Coronary revascularisation in Spain - ECHO · 2017-01-24 · Exposure to surgical revascularization...

Coronary

revascularisation

in Spain

February 2014

García-Armesto S, Comendeiro-Maalooe M, Martinez-Lizaga N, Angulo-Pueyo E, Bernal-Delgado E on behalf of the ECHO consortium

ECHO Atlas on Coronary Revascularisation EUROPEAN COLLABORATION FOR HEALTHCARE OPTIMIZATION (ECHO)

Edited by

Seral Rodríguez M., García Armesto S., Bernal Delgado E. Instituto Aragonés

de Ciencias de la Salud- Instituto de Investigación Sanitaria Aragón.

Acknowledgment and disclaimer

The ECHO Consortium appreciates the key role of the national institutions

that kindly provided the data used in this research project.

ECHO Consortium strives to keep the content of this Atlas accurate according

to rigorous professional standards. Their institutions do not necessarily share

the contents of this report, which is entirely the responsibility of the authors.

Funding

The research leading to these results has

received funding from the European

Community's Seventh Framework Programme

(FP7/2007-2013). Sole responsibility lies with

the authors. The EC is not responsible for any

use that might be made of the information

contained there in.

This ECHO Atlas has been elaborated by the Institute for Health Sciences

In Aragon in partnership with the following organisations:

-

This publication should be cited as

European Collaboration for Healthcare Optimization (ECHO) Project. www.echo-

health.eu . Zaragoza (Spain): Instituto Aragonés de Ciencias de la Salud - Instituto

Investigación Sanitaria Aragón; c2010. García-Armesto S, Comendeiro-Maalooe

M, Martinez-Lizaga N, Angulo-Pueyo E, Bernal-Delgado E on behalf of the ECHO

consortium . ECHO Atlas on Coronary Revascularisation; February 2014

[accessed: date]; Available from: www.echo-health.eu/echo-atlas-reports

More details and ECHO Atlases available at www.echo-health.eu

© ECHO Consortium. Reproduction, distribution, transmission, re-publication,

display or performance, of the Content delivered in this ECHO Atlas is only

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1

EUROPEAN COLLABORATION FOR

HEALTHCARE OPTIMIZATION

I. EXECUTIVE SUMMARY

This report analyses the magnitude and the variation of the surgical

management of ischaemic coronary disease. The analysis is twofold: on the

one hand it examines population exposure to revascularisation surgery, and

on the other, evaluates hospital quality in terms of hospital differences in case

fatality rates.

Percutaneous Coronary Intervention (PCI, commonly known as coronary

angioplasty) and Coronary Artery Bypass Graft (CABG) are effective and safe

revascularization procedures that have improved survival and quality of life in

recent decades. PCI has been proven to be a better option to reduce the risk

of death, especially when few blood vessels are blocked/affected. In

particular, primary PCI supersedes all other alternatives. Nevertheless, CABG

is still considered more effective when dealing with multivessel disease

(involving 3 or more vessels).

Exposure to surgical revascularization

Spain registered 78,585 CID hospitalisations in 2009 (1 admission per 485

adult inhabitants). This Figure was among the lowest of all ECHO countries.

There was a 2.6-fold difference between healthcare areas with the highest

and lowest rates of CID admissions, and systematic variation was moderate,

at 10% higher that randomly expected. More than half of all CID admissions

were labelled as AMI. For these admissions there was an almost 3-fold

difference between healthcare areas with the highest and lowest rates (EQ5-

95).

In the same year, 48,368 PCI interventions and 7,068 CABG surgeries were

recorded. These figures were among the lowest of all ECHO countries. The

PCI rate was similar to that of Portugal and less than half the rate of Slovenia,

the country with the highest rate. Spain´s CABG rate was the lowest of all

ECHO countries, and 3 times lower than that of Denmark.

The differences between healthcare areas with the highest and lowest rates

were 4.5-fold and almost 9.3-fold for PCI and CABG, respectively. Variation

not deemed random was moderate in both cases: 19% and 22% higher than

Mortality and morbidity

from cardiovascular disease

are considered a public

health issue. In fact,

coronary ischaemic disease

is one of the leading causes

of death in Europe.

The study of systematic

variation in its surgical

management, and

associated outcomes, offers

a critical view on how

healthcare organizations

provide care to patients.

2



expected, respectively. For both PCI and CABG, region accounted for over

40% of the observed variation, which suggests a relevant role of regions in

modulating the provision of this intervention.

The geographical approach examined the mismatch between patterns of

burden of coronary ischaemic disease (CID) and the intensity of use of

revascularization procedures. Marked variation in exposure to

revascularisation interventions was observed across healthcare areas.

Moreover, this variation was largely unaffected by the burden of ischemic

disease.

At the regional level an inverse relationship between CABG and PCI

procedures was detected. This may be due to early adopting regions in which

progressively higher levels of PCI led to a decrease in CABG utilisation.

From 2002 to 2009, coronary ischaemic disease admissions decreased slightly

(by 11%), from 1 admission per 392 to 1 admission per 429 adult inhabitants.

Of these hospitalisations, the number corresponding to AMI remained almost

constant.

During the same period, PCI utilisation rates increased by 75%, from 1

admission per 791 to 1 admission per 413 inhabitants. The CABG rate

remained stable over the same period (from 1 admission per 2,899 to 1

admission per 2,857 inhabitants aged 40 or older). Heterogeneous exposure

was observed across the territory for both interventions, as evidenced by

constant, moderate systematic variation over time.

From 2002 to 2009, significantly more CID admissions were recorded in more

deprived healthcare areas than in wealthier ones. Specifically, AMI

admissions were more frequent in worse-off versus better-off areas, with the

gap between the lowest and highest quintiles widening over time. This

finding may reflect a proper response to the population’s needs.

PCI utilisation increased at all income levels, but most of all in more deprived

areas, leading to a significantly higher PCI utilisation rate in those areas.

Conversely, CABG exposure was higher in wealthier areas, and remained

stable in all quintiles.

3



Differences in hospital case-fatality rates

Differences in the risk-adjusted case fatality rates (CFR) after both

revascularisation procedures were marked, with huge variation across

hospitals. “Volume” (number of interventions carried out) has been proposed

as a possible contributor to these differences.

After a sharp decrease, the Spanish risk-adjusted CFR for AMI in 2009 was

93.75 per 1,000 patients aged 18 and older, the lowest rate of all ECHO

countries, and 5.3 per thousand points below the ECHO average. In terms of

exposure, only 5.2% of all Spanish AMI patients were treated at poorly

performing hospitals, the lowest proportion of patients of all ECHO

countries. Almost 40% of AMI patients were admitted to hospitals flagged as

good or even excellent performers, a proportion slightly higher than the

ECHO average.

In-hospital mortality after PCI in Spain underwent a net increase of 5 per

thousand points. In 2009, the risk-adjusted CFR was 25.6 per 1,000 patients

aged 40 and older, by far the highest of all ECHO countries, and almost 6 per

thousand points above the ECHO average. Furthermore, 34% of patients

undergoing PCI were treated at alarm hospitals, while only 4% of patients

underwent interventions at hospitals flagged as good performers (the lowest

share for this procedure of all ECHO countries).

Although in-hospital mortality after CABG appeared to decrease markedly,

Spain´s risk-adjusted CFR after CABG surgery in 2009 was by far the highest

of all ECHO countries, at 66 per 1,000 patients aged 40 and older. This was

over twice the English rate and 16 per thousand points above the ECHO

average. Only 21% of all Spanish patients undergoing CABG surgery in 2009

underwent interventions at high-volume centres (more than 250 procedures

per year), by far the lowest proportion of all ECHO countries, and 60

percentage points below the ECHO average. Moreover, 20.8% of patients

underwent interventions at alert/alarm hospitals, by far the highest

proportion of all ECHO countries.

4



All through this section, paired dot plots are used to show results. The chart on the

left is always intended to give the reader a sense of the magnitude of burden of

disease or utilisation of revascularisation procedures in each country; the image on

the right provides an idea of the actual variation comparable across countries.

Note that each dot represents the relevant health care geographic unit in each

country.

II. INTERNATIONAL COMPARISON

This chapter offers a perspective on the behaviour of Spain as compared with the

other ECHO countries when it comes to ischaemic coronary disease and its

clinical management and treatment. The analysis is two-fold:

a. Geographic approach: this compares the population burden of disease

and the exposure to treatment depending on place of residence (both

the magnitude and the within-country variation) .

b. Hospital approach: this examines the quality of hospital care in terms of

case fatality rates for patients with acute myocardial infarction (AMI) and

for the procedures of choice for this condition. These outcomes are used

to benchmark all hospitals across the ECHO region, providing an overview

of the performance of Spanish hospitals relative to those of other ECHO

countries.

a. Geographic approach

This section provides a broad overview of the incidence of coronary ischaemic

disease (CID) and AMI admissions, taken as a proxy of burden of coronary

disease. It also examines the intensity of use of alternative revascularization

procedures in Spain as compared with other ECHO countries.

The geographic approach focuses on population exposure. The key issue

addressed by this analysis is the correlation between the risk of coronary disease

and access to revascularisation procedures, depending on an individual´s place of

residence.

The cross-country

comparison of the

geographical distribution of

population exposure to

burden of disease and to

intensity of use of

procedures allows the

flagging of situations of

over- and under-use of

revascularisation.

The benchmarking of

hospital case fatality rates

provides an additional

perspective on the quality

and safety of the care

provided and its variation

within each country.

Accounting for specific

organisational features, the

international comparison

provides a wider

perspective.

5



Coronary Ischaemic Disease (CID)

In 2009, Spain recorded the fourth CID admission rate among ECHO countries, at

1 admission per 420 adult inhabitants. This was 33% higher than the

corresponding rate in Portugal, the country with the lowest rate, and 30% lower

than the corresponding rate in England, the country with the highest rate (see

Table 1 in Appendix 1a).

In Spain, residents living in areas with the highest rates were three times more

likely to be admitted for CID than those living in areas with the lowest rates. This

difference was about 2-fold in Denmark, Slovenia, England and Portugal.

Systematic variation not deemed random was moderate to low in all countries,

ranging from 9% higher than expected(Slovenia) to 24% higher than expected

(England).

Figure 1a. Age and sex-standardised CID hospitalisation rates per 10,000 inhabitants (natural scale to compare actual rates).

Year 2009

Figure 1b. Age and sex-standardised CID hospitalisation rates per 10,000 inhabitants (normalised scale to compare degree of

variation). Year 2009

Each dot represents the relevant healthcare administrative area in each ECHO country (Healthcare areas in Spain). The y-axis charts the standardised rate per 10,000 inhabitants (age 18+) for the administrative area. The figure is generated based on the total number of CID hospitalisations recorded in 2009 in ECHO countries. In Figure 1b admission rates have been normalised to facilitate comparison of the degree of variation across countries

6



Acute Myocardial Infarction (AMI)

AMI admission rates were similar to those of other ECHO countries: the Spanish

rate was the lowest (1 hospitalisation per 726 adults), close to that of Portugal.

