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Evaluation of the capacity of the APR-DRG classification system to predict hospital mortality [Valutazione della capacità del sistema di classificazione APR – DRG di predire la mortalità ospedaliera]
No full textInpatient mortality has increasingly been used as an hospital outcome measure. Comparing mortality rates across hospitals requires adjustment for patient risks before making inferences about quality of care based on patient outcomes. Therefore it is essential to dispose of well performing severity measures. The aim of this study is to evaluate the ability of the All Patient Refined DRG system to predict inpatient mortality for congestive heart failure, myocardial infarction, pneumonia and ischemic stroke. Administrative records were used in this analysis. We used two statistics methods to assess the ability of the APR-DRG to predict mortality: the area under the receiver operating characteristics curve (referred to as the c-statistic) and the Hosmer-Lemeshow test. The database for the study included 19,212 discharges for stroke, pneumonia, myocardial infarction and congestive heart failure from fifteen hospital participating in the Italian APR-DRG Project. A multivariate analysis was performed to predict mortality for each condition in study using age, sex and APR-DRG risk mortality subclass as independent variables. Inpatient mortality rate ranges from 9.7% (pneumonia) to 16.7% (stroke). Model discrimination, calculated using the c-statistic, was 0.91 for myocardial infarction, 0.68 for stroke, 0.78 for pneumonia and 0.71 for congestive heart failure. The model calibration assessed using the Hosmer-Leme-show test was quite good. The performance of the APR-DRG scheme when used on Italian hospital activity records is similar to that reported in literature and it seems to improve by adding age and sex to the model. The APR-DRG system does not completely capture the effects of these variables. In some cases, the better performance might be due to the inclusion of specific complications in the risk-of-mortality subclass assignment
[Effect of hospital policies on patient mobility: Siennese experience]. Programmazione ospedaliera e flussi di pazienti: esperienza senese
No full textThe Italian National Health Service (S.S.N.), adopted in 1978 (Law n 833) and based on Beveridge's model, emphasises the citizens freedom to choose and the equal opportunity in accessing health care structures. Local Health Authorities--L.H.A. (U.S.L.--Unità Sanitarie Locali) become owners of almost all the structures in their territories and directly responsible for the satisfaction of all residents health needs. The former hospitals' network, based on independent first, second and third level public hospitals, in potential competition, was dismantled. Hospitals' financing, the main economic role of the S.S.N., was based on the documented running expenses: therefore the hospital interest to attract patients diminished and expenses increased in a uncontrolled way. In 1992, the Italian Government, (re)introduced (Law n 502) the quasi-market administered competition between Italian hospitals, making the major ones independent (Aziende Ospedaliere--A.O.) from the L.H.A. Hospital income from then is based on DRGs; the L.H.A. (and hospitals) leadership is now entrusted to managers and not politicians. We describe now how these changes were experienced by our hospital (A.O. Senese), placed in Southern Tuscany, Italy. We elaborated hospitalisation data regarding residents in the province of Siena (252,000 inhabitants) and activity data regarding its main hospital (A.O. Senese, 1200 beds, 47,000 admissions/year). Using the Gandy's Nomogram, we show the variation of patients mobility from 1988 to 1999. Our survey demonstrates that the Italian hospital system answers well enough to the legislative regulations: following the Law 833/1978 our hospital diminished its ability to attract patients from other areas; at the same time migrations of hospitals patients from Siena increased. Following the Law 502/1992, the power of attraction of our hospital is increased. Nevertheless the flow of escape continued to increase. It appears that to discourage the attraction power means to promote the loss of perceived quality and that it is difficult to correct such effects
Prediction of mortality for congestive heart failure patients: results from different wards of an italian teaching hospital
No full textCongestive heart failure (CHF) constitutes an important public health problem in Italy, evidenced by the high number of hospital admissions each year. Significant inter-hospital as well as interward differences in mortality rates for CHF patients that have been described may, in part, be explained by the differences in the severity of the illness of admitted patients. The goal of this study was to predict 30-day severity-adjusted mortality risk in patients with CHF admitted to wards of a teaching hospital in Siena, Italy, in 1997. A 30-day mortality was determined by linking hospital discharge files with the Tuscany Mortality Registry database. The 3M all patient refined diagnosis related group (APR-DRG) software was used as a risk assessment method. The relationships between death and the following variables were studied by univariate analyses: APR-severity risk, APR-mortality risk, age, sex, length of stay and, discharge ward. Multivariate analysis was also performed to verify the associations between death and those parameters found to be significant by univariate analysis. Unadjusted mortality proportions ranged from 4.3 to 44.0%. Logistic regression analysis demonstrated that APR-mortality risk, length of stay, and discharge ward were significantly and independently associated with 30-day mortality risk in patients with CHF. In summary, 30-day mortality risk varied significantly according to the ward of discharge in an Italian teaching hospital, even after adjustment for severity of illness
Effetti della programmazione ospedaliera sulle migrazioni dei pazienti: esperienza senese
No full textConfronto tra prevalenza delle infezioni ospedaliere ed altri indicatori di processo per la Valutazione della qualità assistenziale
No full textDiagnostic turnaround times as a tool for assessing hospital performance: a pilot study in Italy and Germany
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