Composite Indicator of Potentially

Avoidable Hospitalizations

Yana Gurevich, MD, MPH Canadian Institute for Health Information Presentation to HCQI experts meeting November 14, 2014

1

Project Background

2

Project background • Multiple HCQI indicators measuring potentially

avoidable hospitalizations:

– Asthma

– Chronic Obstructive Pulmonary Diseases (COPD)

– Congestive Heart Failure (CHF)

– Hypertension (HTN)

– Uncontrolled diabetes without complications

– Diabetes short-term complications

– Diabetes long-term complications

3

Project background

Purpose:

• Explore validity and utility of a composite

indicator versus a number of disease specific-

indicators

• Explore the extent to which a composite

indicator improves international comparability

4

Project background

Scope:

• to utilize currently collected indicators of

potentially avoidable hospitalizations

• potentially avoidable hospitalizations for

selected chronic conditions

– for which access to appropriate primary care

could prevent the need for the current

admission to hospital

5

Results

6

Approach

• To address the potential effect of different coding

practices internationally, subgroups were created

• Subgroups represent conditions that can

potentially be coded as a principal diagnosis

interchangeably:

– Asthma + COPD

– CHF + HTN

– 3 Diabetes (uncontrolled, short-term and long-term

complications)

• The overall composite was also calculated

7

Asthma + COPD, 2011 (or nearest year)

8

0

50

100

150

200

250

300

350

400

450

500

Ag

e-S

ex S

tan

dard

ized

Rate

(p

er

100,0

00)

Asthma

COPD

COPD + Asthma

CHF + Hypertension, 2011 (or nearest year)

9

0

100

200

300

400

500

600

700

800

900

Ag

e-S

ex S

tan

dard

ized

Rate

(p

er

100,0

00)

CHF

Hypertension

CHF + Hypertension

Diabetes, 2011 (or nearest year)

10

0

50

100

150

200

250

300

350

400

450

Ag

e-S

ex S

tan

dard

ized

Rate

(p

er

100,0

00)

Uncontrolled

ST

LT

Diabetes Overall

Overall Composite, 2011 (or nearest year)

11

0

200

400

600

800

1000

1200

1400

Ag

e-S

ex S

tan

dard

ized

Rate

(p

er

100,0

00)

COPD + Asthma

CHF + Hypertension

Diabetes Overall

Overall

Overall Composite, 2011 (or nearest year)

12

24% 29%

47%

22%

59% 46% 47% 52% 41%

30% 18%

41%

55%

28%

48% 49% 49%

34%

19%

33% 35%

22%

28%

20%

34% 52%

54%

35% 67%

26% 39% 42% 38%

31% 52%

27%

46% 27%

53%

33% 34% 29%

39% 58% 31%

45% 58%

46% 61% 36%

24%

16% 18%

12% 15% 15% 11% 10%

29% 18%

55%

13% 19% 19% 19%

17% 21% 27%

23% 36%

20%

20%

26%

19%

30%

0

200

400

600

800

1000

1200

1400

Ag

e-S

ex S

tan

dard

ized

Rate

(p

er

100,0

00)

Diabetes Overall

CHF + Hypertension

COPD + Asthma

Overall Composite, 2011 (or nearest year)

International Variation

13

Highest Rate

(per 100,000) Lowest Rate

(per 100,000) Variation

Asthma 151 11 14-fold

COPD 378 23 16-fold

COPD and Asthma 451 58 8-fold

CHF 595 57 10-fold

Hypertension 374 1 374-fold

CHF and Hypertension 810 58 14-fold

Diabetes Uncontrolled 181 3 60-fold

Diabetes Short-term 65 8 8-fold

Diabetes Long-term 271 19 14-fold

Diabetes Overall 405 54 8-fold

Overall 1,339 363 4-fold

Summary of findings

• Results suggest that differences in coding

practices between interchangeable codes do

exist (e.g. Austria, Korea for HTN & CHF)

• Rankings continue to be similar

• Two years of results show similar patterns

• Composite indicator shows reduction in

international variation

• Additional work is required to finalize the

methodology of the composite indicator

14

Suggested methodological adjustments

• Explore exclusion of deaths:

– hospitalization where death occurs is mostly likely not

immediately avoidable

• Explore exclusion of patients age 75 and older:

– older patients have higher morbidity and mortality and are

more likely to require a hospitalization which is not

avoidable

• Refine definitions of the individual conditions as

determined by the UK R&D project

15

Discussion

16

Considerations for the composite indicator

in its current form

Advantages:

• Provides a simple, easy to communicate overall

assessment of primary care

• Has defined scope: avoidable hospitalizations for

selected chronic conditions

• Groups individual conditions in a clinically meaningful

way

• Improves face validity and international comparability

• Allows for inclusion of primary health care indicators in

Health at a Glance

17

Considerations for the composite indicator

in its current form

Disadvantages:

• Not covering the whole universe of potentially

avoidable hospitalizations

– Revising the scope will require substantial R&D work

• Several countries do not submit data for one or more

of the individual conditions, which may result in

exclusion from a composite

18

Key questions

• Do HCQI experts support reporting potentially

avoidable hospitalizations as a composite

indicator in general?

• Do HCQI experts agree with the scope of this

composite indicator as:

– Potentially avoidable hospitalizations for selected

chronic conditions, for which access to appropriate

primary care could prevent the need for the current

admission to hospital?

19

Recommendations for data collection

• Collect data for all 7 chronic conditions

(including hypertension)

• Collect information to support completion of R&D

work:

– Collect counts with and without in-hospital deaths for

the 7 conditions

– Question set to identify any country-specific coding

standards for current selection of chronic conditions

and why data is missing (e.g. not collected vs.

alternate coding practice)

20

Acknowledgments

Canada’s project team • Yana Gurevich, Sunita Karmakar-Hore, Mahbubul Haq

Ireland • Deirdre Mulholland

Israel • Yael Applbaum, Anat Ekka-Zohar, Shulamit Gordon

Italy • Fabrizio Carinci

New Zealand • Vladimir Stevanovic

Singapore • Denise Lee

South Korea • Sun Min Kim, Kyoung Hoon Kim

United Kingdom • Veena Raleigh, Candida Ballantyne

21

22

Thank You!