HCM 515 (KD)

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Research

Q The impact of health policy: the extreme case of Abruzzo, Italy

Lamberto Manzoli*†, Vito Di Candia†, Maria Elena Flacco*, Massimiliano Panella‡, Lorenzo Capasso*, Massimo Sargiacomo§, Paolo Villari** and Angelo Muraglia†

*Department of Medicine and Aging Sciences, University of Chieti, Chieti, Italy; †Regional Healthcare Agency of Abruzzo (ASR-Abruzzo),

Pescara, Italy; ‡University of Piemonte Orientale ‘Amedeo Avogadro’, Novara, Italy; §Department of Business Administration,

University of Chieti, Chieti, Italy; **Department of Public Health and Infectious Diseases, Sapienza University of Rome, Rome, Italy

Summary

During the decade 2000 – 2010, the health-care system of the Abruzzo Region, Italy faced a financial crash and subsequent

recovery. The extent of both was so large to be a case study, which may help addressing general questions including how

much health-care supply can be influenced by cost-containment policies and how such strategies may impact on health-

care appropriateness/efficiency and population health status. We used data publicly available or officially provided by the

Regional informatics system. The health system was deeply revised, and health reforms spanned from one-off emergency

measures to structural long-term policies. From 2000 to 2005, resident’s hospitalization rate increased, achieving 280

admissions � 1000 inhabitants (highest in Italy), and regional per-capita health-care debt almost tripled (þ274%; E1586). From 2006 to 2010, after major health system reforms, the hospitalization rate decreased by 31.4%

(with peaks as high as 74.9% for some diseases), and per-capita debt decreased by 33.0% (E1062). Most

available health-care efficiency/appropriateness indicators improved, and indexes of population health remained sub-

stantially unchanged. In extremely negative contexts, the impact of health reforms on health-care services may be impress-

ive even in the short-run, with no or little trade-off between cost-containment and quality. The reliability of

epidemiological estimates based upon hospital discharge abstract may be low when substantial variations in health

policy occurred.

Introduction

In the last decades, a number of cost-containment

health policies were applied at a National or local

level worldwide.1 – 5 If the effectiveness of health reforms

to reduce costs is established, there are limited em-

pirical data to evaluate how much and how quickly

health-care supply can be influenced by cost-containment

policies, and whether such strategies may trigger an

improvement of health-care appropriateness and/or effi-

ciency, thus ultimately impact on population health

status.6 – 8

Abruzzo is a small Italian region (ffi1,300,000 residents) located at the same latitude of Rome, on the Adriatic

Sea. Although it was neither the poorest nor the oldest

among Italian regions,9 in the first years of the century

the situation of its health-care system was dramatic:

there were 22 public and 13 private hospitals (one every

36,600 residents), including 5.6 inpatient beds per 1000

inhabitants and the region repeatedly showed the highest

annual hospitalization rate (up to 280 � 1000) and hos- pital inappropriateness rate (up to 55%) among Italian

regions.10 – 12 Finally, the per-capita debt due to health-care

spending rose from E424 to E1586 in less than five years

(National official data from CIPE SP NSIS).

Under the pressure of National governments the Abruzzo

Region implemented several actions to try to achieve a

rapid improvement in health-care efficiency and a simi-

larly quick financial recovery. Although some other

regions inside and outside Italy faced somewhat similar

situations, the extent of both the initial crash and the

subsequent recovery were so large to be a case study,

which may help addressing the above general questions

and another seemingly unrelated one: are commonly

used epidemiological estimates of population health

status based upon hospital discharge data reliable on the

short-run?

Accepted 4 December 2012

Correspondence: Lamberto Manzoli, ASR-Abruzzo, Via Attilio Monti 9-65127

Pescara, Italy (Email: [email protected])

International Journal of Care Pathways 2012; 16: 115 – 121 DOI: 10.1177/2040402613479343

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Methods

The data here presented are a concise synthesis of a broader

analysis, made by the Regional Health-care Agency of

Abruzzo upon request from the Regional Government

(Health care and Health Status in Abruzzo. ASR-Abruzzo).

