1. Introdução à Medicina I/II Class 9 Adviser: Alberto Freitas

2. What are PQIs? IntroMedI - class 9 - PQIs

3. QIs Not definitive measures Use hospital discharge inpatient data Based on readily available data IntroMedI - class 9 - PQIs

4. PQIs Primary Healthcare Ambulatory Care Sensitive Conditions “avoidable hospitalization rates are a sensitive indicator for assessing quality of primary ambulatory care” ( Niti et al, 2003) IntroMedI - class 9 - PQIs Prevention starts here.

5. IntroMedI - class 9 - PQIs Source: Ansari Z. Laditka JN. Laditka SB. Access to Health Care and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care Res Rev. 2006; 63:719-742

6. When were they first introduced? IntroMedI - class 9 - PQIs

7. Studies of the kind in other countries United States (Starfied et al.,1991, Sanderson et al., 2000, Kozak et al., 2001) Australia (Ansari et al., 2003, 2006) New Zealand (Sheerin et al., 2006) Canada (Roos et al., 2005, Porter et al., 2007) Singapore (Niti & Ng, 2003) Spain (Sánchez et al., 2004) Italy (Rizza et al., 2007) IntroMedI - class 9 - PQIs

8. Source: Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; March 2007. IntroMedI - class 9 - PQIs

9. This kind of studies evaluate the quality of the healthcare conditions establish patterns allow comparison with past and future works inside and outside the sampling area. IntroMedI - class 9 - PQIs

10. Key-words Ambulatory Care Primary Care Quality of Healthcare Portugal Delivery of Healthcare Prevention Quality Indicators IntroMedI - class 9 - PQIs

11. IntroMedII - class 9 - PQIs Aim

12. RESEARCH QUESTION What is the status of the primary health care system in Portugal and how does it compare to past years and among its regions? IntroMedI - class 9 - PQIs

13. AIMS Assessment of the primary healthcare system quality, in an outpatient setting. Compare different level 2 NUTS*, trends 2000-2005 Lay hypotheses for the observed differences. *except for Azores and Madeira. IntroMedI - class 9 - PQIs

14. IntroMedII - class 9 - PQIs Participants and Methods

15. PARTICIPANTS 6199102 patients’ discharge data from national database (ACSS) 94 Acute Care Public Hospitals (continent) IntroMedI - class 9 - PQIs

16. DATA COLLECTION Data collected from acute care hospital database Variables of interest present in the database or calculated from others INE (Instituto Nacional de Estatística) provides populational and other statistical data IntroMedI - class 9 - PQIs

17. Division in NUTS II IntroMedI - class 9 - PQIs 2000 2001 2002 2003 2004 2005

18. INCLUSION Diagnosis according to PQI EXCLUSION Age <18 MDC = 14 or 15 Transferred from Related non-evaluative conditions IntroMedI - class 9 - PQIs

21. MDC Major Diagnostic Categories (MDC) Formed by dividing all possible principal diagnoses (from ICD-9-CM) into 25 mutually exclusive diagnosis areas.

22. IntroMedI - class 9 - PQIs

23. Source: Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Version 3.1. Rockville, MD: Agency for Healthcare Research and Quality; March 2007.

24. IntroMedI - class 9 - PQIs INVALID Address codes missing. non-existent or belonging to the Azores or Madeira. Absurd age (below 0; over 150) Undetermined Sex (3)

25. IntroMedII - class 9 - PQIs STRATIFICATION NUT II (Norte, Centro, Lisboa, Alentejo, Algarve) Year (2000-2005) Gender Age (0-17; 18-24; 25-34; 35-44; 45-54; 55-64; 65-74; 75+)

26. IntroMedII - class 9 - PQIs

27. RESULTS OVERVIEW

28. IntroMedI - class 9 - PQIs * Overall PQI = Sum of all PQIs except for 2 and 9 *

29. IntroMedI - class 9 - PQIs

30. IntroMedII - class 9 - PQIs

34. CountryGenderPQI1PQI2PQI3PQI5PQI7PQI8PQI9 PT M 20.0423.6289.23155.7718.94156.45 5.24 F 29.2718.9589.2580.8425.38190.29 6.01 USA M 56.2431.18135.41208.137.27463.646.00 F 53.3128.93118.71251.3961.44512.086.53 PQI10PQI11PQI12PQI13PQI14PQI15PQI16 PT M 17.75324.8158.4371.3719.6411.3731.38 F 25.35263.99107.2749.7927.8227.8319.34 USA M 98.72398.89101.0343.7421.3767.9951.22 F 154.39436.39249.2647.9723.07170.2227.64

