Introdução à Medicina II2008/09

Turma 18

Alexandre AlmendraAna CunhaAntónio MirandaCristina CostaGabriela GonçalvesJoana EstevesJoão Pedro BarretoLuísa Costa

Mariana CarvalhoMónica Garrido Pedro CanãoPedro ValenteRita CostaSara BragaTiago Magalhães

INTRODUCTIONINTRODUCTION

♦ Need to evaluate management♠ Control the costs♥ Fulfill new requirements♣ Greater demandings

Creation of information systems that allow to grade the management

INDICATORS

INTR

ODU

CTION

[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June

INDICATORSINDICATORS

In a general way…

…“measurement units” to monitor and evaluate through comparison

between different entities

…are…

Two main functions

Evaluate Describe

INTR

ODU

CTION

[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June

INDICATORSINDICATORS

♠Efficiency ♥Efficacy♣Effectiveness♦Cost-efficiency♠Comparability

♦Availability♣Relevance♥Consistency♠Reliability

INTR

ODU

CTION

[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June

[4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005

PROBLEMS ASSOCIATEDPROBLEMS ASSOCIATED

♠ Lack of technical means♥ Input/Output measurement difficulties♣Availability of funding♦ Employee’s lack of instruction♠ Little dynamism from commissions

responsible for executing indicators♥ Inadequacies of information systems

INTR

ODU

CTION

[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June

[4] Correia L F. Indicadores de Desempenho Económico na Saúde [Internet]. 2005

Facing an inefficient and non productive governmental management of public health systems

Construction of evaluation means for the efficiency and effectiveness levels of health systems

HEALTH INDICATORS

INTR

ODU

CTION

[3] Ribeiro N. Indicadores de Gestão para Administração Pública. TOC. 2000 June

♠ Comparative quality reporting

♠ Public reporting ♠ Pay-for-performance

♣ Public reporting ♣ Pay-for-performance

♣ Comparative quality reporting

INTR

ODU

CTION

INTR

ODU

CTION

The financing of Health entities is based on Diagnosis Related Groups

(DRGs)

Sorting systems for patients in clinically coherent and

homogeneous groups – in a resource consumption point of view

Tendency to rationalize the funds’ distribution process

[5] Bentes M, Gonçalves M, Urbano J, Tranquada S. A utilização dos GDHs como instrumento de financiamento hospitalar. Revista Gestão Hospitalar. 1996 December-1997 January;33: 33-43.

RESEARCH QUESTIONRESEARCH QUESTION

• HOW CAN INDICATORS BE USED TO EVALUATE THE QUALITY OF HEALTHCARE PROVIDED TO IN-PATIENTS IN NATIONAL HOSPITALS?

• WHAT INFORMATION DO THEY PROVIDE ON SPECIFIC ASPECTS: ON PORTUGUESE HEALTH SERVICES PERFORMANCE?

• Norte• Norte• Centro• Centro• Lisboa • Lisboa • Alentejo• Alentejo• Algarve• Algarve• Região Autónoma dos Açores• Região Autónoma dos Açores• Região Autónoma da Madeira

OBJECTIVESOBJECTIVES

Establish a comparison between the different

areas of Portugal

Compare the numbers from 2000 to 2007

Evolution of the services’ quality and efficiency

[25] Nomenclatura de Unidades Territoriais para fins estatísticos , Wikipédia, 2008 [26] Parlamento Europeu, Conselho da União Europeia. Regulamento (CE) N.º 1059/2003 do Parlamento Europeu e do Conselo, relativo à instituição de uma Nomenclatura Comum das Unidades Territoriais Estatísticas (NUTS), Jornal Oficial da União Europeia. 2003 May 26.

WHICH METHODS AND RESOURCES ARE WE GOING

TO USE IN ORDER TO REACH OUR

GOALS?

