The impact of Community Health Centers on inappropriate use of emergency services.

Community Health Centers offer coordinated and comprehensive responses to primary care needs. Our study aims at assessing whether the introduction of such organizational model improved health outcomes measured by inappropriate emergency visits among diabetics in the Emilia-Romagna region of Italy. Using difference-in-differences methods within a staggered treatment setting, we estimate the effect of Community Health Center participation on inappropriate hospital emergency visits between year 2010 and year 2016. We distinguish between emergency department admissions for varying time spans, occurring at daytime during working days, at night-time, as well as during weekends. We show that, the causal effect of the adoption of the community care model leads to a reduction in the probability of inappropriate admissions by an amount ranging between 1.6 and 1.7% points during working days at daytime, with large facilities responsible for most gains by experiencing a decrease ranging between 4 and 3% points. Conversely, we detect no difference at night-time and during weekends. Our results point out that the coordinated care model increases appropriateness among vulnerable patients, and that extending opening hours and the range of services can further enhance such benefits.

Cost Determinants of Continuum-Care Episodes for Hip Fracture.

Many factors affect the healthcare costs and outcomes in patients with hip fracture (HF). Through the construction of a Continuum-Care Episode (CCE), we investigated the costs of CCEs for HF and their determinants. We used data extracted from administrative databases of 5094 consecutive elderly patients hospitalized in 2017 in Emilia Romagna, Italy, to evaluate the overall costs of the CCE. We calculated the acute and post-acute costs from the date of the hospital admission to the end of the CCE. The determinants of costs by type of surgical intervention (total hip replacement, partial hip replacement, open reduction, and internal fixation) were investigated using generalized linear regression models. Regardless of the type of surgical intervention, hospital bed-based rehabilitation in public or private healthcare facilities either followed by rehabilitation in a community hospital/temporary nursing home beds or not were the strongest determinants of costs, while rehabilitation in intermediate care facilities alone was associated with lower costs. CCE's cost and its variability is mainly related to the rehabilitation setting. Cost-wise, intermediate care resulted to be an appropriate setting for providing post-acute rehabilitation for HF, representing the one associated with lower overall costs. Intermediate care organizational setting should be privileged when planning integrated care HF pathways.

Reorganizing territorial healthcare to avoid inappropriate ED visits: does the spread of Community Health Centres make Walk-in-Clinics redundant?

BACKGROUND: Community care has recently been restructured with the development of Community Health Centres (CHCs), forcing a general rethink on the survival of previous organizational solutions adopted to reduce inappropriate ED access, for example Walk-in-Clinics (WiCs). METHODS: We focus on the Italian Emilia-Romagna Region that has made huge investments in CHC development, whilst failing to proceed at a uniform rate from area to area. Estimating panel count data models for the period 2015-2018, we pursue two goals. First we test the existence of a "CHC effect", choosing five urban cities with different degree of development of the CHC model and assessing whether, all else being equal, patients treated by GPs who have their premises inside the CHC show a lower need to seek inappropriate care (Aim 1). Second, we focus our attention on Walk-in-Clinics, investigating the long-established WiC in the city of Parma that currently coexists with three CHCs recently established in the same catchment area. In this case we try to assess whether, and to what extent, the progressive development of the CHCs in the city of Parma has been affecting the dynamics of WiC access (Aim 2). RESULTS: As regards Aim 1, we show that CHCs reduce the probability of inappropriate patient access to emergency care. As regards Aim 2, in the city of Parma patients whose GP belongs to the CHC are less likely to visit the WiC on a workday, with no significant change during the weekend when CHCs are closed, questioning the need to maintain them both in the same area when the CHC model is fully implemented. CONCLUSIONS: Our results confirm the hypothesis that expanding access to primary care settings diminishes inappropriate ED use. In addition, our findings suggest that where CHCs and WiCs coexist in the same area, it may be advisable to implement strategies that bring WiC activities into step with CHC-based general primary care reforms to avoid duplication.

Medical Costs of Patients with Type 2 Diabetes in a Single Payer System: A Classification and Regression Tree Analysis.

