The EuroHOPE- project: Comparison
of treatment and outcome for AMI and
stroke patients in Europe
On behalf of the EuroHOPE-team:
Terje P. Hagen
Department of Health Management and Health Economics,
The Medical Faculty,
University of Oslo
Approaches to international efficiency
comparisons prior to EuroHOPE
 System level analysis
– WHO 2000, Afonso and St. Aubyn 2005
– Challenges in output measurement: How to measure the impact of health
services on health?
 Disease level analysis
– McKinsey healthcare productivity study, OECD aging-related disease (ARD)
project, Technological Change in Healthcare (TECH) Global Research
Network (AMI)
– Possible to relate inputs to outputs but requires nationally representative
patient level data
 Sub-sector level analysis
– Nordic hospital comparison study group (NHCSG)
– Requires that units are comparable and inputs and outputs can be measured
in a similar way
iHEA meeting, 8th of July, Sydney. Contact: timo.t.seppala@thl.fi
What and how EuroHOPE does it?
 Applies both the disease level and the sub-sector level
approaches
 Develops methods to measure outcomes and costs of care of
specific diseases for evaluation of care given in the whole
treatment chain (not yet primary care due to lack of data)
 The methods can be used for
– routine performance evaluation and monitoring
– establishing recommendations for lists of indicators to be
routinely collected and published by the EU (as a part of
European Community Health Indicators)
iHEA meeting, 8th of July, Sydney. Contact: timo.t.seppala@thl.fi
Solutions in EuroHOPE
 Definitions of specific patient groups to maximize comparability
 Extensive risk adjustment
 Standardisation by modelling and computing confidence intervals
 Definitions of episodes
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EFPC, Istanbul, 2013
EuroHOPE
Data
Comparison
of countries,
regions and
hospitals
National
National
discharge
EuroHOPE
register
database
Protocols
National
mortality
register
National
research and
bencmarking
EuroHOPE
research
National
Other
EuroHOPE
national
comparison
registers
data
International
EuroHOPE
comparison
data
Anonymous
individual level
data used for
comparative
research
Definitions of episodes
Total episode of care
First hospital episode
Admission to Admission to
ward A
ward B
Discharge
home or
nursinghome
Outpatient
visit
time
Procedure/treatment
in ward A
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Discharge to
another hospital
EFPC, Istanbul, 2013
Medication
purchase
Risk adjustments based on
comorbidities (AMI)
Comorbidity
ICD-10
ICD-9
ATC/DDD
Hypertension
I10*-I15*
40*
C03*, C07* (with neither coronary artery disease nor atrial
fibrillation indicates hypertension), C08*, C09*
Coronary artery disease
I20*-I25*
410*-414*
N/A
Atrial fibrillation
I48*
4273*
N/A
Cardiac insufficiency
I50*
428*
N/A
Diabetes mellitus
E10*-E14*
250*
A10A*, A10B*
Atherosclerosis
I70*
440*
N/A
Cancer
C00*-C99**, D00*-D09*
140*-208*
L01* (except L01BA01)
COPD and asthma
J44*-J46*
4912*, 496*, 496*
R03*
Dementia
F00*-F03*, G30*
290*, 3310*
N06D*
Depression
F32*-F34*
2960*, 2961*
N06A*
Parkinson’s disease
G20*
332*
N04B*
Mental disorders
F20*-F31*
295*-298* except
2960* and 2961*
N05A* (except N05AB01 and N05AB04), and no dementia
Renal insufficiency
N18*
585*
N/A
Alcoholism
F10*-F19*
291*, 304*, 305*
N/A
Stroke
I60*, I61*, I63*, I64*,
G45*
430*-438*
N/A
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Description of regions used in
EuroHOPE
Country
Description
Finland
Hospital districts and hospital regions
responsible for providing specialised health
care. Smallest districts combined.
20
265 000
Hungary
19 counties and Budapest area providing selfgovernmental administrative duties (not health care).
20
500 000
Italy
City of Turin and Province of Rome (divided into two
smaller units: City of Rome and outside of Rome
municipalities).