Excluded episodes (ambulatory episodes):

♣ Planned admission♥ Release date equals admission date♠ Patients do not change hospitals♦ Patients do not leave against medical advice nor die

%

Inpatient episode 85,4

Ambulatory episode 14,6

METHODS AND R

ESOURC

ES

Database with inpatient episodes from 87 Portuguese public Hospitals between 2000 and 2007

MAIN CHARACTERISTICS OF INPATIENT DATABASEMAIN CHARACTERISTICS OF INPATIENT DATABASE

CHARACTERISTICS %Gender

Male 44,4

Female 55,6Age

≤ 17 19,818 - 24 5,425 - 34 12,635 - 44 9,345 - 54 9,355 - 64 10,865 - 74 14,2

≥75 18,2

METHODS AND R

ESOURC

ES

Nuts IIAlentejo 4,9Algarve 3,7Centro 26,0Lisboa 26,5Norte 33,8

Discharge Year

2000 12,12001 12,22002 12,42003 12,72004 12,62005 13,02006 12,52007 12,5

Total admissions: 7.768.467

ORIGINAL VARIABLESORIGINAL VARIABLES

◦ HOSP_ID◦ EPIS_ID◦ SEXO◦ DDX1-DDX20◦ SRG1-SRG20◦ DSP◦ BIRTH_WGT◦ ADM_TIP◦ HOSP_FROM

METHODS AND R

ESOURC

ES

◦ HOSP_TO◦ TOTDIAS◦ SAIDLAST◦ DRG◦ MDC◦ RESIDE◦ ENT1◦ HOSP_RESIDE◦ DISTANCIA

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions Newborns

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

INDICATORS

Common variables: cod_conc; nuts3; nuts2; ambulatorio; ano_de_alta;

ICD-9-CM code, Portaria nr110-A/2007,January the 23rd of 2007 and attachments II e III

METHODS AND R

ESOURC

ES

ACTIVITY/PRODUCTIONHEALTH CARE QUALITY

DISCHARGED PATIENTS

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions NEWBORNS

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

EXCEPTIONAL ADMISSION EPISODES

SURGICAL ADMISSION TIME COMPLICATION-FREE LONG-TERM ADMISSIONS

READMISSIONS SHORT-TERM INAPPROPRIATE ADMISSIONS

Newborns

VAGINAL DELIVERIES

UNSPECIFIED SURGICAL PROCEDURES

MEDICAL DRG’S COMPLICATIONS

DISCHARGED PATIENTS

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions Newborns

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

EXCEPTIONAL ADMISSION EPISODES

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions Newborns

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

SURGICAL ADMISSION TIME

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions Newborns

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

Surgical admission time

COMPLICATION-FREE LONG-TERM ADMISSIONS

Readmissions Short-term inappropriate admissions Newborns

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

READMISSIONS Short-term inappropriate admissions Newborns

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions SHORT-TERM INAPPROPRIATE ADMISSIONS Newborns

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions NEWBORNS

Vaginal Deliveries

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions Newborns

VAGINAL DELIVERIES

Unspecified surgical procedures

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions Newborns

Vaginal Deliveries

UNSPECIFIED SURGICAL PROCEDURES

Medical DRG’s complications

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions Short-term inappropriate admissions Newborns

Vaginal Deliveries

Unspecified surgical procedures

MEDICAL DRG’S COMPLICATIONS

Exceptional admission episodes Limiar_inf; Limiar_max; Tipo_episode Surgical admission time PRE_OP_days; POS_OP_days; Complication-free long-term admissions

limiarMax; cc_DDX1 cc_DDX20; Int_Sem_CC ; Int_Validos

Readmissions GDHexcepçao; DuracaoDaAlta; Readmissao; Grupos_Diagnostico

Newborns gr4500plus; trauma_na_clavicula; trauma_inespecifico; fetal_distress_during_labour; asfixia_severa; asfixia_inespecifica; prematuro; outras_condicoes_respiratorias_e_no_recem-nascido; respiratory_distress_sindrome; infeccoes_especificas_do_periodo_perinatal; hemorragia_fetal_e_neo-natal; breast_engourgement; problemas_de_pele_ou_temperatura; problemas_alimentares; drug_withdrawal

