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

Different regional organisational models and the quality of health care: The case of coronary artery bypass graft surgery

Objectives: The Italian regions of Emilia-Romagna and Lombardy within the Italian National Health Service provide an opportunity to see if two different approaches to the organisation of care - one more hierarchical and planned, the other more competitive and market-like - influence its quality through examining the relationship between the number of coronary artery bypass grafts (CABGs) and the rate of in-hospital mortality using administrative data for the period 1996-1998. Methods: Descriptive statistics and logistic regression models were used. Results: The volume-outcome relation was statistically significant in both regions (odds ratio 0.71, P < 0.0001). Although CABG performance in Emilia-Romagna was slightly poorer than in Lombardy (OR 1.22, P < 0.05), the potential advantage in terms of the reduced risk of death for patients treated at high-volume versus low-volume hospitals was significantly greater. In Emilia-Romagna, the average performance advantage of high-volume units was more substantial in the case of private accredited hospitals than public hospitals (OR = 0.50, P < 0.0001 versus OR = 0.64, P < 0.0001). In Lombardy, the performance advantage of concentrating CABG procedures was greater in private research hospitals (OR = 0.67, P < 0.0001), whereas results were not statistically significant for the other types of hospital, indicating a good level of performance in both public and private hospitals even at low volumes. This also partially explained the lower mortality rate observed in that region. Conclusions: The degree of hierarchical regionalisation versus market-like arrangements characterising the two systems produced contrasting effects in terms of the quality of CABG surgery. Lombardy's more competitive environment appeared to achieve better performance in terms of a slightly lower probability of adverse outcomes, in a system with no formal assessment of population need and very high per capita revascularisation rates. To improve performance in the more hierarchical system adopted in Emilia-Romagna would require considerable effort to increase CABG surgery in low-volume cardiac units, and to sharpen performance incentives. © The Royal Society of Medicine Press Ltd 2003

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