3
1 634 000
The Netherlands
Provinces responsible for matters of subnational or
regional importance (not health care).
12
1 400 000
Norway
Hospital trusts responsible for providing specialist
health care in their geographical areas.
20
250 000
Scotland
Health boards responsible for health care. Smallest
boards combined.
11
480 000
Sweden
Counties responsible for providing health care.
21
450 000
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Number of
regions
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Average population
size
Acute Myocardial Infarction (AMI)
 inpatient, outpatient, medication administrative data
and death registries
 AMI codes: ICD-9: 410, ICD 10: I21, I22
 inclusion criteria: valid ID, resident, age 18-X
 index hospital admission:
– main diagnosis is AMI, no AMI within 365 prior the
admission
 linkage of individual episodes with patient IDs
 first analysis:
– FIN, HUN, IT, NL, SCO , SWE - 2007
– NOR - 2009
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2-day PCI rate (%) of AMI patients by country,
adjusted for age and sex
45.0
39.5
40.0
35.0
33.1
30.4
30.2
30.0
25.0
27.6
24.4
%
20.0
14.0
15.0
10.0
5.0
0.0
Finland
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Hungary
Italy
EFPC, Istanbul, 2013
Netherlands
Norway
Scotland
Sweden
2-day PCI rate (%) of AMI patients per region
by country, adjusted for age and sex, with
confidence intervals
80%
70%
60%
50%
40%
30%
20%
10%
0%
FINLAND
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HUNGARY
EFPC, Istanbul, 2013
NETHERLANDS
NORWAY
SWEDEN
Mean length of first hospital episode of AMI
patients per region by country, adjusted for age,
sex and previous year hospital days, with
confidence intervals
20
18
16
Days
14
ITALY
12
10
8
6
4
2
FINLAND
HUNGARY
0
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NORWAY
SWEDEN
One-year mortality of AMI patients per region by
country, adjusted for age and sex, with
confidence intervals
60
50
40
% 30
20
10
0
FINLAND
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HUNGARY
NETHERLANDS
EFPC, Istanbul, 2013
NORWAY
SCOTLAND
SWEDEN
Ischaemic stroke
 inpatient, outpatient, medication administrative data
and death registries
 Ischaemic stroke codes ( ICD-9: 433-434, ICD 10: 63
 inclusion criteria: valid ID, resident, age 18-X
 index hospital admission:
– main diagnosis is ischaemic stroke, no stroke
within 365 prior the admission
 linkage of individual episodes with patient IDs
 first analysis:
– FIN, HUN, IT, NL, SCO, SWE - 2007
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EFPC, Istanbul, 2013
Mean length of first hospital episode of stroke
patients per region by country, adjusted for age,
sex and previous year hospital days, with
confidence intervals
25
ITALY
20
Days
15
10
5
FINLAND
HUNGARY
0
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SWEDEN
Mean mortality (30-, 90-day and one-year (%)) of
stroke patients by country, adjusted for age and
sex
40.0
35.0
30.0
25.0
% 20.0
15.0
10.0
5.0
0.0
30-day
Finland
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90-day
Hungary
Italy
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Netherlands
one year
Scotland
Sweden
Mean one-year mortality of stroke patients
per region by country, adjusted for age
and sex, with confidence intervals
50
45
40
35
30
% 25
20
15
10
5
FINLAND
HUNGARY
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0
NETHERLANDS
SCOTLAND
SWEDEN
Conclusions
 Large variation in use of resources and
outcomes between the countries, hospitals
and regions
 Potential for improving efficiency
 Benchmarking (where is the wisdom):
preliminary best performing regions in
EuroHOPE countries
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Next steps
 National and regional indicators to be published at
http://www.eurohope.info
 Development methods for measuring costs
 Scientific articles (clinical, methodological, health
policy orientated)
 Health economic issues such as
– analyses of reasons behind differences in
outcomes and use of resources between the
countries and regions
– relationship between outcomes and cost at
country and hospital level
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EFPC, Istanbul, 2013