[Patterns of health services use and costs in patients with mental disorders in primary care]. / Costes y patrón de uso de servicios en pacientes que demandan atención por problemas mentales en asistencia primaria.

OBJECTIVES: To determine the pattern of services use and costs of patients requiring care for mental disorders (MD) in primary care in the context of routine clinical practice. METHODS: We performed a retrospective study of patients older than 15 consulting primary care at least once for MD, attended by 5 primary care teams in 2004. A comparative group was formed with the remaining outpatients without MD. The main measurements were age, gender, case-mix/comorbidity and health resource utilization and corresponding outpatient costs (drugs, diagnostic tests and visits). Multiple logistic regression analysis and ANCOVA models were applied. RESULTS: A total of 64,072 patients were assessed, of which 11,128 had some type of MD (17.4%; 95% CI, 16.7-18.1). Patients consulting for MD had a greater number of health problems (6.7 vs. 4.7; p < 0.0001) and higher resource consumption, mainly all-type medical visits/patient/year (10.7 vs. 7.2; p < 0.0001). The mean annual cost per patient was higher for patients with MD (851.5 vs. 519.2 euros; p < 0.0001), and this difference remained significant after adjusting by age, sex and comorbidities, with a differential cost of euros 72.7 (95% CI, 59.2-85.9). All components of outpatient management costs were significantly higher in the MD group. CONCLUSIONS: Outpatients seeking care for some type of MD had a high number of comorbidities and showed greater annual cost per patient in the primary care setting.

Costes y patrón de uso de servicios en pacientes que demandan atención por problemas mentales en asistencia primaria / Patterns of health services use and costs in patients with mental disorders in primary care

Objetivos: Determinar el patrón de uso de servicios y costes en pacientes que demandan atención por problemas mentales (PM) en asistencia primaria en situación de práctica clínica habitual. Métodos: Estudio retrospectivo. Se incluyeron pacientes mayores de 15 años, con al menos una demanda de atención por PM, atendidos por 5 equipos de atención primaria durante el año 2004. Se formó un grupo comparativo con el resto de pacientes sin PM. Las variables fueron: edad, sexo, casuística/comorbilidad, utilización de recursos sanitarios y costes ambulatorios correspondientes (medicamentos, procedimientos diagnósticos y visitas). Se empleó el análisis de regresión logística múltiple y modelos de ANCOVA. Resultados: Se incluyeron 64.072 pacientes, de los cuales 11.128 presentaron algún PM (17,4%; intervalo de confianza [IC] del 95%, 16,7-18,1). Los pacientes que demandaron atención por PM presentaron un mayor número de problemas de salud (6,7 frente a 4,7; p < 0,0001) y de utilización de recursos sanitarios, particularmente visitas médicas/paciente/año (10,7 frente a 7,2; p < 0,0001). El coste medio anual en pacientes con PM fue significativamente superior (851,5 frente a 519,2 euros; p < 0,0001) y se mantuvo después de corregir por edad, sexo y comorbilidades, con un coste diferencial de 72,7 euros (IC del 95%, 59,2-85,9). Todos los componentes del coste por paciente fueron mayores en el grupo de pacientes con PM. Conclusiones: Los pacientes que han demandado atención por algún PM presentan un elevado número de comorbilidades y un mayor coste anual por paciente en el ámbito de la atención primaria

Objectives: To determine the pattern of services use and costs of patients requiring care for mental disorders (MD) in primary care in the context of routine clinical practice. Methods: We performed a retrospective study of patients older than 15 consulting primary care at least once for MD, attended by 5 primary care teams in 2004. A comparative group was formed with the remaining outpatients without MD. The main measurements were age, gender, case-mix/comorbidity and health resource utilization and corresponding outpatient costs (drugs, diagnostic tests and visits). Multiple logistic regression analysis and ANCOVA models were applied. Results: A total of 64,072 patients were assessed, of which 11,128 had some type of MD (17.4%; 95% CI, 16.7-18.1). Patients consulting for MD had a greater number of health problems (6.7 vs. 4.7; p < 0.0001) and higher resource consumption, mainly all-type medical visits/patient/year (10.7 vs. 7.2; p < 0.0001). The mean annual cost per patient was higher for patients with MD (851.5 vs. 519.2 euros; p < 0.0001), and this difference remained significant after adjusting by age, sex and comorbidities, with a differential cost of euros 72.7 (95% CI, 59.2-85.9). All components of outpatient management costs were significantly higher in the MD group. Conclusions: Outpatients seeking care for some type of MD had a high number of comorbidities and showed greater annual cost per patient in the primary care setting

Adjusted Clinical Groups use as a measure of the referrals efficiency from primary care to specialized in Spain.

