Assessment of the Assessment of the Portuguese Pediatric Portuguese Pediatric Healthcare ServicesHealthcare Services

• Adriana Alves de Sá Lemos Pinto• Ana Isabel Moreira Ferrão• Ana Rita Ribeiro Mieiro Pinto Dias• Fátima Daniela Almeida Ribeiro • Guadalupe Maria da Silva Costa Marinho• Joana Gomes Amorim• João Sérgio de Lima Soares Neves• Luís Miguel Fernandes Teles• Mafalda Sofia Ferreira Gonçalves• Pedro Martins Pereira• Sara Daniela Correia Miranda• Sara Margarida Preto Roca

Class 1Prof. Alberto Freitas

Introduction

Background

Justification

Aims

Participants

Methods

Description of the chosen PDIs

Result Analysis

Comparison with SábadoMagazine

Expected results

Flow Chart

References

Introdução à Medicina I 2007/2008

Pediatric Quality Indicators

INTRODUCTIONINTRODUCTION“Quality day care from infancy clearly has positive

effects on children’s intellectual, verbal, phisical and

cognitive development, especially when children would

otherwise experience impoverished and relatively

unstimulating home environments. Care of unknown

quality may have deleterious effects.”

Lamb’s, Michael. Handbook of Child Psychology 1998. 104

www.qualityindicators.ahrq.gov/documentation.htm

• In 1994 the Health Care Cost and Utilization Project were developed at the Agency for Health Care Research and Quality; (1)

• 33 indicators were designed to evaluate quality at hospitals; (1)

BackgroundBackground

(1) AHRQ: Agency for healthcare research and quality [Internet]. USA; Measures of Pediatric Health Care Quality Based on Hospital Administrative Data, The Pediatric Quality Indicators.2007 [about 1 screen] Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/

SS

BackgroundBackground

• Pediatric Quality Indicators - “Set of measures that focus on children’s health care quality” (1) - were created;

• The population in study is submitted to several requirements;

(1) AHRQ: Agency for healthcare research and quality [Internet]. USA; Measures of Pediatric Health Care Quality Based on Hospital Administrative Data, The Pediatric Quality Indicators.2007 [about 1 screen] Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/

BackgroundBackground• Provider-level indicators – include cases where a

secondary diagnosis code flags a potentially preventable complication;(1)

• Accidental Puncture or Laceration

• Decubitus Ulcer

• Foreign Body Left During Procedure

• Iatrogenic Pneumothorax in Neonates

• Iatrogenic Pneumothorax in Non-neonates

• Pediatric Heart Surgery Mortality

• Pediatric Heart Surgery Volume (1). AHRQ: Agency for healthcare research and quality [Internet]. USA; Measures of Pediatric Health Care Quality Based on Hospital Administrative Data, The Pediatric Quality Indicators.2007 [about 1 screen] Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/

• Postoperative Hemorrhage or Hematoma

• Postoperative Respiratory Failure

• Postoperative Sepsis

• Postoperative Wound Dehiscence

• Selected Infections Due to Medical Care

• Transfusion Reaction

• Area-level indicators – cases where a patient’s risk of the complication occurred in a separate hospitalization;(1)

• Asthma Admission Rate

• Diabetes Short-term Complication Rate

• Gastroenteritis Admission Rate

• Perforated Appendix Admission Rate

• Urinary Tract Infection Admission Rate (1). AHRQ: Agency for healthcare research and quality [Internet]. USA; Measures of Pediatric Health Care Quality Based on Hospital Administrative Data, The Pediatric Quality Indicators.2007 [about 1 screen] Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/

JustificationJustification

This study can be considered important and innovative since pediatric care is significantly different from adult

care:

• Evaluation of hospitals’ conditions focused on the quality of the pediatric services

provided.

JustificationJustification

• Spread the results of our PDI’s studies

• Choose the best pediatric services

JustificationJustification

• Appeal to hospital’s attention in what

concerns to their position in the ranking

• Improve services’ quality

AimsAims• Evaluate and compare the quality of Pediatric

services in Portugal.– Considering: Location; economical groups and

evolution among several years

• Compare our results with other studies that have already been done: Sábado Magazine and USA Pediatric Quality Indicators.

