Draft OECD Project Medical Practice Variation Country ... · OECD Project Medical Practice...
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OECD Project Medical Practice Variation Country Report: Italy Second meeting of the Expert Group on Medical Practice Variations OECD Headquarters, Paris, 25-26 April 2013 Authors Fabrizio Carinci , Senior Statistician, AGENAS Carla Ceccolini, Statistician, Ministero della Salute Francesco Di Stanislao, Prof. Hygiene & Public Health, Un.Pol.Marche, AGENAS Flavia Carle, Prof.Medical Statistics, Un.Pol.Marche, Ministero della Salute Coordinators Fulvio Moirano, Director, AGENAS Francesco Bevere, Director, DG Programmazione, Ministero della Salute Draft – subject to revisions
Transcript of Draft OECD Project Medical Practice Variation Country ... · OECD Project Medical Practice...
OECD Project Medical Practice Variation Country Report: Italy Second meeting of the Expert Group on Medical Practice Variations OECD
Headquarters, Paris, 25-26 April 2013 Authors Fabrizio Carinci, Senior Statistician, AGENAS Carla Ceccolini, Statistician, Ministero della Salute Francesco Di Stanislao, Prof. Hygiene & Public Health, Un.Pol.Marche, AGENAS Flavia Carle, Prof.Medical Statistics, Un.Pol.Marche, Ministero della Salute Coordinators Fulvio Moirano, Director, AGENAS Francesco Bevere, Director, DG Programmazione, Ministero della Salute
Draft – subject to revisions
Regional governments
Regions have virtually
exclusive responsibility for
the organization and
administration of publicly
funded healthcare
Pop 2011:
N=60,626,442
20 Regions
110 Provinces
Av. Pop. 2011:
N=550,000 ca.
Proxy for LHAs (ASL)
National Health Service France G, Taroni F, Donatini A.The Italian health-care system, Health Econ. 2005 Sep;14(Suppl 1):S187-202.
“Sistema Sanitario Nazionale” (SSN)
LHA
Region
Rome
Essential Levels of Care (LEAs)
Catalogue of SSN benefits positive list
services which SSN is required to provide uniformly in all regions
negative list - ineffective or non relevant benefits (cosmetic surgery, etc)
- entitlement on a case-by-case basis
- inappropriate use of hospital stay: (inpatient vs outpatient)
non-LEA services can be provided by regions using own sources
Activities on performance evaluation
Carinci F, Caracci G, Di Stanislao F, Moirano F.Performance measurement in response to the Tallinn Charter: experiences from the decentralized Italian framework, Health Policy. 2012 Nov;108(1):60-6
Management
Evaluation
National Inter Regional Regional
Responsiveness
Financial Protection
Health
Exchange of Best
Practices
Benchmarking
Governance
(+ Ministry of Finance)
RECOVERY PLANS
ALLOCATION OF NATIONAL BUDGET
Ste
wa
rdship
N
AT
ION
AL
HE
AL
TH
PL
AN
National Outcomes
Project
AGENAS Ministry Of Health (SIVeAS)
Regional Directorate General
Appropriateness
Customer Satisfaction
Civic Auditing
Networks
Improvement Cycle
Clinical
pathways
BSC Mission evaluation Pathways Analysis
Multidimensional Systems
Operational Plans
Outcomes, Appropriateness
Access Indicators
EVALUATION
REFORM
ANALYSIS
Unit in charge AGENCY,
DIRECTORATE, EXTERNAL
STAKEHOLDERS Publications
Papers/Reports Web
Governance
USE OF EVIDENCE
Targets of Operational
Plans
Stewardship
OE
CD
MP
V P
RO
JE
CT
IN
DIC
AT
OR
S
National Hospital Discharge Database
● “Scheda di Dimissione Ospedaliera” (SDO)
– Active since 28.12.1991
– Archived by Date of Discharge
● 2006-2008 ICD-9-CM 2002, DRG v.19
● 2009-today ICD-9-CM 2007, DRG v.24
● N=1 Principal Diagnosis, Procedure (Date)
● N=5 Secondary Diagnoses, Procedures
● Year 2011
– N=1,534 Hospitals
– N=7,458,840 Inpatient Discharges
OE
CD
MP
V P
RO
JE
CT
IN
DIC
AT
OR
S
Indicator
Numerator Definition
(ICD 9 CM Diagnosis)
Denominator Unit Age Groups
Control
Variable
Hospital
Medical Admissions
Type DRG = “M” Population by Province, Region
100,000 15-34
35-44
45-54
55-64
65-74
75+
Caesarean
Sections
(Females)
Any procedure:
74.0-74.2 Classical, low cervical, extraperitoneal caesarean