Vaginal Delivery totalpartos; partoscc; partosnormalUnspecified surgical procedures ProcCirurInespMedical DRG’s complications Drg_mp; ddx_sec_CC; Med_CC; filter_pneumovent;

filter_infectalgal; filter_ulcerpres; filter_MC

Discharged patients

Exceptional admission episodes

Surgical admission time

Complication-free long-term admissions

Readmissions

Short-term inappropriate admissions

Newborns

Vaginal deliveries

Unspecified surgical procedures

Medical drg’s complications

Which variables did we use to calculate these indicators?

RESULTSRESULTS

b) Establish a comparison between the different

areas of Portugal

a) Compare the numbers from 2000 to 2007

RESULTS

A) COMPARISON BETWEEN YEARSA) COMPARISON BETWEEN YEARSR

ESULTS

2000(%) 2001(%) 2002(%) 2003(%) 2004(%) 2005(%) 2006(%) 2007(%)

Exceptional admission episodes

Short-term episode 19,2 19,4 19,7 19,8 19,8 20,3 19,7 19,8

Long-term exceptional episode

2,4 2,1 1,9 1,7 1,6 1,5 1,5 1,5

Complication-free long-term admissions 1) 1,3 1,3 1,0 0,8 0,8 0,6 0,5 0,6

Readmissions 45,8 45,5 46,0 45,9 45,9 46,3 45,8 44,4

Newborns 1,04 1,08 1,15 1,15 1,08 1,06 1,04 1,02

Vaginal Delivery Complications free 75,5 76,4 71,3 74,8 73,9 76,7 72,9 73,5

With complications 24,5 23,6 28,7 25,2 26,1 23,3 27,1 26,5

Unspecified surgical procedures 13,4 12,6 12,3 13,0 12,6 12,4 11,7 11,8

Medical DRG’s complications 10,5 11,3 12,4 12,5 12,2 14,0 13,1 13,91)Calculated from a 1 % sample

2000 2001 2002 2003 2004 2005 2006 2007

1.04

1.08

1.15 1.15

1.081.06

1.041.02

Newborn's problems per cent

2000 2001 2002 2003 2004 2005 2006 2007

24,5%

23,6%

28,7%

25,2%

26,1%

23,3%

27,1%

26,5%

Variações de partos vaginais com complicações

2000 2001 2002 2003 2004 2005 2006 200710.5

11

11.5

12

12.5

13

13.5

14

Variation of Specified and Non-specified Surgical Procedures per year

Non-specified Surgical Procedures

Specified Surgical Procedures

Per

cen

t

2000 2001 2002 2003 2004 2005 2006 2007

10.5%

11.3%

12.4% 12.5%12.2%

14.0%

13.1%

13.9%

Variation of Medical DRG's with CC over the Years

B) COMPARISON BETWEEN NUTS IIB) COMPARISON BETWEEN NUTS IIR

ESULTS

1)Calculated from a 1 % sample

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

Alentejo (%) Algarve(%) Centro(%) Lisboa(%) Norte(%)

Exceptional admission episodes

Short-term episode 16,6 18,3 18,6 21,3 19,8

Long-term exceptional episode 2,1 2,4 1,7 1,9 1,6

Complication-free long-term admissions1) 0,8 1,4 0,9 0,9 0,8

Readmissions 78,6 77,6 75,3 76,7 75,3

Newborns 1,1 1,1 1,5 1,2 1,3

Vaginal Delivery Complications free 86,0 88,3 71,2 73,5 73,5

With complications 14,0 11,7 28,8 26,5 26,5

Unspecified surgical procedures 6,3 3,7 26,7 30,1 27,5

Medical DRG’s complications 4,4 3,2 26,6 29,5 29,9

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THANK YOU FOR YOUR ATTENTIONTHANK YOU FOR YOUR ATTENTION