Medical Costs of Patients with Type 2 Diabetes in a Single Payer System: A Classification and Regression Tree Analysis.

BACKGROUND AND OBJECTIVES: Many studies and systematic reviews have estimated the healthcare costs of diabetes using a cost-of-illness approach. However, in the studies based on this approach patients' heterogeneity is rarely taken into account. The aim of this study was to stratify patients with type 2 diabetes into homogeneous cost groups based on demographic and clinical characteristics. METHODS: We conducted a retrospective cost-of-illness study by linking individual data on health services utilization retrieved from the administrative databases of Emilia-Romagna Region (Italy). Direct medical costs (either all-cause or diabetes-related) were calculated from the perspective of the regional health service, using tariffs for hospitalizations and outpatient services and the unit costs of prescriptions for drugs. The determinants of costs identified in a generalized linear regression model were used to characterize subgroups of patients with homogeneous costs in a classification and regression tree analysis. RESULTS: The study population consisted of a cohort of 101,334 patients with type 2 diabetes, followed up for 1 year, with a mean age of 70.9 years. Age, gender, complications, comorbidities and living area accounted significantly for cost variability. The classification tree identified ten patient subgroups with different costs, ranging from a median of €483 to €39,578. The two subgroups with highest costs comprised dialysis patients, and the largest subgroup (57.9%) comprised patients aged ≥ 65 years without renal, cardiovascular and cerebrovascular complications. CONCLUSIONS: Classification of patients into homogeneous cost subgroups can be used to improve the management of, and budget allocation for, patients with type 2 diabetes.

Are degree of urbanisation and travel times to healthcare services associated with the processes of care and outcomes of heart failure? A retrospective cohort study based on administrative data.

A few studies have found that patients with heart failure (HF) living in less densely populated areas have reduced use of services and poorer outcomes. However, there is a lack of evidence regarding transport accessibility measured as the actual distance between the patient's home and the healthcare facility. The aim of this study was to investigate if different urbanisation levels and travel times to healthcare services are associated with the processes of care and the outcomes of HF. This retrospective cohort study included patients residing in the Local Healthcare Authority of Bologna (2915 square kilometres) who were discharged from hospital with a diagnosis of HF between 1 January and 31 December 2017. Six-month study outcomes included both process (cardiology follow-up visits) and outcome measures (all-cause readmissions, emergency room visits, all-cause mortality). Of the 2022 study patients, 963 (47.6%) lived in urban areas, 639 (31.6%) in intermediate density areas, and 420 (20.8%) in rural communities. Most patients lived ≤30 minutes away from the nearest healthcare facility, either inpatient or outpatient. After controlling for a number of individual factors, no significant association between travel times and outcomes was present. However, rural patients as opposed to urban patients were more likely to see a cardiologist during follow-up (OR 1.42, 99% CI 1.03-1.96). These follow-up visits were associated with reduced mortality within 6 months of discharge (OR 0.53, 99% CI 0.32-0.87). We also found that multidisciplinary interventions for HF were more common in rural than in urban settings (18.8% vs. 4.0%). In conclusion, travel times had no impact on the quality of care for patients with HF. Differences between urban and rural patients were possibly mediated by more proximal factors, some of which are potential targets for intervention such as the availability and utilisation of follow-up cardiology services and multidisciplinary models of care.

The Role of Cardiologists in the Management of Patients with Heart Failure.

Heart failure is a complex clinical syndrome with a remarkable impact on health care systems in terms of patients' morbidity and mortality, as well as direct and indirect costs. It is essential to redesign models of care for patients with heart failure that are tailored on personalized health care needs and carried out in the most appropriate setting. There is some debate about the role of cardiologists in the management of patients with heart failure. Indeed, results regarding the inclination of cardiologists' patients to achieve better outcomes are controversial, given the heterogeneity of studies in terms of study design, population, setting and variables considered. The aim of this chapter is to describe and synthesize the current state of knowledge about the role of specialists in the management of patient with heart failure, and to assess whether there is a type of patients for which cardiologists demonstrate the greatest value or a setting of care where they add more benefit.

