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OECD Project Medical Practice Variation Country Report: Italy Second meeting of the Expert Group on Medical Practice Variations OECD

Headquarters, Paris, 25-26 April 2013 Authors Fabrizio Carinci, Senior Statistician, AGENAS Carla Ceccolini, Statistician, Ministero della Salute Francesco Di Stanislao, Prof. Hygiene & Public Health, Un.Pol.Marche, AGENAS Flavia Carle, Prof.Medical Statistics, Un.Pol.Marche, Ministero della Salute Coordinators Fulvio Moirano, Director, AGENAS Francesco Bevere, Director, DG Programmazione, Ministero della Salute

Draft – subject to revisions

Regional governments

Regions have virtually

exclusive responsibility for

the organization and

administration of publicly

funded healthcare

Pop 2011:

N=60,626,442

20 Regions

110 Provinces

Av. Pop. 2011:

N=550,000 ca.

Proxy for LHAs (ASL)

National Health Service France G, Taroni F, Donatini A.The Italian health-care system, Health Econ. 2005 Sep;14(Suppl 1):S187-202.

“Sistema Sanitario Nazionale” (SSN)

LHA

Region

Rome

Essential Levels of Care (LEAs)

Catalogue of SSN benefits positive list

services which SSN is required to provide uniformly in all regions

negative list - ineffective or non relevant benefits (cosmetic surgery, etc)

- entitlement on a case-by-case basis

- inappropriate use of hospital stay: (inpatient vs outpatient)

non-LEA services can be provided by regions using own sources

Activities on performance evaluation

Carinci F, Caracci G, Di Stanislao F, Moirano F.Performance measurement in response to the Tallinn Charter: experiences from the decentralized Italian framework, Health Policy. 2012 Nov;108(1):60-6

Management

Evaluation

National Inter Regional Regional

Responsiveness

Financial Protection

Health

Exchange of Best

Practices

Benchmarking

Governance

(+ Ministry of Finance)

RECOVERY PLANS

ALLOCATION OF NATIONAL BUDGET

Ste

wa

rdship

N

AT

ION

AL

HE

AL

TH

PL

AN

National Outcomes

Project

AGENAS Ministry Of Health (SIVeAS)

Regional Directorate General

Appropriateness

Customer Satisfaction

Civic Auditing

Networks

Improvement Cycle

Clinical

pathways

BSC Mission evaluation Pathways Analysis

Multidimensional Systems

Operational Plans

Outcomes, Appropriateness

Access Indicators

EVALUATION

REFORM

ANALYSIS

Unit in charge AGENCY,

DIRECTORATE, EXTERNAL

STAKEHOLDERS Publications

Papers/Reports Web

Governance

USE OF EVIDENCE

Targets of Operational

Plans

Stewardship

OE

CD

MP

V P

RO

JE

CT

IN

DIC

AT

OR

S

National Hospital Discharge Database

● “Scheda di Dimissione Ospedaliera” (SDO)

– Active since 28.12.1991

– Archived by Date of Discharge

● 2006-2008 ICD-9-CM 2002, DRG v.19

● 2009-today ICD-9-CM 2007, DRG v.24

● N=1 Principal Diagnosis, Procedure (Date)

● N=5 Secondary Diagnoses, Procedures

● Year 2011

– N=1,534 Hospitals

– N=7,458,840 Inpatient Discharges

OE

CD

MP

V P

RO

JE

CT

IN

DIC

AT

OR

S

Indicator

Numerator Definition

(ICD 9 CM Diagnosis)

Denominator Unit Age Groups

Control

Variable

Hospital

Medical Admissions

Type DRG = “M” Population by Province, Region

100,000 15-34

35-44

45-54

55-64

65-74

75+

Caesarean

Sections

(Females)

Any procedure:

74.0-74.2 Classical, low cervical, extraperitoneal caesarean

74.4 Caesarean section of other specified type

74.99 Other caesarean section unspecified type

Live births by Province, Region

1,000 <19

20-24

25-29

30-34

35-39

40+

Av. LOS by Province, Region

Coronary

Bypass

(CABG)