BACKGROUND: To determine the referral rate (RR) per centre, its main causes and the adjusted efficiency indexes, through the retrospective implementation of the Adjusted Clinical Groups (ACG) in a Spanish primary care setting. METHODS: Design descriptive-retrospective study. Attended patients by five primary care teams (PCT) during the year 2004 were included. General parameters, age, gender, dependent (visits and episodes), and comorbidity of each patient relative to each ACG are used as measures. The RR was defined as the quotient between the number of referrals and the visits made. Efficiency Index (EI) was established dividing the observed by the expected referrals obtained by indirect standardization. Statistical significance P<0.05. RESULTS: Studied patients 81,335 (use: 76.9%), 5.0+/-3.6 episodes and 7.9+/-7.8 visits/patient/year. Percentage of visits with a referral, adjusted for morbidity burden, was 7.5% (CI: 7.3-7.7); age: 48.3+/-22.7 years (women: 55.9%), P=0.000. The average of referrals was of 59.6 per 100 attended patients/year (P=0.000). Visits and episodes explain 34.1-68.1%, respectively (P=0.000), the explanatory power of the classification's variability was of 23.6% (P=0.0001). EI per centre were: 0.95 (CI: 0.82-1.08); 0.78 (CI: 0.63-0.93); 0.88 (CI: 0.73-1.03); 1.15 (CI: 1.03-1.27) and 1.08 (CI: 0.95-1.21), P=0.034 (family practice); and 0.83 (CI: 0.70-0.96); 0.83 (CI: 0.68-0.98); 0.84 (CI: 0.70-0.98); 1.24 (CI: 1.12-1.36) and 1.16 (CI: 1.03-1.29), P=0.041 (paediatrics), respectively. CONCLUSIONS: Adjusted morbidity by ACG explains an important part of the referrals variability. The study results must be interpreted cautiously even after adjustment by age, gender and morbidity. Should the results be confirmed, it would allow an improvement in the measurement of referrals for clinical management in the PCT.

[Comparative study at 4 health centres of efficiency, measured on the basis of ambulatory care groups]. / Estudio comparativo de la eficiencia, medida a partir de los Ambulatory Care Groups, entre 4 centros de salud.

OBJECTIVE: To measure efficiency in the use of resources for the care lists of four primary care centres (PCC), by using ambulatory care Groups (ACGs). DESIGN: Retrospective, observational study. SETTING: Four PC teams. PARTICIPANTS: All patients attended during 2003. MEASUREMENTS: Dependent variables (costs per patient, between medical lists [family medicine, paediatrics] and PCCs) and case load variables. The model of costs for each patient was set by differentiating the semi-fixed and variable costs. The efficiency index (EI) was set as the quotient between the observed real cost and the expected cost on the basis of ACG distribution, by indirect standardization. The study population was 62,311 patients seen, with an average of 4.8+/-3.2 episodes/patient/year. MAIN RESULTS: The total health care cost reached 24,135,236.62 euro, of which 65.2% was for prescription, 28.9% for semi-fixed costs, and 2.9% for cost of specialist referrals. The average total cost per patient/year was 387.34 euro+/-145.87 euro (average relative weight). The EI for each centre was: 0.93 (95% CI, 0.85-1.01), 0.97 (95% CI, 0.89-1.05), 1.04 (95% CI, 0.96-1.12), and 1.05 (95% CI, 0.97-1.13), P < .0001. In addition, differences between the medical lists (rank, 0.63-1.56) and between the paediatrics lists (rank, 0.73-1.26) were found (P = .005). CONCLUSIONS: The ACGs enabled us to estimate the efficiency of our PCCs and care lists. Efficiency cannot be isolated from other dimensions of the quality of health care delivery. Study of the EI improved our understanding of the profile of professionals and health centres.