Slovenia recorded the highest rate, at 1 admission per 449 adult inhabitants,

followed by England, at 1 per 597 adults. Differences between areas with the

highest and lowest rates of AMI hospitalisations were around 2-fold in all ECHO

countries.

Variation not attributable to chance was low to moderate, except in Slovenia

where it reached 34% higher that randomly expected. In Spain 11% of variation

exceeded that which could be randomly expected (see Table 2 in Appendix 1a).

Figure 2a. Age and sex-standardised AMI hospitalisation rates per 10,000 inhabitants (natural scale to compare actual rates).

Year 2009

Figure 2b. Age and sex-standardised AMI hospitalisation rates per 10,000 inhabitants (normalised scale to compare degree of variation).

Year 2009

Each dot represents the relevant healthcare administrative area in each ECHO country (Healthcare areas in Spain). The y-axis charts the standardised rate per 10,000 inhabitants (age 18+) for the administrative area. The figure is generated based on the total number of AMI hospitalisations recorded in 2009 in ECHO countries. In Figure 2b admission rates have been normalised to facilitate comparison of the degree of variation across countries.

7



Percutaneous Coronary Interventions (PCI)

Spain recorded the lowest PCI rate among ECHO countries, at 1 admission per

419 inhabitants aged 40 or older, close to that of Portugal, the country with the

lowest rate. This was half the rate recorded in Slovenia, the country with the

highest rate. Despite its low PCI rate, the difference recorded between

healthcare areas with the highest and lowest rates was close to 5-fold, indicating

marked differences in PCI utilisation across the Spanish territory. Slovenia,

England and Portugal showed similar differences between healthcare areas with

the highest and lowest rates (2.2 to 2.6-fold).

Systematic variation ranged from just 8% higher than expected by chance in

England and Portugal to 1.8 times higher than expected in Slovenia. In Spain this

value was close to the ECHO average, at 22% higher than expected by chance

(see Table 3 in Appendix 1a).

Figure 3a. Age and sex-standardised PCI utilisation rates per 10,000 inhabitants (natural scale to compare actual rates).

Year 2009

Figure 3b. Age and sex-standardised PCI utilisation rates per 10,000 inhabitants (normalised scale to compare degree of


Each dot represents the relevant healthcare administrative area in each ECHO country (Healthcare areas in Spain). The y-axis charts the standardised rate per 10,000 inhabitants (age 40+) for the administrative area. The figure is generated based on the total number of PCI procedures recorded in 2009 in ECHO countries. In Figure 3b admission rates have been normalised to facilitate comparison of the degree of variation across countries.

8



Coronary Artery Bypass Grafting (CABG)

Spain recorded the lowest CABG rate among ECHO countries, at 1 admission per

2959 inhabitants aged 40 or older. This was 3 times less the rate recorded in

Denmark, the country with the highest rate.

Conversely, at the local level, the difference between areas with the highest and

lowest CABG rates was the greatest in all ECHO countries, at close to 10-fold. In

Denmark and England, this difference was around 2-fold.

The systematic part of this variation was high in all countries, reaching 27%

higher that randomly expected in Spain (see Table 4 in Appendix 1a).

Figure 4a. Age and sex-standardised CABG utilisation rates per 10,000 inhabitants (natural scale to compare actual rates).

Year 2009

Figure 4.b. Age and sex-standardised CABG utilisation rates per 10,000 inhabitants (normalised scale to compare degree of


Each dot represents the relevant healthcare administrative area in each ECHO country (Healthcare areas in Spain). The y-axis charts the standardised rate per 10,000 inhabitants (age 40+) for the administrative area. The figure is generated based on the total number of CABG interventions recorded in 2009 in ECHO countries. In Figure 4b intervention rates have been normalised to facilitate comparison of the degree of variation across countries.

9



Funnel plots allow the assessment of the performance of individual hospitals

against the international benchmark. Each hospital (dot) is charted by its risk-

adjusted case fatality rate and the volume of patients or procedures per year. The

benchmark is built based on the average ECHO hospital CFR (risk-adjusted) and its

95% and 99% CIs. The solid grey line represents the ECHO CFR, red lines correspond

to the 95% confidence interval control limits and the dashed blue lines represent to

the 99% confidence interval limits. These thresholds represent the boundary

between expected variation in outcomes (not significantly different from the

average) and significant variation. Outcomes lying beyond the upper thresholds are

indicative of poor performing hospitals (alert or alarm position); outcomes below

the lower limits indicate good or excellent performing hospitals. Outliers (in either

direction) should be investigated further to identify the underlying factors and

should be addressed or used as examples of good practice.

b. Hospital approach

The analysis in the following section focuses on providers, benchmarking for 3

quality outcome indicators. The main parameters of interest are the actual value

of the hospital case-fatality rate (CFR), and the relative position compared to the

ECHO benchmark and its confidence interval limits (95 and 99% levels), built into

a funnel plot. This relative position allows for the classification of hospital

performance as average, good, excellent, alarm and alert.

ECHO benchmarks are generated based on the expected average behaviour,

using data from all hospitals in the 5 countries analysed (multilevel regression

modelling). All CFRs are risk-adjusted for sex, age, severity of the underlying

condition and co-morbidity (Elixhauser index). This way, differences across

providers should not be attributable to patient characteristics, affecting their

inherent probability of dying after admission or surgery (Appendix 4 provides

details about the variables included in the risk-adjustment procedure).

Hospitals with less than 30 patients or procedures/year have been excluded from

the analysis to avoid noise when modelling (Table 5, Appendix 1b, details the

number of hospitals, per indicator, excluded under this criterion, and the

percentage of treated patients). In fact, the amount of interventions conducted

at each hospital, or so-called "volume", is one of the significant explanatory

variables when analysing the risk-adjusted CFR, and has been proposed as a

potential factor contributor to the observed differences in rates across hospitals.

The threshold for high and low-volume hospitals has been empirically set at 250

patients or procedures/year.

Different healthcare

systems across Europe,

with different

organizational features,

may obtain different

outcomes in dealing with

ischaemic coronary

disease. Comparing

outcomes across

individual hospitals in

each country provides

insights as to where

interventions could be

aimed in order to improve

case fatality rates for

patients with coronary

conditions.

International comparison

adds a complementary

perspective to the usual

national-based

benchmarks.

10



In-hospital mortality: Acute Myocardial Infarction (AMI).

In-hospital risk-adjusted CFR per 1,000 AMI patients (urgent admission of

patients aged 18 or older) is a widely used indicator of the quality and safety of

hospital care.

In 2009 in the ECHO area, 146,859 hospital admissions of patients aged 18 or

older were flagged as AMI. Of these, 12,582 died. After risk-adjusting modelling,

the ECHO average CFR was 99.03 per 1,000 hospitalised patients, which means

that 1 in 10 AMI admissions resulted in death.

In Spain in 2009, 1 in every 10.7 AMI patients admitted to a hospital died (risk-

adjusted CFR, 93.75 per 1,000), the lowest rate among ECHO countries, at 5.3 per

thousand points below the ECHO average.

The total number of ECHO hospitals analysed was 435; 55% of these were flagged

as high volume hospitals (more than 250 AMI patients in a year) and cared for

82.5% of the total number of hospitalised AMI patients.

In 2009, 82 out of 202 centres were classed as high volume hospitals, and cared

for 70.6% of all hospitalised AMI patients. In fact, Spain, together with Denmark,

had the second lowest percentage of AMI patients treated at high volume

hospitals in the ECHO area.

Of the 202 Spanish centres, 15 were flagged as alert or alarm performers in

terms of adjusted CFR. In terms of exposure, 5.2% of all AMI patients were

treated at these alert/alarm hospitals, the lowest percentage among all ECHO

countries. Nonetheless, 39.82% of all AMI patients were admitted to hospitals

classed as good or even excellent performers (see Table 6, Appendix 1b, for

further details).

Figure 5 shows the risk-adjusted CFR for each of the ECHO hospitals. Their

position relative to the ECHO benchmark is indicated in the funnel plot.

11



The outcomes shown in the funnel plot indicate good performance; 67% of

hospitals were close to the average, indicating that the risk-adjusted in-hospital

mortality did not differ significantly from the ECHO benchmark.

All but one of the Spanish hospitals flagged as alarm or alert treated less than 250

AMI patients per year.

In-hospital mortality after Percutaneous Coronary Intervention (PCI)

In 2009, 132,737 patients aged 40 or older underwent a PCI procedure at one of

the ECHO country hospitals. Of these, 2,623 died (1 per 51 intervened patients).

The ECHO risk-adjusted CFR was 19.86 per 1,000 patients (age 40+) undergoing a

PCI procedure. That year, Spain had by far the highest risk-adjusted CFR, at 5.7 per

thousand points above ECHO benchmark, and almost 12 per thousand points

above the CFR of England, the country with the lowest rate.

Within the ECHO framework, 80% of the hospitals performing PCI procedures

were high volume and cared for 95.44% of patients undergoing that procedure. In

Figure 5. In-hospital case fatality rate for AMI admissions across hospitals in ECHO countries. Year 2009.

Each dot represents an ECHO hospital that treated more than 30 AMI cases in that year. The expected number of deaths per 1,000 hospitalised patients is based on the average calculated across ECHO hospitals. Spanish hospitals are indicated in blue.

12



Spain the corresponding proportion was 94.5% (see Tables 5 and 7 in Appendix

1b).

Contrary to expectations, the bulk of Spanish alarm hospitals performed more

angioplasties and had worse risk-adjusted case fatality rates than those

performing fewer interventions. All but one of those alert/alarm hospitals were

classed as high volume, and cared for almost 34% of all patients, while only a 4%

of patients underwent interventions at hospitals flagged as good performers, the

lowest share of all ECHO countries (See Table 7, Appendix 1b, for further details).

Figure 6. In-hospital case fatality rate after Percutaneous Coronary Intervention across hospitals in ECHO countries. Year 2009.

Each dot represents an ECHO hospital that performed more than 30 PCIs in that year. The expected number of deaths per 1,000 hospitalised patients is based on the average calculated across ECHO hospitals. Spanish hospitals are indicated in blue.

13



In-hospital mortality after Coronary Artery Bypass Graft (CABG)

In 2009, the 89 ECHO hospitals performing CABG surgery performed

interventions in 33,683 patients aged 40 and older. Of these, almost 4% died. In

terms of risk-adjusted CFR, this death rate represents 1 in every 20 patients

undergoing the procedure. More than half of those 89 centres were categorised

as "high volume", and conducted 82.16% of all CABG procedures performed that

year in ECHO countries.

