Health care performance comparison using a disease-based approach: the EuroHOPE project

DM management in HIV patients: the adoption of population health management to transform the chronic management of HIV

BACKGROUND

The success of antiretroviral therapies has made human immunodeficiency virus (HIV) a chronic disease, changing the care scenario dramatically. This study aimed to measure adherence to diabetes mellitus standards of care provided for people living with HIV (PLWH). Diabetes represents a paradigmatic case for tackling chronic care management in this target group.

METHODS

This retrospective observational study was performed on administrative health data retrieved from 2014 to 2016, with a validated algorithm to identify patients with HIV using: (i) hospital discharge records (ICD9-CM codes); (ii) drug dispensing records (with ATC codes); and (iii) disease-specific exemptions from co-payments for healthcare services. HIV-related treatments, comorbidities and health service utilization were measured, as was adherence to clinical guidelines-recommended standards of care for diabetes.

RESULTS

A population of 738 cases were identified in two Local Health Authorities in Italy, representing a prevalence of 0.14% of the general population, in line with the expected prevalence. Thirty-one cases of HIV patients diagnosed with diabetes were identified, a prevalence ratio of 4.2% compared to the 8% in the overall population. Adherence to diabetes standards of care tested within the same population was low, with the exception of those tests commonly administered for standard HIV follow-up care.

CONCLUSIONS

The use of administrative data, combined with a Population Health Management approach represents a powerful tool for evaluating system capacity to manage HIV comorbidities. Study findings prove that it is time to design new care models for PLWH, affected by one or more chronic conditions, both to prevent their onset and to manage their comorbidities.

Differences in health outcomes for high-need high-cost patients across high-income countries

OBJECTIVE

This study explores variations in outcomes of care for two types of patient personas-an older frail person recovering from a hip fracture and a multimorbid older patient with congestive heart failure (CHF) and diabetes.

DATA SOURCES

We used individual-level patient data from 11 health systems.

STUDY DESIGN

We compared inpatient mortality, mortality, and readmission rates at 30, 90, and 365 days. For the hip fracture persona, we also calculated time to surgery. Outcomes were standardized by age and sex.

DATA COLLECTION/EXTRACTION METHODS

Data was compiled by the International Collaborative on Costs, Outcomes and Needs in Care across 11 countries for the years 2016-2017 (or nearest): Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

PRINCIPAL FINDINGS

The hip sample across ranged from 1859 patients in Aragon, Spain, to 42,849 in France. Mean age ranged from 81.2 in Switzerland to 84.7 in Australia, and the majority of hip patients across countries were female. The congestive heart failure (CHF) sample ranged from 742 patients in England to 21,803 in the United States. Mean age ranged from 77.2 in the United States to 80.3 in Sweden, and the majority of CHF patients were males. Average in-hospital mortality across countries was 4.1%. for the hip persona and 6.3% for the CHF persona. At the year mark, the mean mortality across all countries was 25.3% for the hip persona and 32.7% for CHF persona. Across both patient types, England reported the highest mortality at 1 year followed by the United States. Readmission rates for all periods were higher for the CHF persona than the hip persona. At 30 days, the average readmission rate for the hip persona was 13.8% and 27.6% for the CHF persona.

CONCLUSION

Across 11 countries, there are meaningful differences in health system outcomes for two types of patients.

A methodology for identifying high-need, high-cost patient personas for international comparisons

OBJECTIVE

To establish a methodological approach to compare two high-need, high-cost (HNHC) patient personas internationally.

DATA SOURCES

Linked individual-level administrative data from the inpatient and outpatient sectors compiled by the International Collaborative on Costs, Outcomes, and Needs in Care (ICCONIC) across 11 countries: Australia, Canada, England, France, Germany, the Netherlands, New Zealand, Spain, Sweden, Switzerland, and the United States.

STUDY DESIGN

We outline a methodological approach to identify HNHC patient types for international comparisons that reflect complex, priority populations defined by the National Academy of Medicine. We define two patient profiles using accessible patient-level datasets linked across different domains of care-hospital care, primary care, outpatient specialty care, post-acute rehabilitative care, long-term care, home-health care, and outpatient drugs. The personas include a frail older adult with a hip fracture with subsequent hip replacement and an older person with complex multimorbidity, including heart failure and diabetes. We demonstrate their comparability by examining the characteristics and clinical diagnoses captured across countries.

DATA COLLECTION/EXTRACTION METHODS

Data collected by ICCONIC partners.

PRINCIPAL FINDINGS

Across 11 countries, the identification of HNHC patient personas was feasible to examine variations in healthcare utilization, spending, and patient outcomes. The ability of countries to examine linked, individual-level data varied, with the Netherlands, Canada, and Germany able to comprehensively examine care across all seven domains, whereas other countries such as England, Switzerland, and New Zealand were more limited. All countries were able to identify a hip fracture persona and a heart failure persona. Patient characteristics were reassuringly similar across countries.

CONCLUSION

Although there are cross-country differences in the availability and structure of data sources, countries had the ability to effectively identify comparable HNHC personas for international study. This work serves as the methodological paper for six accompanying papers examining differences in spending, utilization, and outcomes for these personas across countries.

Variations in hip fracture inpatient care in Japan, Korea, and Taiwan: an analysis of health administrative data

BACKGROUND

Little is known about hip fracture inpatient care in East Asia. This study examined the characteristics of patients, hospitals, and regions associated with delivery of hip fracture surgeries across Japan, Korea, and Taiwan. We also analyzed and compared how the resource use and a short-term outcome of the care in index hospitals varied according to factors in the respective health systems.

METHODS

We developed comparable, nationwide, individual-level health insurance claims datasets linked with hospital- and regional-level statistics across the health systems using common protocols. Generalized linear multi-level analyses were conducted on length of stay (LOS) and total cost of index hospitalization as well as inpatient death.

RESULTS

The majority of patients were female and aged 75 or older. The standardized LOS of the hospitalization for hip fracture surgery was 32.5 (S.D. = 18.7) days in Japan, 24.7 (S.D. = 12.4) days in Korea, and 7.1 (S.D. = 2.9) days in Taiwan. The total cost per admission also widely varied across the systems. Hospitals with a high volume of hip fracture surgeries had a lower LOS across all three systems, while other factors associated with LOS and total cost varied across countries.

