Nils Gutacker

Comparing the performance of the Charlson/Deyo and Elixhauser comorbidity measures across five European countries and three conditions.

BACKGROUND The Charlson and Elixhauser comorbidity measures are commonly used methods to account for patient comorbidities in hospital-level comparisons of clinical quality using administrative data. Both have been validated in North America, but there is less evidence of their performance in Europe and in pooled cross-country data, which are features of the European Collaboration for Healthcare Optimization (ECHO) project. This study compares the performance of the Charlson/Deyo and Elixhauser comorbidity measures in predicting in-hospital mortality using data from five European countries in three inpatient groups. METHODS Administrative data is used from five countries in 2008-2009 for three indicators commonly used in hospital quality comparisons: mortality rates following acute myocardial infarction, coronary artery bypass graft surgery and stroke. Logistic regression models are constructed to predict mortality controlling for age, gender and the relevant comorbidity measure. Model discrimination is evaluated using c-statistics. Model calibration is evaluated using calibration slopes. Overall goodness-of-fit is evaluated using Nagelkerkes R(2) and the Akaike information criterion. All models are validated internally by using bootstrapping and externally by using the 2009 model parameters to predict mortality in 2008. RESULTS The Elixhauser measure has better overall predictive ability in terms of discrimination and goodness-of-fit than the Charlson/Deyo measure or the age-sex only model. There is no clear difference in model calibration. These findings are robust to the choice of country, to pooling all five countries and to internal and external validation. CONCLUSIONS The Elixhauser list contains more comorbidities, which may enable it to achieve better discrimination than the Charlson measure. Both measures achieve similar calibration, so for the purpose of ECHO we judged the Elixhauser measure to be preferable.

Hospital variation in patient-reported outcomes at the level of EQ-5D dimensions: evidence from England.

Background. The English Department of Health has introduced routine collection of patient-reported outcome data for selected surgical procedures to facilitate patient choice and increase hospital accountability. However, using aggregate health outcome scores, such as EQ-5D utilities, for performance assessment purposes causes information loss and raises statistical and normative concerns. Objectives. For hip replacement surgery, we explore a) the change in patient-reported outcomes between baseline and follow-up on 5 health dimensions (EQ-5D), b) the extent to which treatment impact varies across hospitals, and c) the extent to which hospital performance on EQ-5D dimensions is correlated with performance on the EQ-5D utility index. Methods. We combine information on pre- and postoperative EQ-5D outcomes with routine inpatient data for the financial year 2009–2010. The sample consists of 21,000 patients in 153 hospitals. We employ hierarchical ordered probit risk-adjustment models that recognize the multilevel nature of the data and the response distributions. The treatment impact is modeled as a random coefficient that varies at the hospital level. We obtain hospital-specific empirical Bayes (EB) estimates of this coefficient. We estimate separate models for each EQ-5D dimension and the EQ-5D utility index and analyze correlations of EB estimates across these. Results. Hospital treatment is associated with improvements in all EQ-5D dimensions. Variability in treatment impact is most pronounced on the mobility and usual activities dimensions. Conversely, only pain/discomfort and anxiety/depression correlate well with performance measures based on utilities. This leads to different assessments of hospital performance across metrics. Conclusions. Our results indicate which hospitals are better than others in improving health across particular EQ-5D dimensions. We demonstrate the importance of evaluating dimensions of the EQ-5D separately for the purposes of hospital performance assessment.

Addressing Missing Data in Patient‐Reported Outcome Measures (PROMS): Implications for the Use of PROMS for Comparing Provider Performance

Abstract Patient‐reported outcome measures (PROMs) are now routinely collected in the English National Health Service and used to compare and reward hospital performance within a high‐powered pay‐for‐performance scheme. However, PROMs are prone to missing data. For example, hospitals often fail to administer the pre‐operative questionnaire at hospital admission, or patients may refuse to participate or fail to return their post‐operative questionnaire. A key concern with missing PROMs is that the individuals with complete information tend to be an unrepresentative sample of patients within each provider and inferences based on the complete cases will be misleading. This study proposes a strategy for addressing missing data in the English PROM survey using multiple imputation techniques and investigates its impact on assessing provider performance. We find that inferences about relative provider performance are sensitive to the assumptions made about the reasons for the missing data.

