Pneumonia burden in elderly patients: a classification algorithm using administrative data.

BACKGROUND: Pneumonia has traditionally been classified into two subtypes: community-acquired pneumonia (CAP) and nosocomial pneumonia (NP). Recently, a new entity has been defined, called healthcare-associated pneumonia (HCAP). Few studies have investigated the potential of population-based, electronic, healthcare databases to identify the incidences of these three subtypes of pneumonia. The aim of this study was to estimate the burden of the three subtypes of pneumonia in elderly patients (aged 65+ years) in a large region of central Italy. METHODS: A retrospective cohort study was performed using linked regional Hospital Information System and Mortality Register. All episodes of pneumonia in elderly patients, who were discharged from the hospital in 2006-2008, were selected for the study. Following a validated ICD-9-coding algorithm, incidents of pneumonia events were classified into three groups (HCAP; probable nosocomial pneumonia, PNP; and CAP). Hospitalisation rates were calculated by age group (65-79, 80+), gender, and year, using the population from the Institute of Statistics (ISTAT) census estimates as denominators. RESULTS: A total of 26,239 pneumonia events occurred in 24,338 patients residing in the Lazio region, aged 65+ years: 2257 HCAP, 6775 PNP, and 17,107 CAP. For all subtypes, the proportion of males was greater than females. Comorbidity status was more severe in HCAP than in the other categories. In-hospital mortality, 30-day mortality, and length of hospital stay were twice higher in HCAP than in CAP episodes. The annual incidence rates were 0.7, 2.1, and 5.4 episodes per 1000 residents for HCAP, PNP, and CAP, respectively. From 2006 to 2008, incidence rates slightly increased for all three subtypes. CONCLUSION: Health care databases can be used to give a timely and inexpensive picture of the epidemiology of pneumonia. HCAP represents a distinct category of pneumonia, with the longest stay, highest mortality, and the greatest comorbidity.

Effect of evidence-based drug therapy on long-term outcomes in patients discharged after myocardial infarction: a nested case­control study in Italy.

PURPOSE: There are some methodological concerns regarding results from observational studies about the effectiveness of evidence-based (EB) drug therapy in secondary prevention after myocardial infarction. The present study used a nested case­control approach to address these major methodological limitations. METHODS: A cohort of 6880 patients discharged from hospital after acute myocardial infarction (AMI) in 2006­2007 was enrolled and followed-up throughout 2009. Exposure was defined as adherence to each drug in terms of the proportion of days covered (cutoff ≥ 75%). Composite treatment groups, that is, groups with no EB therapy or therapy with one, two, three, or four EB drugs), were analyzed. Outcomes were overall mortality and reinfarction. Nested case­control studies were performed for both outcomes, matching four controls to every case (841 deaths, 778 reinfarctions) by gender, age, and individual follow-up. The association between exposure to EB drug therapy and outcomes was analyzed using conditional logistic regression, adjusting for revascularization procedures, comorbidities, duration of index admission, and use of the study drugs prior to admission. RESULTS: Mortality and reinfarction risk decreased with the use of an increasing number of EB drugs. Combinations of two or more EB drugs were associated with a significant protective effect (p < 0.001) versus no EB drugs (mortality: 4 EB drugs: ORadj = 0.35; 95%CI: 0.21­0.59; reinfarction: 4 EB drugs: ORadj = 0.23; 95%CI: 0.15­0.37). CONCLUSIONS: These findings of the beneficial effects of EB polytherapy on mortality and morbidity in a population-based setting using a nested case­control approach strengthen existing evidence from observational studies.

[Definition and validation of a predictive model to identify patients with chronic obstructive pulmonary disease (COPD) from administrative databases]. / Definizione e validazione di un modello predittivo per l'identificazione di pazienti affetti da broncopneumopatia cronica ostruttiva (BPCO) a partire dai sistemi informativi sanitari.