Effect of cardiologist care on 6-month outcomes in patients discharged with heart failure: results from an observational study based on administrative data.

OBJECTIVES: To evaluate the effect of cardiologist care on adherence to evidence-based secondary prevention medications, mortality and readmission within 6 months of discharge in patients with heart failure (HF). DESIGN: Retrospective observational study based on administrative data. SETTING: Local Healthcare Authority (LHA) of Bologna, one of the largest LHAs of Italy with ~870 000 inhabitants. PARTICIPANTS: All patients residing in the LHA of Bologna discharged from hospital with a diagnosis of HF between 1 January 2015 and 31 December 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: Multivariable regression analysis was used to assess the association of inpatient and outpatient cardiologist care with adherence to evidence-based medications, all-cause mortality and hospital readmission (including emergency room visits) within 6 months of discharge. RESULTS: The study population included 2650 patients (mean age 82.3 years). 340 (12.8%) patients were discharged from cardiology wards, while 635 (24.0%) were seen by a cardiologist during follow-up. Inpatient and outpatient cardiologist care was associated with an increased likelihood of adherence to ACE inhibitors/angiotensin receptor blockers (ACEIs/ARBs), ß-blockers and aldosterone antagonists after discharge. The risk of mortality was significantly lower among patients adherent to ACEIs/ARBs and/or ß-blockers (-53% and -28%, respectively); the risk of hospital readmission was significantly lower among patients adherent to ACEIs/ARBs (-28%). CONCLUSIONS: Compared with non-specialist care, cardiologist care improves patient adherence to evidence-based medications and might thus favourably affect mortality and readmission following HF.

[Characteristics and outcomes of acute coronary syndrome in Italian-born patients and immigrants: a population-based observational study using health administrative data of the Emilia-Romagna Region]. / Caratteristiche ed esiti della sindrome coronarica acuta nella popolazione italiana e migrante: uno studio osservazionale basato su dati amministrativi sanitari nella Regione Emilia-Romagna.

BACKGROUND: The aim of this study was to analyze the characteristics and outcomes of patients with acute coronary syndrome (ACS) in relation to country of origin. METHODS: The study population included patients living in the Emilia-Romagna Region and discharged from 2012 to 2014 with a diagnosis of acute myocardial infarction (with [STEMI] and without ST-elevation). The study outcomes were: percutaneous coronary intervention (PCI) within 48 hours of admission for STEMI, 30-day all-cause mortality, 1-year all-cause mortality, 1-year major adverse cardiac and cerebrovascular events (MACCE), and adherence to post-infarction medications. The relationship between outcomes and citizenship was investigated using multiple regression analysis. Potential confounders were identified among diagnoses recorded in the index hospitalization and in all hospitalizations occurring 2 years prior to the index hospitalization. RESULTS: Of the 23 884 study patients, 647 (2.7%) were non-Italians. The mean age of onset of ACS was lower among immigrants (56 years) than among Italians (73 years). Thirty-day mortality was 9.6% while 1-year mortality and MACCE were 19.8% and 20.8%, respectively. The proportion of PCI within 48 hours was 63.2%, while patients adherent to medications were 31.0%. Compared with Italians, patients from Africa and Asia had a reduced probability of undergoing PCI and were less adherent to medications. Adjusted mortality rates were similar between Italians and immigrants, while patients from Asia had a 62% increased probability of experiencing a MACCE during follow-up. CONCLUSIONS: Compared with Italians, immigrant citizens with ACS were younger, less likely to undergo PCI, and less adherent to drug treatment after discharge. Further studies are warranted to identify the determinants of these disparities and to develop organizational models tailored to the specific needs of immigrant patients.

Burden of multimorbidity in relation to age, gender and immigrant status: a cross-sectional study based on administrative data.

