Quality and accessibility of
Portuguese hospital services
through 2000 to 2007
Course: Mestrado Integrado em
Medicina
Subject: Introdução à Medicina I
Class 8
Teacher (adviser) Alberto Freitas
15th December 2008
• Motivations
• Indicators
• Research Question and Aims
• Participants and Methods
• Expected Results
• References
Structure of the presentation

Evaluate the state of Portuguese healthcare

Analyse its evolution through the past eight
years (2000-2007)

Compare the activity and quality indicators
among the different Portuguese regions.
Motivations of the study
Importance
• Mechanisms to assess quality and accessibility
of hospitals
• Factors for accounting and financial
directing
Indicators
What are quality and
activity/productivity indicators?
Indicators
Health care quality indicators
• Measures which contain relevant information
concerning services conditions
• Reflect the health status of a population and
help monitoring health conditions
Indicators
Activity/Productivity indicators
• Evaluate hospital performance
• Express the relation between applied resources
and goals achieved
• Related with public access to healthcare
services
Indicators
Both
quality and activity indicators are
susceptible:
• Actualization of evaluative parameters
• Modification of their relevance in hospital
assessment
Indicators are not fixed evaluative parameters!
Indicators
Indicators
Domain
Mortality
Quality
Hospitalization time
Quality and Activity/Productivity
Postponed surgeries
Quality
Ambulatory episodes
Activity/Productivity
Ambulatory surgeries
Activity/Productivty
Births by Caeserean-section
Activity/Productivity
Main diagnostics
Quality
Surgical procedures, complications
Quality
Indicators
Research Question
• How have health indicators evolved, in
Portugal, during the past 8 years, how is that
reflected in the quality and accessibility of
healthcare services an in which ways can
they be improved?
Research Question and Aims
Provide reliable
nationwide and
regionally comparisons
through a time period
(2000-2007)
Aims
Infer about
qualitative and
accessibility
parameters
Theorize future
evolution and
prioritize indicators
improvements
Research Question and Aims
Study Participants
Target population:
Portuguese continent population
Sampling Methods:
No samples were taken from the dataset of
registers from private and public continental
hospitals
Participants and Methods
Study Participants
Inclusion and exclusion criteria: each indicator
considers all registers, thus no need for criteria
Note: Analysis of only continent private and public
hospitals records
Madeira and the Azores archipelagos use a
different system of classification
Participants and Methods
Study Design
Observational – There was no intervention. Data
was collected from observation of hospital’s
registers
Descriptive – Indicators analysis will describe
accessibility and quality parameters of hospitals
Analytical – Less evident, only few relations are established
between indicators
Participants and Methods
Study Design
Longitudinal – The study consists of a data follow
up through 2000 to 2007
Retrospective – Data was collected from registers
in the past
Prospective – Via the results obtained a future
prospect of the healthcare system will be
presented
Participants and Methods
Data collection methods
Dataset provided by the Health Care System
Central Administration (ACSS) containing all
registers of public and private hospitals in the
continent, from 2000 to 2007
Secondary data – Data wasn’t specifically collected
for this study
Participants and Methods
Data collection methods
SPSS
• Data filtering
(according to each
indicator)
• Statistical calculations
and graphics (Planned
Statistical Analysis)
Microsoft Office
Excel:
• Graphics and tables
Participants and Methods
Variable description
Diagnosis Related Groups - DRG
Classification system for patients admitted to
hospital
• Clinically coherent and homogenous groups
• Consumption of resources
Participants and Methods
Variable description
The International Classification of Diseases, Ninth
Revision, Clinical Modification (ICD-9-CM)
System of codes to diagnoses and procedures
associated with hospital utilization
The ICD-9-CM consists of:
• tabular list containing a numerical list of disease
code numbers;
• classification system for surgical, diagnostic, and
therapeutic procedures
Participants and Methods
Variable description
The International Classification of Diseases,
Ninth Revision, Clinical Modification (ICD-9-CM)
Participants and Methods
Variable description
Hospital ID
Hospital Location – Allows an analysis of the
various regions through the hospitals there
located.
Both allow a regional analysis according to
hospitals location – NUTS
Participants and Methods
Variable description
Nomenclature of territorial
units for statistics (NUTS)
North
Level I: 3 units, of which 1 is the
continent
Centre
Level II: 7 units, of which 5 in
the continent.
Lisbon
Alentejo
Level III: 30 units, of which 28 in the
continent
Madeira
Azores
Algarve
Participants and Methods
Variable description
Discharge date – Year division of each indicator 
essential to evaluate the evolution of indicators