It is worth highlighting that 61.26% of all patients were treated at hospitals

flagged as alert/alarm, while 5.61% were treated at hospitals flagged as

good/excellent performers

The percentage of Spanish patients undergoing CABG surgery who were treated

at higher volume hospitals was 20.9%. None of these hospitals were flagged as

excellent performers, while 26% of hospitals performing CABG were flagged as

alert or alarm performers.

The risk-adjusted case fatality rate after CABG shown in Figure 7, and indicates

poor performance for Spain in 2009. All but two of the alert/alarm hospitals in

this international comparison are Spanish. Relative to the ECHO benchmark, the

Spanish risk-adjusted CFR for CABG was by far the highest, at 15.7 per thousand

points above the ECHO average. This is over twice rate recorded in England, the

country with the lowest rate.

14



Figure 7. In-hospital case fatality rate after CABG across hospitals in ECHO countries. Year 2009.

Each dot represents an ECHO hospitals that performed more than 30 bypass surgeries in that year. The expected number of deaths per 1,000 hospitalised patients is based on the average calculated across ECHO hospitals. Spanish hospitals are indicated in blue.

15



III. IN COUNTRY VARIATION

In this section, the incidence of coronary ischaemic disease and the intensity of

use of alternative revascularization procedures performed in Spain is analysed

from an internal perspective, comparing results in healthcare-relevant

administrative areas (geographic approach) or hospitals (providers approach)

within the country.

The analysis is two-fold, and follows the same structure as described in the

previous chapter:

a. Geographic approach: this compares the burden of disease and the

intensity of exposure to treatment of the population, depending on the

place of residence (i.e., both the magnitude and the within-country

variation across local authorities (áreas sanitarias) and regions.

b. Hospital approach: this examines the quality of hospital care in terms of

case fatality rates for patients with acute myocardial infarction (AMI) and

for the procedures of election in those cases. These outcomes are used

to benchmark individual Spanish hospitals


The magnitude and the variation in coronary conditions and/or revascularization

procedures across the country is mapped out for two healthcare-relevant

administrative tiers: 199 Healthcare Areas and 17 Regions or Comunidades

Autónomas. While healthcare area would represent local provision of care,

regions are used as a surrogate for regional policies affecting all the healthcare

areas they encompass.

Coronary Ischaemic Disease admissions (CID)

In 2009, Spain recorded 78,585 CID admissions, 1 admission per 485 Spanish

adult inhabitants.

There was a 2.6-fold difference in CID admissions between healthcare areas with

the highest and lowest rates. Systematic variation was just 10% higher that

randomly expected, and region accounted for 28% of variation not accounted for

by healthcare areas (see Tables 9 and 10 in Appendix 2a).

CID admissions are

considered a proxy of the

burden of cardiovascular

disease at the geographical

level.

In the ECHO framework

this indicator is used as a

“calibrator” and aids the

interpretation of results

about the intensity of

population exposure to

revascularization

procedures (coronary

artery bypass graft and

percutaneous coronary

intervention).

16



Figure 10. Age and sex-standardised CID hospitalisation rate per 10,000 inhabitants by regions. Year 2009

Figure 11. Observed/expected CID admissions ratio by regions. Year 2009

Maps on the left (standardised rates) show the number of admissions flagged as CID; the darker the colour, the higher the number of admissions (always per

10,000 adult inhabitants). Areas are clustered into 5 quintiles according to their rate value (Q1 to Q5). Legend indicates the range of standardised rates within each quintile. Maps on the right represent the relative risk of hospitalization for CID in each area using the observed to expected ratio of CID hospitalisation as a proxy. Populations living in areas with values >1 (bluish) are overexposed to the risk of CID hospitalisation, while those in areas with a ratio <1 (pink) are underexposed.

Figure 8. Age and sex-standardised CID hospitalisation rate per 10,000 inhabitants by healthcare areas. Year 2009

Figure 9. Observed/expected CID admissions ratio by healthcare areas. Year 2009

17



Healthcare areas with high CID admission rates were located in the southern half

of Spain (Figure 8). Residents in most of these areas had a risk of CID admission

that was at least 20% above the national average (bluish areas in Figure 9). By

contrast, local authorities with low rates, in which residents had a lower risk of

CID hospitalisation, were located in the north-eastern part of the country.

At the regional level, the risk of hospitalization for CID was higher than the

national average for residents in Andalucia, Murcia and Asturias (dark blue areas

in Figure 11). Populations living in País Vasco, Navarra and Madrid had the lowest

risk of CID admissions in the territory (purple areas in Figure 11).

Percutaneous Coronary Interventions (PCI) compared with burden

of Coronary Ischaemic Disease (CID)

During 2009, Spain recorded 48,368 PCI interventions; 1 procedure per 495

inhabitants aged 40 or older.

There was an over 4-fold difference in exposure to the procedure between

healthcare areas with the highest and lowest rates. Moreover systematic

variation was 19% higher than randomly expected, and region explained up to a

44% of this variation, which suggests a role of regions in modulating the provision

of this intervention (see Tables 9 and 10 in Appendix 2a).

Some overlap between the intensity of PCI utilisation and the risk of CID

admission could be expected, given that CID admission is a proxy of the burden of

coronary disease. However, burden of ischemic disease only accounted for 16%

of PCI variation across healthcare areas. At the regional level, some correlation

was observed in the Andalucia, Murcia, Extremadura and Castilla-La Mancha

regions (where high PCI rates coincided with an increased risk of CID admission)

and in País Vasco, Navarra, Aragón, Castilla-León (where low PCI rates coincided

with a reduced risk of CID admission). However, residents in Madrid, Cataluña,

Galicia and Canary Island had high PCI rates together with a low risk of CID

admission, while Asturias showed an increased risk of CID admission together

with low exposure to PCI (Figures 14 and 15).

18



Figure 14. Age and sex-standardised PCI utilisation rate per 10,000 inhabitants by regions. Year 2009

Figure 15. Observed/expected CID admissions ratio, by regions. Year 2009

Maps on the left (standardised rates) show the number of admissions flagged as PCI; the darker the colour, the higher the number of procedures performed, per 10,000 inhabitants aged 40+. Areas are clustered into 5 quintiles according to their rate value (Q1 to Q5). Legend indicates the range of standardised rates within each quintile. Maps on the right represent the relative risk of hospitalization for CID in each area using the observed to expected ratio of CID hospitalisation as a proxy. Populations living in areas with values >1 (bluish) are overexposed to the risk of CID hospitalisation, while those in areas with a ratio <1 (pink) are underexposed.

Figure 12. Age and sex-standardised PCI utilisation rate per 10,000 inhabitants by healthcare areas. Year 2009

Figure 13. Observed/expected CID admissions ratio, by healthcare areas. Year 2009

19



Coronary Artery Bypass Graft (CABG) compared with burden of

Coronary Ischaemic Disease (CID)

In 2009, Spain recorded 7,068 CABG procedures; 1 surgery per 3,378 inhabitants

aged 40 or older.

There was a 9.3-fold difference in exposure to the procedure between healthcare

areas with the highest and lowest rates, and 22% of this variation could not be

deemed random. As seen for PCI utilisation, variation in CABG surgery was highly

influenced by regions; up to 43% of the observed variation was explained by a

regional effect (see Tables 9 and 10 in Appendix 2a).

A certain pattern of high-rate healthcare areas was observed in the north-

western part of the country. With some exceptions, CABG utilisation did not

correlate with burden of disease (Figure 16 and 17). At the regional level, CABG

procedures and the risk of CID hospitalisation appeared to be inversely related,

with the exception of Asturias, whose residents had a higher risk of CID

admission but which had one of the highest CABG rates in the country. In general

however, lower CABG rates were observed in regions with increased risk of CID

hospitalisation, such as Andalucia, Murcia and Castilla-La Mancha (Figures 18 and

19).

20



Figure 18. Age and sex-standardised CABG utilisation rate per 10,000 inhabitants by regions. Year 2009

Figure 19. Observed/expected CID admissions ratio by regions. Year 2009

Maps on the left (standardised rates) show the number of admissions flagged as CABG; the darker the colour, the higher the number of procedures performed, per 10,000 inhabitants aged 40+. Areas are clustered into 5 quintiles according to their rate value (Q1 to Q5). Legend indicates the range of standardised rates within

each quintile. Maps on the right represent the relative risk of hospitalization for CID in each area using the observed to expected ratio of CID hospitalisation as a proxy. Populations living in areas with values >1 (bluish) are overexposed to the risk of CID hospitalisation, while those in areas with a ratio <1 (pink) are underexposed.

Figure 16. Age and sex-standardised CABG utilisation rate per 10,000 inhabitants by healthcare areas. Year 2009

Figure 17. Observed/expected CID admissions ratio by healthcare areas. Year 2009

21



Percutaneous Coronary Interventions (PCI) vs. Coronary Artery

Bypass Graft (CABG)

PCI and CABG are effective and safe revascularization procedures that have

improved survival and quality of life in recent decades. PCI has been proven to be

the best option at reducing the risk of death, particularly when the number of

affected blood vessels is low (primary PCI has superseded all other alternatives).

However, CABG is still considered more effective when dealing with multivessel

disease (3 or more vessels involved).

These procedures can be considered as distinct interventions with different

clinical indications, or, alternatively, as “substitute” approaches for the same

clinical condition. Therefore, analysis of their respective patterns of utilisation

provides some indication as to how populations are being served. Trends in the

same direction for both procedures would rule out the “substitution” hypothesis,

whereas opposing patterns would suggest a certain degree of compensation

across procedures, although the two procedures are not equally effective.

In Spain, although a substitution effect was observed at the regional level, this

phenomenon was near-negligible at the healthcare area level (Figures 22 and 23),

as evidenced by a negative correlation of -0.09.

22



Figure 21. Observed/expected CABG utilisation ratio by healthcare areas. Year 2009

Figure 20. Observed/expected PCI utilisation ratio by healthcare areas. Year 2009

Figure 22. Observed/expected PCI utilisation ratio by regions. Year 2009

Figure 23. Observed/expected CABG utilisation ratio by regions. Year 2009

Maps represent the level of performance of each area, using the “observed to the expected” ratio of the number of revascularisation procedures as a proxy of the risk of cardiovascular intervention. Residents living at areas with values >1 (bluish) are overexposed to the risk of certain cardiovascular interventions, while those in areas with a ratio <1 (pink) are underexposed to the risk of these cardiovascular interventions.

23




The following sections will deal with in-hospital case fatality rates (CFR) across

Spanish hospitals after admission for Acute Myocardial Infarction (AMI) and after

one of the following revascularization procedures; percutaneous coronary

intervention (PCI) and coronary bypass surgery (CABG).

