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Grant Agreement No. 241595. EUprimecare: Quality and Costs of Primary Care in Europe. MD, Antonio Sarría -Santamera ( Institute of Health Carlos III) Stefan Scholz ( University of Bielefeld ) MD Kadri Suija (University of Tartu ). Costs. Access. Health Care: Iron Triangle. Quality. - PowerPoint PPT Presentation
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EUprimecare: Quality and Costs of Primary Care in Europe
Grant Agreement No. 241595
MD, Antonio Sarría-Santamera (Institute of Health Carlos III)Stefan Scholz (University of Bielefeld)MD Kadri Suija (University of Tartu)
Health Care: Iron Triangle
Costs
Quality
Access
Strong Primary Care
What is Strong Primary Care?
Common framework to describe Primary Care models in the EU is not available
Not yet developed a trans-national consensus on how to define Quality of Primary Care
Cost of Primary Care are not well identified in national accounting systems
Background
Objectives
• To contribute to improving the knowledge regarding Primary Care in Europe:
=> exploring the relationships that could exist between Quality and Costs of different models and systems of organizing and delivering PC across Europe
• Institute of Health Carlos III. ISCIII. Spain • Universität Bielefeld. UNIBI. Germany • University of Tartu. UTartu. Estonia • National Institute for Strategic Health Research. GYEMSZI.
Hungary • Országos Alapellátási Intezet. OALI. Hungary • Institute for health and Welfare. THL. Finland • Kaunas University of Medicine. LSMU. Lithuania• Universitá Commerciale Luigi Bocconi. UB. Italy
Partners
Conceptual structure
Identify a methodology to measure Quality in PC
WP 5 & 6
Identify a methodology to measure Costs in PC
WP 3 & 4
WP 7
WP2
Evaluation of PC models
CO
OR
DIN
AT
ION
W
P 1
DIS
SM
INA
TIO
N
W
P 8
To measure the Quality in PC
To measure Costs in PC
ORGANIZATION OF PRIMARY CARE IN
EUROPE
REGULATION
FINANCING
PAYMENTORGANIZATION
ORGANIZATIONAL BEHAVIOUR
• Costs
• Quality
Approach
Evaluation of PC models in Europe
Methodological Approach of a Classification System of PC Models in Europe : Germany, Spain, Estonia, Finland, Hungary, Italia and Lithuania.
Methodology
1. Literature review: Structure or process of PC in Europe Control knobs: financing, regulation, payment,
organization, and organizational behavior
2. Selection of indicators => template design:
Five variables (Control knobs) to optimize healthcare systems results:
Range of services
3. Descriptive Analysis & Principal Component Analysis
Results of Qualitative analysis
Based on a functional perspective, allowed to proposing 5 models:
1.Direct access to specialist
2.Referral required from GP, mainly solo-practices in PC3.Referral required from GP, mainly group-practices in PC
4.Health care centers5.Polyclinics
• Model 1, Direct access to any GP or specialist (Germany)• Model 2, Referral required from GP, mainly solo-
practices in PC (Hungary, Italy)• Model 3, Referral required from GP, mainly group-
practices in PC (Estonia, Lithuania)• Model 4, GPs working mainly in health care centres
(Finland, Spain)• Model 5, Polyclinics (Shemasko). Not necessarily GPs at
all
Functional models
FINANCING Mixed model
(Hungary)
BISMARCK SS(Estonia, Germany,
Lithuania)
BEVERIDGE NHS(Finland, Italy,
Spain)
7% Uninsured
10,6% Private Insurance18,8% Double coverage
Expenditure in HCas GDP
10,5%
6,1% 6,6%
24%
Expenditure in PC
5,7%
16% Double coverage
Descriptive analysis (I)
• Formal mechanisms to guarantee accessibility, equity and quality of healthcare
• Gate-keeping systems, except in Germany
• Facilities:• Mostly public: Finland, Spain, Hungary and Lithuania• Totally private: Germany, Estonia and Italy
• Clinical practice facilities: • Integrated Network: Finland and Spain• Solo & group practices: Germany, Estonia, Italy, Lithuania,
Hungary
REGULATION
ORGANIZATION
Descriptive analysis (II)
• Process to monitoring and improving the quality of medical practice:
Quality management systems measuring clinical and no clinical quality indicators
Clinical practices guidelines Continuing education
ORGANIZATIONAL BEHAVIOUR
Descriptive analysis (III)
Provision of services through national/regional/local health systems (Yes/No)
Private voluntary health insurance (Yes/No)
Geographical distribution of PC services (Yes/No)
Professional income (Capitation/Salary/Fee for service/Out of pocket)
Gatekeeping for specialist (Yes/No) Type of facilities (Public/private) Type of clinical practice (Solo practice/Group practice/ Network)
Improvement programs & Quality management systems (Yes/No)Continuing clinical education program (Yes/No)Local adaptation of clinical practice guideline (Yes/No)
Financing
Regulation
Organization
Payment
Organizational behavior
Framework to define models of Primary Care
Range of services
Framework for classification of health systems based on PCMultidimensional => more complex => more realistic
Healthcare services financingBasic coverageGate-keeping
Private insurances Professional payment
Type of facilities Type of practice
Conclusions
Costs of Primary Care Systems
• Four clinical vignettes representing the main areas of activity of PC:
Acute care Chronic care Health promotion Prevention (vaccination)
Methodology Micro-costing