OBJECTIVES: Many studies have investigated multimorbidity, whose prevalence varies according to settings and data sources. However, few studies on this topic have been conducted in Italy, a country with universal healthcare and one of the most aged populations in the world. The aim of this study was to estimate the prevalence of multimorbidity in a Northern Italian region, to investigate its distribution by age, gender and citizenship and to analyse the correlations of diseases. DESIGN: Cross-sectional study based on administrative data. SETTING: Emilia-Romagna, an Italian region with ∼4.4 million inhabitants, of which almost one-fourth are aged ≥65 years. PARTICIPANTS: All adults residing in Emilia-Romagna on 31 December 2012. Hospitalisations, drug prescriptions and contacts with community mental health services from 2003 to 2012 were traced to identify the presence of 17 physical and 9 mental health disorders. PRIMARY AND SECONDARY OUTCOME MEASURES: Descriptive analysis of differences in the prevalence of multimorbidity in relation to age, gender and citizenship. The correlations of diseases were analysed using exploratory factor analysis. RESULTS: The study population included 622 026 men and 751 011women, with a mean age of 66.4 years. Patients with multimorbidity were 33.5% in 75 years and >60% among patients aged ≥90 years; among patients aged ≥65 years, the proportion of multimorbidity was 39.9%. After standardisation by age and gender, multimorbidity was significantly more frequent among Italian citizens than among immigrants. Factor analysis identified 5 multimorbidity patterns: (1) psychiatric disorders, (2) cardiovascular, renal, pulmonary and cerebrovascular diseases, (3) neurological diseases, (4) liver diseases, AIDS/HIV and substance abuse and (5) tumours. CONCLUSIONS: Multimorbidity was highly prevalent in Emilia-Romagna and strongly associated with age. This finding highlights the need for healthcare providers to adopt individualised care plans and ensure continuity of care.

Risk-adjustment models for heart failure patients' 30-day mortality and readmission rates: the incremental value of clinical data abstracted from medical charts beyond hospital discharge record.

BACKGROUND: Hospital discharge records (HDRs) are routinely used to assess outcomes of care and to compare hospital performance for heart failure. The advantages of using clinical data from medical charts to improve risk-adjustment models remain controversial. The aim of the present study was to evaluate the additional contribution of clinical variables to HDR-based 30-day mortality and readmission models in patients with heart failure. METHODS: This retrospective observational study included all patients residing in the Local Healthcare Authority of Bologna (about 1 million inhabitants) who were discharged in 2012 from one of three hospitals in the area with a diagnosis of heart failure. For each study outcome, we compared the discrimination of the two risk-adjustment models (i.e., HDR-only model and HDR-clinical model) through the area under the ROC curve (AUC). RESULTS: A total of 1145 and 1025 patients were included in the mortality and readmission analyses, respectively. Adding clinical data significantly improved the discrimination of the mortality model (AUC = 0.84 vs. 0.73, p < 0.001), but not the discrimination of the readmission model (AUC = 0.65 vs. 0.63, p = 0.08). CONCLUSIONS: We identified clinical variables that significantly improved the discrimination of the HDR-only model for 30-day mortality following heart failure. By contrast, clinical variables made little contribution to the discrimination of the HDR-only model for 30-day readmission.

[Organisational determinants of adherence to secondary prevention medications after acute myocardial infarction]. / Determinanti organizzativi e assistenziali dell'aderenza alle terapie di prevenzione secondaria nei pazienti con infarto miocardico acuto.

OBJECTIVES: to identify organisational determinants of adherence to evidence-based drug treatments after acute myocardial infarction (AMI), under the hypothesis that low adherence is associated with higher mortality and risk of reinfarction. In particular, we investigated the effect of group vs. single handed practice and multi-professional practice characteristics on patients' adherence to polytherapy after AMI. DESIGN: retrospective cohort study. SETTING AND PARTICIPANTS: residents in the Local Health Authority of Bologna (Italy) who were discharged from any Italian hospital between 2008 and 2011 with a diagnosis of AMI, and followed-up for a year. MAIN OUTCOME MEASURES: adherence to at least three out of the four drug therapies recommended for secondary prevention of AMI (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, ß-blockers, antiplatelet agents, statins). Patients who had at least 80% of days of follow-up covered by drug doses were considered adherent. RESULTS: of the 4,828 post-AMI patients, 31.6% were adherent to polytherapy. General practice characteristics were unrelated to adherence, whereas discharge from cardiology hospital wards was significantly associated with higher patients' adherence (OR 1.97; 95%CI 1.56-2.48). CONCLUSION: general practice organisational models are not associated with higher adherence to evidence-based medications after AMI, whereas cardiologists seem to play a key role in improving patient adherence to polytherapy. Healthcare delivery models should be designed; in them, general practitioners are responsible for the provision of patient-centred care pathways and for care co-ordination with other primary care professionals and specialists, and take an advocacy role for the patient when needed.