CONCLUSION

There were wide variations in resource use for hip fracture surgery in the index hospital within and across the three health systems with similar social health insurance schemes in East Asia. Further investigations into the large variations are necessary, along with efforts to overcome the methodological challenges of international comparisons of health system performance.

Does rehabilitation setting influence risk of institutionalization? A register-based study of hip fracture patients in Oslo, Norway

Background

Reducing the economic impact of hip fractures (HF) is a global issue. Some efforts aimed at curtailing costs associated with HF include rehabilitating patients within primary care. Little, however, is known about how different rehabilitation settings within primary care influence patients’ subsequent risk of institutionalization for long-term care (LTC). This study examines the association between rehabilitation setting (outside an institution versus short-term rehabilitation stay in an institution, both during 30 days post-discharge for HF) and risk of institutionalization in a nursing home (at 6–12 months from the index admission).

Methods

Data were for 612 HF incidents across 611 patients aged 50 years and older, who were hospitalized between 2008 and 2013 in Oslo, Norway, and who lived at home prior to the incidence. We used logistic regression to examine the effect of rehabilitation setting on risk of institutionalization, and adjusted for patients’ age, gender, health characteristics, functional level, use of healthcare services, and socioeconomic characteristics. The models also included fixed-effects for Oslo’s boroughs to control for supply-side and unobserved effects.

Results

The sample of HF patients had a mean age of 82.4 years, and 78.9 % were women. Within 30 days after hospital discharge, 49.0 % of patients received rehabilitation outside an institution, while the remaining 51.0 % received a short-term rehabilitation stay in an institution. Receiving rehabilitation outside an institution was associated with a 58 % lower odds (OR = 0.42, 95 % CI = 0.23–0.76) of living in a nursing home at 6–12 months after the index admission. The patients who were admitted to a nursing home for LTC were older, more dependent on help with their memory, and had a substantially greater increase in the use of municipal healthcare services after the HF.

Conclusions

The setting in which HF patients receive rehabilitation is associated with their likelihood of institutionalization. In the current study, patients who received rehabilitation outside of an institution were less likely to be admitted to a nursing home for LTC, compared to those who received a short-term rehabilitation stay in an institution. These results suggest that providing rehabilitation at home may be favorable in terms of reducing risk of institutionalization for HF patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06703-x.

Health related quality of life and satisfaction with care of stroke patients in Budapest: A substudy of the EuroHOPE project

BACKGROUND

Disadvantaged socioeconomic status is associated with higher stroke incidence and mortality, and higher readmission rate. We aimed to assess the effect of socioeconomic factors on case fatality, health related quality of life (HRQoL), and satisfaction with care of stroke survivors in the framework of the European Health Care Outcomes, Performance and Efficiency (EuroHOPE) study in Hungary, one of the leading countries regarding stroke mortality.

METHODS

We evaluated 200 consecutive patients admitted for first-ever ischemic stroke in a single center and performed a follow-up at 3 months after stroke. We recorded pre- and post-stroke socioeconomic factors, and assessed case fatality, HRQoL and patient satisfaction with the care received. Stroke severity at onset was scored by the National Institutes of Health Stroke scale (NIHSS), disability at discharge from acute care was evaluated by the modified Rankin Score (mRS). To evaluate HRQoL and patient satisfaction with care we used the EQ-5D-5L, 15D and EORTC IN PATSAT 32 questionnaires.

RESULTS

At 3 months after stroke the odds of death was significantly increased by stroke severity (NIHSS, OR = 1.209, 95%CI: 1.125-1.299, p<0.001) and age (OR = 1.045, 95%CI: 1.003-1.089, p = 0.038). In a multiple linear regression model, independent predictors of HRQoL were age, disability at discharge, satisfaction with care, type of social dwelling after stroke, length of acute hospital stay and rehospitalization. Satisfaction with care was influenced negatively by stroke severity (Coef. = -1.111, 95%C.I.: -2.159- -0.062, p = 0.040), and positively by having had thrombolysis (Coef. = 25.635, 95%C.I.: 5.212-46.058, p = 0.016) and better HRQoL (Coef. = 22.858, 95%C.I.: 6.007-39.708, p = 0.009).

CONCLUSION

In addition to age, disability, and satisfaction with care, length of hospital stay and type of social dwelling after stroke also predicted HRQoL. Long-term outcome after stroke could be improved by reducing time spent in hospital, i.e. by developing home care rehabilitation facilities thus reducing the need for readmission to inpatient care.

A performance comparison of patient pathways in Nordic capital areas – a pilot study for ischaemic stroke patients

Aims: This article describes and discusses the extension of performance measurement using an episode-based approach so that the measurement includes primary care, and social and long-term-care services. By using data on incident stroke patients from the capital areas of four Nordic countries, this pilot study: (a) extended the disease-based performance analysis to include new indicators that better describe patient care pathways at different levels of care; (b) described and compared the performance of care given in the four areas; (c) evaluated how additional information changed the rankings of performance between the areas; and (d) described the trends in performance in the capital areas. Methods: The construction of data was based on a common protocol that used routinely collected national registers and statistics linked with local municipal registers. We created new variables describing the timing of discharge to home and institutionalisation, as well as describing the use and cost of primary and social hospital services. Risk adjustment was performed with four different sets of confounders. Results: Differences existed in various performance indicators between the four metropolitan areas. The ranking was sensitive to the risk-adjustment method. The study showed that for stroke patients a performance comparison with data that are only from secondary and tertiary care, and without a valid severity measure, is not sufficient for international comparisons. Conclusions: Extending and deepening international performance analysis in order to cover patient pathways, including primary care and social services, is very useful for benchmarking activities when focusing on diseases affecting older people.

Assessing data protection and governance in health information systems: a novel methodology of Privacy and Ethics Impact and Performance Assessment (PEIPA)

BACKGROUND

Data processing of health research databases often requires a Data Protection Impact Assessment to evaluate the severity of the risk and the appropriateness of measures taken to comply with the European Union (EU) General Data Protection Regulation (GDPR). We aimed to define and apply a comprehensive method for the evaluation of privacy, data governance and ethics among research networks involved in the EU Project Bridge Health.

METHODS

Computerised survey among associated partners of main EU Consortia, using a targeted instrument designed by the principal investigator and progressively refined in collaboration with an international advisory panel. Descriptive measures using the percentage of adoption of privacy, data governance and ethical principles as main endpoints were used for the analysis and interpretation of the results.