Gender – Division into two groups of analysis: men
and women
Age – Stratification based on age
Birth Weight – Obstetrics services
Days of hospital stay – Hospitalization Time
Participants and Methods
Planned statistical analysis
SPSS for Windows
All Indicators:
• Frequencies
• Percentages
Hospitalization Time:
• Means
• Percentiles
• Median
SPSS for Windows and Microsoft Office Excel
Graphics
Tables
Participants and Methods
Examples of applied Methods
Evolution of the ratio between number of
ambulatory procedures and total number of
procedures, from 2000 to 2005
2005
21282
2004
21295
2003
21066
Tot.Ep.
2000
2001
2002
2003
2004
2005
Amb. Ep. Tot.Ep.
733
19572
959
20004
1206
20277
1503
21066
1827
21295
1840
21282
Amb.%
3,75
4,79
5,95
7,13
8,58
8,65
2002
20277
2001
20004
Ep. Amb.
19572
2000
0
5000
10000
15000
20000
Participants and Methods
25000
Examples of applied Methods
Surgery
15%
Ambulatory
Surgeries
Surgeries which
require
hospitalization
85%
Mortality by age group
Mortality by gender
2000
1500
frequency 1000
500
0
1722
831
1133
1002
274
62
<18 18-44 45-64 65-74 75-84 85+
age
6000
5000
4000
frequency 3000
2000
1000
0
5024
2754
male
2270
female
gender
Participants and Methods
total
Examples of applied Methods
10 main diagnostics in Portugal from 2000 to 2005
4549
4%
Main
diagnostic
Perc
Freque enta
ncy
ge
V3000
33%
Valid
Percent
age
Cumulative
Percentage
4549
1112
0,9
0,9
81
43401
1125
0,9
0,9
81,9
4280
1147
0,9
0,9
82,8
336610
1347
1,1
1,1
83,9
V581
1452
1,2
1,2
85,1
55090
1625
1,3
1,3
86,4
486
2182
1,8
1,8
88,1
V3001
3143
2,5
2,5
90,7
650
3410
2,8
2,8
93,5
V3000
8086
6,5
6,5
100
650
13%
43401
4280
5%
5% 36610
5%
V581
6%
55090
7%
V3001
13%
486
9%
•V3000 = Single lb in hospital w/o cs
•650 = Normal delivery
• 43401 = Cere thrombosis w/ inrct
•V3001 = single lb in hospital w cs
•486= Pneumonia, organism unspecified
•55090 = Inguinal hernia, without mention of obstruction or gangrene
•V581= Encounter for chemotherapy and immunotherapy for neoplastic conditions
•36610= Senile cataract, unspecified
•4280 = Congestive heart failure, unspecified
•4549 = Asymptomatic varicose veins
Participants and Methods
Examples of applied Methods
Hospitalization Time – Percentage of hospitalization time of the 10 most frequent indicators in
overall hospitalization time from 2000 to 2005
4.00%
3.50%
3.00%
2.50%
2.00%
2000
1.50%
2001
1.00%
2002
0.50%
0.00%
DRG14
DRG39
DRG89
DRG127
DRG162
DRG359
DRG371
DRG373
DRG390
DRG391
2000
3,19% 0,71% 2,42% 1,70% 0,64% 1,13% 2,04% 3,03% 0,87% 3,35%
2001
2,98% 0,60% 2,40% 1,72% 0,51% 1,12% 2,76% 2,51% 0,78% 2,90%
2002
3,67% 0,62% 2,49% 1,64% 0,55% 1,08% 1,83% 2,73% 0,79% 3,03%
2003
3,29% 0,45% 2,47% 1,75% 0,50% 1,04% 1,64% 2,56% 0,94% 2,85%
2004
3,36% 0,44% 3,12% 1,86% 0,47% 0,94% 1,77% 2,75% 0,75% 2,87%
2005
3,36% 0,49% 3,93% 1,80% 0,39% 0,77% 1,68% 2,26% 0,82% 2,76%
4.00%
3.50%
3.00%
2.50%
2.00%
1.50%
1.00%
0.50%
0.00%
Participants and Methods
2003
2004
2005
Main Expectations – Indicators
Ambulatory Episodes and Ambulatory Surgeries –
Number of ambulatory episodes tends to rise but
its still low
Hospitalization time – Tendency of diminishing
hospitalization episodes and the mean of time of
stay
Mortality – Greater mortality in rural regions;
elderly group likely to have a greater incidence
Expected Results
Main Expectations
• Quality and Accessibility to Portuguese hospitals
are expected to improve during the years in
analysis.
• Likelihood of disparity between rural and urban
regions: rural regions present worst indicators
values.
Expected Results
Limitations
Results from 2% of
the ACSS dataset
Articles and other
information
concerning indicators
Expected Results
Full ACSS dataset may present results that differ:
• Sample is very small
• Sample offers no coverage off all years (only
2000 to 2005)
Expected Results
Limitations
Hospital quality and accessibility also depends on:
• Population lifestyle
• Financing and logistical support
Thus indicators may not reflect the truth about
the healthcare system
Expected Results
Future implications
• Increase of knowledge and understanding of
the Portuguese health system:
– Quality characteristics
– Accessibility characteristics
Expected Results
Future implications
• Suggestions of improvements according to the
results obtained
– Healthcare services impact
• Improved resources management
– Economic impact
• Target financing to needed medical areas
– Social impact
• Improvement of quality of life
Expected Results
•
•
•
•
Portugal
Public and private hospitals
Quality indicators
Organization and administration
Keywords
Keywords
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References
Ana Cláudia Matos Ribeiro
Ana Rita Pereira Eluetério Silva
Carolina Sobrinho Ribeiro
Diogo Costa Branco
Diogo do Fundo Raposo
Ivo Pedro Costa Gomes
João Filipe Pedrosa Bernardes
José Vitor Reis Lopes Gonçalves
Oscar Ricardo Cerqueira Ramos
Maria Leonor Taboas Simões
Natália Sofia de Sousa Silva
Pedro Miguel Aparício Chorão
Sofia Maia Teixeira
Tânia Sofia Gomes Esteves
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joaofbernardes@hotmail,com
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