35. IntroMedII - class 9 - PQIs Significant Associations Life Quality GIP per Capita Life Expectancy at Birth Healthcare Facilities Number of Health Centers per 100.000 pop. Medical visits per inhabitant Number of doctors per 1000 pop. Education Literacy Index Proportion of active population with minimum education (“3º Ciclo”) Proportion of active population with secondary education or higher Neonatal Age of first pregnancy

36. IntroMedII - class 9 - PQIs Significant Associations Overall PQI Acute PQI Diabetes PQI No significant associations found

37. IntroMedII - class 9 - PQIs Doctors (N) r= -0,70 Nurses (N) r= -0,81 Lit. Index r= -0,67 Life exp. r= -0,61 Med. Visits r= -0,59 Health Centres r= 0,74 Hospital Distance r= 0,76

38. IntroMedII - class 9 - PQIs Pop. Density r= -0,96 Med. Visits r= -0,76 Doctors (N) r= -0,53 Life Exp. r= -0,43 Lit. Index r= - 0,40 Hospital Distance r= 0,37

39. IntroMedII - class 9 - PQIs NONE Hospital Distance r= - 0,53 Min. Education r= -0,39 Med. Visits r= 0,71 Life Exp. r= 0,60 Sec. Education r= -0,36 Min. Education r= -0,35

40. IntroMedII - class 9 - PQIs Health Centres r= 0,70 Hospital Distance r= 0,56 Doctors (N) r= -0,68 Lit. Index r= -0,68 Lit. Index r= -0,64 Life Exp. r= -0,40 Hospital Distance r= 0,78 Health Centres r= 0,73

41. IntroMedII - class 9 - PQIs Sec. Education r= 0,49 Min. Education r= 0,52 GDP r= 0,37 Med. Visits r= -0,51 Life Exp. r= -0,51

42. GDP r= 0,54 Minim. Education r= 0,44 Sec. Education r =0,42 Life Exp. r= -0,50 Hospital Distance r= 0,74 Health Centres r= 0,63 Minim. Education r= 0,33 Lit. Index r= -0,62

43. IntroMedII - class 9 - PQIs Med. Visits r= 0,50 GDP r= 0,50 Min. Education r= 0,47 Sec. Education r =0,46 Lit. Index r= 0,38 Med. Visits r= - 0,57

44. IntroMedII - class 9 - PQIs Age 1st Pregnancy r= 0,64 Age 1st Pregnancy r= 0,64 GDP r= 0,70 GDP r= 0,70 Mean Fig.6 Mean age of first child vs LBW Linear Regression

45. IntroMedII - class 9 - PQIs Cost Analysis

46. IntroMedII - class 9 - PQIs

47. Discussion

48. IntroMedII - class 9 - PQIs Prevention There are different levels of prevention 1.Preventing the onset of the condition 2.Preventing the rampage development of symptoms; i.e controling the condition

49. IntroMedII - class 9 - PQIs VariableNorthCentreLisbonAlentejoAlgarve Population Ageing Index 90,9140,1105,9170,8126,2 Cities5141171911 Pop. Density(N/Km 2 ) 175,684,5946,924,383,4 SEDI0,7750,7670,8540,7470,791 CO 2 emissions/Km2 620,131361,7229029,576232,786360,295 Sources: INE, 2005; Cónim C. População e Desenvolvimento Humano- Uma Perspectiva de Quantificação -1970-1999; Marques JL, Martins JM, Castro EA. Análise input-output rectangular inter-regional - emissões de CO 2 em Portugal e o protocolo de Quioto Fig.9 Overall PQI per NUT II

50. IntroMedII - class 9 - PQIs Self-Perception of Health Source: National Health Survey, 1999 Overall PQI

51. IntroMedII - class 9 - PQIs Patient Profile Male Elderly (75 years old +) Living in areas not densely populated

52. IntroMedII - class 9 - PQIs Studies supporting this association: Lockwood et al.Stress-associated preterm delivery: the role of corticotropin-releasing hormone.

