[Epidemiology of femur fracture and characteristics of hospital care in Lazio]

We aimed at describing the epidemiology of femur fracture in elderly hospitalized for femur fracture in Lazio (Italy), and evaluating the association between patient's and hospital characteristics on in-hospital mortality. We conducted a population- and hospital-based study (Lazio region: 5.233.233 inhabitants) among people 65+ years aged.

SOURCE OF DATA

regional hospital register 2002-2003; ICD-9-CM codes for patients' selection 820 e 821. Direct standardization (rate x 1000) and logistic regression analysis (OR, 95% CI) were performed. Overall hospitalization rate in elderly was 7.5%o (10.l%o females vs. 3.9%0 males). 12.033 patients with femur fractures were enrolled in the study period; 21,6% were not treated surgically: in comparison with those who underwent surgery, they were males, residents out of Rome, older and with worst health status. In-hospital mortality rate was 7,97%. In-hospital mortality determinants were: male gender (OR=0.56), older age (85+, OR=3.30), living out of Rome (OR=0.50), comorbidities (Charlson 'index 3: OR=4.44), "others and unspecified parts of femur" as site of fracture (OR=1.84), admission to a private hospital (OR=O. 79) and a surgical treatment (OR=0.20). In conclusion, this study showed the effect of selected individual characteristics on in hospital mortality and suggested a role of early surgical treatment and access to private sector. Regional hospital information systems represent useful tools to address epidemiological impact of hip fracture and its health care resources utilization.

[Performance indicators: INCA (cardiovascular indicators) project]

The objective of INCA project was the development and implementation of Acute Myocardial Infarction (AMI type ST elevation) process and outcome indicators for the regional cardiology units, testing the possibility of using regional healthcare information data to evaluate the quality of provided healthcare within the regional healthcare accreditation process. The project is introduced by an overview of major concepts of evaluating and managing quality of healthcare. We performed a literature review of structure, process and outcome indicators in cardiology and of accreditation standards for cardiology at national and international level. Through consensus procedures and according to international evidence based literature a set of 18 process and outcome indicators for AMI was defined. A specific procedure for data collection has been developed. Education and training of participants on procedures, quality and accreditation was achieved. Expected verifiable end-points have been achieved over a three months period of data collecting throughout 21 cardiology units, differentiated for level of complexity and location, for a total of 409 clinical observed cases of AMI. Analysis of data was followed by the diffusion of results. Successful data collection of clinical performance indicators on a regional basis was achieved. Participants have been trained to quality sciences. Results will be useful to evaluate and design implementation strategies of regional accreditation of health care services within a shared framework. Benchmarking within Regional hospital cardiology care services will be developed following self evaluation and continuous quality improvement cycle activities.

[Factors related to in-hospital mortality after stroke in Lazio region, Italy]

The use of hospital discharge abstracts in estimating the outcome of hospital care represents an ongoing interest in public health. However standardized methodologies are still not available. We carried out a retrospective study to estimate the association between demographic and clinical characteristics and in-hospital mortality after stroke by using administrative data from the Hospital Information System in Lazio Region. We also assessed the relationship between the presence of neurology services and the outcome. We found 12,781 incident episodes of stroke (main diagnosis ICD-9: 430-431-434-436) (49.3% male, mean age = 74 years) admitted in 126 hospitals in the Lazio region for the period 1999-2000. From the hospital discharge abstracts we collected patient demographic and clinical data. The hospitals were classified in centres with and without neurology services. Admissions to hospitals with neurology services were evaluated as predictors of in-hospital mortality after adjustment for gender, age, residence, education, source of admission, type of stroke, heart disease, kidney disease and history of atrial fibrillation. In-hospital mortality (within 30 day) was 25.1%. Female gender, advanced age, residence in Rome, urgent transport, kidney disease and history of atrial fibrillation were associated with an increased risk. Hemorrhagic stroke (ICD-9 = 430-431) had a worse outcome than ischemic stroke (ICD-9 = 434) and acute undefined cerebrovascular disease (ICD-9 = 436). Patients admitted to hospitals with neurology services showed a significantly decreased risk (OR = 0.88, IC95% = 0.79-0.98), particularly in occlusion of cerebral artery (ICD-9 = 434) and in undefined cerebrovascular disease (ICD-9 = 436). Demographic and clinical variables are associated with the outcome of hospitalised stroke patients. Admissions of acute stroke patients in specialized hospitals seem to play a role in reducing the risk of in-hospital mortality.

[The quality of medical records: a retrospective study in Lazio Region, Italy]

INTRODUCTION

Medical records have an important role in the communication among different care providers and in forensic medicine. In Italy, information on completeness and correctness of medical records is scanty, whereas future hospital accreditation could take into account their quality as a proxy of good medical practice.

PURPOSE

We performed a retrospective study in order to assess the quality of medical records in the Lazio region.

METHODS

From all 37009 hospital discharges for five different diseases in 123 hospitals (acute myocardial infarction (AMI), coronary artery bypass surgery, pneumonia, cerebrovascular disorders, breast surgery), registered in the Regional Hospital Information System, we selected a random sample of 2022 (5.5% of the total). Ten physicians, previously trained, reviewed the relative medical charts and filled in "ad hoc" questionnaires.

RESULTS

A total of 1960 (97% of the target) charts were reviewed. Organization and structure of data recording strongly varied. Important differences were found across the diseases for various items: presence of anamnesis 98.1% (range: from 95.6% for breast surgery to 100% for AMI); presence of physical examination 92.7% (range: from 88.1% for breast surgery to 98.5% for AMI), completeness of the daily medical records was good in 70.8% (range: from 34.2% for pneumonia to 93.9% for cerebrovascular disorders). Variability among different type of hospitals was also observed, being teaching hospitals and some private hospitals more accurate.

CONCLUSIONS

Quality of medical records tended to vary across different type of hospitals and different diseases. Actions for improving the quality should be undertaken as a priority. Efforts have to be done in restructuring charts, creating guidelines and training caregivers. The development and application of computer based health information systems should help solving these problems.

Implementation of a surveillance system for stroke based on administrative and clinical data in the Lazio region (Italy): methodological aspects

Stroke is the third leading cause of death and the most important cause of long-term disability in Italy and other developed countries, heavily influencing quality of life and costs of health care. In spite of the widespread occurrence of the disease and its relevant impact in Italy, there is neither a national nor a regional surveillance system of cerebrovascular diseases. A regional surveillance system for stroke has two important aims: to help to interpret the geographical and temporal trends of the disease for health care planning and resource allocation and to allow close monitoring of the quality of stroke services. Age-standardized mortality rates for cerebrovascular diseases in the Lazio region (5,242,709 inhabitants) in the period 1998-99 were 69.4 for males and 59.4 for females per 100,000 inhabitants. In the year 2000, about 3% of all hospital discharges were for cerebrovascular diseases with a hospitalisation rate of 4.36 per 1000 inhabitants. The mean length of stay is 12 days (median of 9 days) and in-hospital death is 15.4%. The admission rate for cerebrovascular diseases to emergency departments is 3.40 per 1000 inhabitants. The goal of the Lazio Regional Health Authority is to implement a surveillance system for stroke based both on current data (mortality and discharge data) and on information collected in a registry for quality assessment of stroke care. The first step of the study is to develop a regional register of acute stroke using an 'ad hoc' data sheet integrated in the computer-based patient record system of clinical and administrative data (GIPSE) operating in all emergency departments in the region.