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

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P 1

DIS

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INA

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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

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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!

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Gracias!