INTRODUÇÃO

1. Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic ResectionVaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection Vaginal Birth After Cesarean Bilateral Artery Catheterization Coronary Artery Bypass Graft Pancreatic Resection INTRODUÇÃO À MEDICINA

2. Introdução à Medicina II INPATIENT QUALITY INDICATORS Headteacher Altamiro da Costa-Pereira, MD, PhD Advisors José Alberto da Silva Freitas, PhD Ricardo Reis Students Adriana Raquel Costa Moura Ana Esperança Pinto Pedrosa Ana Rita da Costa Silva Gomes Ana Sofia da Silva Batista Bárbara Catarina de Oliveira Saldanha Gouveia Carolina Isabel da Costa Silva Gomes Catarina Isabel Ramos Vilas Boas Gonçalves Cristina Daniela Alves Salazar João Miguel Machado Ferreira de Sousa José Carlos Fortunato Marafona Raquel Nadais de Pinho Pereira Pinheiro Rui Pedro Files Flores Sara Francisca Ferreira Fernandes

3. Introdução à Medicina II INPATIENT QUALITY INDICATORS Introduction Why are IQIs so important? AIMS Discussion Pancreatic Resection Methods References Coronary Artery Bypass Graft Results Vaginal Birth After Cesarean Congestive Heart Failure Bilateral Cardiac Catheterization

4. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Indicators HEALTH INDICATORS Mortality Rates for Medical Conditions InpatientQuality Indicators [1][2] InpatientQuality Indicators [1][2] PreventionQuality Indicators PatientSafety Indicators PediatricQuality Indicators Volume of procedures Area-level Utilization Rates Mortality Rates for Surgical Procedures Hospital-level ProcedureUtilization Rates [1] Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and quality, Rockville, MD; [2] Justin B. Dimick; H. Gilbert Welch; John D. Birkmeyer. Surgical Mortality as an Indicator of Hospital Quality: The Problem With Small Sample Size. JAMA, August 18, 2004; 292: 847 – 851.

5. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto IQIs offer a window into the medical care delivered in hospitals.[3] Why are IQIs so important? They provide a comprehensive picture of the level and variation of quality within four components of health care quality: effectiveness, safety, timeliness and patient centeredness.[3] They can be used to flag potencial quality problems and success stories, which can be further investigated.[3] Through them, we can identify differences between hospitals, regions or communities.[3] [3] Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and quality, Rockville, MD

6. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Evaluation of hospital´s quality of care : How can we select good/valid inpatient quality indicators? Aims 1 Analyze several IQI’s selection methods used in studies; 2 Select 5 IQIs and explore their advantages and limitations; 3 Compare IQIs and conclude on how well do they reflect hospital care quality; 4 Conclude about the utilization of IQIs on the evaluation of the quality of healthcare services.

7. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto IQIs’ 1 selection methods

8. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto review Analysis of a series of studies Combination of results simultaneously adequate and representative Answer the central question

9. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto 1 Formulation of the central question; “How are IQIs selected and how well do they reflect a hospital’s quality? – Five IQIs’ example”; 2 Definition of the criteria for selection of the articles (inclusion/exclusion); 3 Definition of the research strategy; Bibliographic data base (MEDLINE and ISI Web of Knowledge); 4 Selection of 5 IQIs to analyze. Procedures frequently used in medical practice or common health problems .

10. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto QUERIES APPLIED 5 Research phase • Statistics on the disease’s prevalence/utilization of procedure; • Definition of the IQI; • Advantages and disadvantages of its utilization. [Bilateral Cardiac Catheterization] or [Bilateral Cardiac Catheterization AND Inpatient Quality Indicator, Health Care] 6 Data collection Evaluate the quality of the five IQIs on the appraisement of a hospital’s services; [Coronary Artery Bypass Graft] or [Coronary Artery Bypass Graft AND Inpatient Quality Indicator , Health Care] or [CABG] 7 Data process and analysis Answer the central question: conclude on how well do IQIs reflect a hospital’s quality. [Pancreatic Resection] or [Pancreatic Resection AND Inpatient Quality Indicator , Health Care] [Congestive Heart Failure] or [Congestive Heart Failure AND Inpatient Quality Indicator , Health Care] or [CHF AND Inpatient Quality Indicator , Health Care] [Vaginal Birth after Cesarean] or [Vaginal Birth after Cesarean AND Inpatient Quality Indicator , Health Care] or [VBAC]

11. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto 1 LANGUAGE Articles dated between 2004 and 2009; Criteria for the selection of articles TIME LIMITATION TITLE AND ABSTRACT English 2 reviewers EXCLUSION Focus on both procedure/health problem and quality indicator

12. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto 2 2 reviewers Inclusioncriteria Inpatient quality Indicators Criteria for the selection of articles Advantages/disadvantages concerning the procedure/medical problem Possible generalization of the results Exclusioncriteria Other types of quality indicators Lack of data associated to the IQI Over specific reviews

13. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto 2 Results

14. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto PR VBAC CABG BCC CHF 11 articles 9 articles 8 articles 4 articles 17 articles 7 4 6 3 6 2 2 2 9 8 Included articles Excluded articles

15. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto IQIs’ selection [4] [4] GIRALDES MDO R Efficiency versus quality in the NHS, in Portugal: methodologies for evaluation Acta Med Port. 2008 Sep-Oct21(5):397-410. E.pub 2009 Jan 16. VAGINAL BIRTH CONGESTIVE HEART FAILURE PANCREATIC RESECTION BILATERAL CARDIAC CORONARY ARTERY BYPASS GRAFT AFTER CESAREAN CATHETERIZATION

16. Pancreatic resection

17. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto • Set limits regarding the number of PRP procedures, to compare different hospitals; • PR volumes are divided into: high, low or medium. MORTALITY INDICATOR VOLUME INDICATOR • Providers with higher volumes have lower mortality rates for the procedure; • Suggests that this providers have some characteristics, either structurally or with regard to procedure that influences mortality[5]. • Indicates the raw volume compared to annual threshold (100 and 200 procedures); • Indicates the number of deaths per 100 pancreatic resection procedures; Rare procedure that requires technical proficiency; • High mortality may be associated with poorer quality of care. Errors in cirurgical management may lead to clinical significally complications; • Hospitals performing a high volume of procedures with an increased complexity may have better outcomes. • Relationship between hospital volume and mortality is unclear[6]; [5] LIEBERMAN, MICHAEL; KILBURN, H; LINDSAY M.A.; MICHAEL, PhD.; BRENNAN Murray F.; M.D; Relation of Perioperative Deaths to Hospital Volume Among Patients Undergoing Pancreatic Resection for Malignancy; Ann Surg. 1995 Nov;222(5):638-45 [6] DIMICK JB; COWAN JAJr; COLLETI LM; Upchurch GR Jr; Hospital Teaching Status and Outcomes of Complex Surgical Procedures in the United States; Arch Surg. 2008 Jan;206(1):13-6. Epub 2007 Oct 18. • Better processes of care and the increasing of hospital procedures may reduce mortality which represents better quality of care.

18. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto • Some factors (finantial conditions of the hospitals and patients characteristics) may cause illusory results [7]; • Introductionofriskadjustment for clinicalfactors (preventconfundingbias); MORTALITY INDICATOR • Not performed frequently enough to judge hospital quality – poor precision [8]. • Proxy measure for quality – shouldbeusedwithotherindicators. Disadvantages VOLUME INDICATOR [7] Marques JR ET; Maciel Filho R; August PN; Overcoming health inequity: potential benefits of a patient-centered open-source public health infostructure; Cad saude publica. 2008 Mar;24(3):547-57. [8] DIMICK Justin B; WELCH H Gilbert; BIKMEYER John D; Surgical Mortality as an Indicator of hospital quality the problem with small sample size; JAMA. 2004; 292(7):847-851.