BACKGROUND AND OBJECTIVES: Many studies and systematic reviews have estimated the healthcare costs of diabetes using a cost-of-illness approach. However, in the studies based on this approach patients' heterogeneity is rarely taken into account. The aim of this study was to stratify patients with type 2 diabetes into homogeneous cost groups based on demographic and clinical characteristics. METHODS: We conducted a retrospective cost-of-illness study by linking individual data on health services utilization retrieved from the administrative databases of Emilia-Romagna Region (Italy). Direct medical costs (either all-cause or diabetes-related) were calculated from the perspective of the regional health service, using tariffs for hospitalizations and outpatient services and the unit costs of prescriptions for drugs. The determinants of costs identified in a generalized linear regression model were used to characterize subgroups of patients with homogeneous costs in a classification and regression tree analysis. RESULTS: The study population consisted of a cohort of 101,334 patients with type 2 diabetes, followed up for 1 year, with a mean age of 70.9 years. Age, gender, complications, comorbidities and living area accounted significantly for cost variability. The classification tree identified ten patient subgroups with different costs, ranging from a median of €483 to €39,578. The two subgroups with highest costs comprised dialysis patients, and the largest subgroup (57.9%) comprised patients aged ≥ 65 years without renal, cardiovascular and cerebrovascular complications. CONCLUSIONS: Classification of patients into homogeneous cost subgroups can be used to improve the management of, and budget allocation for, patients with type 2 diabetes.

Disease management in diabetes care: When involving GPs improves patient compliance and health outcomes.

Although the study of the association between interventions in primary care and health outcomes continues to produce mixed findings, programs designed to promote the greater compliance of General Practitioners and their diabetic patients with guidelines have been increasingly introduced worldwide, in an attempt to achieve better quality diabetes care through the enhanced standardisation of patient supervision. In this study, we use clinical data from the Diabetes Register of one large Local Health Authority (LHAs) in Italy's Emilia-Romagna Region for the period 2012-2015. Firstly, we investigate whether GPs' participation in the local Diabetes Management Program (DMP) leads to improved patient compliance with regional guidelines. Secondly, we test whether the monitoring activities prescribed for diabetics by the Regional diabetes guidelines have a positive impact on patients' health outcomes and increase appropriateness in health care utilization. Our results show that such a Program, which aims to increase GPs' involvement and cooperation in following the Regional guidelines, achieves its goal of improved patient compliance with the prescribed actions. In turn, through the implementation of the DMP and the greater involvement of physicians, Regional policies have succeeded in promoting better health outcomes and improved appropriateness of health care utilization.

Price Changes in Regulated Healthcare Markets: Do Public Hospitals Respond and How?

This paper examines the behaviour of public hospitals in response to the average payment incentives created by price changes for patients classified in different diagnosis-related groups (DRGs). Using panel data on public hospitals located within the Italian region of Emilia-Romagna, we test whether a 1-year increase in DRG prices induced public hospitals to increase their volume of activity and whether a potential response is associated with changes in waiting times and/or length of stay. We find that public hospitals reacted to the policy change by increasing the number of patients with surgical treatments. This effect was smaller in the 2 years after the policy change than in later years, and for providers with a lower excess capacity in the pre-policy period, whereas it did not vary significantly across hospitals according to their degree of financial and administrative autonomy. For patients with medical DRGs, instead, there appeared to be no effect on inpatient volumes. Our estimates also suggest that an increase in DRG prices had no impact on the proportion of patients waiting more than 6 months. Finally, we find no evidence of a significant effect on patients' average length of stay. Copyright © 2016 John Wiley & Sons, Ltd.

Does the extension of primary care practice opening hours reduce the use of emergency services?

Overcrowding in emergency departments generates potential inefficiencies. Using regional administrative data, we investigate the impact that an increase in the accessibility of primary care has on emergency visits in Italy. We consider two measures of avoidable emergency visits recorded at list level for each General Practitioner. We test whether extending practices' opening hours to up to 12 hours/day reduces the inappropriate utilization of emergency services. Since subscribing to the extension program is voluntary, we account for the potential endogeneity of participation in a count model for emergency admissions in two ways: first, we use a two-stage residual inclusion approach. Then we exploit panel methods on data covering a three-year period, thus accounting directly for individual heterogeneity. Our results show that increasing primary care accessibility acts as a restraint on the inappropriate use of emergency departments. The estimated effect is in the range of a 10-15% reduction in inappropriate admissions.

Dealing with minor illnesses: The link between primary care characteristics and Walk-in Centres' attendances.

