1. Comparative evaluation of selected international primary healthcare services using PQIs 21-05-2010 Unidade Curricular de Introdução à Medicina II Head teacher : Altamiro da Costa-Pereira, MD, PhD Supervisors : Alberto Freitas, PhD and Ricardo Reis

2. “Of all the ways to face pathologies perhaps the most important one is PREVENTION.” [1] Healthcare system quality analysis: AVOID unnecessary hospital admissions SAVE time and resources IMPROVE quality of life...through analysis of PQIs. [1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

3. “Of all the ways to face pathologies perhaps the most important one is PREVENTION.” [1] [1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf [2] Moura, A. C., A. M. Oliveira, et al. (2008). "[Evaluating Portuguese primary healthcare through Prevention Quality Indicators (PQIs)]." 35. Unpublished data.

4. Evaluate the quality of oupatient healthcare Improvement of the healthcare system Included in QI’s Included in QI’s Created by AHRQ Created by AHRQ Based on ACSC’s Based on ACSC’s

5. PQI’s by AHRQ PQI1: Diabetes short term complication PQI2: Perforated appendix PQI3: Diabetes long-term complication PQI5: Chronic obstructive pulmonary disease PQI7: Hypertension PQI8: Congestive heart failure PQI9: Low Birth Weight PQI10: Dehydration PQI11: Bacterial pneumonia PQI12: Urinary tract infection PQI13: Angina admission without procedure PQI14: Uncontrolled Diabetes PQI15: Adult Asthma PQI16: Lower- extremity amputation among diabetics PQI1: Diabetes short term complication

7. Participants & Methods Database with hospitalizations in Portuguese mainland public hospitals 2000 - 2007 Portugal All the following conditions

8. Participants & Methods Patients between 20-64 years-old admitted in four Italian cities (Turin, Milan, Bologna, Rome) 2000 - 2007 Italy PQI#3 Diabetes Long-term Complications Admission Rate PQI#5 - Chronic Obstructive Pulmonary Disease PQI#7 - Hypertension without procedures PQI#8 - Congestive Heart Failure without procedures PQI#13 - Angina without procedures PQI#3 Diabetes Long-term Complications Admission Rate PQI#5 - Chronic Obstructive Pulmonary Disease PQI#7 - Hypertension without procedures PQI#8 - Congestive Heart Failure without procedures PQI#13 - Angina without procedures

9. Participants & Methods Angina Asthma Cellulitis Congestive heart failure Congestive pulmonar disease Dehydration Diabetes Gastroenteritis Great evil Hypertension Hypoglycemia Urinary and kidney tract infections Pneumonia Severe ENT Infections Immunizable disorders Convulsions Pulmonary Tuberculosis Other tuberculosis Congenital syphilis Dental problems Iron deficiency anemia Nutritional deficiency Growth Failure Pelvic inflammatory disease Angina Asthma Cellulitis Congestive heart failure Congestive pulmonar disease Dehydration Diabetes Gastroenteritis Great evil Hypertension Hypoglycemia Urinary and kidney tract infections Pneumonia Severe ENT Infections Immunizable disorders Convulsions Pulmonary Tuberculosis Other tuberculosis Congenital syphilis Dental problems Iron deficiency anemia Nutritional deficiency Growth Failure Pelvic inflammatory disease Patients between 0-44 years-old admitted in public Spanish hospitals [3] January – December (2000) [3] José Luis Alfonso, S., V. Joan Sentís, et al. (2004). "[Characteristics of avoidable hospitalization in Spain]." Med Clin (Barc) 122(17): 653-658. Spain

10. Nationwide data with hospitalizations in Singapore [4] 1991 - 1998 Participants & Methods Asthma Congestive heart failure Chronic obstructive pulmonary diseases Diabetes mellitus Hypertension Asthma Congestive heart failure Chronic obstructive pulmonary diseases Diabetes mellitus Hypertension Singapore [4] Niti M, Ng TP. Avoidable hospitalization rates in Singapore, 1991-1998: assessing trends and inequities of quality primary care. J Epidemiol Community Health. 2003; 57: 17-22.

11. Participants & Methods USA Patients over 18 years old admitted in hospitals of USA Data calculated and made available by AHRQ [1] 2004 - 2007 All 14 PQIs [1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

12.  Data retrieved from acute care hospital database  Variables of interest present in selected articles from other countries (Pubmed,INE…)  We retrieved articles from PubMed using the following query: "prevention quality indicators" OR "ambulatory care sensitive" OR "avoidable hospitalizations" OR "avoidable hospitalization" OR "preventable hospitalization" OR "preventable hospitalizations" OR "PQI" OR "primary care quality" AND ”(country of interest)

13.  To calculate, we used a syntax (it allows filter admittance for a given disease) for each indicator of each article and also data provided by AHRQ  After obtaining a certain frequency for each case we divide it by the entire population of Portugal which results on a quotient similar to PQI. For PQI 2 and PQI 9 the denominator is not related to the population.

14. By AHRQ [1] and other sources (depending on the studied country) Based on Diagnoses Codes ICD-9-CM Different criteria for different PQIs Inclusion Pregnancy Childbirth Puerperium Newborn (or other neonates) Cases transferred from other institutions. [1] PQI specific Exclusion [1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

16. Examples of Portuguese Database (in SPSS)

18. Nº per 100000 inhabitants PQI’s 1 to 8 (except PQIs 4 and 6) [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt

19. Nº per 100000 inhabitants PQI’s 10 to 16 [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt

20. [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt [1] Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Oct 27]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdfhttp://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf

21. [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt [5] Rizza P, Bianco A, Pavia M, Angelillo I. Preventable hospitalization and access to primary health care in an area of Southern Italy. BMC Health Services Research. 2007;7(1):134. [9] Agabiti N, Pirani M, Schifano P, Cesaroni G, Davoli M, Bisanti L, et al. Income level and chronic ambulatory care sensitive conditions in adults: a multicity population-based study in Italy. BMC Public Health. 2009;9(1):457.