Hospital readmissions of patients with heart failure: the impact of hospital and primary care organizational factors in Northern Italy.

BACKGROUND: Primary health care is essential for an appropriate management of heart failure (HF), a disease which is a major clinical and public health issue and a leading cause of hospitalization. The aim of this study was to evaluate the impact of different organizational factors on readmissions of patients with HF. METHODS: The study population included elderly resident in the Local Health Authority of Bologna (Northern Italy) and discharged with a diagnosis of HF from January to December 2010. Unplanned hospital readmissions were measured in four timeframes: 30 (short-term), 90 (medium-term), 180 (mid-long-term), and 365 days (long-term). Using multivariable multilevel Poisson regression analyses, we investigated the association between readmissions and organizational factors (discharge from a cardiology department, general practitioners' monodisciplinary organizational arrangement, and implementation of a specific HF care pathway). RESULTS: The 1873 study patients had a median age of 83 years (interquartile range 77-87) and 55.5% were females; 52.0% were readmitted to the hospital for any reason after a year, while 20.1% were readmitted for HF. The presence of a HF care pathway was the only factor significantly associated with a lower risk of readmission for HF in the short-, medium-, mid-long- and long-term period (short-term: IRR [incidence rate ratio]=0.57, 95%CI [confidence interval]=0.35-0.92; medium-term: IRR=0.70, 95%CI=0.51-0.96; mid-long-term: IRR=0.79, 95%CI=0.64-0.98; long-term: IRR=0.82, 95%CI=0.67-0.99), and with a lower risk of all-cause readmission in the short-term period (IRR=0.73, 95%CI=0.57-0.94). CONCLUSION: Our study shows that the HF care specific pathway implemented at the primary care level was associated with lower readmission rate for HF in each timeframe, and also with lower readmission rate for all causes in the short-term period. Our results suggest that the engagement of primary care professionals starting from the early post-discharge period may be relevant in the management of patients with HF.

Mental health services use and management of eating disorders in an Italian Department of Mental Health.

OBJECTIVE: To investigate the clinical characteristics of patients with eating disorders referred to Community Mental Health Centers (CMHCs) in the Department of Mental Health of Bologna, Italy, and to evaluate the number and type of interventions delivered. METHODS: Adult patients with eating disorders who had a first contact with CMHCs between January 1, 2007 and December 31, 2012 were extracted from Bologna Local Health Authority database. Moreover, the hospital discharge records of patients were linked to the mental health information system of Bologna. RESULTS: Among the 276 patients with eating disorders identified, 59 (21.4%) were diagnosed as anorexia nervosa, 77 (27.9%) as bulimia nervosa and 140 (50.7%) as eating disorders not otherwise specified. The mean age of the sample was 37.3 (SD = 13.4), with no significant differences among the three diagnostic groups. The number of CMHCs outpatients increased each year from 2007 to 2011 and decreased in 2012. The proportion of new patients by year comprised about 50% of the total of patients. Psychotherapy accounted for about 10% of the interventions. Day-hospital and hospital admissions concerned 6.1 and 11.6% of the sample. CONCLUSIONS: CMHCs are part of the system of care outlined by the Regional policies for eating disorders and are responsible for providing the first level of outpatient care to adults. To date, there is the need to extend our monitoring across the whole system of care, to assess the implementation of specific and effective strategies to decrease the age of access of patients and to improve the quality of care delivered with the inclusion of evidence-based treatments in the process of care.