Development and Validation of a Score for Adjusting Health Care Costs in General Practice

Value Health. 2015 Sep;18(6):884-95. doi: 10.1016/j.jval.2015.05.004. Epub 2015 Jul 17.


Objective: To develop and validate the Italian Health Search Morbidity (HSM) Index to adjust health care costs in general practice.

Methods: The study population comprised 1,076,311 patients registered in the Health Search CSD Longitudinal Patient Database between January 1, 2008, and December 31, 2010. We randomly selected 538,254 and 538,057 patients to form the development and validation cohorts, respectively. To ensure model convergence, 5% of the aforementioned cohorts were selected randomly to create development and validation samples. The outcome was the total direct health care costs covered by the national health system. Interaction between age and sex, chronic diseases, and acute diseases were entered in a multilevel generalized linear latent mixed model with random intercepts (province of residence and general practitioner) to identify determinants associated with increased or decreased costs. The estimated coefficients were linearly combined to create the HSM Index for individual patients. The score was applied to the validation sample, and measures of predictive accuracy, explained variance, and the observed/predicted ratio were computed to evaluate the model's accuracy.

Results: The mean yearly cost was €414.57 per patient, and the HSM Index had a median value of 5.08 (25th-75th range 4.44-5.98). The HSM Index explained 50.17% of the variation in costs. Concerning calibration, in 80% of the population, the margin of error in the estimation of costs was around 10%.

Conclusions: The HSM Index is a reliable case-mix system that could be implemented in general practice for costs adjustment. This tool should ensure fairer scrutiny of resource use and allocation of budgets among general practitioners.

Keywords: HSM Index; case-mix; costs adjustment; health care costs.

Publication types

  • Validation Study

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Budgets
  • Chronic Disease / economics*
  • Chronic Disease / epidemiology
  • Chronic Disease / therapy*
  • Comorbidity
  • Cost-Benefit Analysis
  • Databases, Factual
  • Female
  • General Practice / economics*
  • Health Care Costs*
  • Health Care Rationing / economics
  • Health Services Needs and Demand / economics
  • Health Services Research
  • Humans
  • Italy
  • Linear Models
  • Male
  • Middle Aged
  • Models, Economic
  • National Health Programs / economics*
  • Needs Assessment
  • Primary Health Care / economics*
  • Reproducibility of Results
  • Time Factors
  • Young Adult