Estudio comparativo de la eficiencia, medida a partir de los Ambulatory Care Groups, entre 4 centros de salud / Comparative study at 4 health centres of efficiency, measured on the basis of ambulatory care groups

Objetivo. Medir la eficiencia en el uso de recursos entre los cupos asistenciales de 4 centros de atención primaria de salud (APS), a partir de la utilización de los Ambulatory Care Groups (ACG). Diseño. Estudio observacional retrospectivo. Emplazamiento. Cuatro equipos de atención primaria. Participantes. Todos los pacientes atendidos durante el año 2003. Mediciones. Variables dependientes (costes por paciente, entre cupos médicos [medicina de familia, pediatría] y centros asistenciales) y de casuística. El modelo de costes para cada paciente se estableció diferenciando los costes semifijos y los variables. El índice de eficiencia (IE) se estableció entre el cociente entre el coste real observado y el coste esperado en función de la distribución ACG, por estandarización indirecta. Resultados principales. La población de estudio fue de 62.311 pacientes atendidos, con una media de 4,8 ± 3,2 episodios/paciente/año. El coste total de la atención sanitaria ascendió a 24.135.236,62 €, de los cuales el 65,2% correspondió a la prescripción de farmacia, el 28,9% a los costes semifijos y el 2,9% al coste de las derivaciones a especialistas. El promedio de coste total por paciente/año fue de 387,34 ± 145,87 € (peso relativo medio). El IE por centro fue de 0,93 (intervalo de confianza [IC] del 95% 0,85-1,01), 0,97 (IC del 95% del 95% 0,89-1,05), 1,04 (IC del 95% 0,96-1,12) y 1,05 (IC del 95%, 0,97-1,13), respectivamente (p < 0,0001). Además, se observan diferencias entre los cupos médicos (rango, 0,63-1,56) y entre los cupos pediátricos (rango, 0,73-1,26) (p = 0,005). Conclusiones. Los ACG permiten realizar una aproximación a la medida de la eficiencia de centros y cupos asistenciales de APS de nuestro entorno. La eficiencia no puede ser considerada de manera aislada de otras dimensiones de la calidad asistencial. El estudio del IE permite profundizar en el conocimiento del perfil de los profesionales y de los centros de salud

Objective. To measure efficiency in the use of resources for the care lists of four primary care centres (PCC), by using ambulatory care Groups (ACGs). Design. Retrospective, observational study. Setting. Four PC teams. Participants. All patients attended during 2003. Measurements. Dependent variables (costs per patient, between medical lists [family medicine, paediatrics] and PCCs) and case load variables. The model of costs for each patient was set by differentiating the semi-fixed and variable costs. The efficiency index (EI) was set as the quotient between the observed real cost and the expected cost on the basis of ACG distribution, by indirect standardization. The study population was 62 311 patients seen, with an average of 4.8±3.2 episodes/patient/year. Main results. The total health care cost reached €24 135 236.62, of which 65.2% was for prescription, 28.9% for semi-fixed costs, and 2.9% for cost of specialist referrals. The average total cost per patient/year was €387.34±€145.87 (average relative weight). The EI for each centre was: 0.93 (95% CI, 0.85-1.01), 0.97 (95% CI, 0.89-1.05), 1.04 (95% CI, 0.96-1.12), and 1.05 (95% CI, 0.97-1.13), P<.0001. In addition, differences between the medical lists (rank, 0.63-1.56) and between the paediatrics lists (rank, 0.73-1.26) were found (P=.005). Conclusions. The ACGs enabled us to estimate the efficiency of our PCCs and care lists. Efficiency cannot be isolated from other dimensions of the quality of health care delivery. Study of the EI improved our understanding of the profile of professionals and health centres

[Measurement of relative cost weights as an effect of the retrospective application of adjusted clinical groups in primary care]. / Medida de los pesos relativos del coste de la asistencia como efecto de la aplicación retrospectiva de los adjusted clinical groups en atención primaria.

OBJECTIVE: The objective of the study is to obtain the cost's relative average weights of the assistance with the retrospective application of the Adjusted Clinical Groups (ACG's) in four teams of Primary Care with an attended population in the habitual clinical practice situation. METHODS: Descriptive study of retrospective character. It was included in the study all attended patients by four teams of Primary Care during year 2003. The main measures were: universal variables (age and gender), dependents (visits and costs) and casuistic and co morbidity. The model of cost per each patient was established differencing the fix costs and the variable ones. Was effected a multiple lineal regression analysis for the prediction of models. The relative cost of each ACG was obtained dividing the average cost of each category among the average cost of each population of reference. RESULTS: The total number of the studied patients was 62,311 (intensity of use: 76.7%), with an average 4.8 +/- 3.2 episodes and 7.8 +/- 7.5 visits/patient/year. The distribution of costs was 24,135,236.41 euro, 28.9% for fix. The total unitary cost per visit/year was 49.62 +/- 24.71 euro and the average of the total cost per patient/year 387.34 +/- 145.87 euro (relative weights of reference). The explicative power of the classification of ACG was 50.1% in visits and 54.9% for total costs. CONCLUSIONS: The ACG are an acceptable system of classification of patients in situation of habitual clinic practice. In case results were confirmed will make possible an improvement in the practice application of ACG as a possible tool for the clinical management in Primary Care centers.