Overall taskTo identify a methodology for cost measurement inprimary care services and to apply it.=> Challenging goal:• extreme variability in terms of professionals involved,
payment mechanisms, services provided across countries• impossible to develop a one-fits-all method, but need to
provide a common and defined framework
Chosen MethodClinical Vignettes= description of a common clinicalsituation, followed by a synthetic questionnaire to besubmitted to professionals solve the problem of the interpretation of identical
questionsare a common denominator in a context of extreme
heterogeneityallow to describe how a certain clinical case is
managed in primary care and to estimate all the resources consumed in the delivery
STEPS
1. To choose the vignettes2. To translate the vignettes3. To validate the vignettes4. To submit the vignettes to primary care professionals5. To collect questionnaires6. To measure resources consumption in the delivery of
services involved in the clinical vignettes
1. Choice of vignettes
Criteria taken into account:• Main areas of primary care systems:
- Disease prevention area- Care of acute but common problems- Care of chronic conditions- Health promotion services
• Primary care activities/services common to all the partners of the consortium
Vignettes
V1: A 70-year-old man in good health comes to the practice asking to be vaccinated against the seasonal influenza
V2: A 2-year-old boy comes to the practice with his mother. The day before the boy had developed cough with nasal discharge and had fever up to 38,2°C. The parent has noted a rattling sound in the child's chest. […] He has mild expiratory dyspnea. His breathing rate is 36 times per minute. […] He has atopic dermatitis but otherwise has been healthy.
VignettesV3: There is a 65-year-old woman among your patients, who has
been diagnosed with type 2 diabetes. She comes in for a follow-up visit: the tests from last week show that her HbA1c is 7%. She has no complications. She has been taking metformin 500 mg x2. You are her main primary care provider for the next 12 months.
V4: A young woman, aged 35, comes to the practice to get a certificate of “good health” for practicing a sport. She is in good health, she does sports, she has a good and satisfying job, she does not drink, nor uses drugs. But, upon you enquiring, she reveals that she has been smoking 20 cigarettes per day for the last 10 years.
STEPS
1. To choose the vignettes2. To translate the vignettes3. To validate the vignettes4. To submit the vignettes to primary care professionals5. To collect questionnaires6. To measure resources consumption in the delivery of
services involved in the clinical vignettes
4. Submission of vignettes
i. personally, by interviewers from each country
ii. professionals of the same kind (e.g., a group of GPs, a group of paediatricians, a group of nurses): the number of the members for each group was 20-30 and different vignettes have been submitted to the same group
iii. written questionnaire : professionals of each group have been requested to answer the questions related to each vignette in writing
4. Submission of vignettesIn total, more than 200 professionals have been interviewed.
Professionals Number Professionals Number Professionals Number Professionals Number
HUNGARY GP 33 Paediatrician 52 GP 32 GP 29
ITALY GP 50 Paediatrician 23 GP 27 GP 50
FINLAND Nurse 5 GP 39 GP 38 GP 39
LITHUANIA GP 30 GP 30 GP 30 GP 30
ESTONIA Nurse 27 GP 23 GP 23 Nurse 24
GP 20 GP 20
Nurse 3 Nurse 3
GERMANY GP 37 Paediatrician 23 GP 33 GP 33
TOTAL 205 211 206 228
4
SPAIN GP 23Paediatrician 21
VIGNETTES
COUNTRY1 2 3
STEPS
1. To choose the vignettes2. To translate the vignettes3. To validate the vignettes4. To submit the vignettes to primary care professionals5. To collect questionnaires6. To measure resources consumption in the delivery of services
involved in the clinical vignettes
6. To measure resources consumption
• Data collected through questionnaires by each partner have been put together and synthesized in four different databases, specific per each vignette/questionnaire, by the Bocconi University team
• This last part of the exercise had two different purposes:=> to measure resources consumption in the delivery of certain
primary care activities to which monetary values could be attributed;
=> to collect data/information useful to carry out an analysis of variation of how the same case is managed within and between countries
6. To measure resources consumption
• Measuring resource consumption Methodology: Time-Driven Activity-Based-Costing = it is a particular development of the better known Activity-Based Costing (ABC) that allows to design cost models in very complex contexts, such as service organizations
The TDABC requires two parameters:
the time required to provide/perform the activity the unit cost of supplying capacity
6. To measure resources consumption: data collected
Each vignette was structured as to gather information about:1. medical and administrative professionals directly involved in the
service;2. the amount of time spent in the activity by the professionals
involved;3. medical material directly used in the provision of the service;4. medical material and other health care services consumed as a
consequence of the service;5. other medical professionals involved as a consequence of the
service described in the vignette.