RESULTS

A total of 15 centres provided relevant information on the processing of sensitive data from 10 European countries. Major areas of concern were noted for: data linkage (median, range of adoption: 45%, 30%-80%), access and accuracy of personal data (50%, 0%-100%) and anonymisation procedures (56%, 11%-100%). A high variability was noted in the application of privacy principles.

CONCLUSIONS

A comprehensive methodology of Privacy and Ethics Impact and Performance Assessment was successfully applied at international level. The method can help implementing the GDPR and expanding the scope of Data Protection Impact Assessment, so that the public benefit of the secondary use of health data could be well balanced with the respect of personal privacy.

A scoping review of core outcome sets and their 'mapping' onto real-world data using prostate cancer as a case study

Background

A Core Outcomes Set (COS) is an agreed minimum set of outcomes that should be reported in all clinical studies related to a specific condition. Using prostate cancer as a case study, we identified, summarized, and critically appraised published COS development studies and assessed the degree of overlap between them and selected real-world data (RWD) sources.

Methods

We conducted a scoping review of the Core Outcome Measures in Effectiveness Trials (COMET) Initiative database to identify all COS studies developed for prostate cancer. Several characteristics (i.e., study type, methods for consensus, type of participants, outcomes included in COS and corresponding measurement instruments, timing, and sources) were extracted from the studies; outcomes were classified according to a predefined 38-item taxonomy. The study methodology was assessed based on the recent COS-STAndards for Development (COS-STAD) recommendations. A ‘mapping’ exercise was conducted between the COS identified and RWD routinely collected in selected European countries.

Results

Eleven COS development studies published between 1995 and 2017 were retrieved, of which 8 were classified as ‘COS for clinical trials and clinical research’, 2 as ‘COS for practice’ and 1 as ‘COS patient reported outcomes’. Recommended outcomes were mainly categorized into ‘mortality and survival’ (17%), ‘outcomes related to neoplasm’ (18%), and ‘renal and urinary outcomes’ (13%) with no relevant differences among COS study types. The studies generally fulfilled the criteria for the COS-STAD ‘scope specification’ domain but not the ‘stakeholders involved’ and ‘consensus process’ domains. About 72% overlap existed between COS and linked administrative data sources, with important gaps. Linking with patient registries improved coverage (85%), but was sometimes limited to smaller follow-up patient groups.

Conclusions

This scoping review identified few COS development studies in prostate cancer, some quite dated and with a growing level of methodological quality over time. This study revealed promising overlap between COS and RWD sources, though with important limitations; linking established, national patient registries to administrative data provide the best means to additionally capture patient-reported and some clinical outcomes over time. Thus, increasing the combination of different data sources and the interoperability of systems to follow larger patient groups in RWD is required.

Multi-level models for heart failure patients' 30-day mortality and readmission rates: the relation between patient and hospital factors in administrative data

Background

This study aims at gathering evidence about the relation between 30-day mortality and 30-day unplanned readmission and patient and hospital factors. By definition, we refer to 30-day mortality and 30-day unplanned readmission as the number of deaths and non-programmed hospitalizations for any cause within 30 days after the incident heart failure (HF). In particular, the focus is on the role played by hospital-level factors.

Methods

A multi-level logistic model that combines patient- and hospital-level covariates has been developed to better disentangle the role played by the two groups of covariates. Later on, hospital outliers in term of better-than-expected/worst-than-expected performers have been identified by comparing expected cases vs. observed cases. Hospitals performance in terms of 30-day mortality and 30-day unplanned readmission rates have been visualized through the creation of funnel plots. Covariates have been selected coherently to past literature. Data comes from the hospital discharge forms for Heart Failure patients in the Lombardy Region (Northern Italy). Considering incident cases for HF in the timespan 2010–2012, 78,907 records for adult patients from 117 hospitals have been collected after quality checks.

Results

Our results show that 30-day mortality and 30-day unplanned readmissions are explained by hospital-level covariates, paving the way for the design and implementation of evidence-based improvement strategies. While the percentage of surgical DRG (OR = 1.001; CI (1.000–1.002)) and the hospital type of structure (Research hospitals vs. non-research public hospitals (OR = 0.62; CI (0.48–0.80)) and Non-research private hospitals vs. non-research hospitals OR = 0.75; CI (0.63–0.90)) are significant for mortality, the mean length of stay (OR = 0.96; CI (0.95–0.98)) is significant for unplanned readmission, showing that mortality and readmission rates might be improved through different strategies.

Conclusion

Our results confirm that hospital-level covariates do affect quality of care, and that 30-day mortality and 30-day unplanned readmission are affected by different managerial choices. This confirms that hospitals should be accountable for their “added value” to quality of care.

Comparisons of readmissions and mortality based on post-discharge ambulatory follow-up services received by stroke patients discharged home: a register-based study

BACKGROUND

Few studies have focused on post-discharge ambulatory care for stroke patients and subsequent differences in readmission and mortality rates. Identifying groups at higher risk according to services received is important when planning post-discharge follow-up in ambulatory care. According to a recent Whitepaper by the Norwegian Government, patients receiving ambulatory care should have follow-up with a general practitioner (GP) within 14 days of hospital discharge.

METHODS

All home discharged stroke cases occurring in Oslo from 2009 to 2014 were included. 90- and 365-day all-cause readmissions and mortality were compared separately for patients categorized based on services received (no services, home nursing, ambulatory rehabilitation and home nursing with ambulatory rehabilitation) and early GP follow-up within 14 days following discharge. Variables used to adjust for differences in health status and demographics at admission included inpatient days and comorbidities the year prior to admission, calendar year, sex, age, income, education and functional score. Cox regression reporting hazard ratios (HR) was used.

RESULTS

There were no significant differences in readmission rates for early GP follow-up. Patients receiving home nursing and/or rehabilitation had higher unadjusted 90- and 365-day readmission rates than those without services (HR from 1.87 to 2.63 depending on analysis, p < 0.001), but the 90-day differences disappeared after risk adjustment, except for patients receiving only rehabilitation. There were no significant differences in mortality rates according to GP follow-up after risk adjustment. Patients receiving rehabilitation had higher mortality than those without services, even after adjustment (HR from 2.20 to 2.69, p < 0.001), whereas the mortality of patients receiving only home nursing did not differ from those without services.