Patient and hospital determinants of primary percutaneous coronary intervention in England, 2003–2013

Objective Primary percutaneous coronary intervention (PPCI) for ST-elevation myocardial infarction (STEMI) is insufficiently implemented in many countries. We investigated patient and hospital characteristics associated with PPCI utilisation. Methods Whole country registry data (MINAP, Myocardial Ischaemia National Audit Project) comprising PPCI-capable National Health Service trusts in England (84 hospital trusts; 92 350 hospitalisations; 90 489 patients), 2003–2013. Multilevel Poisson regression modelled the relationship between incidence rate ratios (IRR) of PPCI and patient and trust-level factors. Results Overall, standardised rates of PPCI increased from 0.01% to 86.3% (2003–2013). While, on average, there was a yearly increase in PPCI utilisation of 30% (adjusted IRR 1.30, 95% CI 1.23 to 1.36), it varied substantially between trusts. PPCI rates were lower for patients with previous myocardial infarction (0.95, 0.93 to 0.98), heart failure (0.86, 0.81 to 0.92), angina (0.96, 0.94 to 0.98), diabetes (0.97, 0.95 to 0.99), chronic renal failure (0.89, 0.85 to 0.90), cerebrovascular disease (0.96, 0.93 to 0.99), age >80 years (0.87, 0.85 to 0.90), and travel distances >30 km (0.95, 0.93 to 0.98). PPCI rates were higher for patients with previous percutaneous coronary intervention (1.09, 1.05 to 1.12) and among trusts with >5 interventional cardiologists (1.30, 1.25 to 1.34), more visiting interventional cardiologists (1–5: 1.31, 1.26 to 1.36; ≥6: 1.42, 1.35 to 1.49), and a 24 h, 7-days-a-week PPCI service (2.69, 2.58 to 2.81). Half of the unexplained variation in PPCI rates was due to between-trust differences. Conclusions Following an 8 year implementation phase, PPCI utilisation rates stabilised at 85%. However, older and sicker patients were less likely to receive PPCI and there remained between-trust variation in PPCI rates not attributable to differences in staffing levels. Compliance with clinical pathways for STEMI is needed to ensure more equitable quality of care.

Choice of hospital: Which type of quality matters?

Highlights • Patients choose hospitals that improve their self-reported health.• Quality, as measured by readmission and mortality rates, is less important.• Healthier patients are more willing or able to travel for higher quality.• Quality competition in the English NHS is possible.• Potential for competition declines rapidly with distance between hospitals.

Amputations in PAD patients - Data from the German Federal Statistical Office

Much effort has been spent to reduce the number of amputees within the last two decades, but it remains unclear how effective the different strategies have been. We analyzed the prevalence of amputations in inpatient cases in the federal statistics. Detailed lists of all amputations coded as major amputations (OPS 5-864) and minor amputations (OPS 5-865) performed in 2005 and 2006, divided into the 4th and 5th number of the OPS-code, were provided by the Federal Statistical Office. In 2006, a total of 62,880 amputations affecting the lower extremities (2005: 63,005) were performed in Germany. Because of multiple amputations within a single case the corresponding cases amounted to 55,705 in 2006 and 55,689 in 2005. Based on these data age-adjusted incidence rates of major amputations per 100,000 inhabitants increased from 2 at the age of < 50 years to 201 at the age of > 80 years. For minor amputations the prevalence rates increased from 4 at the age of < 50 years to 209 at the age of > 80 years. It can be assumed that peripheral arterial disease or neurovascular disease as the underlying disease necessitating the amputation were present in 74.9% of all inpatient cases who finally underwent amputation. There were 12.9% with non-vascular or non-diabetic reasons for amputations. In patients presenting with gangrene, the rate of minor amputations decreased with age, whereas the rate of major amputations increased, especially within the 8th to 10th decades of life. In conclusion, amputations affecting the lower limbs are still a relevant problem in Germany. At the time of an aging German population it has to be an important goal to lower or at least to stabilize the rate of amputations. The DRG statistics enable the Federal Ministry of Health and health politics to monitor amputation rates easily.

Should English healthcare providers be penalised for failing to collect patient-reported outcome measures? A retrospective analysis

Summary Objective The best practice tariff for hip and knee replacement in the English National Health Service (NHS) rewards providers based on improvements in patient-reported outcome measures (PROMs) collected before and after surgery. Providers only receive a bonus if at least 50% of their patients complete the preoperative questionnaire. We determined how many providers failed to meet this threshold prior to the policy introduction and assessed longitudinal stability of participation rates. Design Retrospective observational study using data from Hospital Episode Statistics and the national PROM programme from April 2009 to March 2012. We calculated participation rates based on either (a) all PROM records or (b) only those that could be linked to inpatient records; constructed confidence intervals around rates to account for sampling variation; applied precision weighting to allow for volume; and applied risk adjustment. Setting NHS hospitals and private providers in England. Participants NHS patients undergoing elective unilateral hip and knee replacement surgery. Main outcome measures Number of providers with participation rates statistically significantly below 50%. Results Crude rates identified many providers that failed to achieve the 50% threshold but there were substantially fewer after adjusting for uncertainty and precision. While important, risk adjustment required restricting the analysis to linked data. Year-on-year correlation between provider participation rates was moderate. Conclusions Participation rates have improved over time and only a small number of providers now fall below the threshold, but administering preoperative questionnaires remains problematic in some providers. We recommend that participation rates are based on linked data and take into account sampling variation.