Tipe of studyTipe of study

• Retrospective

• Analytic study

• Longitudinal

• Observational

ParticipantsParticipants

1. Target population

Our study will focus on all impatient pediatric episodes of Portuguese Hospitals, based on administrative and clinical data, from 2000 to 2005.

But…

Who is included in pediatric care?

– People aged under 18 years;

– Not in Major Diagnostic Category 14 (Pregnancy, Childbirth & the Puerperium);

– Not in adult Diagnostic Related Groups. (1)

(1). AHRQ: Agency for healthcare research and quality [Internet]. USA; Measures of Pediatric Health Care Quality Based on Hospital Administrative Data, The Pediatric Quality Indicators.2007 [about 1 screen] Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/

MethodsMethods

• The Accidental Puncture or Laceration indicator is intended to flag cases of complications that arise due to technical difficulties in medical care, specifically those involving an accidental puncture or laceration. (2)

Example – Example – Accidental Puncture or Accidental Puncture or Laceration (PDI1)Laceration (PDI1)

(2). U.S. department of health and human services; AHRQ Quality Indicators Pediatric Quality Measures Clearinghouse [internet], USAgovernment; 2007, March; Available from http://www.qualitymeasures.ahrq.gov/summary/summary.aspx?doc_id=10696

a) Open SPSS data base and apply the general inclusion and exclusion criteria

b) Calculate the numerator

Discharges among cases meeting the inclusion and exclusion rules for the denominator with ICD-9-CM code denoting accidental cut, puncture, perforation, or hemorrhage during medical care in any secondary diagnosis field. (3)

(3). McDonald, K., Measures of Pediatric Health Care Quality Based on Hospital Administrative Data: The Pediatric Quality Indicators, 2006 February 20. 32

1. Apply the specific inclusion and exclusion criteria of the numerator of the chosen PDI

• ICD-9-CM Accidental Puncture or LacerationAccidental Puncture or Laceration Codes

Obtained numerator: 997

c) Calculate the denominator

1. Apply the general inclusion and exclusion criteria of PDI’s

2. Apply the specific inclusion and exclusion criteria of the denominator of the chosen PDI

Included cases:

• All medical and surgical discharges under age 18 defined by specific

DRGs - Diagnostic Related Groups, using ICD-9-CM codes available in

Appendix B (Surgical Discharge DRGs) and E (Medical Discharge

DRGs).

Excluded cases:

•with ICD-9-CM code denoting technical difficulty (e.g., accidental cut, puncture, perforation, or laceration) in the principal diagnosis field;•MDC 14 (pregnancy, childbirth, and puerperium);•normal newborn (DRG 391);•Newborns with birth weight less than 500 grams, available in Appendix G: Low Birth Weight Categories.

Obtained denominator: 784820

d) Divide the numerator by the denominator to obtain the final result.

Final result: (779/ 784820) = 1,245 per 1000

Comparative Result from AHRQ (4) : 0,871 per 1000

(4). U.S. department of health and human services; AHRQ Quality Indicators Pediatric Quality Indicators Comparative Data for Provider Indicators [internet], USAgovernment; 2007, March; Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_provider_comparative_v31.pdf

Chosen PDI’sChosen PDI’s

Quality IndicatorQuality Indicator DescriptionDescription

Accidental Accidental Puncture or Puncture or LacerationLaceration

Cases of technical difficulty per 1,000 eligible discharges (population

at risk). Accidental cut, puncture, perforation or hemorrhage during

medical care.

Foreign Body left Foreign Body left during procedure during procedure

Number of patients with a foreign body unintentionally left in during a

procedure per 1,000 eligible admissions (population at risk). This

indicator is intended to track injuries occurring during a procedure,

specifically accidental cut, puncture, perforation, or laceration.

These procedures may be prevented through proper technique

during procedures.