The reformulation of existing boundaries between primary and secondary care, in order to shift selected services traditionally provided by Emergency Departments (EDs) to community-based alternatives, has determined a variety of organisational solutions. One innovative change has been the introduction of fast-track systems for minor injuries or illnesses, whereby community care providers are involved in order to divert patients away from EDs. These facilities offer an open-access service for patients not requiring hospital treatments, and may be staffed by nurses and/or primary care general practitioners operating within, or alongside, the ED. To date little research has been undertaken on such experiences. To fill this gap, we analyse a Walk-in Centre (WiC) in the Italian city of Parma, consisting of a minor injury unit located alongside the teaching hospital's ED. We examine the link between the utilisation rates of the WiC and primary care characteristics, focusing on the main organisational features of the practices and estimating panel count data models for 2007-2010. Our main findings indicate that the extension of practice opening hours significantly lowers the number of attendances, after controlling for General Practitioner's and practice's characteristics.

An analytic approach for describing and prioritizing health inequalities at the local level in Canada: a descriptive study.

BACKGROUND: We present the health inequalities analytic approach used by the Saskatoon Health Region to examine health equity. Our aim was to develop a method that will enable health regions to prioritize action on health inequalities. METHODS: Data from admissions to hospital, physician billing, reportable diseases, vital statistics and childhood immunizations in the city of Saskatoon were analyzed for the years ranging from 1995 to 2011. Data were aggregated to the dissemination area level. The Pampalon deprivation index was used as the measure of socioeconomic status. We calculated annual rates per 1000 people for each outcome. Rate ratios, rate differences, area-level concentration curves and area-level concentration coefficients quantified inequality. An Inequalities Prioritization Matrix was developed to prioritize action for the outcomes showing the greatest inequality. The outcomes measured were cancer, intentional self-harm, chronic obstructive pulmonary disease, mental illness, heart disease, diabetes, injury, stroke, chlamydia, tuberculosis, gonorrhea, hepatitis C, high birth weight, low birth weight, teen abortion, teen pregnancy, infant mortality and all-cause mortality. RESULTS: According to the Inequalities Prioritization Matrix, injuries and chronic obstructive pulmonary disease were the first and second priorities, respectively, that needed to be addressed related to inequalities in admissions to hospital. For physician billing, mental disorders and diabetes were high-priority areas. Differences in teen pregnancy and all-cause mortality were the most unequal in the vital statistics data. For communicable diseases, hepatitis C was the highest priority. INTERPRETATION: Our findings show that health inequalities exist at the local level and that a method can be developed to prioritize action on these inequalities. Policies should consider health inequalities and adopt population-based and targeted actions to reduce inequalities.

The role of GP's compensation schemes in diabetes care: evidence from panel data.

We investigate the impact of the implementation of Diabetes Management Programs with financial incentives in the Italian Region Emilia-Romagna between 2003 and 2005. We focus on avoidable hospitalisations for diabetic patients for whom GPs receive additional payments exceeding capitation. We estimate a panel count data model to test the hypothesis that those patients under the responsibility of GPs receiving a higher share of their income through ad-hoc payments, are less likely to experience avoidable hospitalisations. Our findings indicate that financial transfers may help improve the quality of care, even when they are not based on the ex-post verification of performance. The estimated effect indicates that, at sample averages, an increase of 100 Euros of the financial incentives paid to GPs (around 17% of the yearly payment received by GPs for diabetes programmes) is expected to reduce the number of diabetic ACSCs by 1%, around 100 cases when projected on the entire region.

GPs and hospital expenditures. Should we keep expenditure containment programs alive?

Pay-for-Performance programs offering additional payments to GPs can be used not only to improve the quality of care but also for cost containment purposes. In this paper, we analyse the impact of removing financial incentives in primary care that were aimed at containing hospital expenditure in the Italian region of Emilia-Romagna during the period 2002-2004. Our analysis draws on regional databanks linking GPs' characteristics to those of their patients (including all sources of public payments made to GPs), together with information on the utilisation of hospital services. The dataset includes 2,936,834 patients, 3229 GPs and 39 districts belonging to 11 Local Health Authorities. We employ a difference-in-difference specification to assess changes in expenditures for avoidable and total hospital admissions. We identify the treatment group with GPs operating in districts where the program is withdrawn during the observation period ("Leavers"). Their performance is compared to that of two separate control groups, namely: GPs working in districts that grant incentives for the entire period ("Stayers") and those working in districts that never introduced measures for the containment of hospitalisations ("Non Participants"). The comparison between treatment and control groups shows that removing incentives does not result in a worse performance by Leavers compared to both control groups. This supports the policy of removing incentives, as such entail extra payments to GPs which, however, do not seem capable of significantly influencing their behaviour in the desired way. Our findings complement previous evidence from the same institutional context showing that only those programs that aim to improve disease management for specific conditions - rather than to simply contain expenditure - have proven successful in reducing avoidable admissions for the target population.