[Prospects of adjusted clinical groups (ACG's) in capitated payment risk adjustment]. / Posibilidades de los grupos clínicos ajustados (ajusted clinical groups-ACGS) en el ajuste de riesgos de pago capitativo.

BACKGROUND: Most patient classification systems have been designed in the United States for the purpose of availing of a tool providing a means of gauging the use of resources. This study was aimed at calculating the mean relative weights (MRW's) for the cost of care at several primary care health facilities as compared to those in the U.S. by using the Adjusted Clinical Groups (ACG's) as a possible capitated payment risk adjustment. METHODS: Descriptive study. All of the clinical records generated by four primary care facilities throughout 2003 were included. The main measurements were: age and gender, resources (visits and costs) and casuistics. The cost model was determined for each individual patient by differentiating the fixed and variable costs. A regression analysis was made for model adjustment purposes. The relative cost of each ACG was calculated by dividing the mean cost of each category by the mean cost of the population as a whole. RESULTS: A total of 62,311 records were studied, revealing an average of 4.8 +/- 3.2 diagnoses and 7.8 +/- 7.5 visits/patient/year. The total expense was 24.1 million euros, the fixed and semi-fixed costs totaling 28.9% and the variable costs 71.1%. The mean total cost/patient/year was 387.34 +/- 145.87? (reference). The adjusted explicative power of the cost of care between the two classifications (U.S. classification vs. the one studied) was 64.3%; p = 0.000). CONCLUSIONS: The generalization of the results must be carefully construed. ACG's show themselves to be a suitable tool, and the mean U.S. RW's could be used for adjusting capitated payment risk adjustments in view of the difficulty of availing of full, consistent databases in our environment. Further research would be required to back up the consistency of the results.

Medida de los pesos relativos del coste de la asistencia como efecto de la aplicación retrospectiva de los adjusted clinical groups en atención primaria / Measurement of relative cost weights as an effect of the retrospective application of adjusted clinical groups in primary care

Objetivo: El objeto del estudio es obtener los pesos relativos medios de los costes de la asistencia con la aplicación retrospectiva de los adjusted clinical groups (ACG) en población atendida por equipos de atención primaria en situación de práctica clínica habitual. Métodos: Estudio descriptivo de carácter retrospectivo. Fueron incluidos en el estudio todos los pacientes atendidos por 4 equipos de atención primaria durante el año 2003. Las principales mediciones fueron: variables universales (edad y sexo), dependientes (visitas y costes) y de casuística o comorbilidad. El modelo de costes para cada paciente se estableció diferenciando los costes fijos y los variables. Se efectuó un análisis de regresión lineal múltiple para la predicción de los modelos. El coste relativo de cada ACG se obtuvo dividiendo el coste medio de cada categoría entre el coste medio de toda la población de referencia. Resultados: El número total de pacientes estudiados fue de 62.311 (intensidad de uso del 76,7%), con una media de 4,8 ± 3,2 episodios y 7,8 ± 7,5 visitas/paciente/año. La distribución de los costes fue de 24.135.236,41 €, el 28,9% fijos. El coste unitario total por visita/año fue de 49,62 ± 24,71 € y el promedio paciente/año de 387,34 ± 145,87 € (pesos relativos de referencia). El poder explicativo de la clasificación ACG fue del 50,1% en las visitas y del 54,9% para los costes totales. Conclusiones: Los ACG se muestran como un aceptable sistema de clasificación de pacientes en situación de práctica clínica habitual. De confirmarse los resultados posibilitarían una mejora en la aplicación práctica de los ACG como una posible herramienta para la gestión clínica en los centros de atención primaria

