A case-mix classification system for explaining healthcare costs using administrative data in Italy

BACKGROUND

The Italian National Health Service (NHS) provides universal coverage to all citizens, granting primary and hospital care with a copayment system for outpatient and drug services. Financing of Local Health Trusts (LHTs) is based on a capitation system adjusted only for age, gender and area of residence. We applied a risk-adjustment system (Johns Hopkins Adjusted Clinical Groups System, ACG® System) in order to explain health care costs using routinely collected administrative data in the Veneto Region (North-eastern Italy).

METHODS

All residents in the Veneto Region were included in the study. The ACG system was applied to classify the regional population based on the following information sources for the year 2015: Hospital Discharges, Emergency Room visits, Chronic disease registry for copayment exemptions, ambulatory visits, medications, the Home care database, and drug prescriptions. Simple linear regressions were used to contrast an age-gender model to models incorporating more comprehensive risk measures aimed at predicting health care costs.

RESULTS

A simple age-gender model explained only 8% of the variance of 2015 total costs. Adding diagnoses-related variables provided a 23% increase, while pharmacy based variables provided an additional 17% increase in explained variance. The adjusted R-squared of the comprehensive model was 6 times that of the simple age-gender model.

CONCLUSIONS

ACG System provides substantial improvement in predicting health care costs when compared to simple age-gender adjustments. Aging itself is not the main determinant of the increase of health care costs, which is better explained by the accumulation of chronic conditions and the resulting multimorbidity.

Mortality from infectious diseases in diabetes

BACKGROUND AND AIMS

To investigate the risk of mortality from infections by comparing the underlying causes of death versus the multiple causes of death in known diabetic subjects living in the Veneto region of Northern Italy.

METHODS AND RESULTS

A total of 185,341 subjects with diabetes aged 30-89 years were identified in the year 2010, and causes of death were assessed from 2010 to 2015. Standardized Mortality Ratios (SMRs) with 95% confidence intervals (CIs) were computed with regional mortality rates as reference. The underlying causes of death and all the diseases reported in the death certificates were scrutinized. At the end of the follow-up, 36,382 subjects had deceased. We observed an increased risk of death from infection-related causes in subjects with diabetes with a SMR of 1.83 (95% CI, 1.71-1.94). The SMR for death from septicemia was 1.91 (95% CI, 1.76-2.06) and from pneumonia was 1.47 (95% CI, 1.36-1.59). The use of the multiple causes of death approach emphasized the association of infectious diseases with mortality.

CONCLUSION

The results of the present study demonstrate an excess mortality due to infection-related diseases in patients with diabetes; more interestingly, by routine mortality analyses, the results show a possible underestimation of the effect of these diseases on mortality.

Excess mortality in 2015: a time series and cause-of-death analysis in Northern Italy

AIMS

To investigate the excess mortality registered in the Veneto Region (Northern Italy) in 2015.

METHODS

A Seasonal Autoregressive Integrated Moving Average Model was applied to predict overall mortality expected in 2014-2015 based on that observed in 2000-2013. The annual percent change in age-standardized rates (APC) was estimated for specific causes of death in 2007-2015.

RESULTS

Compared to 2014, the number of deaths and the overall age-standardized mortality increased in 2015 by 7.8 and 4.5%, respectively. When accounting for time trends, the observed mortality was lower than expected in 2014 (-4.5%) and slightly higher in 2015 (+1.1%). In 2015, mortality increased especially for causes with an already rising trend: neurologic/psychiatric (APC = 1.2; 95% Confidence Interval 0.3-2.0%) and infectious diseases (APC = 5.9; 3.6-8.2%).

CONCLUSIONS

Short-term changes and long-term trends in mortality must be interpreted within the frame of a rapid growth in the population of elderly subjects affected by multiple comorbidities.

