Thomas Jefferson University
Sidney Kimmel Medical College
Asano-Gonnella Center for Research in Medical Education & Health Care

Past Projects Conducted with the Parma Local Health Authority

Faculty and staff of the Center worked on a major series of projects being performed in collaboration with the regional health care system of Emilia-Romagna Region, Italy. Projects included the 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 intra-regional 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.

Parma Local Health Authority

  • Teamwork – Development of a series of profiles of care for the population served by the health districts and primary care units. These “profiles of care” are designed to assist the district managers and primary care units in identifying areas amenable to quality improvement. In the past year, we have conducted focus groups with Parma AUSL primary care physicians to evaluate the cultural and organizational characteristics among the primary care units.
  • Physician empathy – 224 Parma primary care physicians who have 290,000 patients on their panels have completed the Jefferson Scale of Empathy. We analyzed the relationship between physician empathy and outcomes of care in diabetic patients treated by these physicians and found that empathy is significantly associated with clinical outcomes for patients with diabetes mellitus.

Population-based Longitudinal Health Care Database

The Emilia-Romagna Region has developed a population-based longitudinal health care database for the roughly 5 million individuals who are residents of Emilia-Romagna. The database includes encounter-based records of an individual's interaction with the healthcare system using administrative data. Since Italy has a National Health Service, all residents of the region are included, without limitations concerning age or insurance status. The value of the database has been increased by adding clinical classifications mapped from the hospital and pharmacy data. The Disease Staging classification, developed by Center faculty, 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 using 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.

Development & Application of Risk Models

We developed models to predict risk of hospitalization for patients with chronic disease. Details of these models, which perform as well or better than similar models in other countries, were published in BMJ Open. A collaborative grant application submitted by the Regional Health Care Research Agency and Thomas Jefferson University to refine these models was funded by the Italian Ministry of Health. Model results, along with profiles of patients identified as "high risk" are being provided to physicians and other health professionals associated with newly formed "medical homes" to assist in efforts toward proactive management of patients with chronic disease that may reduce the likelihood of preventable, high-cost hospitalization.

Analysis of the Distribution & Outcomes of Surgical Procedures Performed in the Hospitals of the Regione Emilia-Romagna

We analyzed the distribution and outcomes of major surgery in the region focusing on the relationship between volume of procedures performed and patient outcomes. A study of follow-up care for breast cancer survivors was published in Tumori.

Analyses of Intraregional Variation in Utilization & Outcomes

The Center collaborated 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 were designed to identify variation that is not explained by patient characteristics or patient preferences. Analyses included patients undergoing cholecystectomy for cholecystitis, men having a prostatectomy for benign prostatic hypertrophy, patterns of care for patients with congestive heart failure and using of selected pharmaceutical treatments in elderly patients and those with common chronic medical problems. The goal of these analyses was to provide managers of the regional healthcare system and of the local authorities with information useful for improving the quality and efficiency of care in the region.

Assessment of Timeliness & Appropriateness of Acute Hospital Use

The Center 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 used 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 were applied to hospital admissions for residents of Emilia-Romagna and used by managers of 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. 

Quality of End-of-Life Care

We performed analyses using administrative data to measure quality of care at the end of life for patients with cancer. This project, carried out in collaboration with the University of Bologna and the Regional Health and Social Care Research Agency, evaluated key indicators such as use of chemotherpay, hospitalization, home health care, hospice care, and use of pain medication in the last months of life. Results of one of the tasks of this project were published in Palliative Medicine: "Effectiveness of palliative care services: A population-based study of end-of-life care for cancer patients." These results are currently used by the managers responsible in Emilia-Romagna for improving care for patients with cancer at the end of life.

Breast Cancer in the Emilia-Romagna Region: Patterns & Quality of Care

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 Regione Emilia-Romagna administrative database. Our manuscript, “Using Administrative 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” was published in the same journal. 

Profiling Primary Care Physicians within the Emilia-Romagna Region

Thomas Jefferson University collaborated with the Emailia-Romagna Healthcare Authority to profile primary care physicians with a focus on Primary Care Units (PCUs). The aim of the project was to profile physicians by comparing practice patterns among PCUs within each of the 7 Local Health Authorities of the region across various dimensions of care with the goal of assisting the PCUs in assessing and improving the quality of care provided to their patients. The regional health care data was used to perform a descriptive analysis of the selected dimensions of care for the PCUs for each Local Health Authority, including demographic, morbidity and healthcare utilization of PCU patients. At the end of this process, each PCU received a brief summary of the results, which were discussed and used to establish initiatives to improve the quality of care of the PCU patients. Repeating the analyses over time allowed each Local Health Authority to compare and contrast results in order to monitor and evaluate the PCUs’ progress.