OBJECTIVE: To develop and validate a predictive model for the identification of patients with Chronic Obstructive Pulmonary Disease (COPD) among the resident population of the Lazio region, using information available in the regional administrative systems (SIS) as well as clinical data of a panel of COPD patients. SETTING AND PARTICIPANTS: All residents in the Lazio region over 40 years of age in 2007 (2,625,102 inhabitants) MAIN OUTCOME MEASURES: The predictive model was developed through record linkage of health care related consumption patterns among 428 panel patients with confirmed COPD diagnosis in 2006 and a control group of patients without COPD (selection from outpatients specialized health care registry, 1:4). Hospital admission for COPD was defined a priori to be sufficient to identify a COPD patient. For all other panel patients and controls, specific drug use (minimum 2 prescriptions during 12 months) and hospitalization for respiratory causes during the past 9 years were retrieved and compared between panel and control patients. COPD associated factors were selected through a Bootstrap- Stepwise (BS) procedure. The predictive model was validated through internal (cross-validation-bootstrap) and external validation (comparison with external COPD patients with confirmed diagnosis), and through comparison with other COPD identification approaches. RESULTS: The BS procedure identified the following predictors of COPD: consumption of beta 2 agonists, anticholinergics, corticosteroids, oxygen, and previous hospitalization for respiratory failure. For each patient, the expected probability of being affected by COPD was estimated. Depending on the cut-point of expected probability, sensibility ranged from 74.5% to 99.6% and specificity from 37.8% to 86.2%. Using the 0.30 cut-point, the model succeeded in identifying 67% of patients with diagnosis of COPD confirmed with spirometry. The predictive performance increased with increasing COPD severity. Prevalence of COPD turned out to be 7.8 %. The age-specific estimation was similar to results from other approaches. CONCLUSION: The predictive model shows good performance to identify COPD patients, even if it does not allow to identify those patients who have not been registered in the regional health care service or do not request any public health care service.

Definition of patients treated with evidence based drugs in absence of prescribed daily doses: the example of acute myocardial infarction.

PURPOSE: Define patients treated with evidence-based drugs in a cohort discharged after acute myocardial infarction (AMI) in absence of prescribed daily doses (PDD). To compare different drug use measures and analyze their impact on the effect estimate of risk factors related to drug use. METHODS: AMI patients discharged in Rome during 2006-2007 were selected from the Hospital Information System. Drugs claimed during the 12 months after discharge were retrieved. Measures of drug use were defined as: 'continuity' (one prescription each follow-up quarter-year) and the 'proportion of days covered' calculated by defined daily doses (DDDs) or pill counts (PCs) (≥ 80% of individual follow-up). Poly-therapy was defined through the same drug use measure for all drug groups. Kappa index was calculated to analyze the concordance between measures. For each measure we estimated the effect of age, gender and Percutaneous Transluminal Coronary Angioplasty (PTCA) on poly-therapy. RESULTS: Poly-therapy rates varied between 11.5 and 37.8% in the cohort and between 17.3 and 56.9% in patients with at least one prescription for all drugs. Concordance between all measures was high for antiplatelets (k=0.74) and very low for beta-blockers (k=0.22). According to measures used, gender and older age effects slightly varied, while PTCA remained a strong determinant of drug use. CONCLUSIONS: Different measures of exposure to drug treatment may affect the estimate of the proportion of treated patients and the effect estimates of risk factors. Drug dispense registries are useful, but it is necessary to develop and validate methodologies in absence of PDD.

[Chronic obstructive pulmonary disease prevalence estimated using a standard algorithm based on electronic health data in various areas of Italy]. / Stima della prevalenza di broncopneumopatia cronico-ostruttiva basata su dati sanitari correnti, mediante l'uso di un algoritmo comune, in differenti aree italiane.

AIM: to estimate the prevalence of chronic obstructive pulmonary disease (COPD) by integrating various administrative health information systems. METHODS: prevalent COPD cases were defined as those reported in the hospital discharge registry (HDR) and cause of mortality registry (CMR) with codes 490*, 491*, 492*, 494* and 496* of the International diseases classification 9th revision. Annual prevalence was estimated in 35+ year-old residents in six Italian areas ofb different sizes, in the period 2002-2004. We included cases observed in the previous four years who were alive at the beginning of each year. RESULTS: in 2003, age-standardized prevalence rates varied from 1.6% in Venice to 5% in Taranto. Prevalence was higher in males and increased with age. The highest rates were observed in central (Rome) and southern (Taranto) cities, especially in the 35-64 age group. HDR contributed 91% of cases. Health-tax exemption registry would increase the prevalence estimate by 0.2% if used as a third data source. CONCLUSIONS: with respect to the National Health Status survey, COPD prevalence is underestimated by 1%-3%; this can partly be due to the selection of severe and exacerbated COPD by the algorithm used. However, age, gender and geographical characteristics of prevalent cases were comparable to national estimates. Including cases observed in previous years (longitudinal estimates) increased the point estimate (yearly) of prevalence two or three times in each area.