Intensity of integrated cancer palliative care plans and end-of-life acute medical hospitalisation among cancer patient in Northern Italy

A high hospital utilisation at the end of life (EOL) is an indicator of suboptimal quality of health care. We evaluated the impact of the intensity of different Integrated Cancer Palliative Care (ICPC) plans on EOL acute medical hospitalisation among cancer decedents. Decedents of cancer aged 18-84 years, who were residents in two Italian regions, were investigated through integrated administrative data. Outcomes considered were prolonged hospital stay for medical reasons, 2+ hospitalisations during the last month of life and hospital death. The ICPC plans instituted 90 to 31 days before death represented the main exposure of interest. Other variables considered were gender, age class at death, marital status, recent hospitalisation and primary cancer site. Among 6,698 patients included in ICPC plans, 44.3% presented at least one critical outcome indicator; among these, 76.5% died in hospital, 60.3% had a prolonged (12+ days) medical hospitalisation, 19.1% had 2+ hospitalisations at the EOL. These outcomes showed a strong dose-response effect with the intensity of the ICPC plans, which is already evident at levels of moderate intensity. A well-ICPC approach can be very effective-beginning at low levels of intensity of care-in reducing the percentage of patients spending many days or dying in hospital.

Increase in Parkinson's disease-related mortality among males in Northern Italy

BACKGROUND

According to standard mortality statistics based on the underlying cause of death (UCOD), mortality from Parkinson's disease (PD) is increasing in most European countries. However, mortality trends are better investigated taking into account all the diseases reported in the death certificate (multiple causes of death approach, MCOD).

METHODS

All deaths of residents in the Veneto Region (Northern Italy) aged≥45 years with any mention of PD were extracted from 2008 to 2015. The Annual Percent Change (APC) in age-standardized mortality rates was computed both for PD as the UCOD, and by MCOD. The association with common chronic comorbidities and acute complications was investigated by log-binomial regression. The frequency of the mention of PD in death certificates was investigated through linkage with an archive of patients with a previous clinical diagnosis of the disease.

RESULTS

PD was reported in 2.1% of all deaths, rising from 1.9% in 2008 to 2.4% in 2015. Among males, age-standardized rates increased over time both in analyses based on the UCOD (APC +4.1%; Confidence Interval +1.5%,+6.7%), and on MCOD (APC +2.2%; +0.2,+4.2%). Among females time trends were not significant. Mention of PD was associated with that of dementia/Alzheimer and acute infectious diseases. Among known PD patients, the disease was reported only in 60.2% of death certificates.

CONCLUSIONS

Mortality associated to PD is steeply increasing among males in Northern Italy; further investigations on time trends for PD, both through all available electronic health archives and clinical studies, should be set as a priority for epidemiological research.

Growing burden of sepsis-related mortality in northeastern Italy: a multiple causes of death analysis

BACKGROUND

Few population-based data are available on mortality due to sepsis. The aim of the study was to estimate sepsis-related mortality rates and to assess the associated comorbidities.

METHODS

From multiple causes of death data (MCOD) of the Veneto Region (northeastern Italy), all deaths with sepsis mentioned anywhere in the death certificate were retrieved for the period 2008-2013. Among these deaths the prevalence of common chronic comorbidities was investigated, as well as the distribution of the underlying cause of death (UCOD), the single disease selected from all condition mentioned in the certificate and usually tabulated in mortality statistics. Age-standardized mortality rates were computed for sepsis selected as the UCOD, and for sepsis mentioned anywhere in the certificate.

RESULTS

Overall 16,906 sepsis-related deaths were tracked. Sepsis was mentioned in 6.3 % of all regional deaths, increasing from 4.9 in 2008 to 7.7 % in 2013. Sepsis was the UCOD in 0.6 % of total deaths in 2008, and in 1.6 % in 2013. Age-standardized mortality rates increased by 45 % for all sepsis-related deaths, and by 140 % for sepsis as the UCOD. Sepsis was often reported in the presence of chronic comorbidities, especially neoplasms, diabetes, circulatory diseases, and dementia. Respiratory tract and intra-abdominal infections were the most frequently associated sites of infection.

CONCLUSIONS

MCOD analyses provide an estimate of the burden of sepsis-related mortality. MCOD data suggest an increasing importance attributed to sepsis by certifying physicians, but also a real increase in mortality rates, thus confirming trends reported in some other countries by analyses of hospital discharge records.