When analysing data on a provider basis, it should be noted that a large

proportion of the observed variation in outcomes may be due to different meso

and micromanagement arrangements used to address coronary ischaemic

disease.

In-hospital case fatality rate for Acute Myocardial Infarction patients

In 2009, 52,683 admissions in 271 Spanish hospitals were flagged as Acute

Myocardial Infarctions. Of these hospitals, 69 (25.5%, the largest share of any

ECHO country) treated less than 30 patients each (1.38% of total AMI patients),

and were thus excluded from the analysis.

Higher hospital risk-

adjusted case fatality

rates may signal lower

quality of care for

coronary ischemic

conditions.

Funnel plots are used throughout this section to represent the performance of

Spanish hospitals as compared with national standards or benchmarks.

Each hospital (dot and numerical code) is charted according to its risk-adjusted

case fatality rate and the volume of patients or procedures in a year. The

benchmark is based on the average CFR (risk-adjusted) of Spanish hospitals and

the corresponding 95% and 99% CIs. The solid grey line represents the English CFR,

red lines correspond to the 95% confidence interval control limits and the dashed

blue lines represent the 99% confidence interval limits. These thresholds represent

the boundary between expected variation in outcomes (not significantly different

from the average) and unwarranted variation. Outcomes lying above the upper

thresholds are indicative of poor performing hospitals (alert or alarm position);

outcomes below the lower limits indicate good or excellent performing hospitals.

Outliers (in either direction) should be investigated further to identify the

underlying factors and should be addressed or used as examples of good practice.

For methodological reasons, hospitals treating less than 30 episodes or procedures

per year have been excluded from the analysis.

24



Of the 51,955 admissions analysed across the 202 remaining hospitals, 4,210 (8%)

patients died. The overall risk-adjusted CFR was 1 death per 10.7 AMI admissions,

resulting in a countrywide average of 93.75 per 1,000 patients aged 18 and older,

5.3 per thousand points below the ECHO benchmark.

The risk-adjusted CFRs of individual hospitals ranged from 23.23 (5th percentile)

to 181.2 (95th percentile) per 1,000 AMI patients. Thus, depending on the centre

in which they were treated, an AMI patient´s probability of dying could differ by

up to 7.8-fold (see Table 11 in Appendix 2b for further details).

The funnel plot in Figure 24 shows that the results of national benchmarking

differ slightly from those yielded by the international comparison (Figure 5,

Section IIb). Using the national benchmark, 28 hospitals were flagged as

alert/alarm performers (versus 15 according to ECHO standards) and 42 as

good/excellent performers (versus 52 according to ECHO standards).

In 2009, less than three quarters of Spanish hospitals (70.6%) recorded an annual

volume of AMI patients of over 250. This value was set as the threshold for low

Figure 24. In-hospital mortality after AMI admission at Spanish hospitals. Year 2009.

Each dot represents a hospital that treated more than 30 AMI cases. The expected number of deaths per 1,000 hospitalised patients is based on the average calculated for all Spanish hospitals.

25



vs. high volume. A trend towards a decreased share of AMI patients was seen in

higher volume hospitals. In fact, in all but 5 of the 28 cases, the poorest

performers (with a risk-adjusted CFR up to 4 times higher than the national

average) were far below the low-volume threshold (Table 12 in Appendix 2b

provides detailed information on each hospital).

However, with the lowest in-hospital risk-adjusted mortality rate for AMI of all

ECHO countries, the outcomes for Spanish hospitals in 2009 indicate reasonably

good performance: only 10.1% of patients were hospitalised at alert/alarm

performers, while 31.4% of patients were treated at good or excellent centres. A

total of 65.5% of hospitals were classed as average performers, indicating a risk-

adjusted CFR that did not differ significantly from the benchmark.

In-hospital case fatality rate for Percutaneous Coronary

Interventions

In 2009, 43,868 PCI procedures were performed across 81 Spanish hospitals, with

a risk-adjusted case fatality rate of 1 death per 39 interventions in patients aged

40 or older.

PCI CFRs varied widely across hospitals, ranging from zero to 79 deaths per 1,000

patients. Thus, depending on the hospital in which the procedure was performed,

the risk of death could differ by up to 17-fold (EQ5-95) (see Tables 11 and 13 in

Appendix 2b for further details).

Since the Spanish in-country benchmark for PCI was higher than the ECHO

benchmark, in-country benchmarking of Spanish hospital performance was less

demanding than the international comparison. As shown in Figure 25, when

nationally benchmarked, 11 hospitals were flagged as alert/alarm (versus the 25

that were flagged according to ECHO benchmarking), while 14 were deemed

good or excellent performers (versus just 3 according to ECHO benchmarking).

The 11 alert/alarm hospitals (13.6% of the total) treated 15% of all patients

undergoing PCI, while hospitals flagged as good/excellent treated 20% of PCI

patients.

Contrary to expectations, the “volume effect” seemed to be all but reversed for

this particular procedure in Spain: there was a wide dispersion of high-volume

activity hospitals that were flagged as alert. The proportion of hospitals carrying

26



out 500-1,000 procedures/year was the same for alert/alarm centres as for good

or excellent performers.

In-hospital case fatality rate for Coronary Artery Bypass Graft

procedure

In 2009, 71,147 CABG surgeries were performed at 46 Spanish hospitals, of which

5.9% resulted in death, yielding a risk-adjusted hospital CFR 1 death per 15

interventions in patients aged 40 or older.

In terms of individual hospitals, CABG CFRs ranged from 11 (5th percentile) to 145

(95th percentile) deaths per 1,000 interventions. Thus, the risk-adjusted

probability of death for patients undergoing CABG surgery could differ by up 13-

fold, depending on the hospital in which they were treated (see Tables 11 and 14

in Appendix 2b for further details).

Figure 25. In-hospital mortality after undergoing PCI in Spanish hospitals. Year 2009.

Each dot represents a hospital performing more than 30 interventions during the period of analysis. The expected number of deaths per 1,000 hospitalised patients is based on the average calculated for all Spanish hospitals.

s.

Each dot represent each of the hospitals in the country with cases during the period of analysis. The expected number of deceases per 1,000 patients discharged is built on the national average across hospitals.

27



The average hospital risk-adjusted CFR for CABG in Spain in 2009 was much

higher than the ECHO average, as described in Section IIb. Thus, once again, in-

country benchmarking appeared to be less demanding than the international

comparison. As shown in Figure 26, national benchmarking flagged 7 hospitals as

alert/alarm performers (versus 12 labelled as such according to ECHO

benchmarking) while 8 were deemed good or excellent performers (versus 2

labelled as such according to ECHO benchmarking). A total of 67.4% of hospitals

were classed as average performers, indicating a risk-adjusted in-hospital

mortality rate that did not significantly different from the benchmark. In total,

13% of patients underwent interventions at alert/alarm centres, while 20.5%

underwent surgery at hospitals deemed good or excellent performers.

A notable finding was the extremely low percentage of high-volume hospitals

(11%), and hence the very low percentage of patients who underwent CABG

surgery at those centres (only 21%). Moreover, all but one of the high-volume

hospitals were classed as average performers, indicating that that the risk-

adjusted CFR did not differ significantly from the benchmark (see Table 14 in

Appendix 2b for further details).

Figure 26. In-hospital mortality after undergoing CABG surgery in Spain hospitals. Year 2009.

Each dot represents a hospital performing more than 30 interventions during the period of analysis. Given the limited number of centres the risk-adjusted case fatality rates per 1,000 patients undergoing CABG surgery are depicted relative to the ECHO average.

.

28



Identifying trends (upwards, downwards or unchanged) in revascularisation

surgery over time is helpful in understanding the overall dynamic of the

adoption/established use/withdrawal of this medical procedure in relation to the

evolution of the burden of ischemic disease.

Increases in both PCI and CABG could be considered an indication of growing

overexposure if the burden of ischemic disease does not undergo a corresponding

increase. A decrease in PCI rates that is not accompanied by a corresponding

reduction in CID rates could be indicative of underexposure. In turn, decreases in

CABG rates should be observed in tandem with alterations in PCI rates. If PCI rates

rise, further analysis should be performed to determine whether PCI adoption is

substituting CABG. If this is not the case, any decrease should be considered

indicative of underexposure, provided that CID admissions do not show a

corresponding reduction.

The degree of systematic variation indicates how homogeneous a population’s

exposure to the procedure is at each point in time: the higher the SCV, the more

the unwarranted variation in residents´ exposure to the procedure across

healthcare areas.

IV. EVOLUTION OVER TIME


From 2002 to 2009, coronary ischaemic disease admissions decreased slightly (by

11%), from 1 admission per 392 to 1 admission per 429 adult inhabitants. The

systematic portion of this variation remained moderate, at around 11% higher

that randomly expected (see Table 15 in Appendix 3a).

CID admissions labelled as AMI remained almost constant, ranging from 1

admission per 764 to 1 admission per 742 adult inhabitants. Variation not

deemed random also remained moderate and stable (see Table 16 in Appendix

3a).

During the same period, PCI rates increased by 75%, with values almost doubling,

from 1 admission per 791 to 1 admission per 413 inhabitants. The associated

systematic variation remained constant over this period, at around 22% higher

than expected by chance (see Table 17 in Appendix 3a). Thus, differences in

exposure across the territory remained, despite a near doubling of the overall PCI

rate.

During the period 2002-

2009, hospitalisations for

coronary ischaemic disease

remained quite stable, in

contrast to the huge

increase seen in PCI

utilisation.

In terms of hospital

outcomes, average risk-

adjusted CFRs for AMI and

CABG patients improved

over the study period. By

contrast, PCI CFRs

continually increased from

2006. However, individual

analysis reveals several

hospital with evolutionary

patterns that warrant

further investigation to

identify the factors

underlying their success or

failure.

29



The CABG rate remained stable over the same period, moving from 1 admission

per 2,899 to 1 admission per 2,857 inhabitants aged 40 or older. As seen for PCI,

systematic variation in CABG utilisation remained constant and moderate

throughout the study period.

