Elaine J. Yuen

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.

Potentially inappropriate medication prescribing for elderly outpatients in Emilia Romagna, Italy: a population-based cohort study.

BackgroundIn the US, a growing body of epidemiological studies has documented widespread potentially inappropriate medication prescribing among the elderly in outpatient settings. However, only limited information exists in Europe.ObjectiveTo evaluate the prevalence of potentially inappropriate medication prescribing among elderly outpatients in Emilia Romagna, Italy and to investigate factors associated with potentially inappropriate medication prescribing in that setting.MethodsRetrospective cohort study using the Emilia Romagna outpatient prescription claims database from 1 January 2001 to 31 December 2001 linked with information (age, sex and other variables) available from a demographic file of approximately 1 million Emilia Romagna residents aged ≥65 years. The cohort comprised 849 425 elderly patients who had at least one drug prescription during the study period. The prevalence of potentially inappropriate medication prescribing, as defined by the 2002 Beers’ criteria, was measured together with predictors associated with potentially inappropriate medication prescribing.ResultsA total of 152 641 (18%) elderly Emilia Romagna outpatients had one or more occurrences of potentially inappropriate medication prescribing. Of these, 11.5% received prescriptions for two medications of concern and 1.7% for three or more. Doxazosin (prescribed to 23% of subjects) was the most frequently occurring potentially inappropriate prescribed medication, followed by ketorolac (20.5%), ticlopidine (18.3%) and amiodarone (12.6%). Factors associated with greater likelihood of potentially inappropriate medication prescribing were older age, overall number of drugs prescribed and greater number of chronic conditions. The odds of receiving potentially inappropriate prescribed medications were lower for females, subjects living in more urban areas and subjects with a higher income level.ConclusionsThis study provides strong evidence that potentially inappropriate medication prescribing for elderly outpatients is a substantial problem in Emilia Romagna. Focusing on the prevalence of potentially inappropriate medication prescribing and associated predictors can help in the development of educational programmes targeting outpatient practitioners to influence prescribing behaviour and, therefore, reduce potentially inappropriate medication prescribing.

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.

Sedative-hypnotic use and increased hospital stay and costs in older people.

OBJECTIVE: To assess the relationship between sedative‐hypnotic (S/H) utilization, severity of illness, length of stay, and hospital costs among older patients admitted to a tertiary care university hospital.

Sedative-hypnotic use by the elderly: effects on hospital length of stay and costs.

Sedative-hypnotic medications are often used to treat anxiety and sleep disorders, although they may not be used appropriately. Relationships between hospital length of stay (LOS), costs, and levels of sedative-hypnotic use were examined. Charts of 856 elderly patients were reviewed for sedative hypnotic use and categorized into three groups: those whose use exceeded Health Care Financing Administration (HCFA) guidelines, those who used sedative-hypnotic medications but did not exceed HCFA guidelines, and those who did not receive any sedative-hypnotic medications. Patients whose sedative-hypnotic use exceeded guidelines had longer LOS (21.5 exceeding guidelines vs. 12.3 within guidelines vs. 6.7 no use, p≤.001) and higher costs (

Variation in Hospital Use and Avoidable Patient Morbidity

29,245 exceeding guidelines vs.

Severity-Adjusted Differences in Hospital Utilization by Gender:

15,219 within guidelines vs.

An Analysis of Health Services Using Disease Staging: A Pilot Study in the Emilia‐Romagna Region of Italy

7,516 no use, p≤.001.) Even after controlling for severity of illness and comorbid conditions, differences in LOS and costs persisted. This study indicates that sedative-hypnotic medications are frequently prescribed to elderly patients, often in doses exceeding proposed guidelines, and are associated with longer hospital stays and higher hospital costs.

Modeling risk-adjusted capitation rates for Umbria, Italy

Objectives: To determine whether geographical areas with relatively low overall hospitalization rates have higher population-based rates of admission of patients with advanced stages of disease. Methods: Age- and sex-standardized hospital admission rates were calculated for the residents of the 80 Local Health Units in Lombardia, Italy. Using the Disease Staging classification, advanced stage admissions were identified for six common medical and surgical conditions, which it was presumed would reflect untimely hospital admission. Standardized rates of advanced stage admissions were compared in areas with overall high hospitalization rates (high-use areas) and low hospitalization rates (low-use areas). Results: Hospitalization at advanced stages of disease in the low-use areas were significantly higher for the six conditions combined (55.9 vs 43.0 per 100 000; P=0.005), and for external hernia, appendicitis and uterine fibroma, but not for bacterial pneumonia, diverticular disease and peptic ulcer. For the six study conditions combined, residents of overall low-use areas were 30% more likely to be admitted with advanced stages of disease. Conclusion: Low overall hospitalization rates were found to be associated with greater severity of illness at hospitalization and potentially avoidable morbidity for some conditions. Policies aimed at curbing unnecessary hospital admission should consider preserving access for appropriate treatment.

Physician Rationale for Benzodiazepine Prescriptions to Elderly Hospitalized Patients

Gender-based differences in hospital use may result from biological differences or may suggest problems of access to health services and quality of care. We hypoth esized that there should be no difference in hospital care between men and women, given the same diagnosis. Hospitalizations were characterized by severity of ill ness, as this may indicate the timeliness of hospital care. Hospitalizations may be too late (with higher severity of illness) resulting in long stays and high costs, or too early (with lower severity of illness) resulting in care that could be given in alternative treatment settings. Three abdominal conditions were examined which could be misdiagnosed or confused with other diseases involv ing the female reproductive system: appendicitis, diver ticulitis, and cholecystitis. The National Hospital Dis charge Survey (NHDS) was used for analysis. Disease staging was used to assign a severity of illness indicator, ranging from stage 1 (conditions with no complications) to stage 3 (multiple site involvement, poor prognosis). For each disease, the percentage of discharges and the age-adjusted discharge rate per 1000 population was examined by stage of illness and gender. For appendec tomy, there was a significantly greater percentage of men at stage 1 (lower severity) compared to women (73% versus 67%). For diverticular disease, women had higher proportions of stage 2/3 discharges than men for both medical and surgical hospitalizations. For chole cystitis, women had a greater percentage of hospitaliza tions at stage 1 than men, notably for surgical treatment (63% compared with 38%), although more men were admitted at stage 2 for both medical and surgical treat ment. Gender differences in the proportions of hospital ization by severity of illness suggest that there are prob lems in the timely recognition and treatment of appendicitis and diverticulitis in women. However, for cholecystitis, it appears that men, rather than women, have a problem of timely recognition and treatment. Future research may seek to identify additional patient characteristics, physician attitudes, and treatment pro tocols.