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The Johns Hopkins University’s 2007 European Conference

The Johns Hopkins University’s 2007 European Conference. ACG ® as a tool for primary care improvement in a publich health system environment Antoni Arias, M.D., PhD, MsC IASIST S.A. Karlskrona, Landstinget Blekinge, Sweden September 18th-19th, 2007. Our acknowledgments.

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The Johns Hopkins University’s 2007 European Conference

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  1. The Johns Hopkins University’s 2007 European Conference ACG® as a tool for primary care improvement in a publich health system environment Antoni Arias, M.D., PhD, MsC IASIST S.A. Karlskrona, Landstinget Blekinge, Sweden September 18th-19th, 2007

  2. Our acknowledgments This presentation has been prepared with the collaboration of the Basque Health Services Agency (Osakidetza): ACG®applications for clinical management developed in collaboration with:

  3. Contents • The health system in Spain • The contribution of case-mix systems to health care. The Spanish situation. • ACG®in Spain • Applications in Primary Care (PC): • The Basque experience: using ACG®in a public PC network • The use for clinical management • Applications in Integrated Care. Preliminary results. • Some difficulties and limitations • Expectations

  4. Who are we? Healthcare Knowledge International Companies of HKI • CHKS, UK • IASIST, Spain Countries where we operate Leader in health care information delivery in Europe, with extensive and exhaustive databases for benchmarking IASIST, distributor of ACG® in Spain and Portugal

  5. The Health System in Spain • Public health system providing universal health care coverage • Highly decentralized political structure: 17 regional governments with power to establish policies and regulations Financing: from state taxes Purchasing: 17 governments Provision: mainly public through 17 regional agencies

  6. Organization of health care delivery • Splitted health care divisions: • Primary Health Care • Specialized Care (Hospitals) • Specific budgets and management structure • Primary care: geographic structure (Basic Health Areas) • Each BHA is served by a Primary Care Team (PCT) • Coordination between Primary Care and Specialized Care never achieved • Current trends: Integrated Health Care • Unification of primary and specialized care organizations into a single management agency and budget

  7. Introduction of case-mix measures in Spain Minimum Basic Data Set Data Goverment decision DRG Implementation DRG Research Hospitals 1980 1990 2000 ACG Patchy Implem. ACG Research Primary Care Data Minimum Basic Data Set Goverment decision

  8. Current ACG® situation in Spain BASQUE COUNTRY (2004) 2,1 M 100% ARAGÓN (2007) 1,2 M (100%) CATALONIA (2005) 1,2 M (17%) Pilot projects 2 milion pat.

  9. The Basque experience • Aim: To set up ACG® system as a tool to analyze morbidity of population • Objectives: • To increase the knowledge of health care professionals about ACG® and share with them the results • To detect organizational factors that affect validity of ACG® in real life practice environment • To set up practical applications • Up to now: two years of validation and applicability studies (October, 2004-September, 2006)

  10. The Basque experience Percentage of visits registered in the electronic health record Osakidetza (2004-2007) 80,6% Abril 2007 2006 2005 2004 Common information system: 3S-Osabide

  11. The Basque experience • Criteria of data quality to include a doctor into the study group: • Level of use of the health electronic record system (> 4 diagnostic registration/patient) • Diagnostic registration coded (< 22% of diagnostics as literal quotations) • Valid diagnostic coding (<10% of errors in ICD-9-CM coding, based on a sample of 250 patients for each doctor)

  12. The Basque experience • Population and medical units included into the study have substantially increased:

  13. The Basque experience 63 % Distribution of patients by no. of ADG 25% 12 % 0,2 %

  14. The Basque experience Distribution of patients by ACG, Osakidetza 2005-06 4100: 2-3 ADG combined, age >34 003:Acute minor, age 6+

  15. The Basque experience Challenges for the near future: • To reduce the time span between data collection and delivery of results • To achieve the inclusion of 70% of units into the study • To deliver information to 100% of medical units • To improve the coding process • To improve the electronic health recording systems • To develop applications of data for clinical management

  16. ACG® for clinical management: Our experience • Delivery of useful information to improve clinical care through performance comparison with peers • Adressed to action

  17. Information for clinical management Dimensions of analysis Levels of analysis Demand Population coverage No. of patients/year Age and gender profile Analysis of overusers Attended non-assigned population External standard Organization Primary Care Team (PCT) Case-mix Relative morbidity index Frequency of ACG and EDC Resource utilization bands (RUB) Professional Efficiency Visits Pharmacy cost Referred specialist consultation Volum/cost lab tests Volum/cost X-ray Total cost

  18. 2,00 1,60 1,20 0,80 0,40 0,79 1,03 0,96 0,89 0,46 1,56 0,64 0,64 1,69 1,74 0,00 347 365 368 372 381 391 395 397 1077 1932 Information for clinical management:An example Complexity / Morbidity burden Relative weight, by PCT Lowest complexity Relative W: 0,46 54% lower morbidity burden Highest complexity Relative W: 1,74 74% higher morbidity burden