53. IntroMedII - class 9 - PQIs VariableUSAPortugalYearSource Human Development Index (HDI) 0,951 (ranked 12th) 0,897 (ranked 29th) 2005UNDP report 2007/2008 Obesity32,0%14.2%2004Health 2007 (USA) Overweight and obesity in Portugal: national prevalence in 2003– 2005 Smoking prevalence 23.9%35.8%2005WHO CO 2 emissions (ton per capita) 20,65,62004UNDP report 2007/2008 Hypertension 30,2%20,0%2004/5National Health Survey (PT) Health 2007 (USA) Diabetes7,0%6,5%2005National Institute of Diabetes National Health Survey (PT) COPD Hypertensio n CHF Asthma COPD Asthma CHF Hypertensio n CHF Diabetes Hypertension

54. IntroMedII - class 9 - PQIs VariableUSAPortugalYearSource Access to drinking water 99% 2006WHO Life expectancy at birth (years) 77,977,72005UNDP report 2007/2008 ClimateDfa/b, Cfa, BSh/k, Csb, BWk. Csb (north), Csa (south) 2006Kottek et al, World map of Koppen-Geiger climate classification update. EthniesHeterogeneousN/A2006US Census Bureau. Male/Female49%/51%48,4% 51,6% 2005US Census Bureau INE >65 y 12,4%17,0%2005US Census Bureau INE Wet all seasons: Dfa – snow, fully humid, hot summer ; Dfb – snow, fully humid, warm summer Humid subtropical: Cfa – warm temperature, flly humid, hot summer Dry semiarid BSk – arid, steppe, cold arid BSh – arid, steppe, hot arid Dry arid BWk – arid, desert, cold arid Mediteranean Csb – warm temperature, summer dry, warm summer Csa – warm temperature, summer dry, hot summer. Dehydration

55. IntroMedII - class 9 - PQIs Spain

56. IntroMedII - class 9 - PQIs Socioeconomic factors: gender age Income Propensity to seek care according to perceived health needs Hospital bed availability Regular source of care or continuity of care Differences in healthcare service (Public/Private healthcare; Insurances) Coding Issues Lack in Epidemiological Studies (or inconsistent) Intra-regional variations Study Limitations

57. IntroMedII - class 9 - PQIs Conclusions From 55 years old on: There is a clear increase in avoidable hospitalizations Males present higher avoidable hospitalizations rates Differences among years are not significant Norte presents the best quality/cost ratio Portugal shows a more efficient primary healthcare system than USA or Spain. Some heterogeneity among regions points to uneven primary healthcare supply Further study is required to evaluate yearly trends and precise factors which influence PQ.

58. IntroMedII - class 9 - PQIs Future Research Multivariate analysis of correlations Litoral/Interior Analysis Wider timespan (Pre and Post SNS restructuration) Careful analysis of economical indexes and prevalence of analysed conditions Further International Comparison

59. IntroMedII - class 9 - PQIs

60. IntroMedI - class 9 - PQIs REFERENCES PQI Info Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators: Hospital Admission for Ambulatory Care Sensitive Conditions. Version 3.1. Rockville (MD): Agency for Healthcare Research and Quality; March 2007. Farquhar, M. AHRQ Quality Indicators [slides]. Rockville (MD): Agency for Healthcare Research and Quality; 2005. 20 slides colour. General Questions about the AHRQ QIs [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; July 2004 [cited 2007 Oct 31]. Available from: http://www.qualityindicators.ahrq.gov/general_faq.htm AHRQ Prevention Quality Indicators Overview [Internet]. Rockville (MD): Agency for Healthcare Research and Quality; July 2004 [cited 2007 Oct 31]. Available from: http://www.qualityindicators.ahrq.gov/pqi_overview.htm Agency for Healthcare Research and Quality. Prevention Quality Indicators: Technical Specifications. Version 3.2. Rockville (MD): AHRQ; March 2008.

61. IntroMedI - class 9 - PQIs Related Articles Ansari Z, Laditka JN, Laditka SB. Access to Healthcare and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care Res Rev. 2006; 63:719-42 Billings J, Zeitel L, Lukomnick J, Carey TS, Blank AE, Newman L. Impact of socioeconomic status on hospital use in New York City. Health Aff (Millwood). 1993; 2:162-9. Starfield B. Primary care and health: a cross-national comparison. JAMA. 1991; 266:2268-71. Sanderson C, Dixon J. Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care. J Health Serv Res Policy. 2000, 5:222-30. Kozak LJ, Hall MJ, Owings MF. Trends in Avoidable Hospitalizations, 1980-1998. Health Aff. 2001; 2 (20): 225-32. Casanova C, Starfield B. Hospitalizations of children and access to primary care: a cross- national comparison. Int J Health Serv. 1995; 25:283-94. Ansari Z, Barbetti T, Carson NJ, Auckland MJ, Cicuttini F: The Victorian ambulatory care sensitive conditions study: rural and urban perspectives. Soz Praventivmed. 2003; 48:33- 43.