Impact on colorectal cancer mortality of screening programmes based on the faecal immunochemical test

OBJECTIVE

Colorectal cancer (CRC) screening programmes based on the guaiac faecal occult blood test (gFOBT) reduce CRC-specific mortality. Several studies have shown higher sensitivity with the faecal immunochemical test (FIT) compared with gFOBT. We carried out an ecological study to evaluate the impact of FIT-based screening programmes on CRC mortality.

DESIGN

In the Veneto Region (Italy), biennial FIT-based screening programmes that invited 50-69-year-old residents were introduced in different areas between 2002 and 2009. We compared CRC mortality rates from 1995 to 2011 between the areas where screening started in 2002-2004 (early screening areas (ESA)) and areas that introduced the screening in 2008-2009 (late screening areas (LSA)) using Poisson regression models. We also compared available data on CRC incidence rates (1995-2007) and surgical resection rates (2001-2012).

RESULTS

Before the introduction of screening, CRC mortality and incidence rates in the two areas were similar. Compared with 1995-2000, 2006-2011 mortality rates were 22% lower in the ESA than in the LSA (rate ratio (RR)=0.78; 95% CI 0.68 to 0.89). The reduction was larger in women (RR=0.64; CI 0.51 to 0.80) than in men (RR=0.87; CI 0.73 to 1.04). In the ESA, incidence and surgery rates peaked during the introduction of the screening programme and then returned to the baseline (2006-2007 incidence) or dropped below initial values (surgery after 2007).

CONCLUSIONS

FIT-based screening programmes were associated with a significant reduction in CRC mortality. This effect took place much earlier than reported by gFOBT-based trials and observational studies.

Thyroid surgical practices shaping thyroid cancer incidence in North-Eastern Italy

AIM

To investigate the effects of changing surgical practices on thyroid cancer incidence in the Veneto Region (North-Eastern Italy).

METHODS

Hospital discharge records of the period 2000-2010 were analyzed to detect trends in thyroid surgery rates by type of surgery and diagnosis. The association between surgery rates for benign and malignant diseases across the 21 Local Health Units (LHUs) was assessed by Poisson regression. In a second step, clinical and pathological charts of the year 2010 were retrieved from the larger regional surgical center. The proportions of total and incidental papillary thyroid micro carcinoma (PTMC) were compared with historical data. Factors influencing an incidental diagnosis of PTMC were analyzed by logistic regression.

RESULTS

Among 26,000 procedures performed in the Region, there was an increase with time in the proportion of total thyroidectomies (from 67% to 78%) and surgeries with a diagnosis of thyroid cancer (from 17% to 28%). Cancer surgery rates across LHUs resulted associated to surgery rates for benign diseases (P<0.001). In the largest regional center, the proportion of PTMC increased from 35% to 56%, of whom almost 60% were incidental cases. The probability of finding an incidental PTMC was higher in total thyroidectomies than in other procedures (odds ratio=1.84, 95% confidence interval 1.08-3.14).

CONCLUSION

Data from the Veneto Region suggest that the increase in PTMC is due to several factors: increased preoperative diagnosis, total gland removal, extensive histological examination. Moreover, geographical variations in cancer incidence were associated to surgery rates for benign diseases.

Descriptive epidemiology of chronic liver disease in northeastern Italy: an analysis of multiple causes of death

Background

The analysis of multiple causes of death data has been applied in the United States to examine the population burden of chronic liver disease (CLD) and to assess time trends of alcohol-related and hepatitis C virus (HCV)-related CLD mortality. The aim of this study was to assess the mortality for CLD by etiology in the Veneto Region (northeastern Italy).

Methods

Using the 2008–2010 regional archive of mortality, all causes registered on death certificates were extracted and different descriptive epidemiological measures were computed for HCV-related, alcohol-related, and overall CLD-related mortality.