CORONARY ISCHAEMIC DISEASE

ASTHMA

ACUTE MYOCARDIAL INFARCTION

0

5

10

15

20

25

30

2002 2003 2004 2005 2006 2007 2008 2009

Stan

dar

dis

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isc

hae

mic

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eas

e

ho

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r 1

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00

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itan

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em

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Ischaemic disease hospitalisations

Systematic variation in ischaemic disease hospitalisations across healthcare areas

0.0

3.0

6.0

9.0

12.0

15.0

2002 2003 2004 2005 2006 2007 2008 2009St

and

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r 1

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0.2

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om

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Var

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AMI hospitalisations Systematic variation in AMI hospitalisations across healthcare areas

PERCUTANEOUS CORONARY INTERVENTION CORONARY ARTERY BYPASS GRAFT

0

5

10

15

20

25

2002 2003 2004 2005 2006 2007 2008 2009

Stan

dar

dis

ed

PC

I ra

te p

er

10

,00

0

inh

abit

ants

0.0

0.2

0.4

0.6

0.8

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om

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t o

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aria

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PCI utlisation Systematic variation in PCI utilisation across healthcare areas

a<

0

1

2

3

4

5

2002 2003 2004 2005 2006 2007 2008 2009

Stan

dar

dis

ed

CA

BG

rat

e p

er

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,00

0 i

nh

abit

ants

0

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1

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atic

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mp

on

en

t o

f

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iati

on

CABG utilisation Systematic Variation in CABG utilisation across healthcare areas

Figure 27. Temporal evolution of cardiovascular indicators (geographical approach)

30



This section describes several selected examples.

In addition these specific examples of changes in revascularisation utilisation, it is

useful to consider the distribution of bubbles in 2009: as all began in the same

utilisation quintile in 2002, the variety of colours they have acquired by the final

year (one colour for each quintile of utilisation intensity) provides an indication of

the degree to which the medical practice underlying this utilisation pattern has

become established, and of its homogeneity over time and across healthcare

areas.

Trends in healthcare administrative areas within the lowest and

highest quintiles of PCI and CABG utilisation.

As mentioned above, the Spanish PCI rate increased sharply over the period

2002-2009. Analysis of the evolution of healthcare areas whose PCI rates were

among the lowest at the beginning of the study period (Q1) revealed subsequent

spreading across all utilisation quintiles over time (Figure 28). For example, in one

rates increased over time, reaching the fourth quintile in 2009. By contrast, the

other retained the lowest rates for the entire study period. The same

phenomenon is illustrated in Figure 29, but in this case for healthcare areas that

began at the top of the utilisation range (Q5). Most areas remained in the higher

utilisation quintiles (Q5 or Q4), as seen in the case of one. The other, showed

marked decreases in their rates, and ended the study period in the lowest

quintile of PCI utilisation (Q1).

Similar patterns were observed for CABG surgery. For example, both showed low

rates in 2002, but evolved quite differently over time. While one remained

among the lowest quintiles, the other reached the highest utilisation levels by the

end of the study period (Figure 30).

Areas with the highest rates of CABG utilisation in 2002 (Q5, in orange) also

showed uneven evolution over the study period, although most remained in the

top utilisation quintiles. Conversely, several areas, showed steady decreases in

their CABG rates over time, ending the study period in the lowest quintile of

exposure (Figure 31).

31



Figure 28. Trends in PCI utilisation rates in healthcare areas

showing the lowest rates at the beginning of the study period. Figure 29. Trends in PCI utilisation rates in healthcare areas

showing the highest rates at the beginning of the study period.

Figure 30. Trends in CABG utilisation rates in healthcare areas showing the lowest rates at the beginning of the study period.

Figure 31. Trends in CABG utilisation rates in healthcare areas showing the highest rates at the beginning of the study period.

32




To study in-hospital mortality throughout the period of analysis, several examples

are provided showing the evolution of hospitals with the lowest or highest rates

at the beginning of the study period.

Dynamic bubble plots show the sequence of results from funnel plots assessing

annual outcomes throughout the period of analysis. The size of the bubble is

proportional to the number of patients or interventions. Hospitals flagged as

good or even excellent performers (blue bubbles) in 2002 are expected to remain

blue for the duration of the study period. However, hospitals identified at the

beginning of the period as poor performers in the alert/alarm position (orange

bubbles) should show improvements over time (turning to green (average) or,

ideally, bluish).

Departures from this pattern are considered undesirable, and warrant further

analysis.

33



In-hospital case fatality rate trends for Acute Myocardial Infarction

patients, 2002-2009.

Figure 32 shows four examples of hospitals whose risk-adjusted CFR for AMI

patients improved or worsened, or remained unchanged during the period

analysed.

One hospital began with an average rating, but improved to excellent over the

study period. Both hospitals (high activity volume) and the other (low activity

volume - note that the size of the bubble is proportional to the number of cases

treated) began with excellent and good performance ratings, respectively. The

former, after maintaining its rating for several years, dropped to alert, while the

latter showed fluctuations to average and less safe. the other, on the other hand,

is an example of a hospital that improved its performance throughout the study

period, starting at alert and ending at average. Further details on the evolution of

the relative performance of Spanish hospitals for AMI admissions throughout this

period are provided in Appendix 3b, Table19.

Figure 32. In-hospital mortality trends for AMI, 2002-2009, showing some of the highest and lowest rates and their evolution.

Bubbles represent individual hospitals. The larger the bubble, the higher the number of hospitalised AMI patients at that hospital. Dark-blue bubbles represent hospitals with risk-adjusted case fatality rates below the CI-99% control limit, and thus classed as “excellent”. Light-blue bubbles represent hospitals with risk-adjusted case fatality rates below the CI-95% control limit, and thus classed as “good”. Yellow bubbles represent hospitals with risk-adjusted case fatality rates above the CI-95% control limit, and thus classed as alert. Orange bubbles represent hospitals with risk-adjusted case fatality rates above the CI-99% control limit, and thus classed as alarm.

34



In-hospital case fatality rate for Percutaneous Coronary Intervention,

2002-2009.

As shown in Figure 33, the analysis revealed some hospitals beginning and ending

the study period with an alert/alarm rating, after some fluctuations to average,

others showing non-significant fluctuations to end the study period with an alarm

rating, an yet others showing improvements in performance, moving from alert

to an excellent rating while increasing their volume of activity. The other hospital

is an example of fluctuating evolution, moving between average and excellent.

Further details on the evolution of the relative performance of Spanish hospitals

for PCI throughout this period are provided in Appendix 3b, Table 20.

Figure 33. In-hospital mortality trends for PCI, 2002-2009, showing some of the highest and lowest rates and their evolution

Bubbles represent individual hospitals. The larger the bubble, the higher the number of hospitalised PCI patients at that hospital. Dark-blue bubbles represent hospitals with risk-adjusted case fatality rates below the CI-99% control limit, and thus classed as “excellent”. Light-blue bubbles represent

hospitals with risk-adjusted case fatality rates below the CI-95% control limit, and thus classed as “good”. Yellow bubbles represent hospitals with risk-adjusted case fatality rates above the CI-95% control limit, and thus classed as alert. Orange bubbles represent hospitals with risk-adjusted case fatality rates above the CI-99% control limit, and thus classed as alarm.

35



In-hospital case fatality rate trends for Coronary Artery Bypass Graft

surgery, 2002-2009.

Analysis of coronary artery bypass CFRs revealed marked changes in performance

in some hospitals during the period of analysis. Figure 34 shows two examples:,

whose risk-adjusted CFR decreased dramatically after several years in the alert

position, ending the study period with a good/excellent rating; and the other,

whose performance started at average, fluctuated to excellent, returned to

average, and ended up at alarm. One hospital remained in the alert/alarm

position, while the other remained steady in the excellent position throughout

the period analysed. Further details on the evolution of the relative performance

of Spanish hospitals for CABG throughout this period are provided in Appendix

3b, Table 21.

Figure 34. In-hospital mortality trends for CABG, 2002-2009, showing some of the highest and lowest rates and their evolution

Bubbles represent individual hospitals. The larger the bubble, the higher the number of hospitalised CABG patients at that hospital. Dark-blue bubbles represent hospitals with risk-adjusted case fatality rates below the CI-99% control limit, and thus classed as “excellent”. Light-blue bubbles represent hospitals with risk-adjusted case fatality rates below the CI-95% control limit, and thus classed as “good”. Yellow bubbles represent hospitals with risk-adjusted case fatality rates above the CI-95% control limit, and thus classed as alert. Orange bubbles represent hospitals with risk-adjusted case fatality rates above the CI-99% control limit, and thus classed as alarm.

36



The graphs in this section provide some sense of the behaviour of CID admissions

and revascularization procedures as a function of the average level of affluence in

a healthcare area. At a glance, these graphs indicate whether differences exist

between better-off and worse-off areas, and whether these differences vary over

time.

The wider the gap between the most and least deprived quintiles, the more

inequitably distributed the exposure to revascularisation surgery. It is also useful

to observe the 95% confident intervals (whiskers) above and below the annual

rates estimated for quintiles 1 and 5. Only those that do not overlap signal a

statistically significant difference between wealthier and deprived areas.

The desired pattern is one which shows no statistically significant differences

across healthcare areas as a function of income, or at least the disappearance of

any existing gap over time. atributable

V. SOCIAL GRADIENT

Significantly more CID admissions were recorded in the most deprived healthcare

areas (Q1) than in the wealthiest ones (Q5). Analyis of CID admissions labelled as

AMI revealed that worse-off areas recorded more admissions than better-off

ones, with the gap between the lowest and highest quintiles widening over time.

When analysing PCI utilisation, the most deprived areas showed significantly

higher rates than the more affluent areas from 2006 onwards. Moreover, the gap

between the lowest and highest quintiles became wider over time. It is worth

noting that the increase in utilisation rates in the most deprived areas was 2.5

times greater than that seen in the most affluent areas (see Table 17 in Appendix

3a).

The opposite pattern was observed for CABG surgery, which was significantly

more frequent in wealthier areas than in worse-off ones between 2004 and 2009.

Again, the gap between the lowest and highest quintiles became slightly wider

over time, due this time to a slight increase in CABG utilisation in better-off areas.

Nevertheless, although significant, the difference in the absolute value between

the lowest and highest quintiles was quite small, at 1.6 admissions/per 10,000

inhabitants (see Table 18 in Appendix 3a)

The most deprived

healthcare areas had higher

CID admissions and

significantly higher PCI

utilisation rates than the

most affluent areas. By

contrast, CABG utilisation

was higher in wealthier

areas than in worse-off

areas.

37



The variation in CID admissions across areas described in previous sections thus

appears to be related to income at the area level. Since worse-off areas bear a

greater burden of CID admissions and, specifically, of AMI hospitalisations, we

could expect that these areas have a greater need for health care than high-

income areas. This was observed for PCI use, but not for CABG, which was more

frequent in wealthier areas. Despite the huge increase in PCI utilisation in

deprived areas, the higher number of CID admissions and the growing rate in AMI

in these areas warrant further investigation to determine whether there are

barriers to equity of access to CABG procedures, or other treatments, in these

areas.

CORONARY ISCHAEMIC DISEASE ACUTE MYOCARDIAL INFARCTION

0

10

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40

2002 2003 2004 2005 2006 2007 2008 2009

Sta

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ate

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PERCUTANEOUS CORONARY INTERVENTION CORONARY ARTERY BYPASS GRAFT

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dard

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Figure 35. Trends in standardised rates by income quintile.