6. To measure resources consumption: data collected
Moreover, for each vignette, partner countries have provided: cost of the professionals directly involved; cost of administrative staff involved; cost of the medical material directly used; cost of the medical material and other health care services
consumed as a consequence of the service; cost of other medical professionals involved as a consequence
of the service; direct cost paid by patients for the provision of the service; estimation of overheads costs.
SOME RESULTS FROM THE VIGNETTES
V2 – A sick 2-year-old boy:Professionals involved
Country Total cases PaediatricianGeneral
Physician Nurse SecretaryOther PC
professional
Hungary 52 100,00% 50,00% 28,85% 30,77%
Italy 23 100,00% 8,70% 21,74% 0,00%
Finland 39 100,00% 66,67% 33,33% 10,26%
Lithuania 30 100,00% 60,00% 10,00% 10,00%
Estonia 23 100,00% 69,57% 8,70% 17,39%
Spain 21 100,00% 47,62% 9,52% 0,00%
Germany 23 100,00% 0,00% 86,96% 0,00%
All countries 211 100,00% 46,45% 28,44% 12,80%
V2 – A sick 2-year-old boy:Time spent in the visit
Hungary Italy Finland Lithuania Estonia Spain Germany
Paediat./General Physician
Average time per case 13,9 16,3 13,8 15,7 14,7 13,4 12,7
Nurse
Average time per case 3,3 0,7 6,3 5,3 4,0 6,2 0,0
Other PC professional
Average time per case 2,5 0,0 0,8 0,4 0,7 0,0 0,0
Total time per case 19,8 17,0 20,9 21,4 19,3 19,6 12,7
V2 – A sick 2-year-old boy:Time - variability within countries
Hungary Italy Finland Lithuania Estonia Spain Germany
Paediat./General Physician
Min 5 10 1 1 1 6 5
Max 30 38 30 30 20 40 30
ST.DEV. 6,64 5,92 5,82 5,97 5,48 7,70 5,90
Average time per patient 13,88 16,35 13,85 15,67 14,65 13,38 12,65
V2 – A sick 2-year-old boy:Clinical behaviors
Hungary Italy Finland Lithuania Estonia Spain GermanyAll
countries
Pharmacological Treatment 94,23% 95,65% 87,18% 76,67% 65,22% 100,00% 95,65% 88,15% Categories of drugs Fever reducer 24,49% 54,55% 5,88% 26,09% 0,00% 42,86% 9,09% 23,12%Bronchodilator 81,63% 50,00% 97,06% 73,91% 80,00% 85,71% 100,00% 82,26%Antibiotics 18,37% 36,36% 2,94% 21,74% 20,00% 4,76% 0,00% 14,52%Anti-inflammatory 10,20% 36,36% 0,00% 4,35% 0,00% 0,00% 0,00% 7,53%
Hungary Italy Finland Lithuania Estonia Spain Germany All countries
Diagnostic tests 38,46% 30,43% 46,15% 50,00% 82,61% 0,00% 26,09% 40,28%
Specialist involved 40,38% 8,70% 64,10% 23,33% 17,39% 4,76% 0,00% 28,44%
V2 – A sick 2-year-old boy:Micro-costing
Hungary Italy Finland Lithuania Estonia Spain GermanyPaediat./General Physician € 3,86 € 26,83 € 14,13 € 4,17 € 5,05 € 16,24 € 59,51
Nurse € 0,74 € 0,27 € 3,01 € 0,79 € 0,58 € 5,34
Secretary € 0,55 € 0,67 € 0,45 € 0,02 € 0,06 € 0,04 Assistant/Trainee € 0,70 € - € 0,61 € 0,03 € 0,09 € -
TOTAL LABOUR COST € 5,86 € 27,78 € 18,20 € 5,01 € 5,78 € 21,62 € 59,51
DRUGS COST € 8,47 € 11,83 € 9,28 € 5,11 € 3,59 € 4,66 € 13,07
TESTS COST € 3,40 € 4,71 € 2,92 € 4,29 € 4,52 € - € 16,03
OUT-OF-POCKET € - € - € - € - € - € - € - TOTAL COST € 17,72 € 44,32 € 30,39 € 14,41 € 13,88 € 26,27 € 88,62
Ho
url
y c
ost
Methodology Macro-costing
• Actual costs: Real not estimated• Usual accounting principles and practices• Indicated in the estimated overall budget
IncludesPersonnel CostsDurable EquipmentConsumables and supplies identifiable
Quality of Primary Care Systems
Quality dimensions, criteria, indicators
QUALITY DIMENSIONS: definable, measurable and actionable attributes of the quality of care.
