Reorganizing territorial healthcare to avoid inappropriate ED visits: does the spread of Community Health Centres make Walk-in-Clinics redundant?

BACKGROUND: Community care has recently been restructured with the development of Community Health Centres (CHCs), forcing a general rethink on the survival of previous organizational solutions adopted to reduce inappropriate ED access, for example Walk-in-Clinics (WiCs). METHODS: We focus on the Italian Emilia-Romagna Region that has made huge investments in CHC development, whilst failing to proceed at a uniform rate from area to area. Estimating panel count data models for the period 2015-2018, we pursue two goals. First we test the existence of a "CHC effect", choosing five urban cities with different degree of development of the CHC model and assessing whether, all else being equal, patients treated by GPs who have their premises inside the CHC show a lower need to seek inappropriate care (Aim 1). Second, we focus our attention on Walk-in-Clinics, investigating the long-established WiC in the city of Parma that currently coexists with three CHCs recently established in the same catchment area. In this case we try to assess whether, and to what extent, the progressive development of the CHCs in the city of Parma has been affecting the dynamics of WiC access (Aim 2). RESULTS: As regards Aim 1, we show that CHCs reduce the probability of inappropriate patient access to emergency care. As regards Aim 2, in the city of Parma patients whose GP belongs to the CHC are less likely to visit the WiC on a workday, with no significant change during the weekend when CHCs are closed, questioning the need to maintain them both in the same area when the CHC model is fully implemented. CONCLUSIONS: Our results confirm the hypothesis that expanding access to primary care settings diminishes inappropriate ED use. In addition, our findings suggest that where CHCs and WiCs coexist in the same area, it may be advisable to implement strategies that bring WiC activities into step with CHC-based general primary care reforms to avoid duplication

Risk Adjustment for CABG surgery: an administrative approach versus Euroscore

OBJECTIVE. To determine the ability of administrative data in predicting mortality for patients undergoing coronary artery bypass graft surgery (CABG). METHODS.Administrative databases on hospital discharge abstracts (SDO) of the Italian region Emilia Romagna and death registry data for year 2000. We used a multivariate logistic regression analysis to compare an ICD-9-CM risk adjustment approach based on administrative variables (such as age, gender, principal diagnosis, combined operation, previous cardiac surgery, emergency admission and Charlson comorbidity index) with a risk adjustment approach based on the clinical Euroscore to predict in-hospital and 60-day mortality and to assess hospital performance. Results. The risk adjustment approach based on ICD-9-CM data provides good explanatory ability in models assessing outcomes (the c statistics obtained are very close, c= 0.78 for in-hospital mortality in both approaches and c = 0.78 for the administrative model vs. 0.79 for the clinical one, considering 60-day mortality). CONCLUSIONS. With the growing completeness and accuracy of administrative data, this result seems to be of particular importance if we consider the possibility of adapting and applying administrative approaches to illnesses other than cardiovascular diseases, for which several clinical risk indexes - such as Euroscore - have been successfully developed

The analysis of a cardiological network in a regulated setting: a spatial interaction approach

We analyse referral patterns for patients undergoing percutaneous transluminal coronary angioplasty (PTCA) in the Emilia Romagna region of Italy, a procedure for which the assumption of a negative association between volume and adverse outcomes is used to justify its territorial concentration. Nevertheless, recent clinical evidence shows PTCA superiority for immediate treatment of acute myocardial infarction, which advises an increase in the number of points of delivery. Our paper aims to develop analytical tools designed to provide support to policy makers when they are asked to evaluate the spatial distribution of catheterisation laboratories that perform PTCA. Information is drawn from the regional administrative hospital discharge data (SDO) for the year 2002. We first use entropy indexes to investigate the spatial accessibility of the cardiological network. Secondly, by means of a gravity model estimated using Bayesian techniques we identify the determinants of patient flows in terms of demand and supply factors. Our results suggest that information on destinations is processed hierarchically and that agglomeration-like forces are dominant. Furthermore, although self-sufficiency of provision at the provincial level has been achieved to a large extent, there is still scope to improve the organisational efficiency of the network

Economic incentives in general practice: The impact of pay-for-participation and pay-for-compliance programs on diabetes care

Objectives: We investigate the impact on quality of care of the introduction of two financial incentives in primary care contracts in the Italian region Emilia Romagna: payfor- participation and pay-for-compliance with best practices programs. Methods: We concentrate on patients affected by diabetes mellitus type 2, for which the assumption of responsibility and the adoption of clinical guidelines are specifically rewarded. We test the hypothesis that, other things equal, patients under the responsibility of general practitioners (GPs) receiving a higher share of their income through these programs are less likely to experience hospitalisation for hyperglycaemic emergencies. To this end, we examine the combined influence of physician, organisational and patient factors by means of multilevel modelling for the year 2003. Results: Programs aimed at stimulating GP assumption of responsibility in disease management significantly reduce the probability of hyperglycaemic emergencies for their patients. Conclusions: Although it has been recognised that incentive-based remuneration schemes can have an impact on GP behaviour, there is still weak empirical evidence on the extent to which such programs influence healthcare outcomes. Our results support the hypothesis that financial transfers may contribute to improve quality of care, even when they are not based on the ex-post verification of performances