This article in the supplement issue on the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT)-project describes the PERFECT AMI (acute myocardial infarction) Database, which is developed to measure the performance of hospitals and hospital districts in Finland. We analyse annual trends and regional differences in performance indicators and whether the utilisation of services and costs of hospital care are related to improvement in survival of AMI patients.
The study population consists of ten annual cohorts (1998-2007) of patients hospitalised for AMI.
Since 1998 the treatment pattern has changed rather radically, the utilisation rate of percutaneous coronary intervention (PCI) has increased and coronary procedures have been performed earlier after myocardial infarction. Outcome measured by various measures of mortality has improved considerably. However, trends in the development of the use of services and outcomes are not similar between hospital districts. An increase in cost was positively and statistically significantly related to decrease in mortality, but the effect was not very strong.
There is potential for decreased mortality from actions that do not increase the costs and for enhancing performance in the regions and hospitals with poor performance.
Treatment of stroke consumes a significant portion of all healthcare expenditure. We developed a system for monitoring costs from individual patient data on a national level in Finland.
Multiple national administrative registers were linked to gain episode-of-care data on all hospital-treated patients with incident stroke over the years 1999 to 2007 (n = 94,316). Inpatient and specialist outpatient costs were evaluated with a cost database, long-term care costs with fixed prices, and medication costs with true retail prices.
For the patients of Year 2007, the mean 1-year costs after an ischemic stroke were $29 580, after an intracerebral hemorrhage $36,220, and after a subarachnoid hemorrhage $42,570, valued in Year 2008 U.S. dollars. Only part of these costs are attributable to stroke, because the annual costs prior to stroke were significant, $8900 before ischemic stroke, $7600 before intracerebral hemorrhage, and $4200 before subarachnoid hemorrhage. Older patients with ischemic stroke, and, among patients with ischemic stroke and subarachnoid hemorrhage, women, incurred higher costs. The mean estimated lifetime costs were $130,000 after ischemic stroke or intracerebral hemorrhage and $80,000 after subarachnoid hemorrhage. Annually $1.6 billion is spent in the care of Finnish patients with stroke, which equals to 7% of the national healthcare expenditure, or 0.6% of the gross domestic product. Costs of patients with stroke are increasing with prolonged survival and the aging population.
Treatment of patients with stroke is a large national investment. Setting up a nationwide system for continuous monitoring of stroke costs is feasible. Cost data should optimally be evaluated in conjunction with effectiveness and performance indicators.
Previous studies show better outcomes for patients with stroke receiving care in stroke units, but many different stroke unit criteria have been published. In this study, we explored whether stroke centers fulfilling standardized Brain Attack Coalition criteria produce better patient outcomes than hospitals without stroke centers.
We did an observational register-linkage study of all patients with ischemic stroke treated in Finland between 1999 and 2006. After exclusion of recurrent strokes and nonanalyzable patients, we included 61 685 consecutive patients treated in 333 hospitals classified in national audits either as Comprehensive Stroke Centers, Primary Stroke Centers, or General Hospitals according to Brain Attack Coalition criteria. Primary outcome measures were case-fatality and being in institutional care 1 year after stroke.
Care in stroke centers was associated with lower 1-year case-fatality and reduced institutional care compared with General Hospitals. The number-needed-to-treat to prevent 1 death or institutional care at 1 year was 29 for Comprehensive Stroke Centers and 40 for Primary Stroke Centers versus General Hospitals. Patients treated in stroke centers had lower mortality during the entire follow-up of up to 9 years and their median survival was increased by 1 year.
This study shows a clear association between the level of acute stroke care and patient outcome and supports use of published criteria for primary and comprehensive stroke centers.
We analysed registry-based data on 14,915 patients treated for pertrochanteric fracture obtained from the Finnish Health Care Register during the years 1999-2009. Data on the comorbidities, residential status and deaths of the cohort were extracted from several Finnish registries using patients' unique personal identification numbers. The use of intramedullary implants increased substantially during the study period. One-year mortality was slightly higher in the patients treated with intramedullary implant (26.6% vs. 24.9%; P=0.011). In the first year after the fracture, there were more new operations on hip and thigh in patients treated with an intramedullary implant (11.1% vs. 8.9%; P
In health care, measures of performance are needed at producer level for improving the treatment processes and at system level for steering purposes. In addition, measures that enable reliable comparisons of producers with respect to each other should encourage them to develop their treatment processes to attain better positioning in benchmarking.
The main innovation of the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT) project is to measure performance using existing linkable information available from registers within well-defined care episodes in a whole population. Finnish health care and related registers are used for constructing the disease-specific databases, with rich content on treatment processes and complete follow-up data.
The PERFECT project has developed numerous performance indicators that can be used to evaluate health policy actions as well as to create regional and hospital-level benchmarking data. In PERFECT, the idea is to eliminate individual-level variation from the performance indicators by using individual-level data and proper risk adjustment methods. The focus of our interest is in the variation at the producer or regional level.
Our experience shows that the utilization of population-level health care registers with an episode-of-care approach enables a continual system and producer-level performance measurement.