QUALITY CRITERIA: explicit (reliable, valid and acceptable) quality requirements.
QUALITY INDICATOR: variables that measure the realization of criteria. An indicator provides evidence that a certain condition exists or certain results have or have not been achieved.
Edward Kelley and Jeremy Hurst: Health Care Quality Indicators Project Conceptual Framework Paper. OECD HEALTH WORKING PAPERS. 09-Mar-2006
http://www.oecd.org/dataoecd/1/34/36262514.pdf
Principles for Best Practice in Clinical Audit. 2002 National Institute for Clinical Excellence. Radcliffe Medical Press LtdDonabedian A: Explorations in Quality Assessment and Monitoring, Volume I. The Definition of Quality and Approaches to its Assessment. Ann Arbour, MI , Health Administration Press; 1980:1-164.
Criteria DIMENSIONS CRITERIA
Access Geographical access Access via telecommunication toolsAccess in timeAppointment system
Equity Waiting timeHuman resourcesFinancial constrains
Appropriateness Professional trainingContinuous educationCompetences in PHC /servicesPrevention servicesLong-term careEvidence based practice/guidelines
CriteriaDIMENSIONS CRITERIA
Appropriateness •Usual source of care •Referral system•Continuity of care and medical information in PHC and across providers•Team-work in PHC•Clinical criteria related to preventive activities and management of chronic diseases
Patient satisfaction/patient centeredeness
•Safety regarding medical records•Hygiene/Infection control
Professional satisfaction
•Equipment (medical/non-medical)•Quality management tools (job description, audit)•Reporting system of critical incidence
• Focus Group Discussion :Patients (n= 53)Primary care professionals (n= 64)7 countries: Estonia, Finland, Germany, Hungary, Italy,
Lithuania, Spain.
• Helped to understand the views about quality in the different partner countries and to set a list of quality criteria
• Non-clinical indicators for each criteria were identified from the literature review and prioritized by scoring according to importance and measurability
Methodology Quality Indicators
60 Quality Indicators (approx) selected to measure Quality of PC in Europe
Methodology Quality Indicators
Population Survey: A sample of 3.020 persons 25-75 years old 7 countries participating in the project Domains:
Methodology Quality at the Population Level
Socio-demographic
Utilization of services
Satisfaction
Self-perceived
health
Prevention and health
promotion interventions
Professional survey:
Medical records:
Diabetes and high blood pressure 9 indicators Specific approach for extracting data in each country
(sample)
Methodology Quality at the Clinical Level
Clinical quality indicators DM2• Screened for HbA1c/12 months HbA1c < 7%
• Screened for total cholesterol level/12 months
• Total cholesterol < than 4,5 mmol/l BP < 130/80 mmHg
• Eye examination (fundus photography or ophthalmologist consultation recorded)/12 months
Clinical quality indicators HBP
• % Patients < 140/90 mmHg
• % Patients with total cholesterol screened
within a year
INDICATOR Estonia Lithuania Finland Hungary Germany Italy
BP for HBP≤ 140/90 ≤140/90 ≤ 140/85 ≤140/90 NA NA
BP for DM2 ≤130/85 ≤130/80 <130/80 ≤130/80 <140/90 ≤ 130/80
Targets of the clinical indicators in each country
INDICATOR ESTONIA LITHUANIA FINLAND HUNGARY GERMANY ITALY
BP for both, DM2 + HBP
≤130/85 ≤130/80 <130/80 ≤130/80 NA NA
Chol level for DM2 + statin treatment
>4.5 >4.8 >4.5 >4.5 NA NA
HbA1c level for insulin
≥8.5 ≥8.5 ≥7.0 ≥7.0 >8.5 6.5-7.0?
Targets of the clinical indicators in each country
Dank! Tänan!
Kiitos!KÖSZÖNÖM!
Grazie!ačiū!
Gracias!
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