The EuroHOPE- project: Comparison of treatment and outcome for AMI and stroke patients in Europe On behalf of the EuroHOPE-team: Terje P. Hagen Department of Health Management and Health Economics, The Medical Faculty, University of Oslo

Approaches to international efficiency comparisons prior to EuroHOPE  System level analysis –WHO 2000, Afonso and St. Aubyn 2005 –Challenges in output measurement: How to measure the impact of health services on health?  Disease level analysis –McKinsey healthcare productivity study, OECD aging-related disease (ARD) project, Technological Change in Healthcare (TECH) Global Research Network (AMI) –Possible to relate inputs to outputs but requires nationally representative patient level data  Sub-sector level analysis –Nordic hospital comparison study group (NHCSG) –Requires that units are comparable and inputs and outputs can be measured in a similar way iHEA meeting, 8th of July, Sydney. Contact:

What and how EuroHOPE does it?  Applies both the disease level and the sub-sector level approaches  Develops methods to measure outcomes and costs of care of specific diseases for evaluation of care given in the whole treatment chain (not yet primary care due to lack of data)  The methods can be used for –routine performance evaluation and monitoring –establishing recommendations for lists of indicators to be routinely collected and published by the EU (as a part of European Community Health Indicators) iHEA meeting, 8th of July, Sydney. Contact:

Solutions in EuroHOPE  Definitions of specific patient groups to maximize comparability  Extensive risk adjustment  Standardisation by modelling and computing confidence intervals  Definitions of episodes EFPC, Istanbul, 20139th September 2013

EuroHOPE Data National discharge register National mortality register Other national registers National EuroHOPE database National EuroHOPE comparison data Protocols International EuroHOPE comparison data Anonymous individual level data used for comparative research Comparison of countries, regions and hospitals EuroHOPE research National research and bencmarking

Definitions of episodes Admission to ward A Procedure/treatment in ward A Admission to ward B Discharge to another hospital Outpatient visit Medication purchase Total episode of care First hospital episode time Discharge home or nursinghome EFPC, Istanbul, 20139th September 2013

Risk adjustments based on comorbidities (AMI) EFPC, Istanbul, 2013 ComorbidityICD-10ICD-9ATC/DDD HypertensionI10*-I15*40*C03*, C07* (with neither coronary artery disease nor atrial fibrillation indicates hypertension), C08*, C09* Coronary artery diseaseI20*-I25*410*-414*N/A Atrial fibrillationI48*4273*N/A Cardiac insufficiencyI50*428*N/A Diabetes mellitusE10*-E14*250*A10A*, A10B* AtherosclerosisI70*440*N/A CancerC00*-C99**, D00*-D09*140*-208*L01* (except L01BA01) COPD and asthmaJ44*-J46*4912*, 496*, 496*R03* DementiaF00*-F03*, G30*290*, 3310*N06D* DepressionF32*-F34*2960*, 2961*N06A* Parkinson’s diseaseG20*332*N04B* Mental disordersF20*-F31*295*-298* except 2960* and 2961* N05A* (except N05AB01 and N05AB04), and no dementia Renal insufficiencyN18*585*N/A AlcoholismF10*-F19*291*, 304*, 305*N/A StrokeI60*, I61*, I63*, I64*, G45* 430*-438*N/A 9th September 2013

Description of regions used in EuroHOPE EFPC, Istanbul, 2013 CountryDescriptionNumber of regions Average population size Finland Hospital districts and hospital regions responsible for providing specialised health care. Smallest districts combined Hungary19 counties and Budapest area providing self- governmental administrative duties (not health care) ItalyCity of Turin and Province of Rome (divided into two smaller units: City of Rome and outside of Rome municipalities) The NetherlandsProvinces responsible for matters of subnational or regional importance (not health care) NorwayHospital trusts responsible for providing specialist health care in their geographical areas ScotlandHealth boards responsible for health care. Smallest boards combined SwedenCounties responsible for providing health care th September 2013

Acute Myocardial Infarction (AMI)  inpatient, outpatient, medication administrative data and death registries  AMI codes: ICD-9: 410, ICD 10: I21, I22  inclusion criteria: valid ID, resident, age 18-X  index hospital admission: –main diagnosis is AMI, no AMI within 365 prior the admission  linkage of individual episodes with patient IDs  first analysis: –FIN, HUN, IT, NL, SCO, SWE –NOR EFPC, Istanbul, 20139th September 2013

2-day PCI rate (%) of AMI patients by country, adjusted for age and sex EFPC, Istanbul, 20139th September 2013

2-day PCI rate (%) of AMI patients per region by country, adjusted for age and sex, with confidence intervals FINLANDHUNGARYNORWAYSWEDEN EFPC, Istanbul, 2013 NETHER- LANDS 9th September 2013

Mean length of first hospital episode of AMI patients per region by country, adjusted for age, sex and previous year hospital days, with confidence intervals EFPC, Istanbul, 2013 FINLAND HUNGARY NORWAY SWEDEN ITALY 9th September 2013

One-year mortality of AMI patients per region by country, adjusted for age and sex, with confidence intervals EFPC, Istanbul, 20139th September 2013

Ischaemic stroke  inpatient, outpatient, medication administrative data and death registries  Ischaemic stroke codes ( ICD-9: , ICD 10: 63  inclusion criteria: valid ID, resident, age 18-X  index hospital admission: –main diagnosis is ischaemic stroke, no stroke within 365 prior the admission  linkage of individual episodes with patient IDs  first analysis: –FIN, HUN, IT, NL, SCO, SWE EFPC, Istanbul, 20139th September 2013

Mean length of first hospital episode of stroke patients per region by country, adjusted for age, sex and previous year hospital days, with confidence intervals EFPC, Istanbul, 2013 FINLAND HUNGARY SWEDEN ITALY 9th September 2013

Mean mortality (30-, 90-day and one-year (%)) of stroke patients by country, adjusted for age and sex EFPC, Istanbul, 20139th September 2013

Mean one-year mortality of stroke patients per region by country, adjusted for age and sex, with confidence intervals EFPC, Istanbul, 2013 FINLAND HUNGARY NETHERLANDS SCOTLAND SWEDEN 9th September 2013

Conclusions  Large variation in use of resources and outcomes between the countries, hospitals and regions  Potential for improving efficiency  Benchmarking (where is the wisdom): preliminary best performing regions in EuroHOPE countries EFPC, Istanbul, 20139th September 2013

Next steps  National and regional indicators to be published at  Development methods for measuring costs  Scientific articles (clinical, methodological, health policy orientated)  Health economic issues such as –analyses of reasons behind differences in outcomes and use of resources between the countries and regions –relationship between outcomes and cost at country and hospital level EFPC, Istanbul, 20139th September 2013