Any procedure:

36.1, 36.11-36.19

Aortocoronary bypass for heart revascularization

Population by Province, Region

100,000 20-49

50-64

65-74

75+

Av. LOS by Province, Region

Coronary

Angioplasty (PTCA)

Any procedure:

36.0 Removal Of Coronary Artery Obstruction

and Insertion Of Stent(s)

Population by Province, Region

100,000 20-49

50-64

65-74

75+

Catheterization Any procedure:

37.21 Right Heart Cardiac Catheterization

37.22 Left Heart Cardiac Catheterization

37.23 Combined Right Left Heart Cardiac Catheterization

Population by Province, Region

100,000 20-49

50-64

65-74

75+

Statistical Outputs

● Age, Sex Standardized Rates by Province, Region

– Median(Range), Percentiles, CV

– Barplots

● Geographical Variation of Indicators and Mean LOS

– Maps

● Excess Variation

– Funnel Plots

● Temporal trends 2007-2011

– Boxplots

● Multivariate patterns

– Starplots

Hospital Medical Admissions – Italy 2011

Hospital Medical Admissions – Italy 2011

Hospital Medical Admissions – Italy 2011

Caesarean Sections – Italy 2011

Caesarean Sections – Italy 2011

Caesarean Sections – Mean LOS - Italy 2011

Caesarean Sections – Italy 2011

Coronary Bypass (CABG) – Italy 2011

Coronary Bypass (CABG) – Italy 2011

Coronary Bypass (CABG) Mean LOS – Italy 2011

Coronary Bypass (CABG) – Italy 2011

Coronary Angioplasty (PTCA) – Italy 2011

Coronary Angioplasty (PTCA) – Italy 2011

Catheterization – Italy 2011

Catheterization – Italy 2011

Catheterization – Italy 2011

Knee Replacement – Italy 2011

Knee Replacement – Italy 2011

Knee Replacement – Mean LOS - Italy 2011

Knee Replacement – Italy 2011

Knee Arthroscopy – Italy 2011

Knee Arthroscopy – Italy 2011

Knee Arthroscopy – Italy 2011

Surgery after Hip Fracture – Italy 2011

Surgery after Hip Fracture – Italy 2011

Surgery after Hip Fracture – Mean LOS - Italy 2011

Surgery after Hip Fracture – Italy 2011

Histerectomy – Italy 2011

Histerectomy – Italy 2011

Histerectomy – Mean LOS - Italy 2011

Histerectomy – Italy 2011

Trends MPV Indicators – Italy 2007-2011

Trends MPV Mean LOS – Italy 2007-2011

Trends MPV Indicators by Region – Italy 2007

Trends MPV Indicators by Region – Italy 2008

Trends MPV Indicators by Region – Italy 2009

Trends MPV Indicators by Region – Italy 2010

Trends MPV Indicators by Region – Italy 2011

Policy implications

● Fostered activities on cost containment (“Recovery Plans”) and Performance Evaluation (“National Outcomes Program”) appear to positively impact on the progressive reduction of excess rates

● Nevertheless, a very high geographical variation is still observed for different indicators, particularly Caesarean sections and Catetherization

● Large deviation from national rates raise concerns on the level of equity and fair access to the most appropriate treatment for all Italian citizens

● A larger pool of control variables by territorial unit (structural and population-based, e.g. different prevalence of major risk factors) is needed to explain the excess variability of standardized rates.

● Risk adjustment techniques shall be used to incorporate multilevel explanatory variables (structural and population-based - risk factors, prevalence of diseases, etc)

Conclusions

● The existing patterns of medical practice variations in Italy deserve to be further explored in order to identify potential determinants and relevant policy options.

● Sharing these results internally (particularly with regional decision makers, health professionals, scientific associations and representatives of citizens) is paramount to attempt reducing the excess variations and gain more efficiency and equity at the national level.

● International comparisons will provide the essential set of common reference values and a toolbox of externally validated methods.