Does the quality and outcomes framework reduce psychiatric admissions in people with serious mental illness? A regression analysis

Background The Quality and Outcomes Framework (QOF) incentivises general practices in England to provide proactive care for people with serious mental illness (SMI) including schizophrenia, bipolar disorder and other psychoses. Better proactive primary care may reduce the risk of psychiatric admissions to hospital, but this has never been tested empirically. Methods The QOF data set included 8234 general practices in England from 2006/2007 to 2010/2011. Rates of hospital admissions with primary diagnoses of SMI or bipolar disorder were estimated from national routine hospital data and aggregated to practice level. Poisson regression was used to analyse associations. Results Practices with higher achievement on the annual review for SMI patients (MH9), or that performed better on either of the two lithium indicators for bipolar patients (MH4 or MH5), had more psychiatric admissions. An additional 1% in achievement rates for MH9 was associated with an average increase in the annual practice admission rate of 0.19% (95% CI 0.10% to 0.28%) or 0.007 patients (95% CI 0.003 to 0.01). Conclusions The positive association was contrary to expectation, but there are several possible explanations: better quality primary care may identify unmet need for secondary care; higher QOF achievement may not prevent the need for secondary care; individuals may receive their QOF checks postdischarge rather than prior to admission; individuals with more severe SMI may be more likely to be registered with practices with better QOF performance; and QOF may be a poor measure of the quality of care for people with SMI.

Socioeconomic inequality in hip replacement in four European countries from 2002 to 2009--area-level analysis of hospital data.

BACKGROUND Cross-country comparisons of socioeconomic equity in health care typically use sample survey data on general services such as physician visits. This study uses comprehensive administrative data on a specific service: hip replacement. METHODS We analyse 651 652 publicly funded hip replacements, excluding fractures and accidents, in adults over 35 in Denmark, England, Portugal and Spain from 2002 to 2009. Sub-national administrative areas are split into socioeconomic quintile groups comprising approximately one-fifth of the national population. Area-level Poisson regression with Huber-White standard errors is used to calculate age-sex standardised hip replacement rates by quintile group, together with gaps and ratios between richest and poorest groups (Q5 and Q1) and the middle group (Q3). RESULTS We find pro-rich-area inequality in England (2009 Q5/Q1 ratio 1.35 [CI 1.25-1.45]) and Spain (2009 Q5/Q1 ratio 1.43 [CI 1.17-1.70]), pro-poor-area inequality in Portugal (2009 Q5/Q1 ratio 0.67 [CI 0.50-0.83]) and no significant inequality in Denmark. Pro-rich-area inequality increased over time in England and Spain but not significantly. Within-country differences between socioeconomic quintile groups are smaller than between-country differences in general population averages: hip replacement rates are substantially lower in Portugal and Spain (8.6 and 7.4 per 10 000 in 2009) than England and Denmark (20.2 and 27.8 per 10 000 in 2009). CONCLUSION Despite limitations regarding individual-level inequality and area heterogeneity, analysis of area-level data on publicly funded hospital activity can provide useful cross-country comparisons and longitudinal monitoring of socioeconomic inequality in specific health services. Although this kind of analysis cannot provide definitive answers, it can raise important questions for decision makers.

Hospital admissions for severe mental illness in England: Changes in equity of utilisation at the small area level between 2006 and 2010

Severe Mental Illness (SMI) encompasses a range of chronic conditions including schizophrenia, bipolar disorder and psychoses. Patients with SMI often require inpatient psychiatric care. Despite equity being a key objective in the English National Health Service (NHS) and in many other health care systems worldwide, little is known about the socio-economic equity of hospital care utilisation for patients with SMI and how it has changed over time. This analysis seeks to address that gap in the evidence base. We exploit a five-year (2006–2010) panel dataset of admission rates at small area level (n = 162,410). The choice of control variables was informed by a systematic literature search. To assess changes in socio-economic equity of utilisation, OLS-based standardisation was first used to conduct analysis of discrete deprivation groups. Geographical inequity was then illustrated by plotting standardised and crude admission rates at local purchaser level. Lastly, formal statistical tests for changes in socio-economic equity of utilisation were applied to a continuous measure of deprivation using pooled negative binomial regression analysis, adjusting for a range of risk factors. Our results suggest that one additional percentage point of area income deprivation is associated with a 1.5% (p < 0.001) increase in admissions for SMI after controlling for population size, age, sex, prevalence of SMI in the local population, as well as other need and supply factors. This finding is robust to sensitivity analyses, suggesting that a pro-poor inequality in utilisation exists for SMI-related inpatient services. One possible explanation is that the supply or quality of primary, community or social care for people with mental health problems is suboptimal in deprived areas. Although there is some evidence that inequity has reduced over time, the changes are small and not always robust to sensitivity analyses.