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Collaboration with the Regional Health and Social Care Agency emilia-romagna, Italy

The Center contin­ued a major series of projects in collaboration with the Regional Agency for Health and Social Care of the Emilia-Romagna Region of Italy. These projects address a wide range of issues in health care or­ganization, financing of the health care system, and quality improvement activities. Ongoing activities include: devel­opment of models to predict risk of hospitaliza­tion for patients with chronic disease, analyses of the distribution and outcomes of surgical services for patients with cancer; analyses of intraregional variation in medical, surgical and pharmaceutical treatment, refinement of a method for assessing the timeliness and appropriateness of acute hospitalization, analyses of patterns and quality of care for women with breast cancer, development of "profiles" of care provided by primary care teams, and studies of the integration of hospital and outpatient care.

Working with the Emilia-Romagna Region, the Center helped to design a population-based longitudinal health care database for the 5 mil­lion individuals who were residents of Emilia-Romagna in the period 2002 through 2011. The database is built from encounter-based re­cords of an individual’s interaction with the health care system using administrative data, capable of individual and geographic levels of analyses. Since Italy has a National Health Service, all residents of the region are included, without limitations concerning age or insurance status. The database includes:

  • Demographic information for all residents, including gender, birth and death dates, location of birth, current residence, and primary care physician.
  • Hospital discharge abstract data, including ICD-9-CM diagnosis and procedure codes, admission and discharge dates, and DRG-based payments.  These data include both acute hospital stays and “day hospital” encounters.
  • Outpatient pharmacy data at the individual prescription level, including drug codes, pharmacy payments, and patient co-payments.
  • Specialty care, including type of service (laboratory, diagnostics, therapeutic procedures, rehabilitation, specialist visits), service costs, patient co-payments, dates of service, and physician information.
  • Home health data, including the type of service, provider of the service (physician, nurse, therapist, etc.), hours of service provided, number of visits, reason for the visit, and diagnosis.
  •  Hospice data.
  • Information on each primary care physician in the region, including payments received, specialty, years in practice, and patient load.

All of this information, linkable at both patient and physician levels, is currently available for nine consecutive years (2002-2011) with con­tinuing data collection.

The value of the database has been increased by adding clinical classifications mapped from the hospital and pharmacy data.  The Disease Stag­ing classification has been used to classify the severity of primary diagnosis and co-morbidity for hospitalized patients and to identify individuals who may be at higher risk for utilizing more extensive or expensive health services in the future.  Another set of indicators (Chronic Condition Drug Groups - CCDGs) uses outpa­tient pharmacy data and the Italian national formulary to identify individuals with selected chronic diseases.

The goal of this project being performed in collaboration with the Agenzia Sanitaria e Sociale Regionale is to provide information that would be helpful to the Local Health Authorities, districts, and Primary Care Teams and Medical Homes by identifying people at high risk of future hospitalization. This information can then be used to identify individuals who may benefit from participating in chronic care case/disease management programs. Using data from the regional longitudinal database, we defined clinical indicators as predictors, defined a dependent variable to capture potentially avoidable/ambulatory-care-sensitive hospitalizations, and then applied our modeling approach to predict the risk of hospitalization for residents of the region. Analysis of the clinical characteristics of the members of the resulting risk categories confirmed that our model had been successful in stratifying the population. Assess-ment of the model’s performance is very promising with the C-statistic of 0.82 demonstrating the model’s ability to identify high-risk patients.

Reports which included results for each of the 11 Local Health Authorities within the Regione Emilia-Romagna were prepared and presented to management and medical directors.  We were especially pleased to learn that a competitive grant application prepared by Jefferson and the Agenzia Sanitaria e Sociale Regionale has been selected for funding by the Italian Ministry of Health. This grant will enable us to update the risk models with more recent data, to assess the value of longitudinal data modeling, and to model patient transition among risk categories.   The results of the risk models have been used to provide reports profiling high risk patients to their primary care physicians and their “medical homes”. Scott Keith, Ph.D., assistant professor of biostatistics at TJU is collaborating with the Center on this project.

There is extensive literature supporting the existence of a positive relationship between surgical procedure volume and patient outcomes.  The goal of this project is to describe the distribution of selected major cancer surgery in hospitals in the Regione Emilia-Romagna and assess differences in patient outcomes.  This information can be used by the region in its plans to review the distribution of surgical services at hospitals in Emilia-Romagna to best serve the population.

