 Long-term exceptional episode 2,062,361,731,941,55 Readmissions5,555,705,945,255,17 Newborns problems1,081,121,451,211,32 Short-term inappropriate admissions Surgical DRG3,763,944,325,577,17 Medical DRG1,331,631,041,631,06 Vaginal DeliveryWith complications13,913,4 27,2 27,325,9 Unspecified surgical procedures0,960,74 0,76 0,840,61 Medical DRGs complications 1) 22,515,9 19,0 20,616,2 Variation of overall indicators according to Portuguese regions (percentages) 1) Data from 1% sample AlentejoAlgarveCentroLisboaNorte Exceptional admission episodes Short-term episode16,618,318,621,319,8 Long-term exceptional episode 2,062,361,731,941,55 Readmissions5,555,705,945,255,17 Newborns problems1,081,121,451,211,32 Short-term inappropriate admissions Surgical DRG3,763,944,325,577,17 Medical DRG1,331,631,041,631,06 Vaginal DeliveryWith complications13,913,4 27,2 27,325,9 Unspecified surgical procedures0,960,74 0,76 0,840,61 Medical DRGs complications 1) 22,515,9 19,0 20,616,2 Variation of overall indicators according to Portuguese regions (percentages) 1) Data from 1% sample

30. Total episodes Readmissions ( 5,5%) Total Readmissions After Short term admission (34%) Shortening LOS does not appear to result in increased rates of readmissions within 30 days after discharge [29] Brief hopitalizations often led to rapid readmissions within one month of discharge [30] [29] Westert G P, Lagoe R K, keslimaki I, Leyland A, Murphy M. An international study of hospital readmissions and related utilization in Europe and the USA. [30] Harrison M L, Graff L A, Roos N P, Brownell M D. Discharging patients earlier from Winnipeg hospitals: does it adversely affect quality of care?

31. Longer LOS [31] Baldi S, Scappaticci E, Oliaro A, Pischelda F, Mancuso M. Medical complications in lung resections [32] Bonis P A, Pickens G T, Rind D M, Foster D A.Association of a clinical knowledge support system with improved patient safety, reduced complications and shorter length of stay among Medicare beneficiaries in acute care hospitals in the United States [33] Suwanwela N C, Eusattasak N, Phanthumchinda K, Piravej K, Locharoenkul C. Combination of acute stroke unit and short-term stroke ward with early supported discharge decreases mortality and complications after acute ischemic stroke. Total of long-term exceptional episodes Complications (36,5%) Total of long-term exceptional episodes in Medical DRGs Complications (41,3%) Higher consume of resources [31] Increase of health care costs [31]

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