19. Coronary Artery Bypass Graft

20. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Coronary Artery Bypass Graft Indicates raw volume compared to annualthreshold (100 and 200 procedures) Indicates thenumberofCABGsper 100,000 population Indicates thenumberofdeathsper 100 CABG procedures Itisnecessary to setlimitsregardingthenumberof CABG procedures to compare differenthospitals; CABG volume isdividedinto: high, lowormedium; To beconsidered a goodmeasureofquality, theproceduremusthaveboth a relativelyhighmortality rate andbeperformedfrequently; Volume Indicator Area-levelutilizationindicator MortalityIndicator Coronary artery bypass graft is a form of bypass surgery that can create new routes around narrowed and blocked coronary arteries, allowing increased blood flow to the oxygen delivery and nutrients to the heart muscles. The limits do notcorrespond to a certainamountbut are derivedfromanevaluationoftheassociationbetweenhospitals’ CABG volume andin-hospitalmortality. This rate depends on certain factors, including the finantial conditions of the hospital – the mortality rate is higher in hospitals less developed [9]. [9] Dimick J, Welch H, Birkmeyer. Surgical Mortality as an indicator of Hospital Quality: The Problem With Small Sample Size. JAMA. 2004

21. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Coronary Artery Bypass Graft • The associationbetween CABG proceduresandmortality rates isnotconstant; • Patients at high-volume CABG hospitals are at a lower mortality risk than patients at lower volume hospitals [10][11]; • This association has been declining over time because of the improvement of cirurgical training and technical advances[12]; • Other studies: the correlation between the number of surgeries and mortality is weak[13] and depends on the age of the studies’ participants[14]. Volume Indicator MortalityIndicator [10] Rathore S, Epstein A, et al. Hospital Coronary Artery Bypass Surgery Volume and Patient Mortality, 1998-2000. Annals of Surgery. January 2004 [11] Shahian D, O’Brien S, Normand S, et al. Association of hospital coronary artery bypass volume with processes of care, mortality, morbidity, and the Society of Thoracic Surgeons composite quality score. The Journal of Thoracic and Cardiovascular Surgery. February 2010 [12] Volume and outcome of CABG surgery: are more and less the same? [13] Mesquita ET, Ribeiro A, Araújo MP, Campos LA, Fernandes MA, Colafranceschi AS, Silveira CG, Nunes E, Rocha AS. Indicators of healthcare quality in isolated coronary artery bypass graft surgery performed at a tertiary cardiology center. Arq Bras Cardiol. May 2008 [14] Adogwa O, Costich JF, Hill R, Slavova S. Does higher surgical volume predict better patient outcomes? J Ky Med Assoc.. January 2009

22. Vaginal Birth After Cesarean

23. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Vaginal Birth After Cesarean ? Provider-level indicator that estimates vaginal births per 100 discharges (fix volume of labors in a hospital) with a diagnosis of previous cesarean delivery Represents the relative risks and benefits of a trial of labor in patients with previous cesarean delivery Observed differences represent true differences in provider performance rather than random variation Disadvatanges Good precision • reduce medical costs substantially;[15] • long term risks of a cesarean section include uterine rupture, maternal anemia and infection, perinatal death and others);[15] • unsuccessful trial of labor (TOL), in which a woman undergoes a repeated cesarean delivery instead of a vaginal delivery, has a higher rate of complications compared to a VBAC and elective repeat cesarean delivery (ERCD); • the overall benefitsof TOL are directly related to having a VBAC as these women typically have the lowest morbidity; • maternal mortality is low: 3.8 per 100 000 women who undergo a TOL die versus 13.4 per 100 000 women who undergo a ECRD die; Higher rates representbetterquality Underused procedure Advantages [15] McGrath P, Phillips E; Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean delivery; Monash Bioeth Rev. 2009 Sep;28(3):22.1-19

24. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Vaginal Birth After Cesarean • the delivery category with fewest complications is repeat cesarean – 72% had no complications[16]; • IQI measure is associated to a personal choice (whether to take or not risks on a surgery); • VBAC posed a higher risk than an elective cesarean (EC)[16]; • dependent on medical advisement[17]; • facts tend to change a mother’s choice[17]; [16] McGrath P, Phillips E; Bioethics and birth: insights on risk decision-making for an elective caesarean after a prior caesarean delivery; Monash Bioeth Rev. 2009 Sep;28(3):22.1-19 [17] Gregory KD, Korst LM, Fridman M, Shihady I, Broussard P, Fink A, Burnes Bolton L.; Vaginal birth after cesarean: clinical risk factors associated with adverse outcome; Am J Obstet Gynecol. 2008 Apr;198(4):452.e1-10; discussion 452.e10-2.

25. Congestive Heart Failure

26. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Congestive Heart Failure Progressivecronicdiseaseand a relativelycommonadmissionwithsubstantialshort-termmortality CHF mortality rate is a mortalityindicator for inpatientconditionsandmeasuresthenumberofdeathsper 100 dischargeswith principal diagnosiscodeof CHF Mortality rate from CHF has progressively declined over time[19] mainly because it can be significally reduced with appropriate terapy [20] CHF is an important public health problem, in part because survival following diagnosis is poor[18] CHF mortality has been widely used as a quality indicator: it is precise [21] and captures an aspect of quality that is regarded as important As better processes ofcaremayreduceshort-termmortality, CHF mortality rates couldbeused to indicatethequalityofhealthcarefacilities [18] Goff, DC, Jr., Pandey DK, Chan FA, et al. Congestive heart failure in the United States: is there more than meets the I(CD code)? The Corpus Christi Heart Project. Arch Intern Med 2000 [19] Ni H, Hershburger FE. Was the decreasing trend in hospital mortality from heart failure attributable to improved hospital care? The Oregon experience, 1991-1995. Am J Manage care 1999 [20] Maclntyre K, Capewell IS, Stewart S, et al. Evidence of improving prognosis in heart failure: trends in case fatality in 66547 patients hospitalized between 1986 and 1995. Circulation 2000 [21] Nationwide Inpatient Sample and State Databases.Healthcare Cost and Utilization Project. Agency for Healthcare Research and Quality, Rockville, MD.

27. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Limitations Mortality is greatly influenced by other factors that can lead to bias. Differences in mortality rates between hospitals can be attributed to unobserved patients and hospital characteristics [22]. • Bias caused by the admitting decision – failing to admit the sickest patients could improve a hospital’s survival rate [24] • In-hospital mortality measures may encourage early post-operative discharge and thereby shift deaths to skilled nursing facilities or outpatient settings [25] • Mortality rate may depend on the type of healthcare facility • Specialized hospitals have modestly lower risk and rate of short term mortality than general hospitals [23] • Patients at teaching hospitals have better survival rates than those among other hospitals [24] GENERAL [22] Werner, RM, Bradlow, ET. Relationship between Medicare’s Hospital compare performance measures and mortality rates. JAMA 2006 [23] Nallamothu, BK, Wang, Y, Cram, P, et al. Acute myocardial infarction and congestive heart failure outcomes at specialty cardiac hospitals. Circulation 2007 [24] Poses, RM, McClish, DK, Smith, WR, et al. Results of report cards for patients with congestive heart failure depend on the method used to adjust for severity. Ann Intern Med 2000 [25] Rosenthal, GE, Baker, DW, Noris, DG, et al. Relationships between in-hospital and 30-day standardized hospital mortality: implications for profiling hospitals. Health Services Research 2000

28. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Limitations Ascertaining deaths that occur after discharge is tedious and expensive if done through primary data collection and may raise concerns about risks to the patient confidentiality [26]. Hospitals inregionswith a largerelderlypopulationwillhavehighermortality rate, withoutbeingdirectlyassociatedwithqualityofcare. CHF is a conditionthatincreasesexponentiallywithaging. As the size of the elderly population increases, the substancial morbidity and mortality attributable to CHF will continue to increase [26]. PARTICULAR [26] Rosenthal, GE, Baker, DW, Noris, DG, et al. Relationships between in-hospital and 30-day standardized hospital mortality: implications for profiling hospitals. Health Services Research 2000