Results

The crude mortality rate of all CLD was close to 40 per 100,000 residents. In middle ages (35 to 74 years) CLD was mentioned in about 10% and 6% of all deaths in males and females, respectively. Etiology was unspecified in about half of CLD deaths. In females and males, respectively, HCV was mentioned in 44% and 21% and alcohol in 11% and 26% of overall CLD deaths. A bimodal distribution with age was observed for HCV-related proportional mortality among females, reflecting the available seroprevalence data.

Conclusions

Multiple causes of death analyses can provide useful insights into the burden of CLD mortality according to etiology among different population subgroups.

Mortality after esophageal and gastric cancer resection

BACKGROUND

Contrasting findings on trends and determinants of operative mortality after surgery for esophageal and gastric cancer have been reported from population-based studies.

METHODS

Discharge records of residents in the Veneto Region (northeastern Italy) with a diagnosis of esophageal or gastric cancer and intervention codes for esophagectomy or gastrectomy were extracted for the years 2000-2009. In-hospital, 30-day, 90-day, and perioperative (30-day + in-hospital) mortality were computed. The influence of patient and hospital variables on in-hospital mortality was assessed through multilevel models.

RESULTS

Overall, 6,500 resections were performed in the period of 2000-2009, with a 10 % decline in the second half of the study period. In-hospital mortality was 4.6 % (5.3 % in 2000-2004 and 3.8 % in 2005-2009) and was higher for extended total gastrectomy and total esophagectomy. In 2005-2009 mortality declined for all resection types except extended total gastrectomy (8.0 %). For esophageal procedures, 30-day mortality was lower than in-hospital or perioperative mortality. A protective effect of procedural volume was found for esophageal but not for gastric resections; among gastric procedures, mortality was higher in male patients and in extended total gastrectomy patients.

CONCLUSIONS

Analyses of discharge records allowed investigation at a population level of time trends (downward mainly for esophageal resections) and determinants of perioperative mortality (hospital volume, gender, and procedure type).

Increasing incidence and mortality of infective endocarditis: a population-based study through a record-linkage system

Background

Few population-based studies provide epidemiological data on infective endocarditis (IE). Aim of the study is to analyze incidence and outcomes of IE in the Veneto Region (North-Eastern Italy).

Methods

Residents with a first hospitalization for IE in 2000-2008 were extracted from discharge data and linked to mortality records to estimate 365-days survival. Etiology was retrieved in subsets of this cohort by discharge codes and by linkage to a microbiological database. Risk factors for mortality were assessed through logistic regression.

Results

1,863 subjects were hospitalized for IE, with a corresponding crude rate of 4.4 per 100,000 person-years, increasing from 4.1 in 2000-2002 to 4.9 in 2006-2008 (p = 0.003). Median age was 68 years; 39% of subjects were hospitalized in the three preceding months. 23% of patients underwent a cardiac valve procedure in the index admission or in the following year. Inhospital mortality was 14% (19% including hospital transfers); 90-days and 365-days mortality rose through the study years. Mortality increased with age and the Charlson comorbidity index, in subjects with previous hospitalizations for heart failure, and (in the subcohort with microbiological data) in IE due to Staphylococci (40% of IE).

Conclusions

The study demonstrates an increasing incidence and mortality for IE over the last decade. Analyses of electronic archives provide a region-wide picture of IE, overcoming referral biases affecting single clinic or multicentric studies, and therefore represent a first fundamental step to detect critical issues related to IE.

Population-based analyses of radical cystectomy and urinary diversion for bladder cancer in northern Italy

OBJECTIVE

•To provide updated figures on urinary diversion, length of stay and mortality after cystectomy in two regions of northern Italy.

PATIENTS AND METHODS

•Discharge records of patients undergoing cystectomy for bladder cancer in 2000-2008 were extracted from the regional archives of hospital discharges. •Data on partial vs radical cystectomy and type of urinary diversion were obtained from intervention codes. •The influence of demographic characteristics, year of intervention, presence of comorbidities and hospital cystectomy volume on the adoption of a continent diversion and on in-hospital mortality was assessed through multilevel models.

