Marc Carreras

La medida de la morbilidad atendida en una organización sanitaria integrada

INTRODUCTION Understanding the quality, costs and outcomes of healthcare services requires precise determination of the morbidity in a population. Measurement of morbidity in a population and its association with the services provided remains to be performed. The aim of this article was to present our experience of using clinical risk groups (CRGs) to measure morbidity in an integrated healthcare organization (IHO). METHODS We studied the population attended by an IHO in a county (approximately 120,000 patients) from 2002 to 2005. CRGs were used to measure morbidity. A descriptive analysis was performed of the populations distribution in CRG categories and utilization rates. RESULTS One or more chronic diseases was found in 15.5% of the population, significant acute illness was found in 9%, minor chronic diseases was found in 7% and very severe diseases was found in 0.5%. Between 2002 and 2005, the number of individuals with chronic disease increased by 8%. The burden of illness increased with age. However, at all ages, at least 40% of the population remained healthy. Comorbidity in chronic illnesses was a crucial factor in explaining healthcare resource utilization. CONCLUSIONS The CRG grouping system aids analysis at different levels for clinical administration. Due to its composition, this system allows better understanding of the use, costs and quality of the set of services received by a population.

Estimates of patient costs related with population morbidity: can indirect costs affect the results?

A number of health economics studies require patient cost estimates as basic information input. However, the accuracy of cost estimates remains generally unspecified. We propose to investigate how the allocation of indirect costs or overheads can affect the estimation of patient costs and lead to improvements in the analysis of patient cost estimates. Instead of focussing on the costing method, this paper will highlight observed changes in variation explained by a methodology choice. We compare four overhead allocation methods for a specific Spanish population adjusted using the Clinical Risk Groups model. Our main conclusion is that the amount of global variation explained by the risk adjustment model depends mainly on direct costs, regardless of the cost allocation methodology used. Furthermore, the variation explained can be slightly increased, depending on the cost allocation methodology, and is independent of the level of aggregation in the classification system.

Análisis de la población diabética de una comarca: perfil de morbilidad, utilización de recursos, complicaciones y control metabólico

OBJECTIVE To describe the characteristics of a diabetic population, morbidity profile, resource consumption, complications and degree of metabolic control. DESIGN Cross-sectional study during 2010. LOCATION Four Health Areas (91.301 people) where the integrated management organization Serveis de Salut integrated Baix Empordà completely provide healthcare assistance. PARTICIPANTS 4.985 diabetic individuals, identified through clinical codes using the ICD-9-MC classification and the 3M? Clinical Risk Groups software. MAIN MEASUREMENTS Morbidity profile, related complications and degree of metabolic control were obtained for the target diabetic population. We analyzed the consumption of healthcare resources, pharmaceutical and blood glucose reagent strips. All measurements obtained at individual level. RESULTS 99.3% of the diabetic population were attended at least once at a primary care center (14.9% of visits). 39.5% of primary care visits and less than 10% of the other scanned resources were related to the management of diabetes. The pharmaceutical expenditure was 25.4% of the population consumption (average cost ?1.014,57). 36.5% of diabetics consumed reagents strips (average cost ?120,65). The more frequent CRG are 5424-Diabetes (27%); 6144-Diabetes and Hypertension (25,5%) and 6143-Diabetes and Other Moderate Chronic Disease (17,2%). The degree of disease control is better in patients not consumers of antidiabetic drugs or treated with oral antidiabetic agents not secretagogues. CONCLUSIONS Comorbidity is decisive in the consumption of resources. Just a few part of this consumption is specifically related to the management of diabetes. Results obtained provide a whole population approach to the main existing studies in our national and regional context.

Los grupos de morbilidad ajustados: un debate pendiente

Hemos leído con atención el artículo de Monterde et al. «Los grupos de morbilidad ajustados: nuevo agrupador de morbilidad poblacional de utilidad en el ámbito de la atención primaria»1. En el artículo se menciona su posible implantación en el Sistema Nacional de Salud (SNS). No obstante, desde nuestro punto de vista, la metodología descrita suscita algunas dudas que exponemos a continuación. El objetivo del artículo es presentar un nuevo agrupador de morbilidad y comprobar su valor explicativo, pero no se especifica qué riesgo explicaría. Huntley et al.2, cuyo testigo dicen recoger, señalan que se necesitan medidas diferentes para evaluar resultados distintos y que es necesario evaluar la asociación existente entre la medida y el resultado. Por ello sorprende la comparación con el índice de Charlson ----predictor de mortalidad---y con el número de enfermedades crónicas ----sin justificar el motivo---y no con otros agrupadores de morbilidad poblacional. Los autores justifican el desarrollo de un nuevo agrupador por diversas limitaciones relacionadas con los Clinical Risk Groups ® (CRG). Sin embargo, estas limitaciones no se manifiestan en la amplia literatura disponible sobre aplicación de los CRG, en diferentes territorios y organizaciones como el País Vasco, la Comunidad Valenciana y la comarca del Baix Empordà (Girona)3--5. En relación con la estructura de los GMA los autores señalan que se han tenido en cuenta 2 factores, la multimorbilidad y la complejidad. La medida de la morbilidad se establece considerando unas Agrupaciones de Códigos Diagnósticos (ACD), que a pesar de ser el pivote del sistema no se especifican en el cuerpo del artículo. Por otra parte se desconoce si estas agrupaciones se han obtenido desde una perspectiva clínica o desde una perspectiva estadística. Sobre la complejidad, los autores indican que se obtiene «a partir de modelos cuali-cuantitativos donde se reco-

Analysing the Costs of Integrated Care: A Case on Model Selection for Chronic Care Purposes

Background: The objective of this study is to investigate whether the algorithm proposed by Manning and Mullahy, a consolidated health economics procedure, can also be used to estimate individual costs for different groups of healthcare services in the context of integrated care. Methods: A cross-sectional study focused on the population of the Baix Empordà (Catalonia-Spain) for the year 2012 (N = 92,498 individuals). A set of individual cost models as a function of sex, age and morbidity burden were adjusted and individual healthcare costs were calculated using a retrospective full-costing system. The individual morbidity burden was inferred using the Clinical Risk Groups (CRG) patient classification system. Results: Depending on the characteristics of the data, and according to the algorithm criteria, the choice of model was a linear model on the log of costs or a generalized linear model with a log link. We checked for goodness of fit, accuracy, linear structure and heteroscedasticity for the models obtained. Conclusion: The proposed algorithm identified a set of suitable cost models for the distinct groups of services integrated care entails. The individual morbidity burden was found to be indispensable when allocating appropriate resources to targeted individuals.