CONCLUSIONS

Our results indicate that the observed differences in unadjusted readmission and mortality rates according to GP follow-up and home nursing were largely due to differences in health status at admission, likely unrelated to the stroke. On the other hand, mortality for patients receiving ambulatory rehabilitation was twice as high compared to those without, even after adjustment and irrespective of also receiving home nursing. Hence, assessing the needs of these patients during discharge planning and providing careful follow-up after discharge seems important.

Headline indicators for monitoring the performance of health systems: findings from the european Health Systems_Indicator (euHS_I) survey

Background

Cross-country comparisons of health system performance have become increasingly important. Clear evidence is needed on the prioritization of health system performance assessment (HSPA) indicators. Selected “leading” or “headline” HSPA indicators may provide early warnings of policy impacts. The goal of this paper is to propose a set of headline indicators to frame and describe health system performance.

Methods

We identified overlaps and gaps in the availability of reported indicators by looking at HSPA initiatives in Member States (MSs) of the European Union (EU), the European Commission as well as international institutions (e.g. OECD, WHO-EUR). On that basis, we conducted a two-stage online survey, the european Health System_Indicator (euHS_I) survey. The survey sought to elicit preferences from a wide range of HSPA experts on i) the most relevant HSPA domain(s), i.e. access, efficiency, quality of care, equity, for a specific indicator, and ii) the importance of indicators regarding their information content, i.e. headline, operational, explanatory. Frequency analysis was performed.

Results

We identified 2168 health and health system indicators listed in 43 relevant initiatives. After adjusting for overlaps, a total of 361 indicators were assessed by 28 experts in the 1st stage of the survey. In the 2nd stage, a more balanced set of 95 indicators was constructed and assessed by 72 experts from 22 EU MSs and 3 non-EU countries. In the domain access experts assessed share of population covered by health insurance as the top headline indicator. In the domain efficiency, the highest rank was given to Total health care expenditure by all financing agents, and in the domain quality of care to rate of hospital-acquired infections. Percentage of households experiencing high levels/catastrophic of out-of-pocket health expenditures results as the top headline indicator for domain equity.

Conclusions

HSPA indicators from different initiatives largely overlap and public health indicators dominate over health systems aspects. The survey allowed to quantify overlaps and gaps in HSPA indicators, their expert allocation to domain areas and establishment of an informed hierarchy structure. Yet, results show that more multidisciplinary work is needed to ensure the availability of accurate efficiency indicators which are comparable across countries.

Electronic supplementary material

The online version of this article (10.1186/s13690-018-0278-0) contains supplementary material, which is available to authorized users.

Implementation Research to Address the United States Health Disadvantage: Report of a National Heart, Lung, and Blood Institute Workshop

Four decades ago, U.S. life expectancy was within the same range as other high-income peer countries. However, during the past decades, the United States has fared worse in many key health domains resulting in shorter life expectancy and poorer health-a health disadvantage. The National Heart, Lung, and Blood Institute convened a panel of national and international health experts and stakeholders for a Think Tank meeting to explore the U.S. health disadvantage and to seek specific recommendations for implementation research opportunities for heart, lung, blood, and sleep disorders. Recommendations for National Heart, Lung, and Blood Institute consideration were made in several areas including understanding the drivers of the disadvantage, identifying potential solutions, creating strategic partnerships with common goals, and finally enhancing and fostering a research workforce for implementation research. Key recommendations included exploring why the United States is doing better for health indicators in a few areas compared with peer countries; targeting populations across the entire socioeconomic spectrum with interventions at all levels in order to prevent missing a substantial proportion of the disadvantage; assuring partnership have high-level goals that can create systemic change through collective impact; and finally, increasing opportunities for implementation research training to meet the current needs. Connecting with the research community at large and building on ongoing research efforts will be an important strategy. Broad partnerships and collaboration across the social, political, economic, and private sectors and all civil society will be critical-not only for implementation research but also for implementing the findings to have the desired population impact. Developing the relevant knowledge to tackle the U.S. health disadvantage is the necessary first step to improve U.S. health outcomes.

Unraveling the drivers of regional variation in healthcare spending by analyzing prevalent chronic diseases

Background

To indicate inefficiencies in health systems, previous studies examined regional variation in healthcare spending by analyzing the entire population. As a result, population heterogeneity is taken into account to a limited extent only. Furthermore, it clouds a detailed interpretation which could be used to inform regional budget allocation decisions to improve quality of care of one chronic disease over another. Therefore, we aimed to gain insight into the drivers of regional variation in healthcare spending by studying prevalent chronic diseases.

Methods

We used 2012 secondary health survey data linked with claims data, healthcare supply data and demographics at the individual level for 18 Dutch regions. We studied patients with diabetes (n = 10,767) and depression (n = 3,735), in addition to the general population (n = 44,694). For all samples, we estimated the cross-sectional relationship between spending, supply and demand variables and region effects using linear mixed models.

Results

Regions with above (below) average spending for the general population mostly showed above (below) average spending for diabetes and depression as well. Less than 1% of the a-priori total variation in spending was attributed to the regions. For all samples, we found that individual-level demand variables explained 62-63% of the total variance. Self-reported health status was the most prominent predictor (28%) of healthcare spending. Supply variables also explained, although a small part, of regional variation in spending in the general population and depression. Demand variables explained nearly 100% of regional variation in spending for depression and 88% for diabetes, leaving 12% of the regional variation left unexplained indicating differences between regions due to inefficiencies.

Conclusions

The extent to which regional variation in healthcare spending can be considered as inefficiency may differ between regions and disease-groups. Therefore, analyzing chronic diseases, in addition to the traditional approach where the general population is studied, provides more insight into the causes of regional variation in healthcare spending, and identifies potential areas for efficiency improvement and budget allocation decisions.

Electronic supplementary material

The online version of this article (10.1186/s12913-018-3128-4) contains supplementary material, which is available to authorized users.

Cost-utility of First-line Disease-modifying Treatments for Relapsing-Remitting Multiple Sclerosis

PURPOSE

This study evaluated the cost-effectiveness of first-line treatments of relapsing-remitting multiple sclerosis (RRMS) (dimethyl fumarate [DMF] 240 mg PO BID, teriflunomide 14 mg once daily, glatiramer acetate 20 mg SC once daily, interferon [IFN]-β1a 44 µg TIW, IFN-β1b 250 µg EOD, and IFN-β1a 30 µg IM QW) and best supportive care (BSC) in the health care payer setting in Finland.