74.4 Caesarean section of other specified type
74.99 Other caesarean section unspecified type
Live births by Province, Region
1,000 <19
20-24
25-29
30-34
35-39
40+
Av. LOS by Province, Region
Coronary
Bypass
(CABG)
Any procedure:
36.1, 36.11-36.19
Aortocoronary bypass for heart revascularization
Population by Province, Region
100,000 20-49
50-64
65-74
75+
Av. LOS by Province, Region
Coronary
Angioplasty (PTCA)
Any procedure:
36.0 Removal Of Coronary Artery Obstruction
and Insertion Of Stent(s)
Population by Province, Region
100,000 20-49
50-64
65-74
75+
Catheterization Any procedure:
37.21 Right Heart Cardiac Catheterization
37.22 Left Heart Cardiac Catheterization
37.23 Combined Right Left Heart Cardiac Catheterization
Population by Province, Region
100,000 20-49
50-64
65-74
75+
Statistical Outputs
● Age, Sex Standardized Rates by Province, Region
– Median(Range), Percentiles, CV
– Barplots
● Geographical Variation of Indicators and Mean LOS
– Maps
● Excess Variation
– Funnel Plots
● Temporal trends 2007-2011
– Boxplots
● Multivariate patterns
– Starplots
Hospital Medical Admissions – Italy 2011
Hospital Medical Admissions – Italy 2011
Hospital Medical Admissions – Italy 2011
Caesarean Sections – Italy 2011
Caesarean Sections – Italy 2011
Caesarean Sections – Mean LOS - Italy 2011
Caesarean Sections – Italy 2011
Coronary Bypass (CABG) – Italy 2011
Coronary Bypass (CABG) – Italy 2011
Coronary Bypass (CABG) Mean LOS – Italy 2011
Coronary Bypass (CABG) – Italy 2011
Coronary Angioplasty (PTCA) – Italy 2011
Coronary Angioplasty (PTCA) – Italy 2011
Catheterization – Italy 2011
Catheterization – Italy 2011
Catheterization – Italy 2011
Knee Replacement – Italy 2011
Knee Replacement – Italy 2011
Knee Replacement – Mean LOS - Italy 2011
Knee Replacement – Italy 2011
Knee Arthroscopy – Italy 2011
Knee Arthroscopy – Italy 2011
Knee Arthroscopy – Italy 2011
Surgery after Hip Fracture – Italy 2011
Surgery after Hip Fracture – Italy 2011
Surgery after Hip Fracture – Mean LOS - Italy 2011
Surgery after Hip Fracture – Italy 2011
Histerectomy – Italy 2011
Histerectomy – Italy 2011
Histerectomy – Mean LOS - Italy 2011
Histerectomy – Italy 2011
Trends MPV Indicators – Italy 2007-2011
Trends MPV Mean LOS – Italy 2007-2011
Trends MPV Indicators by Region – Italy 2007
Trends MPV Indicators by Region – Italy 2008
Trends MPV Indicators by Region – Italy 2009
Trends MPV Indicators by Region – Italy 2010
Trends MPV Indicators by Region – Italy 2011
Policy implications
● Fostered activities on cost containment (“Recovery Plans”) and Performance Evaluation (“National Outcomes Program”) appear to positively impact on the progressive reduction of excess rates
● Nevertheless, a very high geographical variation is still observed for different indicators, particularly Caesarean sections and Catetherization
● Large deviation from national rates raise concerns on the level of equity and fair access to the most appropriate treatment for all Italian citizens
● A larger pool of control variables by territorial unit (structural and population-based, e.g. different prevalence of major risk factors) is needed to explain the excess variability of standardized rates.
● Risk adjustment techniques shall be used to incorporate multilevel explanatory variables (structural and population-based - risk factors, prevalence of diseases, etc)
Conclusions
● The existing patterns of medical practice variations in Italy deserve to be further explored in order to identify potential determinants and relevant policy options.
● Sharing these results internally (particularly with regional decision makers, health professionals, scientific associations and representatives of citizens) is paramount to attempt reducing the excess variations and gain more efficiency and equity at the national level.
● International comparisons will provide the essential set of common reference values and a toolbox of externally validated methods.
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