Carol Rabinowitz

Long-term retention of graduates from a program to increase the supply of rural family physicians.

Purpose To determine the long-term retention of rural family physicians graduating from the Physician Shortage Area Program (PSAP) of Jefferson Medical College. Method Of the 1,937 Jefferson graduates from the classes of 1978–1986, the authors identified those practicing rural family medicine when their practice location was first determined. The number and percent of PSAP and non-PSAP graduates practicing family medicine in the same rural area in 2002 were then identified, and compared to the number of those graduates practicing rural family medicine when they were first located in practice 11–16 years earlier. Results After 11–16 years, 68% (26/38) of the PSAP graduates were still practicing family medicine in the same rural area, compared with 46% (25/54) of their non-PSAP peers (p= .03). Survival analysis showed that PSAP graduates practice family medicine in the same rural locality longer than non-PSAP graduates (p = .04). Conclusions These results are the first to show long-term rural primary care retention that is longer than the median duration. This outcome combined with previously published outcomes show that the PSAP represents the only program that has resulted in multifold increases in both recruitment (eight-fold) and long-term retention (at least 11–16 years). In light of recent national recommendations to increase the total enrollment in medical schools, allocating some of this growth to developing and expanding programs similar to the PSAP would make a substantial and long lasting impact on the rural physician workforce.

Prevalence and predictors of potential drug–drug interactions in Regione Emilia-Romagna, Italy

Background and objective:  Drug–drug interactions (DDIs) are preventable medication errors associated with potentially serious adverse events and death. Several studies have examined the prevalence of potential DDIs among ambulatory patients in various countries. Limited recent data on the prevalence of potential DDIs in Italy are available in the medical literature. The objective of this study was to estimate the prevalence of clinically important potential DDIs among the approximately 4 million residents of Regione Emilia‐Romagna (RER), Italy, and to examine possible predictors of potential DDI exposure.

Using pharmacy data to identify those with chronic conditions in Emilia Romagna, Italy.

Background and objectives: Automated pharmacy data have been used to develop a measure of chronic disease status in the general population. The objectives of this project were to refine and apply a model of chronic disease identification using Italian automated pharmacy data; to describe how this model may identify patterns of morbidity in Emilia Romagna, a large Italian region; and to compare estimated prevalence rates using pharmacy data with those available from a 2000 Emilia Romagna disease surveillance study. Methods: Using the Chronic Disease Score, a list of chronic conditions related to the consumption of drugs under the Italian pharmaceutical dispensing system was created. Clinical review identified medication classes within the Italian National Therapeutic Formulary that were linked to the management of each chronic condition. Algorithms were then tested on pharmaceutical claims data from Emilia Romagna for 2001 to verify the applicability of the classification scheme. Results: Thirty-one chronic condition drug groups (CCDGs) were identified. Applying the model to the pharmacy data, approximately 1.5 million individuals (37.1%) of the population were identified as having one or more of the 31 CCDGs. The 31 CCDGs accounted for 77% (E556 million) of 2001 pharmaceutical expenditures. Cardiovascular diseases, rheumatological conditions, chronic respiratory illness, gastrointestinal diseases and psychiatric diseases were the most frequent chronic conditions. External validation comparing rates of the diseases found through using pharmacy data with those of a 2000 Emilia Romagna disease surveillance study showed similar prevalence of illness. Conclusions: Using Italian automated pharmacy data, a measure of population-based chronic disease status was developed. Applying the model to pharmaceutical claims from Emilia Romagna 2001, a large proportion of the population was identified as having chronic conditions. Pharmacy data may be a valuable alternative to survey data to assess the extent to which large populations are affected by chronic conditions.

Using administrative data to identify and stage breast cancer cases: implications for assessing quality of care.