In brief, demographic data for both Italy and Abruzzo

were publicly available from the Italian Institute of

Statistics,13 and hospital data were extracted from the

administrative discharge abstract database (Italian SDO),

officially validated by the Regional informatics system,

which provided all data (excepted those for which a refer-

ence has been provided). In estimating the rate of cause-

specific admissions, we adopted the version of ICD that

was in use in that year (1997 Italian Version of the ICD-9-

CM up to the year 2004; 2002 International version of the

ICD-9-CM up to the year 2009; 2007 International version

of the ICD-9-CM for the year 2010).

Because in the Italian Health Care System the regions

only cover the expenses of their residents, but cost-

reduction policies (i.e. expenditure ceilings for single hospi-

tals) may be directed towards all admissions made by

regional hospitals (thus including also patients coming

from other regions, that are free to chose every hospital in

Italy), the hospitalization rate trend was estimated in two

ways: (a) comparing all admissions made by regional hospi-

tals (which includes residents and non-residents that were

treated in Abruzzo); (b) comparing the rate of admissions

made by residents in Abruzzo (in hospitals located either

inside or outside the Region).

We considered the whole decade 2000 – 2010: we started

from 2000 because in that year a National reform gradually

shifting to the Regions the responsibility of health-care

budget (Fiscal Federalism) was approved;14 and ended

with 2010 because 2011 definitive data were not available

yet (however, preliminary data confirm the decreasing

trend: 22.5% as compared with 2010). When not otherwise

stated, admission rates are referred to all hospital admis-

sions (ordinary and day-hospital/day-surgery; only ambu-

latory patients being excluded). The study did not require

ethics approval.

Results

Health reforms

The main health care and/or cost-containment policies

that were implemented between 2000 and 2010 in

Abruzzo have been reported in Table 1 in chronological

order. Because of some successions in the local government

and National commissioners, the reforming process

was somewhat chaotic and did not follow a uniform

evidence-based methodology defined a priori, such as in

other cases.15,16 The health system was deeply revised, and

health reforms spanned from one-off emergency measures

such as spending ceilings and inappropriateness thresholds

(with associated economic penalties) for single hospitals,

recruitment bans and hospital closure or conversion, to

structural long-term policies including the first authoriz-

ation/accreditation system, a monitoring system based

upon pre-established targets for public sector directors, and

a broad re-organization of hospital, ambulatory, long-term

and primary care systems (with the Regional Health Care

Plan 2008 – 2010). Notably, none of the latter structural

measures has been completely implemented yet.

Demographic, health care and health status indicators

As shown in the Figure 1, in Italy and Abruzzo both the

total number and the rate of hospitalizations increased up

Table 1 Main health policy measures adopted in the Abruzzo Region, Italy between 2000 and 2010 (in chronological order)

1 2000, February: A National reform of health-care financing system was approved, that gradually transferred to the Regions the responsibility of health-care budget

(fiscal federalism).14 In the same year, on April, a new Regional government (n. 1) took office

2 2005, March: A ‘Pact for Health’ between the Italian State and single regions was signed.17 The document included an obligation for regions to maintain

a financial balance. In the same year, on April, a new Regional government (n. 2) took office. Neither major changes to the regional health-care system

nor cost-containment plans were released before this period

3 2006, June: Regional Law n. 20 included several specific actions to reduce hospitalization rate (i.e. spending ceilings for hospitals and financial penalties

for violations) and decreased inappropriateness through a regional monitoring system36 (only partially implemented)

4 2006, October: The Abruzzo Region, together with Calabria, Campania, Lazio, Liguria, Molise, Sardinia and Sicily was officially requested by the National

Government to develop a Recovery Plan. This plan was signed on March 6, 2007 with the Ministry of Health, which hold a monitoring role on plan application

5 2007, April: Regional Law n. 6 included a broad reform of the hospital network, implementing a ‘hub and spoke’ model and reducing and reallocating hospital

beds37 (which decreased from an estimated 6167 in 2005 to 4678 in 2010; 224.1%)