METHODS

The primary outcome was the modeled incremental cost-effectiveness ratio (ICER; €/quality-adjusted life-year [QALY] gained, 3%/y discounting). Markov cohort modeling with a 15-year time horizon was employed. During each 1-year modeling cycle, patients either maintained the Expanded Disability Status Scale (EDSS) score or experienced progression, developed secondary progressive MS (SPMS) or showed EDSS progression in SPMS, experienced relapse with/without hospitalization, experienced an adverse event (AE), or died. Patients׳ characteristics, RRMS progression probabilities, and standardized mortality ratios were derived from a registry of patients with MS in Finland. A mixed-treatment comparison (MTC) informed the treatment effects. Finnish EuroQol Five-Dimensional Questionnaire, Three-Level Version quality-of-life and direct-cost estimates associated with EDSS scores, relapses, and AEs were applied. Four approaches were used to assess the outcomes: cost-effectiveness plane and efficiency frontiers (relative value of efficient treatments); cost-effectiveness acceptability frontier, which demonstrated optimal treatment to maximize net benefit; Bayesian treatment ranking (BTR); and an impact investment assessment (IIA; a cost-benefit assessment), which increased the clinical interpretation and appeal of modeled outcomes in terms of absolute benefit gained with fixed drug-related budget. Robustness of results was tested extensively with sensitivity analyses.

FINDINGS

Based on the modeled results, teriflunomide was less costly, with greater QALYs, versus glatiramer acetate and the IFNs. Teriflunomide had the lowest ICER (24,081) versus BSC. DMF brought marginally more QALYs (0.089) than did teriflunomide, with greater costs over the 15 years. The ICER for DMF versus teriflunomide was 75,431. Teriflunomide had >50% cost-effectiveness probabilities with a willingness-to-pay threshold of <€77,416/QALY gained. According to BTR, teriflunomide was first-best among the disease-modifying therapies, with potential willingness-to-pay thresholds of up to €68,000/QALY gained. In the IIA, teriflunomide was associated with the longest incremental quality-adjusted survival and time without cane use. Generally, primary outcomes results were robust, based on the sensitivity analyses. The results were sensitive only to large changes in analysis perspective or mixed-treatment comparison.

IMPLICATIONS

The results were sensitive only to large changes in analysis perspective or MTC. Based on the analyses, teriflunomide was cost-effective versus BSC or DMF with the common threshold values, was dominant versus other first-line RRMS treatments, and provided the greatest impact on investment. Teriflunomide is potentially the most cost-effective option among first-line treatments of RRMS in Finland.

Applying spatio-temporal models to assess variations across health care areas and regions: Lessons from the decentralized Spanish National Health System

OBJECTIVE

To illustrate the ability of hierarchical Bayesian spatio-temporal models in capturing different geo-temporal structures in order to explain hospital risk variations using three different conditions: Percutaneous Coronary Intervention (PCI), Colectomy in Colorectal Cancer (CCC) and Chronic Obstructive Pulmonary Disease (COPD).

RESEARCH DESIGN

This is an observational population-based spatio-temporal study, from 2002 to 2013, with a two-level geographical structure, Autonomous Communities (AC) and Health Care Areas (HA).

SETTING

The Spanish National Health System, a quasi-federal structure with 17 regional governments (AC) with full responsibility in planning and financing, and 203 HA providing hospital and primary care to a defined population.

METHODS

A poisson-log normal mixed model in the Bayesian framework was fitted using the INLA efficient estimation procedure.

MEASURES

The spatio-temporal hospitalization relative risks, the evolution of their variation, and the relative contribution (fraction of variation) of each of the model components (AC, HA, year and interaction AC-year).

RESULTS

Following PCI-CCC-CODP order, the three conditions show differences in the initial hospitalization rates (from 4 to 21 per 10,000 person-years) and in their trends (upward, inverted V shape, downward). Most of the risk variation is captured by phenomena occurring at the HA level (fraction variance: 51.6, 54.7 and 56.9%). At AC level, the risk of PCI hospitalization follow a heterogeneous ascending dynamic (interaction AC-year: 17.7%), whereas in COPD the AC role is more homogenous and important (37%).

CONCLUSIONS

In a system where the decisions loci are differentiated, the spatio-temporal modeling allows to assess the dynamic relative role of different levels of decision and their influence on health outcomes.

Linking Swedish health data registers to establish a research database and a shared decision-making tool in hip replacement

BACKGROUND

Sweden offers a unique opportunity to researchers to construct comprehensive databases that encompass a wide variety of healthcare related data. Statistics Sweden and the National Board of Health and Welfare collect individual level data for all Swedish residents that ranges from medical diagnoses to socioeconomic information. In addition to the information collected by governmental agencies the medical profession has initiated nationwide Quality Registers that collect data on specific diagnoses and interventions. The Quality Registers analyze activity within healthcare institutions, with the aims of improving clinical care and fostering clinical research.

MAIN BODY

The Swedish Hip Arthroplasty Register (SHAR) has been collecting data since 1979. Joint replacement in general and hip replacement in particular is considered a success story with low mortality and complication rate. It is credited to the pioneering work of the SHAR that the revision rate following hip replacement surgery in Sweden is amongst the lowest in the world. This has been accomplished by the diligent follow-up of patients with feedback of outcomes to the providers of the healthcare along with post market surveillance of individual implant performance. During its existence SHAR has experienced a constant organic growth. One major development was the introduction of the Patient Reported Outcome Measures program, giving a voice to the patients in healthcare performance evaluation. The next aim for SHAR is to integrate patients' wishes and expectations with the surgeons' expertise in the form of a Shared Decision-Making (SDM) instrument. The first step in building such an instrument is to assemble the necessary data. This involves linking the SHARs database with the two aforementioned governmental agencies. The linkage is done by the 10-digit personal identity number assigned at birth (or immigration) for every Swedish resident. The anonymized data is stored on encrypted serves and can only be accessed after double identification.

CONCLUSION

This data will serve as starting point for several research projects and clinical improvement work.

Productivity benchmarks for operative service units

BACKGROUND

Easily accessible reliable information is crucial for strategic and tactical decision-making on operative processes. We report development of an analysis tool and resulting metrics for benchmarking purposes at a Finnish university hospital.

METHODS

The analysis tool is based on data collected in a resource management system and an in-house cost-reporting database.