38



VI. POLICY IMPLICATIONS

Coronary ischaemic disease is one of the leading causes of death, disability and

decreased quality of life in Europe, and together with cancer was the main cause

of death in Spain in 2009. It is also a leading cause of premature death in men,

generating important social costs associated with potential years of life lost.

Mortality and morbidity associated with cardiovascular disease have thus become

an important issue for all health systems in Europe, as well as an important driver

of health expenditure.

Several studies in the last decade have shown that the incidence of coronary

heart disease in the northern half of Europe, particularly Scandinavian countries,

is higher than in the south. Even though hospitalisations for ischemic heart

disease are decreasing overall, higher rates were recorded in England and

Denmark (in this order) than in Spain and Portugal. This factor should be taken

into account when assessing and comparing hospitalisation rates and the

intensity of consequent interventions. This section highlights specific factors in

the Spanish healthcare system and/or the organisational processes that may

contribute to the observed results and thus may warrant further examination.

The mapping of burden of coronary disease and PCI intensity of use produces in

some cases contradicting patterns: reveals contradicting patterns in some cases:

some Healthcare Areas with the highest PCI utilisation rates had a lower relative

risk of CID hospitalisation, while others had a very high relative risk. Given the

potential benefit of primary PCI, two hypotheses, which may be concomitant

rather than alternative, should be considered. A higher number of early

interventions could prevent hospitalisation at later disease stages, and thus,

reduce the corresponding admission rate. However, the local risk of being

hospitalised due to CID should drive the need for PCI procedures and hence the

local intensity of use. If that were not the case, such a high intensity of PCI

revascularisation unrelated to need could indicate over-utilisation of the

procedure, i.e., over-exposure of the population and hence inadequate provision

of care.

The geographical analysis revealed a significant role of regions in explaining the

observed variation in the population’s exposure to PCI or CABG: regions

accounted for more than 40% of the variation not attributable to areas. This may

be due to the application of different regional health plans or different

39



implementations of national strategies at the local level1 highlighting the

important role of regions in modulating certain health policies, and consequently,

the provision of healthcare services, including these interventions. Alternatively,

the existence of a concentration of early adopters (high-tech hospitals acting as

referral hospitals for all citizens within a region) could explain the large

component of variation attributable to regions.

At the Healthcare area level, only PCI utilisation appeared to be positively

associated with the burden of disease, although this association was small. The

joint analysis of the utilisation patterns for both revascularisation procedures (PCI

and CABG) provides some evidence to suggest a general (in terms of regions)

substitution effect. Nonetheless, a case-by-case analysis of discrepant trends

could provide further insight. In such cases, it would be important to identify

factors other than need or technological changes that may contribute to the

observed revascularisation rates.

Analysis of case fatality rates at the hospital level revealed that Spanish risk-

adjusted in-hospital mortality for AMI patients significantly after 2002, and was

among the lowest of all ECHO countries in 2009. Detailed analysis revealed that

most Spanish hospitals (almost 65.5%) treated AMI patients within the expected

(average) levels of quality and safety. However, detailed analysis revealed two

extreme patterns of care provision. On one hand, 13.8% of hospitals (treating

almost 10% of all Spanish AMI patients) recorded in-hospital mortality rates that

were significantly higher than expected, and were consequently flagged as alert

or alarm. On the other hand, 20.7% of hospitals (treating 31.4% of all AMI

patients) had significantly lower than expected risk-adjusted CFRs and were

flagged as good or excellent. The quantified effect on variation attributable to the

hospital of treatment was 1.252. In the case of AMI, this means that pairs of

similar, randomly chosen patients from two different hospitals would have a 25%

difference in the risk of dying depending on where they were hospitalised.

Analysis of in-hospital mortality after revascularization reveals a more worrying

picture. Risk-adjusted CFRs for both PCI and CABG in 2009 were the highest

across ECHO countries. Two specific findings were of concern: the increase in risk-

adjusted CFR after PCI, and the fact that Spain had the highest proportion of

ECHO hospitals with an alarm rating performing PCI and CABG. In the case of PCI,

similar patients treated in different hospitals could have a differential risk of

dying as high as 44%. This figure increased to 65% for CABG.

1 Ministerio de Sanidad y Consumo. Estrategia en Cardiopatía Isquémica del SNS. 2006

2 Calculated throughout the Median Odds Ratio [MOR]

40



Volume has been proposed as one potential factors underlying these differences.

In fact, the vast majority of Spanish hospitals registered a volume of annual

patients well below the ECHO high-volume threshold. The lower the volume the

higher the probability of poorer outcomes. Other countries in ECHO, such as

Denmark, have recently implemented reforms addressing this issue, encouraging

centralisation of specialised interventions into fewer centres, such that the

minimum amount of procedures per centre is guaranteed to maintain high level

of expertise and quality. In the case of England, a provision was introduced

whereby hospitals were required to perform more than 300 CABG a year to

acquire accreditation.

The literature recommends assessing a number of critical factors that may

account for differences in hospital outcomes (at both local and global levels).

These include pre-hospital diagnosis and planning of urgent transportation to the

appropriate medical centre. Assessing the relationship with the eventual hospital

of reference could provide important insights as to whether there is a well-

defined, stable and fluid bypass circuit or special techniques for severe patients,

and whether transfer to reference centres occurs immediately or within 24 hours,

depending on the severity of the situation. Analysis of these are key components

of successful treatment could be very helpful in improving patient outcomes as

well as overall health system costs.

The analysis conducted suggests that there is room to improve outcomes in the

Spanish system. The burden of disease and revascularisation rates are generally

lower as compared with other ECHO countries, but do not appear to relate to one

another, suggesting that factors other than need or technological change may

drive revascularisation intensity.

On the other hand the surgical outcomes of Spanish hospitals were rather poor

when assessed by international benchmarking. The comparatively poor results of

some Spanish hospitals for PCI and CABG patients, as assessed by national

standards, also warrant closer analysis. The fact that only 21% of patients

undergoing CABG were treated in high-volume hospitals deserves further

consideration.

41



Table 1. General descriptive statistics for burden of disease: CID admissions

Stand. Rate: Age- and sex-standardised rate per 10,000 inhabitants (Reference population: ECHO countries, 2009); EQ: extremal quotient; SCV: systematic component of variation.

Table 2. General descriptive statistics for burden of disease: AMI admissions


Table 3. General descriptive statistics for utilisation of PCI procedure


Table 4. General descriptive statistics for utilisation of CABG surgery


CORONARY ISCHAEMIC DISEASE

DENMARK ENGLAND PORTUGAL SLOVENIA SPAIN

Cases 13225 141167 14526 4288 78585

Stand. Rate 30.68 34.32 17.86 32.40 23.79 EQ5-95 2.32 2.16 2.12 1.89 3.04

SCV 0.14 0.24 0.15 0.09 0.10



Cases 6711 69713 11365 2911 46206

Stand. Rate 15.90 16.76 13.80 22.29 13.78

EQ5-95 1.91 2.63 2.37 1.67 2.98

SCV 0.05 0.15 0.05 0.34 0.11

PERCUTANEOUS CORONARY INTERVENTION


Cases 9253 63220 10587 5025 48368

Stand. Rate 37.50 27.18 21.37 60.16 23.89

EQ5-95 1.86 2.20 2.24 2.61 4.71

SCV 0.33 0.08 0.08 1.97 0.22

CORONARY ARTERY BYPASS GRAFT


Cases 2371 20434 2446 774 7068

Stand. Rate 9.99 9.00 4.77 9.77 3.38

EQ5-95 1.71 2.33 7.42 5.32 9.83

SCV 0.50 0.41 0.19 0.74 0.27

APPENDIX 1a:

International

Comparison across

ECHO countries

GEOGRAPHICAL

APPROACH

Year 2009

42



Table 5. Data for hospitals and patients included* in the analysis.

Hospitals recording less than 30 patients or procedures per year have been excluded from the analysis to avoid noise

when estimating risk-adjustment by logistic multivariate modelling.

Table 6: ECHO hospitals' description and relative performance per country for

hospitalised AMI patients (ECHO benchmark estimation)

Hospitals>250: Hospitals above the activity threshold of 250 AMI hospitalisations a year; Alarm position: hospitals above the CI-99 limit; Alert position: hospitals above the CI-95 limit; Good performers: hospitals below the CI-95 limit; Excellent performers: hospitals below the CI-99 limit. The percentage of AMI patients in the country hospitalised at each hospital type is shown in brackets.

ECHO DENMARK ENGLAND PORTUGAL SLOVENIA SPAIN


Total discharges 147670 8124 71001 12391 3471 52683

Total nº hospitals 522 35 154 46 16 271

Hospitals excluded 87 5 5 6 2 69

(% patients excluded) 0.55% 0.48% 0.01% 0.28% 0.06% 1.38%

Discharges analysed 146859 8085 70994 12356 3469 51955

Nº Hospitals analysed 435 30 149 40 14 202




Hospitals excluded 84 18 24 9 1 32

% patients excluded 0.32% 0.43% 0.18% 0.92% 0.29% 0.36%






Hospitals excluded 56 11 24 4 --- 17

% patients excluded 0.24% 1.26% 0.14% 0.16% --- 0.25%





Discharges 146859 8085 70994 12356 3469 51955

Deceased 12582 674 6281 1183 240 4204

Nº Hospitals 435 30 149 40 14 202 Hospitals > 250 (% patients treated)

239 (82.47%)

6 (70.3%)

125 (93.9%)

23 (79%)

3 (66.59%)

82 (70.59%)

Average expected Risk-adjusted CFR

99.03 133.45 94.41 109.57 101.58 93.75

Hosp. Alarm position (% patients treated)

40 (5.83%)

10 (21.13%)

9 (4.30%)

10 (20.31%)

3 (7.81%)

6 (1.09%)

Hosp. Alert position (% patients treated)

18 (3.19%)

3 (3.45%)

6 (3.54%)

1 (1.45%)

1 (1.59%)

9 (4.09%)

Hosp. Good performers (% patients treated)

42 (11.42%)

2 (3.15%)

14 (10.65%)

3 (9.43%)

2 (5.85%)

20 (13.97%)

Hosp. Excellent performers (% patients treated)

67 (26.7%)

5 (60.63%)

22 (23.6%)

5 (19.06%)

3 (51.14%)

32 (25.85%)

APPENDIX 1b:

International

Comparison across

ECHO countries

HOSPITAL

APPROACH

Year 2009

43



Table 7: ECHO hospitals: description and relative performance per country for

patients undergoing PCI (ECHO benchmark estimation)

Hospitals>250: Hospitals above the activity threshold of 250 PCI a year; Alarm position: hospitals above the CI-99 limit; Alert position: hospitals above the CI-95 limit; Good performers: hospitals below the CI-95 limit; Excellent performers: hospitals below the CI-99 limit. The percentage of patients in the country undergoing a PCI procedure at each hospital type is shown in brackets.

