Open Access Study protocol

The relationship between effectiveness and costs measured by a risk-adjusted case-mix system: multicentre study of Catalonian population data bases

Antoni Sicras-Mainar1*, Ruth Navarro-Artieda2, Milagrosa Blanca-Tamayo3, Soledad Velasco-Velasco4, Esperanza Escribano-Herranz4, Josep Ramon Llopart-López4, Concepción Violan-Fors5, Josep Maria Vilaseca-Llobet6, Encarna Sánchez-Fontcuberta6, Jaume Benavent-Areu6, Ferran Flor-Serra7, Alba Aguado-Jodar7, Daniel Rodríguez-López7, Alejandra Prados-Torres8 and Jose Estelrich-Bennasar9

Author Affiliations

1 Directorate of Planning, Badalona Serveis Assistencials SA, Badalona, Barcelona, Spain

2 Medical Documentation, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain

3 Psychiatry Department, Badalona Serveis Assistencials SA, Badalona, Barcelona, Spain

4 Directorate of Planning, Badalona Serveis Assistencials SA, Badalona, Barcelona, Spain

5 Jordi Gol i Gurina Primary Health Care Research Institute, IDIAP, Barcelona, Spain

6 GESCLINIC – Corporació Sanitària Clínic, Barcelona, Spain

7 Directorate of Primary Health Care, Consorci Sanitari Integral, Barcelona, Spain

8 Health Sciences Institute of Aragon, Zaragoza, Spain

9 Primary Health Care Management of Mallorca, Palma de Mallorca, Spain

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BMC Public Health 2009, 9:202  doi:10.1186/1471-2458-9-202

Published: 25 June 2009



The main objective of this study is to measure the relationship between morbidity, direct health care costs and the degree of clinical effectiveness (resolution) of health centres and health professionals by the retrospective application of Adjusted Clinical Groups in a Spanish population setting. The secondary objectives are to determine the factors determining inadequate correlations and the opinion of health professionals on these instruments.


We will carry out a multi-centre, retrospective study using patient records from 15 primary health care centres and population data bases. The main measurements will be: general variables (age and sex, centre, service [family medicine, paediatrics], and medical unit), dependent variables (mean number of visits, episodes and direct costs), co-morbidity (Johns Hopkins University Adjusted Clinical Groups Case-Mix System) and effectiveness.

The totality of centres/patients will be considered as the standard for comparison. The efficiency index for visits, tests (laboratory, radiology, others), referrals, pharmaceutical prescriptions and total will be calculated as the ratio: observed variables/variables expected by indirect standardization.

The model of cost/patient/year will differentiate fixed/semi-fixed (visits) costs of the variables for each patient attended/year (N = 350,000 inhabitants). The mean relative weights of the cost of care will be obtained. The effectiveness will be measured using a set of 50 indicators of process, efficiency and/or health results, and an adjusted synthetic index will be constructed (method: percentile 50).

The correlation between the efficiency (relative-weights) and synthetic (by centre and physician) indices will be established using the coefficient of determination. The opinion/degree of acceptance of physicians (N = 1,000) will be measured using a structured questionnaire including various dimensions. Statistical analysis: multiple regression analysis (procedure: enter), ANCOVA (method: Bonferroni's adjustment) and multilevel analysis will be carried out to correct models. The level of statistical significance will be p < 0.05.