RESULTS

The exercise reports key metrics for four operative service units and six surgical units from 2014 and the change from year 2013. Productivity, measured as total costs per total hours, ranged from 658 to 957 €/h and utilization of the total available resource hours at the service unit level ranged from 66% to 74%. The lowest costs were in a unit running only regular working hour shifts, whereas the highest costs were in a unit operating on 24/7 basis. The tool includes additional metrics on operating room (OR) scheduling and monthly data to support more detailed analysis.

CONCLUSION

This report provides the hospital management with an improved and detailed overview of its operative service units and the surgical process and related costs. The operating costs are associated with on call duties, size of operative service units, and the requirements of the surgeries. This information aids in making mid- to long range decisions on managing OR capacity.

Risk adjustment in measurements of predicted mortality after myocardial infarction

BACKGROUND

In 2014, the government introduced elements of quality-based funding (pay-for-performance) for the hospital sector. Survival is included as a quality indicator. If such quality indicators are to be used for funding purposes, it must be established that the observed variations are caused by conditions that the hospital trusts are able to influence, and not by any underlying variables. The objective of this study was to investigate how the predicted mortality after myocardial infarction was influenced by various forms of risk adjustment.

MATERIAL AND METHOD

Data from the Norwegian Patient Register on 10,717 patients who had been discharged with the diagnosis of myocardial infarction in 2009 were linked to data on socioeconomic status, comorbidity, travel distances and mortality. The predicted 30-day mortality after myocardial infarction was analysed at the hospital-trust level, using three different models for risk adjustment.

RESULTS

Unadjusted 30-day mortality was highest in the catchment area of Førde Hospital Trust (12.5%) and lowest in Asker og Bærum (5.2%). Risk adjustment changed the estimates of mortality for many of the hospital trusts. In the model involving the most comprehensive risk adjustment, mortality was highest in the catchment area of Akershus University Hospital (10.9%) and lowest in the catchment areas of Sunnmøre Hospital Trust (5.2%) and Nordmøre og Romsdal Hospital Trust (5.2%).

INTERPRETATION

The variation in treatment quality between the hospital trusts, as measured by predicted mortality after myocardial infarction, is influenced by the methods used for risk adjustment. If the quality-based funding scheme is to continue, well-documented models for risk adjustment of the quality indicators need to be established.

Acute Myocardial Infarction, Use of Percutaneous Coronary Intervention, and Mortality: A Comparative Effectiveness Analysis Covering Seven European Countries

Percutaneous coronary interventions (PCI) on acute myocardial infarction (AMI) patients have increased substantially in the last 12-15 years because of its clinical effectiveness. The expansion of PCI treatment for AMI patients raises two questions: How did PCI utilization rates vary across European regions, and which healthcare system and regional characteristic variables correlated with the utilization rate? Were the differences in use of PCI associated with differences in outcome, operationalized as 30-day mortality? We obtained our results from a dataset based on the administrative information systems of the populations of seven European countries. PCI rates were highest in the Netherlands, followed by Sweden and Hungary. The probability of receiving PCI was highest in regions with their own PCI facilities and in healthcare systems with activity-based reimbursement systems. Thirty-day mortality rates differed considerably between the countries with the highest rates in Hungary, Scotland, and Finland. Mortality was lowest in Sweden and Norway. The associations between PCI and mortality were remarkable in all age groups and across most countries. Despite extensive risk adjustment, we interpret the associations both as effects of selection and treatments. We observed a lower effect of PCI in the higher age groups in Hungary.

Comparative Analysis of Treatment Costs in EUROHOPE

This study examines the challenges of estimating risk-adjusted treatment costs in international comparative research, specifically in the European Health Care Outcomes, Performance, and Efficiency (EuroHOPE) project. We describe the diverse format of resource data and challenges of converting these data into resource use indicators that allow meaningful cross-country comparisons. The three cost indicators developed in EuroHOPE are then described, discussed, and applied. We compare the risk-adjusted mean treatment costs of acute myocardial infarction for four of the seven countries in the EuroHOPE project, namely, Finland, Hungary, Norway, and Sweden. The outcome of the comparison depends on the time perspective as well as on the particular resource use indicator. We argue that these complementary indicators add to our understanding of the variation in resource use across countries.

Outcome, Use of Resources and Their Relationship in the Treatment of AMI, Stroke and Hip Fracture at European Hospitals

The aim of the present study was to compare the quality (survival), use of resources and their relationship in the treatment of three major conditions (acute myocardial infarction (AMI), stroke and hip fracture), in hospitals in five European countries (Finland, Hungary, Italy, Norway and Sweden). The comparison of quality and use of resources was based on hospital-level random effects models estimated from patient-level data. After examining quality and use of resources separately, we analysed whether a cost-quality trade-off existed between the hospitals. Our results showed notable differences between hospitals and countries in both survival and use of resources. Some evidence would support increasing the horizontal integration: higher degrees of concentration of regional AMI care were associated with lower use of resources. A positive relation between cost and quality in the care of AMI patients existed in Hungary and Finland. In the care of stroke and hip fracture, we found no evidence of a cost-quality trade-off. Thus, the cost-quality association was inconsistent and prevailed for certain treatments or patient groups, but not in all countries.

European Regional Differences in All-Cause Mortality and Length of Stay for Patients with Hip Fracture

The objective of this study was to compare healthcare performance for the surgical treatment of hip fractures across and within Finland, Hungary, Italy, the Netherlands, Norway, Scotland, and Sweden. Differences in age-adjusted and sex-adjusted 30-day and one-year all-cause mortality rates following hip fracture, as well as the length of stay of the first hospital episode in acute care and during a follow up of 365 days, were investigated, and associations between selected country-level and regional-level factors with mortality and length of stay were assessed. Hungary showed the highest one-year mortality rate (mean 39.7%) and the lowest length of stay in one year (12.7 days), whereas Italy had the lowest one-year mortality rate (mean 19.1 %) and the highest length of stay (23.3 days). The observed variations were largely explained by country-specific effects rather than by regional-level factors. The results show that there should still be room for efficiency gains in the acute treatment of hip fracture, and clinicians, healthcare managers, and politicians should learn from best practices. This study demonstrates that an international comparison of acute hospital care is possible using pooled individual-level administrative data.