AIMS AND BACKGROUND The study evaluated the use of Italian hospital discharge data (SDO, scheda di dimissione ospedaliera) for identifying women with incident breast cancer, determining stage at diagnosis and assessing quality of care. STUDY DESIGN Women aged 20+ years residing in the Regione Emilia-Romagna, Italy, between 2002 and 2005 were studied. Case identification using algorithms based on ICD-9-CM codes on hospital discharge data were compared with AIRTUM-accredited cancer registry data. Sensitivity, specificity and positive predictive value were computed overall, by age and cancer stage. Compliance with guidelines for radiation therapy using registry and hospital data were compared. RESULTS A total of 11,615 women was identified by AIRTUM-accredited cancer registries as incident cases, whereas 10,876 women were identified by the SDO algorithm. Sensitivity was 84.8%, specificity was 99.9%, and the positive predictive value was 90.6%. Of the 1,022 who were false positives, 363 (35.5%) were women identified in registry data as having an incident case prior to 2002 and therefore were not included in the analysis. There were 1,761 false negatives; nearly 50% were over 70 years of age or did not undergo a surgical procedure and therefore were not included in our SDO-based case finding. Sensitivity declined as the patient population became older. However, we observed relatively good positive predictive value for all age groups. Algorithms using the SDO data did not clearly identify specific cancer stages. However, the algorithm may have utility where stages are grouped together for use in quality measures. CONCLUSIONS Cases were identified with good sensitivity, specificity and positive predictive value with SDO data, with better rates than similar previously published algorithms based on Italian data. These hospital claims-based algorithms facilitate quality of care analyses for large populations when registry data are not available by identifying individual women and their subsequent use of health care services.

Increasing appropriateness of hospital admissions in the Emilia-Romagna region of Italy

Objectives: The Emilia-Romagna region of Italy has reduced the number of available hospital beds and introduced financial incentives to curb hospital use. The goal of this study was to assess the impact of these policies on changes over time in the number of acute hospital admissions classified in diagnosis related groups (DRGs) that could be treated safely and effectively in alternative, less costly settings. Methods: The assessment of the appropriate site of care was based on analysis of hospital discharge data for all hospitals for the selected diagnosis related groups in the Emilia-Romagna region for 2001 to 2005. The necessity for acute hospital admission was based on the severity of a patients principal diagnosis, co-morbid diseases and, for surgical admissions, procedure performed. Results: From 2001 to 2005, potentially inappropriate medical admissions of more than one day decreased from 20,076 to 11,580, a 42% decrease. Inappropriate admissions decreased in both public and private hospitals but there remained a higher rate of inappropriate admissions to private hospitals. Potentially inappropriate medical admissions accounted for 128,319 bed-days in 2001 and 68,968 bed-days in 2005, a reduction of 59,351 bed-days. Potentially inappropriate surgical admissions decreased from 7383 in 2001 to 4349 in 2005, a 41% decrease. Bed-days consumed by inappropriate surgical admissions decreased from 23,181 in 2001 to 13,660 in 2005. Conclusions: The Emilia-Romagna region has succeeded in reducing the use of acute hospital beds for patients in selected diagnosis related groups. However, there are still substantial numbers of admissions that could potentially be treated in less costly settings.

Assessing Adverse Events of Postprostatectomy Radiation Therapy for Prostate Cancer: Evaluation of Outcomes in the Regione Emilia-Romagna, Italy

PURPOSE Although the likelihood of radiation-related adverse events influences treatment decisions regarding radiation therapy after prostatectomy for eligible patients, the data available to inform decisions are limited. This study was designed to evaluate the genitourinary, gastrointestinal, and sexual adverse events associated with postprostatectomy radiation therapy and to assess the influence of radiation timing on the risk of adverse events. METHODS The Regione Emilia-Romagna Italian Longitudinal Health Care Utilization Database was queried to identify a cohort of men who received radical prostatectomy for prostate cancer during 2003 to 2009, including patients who received postprostatectomy radiation therapy. Patients with prior radiation therapy were excluded. Outcome measures were genitourinary, gastrointestinal, and sexual adverse events after prostatectomy. Rates of adverse events were compared between the cohorts who did and did not receive postoperative radiation therapy. Multivariable Cox proportional hazards models were developed for each class of adverse events, including models with radiation therapy as a time-varying covariate. RESULTS A total of 9876 men were included in the analyses: 2176 (22%) who received radiation therapy and 7700 (78%) treated with prostatectomy alone. In multivariable Cox proportional hazards models, the additional exposure to radiation therapy after prostatectomy was associated with increased rates of gastrointestinal (rate ratio [RR] 1.81; 95% confidence interval [CI] 1.44-2.27; P<.001) and urinary nonincontinence events (RR 1.83; 95% CI 1.83-2.80; P<.001) but not urinary incontinence events or erectile dysfunction. The addition of the time from prostatectomy to radiation therapy interaction term was not significant for any of the adverse event outcomes (P>.1 for all outcomes). CONCLUSION Radiation therapy after prostatectomy is associated with an increase in gastrointestinal and genitourinary adverse events. However, the timing of radiation therapy did not influence the risk of radiation therapy-associated adverse events in this cohort, which contradicts the commonly held clinical tenet that delaying radiation therapy reduces the risk of adverse events.