Table 8: ECHO hospitals: description and relative performance per country for

patients undergoing CABG (ECHO benchmark estimation)

Hospitals>250: Hospitals above the activity threshold of 250 CABG a year; Alarm position: hospitals above the CI-99 limit; Alert position: hospitals above the CI-95 limit; Good performers: hospitals below the CI-95 limit; Excellent performers: hospitals below the CI-99 limit. The percentage of patients in the country undergoing CABG surgery at each hospital type is shown in brackets.



Discharges 132737 9266 64139 10661 4803 43868

Deceased 2623 255 924 188 143 1113

Nº Hospitals 199 7 73 30 8 81

Hospitals > 250 (% patients treated)

159 (95.44%)

7 (100%)

64 (97.17%)

15 (84.05%)

5 (97.04%)

68 (94.53%)


19.86 22.78 13.70 20.77 15.61 25.59


28 (17.26%)

4 (67.47%)

1 (1.55%)

3 (9.69%)

2 (74.47%)

18 (25.19%)


10 (3.9%)

--- ---

2 (1.80%)

1 (1.76%)

--- ---

7 (8.74%)


17 (4.8%)

2 (7.52%)

13 (7.80%)

--- ---

1 (5.58%)

1 (0.92%)


15 (15.51%)

--- ---

12 (28.27%)

1 (9.80%)

--- ---

2 (3.20%)

CORONARY ARTERY BYPASS GRAFT ECHO DENMARK ENGLAND PORTUGAL SLOVENIA SPAIN

Discharges 33683 2360 21006 2492 678 7147

Deceased 1212 96 571 87 37 421

Nº Hospitals 89 6 29 6 2 46


46 (82.16%)

5 (93.43%)

29 (100%)

6 (100%)

1 (70.06%)

5 (20.93%)


50.33 44.54 27.81 33.55 44.97 66


9 (3.58%)

--- ---

--- ---

--- ---

--- ---

9 (16.87%)


4 (2.03%)

--- ---

--- ---

1 (16.21%)

--- ---

3 (3.92%)


13 (20.65%)

--- ---

8 (26.09%)

2 (32.58%)

1 (29.94%)

2 (6.46%)


18 (40.61%)

1 (24.79%)

16 (60.32%)

1 (16.97%)

--- ---

--- ---

APPENDIX 1b:

International

Comparison across

ECHO countries

HOSPITAL

APPROACH

Year 2009

44



Table 9: Descriptive statistics for burden of coronary disease and use of revascularisation procedures across healthcare areas.

Stand. Rate: Age- and sex-standardised rate per 10,000 inhabitants (Reference population: national 2009); sR Px: percentile x of Stand. Rate distribution; EQ: Extremal quotient; ICC: Intra class

correlation coefficient

Table 10: Relative risk of exposure to coronary disease and revascularisation procedures across healthcare areas.

SUR: Standardised admission/Utilization Ratio (observed/expected); SUR Px: percentile x of the SUR distribution; SCV: Systematic Component of Variation.

CID AMI PCI CABG

Cases 78,585 46,206 48,368 7,068

Population 39,808,144 39,808,144 22,988,560 22,988,560

Crude Rate 21.22 12.22 20.21 2.97

Stand. Rate 20.63 11.91 20.22 2.96

sR Min. 4.6 1.5 0.13 0.16

sR Max. 43.06 23.15 70.02 7.83

sR. P5 12.45 6.36 7.92 0.66

sR. P25 16.37 9.45 14.96 1.88

sR. P50 20.03 11.59 19.27 2.82

sR. P75 23.58 13.96 23.65 3.84

sR. P95 32.56 18.46 35.74 6.09

EQ5-95 2.61 2.9 4.51 9.28

EQ25-75 1.44 1.48 1.58 2.04

ICC 0.28 0.14 0.44 0.43

CID AMI PCI CABG

SUR Min. 0.25 0.21 0.01 0.07

SUR Max. 2.17 2 3.28 2.54

SUR P5 0.63 0.54 0.39 0.21 SUR P25 0.83 0.81 0.7 0.6 SUR P50 1.02 0.99 0.91 0.92

SUR P75 1.19 1.19 1.14 1.25

SUR P95 1.63 1.57 1.72 1.96

SCV 0.1 0.09 0.19 0.22

APPENDIX 2a:

Tables Spain

WITHIN-Country

analysis

GEOGRAPHICAL

APPROACH

Year 2009

45



Table 11: Descriptive statistics for hospital activity and outcomes.

CFR: Case Fatality Rate per 1,000 hospitalised patients or patients undergoing procedure; R-adj CFRx: risk-adjusted CFR of percentile x of the CFR distribution; Rho Statistic: cluster effect; MOR (median odds ratio): variation between clusters.

Table 12: Hospital outcomes for Acute Myocardial Infarction patients* (national benchmark estimation)

AMI in-hospital

mortality PCI in-hospital

mortality CABG in-hospital

mortality

Deceased 4210 1113 421

N. hospitals 203 81 46

Crude CFR 88.60 24.62 61.57

Risk-adjusted CFR 93.75 25.59 66.00

R-adj CFR5 23.23 3.41 11.29

R-adj CFR95 181.20 56.75 144.72

Rho Statistic 0.016 0.042 0.077

MOR 1.25 1.44 1.65

APPENDIX 2b:

Tables Spain

WITHIN-Country

analysis

HOSPITAL

APPROACH

Year 2009

46



APPENDIX 2b:

Tables Spain

WITHIN-Country

analysis

HOSPITAL

APPROACH

Year 2009

47



APPENDIX 2b:

Tables Spain

WITHIN-Country

analysis

HOSPITAL

APPROACH

Year 2009

48



(i) Total number of AMI admissions per hospital during the period of analysis. * Hospitals with less than 30 AMI admissions per year are excluded from the analysis. CFR: Crude case fatality rate per 1,000 hospitalised AMI patients; sCFR: Risk-adjusted Case Fatality Rate per 1,000 hospitalised AMI patients. Hospitals above the CI-99 control limit are considered in “Alarm position”; hospitals above the CI-95 control limit are considered in an “Alert position”; hospitals below the

CI-95 control limit are considered “Good performers” and hospitals below the CI-99 control limit are considered “Excellent performers”.

Table 13: Hospital outcomes for Percutaneous Coronary Interventions, year 2009. (national benchmark estimation)*

APPENDIX 2b:

Tables Spain

WITHIN-Country

analysis

HOSPITAL

APPROACH

Year 2009

49



(i) Total number of interventions per hospital accumulated during the period of analysis. Hospitals performing less than 30 interventions per year were excluded from the analysis

CFR: Crude case fatality rate per 1,000 patients undergoing a PCI procedure; sCFR: Risk-adjusted Case Fatality Rate per 1,000 patients undergoing a PCI procedure. Hospitals above the CI-99 control limit are considered in “Alarm position”; hospitals above the CI-95 control limit are considered in an “Alert position”; hospitals below the CI-95 control limit are considered “Good performers” and hospitals below the CI-99 control limit are considered “Excellent performers”.

APPENDIX 2b:

Tables Spain

WITHIN-Country

analysis

HOSPITAL

APPROACH

Year 2009

50



Table 14: Hospital outcomes for Coronary Artery Bypass Graft, year 2009. National benchmark estimation*

(i) Total number of interventions per hospital during the period of analysis. CFR: Crude case fatality rate per 1,000 patients undergoing a PCI procedure; sCFR: Risk-adjusted Case Fatality Rate per 1,000 patients undergoing a CABG procedure. Hospitals above the CI-99 control limit are considered in “Alarm position”; hospitals above the CI-95 control limit are considered in an “Alert

position”; hospitals below the CI-95 control limit are considered “Good performers” and hospitals below the CI-99 control limit are considered “Excellent performers”.

APPENDIX 2b:

Tables Spain

WITHIN-Country

analysis

HOSPITAL

APPROACH

Year 2009

51



Table 15. Spanish descriptive statistics for burden of disease over time: CID

Stand. Rate & sR: Age-sex Standardised Rate (Reference population: national 2002); sR Qx: quintile x of sR distribution; SCV: Systematic Component of Variation.

Table 16. Spanish descriptive statistics for burden of disease over time: AMI

Stand. Rate & sR: Age- and sex-standardised rate per 10,000 inhabitants (Reference population: national 2002); sR Qx: quintile x of sR distribution; SCV: Systematic component of variation.

Table 17. Spanish descriptive statistics for procedure utilisation over time: PCI


Table 18. Spanish descriptive statistics for procedure utilisation over time: CABG


CORONARY ISCHAEMIC

2002 2003 2004 2005 2006 2007 2008 2009

Cases 88670 89838 88899 86158 85239 83756 81265 78585

Stand. Rate 25.5 26.22 26.29 25.28 25.29 24.7 24.05 23.31 sR Q1. 27.38 28.60 28.61 28.59 28.98 28.43 27.83 27.02 sR Q5. 21.54 21.89 22.22 19.45 19.90 19.69 18.89 18.48

SCV 0.1 0.1 0.1 0.11 0.11 0.11 0.11 0.13


2002 2003 2004 2005 2006 2007 2008 2009

Cases 45834 47225 47427 47144 46020 45684 46447 46206


SCV 0.09 0.09 0.08 0.09 0.09 0.1 0.11 0.12


2002 2003 2004 2005 2006 2007 2008 2009

Cases 27566 31919 35837 39624 42696 45320 45557 48368


SCV 0.22 0.21 0.2 0.22 0.23 0.24 0.23 0.22


2002 2003 2004 2005 2006 2007 2008 2009

Cases 7396 7756 7663 7175 7078 7264 7326 7068


SCV 0.22 0.17 0.17 0.19 0.19 0.3 0.24 0.22

APPENDIX 3a3a:

Tables Denmark

Evolution over

time

GEOGRAPHICAL

APPROACH

Period of

analysis: 2002-

2009

APPENDIX 3a:

Tables Spain

Evolution over time

GEOGRAPHICAL

APPROACH

Period of analysis:

2002-2009

52



Table 19. Evolution of the relative performance of Spanish hospitals for AMI admissions (in-country benchmark estimation).

Hospitals>250: Hospitals above the activity threshold of 250 AMI hospitalisations a year; Alarm position: hospitals above the CI-99 limit; Alert position: hospitals above the CI-95 limit; Good performers: hospitals below the CI-95 limit; Excellent performers:

hospitals below the CI-99 limit. The percentage of patients in the country undergoing AMI at each hospital type is shown in brackets.