Prognostic factors and determinants of fatal outcome due to bacterial meningitis in the Lazio region of Italy, 1996-2000.

OBJECTIVES: To estimate case fatality rates (CFR) of bacterial meningitis and analyze factors associated with mortality due to bacterial meningitis in the Italian region of Lazio. METHODS: Patients reported with bacterial meningitis during the period 1996-2000, who died within 30 days from hospitalization (cases), were compared with survivors (controls) for factors related to healthcare. Age, gender, residence, bacterial agent, co-morbidities, and signs of disease severity were also analyzed in the final model. Healthcare factors were analyzed using current surveillance databases. RESULTS: Disease severity (OR=8.84; 95% CI=3.35-23.34) and age >44 years (OR=4.59; 95% CI=2.01-10.48) were the risk factors most strongly associated with death, while treatment in an infectious diseases ward was a protective factor, although modified by patient residence and by co-morbidities. CONCLUSIONS: This protective effect was possibly due to differences in treatment protocols between the infectious diseases ward and other wards. The protective effect was found to be stronger for residents of Rome, suggesting delayed access to infectious diseases wards for non-residents. The difference in risk of dying from meningitis at younger ages than that found in other studies should be further evaluated, using information on bacteria serogroups and antibiotic susceptibility.

The Italian CABG Outcome Study: short-term outcomes in patients with coronary artery bypass graft surgery.

OBJECTIVE: During the last decade, a worldwide growing interest in evaluating performance of health services through 'outcome studies' took place. This study started in early 2002 and represents the first National Health System (NHS) experience to evaluate adjusted performance indicators at national level. The aim of this study was to compare 30 days mortality after coronary artery bypass graft (CABG) between cardiac surgery centres, adjusting by confounding risk factors. METHODS: All patients, aged 15-99 years, undergoing a CABG intervention after 1st January 2002 in 82 participating centres were eligible for this observational longitudinal study. For each patient, data on severity and risk factors were collected (type of procedure, haemodynamic condition, co-morbidities, recent myocardial infarction and unstable angina, ventricular function, emergency condition, vital status at 30 days). Using a multiple logistic regression analysis the best predictive model was developed for risk-adjustment; a cross-validation procedure was applied; specific risk adjusted mortality rates (RAMR) were estimated. The overall study population was used as reference standard. RESULTS: 34,310 isolated CABG were performed in 64 of the 82 participating centres. Thirty days mortality resulted 2.61%, ranging from 0.33 to 7.63%; eight centres presented a RAMR significantly lower and seven significantly higher than the reference. CONCLUSIONS: The study provides valid measures of the heterogeneity between outcomes of the Italian cardiac surgery centres, to support decision-making by NHS management and individual patients. Although not statistically significant, RAMR dropped from year 2002 to 2004 (2.8-2.4%) suggesting that this comparative outcome assessment can contribute to the improvement of performances in cardiac surgery.

[Introduction to risk adjustment methods in comparative evaluation of outcomes]. / Introduzione ai metodi di risk adjustment nella valutazione comparativa degli esiti.

The increasing demand for comparative evaluation of outcomes requires the development and diffusion of epidemiologic research, the ability to correctly conduct analyses and to interpret results. When healthcare outcomes are used for comparing quality of care across providers, failure to use methods of risk adjustment to account for any variation in patient populations can lead to misinterpretation of the findings. The purpose of this paper is to provide a detailed but easy-reading review of different risk adjustment methodologies to compare health care outcomes. The paper is divided in two parts. Introduction describes the difference between experimental and observational studies, the role of confounding in observational studies and the ways confounding is identified and controlled (propensity adjustment and risk adjustment), Specific part on risk adjustment describes: (1) the methods for constructing the severity measures; (2) the methods that use the severity measures to obtain "adjusted" outcome measures for valid comparison between groups (stratified analysis, indirect and direct standardization); (3) identification and management of effect modification; (4) the methods to gain the precision of the estimates; (5) the risk adjustment methods used with multiple comparisons and (6) introduction to other models (multi-level models) used for risk adjustment. For policy makers and planners, epidemiologists and clinicians it is important to understand which factors can improve or worsen the effectiveness of treatments and services and to compare the performances of hospitals and healthcare providers. Decisions should be based on the validity and precision of study results, by using the best scientific knowledge available. The statistical methods described in this review cannot measure reality as it truly is, but can produce images of it, defining limits and uncertainties in terms of validity and precision. Since any risk-adjustment model used for comparative evaluation of outcomes must be time- and population-specific, only the studies that use credible risk adjustment strategies are more likely to yield reliable findings.