Based on a review of the literature and consideration of complexity and frequency, the following procedures were selected for analysis:

  • Gastrointestinal procedures (pancreatictomy, excision of esophagus/ esophagomyotomy, local excision or destruction of liver tissue or lesion / lobectomy of liver, incision, excision, and anastomosis of the intestines, gastrectomy, resection of rectum) for patients with cancer
  • Urologic procedures (nephrectomy, cystictomy) for kidney/bladder cancer
  • Surgery for lung cancer (segmental resection of lung, lobectomy of lung, pneumonectomy)
  • Radical prostatectomy for prostate cancer
  • Ovarian cancer surgery
  • Breast cancer surgery (mastectomy, lumpectomy)

Analyses using hospital discharge abstract data showed that some highly complex surgical procedures are being performed in hospitals where these procedures are performed infrequently.  Patients having their procedures at higher volume hospitals tend to have lower in hospital mortality and better survival rates than those having surgery at low volume hospitals.  In addition, significant intra-regional geographic variation was observed in rates of surgery for men having a radical prostatectomy for prostate cancer and for women having surgery for breast cancer.  These results, together with evidence reported in the literature, were presented to the director general of the regional health system and the directors general and medical directors of the local health authorities to help in their efforts to reorganize and rationalize the distribution of surgical services in the region.

The Center is collaborating with the Regional Agency for Health and Social Care of the Emilia-Romagna Region of Italy in the development of a series of analyses and reports focused on variation in utilization and outcomes for selected high frequency medical and surgical treatments.  These reports, currently in the early stages of development, are designed to try to identify variation that is not explained by patient characteristics or patient preferences.  Initial analyses include patients undergoing cholecystectomy for cholecystitis, men having a prostatectomy for benign prostatic hypertrophy, patterns of care for patients with congestive heart failure, and utilization of selected pharmaceutical treatments in elderly patients and those with common chronic medical problems.  The goal of initial analyses will be to provide the regions and local health authorities with information useful for improving the quality and efficiency of care in the region.

The Center has developed a method to identify potentially inappropriate acute hospital admissions (patients who could be effectively and safely treated in alternative, less costly settings) as well as “late” hospital admissions (patients who could have benefited from diagnosis and treatment at an earlier stage of their disease).  This methodology uses standard hospital discharge abstract data to evaluate the severity of a patient’s principal diagnosis, using the Disease Staging classification, the presence and severity of co-morbid disease, and the nature of surgical procedures performed.  The method has been reviewed by a panel of Italian physicians which confirmed the validity of the approach. The revised criteria have been applied to hospital admissions for residents of the Emilia-Romagna Region and used by the region, local health units, and hospitals as a part of the planning process designed to efficiently meet the health care needs of the population.  Currently, the list of DRGs to be assessed is being expanded to include a total of 108 diagnostic groups.

Despite major advances in screening, diagnosis, and treatment, cancer remains one of the major causes of death in the developed world.  Substantial resources are spent on end-of-life care for patients with cancer. A number of studies have shown an overuse of aggressive medical and surgical treatment at the end-of-life.  According to some analyses, patients often receive more aggressive care than what would be preferred by many. Conversely, some studies have shown an underuse of appropriate care for patients with cancer.

Understanding the type and quality of end-of-life care received by patients is an important health policy concern. The proposed analyses are designed to document end-of-life care for patients with cancer in the Regione Emilia-Romagna including analyses of intra-regional variations among the AUSL in the region. The
goal of the project is to provide information to the regional oncology commission and the directors general and medical directors of the Emilia-Romagna Region and Local Health Authorities to assist in the goals of improving the quality and efficiency of care provided in the last months of life to patients with cancer.

Center researchers collaborated with the Emilia-Romagna regional cancer care commission in an analysis of compliance with American Society of Clinical Oncology radiation and chemotherapy guidelines for women with breast cancer. This project used tumor registry data for women with breast cancer data merged with information from the RER administrative database. Our manuscript: “Using Adminis-trative Data to Identify and Stage Breast Cancer Cases: Implications for Assessing Quality of Care” was published in Tumori.  An additional study: “Variation among Local Health Units in Follow-up Care of Breast Cancer Patients in Emilia-Romagna-Italy” has been accepted for publication in the same journal.  We have begun additional analyses of variation in compliance with radiation therapy guidelines and long term survival for women with breast cancer.