6 2007, July: Regional Law n. 32 included the first authorization and accreditation system for hospitals and ambulatories.38 The accreditation manual was then

released on July 2008

7 2008, March: Regional Law n. 5 included the Regional Health-care Plan 2008 – 2010.39 This plan enumerated a number of reforms of outpatient and inpatient

services, i.e. establishing a balance scorecard model for the continuous performance evaluation of health-care providers, and a unified expenditure reporting

system (although both were only partially implemented)

8 2008, September: a Commissioner was nominated by the Central Government to pursue cost-reduction interventions (Decree of the Cabinet) and address some

Recovery Plan targets that were not achieved. The commissioner established BSC targets, prohibited hiring of health professionals and redefined private sector

ceilings. The commissioner also terminated the two-year process to identify and stop the incorrect allocation of large amounts of the health-care budget that

were diverted to other public sectors

9 2008, December: Regional government n. 3 took office; the previous government resigned before the term as a consequence of a vast criminal investigation (ongoing)

10 2009, December: The Cabinet replaced the previous Commissioner with the President of the Region, who expanded existing policies (i.e. thresholds for hospital

inappropriateness were set and three private and four public hospitals were closed or converted to ambulatory or long-term care clinics)

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to 2004, achieving a plateau in 2005 (þ7.2% in Abruzzo; þ2.2% in Italy). Starting from 2006, after the ‘Pact for Health’ between the Italian State and single regions was

signed,17 and a new Regional Government took office,

both indices showed an unremitting decrease, which

however was much larger in Abruzzo (231.4%) than in

the rest of the country (212.2%). If we consider the last

quinquennium only, the admissions made by residents

and hospitals from Abruzzo were reduced by 28.5%

(2102,701 admissions) and 36.0% (2134,020), respectively

(Table 2). The overall trend was similar for day-surgery or

day-hospital admissions (229.2% overall, data not

shown). The admissions by private hospitals from Abruzzo

decreased by 54.8% in the last five years.

The admission rates for specific diseases substantially fol-

lowed the overall admission rate: the hospitalization rates

for cardiovascular diseases and cancer slightly increased

from 2000 to 2005, then sharply decreased (Table 2).

Admissions for diabetes were already decreasing in 2005,

but they showed an astonishing reduction in the sub-

sequent quinquennium (274.9%). Several other cause-

specific admission rates were also analysed, all of them

showing a trend similar to that of cardiovascular diseases

(data not shown).

We also reported separately the rates of admissions made

by residents outside the region because it may be expected

that, as a reaction to a diminished propensity to accept

patients in regional hospitals, many residents may have

decided to be hospitalized in hospitals located outside

the region, just moving the issue from Abruzzo to other

regions (Italian residents have the freedom to use all hospi-

tals throughout the country). In the last five years,

although passive mobility rates invariably increased, with

the only exception of diabetes, such an increase was large

in percentage (þ16.4%) but limited in absolute terms (þ6071 admissions) and could not balance the decrease of the admissions made inside the Region (2108,772

admissions).

Reflecting the trend of hospitalization rates, from 2000 to

2005, despite an increase of per-capita budget for health

care (þ37.0% – Table 2), the regional per-capita debt for health care almost tripled (þ274%), then harshly decreased in the following quinquennium (233.0%).

Clearly, reducing hospitalizations is not of value per se,

as after a certain threshold hospital admissions are required

and their denial could result in low-quality health care

and poorer population health status. Indeed, concern-

ing the question whether health policies may trigger an

Figure 1 Ten-year trend of the number of hospitalizations in Italy and Abruzzo Region (residents). The initial value ‘0.0’ represents the number of admissions that were made in the year 2000; the percentages of increase/decrease are all referred to this number

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improvement/worsening in health-care appropriateness

and/or efficiency, thus impacting on the health status of

the population, it should be pointed out that, like most

experts in the field,18 we did not have precise, standardized,

severity adjusted data on the quality of health care for the

entire period. Also, using hospital discharge data to estimate

population health, as commonly made,19 – 22 could be a con-

ceptual loop: with such a large hospitalization rate decrease

the indicators based upon hospitalization rates (i.e. Agency

for Healthcare Research and Quality Prevention Quality

Indicators23 reported in Table 3) obviously improved but

this could not be reliable. However, some representative

data were available in the Region for the years 2005 and

2010.