Individual and Regional-level Factors Contributing to Variation in Length of Stay After Cerebral Infarction in Six European Countries

Using patient-level data for cerebral infarction cases in 2007, gathered from Finland, Hungary, Italy, the Netherlands, Scotland and Sweden, we studied the variation in risk-adjusted length of stay (LoS) of acute hospital care and 1-year mortality, both within and between countries. In addition, we analysed the variance of LoS and associations of selected regional-level factors with LoS and 1-year mortality after cerebral infarction. The data show that LoS distributions are surprisingly different across countries and that there is significant deviation in the risk-adjusted regional-level LoS in all of the countries studied. We used negative binomial regression to model the individual-level LoS, and random intercept models and ordinary least squares regression for the regional-level analysis of risk-adjusted LoS, variance of LoS, 1-year risk-adjusted mortality and crude mortality for a period of 31-365 days. The observed variations between regions and countries in both LoS and mortality were not fully explained by either patient-level or regional-level factors. The results indicate that there may exist potential for efficiency gains in acute hospital care of cerebral infarction and that healthcare managers could learn from best practices.

A Window on Geographic Variation in Health Care: Insights from EuroHOPE

The aim of EuroHOPE was to provide new evidence on the performance of healthcare systems, using a disease-based approach, linkable patient-level data and internationally standardized methods. This paper summarizes its main results. In the seven EuroHOPE countries, the Acute Myocardial Infarction (AMI), stroke and hip fracture patient populations were similar with regard to age, sex and comorbidity. However, non-negligible geographic variation in mortality and resource use was found to exist. Survival rates varied to similar extents between countries and regions for AMI, stroke, hip fracture and very low birth weight. Geographic variation in length of stay differed according to type of disease. Regression analyses showed that only a small part of geographic variation could be explained by demand and supply side factors. Furthermore, the impact of these factors varied between countries. The findings show that there is room for improvement in performance at all levels of analysis and call for more in-depth disease-based research. In using international patient-level data and a standardized methodology, the EuroHOPE approach provides a promising stepping-stone for future investigations in this field. Still, more detailed patient and provider information, including outside of hospital care, and better data sharing arrangements are needed to reach a more comprehensive understanding of geographic variations in health care.

Implementation of Departmental Quality Strategies Is Positively Associated with Clinical Practice: Results of a Multicenter Study in 73 Hospitals in 7 European Countries

BACKGROUND

Given the amount of time and resources invested in implementing quality programs in hospitals, few studies have investigated their clinical impact and what strategies could be recommended to enhance its effectiveness.

OBJECTIVE

To assess variations in clinical practice and explore associations with hospital- and department-level quality management systems.

DESIGN

Multicenter, multilevel cross-sectional study.

SETTING AND PARTICIPANTS

Seventy-three acute care hospitals with 276 departments managing acute myocardial infarction, deliveries, hip fracture, and stroke in seven countries.

INTERVENTION

None.

MEASURES

Predictor variables included 3 hospital- and 4 department-level quality measures. Six measures were collected through direct observation by an external surveyor and one was assessed through a questionnaire completed by hospital quality managers. Dependent variables included 24 clinical practice indicators based on case note reviews covering the 4 conditions (acute myocardial infarction, deliveries, hip fracture and stroke). A directed acyclic graph was used to encode relationships between predictors, outcomes, and covariates and to guide the choice of covariates to control for confounding.

RESULTS AND LIMITATIONS

Data were provided on 9021 clinical records by 276 departments in 73 hospitals. There were substantial variations in compliance with the 24 clinical practice indicators. Weak associations were observed between hospital quality systems and 4 of the 24 indicators, but on analyzing department-level quality systems, strong associations were observed for 8 of the 11 indicators for acute myocardial infarction and stroke. Clinical indicators supported by higher levels of evidence were more frequently associated with quality systems and activities.

CONCLUSIONS

There are significant gaps between recommended standards of care and clinical practice in a large sample of hospitals. Implementation of department-level quality strategies was significantly associated with good clinical practice. Further research should aim to develop clinically relevant quality standards for hospital departments, which appear to be more effective than generic hospital-wide quality systems.

A multilevel analysis of mortality following acute myocardial infarction in Norway: do municipal health services make a difference?

OBJECTIVES

Studies link area features such as neighbourhood socioeconomic deprivation to poor health outcomes. However, there is a paucity of research based on representative data investigating the effects of area-level health services on mortality. This study examines the extent to which municipal health services account for municipal variation in all-cause and cardiovascular disease (CVD) mortality. We hypothesise that unfavourable municipal features (eg, fewer available places for rehabilitation) are associated with higher risk of mortality after accounting for patients' characteristics.

DESIGN

Population data from Norwegian national/municipal registrars are analysed using multilevel logistic regression in this prospective cohort study.

SETTING AND PARTICIPANTS

The analytic sample (9412 patients aged 18+ from 336 municipalities) constitutes 87.7% of the nationwide population of Norwegian adults who were hospitalised for acute myocardial infarction (AMI) in 2009 and discharged alive.

PRIMARY OUTCOME MEASURES

All-cause and CVD mortality occurring within 365 days after the first day of hospitalisation for AMI.

RESULTS

There was a small but significant variation at the municipal level in all-cause mortality (0.5%; intraclass correlation coefficient=0.005) but not CVD mortality. There were no significant fixed effects of municipal health services on mortality in bivariate models. Patients' characteristics (eg, gender, comorbidities) fully accounted for the observed municipal variation in mortality. Being male versus female (OR=1.21, 95% CI 1.02 to 1.43), or having been previously diagnosed with dementia versus not (OR=2.06, 95% CI 1.53 to 2.77) were also linked to higher odds of death.

CONCLUSIONS

Municipal variation in all-cause mortality for Norwegian patients with AMI appears to be driven not by differences across municipalities in health service levels, but by differences across municipalities in the composition of patients. Focusing on chronic disease prevention and treatment, and tackling personal and structural risk factors embedded within patients' sociodemographic characteristics, may be especially beneficial for longevity.

Mortality and Length of Stay of Very Low Birth Weight and Very Preterm Infants: A EuroHOPE Study

The objective of this paper was to compare health outcomes and hospital care use of very low birth weight (VLBW), and very preterm (VLGA) infants in seven European countries. Analysis was performed on linkable patient-level registry data from seven European countries between 2006 and 2008 (Finland, Hungary, Italy (the Province of Rome), the Netherlands, Norway, Scotland, and Sweden). Mortality and length of stay (LoS) were adjusted for differences in gestational age (GA), sex, intrauterine growth, Apgar score at five minutes, parity and multiple births. The analysis included 16,087 infants. Both the 30-day and one-year adjusted mortality rates were lowest in the Nordic countries (Finland, Sweden and Norway) and Scotland and highest in Hungary and the Netherlands. For survivors, the adjusted average LoS during the first year of life ranged from 56 days in the Netherlands and Scotland to 81 days in Hungary. There were large differences between European countries in mortality rates and LoS in VLBW and VLGA infants. Substantial data linkage problems were observed in most countries due to inadequate identification procedures at birth, which limit data validity and should be addressed by policy makers across Europe.

