Is quality of data challenging communication to policy makers and the general public? The example of the Italian NHS outcome Evaluation program

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1 Is quality of data challenging communication to policy makers and the general public? The example of the Italian NHS outcome Evaluation program Marina Davoli National Outcome Evaluation Programme

2 Betrán AP et al. Rates of caesarean section: analysis of global and regional and national estimates. Paediatric and Perinatal Epidemiology 2007;21(2):

3

4 The National Outcome Evaluation Programme measures the outcome variability among providers and/or health care local units in Italy Outcome measures by Hospital/ Local Health Unit Audit tools Report Card ER Informa>on by Hospital/ System Local Health Unit Pilot studies

5 57 outcome or proxy indicators, 49 volume of care indicators and 23 hospitalization indicators Outcome measures by Hospital/ Local Health Unit Audit tools Report Card ER Informa>on by Hospital/ System Local Health Unit Pilot studies

6 Proportion (adj) of PRIMARY CESAREAN sections, Italy % 26%

7 Proportion (adj) of primary cesarean sections, Italy 2009

8 Proportion (adj) of primary cesarean sections, Italy 2013

9 BMJ Qual Saf 2012;21:127e134

10 Mean = 26% Proportion (adj) of primary cesarean deliveries, Italy 2013

11 1. Providers (public and private hospitals) 2. «Health Care Payers» (local health unit) Outcome measures by Hospital/ Local Health Unit Audit tools Report Card ER Informa>on by Hospital/ System Local Health Unit Pilot studies

12 Proportion (adj) of primary cesarean deliveries by hospital, Italy 2013

13 HOSPITAL n. 10 Proportion of primary cesarean sections Temporal trend! Adjusted proportions

14 Maternal and neonatal clinical factors associated with caesarean section Prevalence (%) Risk Ra4o Risk Ra4o Adj. RR P- value Maternal age class years (reference) years < years < years years < years < Thyroid disease < Diabetes < Anemias < Coagula>on defects < Hypertension < Heart disease < [ other omi+ed characteris0cs ] Asthma < Liver disorders in pregnancy < Cardiovascular disease in pregnancy < Renal disease in pregnancy < High- risk pregnancy < Antepartum hemorrhage, placenta previa < Eclampsia/pre- eclampsia < Mul>ple pregnancy < Malposi4on and malpresenta4on of the fetus < Excessive development of the infant < Fetal abnormality < Fetal distress < Intrauterine growth retarda>on < Pathology of the amnio>c fluid < Crude Adjusted 95% CI for Adjusted

15 Prevalence of HFH in 540 Italian hospitals, 2010 Di Martino M et al BMC Public Health, under review

16

17 Di Martino M et al BMC Public Health, under review

18 Di Martino M et al BMC Public Health, under review

19

20 REGIONAL ACT TO REDUCE CESAREAN SECTION RATE In the year 2008, the government of Regione Campania, given the high rate of cesarean sections, approved a «pay for performance act» according to which those cesarean sections without a diagnosis of a risk factor for cesarean rate (among which malposition and malpresentation of the fetus) would have had the same fee of a vaginal delivery.

21 Crude and adjusted primary CS proportions for 27 hospital with HFH %>95 percentile "About 63% of these maternity units were located in the Campania region".

22 Crude and adjusted primary CS propor>ons by Local Health Unit in the Campania region Crude CS proportion a Adjusted CS proportion (Standard definition b ) Adjusted CS proportion (Modified definition c ) LHU Avellino LHU Benevento LHU Caserta LHU Napoli LHU Napoli LHU Napoli LHU Salerno a Propor>ons are expressed as percentages. b Standard defini+on of malposi>on and malpresenta>on of the fetus: ICD- 9- CM 652. c Modified defini+on: ICD- 9- CM 652, excluding (High fetal head at term). LHU: Local Health Unit.

23 23 National Health Information System: hospital discharges Car le Ministry of Health: correspondence between NHIS and clinical charts Preliminary results on 1117 clinical charts % Nc < 5 % Nc 5-30 % Nc > 30 Figura 1. % of clinical charts with information non corresponding to the HIS as of 8 gennaio 2013

24 24 AUDIT TOOLS Outcome measures by Hospital/ Local Health Unit Audit tools Report Card ER Informa>on by Hospital/ System Local Health Unit Pilot studies

25 Proportion of primary cesarean deliveries by hospital, Italy 2013; Radg-Rcrude

26 Struttura Regione prov N % grezza % adj Patologia liquido amniotico (ric. ind.) Anomalie fetali (ric. ind.) Posizione e presentazione anomale del feto (ric. ind.) Gravidanza multipla (ric. ind.) % % % % ITALIA ,98 4,1 0,7 5,1 1,9 CASA DI CURA 'SALUS' - BRINDISI Puglia BR ,66 7,60 5,9 0,4 27,9 1,8 CASA DI CURA VILLA DELLE QUERCE Campania NA ,73 52,13 21,0 2,3 46,2 1,1 AZIENDA OU FERRARA Emilia Romagna FE ,03 4,41 6,4 0,9 22,2 2,6 AZIENDA OSP. UNIV. G. MARTINO Sicilia ME ,59 13,40 5,8 0,7 7,2 3,5 A.O.U. 'FEDERICO II' DI NAPOLI Campania NA ,40 31,66 5,1 16,5 7,9 7,0 CLINICA SAN MICHELE Campania CE ,17 44,50 17,9 0,3 23,9 1,3 PO AVEZZANO 'S. FILIPPO E NICOLA' Abruzzo AQ ,90 41,98 0,9 0,0 2,3 1,4 P.O. LANCIANO Renzetti Abruzzo CH ,63 41,06 0,2 0,0 1,6 0,3 OSPEDALE DI TARQUINIA Lazio VT ,55 49,12 0,0 0,0 4,0 0,0 OSPEDALE GALLIPOLI- 'SACRO CUORE DI GESU' Puglia LE ,44 58,84 0,5 0,0 3,5 1,0 VILLA BIANCA S.p.A. Campania NA ,31 84,06 1,8 0,4 3,6 1,4

27 Outcome measures by Hospital/ Local Health Unit The outcome measures represent assessment tools to support clinical and organizational audit programs aimed at improving both effectiveness and equity in the NHS. They have to pass through a Audit tools Report Card ER Informa>on by Hospital/ System Local Health Unit Pilot studies proper audit on quality of data. The program does not classify or judge hospitals or health professionals

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