Table 20. Evolution of the relative performance of Spanish hospitals for patients undergoing a PCI procedure (in-country benchmark estimation)

Hospitals>250: Hospitals above the activity threshold of 250 PCI a year; Alarm position: hospitals above the CI-99 limit; Alert

position: hospitals above the CI-95 limit; Good performers: hospitals below the CI-95 limit; Excellent performers: hospitals below the CI-99 limit. The percentage of patients in the country undergoing a PCI procedure at each hospital type is shown in brackets.


2002 2003 2004 2005 2006 2007 2008 2009

Discharges 46732 53303 53245 53183 51719 51790 52388 51985

Deceased 5224 5810 5432 5271 4675 4673 4584 4210

Nº Hospitals 184 200 201 203 195 197 203 203


78 (73.32%)

88 (73.5%)

88 (73.65%)

89 (73.97%)

90 (74.58%)

82 (70.62%)

86 (72.64%)

82 (70.55%)


120.43 117.16 110.26 107.22 98.70 101.35 94.70 93.75


18 (10.1%)

18 (6.62%)

20 (7.34%)

18 (9.23%)

15 (5.04%)

17 (6.29%)

17 (6.28%)

16 (5.23%)


9 (4.36%)

9 (3.43%)

6 (3.39%)

11 (4.79%)

16 (6.05%)

6 (1.67%)

9 (3.75%)

12 (4.91%)


10 (6.94%)

14 (5.46%)

10 (4.45%)

13 (6.6%)

16 (9.86%)

8 (4.72%)

15 (10.76%)

17 (12.92%)


18 (18.3%)

21 (17.24%)

23 (21.31%)

21 (19.37%)

22 (17.26%)

25 (20.51%)

15 (9.03%)

25 (18.52%)


2002 2003 2004 2005 2006 2007 2008 2009

Discharges 22662 30826 34026 38022 40580 42161 42287 43868

Deceased 465 705 737 895 888 956 1033 1113

Nº Hospitals 61 75 78 77 79 79 80 81


35 (83.92%)

48 (87.71%)

51 (87.82%)

60 (92.16%)

66 (95.23%)

65 (94.11%)

68 (95.24%)

68 (94.53%)


20.22 23.07 20.53 23.55 22.14 23.31 24.70 25.59


9 (16.77%)

11 (16.32%)

10 (14.92%)

9 (14.13%)

10 (13.79%)

11 (13.93%)

12 (14.44%)

10 (13.75%)


2 (3.76%)

1 (1.47%)

3 (7.66%)

4 (4.84%)

3 (3.98%)

4 (4.31%)

3 (3.1%)

1 (1.19%)


4 (8.19%)

8 (13.67%)

4 (4.83%)

5 (5.8%)

8 (12.20%)

9 (9.47%)

8 (11.2%)

8 (10.18%)


2 (7.82%)

3 (5.02%)

2 (5.34%)

5 (9.99%)

3 (4.93%)

3 (5.66%)

4 (5.26%)

6 (9.78%)

APPENDIX 3b:

Tables Spain

Evolution over time

HOSPITAL

APPROACH

Period of analysis:

2002-2009

53



Table 21. Evolution of the relative performance of Spanish hospitals for patients undergoing CABG surgery (in-country benchmark estimation)

Hospitals>250: Hospitals above the activity threshold of 250 CABG a year; Alarm position: hospitals above the CI-99 limit; Alert position: hospitals above the CI-95 limit; Good performers: hospitals below the CI-95 limit; Excellent performers: hospitals below the CI-99 limit. The percentage of patients in the country undergoing CABG surgery at each hospital type is shown in brackets.


2002 2003 2004 2005 2006 2007 2008 2009

Discharges 6732 8000 7881 7355 7265 7257 7457 7147

Deceased 531 616 580 539 524 510 534 421

Nº Hospitals 35 44 44 45 45 45 45 46


9 (38.19%)

9 (32.59%)

8 (30.97%)

5 (19.71%)

4 (15.36%)

7 (26.87%)

6 (23.63%)

5 (20.93%)


88.12 85.54 81.31 80.58 81.38 77.25 82.44 66.00


4 (7.77%)

5 (9.09%)

6 (10.3%)

4 (8.67%)

4 (6.28%)

3 (4.46%)

4 (4.69%)

6 (11.59%)


3 (7.58%)

2 (3.79%)

1 (1.42%)

2 (2.38%)

3 (5.2%)

2 (5.43%)

2 (3.66%)

1 (1.33%)


4 (12.4%)

7 (22.55%)

6 (15.05%)

4 (10.65%)

--- ---

2 (5.43%)

6 (17.58%)

5 (10.98%)


4 (15.29%)

6 (18.11%)

4 (12.65%)

6 (17.59%)

5 (14.21%)

4 (11.97%)

4 (10.31%)

3 (9.47%)

APPENDIX 3b:

Tables Spain

Evolution over

time

HOSPITAL

APPROACH

Period of

analysis: 2002-

2009

54



Cardiovascular Ischaemic Disease and AMI, as well as the revascularisation

procedures PCI and CABG, are used as geographical and hospital-specific

indicators within the ECHO performance model.

This has certain implications both for methodology and the interpretation of

results. This report is based on ecological analyses; data aggregated at a certain

geographical level serve as the unit of analysis for this report. Thus, correct

interpretation of the findings provides an indication of the risk of exposure to

hospitalisation for cardiovascular conditions or revascularisation procedures for a

population living in a given area (as opposed to the risk for an individual patient).

Individual data are subsequently analysed from a provider perspective and risk-

adjusted within multivariate logistic 2-level hierarchical model, and then clustered

according to hospitals. Interpretation of these data provides an indication of the

risk of dying after being hospitalised and/or treated in a specific hospital relative

to national or ECHO country benchmarks.

Main endpoints:

This report maps standardised utilisation rates per geographical area as well as

risk-adjusted case fatality rates per provider, analysing events affected by

healthcare quality. As a summary measure of variation, the report includes the

classical statistics Ratio of Variation between extremes, Component of Systematic

Variation and Rho Statistic (cluster effect) and the Median Odds Ratio (MOR)

statistic, a measure of the variation among hospitals that compares pairs of

patients with comparable risk selected from two, randomly chosen hospitals.

MOR provides information as to how heterogeneity across hospitals increases the

individual odds of experiencing the outcome of interest, in this case case-

fatalities.

Instruments:

In the geographical approach, as this was an ecological study, each admission was

allocated to the place of residence of the patient, which in turn was linked to a

meaningful geographic unit; the 199 healthcare areas and the 17 Regions that

comprise the Spanish National Health System.

For risk-adjustment of the hospital approach within the multivariate logistic 2-

level hierarchical model, the following variables were included:

– Age and sex

APPENDIX 4:

Technical note

55



– For patients with a primary diagnosis of AMI, classification as transmural (with

ST segment elevation, STEMI), non-STEMI or unclassified. Whether the patient

underwent heart valve replacement and/or implantation of a cardiac or

circulatory assistance device was also noted.

– Whether the intervention consisted of major structural surgery (including

repair or revision of atrial and ventricular septa, cardiotomy, pericardiotomy,

pericardiectomy and excision of a heart lesion).

– Specific measures of the severity of the underlying condition (42 co-morbidities

included in the Elixhauser index), listed below:

Cardiac arrhythmias Drugs abuse

Valvular disease Lymphoma

Congestive heart failure Solid tumor without metastasis

Chronic lung disease Metastatic cancer

Hypertension, uncomplicated Weight loss

Hypertension, complicated Psychoses

Total hypertension disease Depression

Pulmonary circulation disorders AIDS/HIV

Renal failure Fluid and electrolyte disorders

Pre-existing hypertension complicating pregnancy

Peptic ulcer disease excluding bleeding

Other hypertension in pregnancy Deficiency anemia

Diabetes, without chronic complications Blood loss anemia

Diabetes, with chronic complications Coagulopathy

Hypothyroidism Rheumatoid arthritis/collagen vascular diseases

Liver disease Peripheral vascular disorders

Obesity Paralysis

Alcohol abuse Other neurological disorders

For both approaches, the operational definitions for each indicator are detailed in

the coding Table in Appendix 5. The indicators used are based on those in use in

the international arena, as proposed by AHRQ and OECD. For the analysis of

variation across countries indicators were subjected to a construct validity process

developed by the Atlas VPM project in Spain. Furthermore, as part of a task within

the ECHO project, cross-walks across different diseases and procedure

classifications were constructed in order to face-validate the indicators used.

APPENDIX 4:

Technical note

56



This report is based on hospital admissions registered in the National Discharges Dataset (CMBD). Cross- and in-country sections were built based on 2009 discharge data, whereas time-trends and social gradient analyses used data from the period 2002-2009.

Social gradient data were obtained from the Atlas VPM dataset, based on original data from the La Caixa 2003 annual report.

APPENDIX 4:

Technical note

57



Diagnosis and procedures codes ICD9-CM

Primary diagnosis Secondary diagnosis2-30 Procedures

Inclusions Exclusions Inclusions Exclusions Inclusions Exclusions

Ischaemic Disease Age 18+ Type of admission unplanned

410.*, 411.1, 411.8, 413.* 414.01 (IF DX2-30 411.1)*

410.*, 411.1, 411.8, 413.* 414.01 (IF DX2-30 411.1)*

Acute Myocardial Infarction (AMI) Age 18+ Type of admission unplanned

410.* 410.*

Percutaneous Coronary Interventions (PCI) Age 40+

36.01, 36.02, 36.05, 36.06, 36.07, 36.08, 36.09, 00.66

Coronary Artery Bypass Grafting (CABG) Age 40+

36.10, 36.11, 36.12, 36.13, 36.14, 36.15, 36.16, 36.17, 36.19

APPENDIX 5:

Definitions

58



Diagnosis and procedures codes ICD9-CM

Primary diagnosis Secondary diagnosis2-30 Procedures

Inclusions Exclusions Inclusions Exclusions Inclusions Exclusions

Acute Myocardial Infarction in Hospital Mortality Age 18+

410.* 630.*-677.* 630.*-677.*

Percutaneous Coronary Interventions in Hospital Mortality Age 40+

630.*-677.* 630.*-677.*

36.01, 36.02, 36.05, 36.06, 36.07, 36.08, 36.09, 00.66

Coronary Artery Bypass Grafting in Hospital Mortality Age 40+

630.*-677.* 630.*-677.*

36.10, 36.11, 36.12, 36.13, 36.14, 36.15, 36.16, 36.17, 36.19

APPENDIX 5:

Definitions

Coronary revascularisation in Spain - ECHO · 2017-01-24 · Exposure to surgical revascularization...

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