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

2. 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 Image source: http://www.parklandhealthcenter.org/phc_content.aspx?id=3778 Prevention starts here.

3. 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

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

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

6. 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

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

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

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

10. 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+)

11. IntroMedII - class 9 - PQIs

12. 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

13. IntroMedII - class 9 - PQIs RESULTS OVERVIEW

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

15. IntroMedI - class 9 - PQIs

16. IntroMedII - class 9 - PQIs

20. 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

21. IntroMedII - class 9 - PQIs Significant Correlations Overall PQI Acute PQI Diabetes PQI No relevant associations found

22. IntroMedII - class 9 - PQIs Significant Correlations 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 Neonatal mortality rate

23. IntroMedII - class 9 - PQIs GIP per capita LBWAngina Urinary Inf. Asthma p < 0.05 0.35 < r < 0.7 r= 0.699 r=0,539 r=0,499 r=0,365

24. IntroMedII - class 9 - PQIs Life expectancy Diab. short- term Perf. Appendix Angina Dehydration p < 0.05 -0.62 < r < -0.38 r=-0,611 r=-0,457 r=-0,503 r=-0,399

25. IntroMedII - class 9 - PQIs Life expectancy COPD p < 0.01 r = 0.60

26. IntroMedII - class 9 - PQIs Health Centers Diab. short- term Dehydration Diab. LE amp. Heart Failure p < 0.01 0,631< r <0,735 r= 0,7 r= 0,631 r= 0,731 r= 0,735

27. IntroMedII - class 9 - PQIs Medical Visits Diab. short- term Perf. Appendix Urinary Inf. Asthma p < 0.05 -0,761< r <-0,513 r= -0,567r= -0,761 r= -0,513 r= -0,596

28. IntroMedII - class 9 - PQIs Medical Visits COPD p < 0.01 r = 0.71

29. IntroMedII - class 9 - PQIs n. of doctors Diab. short- term Perf. Appendix Heart failure p < 0.02 -0,681< r <-0,530 r= -0,681 r= -0,530 r= -0,675

30. IntroMedII - class 9 - PQIs Literacy Index Diab. short- term Perf. Appendix Heart failureDehydration Diab. LE amp. p < 0.05 -0,680< r <-0,390 r= -0,615 r= -0,644r= -0,680 r= -0,390 r= -0,647

31. IntroMedII - class 9 - PQIs Literacy Index Asthma p < 0.01 r = 0.37

32. IntroMedII - class 9 - PQIs Education Urinary Inf. Asthma Angina p < 0.05 0,383< r <0,472 r= 0,472 r= 0,383 r= 0,430

33. IntroMedII - class 9 - PQIs Education Hypertension COPD p < 0.05 - 0.37 < r < - 0.35 r= -0,288 r= -0,357

34. IntroMedII - class 9 - PQIs p < 0.01 r= 0,64

35. IntroMedII - class 9 - PQIs What is missing? Done Indicator Calculation Indicator Stratification Indicator Comparison Correlations To Do Correlation with Costs Discuss Results Further bibliographic search Comparison with foreign countries

36. IntroMedI - class 9 - PQIs REFERENCES 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 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 anm,mid Quality; March 2007. 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

37. IntroMedI - class 9 - PQIs Ansari Z, Laditka JN, Laditka SB. Access to Health Care 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.

38. IntroMedI - class 9 - PQIs 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. 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.

39. IntroMedI - class 9 - PQIs 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 health care 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. 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.

40. IntroMedI - class 9 - PQIs Booth GL, Hux JE. Relationship Between Avoidable Hospitalizations for Diabetes Mellitus and Income Level. Arch Intern Med. 2003; 163:101-6. 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) Agency for Healthcare Research and Quality. Prevention Quality Indicators: Technical Specifications. Version 3.2. Rockville (MD): Agency for Healthcare Research and Quality; March 2008. SPSS for Windows, Rel. 15.0.0 2006. Chicago (IL): SPSS Inc.

41. 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

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