Chosen PDI’sChosen PDI’s

Selected Selected infection due to infection due to

medical caremedical care

Number of patients with specific infection codes per 1,000 eligible

admissions. This indicator is intended to capture infections that are

due to medical care, but are limited to those easily captured using

administrative data. This indicator likely captures mostly line and

other vascular access related infections. High quality care is likely to

reduce the risk for this complication.

Gastroenteritis Gastroenteritis admission admission

raterate

Number of patients admitted for gastroenteritis per 100,000

population. This indicator is intended to identify hospitalizations for

gastroenteritis, where gastroenteritis is identified as the principal

reason for hospitalization. Timely and effective care for

gastroenteritis, such as oral rehydration therapy, may reduce the

need for hospitalization.

Chosen PDI’sChosen PDI’s

Pediatric heart Pediatric heart surgery volumesurgery volume

Number of patients undergoing surgery for congenital heart disease.

Discharges with a procedure codes for surgical intervention for

congenital heart disease or non-specific heart surgery with a

diagnosis code of congenital heart disease in any field.

Results

Results were divided in:

• Discharge Data: evaluation and comparison of the PDI’s along the years, from 2000 to 2005

• Tipe A: analysis by economic groups:

• 1

• 2

• 3

• 4

• Tipe C: analysis by administrative division

• 1 – Central Hospital

• 2 – District Hospital

• 3 – Distric Hospital of level 1

• Hospital reside : study includes the analysis of the variable “Hospital ID”, which means the values of Pediatric Quality Indicators were calculated to each Hospital and compared.

Decrease of tecnology, complexity and specialisation

PDPDI 1 - Accidental Puncture or I 1 - Accidental Puncture or LacerationLaceration

2,287

0,452 0,4598

0

0,5

1

1,5

2

2,5

3

1 2 3

Per

100

0

Type C

PDI 1= 997 / 784820 = 1,245 per 1000

Rate per 1000 (AHRQ)= 0,871

PDI 3 - PDI 3 - Foreign Body left during Foreign Body left during

procedureprocedure

PDI 3 = 34 / 784810 = 0,043322588 per 1000

Rate per 1000 (AHRQ)= 0,034

0,054

0,068

0,045

0,03

0,03

0,032

0

0,01

0,02

0,03

0,04

0,05

0,06

0,07

0,08

2000 2001 2002 2003 2004 2005

Pe

r 1

00

0

Discharge Date

0,068

0,0240,030

0

0,01

0,02

0,03

0,04

0,05

0,06

0,07

0,08

1 2 3

Pe

r 1

00

0

Type C

0,04

0,071

0,03 0,032

0

0,01

0,02

0,03

0,04

0,05

0,06

0,07

0,08

1 2 3 4

Pe

r 1

00

0

Type A

PDI 7 - Pediatric Heart PDI 7 - Pediatric Heart Surgery VolumeSurgery Volume

PDI 7 - Pediatric Heart PDI 7 - Pediatric Heart Surgery VolumeSurgery Volume

49

66

30

10

20

30

40

50

60

70

80

1 2 4

Nu

mb

er o

f cas

es

Type A

PDI 7 frequency = 118

PDI 12 - Selected infection due to PDI 12 - Selected infection due to medical caremedical care

0,019

0,082

0,124

0,19

0,1

0,227

0

0,05

0,1

0,15

0,2

0,25

2000 2001 2002 2003 2004 2005

Per

100

0

Discharge Date

0,109

0,135

0

0,02

0,04

0,06

0,08

0,1

0,12

0,14

0,16

1 2

Per

100

0

Type C

0,1240,160

0,115

00,020,040,060,08

0,10,120,140,160,18

1 2 4

Per

100

0

Type A

Central Hospitals

0

1

2

3

4

5

6

7

8

2 6 24 54 88

‰

Rate per 1000 (AHRQ)= 2.677

PDI 12 = 69 / 569861 = 0,12 per 1000

PDI 16 - Gastroenteritis PDI 16 - Gastroenteritis admission rate admission rate

PDI 16 frequency = 38469

5. Compare our PDIs results with the ones obtained in other studies

There are studies that evaluate the Quality of Pediatric Services based

on Pediatric Quality Indicators

Investigation published by Sábado Investigation published by Sábado MagazineMagazine

• Ranking of the best pediatric services in Pediatric Health care (5)

1st Hospital Amadora-Sintra

2nd Hospital de Leiria

3rd Centro Hospitalar da Cova da Beira

4th Hospital de Castelo Branco

5th Hospital de Braga

(5). Sábado, 2007, December, Supl 188: 8-18.