29. Bilateral Cardiac Catheterization

30. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Less influenced by discharge variation BCC is considered appropriate in the presence of certain clinical indications Bilateral Cardiac Catheterization Signal ratio very high at 96,2% - observed differences in provider performance likely represent true differences, rather than random variations The validity rests on the assumption that the prevalence of this clinical indication is low and relatively uniformed Hospital-level Procedure Utilization Rates Cardiac catheterization is a diagnostic test that can show if blood vessels to the heart are narrowed or blocked; Substantial variation in the use of BCC at two large community hospitals was found, even after adjusting for clinical indications [29] Advantages Disadvantages A liquid dye is injected into the arteries of the heart through a catheter, a long narrow tube that is fed through an artery, usually in the thigh, to arteries in the heart[27] Based on empirical evidence – very precise [28] Precise General procedure Other source of potential bias: large number of catheterizations performed on an outpatient basis [29] Malone ML, Bajwa TK, Battiola RJ, et al. Variation among cardiologists in the utilization of right heart catheterization at time of coronary angiography [see comments]. CathetCardiovascDiagn 1996;37(2):125-30. [28]Nationwide inpatient sample and state databases. Health care cost and utilization project. Agency for healthcare research and quality, Rockville, MD [27]http://www.dshs.state.tx.us/THCIC/publications/hospitals/IQIReport2004/Chart25.pdf

31. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto DISCUSSION 3

32. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Higher procedure volume has lower mortality rates as it depends on technical profeciency and pacient’s characteristics (low precision); PR Better processes of treatment can contribute for reducing short term mortality (that depends on the characteristic of each hospital and patient). It is a precise indicator and serves as base for comparative studies of care’s quality; CHF IQI combination must be done to allow a precise evaluation of a hospital’s quality Must have a relatively high mortality rate and be performed frequently. The association between CABG procedures and mortality rate depends on the volume of procedure of each hospital. It also depends on several factors as financial conditions. The analysis must not be done separating the volume from the mortality rate (imprecise predictor of quality); CABG BCC It is considered appropriate in the presence of certain clinical factors and contraindicated in most patients so lower rates represent better quality. Significance of the result isn’t affected by external factors (high precision rates); VBAC High rates represent better quality. Factors related with the mother’s health (for instance, obesity and uterine conditions) can influence the success rates (good measure).

33. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto The collection of inpatient quality indicators represents a part of the actual state of care’s quality using literature data. However, this indicators must be used cautiously because the research done has limitation. Language Contradiction Adaptation problems Articles which seemed to have good information were not available free of charge and were not able to obtain even after contacting the corresponding author Paucity of information Availability Led to the inclusion of articles since 1990 and might have resulted in outdated information (the volume of procedures may be lower, the incidence of diseases may be different and the technology available is not the same) The data found concerns mostly the USA so it is hard to transpose the conclusions to the reality of Portugal

34. INTRODUÇÃO À MEDICINA II Faculdade de Medicina da Universidade do Porto Although this information represents a rich data source that can provide valiable information it should not be used as a definitive source. This review allowed to reveal real quality problems for which quality improvement programs can be initiated It also showed that additional clinical information is required to understand the quality issues.

35. ? Are patients more severely ill? These indicators provide a starting point for further investigations that might explore severity of illness differences Is there evidence of higher complication rates that suggest a problem in quality of care? Another question that might be explored: for hospitals with low volumes of particular procedures, what are the patient outcomes?  Need for establishing patterned criteria that allow classification of a hospital's volume of procedures (high, medium or low volume) For example, hospitals with higher than average mortality rates for specific procedures or conditions should probe the underlying reasons: Is there a problem in the selection of patients for this particular procedure? Is there a quality-of-care problem? What is the mortality rate for patients who receive this procedure at this hospital compared with other hospitals? What is the resource use associated with receiving this procedure at this hospital compared with other hospitals?

39. THE END