Benchmarking Controlled Trial--a novel concept covering all observational effectiveness studies

The Benchmarking Controlled Trial (BCT) is a novel concept which covers all observational studies aiming to assess effectiveness. BCTs provide evidence of the comparative effectiveness between health service providers, and of effectiveness due to particular features of the health and social care systems. BCTs complement randomized controlled trials (RCTs) as the sources of evidence on effectiveness. This paper presents a definition of the BCT; compares the position of BCTs in assessing effectiveness with that of RCTs; presents a checklist for assessing methodological validity of a BCT; and pilot-tests the checklist with BCTs published recently in the leading medical journals.

The determinants of efficiency in the Canadian health care system

In spite of the vast number of studies measuring economic efficiency in health care, there has been little take-up of this evidence by policy-makers to date. This study provides an illustration of how a system-level study drawing on best practice in empirical measurement of efficiency may be of practical use to health system decision makers and managers. We make use of the rich data available in Canada to undertake a robust two-stage data envelopment analysis to calculate efficiency at the regional (sub-provincial) level. Decisions about what the health system produces (the outcome to measure efficiency against) and what are the resources it has to produce that outcome were based on interviews and consultation with health system decision makers. Overall, we find large inefficiencies in the Canadian health care system, which could improve outcomes (here, measured as a reduction in treatable causes of death) by between 18 and 35% across our analyses. Also, we find that inefficiencies are the result of three main sets of factors that policy makers could pay attention to: management factors, such as hospital re-admissions; public health factors, such as obesity and smoking rates; and environmental factors such as the population’s average income.

Comparing ischaemic stroke in six European countries. The EuroHOPE register study

BACKGROUND AND PURPOSE

The incidence of hospitalizations, treatment and case fatality of ischaemic stroke were assessed utilizing a comprehensive multinational database to attempt to compare the healthcare systems in six European countries, aiming also to identify the limitations and make suggestions for future improvements in the between-country comparisons.

METHODS

National registers of hospital discharges for ischaemic stroke identified by International Classification of Diseases codes 433-434 (ICD-9) and code I63 (ICD-10), medication purchases and mortality were linked at the patient level in each of the participating countries and regions: Finland, Hungary, Italy, the Netherlands, Scotland and Sweden. Patients with an index admission in 2007 were followed for 1 year.

RESULTS

In all, 64,170 patients with a disease code for ischaemic stroke were identified. The number of patients registered per 100,000 European standard population ranged from 77 in Scotland to 407 in Hungary. Large differences were observed in medication use. The age- and sex-adjusted all-cause case fatality amongst hospitalized patients at 1 year from stroke was highest in Hungary at 31.0% (95% confidence interval 30.5-31.5). Regional differences in age- and sex-adjusted 1-year case fatality within countries were largest in Hungary (range 23.6%-37.6%) and smallest in the Netherlands (20.5%-27.3%).

CONCLUSIONS

It is feasible to link population-wide register data amongst European countries to describe incidence of hospitalizations, treatment patterns and case fatality of ischaemic stroke on a national level. However, the coverage and validity of administrative register data for ischaemic stroke should be developed further, and population-based and clinical stroke registers should be created to allow better control of case mix.

Health research and systems' governance are at risk: should the right to data protection override health?

The European Union (EU) Data Protection Regulation will have profound implications for public health, health services research and statistics in Europe. The EU Commission's Proposal was a breakthrough in balancing privacy rights and rights to health and healthcare. The European Parliament, however, has proposed extensive amendments. This paper reviews the amendments proposed by the European Parliament Committee on Civil Liberties, Justice and Home Affairs and their implications for health research and statistics. The amendments eliminate most innovations brought by the Proposal. Notably, derogation to the general prohibition of processing sensitive data shall be allowed for public interests such as the management of healthcare services,but not health research, monitoring, surveillance and governance. The processing of personal health data for historical, statistical or scientific purposes shall be allowed only with the consent of the data subject or if the processing serves an exceptionally high public interest, cannot be performed otherwise and is legally authorised. Research, be it academic, government,corporate or market research, falls under the same rule.The proposed amendments will make difficult or render impossible research and statistics involving the linkage and analysis of the wealth of data from clinical,administrative, insurance and survey sources, which have contributed to improving health outcomes and health systems performance and governance; and may illegitimise efforts that have been made in some European countries to enable privacy-respectful data use for research and statistical purposes. If the amendments stand as written, the right to privacy is likely to override the right to health and healthcare in Europe.

Risk adjustment of health-care performance measures in a multinational register-based study: A pragmatic approach to a complicated topic

Objectives:

Health-care performance comparisons across countries are gaining popularity. In such comparisons, the risk adjustment methodology plays a key role for meaningful comparisons. However, comparisons may be complicated by the fact that not all participating countries are allowed to share their data across borders, meaning that only simple methods are easily used for the risk adjustment. In this study, we develop a pragmatic approach using patient-level register data from Finland, Hungary, Italy, Norway, and Sweden.

Methods:

Data on acute myocardial infarction patients were gathered from health-care registers in several countries. In addition to unadjusted estimates, we studied the effects of adjusting for age, gender, and a number of comorbidities. The stability of estimates for 90-day mortality and length of stay of the first hospital episode following diagnosis of acute myocardial infarction is studied graphically, using different choices of reference data. Logistic regression models are used for mortality, and negative binomial models are used for length of stay.

Results:

Results from the sensitivity analysis show that the various models of risk adjustment give similar results for the countries, with some exceptions for Hungary and Italy. Based on the results, in Finland and Hungary, the 90-day mortality after acute myocardial infarction is higher than in Italy, Norway, and Sweden.

Conclusion:

Health-care registers give encouraging possibilities to performance measurement and enable the comparison of entire patient populations between countries. Risk adjustment methodology is affected by the availability of data, and thus, the building of risk adjustment methodology must be transparent, especially when doing multinational comparative research. In that case, even basic methods of risk adjustment may still be valuable.