This article in the supplement on the PERFormance, Effectiveness, and Costs of Treatment episodes (PERFECT)-project aims to measure the performance and quality of hip fracture treatment by analysing annual trends and regional differences in developed performance indicators.
The PERFECT Hip Fracture Database contains all hip fracture patients identified from the Hospital Discharge Register in Finland since 1999. Follow-up data from several administrative registers were also linked to the database. Several risk-adjusted performance indicators were developed.
In 2007 (compared with 1999), 4.1 percentage points fewer patients had died and 7.5 percentage points more patients were at home four months after fracture. The mean length of treatment had shortened from about 50 to about 45 days, and the mean costs of treatment per patient during the year following hip fracture had increased from about €18,000 to almost €20,000. There was extensive variation between the hospitals in the proportion of patients with an operative delay longer than two days and clear differences between hospital districts in several performance indicators.
Outcomes of hip fracture treatment in Finland have been improved in recent years, but regional variation exists. Register-based data are useful for performance assessment of hip fracture treatment.
We previously found a positive association between calcium plus vitamin D and antiosteoporotic drugs and survival among hip fracture patients. Our aim was to verify this observation using a nationwide database. A retrospective cohort of home-discharged hip fracture patients aged 50 years or older (n = 23,615) was enrolled from the national database. Primary exposure was medical treatment for osteoporosis, and the outcome was all-cause mortality. Cumulative mortalities were calculated using the Kaplan-Meier estimator. The relationship between mortality and medication purchases was modeled using Cox's proportional hazards regression with time-dependent covariates for medication use. One in 4 women and 1 in 10 men with a hip fracture were treated for osteoporosis in Finland. Unadjusted 1-year mortality was lower among patients who purchased calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs than among those who did not purchase these medications [hazard ratio (HR) = 0.74, 95% confidence interval (CI) 0.67-0.81]. The difference in unadjusted cumulative mortality remained in favor of the drug users for at least 5 years. Among men, the use of calcium plus vitamin D or vitamin D supplements was associated with lower 1-year mortality even after adjustments for observed confounders (HR = 0.74, 95% CI 0.56-0.97). Among women, the use of antiosteoporotic drugs was associated with lower mortality (HR = 0.79, 95% CI 0.67-0.93). There was a tendency to even better survival in both genders if calcium plus vitamin D or vitamin D supplements and antiosteoporotic drugs were used simultaneously, the HR being 0.72 (95% CI 0.50-1.03) in men and 0.62 (95% CI 0.50-0.76) in women.
Stroke databases are established to systematically evaluate both the treatment and outcome of stroke patients and the structure and processes of stroke services. Comprehensive data collection on this common disease is resource-intensive, and national stroke databases often include only patients from selected hospitals. Here we describe an alternative national stroke database.
We established a nationwide stroke database with multiple administrative registry linkages at the individual-patient level. Information on comorbidities; treatments before, during, and after stroke; living status; recurrences; case fatality; and costs were collected for each hospital-treated stroke patient.
The current database includes 94 316 patients with incident stroke between January 1999 and December 2007, with follow-up until December 2008. Annually, 10 500 new patients are being added. One-year recurrence was 13% and case fatality was 27% during the study period. In 2007, 86% of patients survived 1 month and 77% were living at home at 3 months, but the proportion treated in stroke centers (62%) or with nationally recommended secondary preventive medication after ischemic stroke (49%) was still suboptimal.
In comparison with other national stroke databases, our method enables higher coverage and more thorough follow-up of patients. Information on long-term recurrences, case fatality, or costs is not often included in national stroke databases. Our database has low maintenance costs, but it lacks detailed data on in-hospital processes. Use of national administrative data, where such linkage is possible, saves resources, achieves high rates of long-term follow-up, and allows for comprehensive monitoring of the burden of the disease.
This article in this supplement issue on the Performance, Effectiveness, and Costs of Treatment episodes (PERFECT) project describes trends in Finnish stroke treatment and outcome.
The PERFECT Stroke study uses multiple national registry linkages at individual patient level to produce a national stroke database with comprehensive follow-up of all hospital-treated stroke patients in Finland.
There were 94,316 incident stroke patients treated in Finnish hospitals from 1999 to 2007. Lengths-of-stays decreased after ischemic stroke (IS), and increased after intracerebral (ICH) and subarachnoid (SAH) hemorrhage. Ten-year survival improved in IS (hazard ratio 0.75; 95% CI 0.71-0.79) and ICH patients (0.88; 0.79-0.97), increasing median survival by 2 and 1 life-years respectively. This has translated into more days spent home among IS patients, but not among ICH patients. Treatment by neurologists improved the survival of IS (odds ratio [OR] 1.77; 95% CI 1.70-1.84) and ICH patients (OR 1.55; 95% CI 1.40-1.69), and treatment by neurosurgeons of SAH patients (OR 2.66; 95% CI 2.25-3.16), the effects were further improved by care in specialized stroke centers.
The survival of Finnish IS and ICH patients has improved. Specialized acute care was associated with improved outcome.