First, most of the existing indices of efficiency and organ-

izational appropriateness of hospital care substantially

improved from 2005 to 2010 (years with similar mean

patient’s age: 55.5 years): ordinary admissions for poten-

tially inappropriate diagnosis-related groups (DRGs);

repeated admissions; surgical DRGs from surgical wards;

ordinary admissions shorter than three days. Even the

only negative result – a 12.7% increase of the average

length of stay – could be interpreted with some tolerance,

because of a 7.0% increase in average DRG weight from

2006 (the 1st year in which the 19th DRG version was

used) to 2010, and given the above mentioned decrease of

very short admissions (which carried a high likelihood

of inappropriateness) (Table 3).

Second, patient safety indicators that were available from

independent sources,20 – 22,24,25 caesarean delivery rates and

the overall age-standardized cancer mortality did not

change substantially or slightly improved.

Third, the proportion of patients that were satisfied or

largely satisfied with the health-care system increased by

46.6% in the period 2005 – 2010, although remaining

lower than the Italian average (39.1% – Table 3).9

Fourth, as regards outpatient and residential care, unfor-

tunately the available data are scarce and only allow the

computation of some indirect indicators. Compared with

year 2005, in 2010 the average number of persons cared

by each primary-care physician decreased from 1228 to

1175; the mean number of children for pediatrician

remained stable (n ¼ 185); the overall per-capita annual

drug expenditure slightly increased (from E225 to E230);

the per-capita number of ambulatory visits/interventions

increased (þ18.4%) but 2005 data were largely incomplete; the rates of nursing home or hospice beds per elderly resi-

dent remained low (both below 3 � 1000). Finally, concerning population health status, from 2005

to 2010 life-expectancy at birth slightly increased,9 the

overall standardized cancer incidence also decreased,26

and although the average pharmaceutical consumption

increased (þ23% in the defined daily dose �1000 inhabi- tants), this was in line with the rest of Italy (þ18%) and was probably caused by the expiry of the patent of several

widely-used drugs.27,28

Table 2 Residents, hospital admissions and financial summary in Italy and Abruzzo Region, in the years 2000, 2005 and 2010

2000 2005 2010 D05 – 00 D10 – 05

Demographic data

No. of residents in Abruzzo 1,281,283 1,299,272 1,338,898 þ1.4 þ3.0 Percentage of elderly (�65 years) 20.0 21.1 21.3 þ5.5 þ0.9 Aging index (elderly/0 – 14 years) 142 156 163 þ9.9 þ4.5

Overall no. of hospitalizations

In Italy 12,671,564 12,955,882 11,121,825 þ2.2 214.2 Made by hospitals located in Abruzzo� 347,632 372,590 238,570 þ7.2 236.0 Public hospitals 291,112 289,373 202,353 20.6 230.1

Private hospitals 56,520 83,217 36,217 þ47.2 256.5 Made by residents in Abruzzo† 344,243 360,729 258,028 þ4.8 228.5 Treated outside the Region only 33,128 36,932 43,003 þ11.5 þ16.4

Hospitalization rates of Abruzzo residents

Admissions for any cause (�1000) Treated inside and outside the Region† 268.7 278.3 193.5 þ3.6 230.5 Treated outside the Region only 25.9 28.8 32.6 þ11.2 þ13.2 Admissions for CHD (�10,000)‡ Treated inside and outside the Region† 369.3 382.8 267.1 þ3.7 230.2 Treated outside the Region only 23.9 28.7 32.3 þ20.1 þ12.5 Admissions for cancer (�10,000)§ Treated inside and outside the Region† 201.4 219.4 176.8 þ8.9 219.4 Treated outside the Region only 28.7 31.2 35.7 þ8.7 þ14.4 Admissions for diabetes (�10,000)�� Treated inside and outside the Region† 29.2 28.7 7.2 21.7 274.9

Treated outside the Region only 2.9 1.9 1.8 234.5 25.3

Financial data

Per capita budget for public health care, E 1095 1500 1712 þ37.0 þ14.1 Per capita reg. health-care system debt, E 424 1586 1062 þ274.1 233.0