Students' gender and examination of patients in a third-year family medicine clerkship.

No abstract available.

Using hospital discharge abstract data to identify incident breast cancer cases and assess quality of care

This study assesses the feasibility of using hospital discharge data to identify women with incident breast cancer, and it evaluates the use of these data to assess compliance with an indicator of quality of care. The study’s goals are to: 1) compare breast cancer case-finding algorithms based upon ICD-9 CM codes found in hospital discharge data with cancer registry data and 2) compare the utility of these algorithms for use with a selected quality indicator.

Risk adjustment in a non-market-based system: the case of Emilia-Romagna, Italy

Risk adjustment is a useful tool for setting budgets in non-market-based healthcare systems. This paper develops a prospective risk adjuster for 4 million residents of Regione Emilia-Romagna, Italy. The risk adjuster predicts hospital and pharmacy costs based on clinical information collected in the prior year in 114 Disease Staging Groups based upon hospital data and 31 Chronic Condition Drug Groups based upon pharmacy data. For the prospective risk adjuster, model R-squareds of 7.8% for hospital costs and 25.3% for pharmacy costs is reported. The risk adjuster is evaluated on individual and group predictive accuracy and ways to use the adjuster as a budgeting tool during negotiations between local health unit and district managers are discussed.

PCN15 STATIN USE AND THE RISK OF COLORECTAL CANCER: A POPULATION-BASED COHORT STUDY

PCN14 SYSTEMATIC REVIEW OF EFFICACY OUTCOMES REPORTED IN RANDOMISED CONTROLLED TRIALS OF FIRST-LINE (1L) THERAPIES FOR METASTATIC BREAST CANCER (MBC) Harper C, McCormick AL, Sabaté E Complete Medical Group, Glasgow, UK, Complete Medical Group, Macclesfield, UK, F. Hoffmann—La Roche Ltd, Basel, Switzerland OBJECTIVES: There is currently some debate around the optimal role of overall survival (OS) as a gold standard in assessing the benefits of oncology products. The objective of this analysis was to provide evidence to inform this discussion from a review of the clinical outcomes in 1L mBC trials reported over the last 10 years. METHODS: MEDLINE and Cochrane databases were searched to identify randomised controlled trials of treatments for 1L mBC published between January 1998 and February 2009. Studies in exclusively human epidermal growth factor receptor 2-positive populations were excluded. RESULTS: Clinical efficacy data were extracted from 36 trials. All 36 trials reported response rate (RR), 34 reported a progressionbased end point and 33 reported OS. The most commonly stated primary efficacy end points were progression-based; only 6 trials stated OS as the primary end point. Improvement in median OS ranged from 0.1 to 7.8 months, improvement in median progression-free survival (PFS) ranged from 0.1 to 6.4 months and improvement in RR ranged from 0.3% to 28%. Fourteen trials (39%) reported a significant progression-based benefit, 4 of which (36%) reported significant median OS. Each of these 4 trials also reported a significant benefit in RR and median PFS. CONCLUSIONS: Overall, very few 1L mBC trials have reported a significant median OS benefit. Where a significant OS benefit was reported, a significant overall RR and PFS benefit was also reported. These findings appear important in light of the ongoing debate on the relevance of currently used clinical end points in mBC trials.