[Functional recovery in post-acute rehabilitation: patient characteristics and treatment effect]. / Il recupero funzionale nella riabilitazione post acuzie: caratteristiche dei pazienti ed effetto dei trattamenti.

OBJECTIVE: Most studies on the effectiveness of rehabilitation consider only particular rehabilitation treatments for particular conditions, and do not give a global vision of the issue. This study evaluated the effectiveness of various types of post acute rehabilitative care in patients with different diagnoses by investigating the association between treatments and functional gain by type of impairment and severity on admission. DESIGN, SETTING AND PARTICIPANTS: Information on the characteristics of patients and the rehabilitative treatments was collected using an Italian version of the Minimum Data Set-Post Acute Care. The questionnaire was created and validated by the Centers for Medicare and Medicaid Services, it is divided in various section and was filled in at regular intervals throughout the hospital stay. Patients included in the study were 1918. MAIN OUTCOME MEASURES: We used factor analysis to summarize each section in a single continuous variable. The observed functional gain was calculated as the difference between functional status at the beginning and at the end of the admission. A multiple linear regression analysis was performed to evaluate the association between rehabilitation treatments and functional gain, adjusting for patient characteristics and severity at admission. The effectiveness of the treatments were obtained by calculating the difference between the overall functional gain of the hospital stay and the predicted functional gain of the stay in the absence of rehabilitation treatments. RESULTS AND CONCLUSION: The effectiveness of treatments differs across diagnostic class and it is associated directly with severity of functional status at admission. In most cases, the positive effect of treatments combines with the spontaneous functional gain; in other cases the positive effect of treatments opposes the spontaneous deterioration of patient functional status.

Evaluating outcomes of hospital care following coronary artery bypass surgery in Rome, Italy.

OBJECTIVE: Monitoring health outcomes across hospitals has become a growing interest as a potential means to promote quality of care, but in Italy it is at the beginning stage. We aimed at comparing the performance of different cardiac surgery units and testing the utility of routinely collected data in this respect. METHODS: From the Lazio region hospital information system (HIS), we selected a cohort of 1603 individuals (84% males; mean age 63 years, SD 8) residing in Rome (2,685,890 inhabitants), who underwent isolated coronary artery bypass surgery (CABG, ICD-9-CM code: 36.1) in the period 1996-97 in seven major cardiac surgery units in the city. They were identified as A, B, C (teaching), D and E (non-teaching) units. Information on vital status at 30 days after the CABG surgery was obtained through an automatic record linkage with the Municipal Registry of Rome. The association between cardiac surgery units and outcome was evaluated through logistic regression taking into account the following a priori risk factors in different models: gender, age, socio-economic status, type of ischaemic heart disease and comorbidities. RESULTS: The overall mortality was 5.4% (range 2.1-11.4%). Statistically significant predictors of outcome included: age (OR=7.5 for age> or =70 vs. 35-49 years), acute myocardial infarction (OR=32.7 vs. acute-subacute forms/angina), chronic myocardial ischaemia (OR=4.2 vs. acute-subacute forms/angina), other heart diseases (OR=4.8), chronic renal disease (OR=16.0) and peripheral arterial disease (OR=2.9). Statistically significant variability in mortality was observed across hospitals; taking hospital A as reference, hospital D showed the highest risk (OR=5.7, 95% CI=1.9-17.3, in the fully adjusted model). CONCLUSIONS: We suggest that a true variation in quality of care play a role in the observed differences across hospitals, although chance and inaccurately measured risk factors cannot be excluded. Despite some limitations, the HIS is a valid tool for screening cardiac surgery units with poor performance.