  19. Information for clinical management:An example Efficiency Pharmacy cost x patient: observed ( ) and expected ( ) Efficiency Index: 0,79 21% undercost 943.000 € Efficiency Index: 1,27 27% overcost 737.000 € 400 350 300 250 200 150 100 50 0 001 002 003 004 005 006 007 008 009 Estándar 182,58 291,57 274,75 212,19 337,71 289,03 328,99 287,14 196,36 270,49 Mean Cost (€) 231,02 271,59 293,94 243,63 296,59 295,57 258,10 280,21 241,01 270,49 Mean cost (€) expected Overcost or undercost, related to standard Efficiency Index 1,07 0,97 0,87 1,14 0,98 1,27 1,02 0,81 0,79 Impact (€) 943.068 510.658 280.254 481.278 715.386 121.540 736.869 144.487 281.209

  20. Information for clinical management:An example Medical practice, clinical conditions (EDC) PCT with lower prevalence Hypertensive patients are grouped in several ACG with different morbidity burden CAR14 – Hypertension, without severe complications 1.711 Patients % Patients, by acg Prevalence x 1.000 Patients PCT Standard PCT: 104,1 Standard: 122,9 18,7 8,8 12,0 13,6 15,6 Visits x patient (PCT – Standard) 25,3 13,6 17,7 19,4 21,0 976 511 549 797 686 €Pharmacy x patient (PCT – Standard) 913 494 557 840 570

  21. Visits €Pharmacy 14,2 739 PCT Observed PCT Expected 20,1 707 PCT Efficiency Index 0,71 1, 05 37% 34% Upper R. T. inf. Impact 9.991 55.800 23% 20% Musc.-esk. symp 22% 20% Lipid disorder Information for clinical management:An example Medical practice, clinical conditions (EDC) CAR14 – Hypertension, without severe complications Associated EDC Hypertensive patients have other associated EDC with impact in their morbidity: Higher prevalence of respiratory infections, musc.-esk. symptoms and lipid disorders Standard Hypertensive patients are attended with less visits (19% less) and higher pharmacy cost (5%)

  22. Integrated care: ongoing research Disease burden and coding: relationship between no. of diagnostics and disease burden Adding hospital-based diagnostics increase the disease burden (weight) of populations Increase is lower as higher is the no. of diagnostics in primary care +0,48 Mean weight +1,46 Primary Care Primary + Hospital Care No. diagnostics/patient

  23. Integrated care: ongoing research Total Cost Explanatory Power Analysis • Goal: to test wether acg can explain individual healthcare costs All costs included: Inpatient, outpatient, Primary Health Care, Drugs, Skilled Nursing Facilities Data year: 2005 Population: 151.542 inhabitants (Inner Area of Catalonia) Providers: 10 Primary Care; 1 hospital Healthcare users: 124.943 users (82%) Avg. Cost per inhabitant: 643 € Avg. Cost per user: 780 € (Max: 202.700€ - Min: 0,44€)

  24. Integrated care: ongoing research Total Cost Explanatory Power Analysis • ACG explanatory power on individual patient costs range from 23% (costs untransformed nor untrimmed) to 52% (costs untransformed but trimmed) • Age & Sex highest explanatory power reaches 10% (costs untransformed but trimmed)

  25. Integrated care: ongoing research Pharmacy Cost Explanatory Power (Cost in €) Analysed 72% of pharmacy cost, more representative in primary care (78%) than in specialized care (45%) aWithout diagnostic data bEstimated population cExcept cost of antineoplastic drugs dNo data available at the moment

  26. 16,1% 41,1% 18,3% 35,5% Total pharmacy (PC+SC) (*) • Age & sex • ACG • Multiple regression • ANOVA 72% Cost Integrated care: ongoing research Pharmacy Cost Explanatory Power Explanatory variables Method used Explanatory power All Inliers 16,1% 41,0% 18,5% 35,4% Pharmacy Pcare (*) • Age & sex • ACG • Multiple regression • ANOVA 78% cost (*) All explanatory variables analysed with logarithmic transformation

  27. Up to now … • Certainty about the potential of ACG® to better know the subject of the health care business: THE PATIENT • The resulting information raises a lot of questions • THE CHALLENGE: to develop a way of analysis useful to answer those questions and take actions to improve • The use of such information to improve practice and management is a learning process that needs to be worked out

  28. Up to now … • Main focus of interest of our clients in ACG® • To measure differences in disease burden among populations attended by different PCT • CASE MANAGEMENT: to identify overusers (e.g., visits) and their clinical profile. • DISEASE MANAGEMENT: to adjust performance indicators in relevant PC conditions (diabetes, hypertension, …) • OVERALL PERFORMANCE IMPROVEMENT: introducing objectives in contracts between providers and purchasers (quality of data, efficiency indicators)

  29. Difficulties and limitations • No agreement of minimun data set on patients in primary health care at national level • Critical issue: to facilitate diagnostic registration by doctors in their clinics • There is high variability in exhaustivity of diagnostics recording: data will improve as we used it • Quality of data is essential for research. However, it must NOT be a restrictive factor to use it for clinical management: with no data use and feed-back , professionals will not care about ACG® usefulness and will not register the necessary data

  30. Expectations • To get better recording of clinical data • ¿Which will be the added value of the RX-Model to the current ACG® ? • To link quality indicators to efficiency indicators • To link specialized care data to primary care data to get an integrated appraisal of morbidity and health care use. • To develop further the application to clinical management • To apply ACG® for case/disease management • To extend ACG® use to capitative payment or budgeting

  31. Thank you very much! aarias@iasist.com www.iasist.com

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