Incentives in primary care and their impact on potentially avoidable hospital admissions.

Financial incentives in primary care have been introduced with the purpose of improving appropriateness of care and containing demand. We usually observe pay-for-performance programs, but alternatives, such as pay-for-participation in improvement activities and pay-for-compliance with clinical guidelines, have also been implemented. Here, we assess the influence of different programs that ensure extra payments to GPs for containing avoidable hospitalisations. Our dataset covers patients and GPs of the Italian region Emilia-Romagna for the year 2005. By separating pay-for-performance from pay-for-participation and pay-for-compliance programs, we estimate the impact of different financial incentives on the probability of avoidable hospitalisations. As dependent variable, we consider two different sets of conditions for which timely and effective primary care should be able to limit the need for hospital admission. The first is based on 27 medical diagnostic related groups that Emilia-Romagna identifies as at risk of inappropriateness in primary care, while the second refers to the internationally recognised ambulatory care-sensitive conditions. We show that pay-for-performance schemes may have a significant effect over aggregate indicators of appropriateness, while the effectiveness of pay-for-participation schemes is adequately captured only by taking into account subpopulations affected by specific diseases. Moreover, the same scheme produces different effects on the two sets of indicators used, with performance improvements limited to the target explicitly addressed by the Italian policy maker. This evidence is consistent with the idea that a "tunnel vision" effect may occur when public authorities monitor specific sets of objectives as proxies for more general improvements in the quality of health care delivered.

Economic incentives in general practice: the impact of pay-for-participation and pay-for-compliance programs on diabetes care.

OBJECTIVES: We investigate the impact on quality of care of the introduction of two financial incentives in primary care contracts in the Italian region Emilia Romagna: pay-for-participation and pay-for-compliance with best practices programs. METHODS: We concentrate on patients affected by diabetes mellitus type 2, for which the assumption of responsibility and the adoption of clinical guidelines are specifically rewarded. We test the hypothesis that, other things equal, patients under the responsibility of general practitioners (GPs) receiving a higher share of their income through these programs are less likely to experience hospitalisation for hyperglycaemic emergencies. To this end, we examine the combined influence of physician, organisational and patient factors by means of multilevel modelling for the year 2003. RESULTS: Programs aimed at stimulating GP assumption of responsibility in disease management significantly reduce the probability of hyperglycaemic emergencies for their patients. CONCLUSIONS: Although it has been recognised that incentive-based remuneration schemes can have an impact on GP behaviour, there is still weak empirical evidence on the extent to which such programs influence healthcare outcomes. Our results support the hypothesis that financial transfers may contribute to improve quality of care, even when they are not based on the ex-post verification of performances.

The analysis of a cardiological network in a regulated setting: a spatial interaction approach.

We analyse referral patterns for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) in the Emilia Romagna region of Italy, a procedure for which the assumption of a negative association between volume and adverse outcomes is used to justify its territorial concentration. Nevertheless, recent clinical evidence shows PTCA superiority for immediate treatment of acute myocardial infarction, which advises an increase in the number of points of delivery. Our paper aims to develop analytical tools designed to provide support to policy makers when they are asked to evaluate the spatial distribution of catheterisation laboratories that perform PTCA. Information is drawn from the regional administrative hospital discharge data (SDO) for the year 2002. We first use entropy indexes to investigate the spatial accessibility of the cardiological network. Secondly, by means of a gravity model estimated using Bayesian techniques we identify the determinants of patient flows in terms of demand and supply factors. Our results suggest that information on destinations is processed hierarchically and that agglomeration-like forces are dominant. Furthermore, although self-sufficiency of provision at the provincial level has been achieved to a large extent, there is still scope to improve the organisational efficiency of the network.

Risk adjustment for coronary artery bypass graft surgery: an administrative approach versus EuroSCORE.