Differences in access to coronary care unit among patients with acute myocardial infarction in Rome: old, ill, and poor people hold the burden of inefficiency.

BACKGROUND: Direct admission to Coronary Care Unit (CCU) on hospital arrival can be considered as a good proxy for adequate management in patients with acute myocardial infarction (AMI), as it has been associated with better prognosis. We analyzed a cohort of patients with AMI hospitalized in Rome (Italy) in 1997-2000 to assess the proportion directly admitted to CCU and to investigate the effect of patient characteristics such as gender, age, illness severity on admission, and socio-economic status (SES) on CCU admission practices. METHODS: Using discharge data, we analyzed a cohort of 9127 AMI patients. Illness severity on admission was determined using the Deyo's adaptation of the Charlson's comorbidity index, and each patient was assigned to one to four SES groups (level I referring to the highest SES) defined by a socioeconomic index, derived by the characteristics of the census tract of residence. The effect of gender, age, illness severity and SES, on risk of non-admission to CCU was investigated using a logistic regression model (OR, CI 95%). RESULTS: Only 53.9% of patients were directly admitted to CCU, and access to optimal care was more frequently offered to younger patients (OR = 0.35; 95%CI = 0.25-0.48 when comparing 85+ to >=50 years), those with less severe illness (OR = 0.48; 95%CI = 0.37-0.61 when comparing Charlson index 3+ to 0) and the socially advantaged (OR = 0.81; 95%CI = 0.66-0.99 when comparing low to high SES). CONCLUSION: In Rome, Italy, standard optimal coronary care is underprovided. It seems to be granted preferentially to the better off, even after controversial clinical criteria, such as age and severity of illness, are taken into account.

[Supply of outpatient care in the Lazio region: geographic distribution and characteristics of outpatient clinics]. / Il sistema dell'offerta di prestazioni di assistenza specialistica ambulatoriale nella regione Lazio.

Outpatient care accounts every year for a large share of the National Health Fund spending, however characteristics of supply have not been thoroughly investigated. Objective of the study is the description of the outpatient care system of Lazio region and of the main characteristics of outpatient clinics, through indicators obtained using data from the Outpatient Care Information System (SIAS) for 1999. Outpatient clinics were classified into three categories: ASL managed clinics, private clinics and hospital trusts. Absolute and relative density of supply (respectively DAO and DRO) were used as indicators of clinics distribution in the regional area. Number of specialties, average procedure weight and volume of procedures performed were used as indicators of complexity. Absolute density of supply (DAO = n. of dispatch points/population) is generally high, and a large and statistically significant variability is observed (p < 0.001). The relative density (i.e. the correlation coefficient between DAO and population density) is positive overall (r = 0.43), but it is higher within the private sector (r = 0.62) independently from provider category. Statistically significant differences were observed among categories of providers in terms of average number of specialties (ASL managed: 9.9; private clinics: 1.7; hospital trusts: 16.1), average weight (ASL managed: 1.1; private clinics: 0.9; hospital trusts: 1.3) and average volume of procedures supplied (ASL managed: 35.000; private clinics: 59.000; hospital trusts: 282.000). The administrative SIAS database was a useful tool to define indicators aimed at describing characteristics of the outpatient care system, although these results must be confirmed with a higher and more homogeneous level of coverage.

Occurrence of inflammatory bowel disease in central Italy: a study based on health information systems.

BACKGROUND: The burden of inflammatory bowel diseases, including Crohn's disease and ulcerative colitis, has never been estimated in Italy using administrative data sources. Our objective was to measure the occurrence of inflammatory bowel diseases in the Lazio region (Italy) using administrative data and to test the sensitivity of the Crohn's disease case-finding algorithm with respect to clinical diagnosis. METHODS: We conducted a population-based cross-sectional study identifying prevalent and incident cases. We estimated occurrence rates of inflammatory bowel diseases using hospital discharges or activation of copayment exemptions. Sensitivity was calculated from 2358 subjects with clinical diagnosis of Crohn's disease. RESULTS: Exemptions identified more than 20% of the cases. Prevalence rates (per 100,000) on December 31, 2009 for males and females were 177 and 144 for ulcerative colitis and 91 and 81 for Crohn's disease, respectively. The incidence rates during the years 2008-2009 were 14.5 and 12.2 for ulcerative colitis and 7.4 and 6.5 for Crohn's disease for males and females, respectively. The sensitivity of the administrative sources was 82.2%. CONCLUSIONS: Health and population data sources allow the estimation of inflammatory bowel diseases occurrence. The age-specific peaks of diagnosis were consistent with those reported in other studies. Sensitivity may be affected by temporal changes in the quality of the data sources.

