Dossier n. 266/2019 [Abstract] Impact analysis of “Case della salute” on health indicators. Emilia-Romagna population, 2009-2016

Background

The development of the Community Health Centres (Case della Salute) in Emilia-Romagna Region, formally started in 2010, is part of a more extensive process of reorganization of health and social care and primary/secondary care, to improve appropriateness and continuity of the response to regional population needs.

When relevant and consistent organizational innovations are introduced with huge dedicated resources, it becomes absolutely necessary to implement systems that can measure the achieved results, in terms of adequacy of services provided with respect to the demand, effectiveness and efficiency. To comply with the request by the Directorate-General Personal Care, Health and Welfare, in December 2016 the Regional Health and Social Agency has therefore set up a technical working group with representatives of the Directorate-General itself, of Health Authorities, of Local Authorities, of patient and volunteer associations. Aim of this group was:

• to define a model for assessing the impact of the organizational innovation “Case della Salute” at regional level;
• to set up a monitoring system of the “Case della Salute”, that may contribute both to continuous quality improvement and to regional and local governance.

Objectives

• To evaluate the impact of the “Case della Salute” on specific health indicators in the assisted population, which can be calculated from current regional administrative databases.
• To describe the implementation level of the “Case della Salute” and to evaluate the correlation between actions and/or specific characteristics of these structures and health indicators.

Materials and methods

Development of the impact assessment model

A non-systematic scoping review of the literature was performed to identify monitoring and impact indicators derived from primary care assessment models and outpatients organizational settings such as “Casa della Salute” (characterized by a team-based care; a patient-centred, comprehensive and coordinated care across settings and specialty care; attention to care quality and safety). Based on the results of literature review, on information availability in administrative databases and on expert consensus process, some indicators for data analysis have been selected.

Survey on the implementation level of the “Casa della Salute” model

A specific regional working group identified the main functions of the “Casa della Salute” model. An 18-item questionnaire was therefore developed to explore the dimensions identified and was sent to the Primary Health Departments of the Local Health Authorities to be filled in.

Analysis of administrative database

The evaluation of the selected indicators used the following administrative databases:

• regional assisted population register
• hospital discharge records
• outpatients and inpatients prescriptions of drugs
• home care accesses
• Emergency Room accesses
• registry of health and social care structures
• general practitioners registry
• national population registry

The analysis concerned a cohort of patients aged ≥18 years in their referral to the regional Health care system from 2009 to 2016.

In order to estimate the effects before and after the implementation of the “Case della Salute”, the “difference in differences” statistical analysis was used. Two periods were evaluated separately: the one immediately following the start of the “Case della Salute”, the so called “transitional year” and the years following the implementation, “after activation”. The variability detected between the estimated impact measurements for each “Casa della Salute” was investigated using the interquartile difference index (IQR).

The analysis was conducted for two levels of territorial aggregation: the regional one and the Local Health Authority level.

With the aim of identifying whether the variability observed in 2016 in the selected indicators could be attributed to the intrinsic characteristics of the “Casa della Salute” detected through the questionnaire, the statistical significance of the associations between each function and the indicators themselves was evaluated. For each indicator an exploratory univariate analysis and then a multivariate one, using a multilevel logistic model, were carried out.

Results

Development of the impact assessment model

The evaluation models identified and selected were: the USA Patient Centred Medical Home (PCMH); the “Casa della Salute” model of Tuscany Region (Italy); the models of primary care (Gringos et al. 2010, Pavlic et al. 2015, Shi et al. 2001, WHO Europe 2010) and integrated care (Bonciani et al. 2015, Expert Group 2017, Oelke et al. 2015).

Seven outcome indicators were identified to evaluate the impact of Case della Salute:

• accesses to the Emergency Room
• hospitalizations for ambulatory care sensitive conditions (ACSC)
• home care accesses
• polypharmacy
• consumption of inappropriate drugs
• repeated hospitalizations
• lengthy hospitalizations (over threshold values)

Survey on the implementation level of the “Casa della Salute” model

Thirty-three questionnaires related to low complexity “Casa della salute” and 51 related to medium-high complexity “Casa della salute” were analysed. On average, in December 2016 all the “Case della salute” have developed most of the typical functions to a lesser or greater extent, without substantial differences between low or medium-high complexity structures.

Analysis of administrative database

In the implementation period of the “Case della Salute”, access frequency to Emergency Rooms was significantly lower in patients living nearby a “Casa della Salute” compared to people living in areas not served by a Casa della Salute, with an impact equal to 21.1% of ER access reduction; the frequency of ACSC hospitalizations was slightly lower (-3.6%); home care accesses were slightly higher (+5.5%); no differences were observed in drugs prescription to elderly people (polypharmacy and inappropriate drugs) or in repeated or over-threshold admissions, compared to the unexposed population.

When the general practitioner operates within the “Casa della Salute”, the reduction of ER accesses and of ACSC hospital admissions is greater (respectively -29.2% compared to -16%, and -5.5% vs a non-significant impact). The home care accesses are slightly more frequent when the general practitioner operates inside the “Casa della Salute” (+ 5.6%) compared to the situation when the GP works outside the structure (+5.4%).

In the regional model, the interquartile difference calculated between the “Case della Salute” was equal to:

• for ER accesses, IQR = 45.6%
• for ACSC hospitalizations, IQR = 22.2%
• for home care accesses, IQR = 29.1%.

The interquartile difference between the “Case della Salute”, calculated when the impact on the indicators is determined through local models, was instead:

• for ER accesses, IQR = 49.8%
• for ACSC hospitalizations, IQR = 33.1%
• for home care accesses, IQR = 38%.

As for the investigation on “Case della Salute” features studied through the questionnaires, the univariate and multivariate analyses revealed that the variability observed between the structures cannot be attributed only to treated patient case-mix but it is partly due also to the characteristics found in the “Case della Salute” themselves. However, it was not possible to outline a clear picture of association between specific features and outcomes considered; this can be probably explained by considering that there might be other characteristics of the “Case della Salute” associated with the investigated effects that have not been studied, while the features included in the survey have been self-certified and therefore may not correspond to reality.

Conclusions

This study showed:

• in almost the entire region a significant and constant effect of the “Case della Salute” on Emergency Room access and an equally significant effect - but less relevant and widespread - on hospitalization for ambulatory care sensitive conditions and on home care delivered;
• a stronger effect in patients assisted by general practitioners performing their activity partially or completely within the “Casa della Salute”;
• a wide variability in the effects between regional areas and the “Case della Salute”, which however could not be explained using only questionnaire results.

Key words

Community Health Centres, indicators, monitoring, impact, difference in differences model, administrative databases