OBJECTIVE: To determine the ability of administrative data in predicting in-hospital mortality for patients undergoing coronary artery bypass graft surgery. METHODS: Patient data were obtained from the administrative databases on hospital discharge abstracts of the Italian region Emilia Romagna for the years 2000-2001. We used a multivariate logistic regression analysis to compare an ICD-9-CM risk adjustment approach based on administrative variables (such as age, gender, principal diagnosis, combined operation, previous cardiac surgery, emergency admission, and Charlson comorbidity index) with a risk adjustment approach based on the clinical European System for Cardiac Operative Risk Evaluation (EuroSCORE) to predict in-hospital mortality and to assess hospital performance. In order to distinguish complications of care from comorbidities, we linked hospital data across multiple episodes of care up to 1 year before the admission for coronary artery bypass graft (CABG). RESULTS: The risk adjustment approach based on ICD-9-CM data provides good explanatory ability in models assessing in-hospital mortality (the c statistics obtained are very close: c = 0.76 in 2000 and c = 0.80 in 2001 for the administrative model versus 0.78 in 2000 and 0.77 in 2001 for the clinical one) and in those ranking the centres (c = 0.78 in 2000 in both approaches, and c = 0.82 for the administrative model versus c = 0.78 for the clinical one in 2001). CONCLUSIONS: Adding some administrative variables considered proxy for clinical complexity to the administrative model and linking hospital data across patients' multiple episodes of care eliminated much of the difference in effectiveness between the clinical and administrative risk adjustment approach. Focusing on the health policy context of measuring CABG death rates, our study strengthened the thesis that, with the growing improvement in accurate coding practice, administrative databases could provide a valuable and economical source for health planning and research.

Different regional organisational models and the quality of health care: the case of coronary artery bypass graft surgery.

OBJECTIVES: The Italian regions of Emilia-Romagna and Lombardy within the Italian National Health Service provide an opportunity to see if two different approaches to the organisation of care--one more hierarchical and planned, the other more competitive and market-like--influence its quality through examining the relationship between the number of coronary artery bypass grafts (CABGs) and the rate of in-hospital mortality using administrative data for the period 1996-1998. METHODS: Descriptive statistics and logistic regression models were used. RESULTS: The volume-outcome relation was statistically significant in both regions (odds ratio 0.71, P < 0.0001). Although CABG performance in Emilia-Romagna was slightly poorer than in Lombardy (OR 1.22, P < 0.05), the potential advantage in terms of the reduced risk of death for patients treated at high-volume versus low-volume hospitals was significantly greater. In Emilia-Romagna, the average performance advantage of high-volume units was more substantial in the case of private accredited hospitals than public hospitals (OR = 0.50, P < 0.0001 versus OR = 0.64, P < 0.0001). In Lombardy, the performance advantage of concentrating CABG procedures was greater in private research hospitals (OR = 0.67, P < 0.0001), whereas results were not statistically significant for the other types of hospital, indicating a good level of performance in both public and private hospitals even at low volumes. This also partially explained the lower mortality rate observed in that region. CONCLUSIONS: The degree of hierarchical regionalisation versus market-like arrangements characterising the two systems produced contrasting effects in terms of the quality of CABG surgery. Lombardy's more competitive environment appeared to achieve better performance in terms of a slightly lower probability of adverse outcomes, in a system with no formal assessment of population need and very high per capita revascularisation rates. To improve performance in the more hierarchical system adopted in Emilia-Romagna would require considerable effort to increase CABG surgery in low-volume cardiac units, and to sharpen performance incentives.

Vertical integration and contractual network in the cardiovascular sector: the experience of the Italian region Emilia Romagna.

OBJECTIVE: We analysed the integrated planning model adopted by the Italian region Emilia Romagna in year 2000 to cover the entire range of treatment of cardiovascular disease. This model, called "hub and spoke", provides for the transfer of patient care and treatment from peripheral units (the spokes) to central units (the hubs) once a certain complexity threshold has been reached. METHODS: We examined inter-temporal variations in patients flows for the selection/referral and follow-up phases between cardiac surgery and cardiology units during two periods characterised by different organisational set-ups, in order to reflect on the progress being made in the organisation of the network. The database consisted of regional records of hospital discharges during the 1997-2001 period. RESULTS: The investigation pointed to the achievement of a good degree of coordination between structures at different levels of specialisation in the case of cardiac surgery, for which six centres were selected already in 1996. On the other hand, the more recent introduction of a hierarchical system for interventional cardiology points to the prevalence of operations on patients previously treated within the same centre, to admissions by direct access, and to follow-up mainly conducted within the hub providing the initial service. CONCLUSIONS: Despite the progress made towards the more effective rationalisation of the health care network, there is still room for improvement in relations between different centres, in particular with regard to the clearer definition of the roles and interdependence of those intermediate-level centres located between the hub centres and basic healthcare facilities.