Risk adjustment and outcome research. Part I.

OBJECTIVE: The increasing demand for comparative evaluation of outcomes requires the development and diffusion of epidemiologic research, the ability to correctly formulate hypotheses, to conduct analyses and to interpret the results. The purpose of this paper is to provide a detailed but easy-reading review of epidemiologic methods to compare healthcare outcomes, particularly risk-adjustment methods. METHODS: The paper is divided into three parts. Part I describes confounding in observational studies, the ways confounding is identified and controlled (propensity adjustment and risk adjustment), and the methods for constructing the severity measures in risk-adjustment procedures. CONCLUSIONS: It is becoming increasingly important for policy makers and planners to identify which factors may improve or worsen the effectiveness of treatments and services and to compare the performances of providers. Politicians, managers, epidemiologists, and clinicians should make their decisions based on the validity and precision of study results, by using the best scientific knowledge available. The statistical methods described in this review cannot measure 'reality' as it 'truly' is, but can produce 'images' of it, defining limits and uncertainties in terms of validity and precision. Studies that use credible risk-adjustment strategies are more likely to yield reliable and applicable findings.

Toward a new payment system for inpatient rehabilitation. Part II: Reimbursing providers.

BACKGROUND: The major fault with existing reimbursement systems lies in their failure to discriminate for the effectiveness of stay, both when paying per day and when paying per episode of treatment. OBJECTIVES: We sought to define an average length of effective stay and recovery trends by impairment category, to design a prospective payment system that takes into account costs and expected recovery trends, and to compare the calculated reimbursement with the predicted costs estimated in a previous study (Saitto C, Marino C, Fusco D, et al. A new prospective payment system for inpatient rehabilitation. Part I: predicting resource consumption. Med Care. 2005;43:844-855). RESEARCH DESIGN: We considered all rehabilitation admissions from 5 Italian inpatient facilities during a 12-month period for which total cost of care had already been estimated and daily cost predicted through regression model. We ascertained recovery trends by impairment category through repeated MDS-PAC schedules and factorial analysis of functional status. We defined effective stay and daily resource consumption by impairment category and used these parameters to calculate reimbursement for the admission. We compared our reimbursement with predicted cost through regression analysis and evaluated the goodness of fit through residual analysis. RESULTS: We calculated reimbursement for 2079 admissions. The r(2) values for the reimbursement to cost correlation ranged from 0.54 in the whole population to 0.56 for "multiple trauma" to 0.85 for "other medical disorders." The best fit was found in the central quintiles of the cost and severity distributions. CONCLUSION: For each impairment category, we determined the number of days of effective hospital stay and the trends of functional gain. We demonstrated, at least within the Italian health care system, the feasibility of a reimbursement system that matches costs with functional recovery. By linking reimbursement to effective stay adjusted for trends of functional gain, we suggest it is possible to avoid both needless cuts and extensions of hospital admissions.

Toward a new payment system for inpatient rehabilitation. Part I: Predicting resource consumption.