Methods used in the article published by Sábado magazine(6)

Our methods

Target population

• Patients hospitalized in Portugal Continental Public Hospitals

• Patients hospitalized in Portugal Continental Public Hospitals with:

- Age under 18 years

- Not in adult diagnosis related group

- Not in major diagnosis category (pregnancy, childbirth and puerperium)

Software

• Disease Staging • SPSS

Data base

• Direcção-Geral de Saúde

• ACSS (Administração Central do Sistema de Saúde)

Methods used in the Methods used in the investigationinvestigation

Methods used in the article published by Sábado magazine(6)

Our methods

Range of study•2003-2005 •2000-2005

Variables

•Mortality •Complications•Readmissions•General Performance

•Hospital’s ID•Primary diagnosis•Secondary diagnosis•Diagnosis and surgical procedure •Diagnosis Related Group (DRG)

Methods used in the Methods used in the investigationinvestigation

Methods used in Sábado Methods used in Sábado MagazineMagazine

Methods used in the article published by Sábado magazine(6)

Our methods

Variables

•Birth Weight•Length of stay at the hospital•Age (in years)•Major diagnosis category•Residence area•Kind of hospital•Hospitals (division per economic groups)•Administrative division •Hospital localization

Expected ResultsExpected Results

• Differences between results of litoral and inner country PDIs, being the litoral services the most developed.

• Evolution of the PDIs from 2000 to 2005.

• Similarites and differences between our results and the ones obtained by other studies.

Research on the theme AHRQ

Calculate one quality indicator of each type(with SPSS)

Research on the theme on pubmed

Useful for our work

articles obtained

Read title and abstract (2 reviewers)

NoYes Exclude articleObtain full article

Analysis of the information obtained

Calculate the quality indicators

End

Article

First protocol

Second protocol

Data analysis in AHRQ software

Compare results between different

hospitals

Compare results between various

regions of the country

Analise the resultsFinal presentation

Analyse the next article

Analyse the first article

Are there more articles

No

Yes

Yes

Full papers obtained

Compare results between different

hospitals

Manual Creation of the sintax

Third protocol and presentaion

ReferencesReferences1. AHRQ: Agency for healthcare research and quality [Internet]. USA; Measures of Pediatric Health Care Quality

Based on Hospital Administrative Data, The Pediatric Quality Indicators.2007 [about 1 screen] Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/

2. IBIS-PH: Utah’s Indicator-Based Information System for Public Health [Internet]. Salt Lake City: Center for Health Data Utah Department of Health; Indicators Profile - Complete Indicator Profile of Ambulatory Care Sensitive Conditions: Asthma Hospital Discharges Among Children; November 2004. [about 9 screens]; Available from: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=citmed.section.59530

3. McDonald, K., Measures of Pediatric Health Care Quality Based on Hospital Administrative Data: The Pediatric Quality Indicators, 2006 February 20. 32

4. U.S. department of health and human services; AHRQ Quality Indicators Pediatric Quality Indicators Comparative Data for Provider Indicators [internet], USAgovernment; 2007, March; Available from: http://www.qualityindicators.ahrq.gov/downloads/pdi/pdi_provider_comparative_v31.pdf,

5. Sábado, 2007, December, 188[suppl]: 8-18.

6. Costa C, Lopes S. Avaliação do Desempenho dos Hospitais Públicos em Portugal Continental – 2005. ENSP, 2007 (www.ensp.unl.pt).