RESULTS

•The crude cystectomy rate was close to 10 per 100,000. •The share of partial cystectomies declined from 5.5% in 2000-2002 to 3.0% in 2006-2008. •A continent diversion was adopted in 35% of radical cystectomies, with higher rates in young male patients treated in high-volume hospitals. •Median length of stay declined from 20 days in 2000-2002 to 18 in 2006-2008; in-hospital mortality decreased from 3.2% to 2.2%.

CONCLUSION

•This first population-based report on cystectomies for bladder cancer from continental Europe evidences a limited role of partial cystectomy, a high proportion of continent diversion and a decreasing trend of length of stay and in-hospital mortality.

Peptide-peptoid hybrids based on (1-11)-parathyroid hormone analogs

A series of peptide-peptoid hybrids, containing N-substituted glycines, were synthesized based on the H-Aib-Val-Aib-Glu-Ile-Gln-Leu-Nle-His-Gln-Har-NH(2) (Har = Homoarginine) as the parent parathyroid hormone (1-11) analog. The compounds were pharmacologically characterized in their agonistic activity at the parathyroid hormone 1 receptor.

Quality of care in congestive heart failure in the elderly: epidemiological evidence of a gap between guidelines and clinical practice

BACKGROUND AND AIMS

This study aimed at evaluating the quality of care in elderly patients hospitalized for heart failure, compared with that received by subjects of younger age.

METHODS

A cross-sectional retrospective study was performed on hospitalized subjects for heart failure in the Veneto Region (4.5 million inhabitants), located in North-East Italy, for the year 2004. Through consultation of clinical charts, performance of echocardiography, and prescription of ACE-inhibitors and beta-blockers were evaluated in each patient. Multivariate statistical analysis was used to test the association between age and the end-points of interest: prescription of ACE-inhibitors or beta- blockers and performance of echocardiography.

RESULTS

The percentage of patients with prescriptions for ACE-inhibitors decreased with age, from 75% for patients under 65 years, to 62% for subjects over 84 years (p=0.02). A similar, but more marked, finding was observed for prescriptions of beta- blockers (56% in subjects aged <65 yrs vs 16% in those aged >84 yrs) (p<0.001). Evaluation of echocardiography was performed in 61% of subjects under 65 and in 22% in those over 84 (p<0.001). After statistical adjustment, age remained a significant predictor of prescription for beta-blockers and performance of echocardiography, but no longer for prescription of ACE-inhibitors.

CONCLUSIONS

Among the elderly, age was a negative predictor of beta-blocker prescription and echocardiographic evaluation, but did not affect prescriptions for ACE-inhibitors.

Fast determination of histamine in cheese by nuclear magnetic resonance (NMR)

A rapid and quantitative (1)H nuclear magnetic resonance (NMR) method was developed to analyze histamine in cheeses. The procedure is simple because the acid extract is analyzed directly, without any need for further filtration, derivatization, or other manipulation. This NMR method was demonstrated to be specific by 2D total correlation spectroscopy (TOCSY) and heteronuclear multiple-quantum coherence (HMQC) experiments and reliable in terms of linearity, accuracy, recovery, repeatability, and limits of detection (LOD). Good precision, with relative standard deviation (RSD) <4%, recovery of 100%, and a range of 0.6-1 mg/kg for the LOD were obtained. The NMR method was successfully applied to different types of cheese, ranging from soft to hard. No interference from free amino acids, proteins, and other natural components was detected. The NMR method could be transferred to other kinds of food.

Seat belt use among rear passengers: validity of self-reported versus observational measures

BACKGROUND

The effects of seat belt laws and public education campaigns on seat belt use are assessed on the basis of observational or self-reported data on seat belt use. Previous studies focusing on front seat occupants have shown that self-reports indicate a greater seat belt usage than observational findings. Whether this over-reporting in self reports applies to rear seat belt usage, and to what extent, have yet to be investigated. We aimed to evaluate the over-reporting factor for rear seat passengers and whether this varies by gender and under different compulsory seat belt use conditions.