BACKGROUND: The measures of clinical status used to predict costs must pay the most attention possible to medical conditions and clinical complexity. Length of stay (LOS), which has been used as a proxy for resource consumption, is not a direct measure of costs. Classification and regression trees, which are used in defining iso-resource groups, can be affected by overfitting and are based on a priori choices of the splitting attributes. Finally, current approaches are mainly concerned in estimating average group costs and do not attempt to estimate individual case costs. OBJECTIVES: We sought to define comprehensive measures of clinical status and detailed measures of resource consumption. We also sought to predict individual inpatient rehabilitation costs through multiple regression models. RESEARCH DESIGN: A prospective analysis was conducted of all rehabilitation cases admitted to 5 Italian inpatient facilities during a period of 12 months. All admissions underwent repeated Minimum Data Set-Post Acute Care (MDS-PAC) schedules to collect information on clinical status and treatment provided. We used factorial analysis to yield continuous variables representing clinical characteristics, and we priced treatments to obtain cost of stay. We used linear regression models to predict cost of stay and validated the model-based cost predictions by data-splitting. RESULTS: We collected 9720 MDS-PAC schedules from 2702 hospital admissions. The multivariate regression models fitted costs reasonably well with r(2) values of at least 0.34. On cross-validation, the ability of the regression models to predict cost was confirmed. CONCLUSION: We were able to estimate actual rehabilitation costs and define reliable regression models to predict costs from individual patient characteristics. Our approach identifies the contribution of any single patient characteristic to rehabilitation cost and tests the assumptions of the analysis.

Diabetes management by hospital-affiliated diabetes centres in Lazio, Italy.

BACKGROUND: In Italy, diabetes centres are considered to provide adequate care but little is known about their performance. METHODS: Inpatient and outpatient administrative databases were used to select and study a cohort of 2,568 diabetic patients. Adherence to guidelines and effect of patient characteristics and diabetes centre on treatment was assessed. Mortality rate was calculated. RESULTS: Patients averaged 9.3 outpatient visits per year. Each patient received a mean of 21.8 ambulatory services per year but only 2.21 Haemoglobin A1C tests, and only 0.56 procedures suggested by the guidelines. Diabetes management depended mainly on the care centre. A mortality rate of 6.9 per hundred person-years was observed. CONCLUSIONS: Hospital-affiliated centres do not ensure adequate diabetes management.

Outcome of patients with cardiac diseases admitted to coronary care units: a report from Lazio, Italy.

BACKGROUND: Coronary care units (CCUs) currently treat a variety of diseases, but little is known about the effectiveness of CCUs on heart conditions other than acute myocardial infarction. OBJECTIVES: The objectives of this study were to evaluate the association between direct admission to CCUs and the risk of inhospital death in patients with heart disease, to investigate factors affecting direct admission to a CCU, and to assess the effect of CCU admission on the use of invasive procedures in patients with arrhythmias. RESEARCH DESIGN: We conducted a retrospective analysis of discharge-abstract data from Lazio, Italy, hospitals. We used logistic regression, propensity score, and instrumental variable analysis to compare inhospital risk of death between patients admitted to CCUs and to ordinary wards in 13 different groups of heart disease. We used linear regression to study the association between the rate of CCU admission and the relative risk of death. RESULTS: The study included 181,049 heart disease admissions, of which 8620 were admitted to CCUs (4.8%). Risk of death was significantly lower in patients admitted directly to CCUs for "acute myocardial infarction" (odds ratio [OR], 0.57), "acute ischemic heart disease" (OR, 0.55), and "other arrhythmias" (OR, 0.56). Mortality ORs were inversely related to the rate of CCU admission. CCU patients with arrhythmias received more invasive procedures (OR, 2.70) than non-CCU patients. CONCLUSION: Direct admission to a CCU is associated with a decrease in mortality for patients with "acute myocardial infarction," "acute heart ischemia," and "other arrhythmias." Patients most likely to benefit from CCU care are preferentially admitted to CCUs. CCUs make larger use of invasive procedures than ordinary wards.

A follow-up analysis of transient ischemic attack patients suggests unsatisfactory disease management and possible underutilization of carotid endarterectomy in Lazio, Italy.

We evaluated the disease management of transient ischemic attack in patients admitted to Lazio hospitals from July 1997 to June 1998. We assessed the effects of patient characteristics including chronic comorbidities on the use of diagnostic procedures, endarterectomy, and on the risk of adverse cerebrovascular outcome or death. There were 2,608 patients in the study who were followed up over a 18- to 30-month period. Carotid surgery was performed on 1.15% of the subjects, total mortality was 34.7 per 1,000 person-years and adverse cerebrovascular outcome was observed in 38.1 per 1,000 person-years. Chronic comorbidities did affect the mortality rate and the rate of adverse outcome, but not the rate of endarterectomies. Carotid surgery was infrequently performed in study subjects. It seems that this potentially stroke-preventive treatment was not offered to suitable candidates in many instances.