Objective: The objective of the study is to obtain the cost's relative average weights of the assistance with the retrospective application of the Adjusted Clinical Groups (ACG's) in four teams of Primary Care with an attended population in the habitual clinical practice situation. Methods: Descriptive study of retrospective character. It was included in the study all attended patients by four teams of Primary Care during year 2003. The main measures were: universal variables (age and gender), dependents (visits and costs) and casuistic and co morbidity. The model of cost per each patient was established differencing the fix costs and the variable ones. Was effected a multiple lineal regression analysis for the prediction of models. The relative cost of each ACG was obtained dividing the average cost of each category among the average cost of each population of reference. Results: The total number of the studied patients was 62,311 (intensity of use: 76.7%), with an average 4.8 ± 3.2 episodes and 7.8 ± 7.5 visits/patient/year. The distribution of costs was 24,135,236.41 €, 28.9% for fix. The total unitary cost per visit/year was 49.62 ± 24.71 € and the average of the total cost per patient/year 387.34 ± 145.87 € (relative weights of reference). The explicative power of the classification of ACG was 50.1% in visits and 54.9% for total costs. Conclusions: The ACG are an acceptable system of classification of patients in situation of habitual clinic practice. In case results were confirmed will make possible an improvement in the practice application of ACG as a possible tool for the clinical management in Primary Care centers

Posibilidades de los grupos clínicos ajustados (ajusted clinical groups-acgs) en el ajuste de riesgos de pago capitativo / Prospects of adjusted clinical groups (ACG´s) in capitated payment risk adjustment

Fundamento: La mayoría de los sistemas de clasificación depacientes han sido diseñados en Estados Unidos con la finalidad dedisponer de una herramienta que facilite una medida en la utilizaciónde los recursos. El objeto del estudio fue obtener los pesos relativos(PR) medios del coste de la asistencia en varios equipos de atenciónprimaria de salud, en comparación con los americanos, mediante laaplicación de los Grupos Clínicos Ajustados (ACGs), como un posibleajuste de riesgos de pago capitativo.Métodos: Estudio descriptivo. Se incluyeron todas las historiasclínicas generadas por cuatro equipos de atención primaria durante elaño 2003. Las principales mediciones fueron: edad y sexo, recursos(visitas y costes) y casuística. El modelo de costes para cada pacientese estableció diferenciando los costes fijos y variables. Se efectuóun análisis de regresión para la corrección del modelo. El coste relativode cada ACG se obtuvo dividiendo el coste medio de cada categoríaentre el coste medio de toda la población de referencia.Resultados: El número total de historias estudiadas fue de62.311, con una media de 4,8±3,2 diagnósticos y 7,8±7,5visitas/paciente/año. El gasto total fue de 24,1 millones de euros, loscostes fijos o semifijos representan el 28,9% y los variables el71,1%. El promedio de coste total por paciente/año fue de387,34±145,87? (referencia). El poder explicativo corregido delcoste de la asistencia entre las dos clasificaciones (estadounidenserespecto a la estudiada) fue del 64,3%; p=0,000).Conclusiones: La generalización de los resultados debe de interpretarsecon prudencia. Los ACGs se muestran como un instrumentoadecuado y podrían utilizarse los PR medios estadounidenses parael ajuste del riesgo en el pago capitativo, ante la dificultad de tenerbases de datos amplias y consistentes en nuestro medio. Sería necesarioesperar nuevas investigaciones que refuercen la consistencia delos resultados

Background: Most patient classification systems have beendesigned in the United States for the purpose of availing of a toolproviding a means of gauging the use of resources. This study wasaimed at calculating the mean relative weights (MRW´s) for thecost of care at several primary care health facilities as compared tothose in the U.S. by using the Adjusted Clinical Groups (ACG´s) asa possible capitated payment risk adjustment.Methods: Descriptive study. All of the clinical records generatedby four primary care facilities throughout 2003 were included.The main measurements were: age and gender, resources (visits andcosts) and casuistics. The cost model was determined for each individualpatient by differentiating the fixed and variable costs. Aregression analysis was made for model adjustment purposes. Therelative cost of each ACG was calculated by dividing the mean costof each category by the mean cost of the population as a whole.Results: A total of 62,311 records were studied, revealing anaverage of 4.8±3.2 diagnoses and 7.8±7.5 visits/patient/year. Thetotal expense was 24.1 million euros, the fixed and semi-fixed coststotaling 28.9% and the variable costs 71.1%. The mean totalcost/patient/year was 387.34±145.87? (reference). The adjustedexplicative power of the cost of care between the two classifications(U.S. classification vs. the one studied) was 64.3%; p=0,000).Conclusions: The generalization of the results must be carefullyconstrued. ACG´s show themselves to be a suitable tool, and themean U.S. RW´s could be used for adjusting capitated payment riskadjustments in view of the difficulty of availing of full, consistentdatabases in our environment. Further research would be required toback up the consistency of the results