62. IntroMedI - class 9 - PQIs Sheerin I, Allen G, Henare M, Craig K. Avoidable hospitalizations: potential for primary and public health initiatives in Canterbury, New Zealand. N Z Med J. 2003; 119(1236). Roos LL, Walld R, Uhanova J, Bond R: Physician visits, hospitalizations, and socioeconomic status: ambulatory care sensitive conditions in a Canadian setting. Health Serv Res. 2005, 40:1167-85. Porter J, Herring J, Lacroix J, Levinton C. Avoidable Admissions and Repeat Admissions: What Do They Tell Us? Healthc Q. 2007, 10:26-28. 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. Sanchez JLA, Vilalta JS, Perepérez SB, Martínez IM. Characteristics of avoidable hospitalization in Spain. Med Clin (Barc). 2004; 122(17):653-8. Weissman JS, Gatsonis C, Epstein AM. Rates of avoidable hospitalization by insurance status in Massachusetts and Maryland. JAMA. 1992; 268:2388-94.

63. IntroMedI - class 9 - PQIs Pappas G, Hadden WC, Kozak LJ, Fisher GF. Potentially Avoidable Hospitalization inequalities in rates between US socioeconomic groups. Am J Public Health. 1997; 87:811-6. Booth GL, Hux JE. Relationship Between Avoidable Hospitalizations for Diabetes Mellitus and Income Level. Arch Intern Med. 2003; 163:101-6. Data Sources Administração Central do Sistema de Saúde, IP (ACSS). www.acss.min-saude.pt Statistics Portugal [Internet]. Lisbon: INE. 1864- [cited 2008 Mar 30]. http://www.ine.pt Regulation (EC) No 1059/2003 of the European Parliament and of the Council of 26 May 2003 on the establishment of a common classification of territorial units for statistics (NUTS) (Official Journal L 154, 21/06/2003) Departamento de Gestão Financeira. Serviço Nacional de Saúde – Contas Globais 2000 [Internet]. IGIF; 2002 Sep [cited 2008 Apr 19]. 192p. Available from: http://www.acss.min- saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2000.pdf

64. IntroMedI - class 9 - PQIs Departamento de Gestão Financeira. Serviço Nacional de Saúde – Contas Globais 2001 [Internet]. IGIF; 2003 Nov [cited 2008 Apr 19]. 171p. Available from: http://www.acss.min- saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2001.pdf Departamento de Consolidação e Controlo de Gestão do SNS. Serviço Nacional de Saúde – Contas Globais 2002 [Internet]. IGIF; 2004 Apr [cited 2008 Apr 19]. 237p. Available from: http://www.acss.min- saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2002.pdf Departamento de Consolidação e Controlo de Gestão do SNS. Serviço Nacional de Saúde – Contas Globais 2003 [Internet]. Lisbon: Instituto de Gestão Informática e Financeira da Saúde; 2005 Apr [cited 2008 Apr 19]. 223p. Available from: http://www.acss.min- saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2003.pdf Departamento de Consolidação e Controlo de Gestão do SNS. Serviço Nacional de Saúde – Contas Globais 2004 [Internet]. Lisbon: Instituto de Gestão Informática e Financeira da Saúde; 2006 Mar [cited 2008 Apr 19]. 187p. Available from: http://www.acss.min- saude.pt/Downloads_ACSS/relatorios_contas/Relatorio_Contas_2004.pdf

65. IntroMedII - class 9 - PQIs Software SPSS for Windows, Rel. 15.0.0 2006. Chicago (IL): SPSS Inc. Microsoft Frontpage 2003, Rel. 11.5516.8202. USA: Microsoft Corporation. International Data Health, United States, 2007 ;U.S. Department of Health and Human Services; Centers for Disease Control and Prevention; National Center for Health Statistics World Health Organization. Available from:www.who.int/en M. C. Peel, B. L. Finlayson, and T. A. McMahon. Updated world map of the Koppen-Geiger climate classification National Diabetes Statistics. Available from: diabetes.niddk.nih.gov/dm/pubs/statistics/ U.S. Census Bureau. Available from:www.census.gov/

66. IntroMedI - class 9 - PQIs Protocol developed by: Ana Catarina Moura, mimed07028@med.up.pt Ana Margarida Oliveira, mimed07022@med.up.pt Bárbara Mendonça, mimed07248@med.up.pt Cláudia Pereira, mimed07173@med.up.pt Hélio Alves, mimed07223@med.up.pt João Miguel Rego, mimed07261@med.up.pt José Pedro Pinto, mimed07054@med.up.pt Maria Francisca Costa, mimed07093@med.up.pt Maria Guiomar Pinheiro, mimed07095@med.up.pt Nelson Couto, mimed07135@med.up.pt Ricardo Reis, mimed07115@med.up.pt José Alberto Silva Freitas, alberto@med.up.pt

67. IntroMedI - class 9 - PQIs Thank you for your time