METHODS

The study was conducted in the Veneto Region, an area in the North-East of Italy with a population of 4.7 million. The prevalence of seat belt use among rear seat passengers was determined by means of a cross-sectional self-report survey and an observational study. Both investigations were performed in two time periods: in 2003, when rear seat belt use was not enforced by primary legislation, and in 2005, after rear seat belt use had become compulsory (June 2003). Overall, 8138 observations and 7902 interviews were recorded. Gender differences in the prevalence of rear seat belt use were examined using the chi-square test. The over-reporting factor, defined as the ratio of the self-reported to the observed prevalence of rear seat belt use, was calculated by gender before and after the rear seat belt legislation came into effect.

RESULTS

Among rear seat passengers, self-reported rates were always higher than the observational findings, with an overall over-reporting factor of 1.4. We registered no statistically significant changes over time in the over-reporting factor, nor any major differences between genders.

CONCLUSION

Self-reported seat belt usage by rear passengers represents an efficient alternative to observational studies for tracking changes in actual behavior, although the reported figures need to be adjusted using an appropriate over-reporting factor in order to gain an idea of genuine seat belt use.

Diffusion of good practices of care and decline of the association with case volume: the example of breast conserving surgery

BACKGROUND

Several previous studies conducted on cancer registry data and hospital discharge records (HDR) have found an association between hospital volume and the recourse to breast conserving surgery (BCS) for breast cancer. The aim of the current study is to depict concurrent time trends in the recourse to BCS and its association with hospital volume.

METHODS

Admissions of breast cancer patients for BCS or mastectomy in the period 2000-2004 were identified from the discharge database of the Veneto Region (Italy). The role of procedural volume (low < 50, medium 50-100, high > 100 breast cancer surgeries/year), and of individual risk factors obtainable from HDR was assessed through a hierarchical log-binomial regression.

RESULTS

Overall, the recourse to BCS was higher in medium (risk ratio = 1.12, 95% confidence interval 1.07-1.18) and high-volume (1.09, 1.03-1.14) compared to low-volume hospitals. The proportion of patients treated in low-volume hospitals dropped from 22% to 12%, with a concurrent increase in the activity of medium-volume providers. The increase over time in breast conservation (globally from 56% to 67%) was steeper in the categories of low- and medium-volume hospitals with respect to high caseload.

CONCLUSION

The growth in the recourse to BCS was accompanied by a decline of the association with hospital volume; larger centers probably acted as early adopters of breast conservation strategies that subsequently spread to smaller providers.

Monitoring the occurrence of diabetes mellitus and its major complications: the combined use of different administrative databases

OBJECTIVE

Diabetes mellitus is a growing public health problem, for which efficient and timely surveillance is a key policy. Administrative databases offer relevant opportunities for this purpose. We aim to monitor the incidence of diabetes and its major complications using administrative data.

STUDY DESIGN AND METHODS

We study a population of about 850,000 inhabitants in the Veneto Region (Italy) from the end of year 2001 to the end of year 2004. We use four administrative databases with record linkage. Databases of drug prescriptions and of exemptions from medical charge were linked to identify diabetic subjects; hospital discharge records and mortality data were used for the assessment of macrovascular and renal complications and vital status.

RESULTS

We identified 30,230 and 34,620 diabetic subjects at the start and at the end of the study respectively. The row prevalence increased from 38.3/1000 (95% CI 37.2-39.5) to 43.2/1000 (95% CI 42.3-44) for males and from 34.7/1000 (95% CI 33.9-35.5) to 38.1/1000 (95% CI 37.4-39) for females. The mean row incidence is 5.3/1000 (95% CI 5-5.6) person years for males and 4.8/1000 (95% CI 4.4-5.2) person years for females. The rate of hospitalisations for cardiovascular or kidney diseases is greatly increased in diabetic people with respect to non diabetics for both genders. The mortality relative risk is particularly important in younger age classes: diabetic males and females aged 45-64 years present relative risk for death of 1.7 (95% CI 1.58-1.88) and 2.6 (95% CI 2.29-2.97) respectively.

CONCLUSION

This study provides a feasible and efficient method to determine and monitor the incidence and prevalence of diabetes and the occurrence of its complications along with indexes of morbidity and mortality.