�Including only patients admitted into hospitals located in Abruzzo ( passive mobility excluded) †Including only residents in Abruzzo, either admitted in hospitals inside or outside the Region ‡CHD ¼ Coronary heart diseases. Main diagnosis ICD-9-CM codes 390 – 459 §Main diagnosis ICD-9-CM codes 140 – 239 ��Main diagnosis ICD-9-CM code 250

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Accurate analyses are available on the effect on health-care

supply and population health of financial crisis,3,4,29 as well

as several comparisons among National health-care systems

exist.30,31 However, there are limited empirical data to quan-

tify the potential effects of health reforms on health-care

supply of developed countries in the short term.1,2,7

Our data suggest that the influence of health policy on

hospital supply can be remarkable and relatively quick:

after the start of a series of severe cost-containment policies

and health-care reforms, in five years the overall hospitaliz-

ation rate of the residents of Abruzzo decreased by 30.5%,

and the overall number of admissions made in the region

decreased by 36.0%. Such a reduction seems even more con-

spicuous if we consider that, in the same period, the overall

population slightly aged, the incidence of some chronic

high-impact diseases such as diabetes or cancer increased

in Italy,32 finally that an earthquake took place on 6 April

2009 in L’Aquila (Abruzzo chief town) and near provinces,

causing 308 deaths and thousands of serious injures and

damages to health-care facilities.

Certainly, it is possible that the observed change was

caused by reasons other than the adopted policies.

Potential, non-mutually exclusive alternative explanations

include a decrease in the incidence of serious diseases,

some drastic lifestyle changes and quantitative or qualitat-

ive improvements in outpatient service supply.

As regards disease incidence, the size and timing

of the changes are incompatible with long-term trends of

all non-infectious diseases, most of which showed stable

or increasing incidence in recent years in the rest

of Italy.26,32,33 Moreover, even the most common infectious

diseases, for which National registry data are available, did

not show a substantial reduction (with the exception of

chickenpox).34

Concerning lifestyles, current data do not support the thesis

of a relevant improvement: from 2005 to 2010 smoking (from

23% to 22%), obesity (11.8% versus 11.7%) and alcohol use

(68%) prevalence remained substantially stable.20,35

With regard to outpatient service supply, available data

indicate that, in the last quinquennium, the quantity

remained substantially stable (number of citizens per

general practitioners (GPs) or pediatrician; rates of nursing

home or hospice beds per elderly; number of home care

visits, etc.).

Concerning the quality of primary, ambulatory and resi-

dential care, we have no data to attempt a meaningful

evaluation, and in fact it may be possible that the overall

quality did not change or even worsened. In any case,

even assuming that a significant improvement took place,

it would be impossible to discern whether this progress

occurred independently of or it was determined, at least

in part, by the reorganization of the health-care system,

which included also some measures directed to these set-

tings (i.e. the creation of consortia of labs and GPs and a

partial rationalization of their network).

Table 3 Selected indices of Abruzzo health-care system efficiency and appropriateness, and population health status, in 2005 and 2010

Indicator 2005 2010 D, %

AHRQ Prevention Quality Indicators (3100,000) 21 – 25

Hospitalization rate for uncontrolled diabetes� 29.2 18.7 236.0

Hospitalization rate for asthma in the adults 47.2 7.61 283.9

Hospitalization rate for influenza in the elderly 17.2 4.2 275.6

Hospital care

Ordinary admissions assigned to DRGs potentially inappropriate according

to the Italian Ministry of Health, %40 16.1 6.5 259.6

Repeated admissions, % 9.2 5.9 235.9

Surgical DRGs from surgical wards, % 30.8 61.0 þ98.1 Ordinary admissions shorter than 3 days, % 30.7 23.2 224.4

Mean length of stay, days (excluding rehabilitation/long stay admissions) 6.05 6.82 þ12.7 Mean DRG weight ( proxy of case-mix severity)† 0.98 1.05 þ7.0 Caesarean deliveries, %9 43.1 43.6 þ1.1