22. [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt [3] José Luis Alfonso S, Joan Sentís V, Sergio Blasco P, Isabel Martínez M. [Characteristics of avoidable hospitalization in Spain]. Med Clin (Barc). 2004;122(17):653-8.

23. [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt [3] José Luis Alfonso S, Joan Sentís V, Sergio Blasco P, Isabel Martínez M. [Characteristics of avoidable hospitalization in Spain]. Med Clin (Barc). 2004;122(17):653-8.

24. [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt [4] Niti M, Ng TP. Avoidable hospitalization rates in Singapore, 1991–1998: assessing trends and inequities of quality in primary care. Journal of Epidemiology and Community Health. 2003 January 2003;57(1):17-22.

26.  Italy vs Portugal Higher rates in Italy in all of the five conditions compared. Worse food habits might be a reason, due to a diet rich in lipids, carbohydrates, fats and vegetable oils. [8] Therefore, cultural, social and economical disparities are, among other factors, na explanation for the results obtained [8]. [8] Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pthttp://www.ine.pt

27.  Singapore vs. Portugal Portugal has for Chronic Obstructive Pulmonary disease, Diabetes Mellitus and Hypertension higher rates, explained by: Environmental issues Cultural issues Singapore presents higher rates for: Asthma (climate) Congestive heart failure (diet enriched in lipids) Comparison between these two countries is not reliable as this two countries have great cultural, economical and social disparities and the results for Singapore match the year 1998, as Portuguese results match the year 2000.

28.  USA vs Portugal USA hospitalization rates are higher than in Portuguese ones except PQI 13 and 14, which are related with angina and diabetes, respectively. WHY? USA is more developed than us and therefore: greater pollution; greater racial disparities; greater obesity; other conditions that may lead to higher rates of unnecessary hospitalizations. However PQI 13 and 14 may be explained by our diet, which is often exaggerated in quantity and impoverished in quality.

29.  Spain vs Portugal In the comparison made with Spain, we found that in the 24 conditions faced Portugal has, in eight of them, higher rates. This is one of the most reliable of our comparisons because Portugal and Spain have cultural and ethnical similarities due to geographical proximity (same pollution values, same food habits, etc). Overall, we may infer that spain’s prevention system is worst than ours

30. 1. Agency for Healthcare Research and Quality. Guide to Prevention Quality Indicators, Ver 3.1 [Internet]. 2007 Mar [cited 2009 Dec 7]. 59p. Available from: http://www.qualityindicators.ahrq.gov/downloads/pqi/pqi_guide_v31.pdf 2. Moura, A. C., A. M. Oliveira, et al. (2008). "[Evaluating Portuguese primary healthcare through Prevention Quality Indicators (PQIs)]." 35. Unpublished data. 3. José Luis Alfonso, S., V. Joan Sentís, et al. (2004). "[Characteristics of avoidable hospitalization in Spain]." Med Clin (Barc) 122(17): 653-658. 4. Niti M, Ng TP. Avoidable hospitalization rates in Singapore, 1991-1998: assessing trends and inequities of quality primary care. J Epidemiol Community Health. 2003; 57: 17-22. 5. Rizza P, Bianco A, Pavia M, Angelillo IF. Preventable hospitalization and access to primary healthcare in an area of Southern Italy. BMC Health Serv Res. 2007; 7:134. 6. Ansari Z, Laditka JN, Laditka SB. Access to Healthcare and Hospitalization for Ambulatory Care Sensitive Conditions. Med Care Res Rev. 2006; 63:719-42 7. Alfradique, M. E., P. d. F. Bonolo, et al. (2009). "Internações por condições sensíveis à atenção primária: a construção da lista brasileira como ferramenta para medir o desempenho do sistema de saúde (Projeto ICSAP - Brasil)." Cadernos de Saúde Pública 25: 1337-1349. 8. Statistics Portugal [internet]. Lisbon: INE 1864- [cited 2010 April 06]. Available from: http://www.ine.pt 9. Agabiti N, Pirani M, Schifano P, Cesaroni G, Davoli M, Bisanti L, et al. Income level and chronic ambulatory care sensitive conditions in adults: a multicity population- based study in Italy. BMC Public Health. 2009;9(1):457.

31.  Ana Sara Ferreira, mimed09219@med.up.pt  Andreia Sofia Teixeira, mimed09242@med.up.pt  Catarina Lombo, mimed09237@med.up.pt  Diogo Milheiro, mimed09049@med.up.pt  Diogo Teixeira, mimed09046@med.up.pt  Henrique Teixeira, mimed09042@med.up.pt  Inês Pessanha Silva, mimed09059@med.up.pt  Mariana Magalhães, mimed09100@med.up.pt  Miguel Coimbra, mimed09120@med.up.p  Pedro Carvalho, mimed09135@med.up.pt  Paulo Lopes, mimed09250@med.up.pt  Samuel Queirós, mimed09150@med.up.pt  Tiago Barbosa, mimed09188@med.up.pt Thank you for your time…