OECD patient safety indicators (3100,000 admissions) 19,21,22,24,25

Infections due to medical care� 5.45 2.72 250.1

Obstetric trauma during natural delivery� 298 294 21.3

Pulmonary embolism or DVT after surgery� 140 152 þ8.6 Overall health system

Patients satisfied or very satisfied of the health-care system, %9 23.2 34.8 þ46.6 Overall std malignant cancer mortality (�100,000), women26 309 319 þ3.2 Overall std malignant cancer mortality (�100,000), men26 374 364 22.7

Population health status

Mean life-expectancy at birth, women (y)9 84.2 84.8 þ0.7 Mean life-expectancy at birth, men (y)9 78.1 79.1 þ1.3 Overall std malignant cancer incidence (�100,000), women26 145 136 26.2 Overall std malignant cancer incidence (�100,000), men26 234 219 26.4 Average pharmaceutical consumption (ddd �1000)27,28 786 964 þ22.6

AHRQ ¼ Agency for Healthcare Research and Quality, OCED ¼ Organization for Economic Cooperation and Development, DVT ¼ deep venous thrombosis, ddd ¼ defined daily dose,

DRG ¼ diagnosis-related group �The values in the first column (i.e. 5.45) are referred to 2007, the first year with available data †The first value (0.93) is referred to 2006, the first year in which the 19th DRG version was used

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With regard to health-care quality and population health,

considering available data in the last quinquiennium we

have some indications of an overall improvement of the

regional health system efficacy and appropriateness, and

we have no reasons to believe that the general health

status relevantly varied.

A last important question which emerged during the

analysis pertains the reliability, especially in the short-run,

of commonly used epidemiological estimates of population

health status based upon hospital discharge data. Most

reports, even those produced by official Institutions in

developed countries, estimate the trend of some diseases,

for which no registries are available, using the number

(or rate) of hospital admissions for such diseases.9,19 – 21

Adopting this method, an independent observer might

have concluded that in five years, in Abruzzo, cardiovascu-

lar disease, cancer and diabetes incidence decreased by

30.2%, 19.4% and 74.9% respectively (and also that, i.e.

mental disorders and Alzheimer disease dropped by 45.9%

and 30.4%). As mentioned, this is impossible. Although

the limitations of hospital discharge abstract data are typi-

cally listed in most of the cited reports, the present analysis

reinforces the need of (a) extra caution when using (and

interpreting) such data to estimate disease trends or health-

care needs and of (b) primary care data to support or inte-

grate hospital discharge data.

Conclusions

Although it is easier to improve when the starting point

is low, the case discussed here represents a somewhat

extreme example of the impressive impact that health

reforms may have on health-care services even in the short-

run. Available data suggest that there may be little

trade-off between cost-containment and quality, and no

suggestion was found of a decline of population health

status. Current data are however limited, and longer-term

analysis will be required to confirm present findings.

Lessons learnt:

(1) The impact of health reforms on health-care services

may be impressive even in the short-run and in

Western countries, with no or little trade-off between

cost-containment and quality.

(2) The reliability of epidemiological estimates based

upon hospital discharge abstract may be low when

substantial variations in health policy occurred.

DECLARATIONS

Competing interests: None.

Funding: This work was not funded.

Ethical approval: This work did not require ethical approval.

Guarantor: Lamberto Manzoli

Author’s contributions: All authors participated in the

design, analysis and interpretation of the study. LM, VDC

and AM were involved in all phases of the study. LM led

the statistical analysis and assisted VDC and MEF and LC

in data extraction. LM, MP and PV wrote the manuscript.

All authors had full access to all of the data (including stat-

istical reports and tables) in the study and can take respon-

sibility for the integrity of the data and the accuracy of the

data analysis.

Acknowledgements: The authors are grateful to the follow-

ing Doctors or Institutions for the provision of data:

Camillo Odio, Lorenzo Venturini, Rossana Cassiani,

Giancarlo Diodati, the Unit “Collective Prevention” and

the Unit “Management of Healthcare flows, informatics

Procedures and Health Emergency” of the Ministry of

Health of the Abruzzo Region.

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