The impact of co-morbidity on the level of primary and secondary outpatient care: Implications for structuring a primar

1. 2007 European ACG Conference, Karlskrona, Sweden 18-19 Sep, 2007 The impact of co-morbidity on the level of primary and secondary outpatient care: Implications for structuring a primary health care delivery system Arnoldas Jurgutis1, PhD Arvydas Martinkėnas1, PhD Klaus Lemke2, PhD 1Associate professor, Department of Public Health, Faculty of Health Sciences, Klaipėda University, Lithuania 2 Senior analyst, The Johns Hopkins University, Bloomberg School of Public Health, Health Services Research & Development Center, Baltimore, United States Arnoldas Jurgutis

2. Primary health care reform in Lithuania Since 1991 strengthening the role of primary health care following WHO recommendations: 1995 - family physicians started to be introduced in the system Trained in the residency (3 years) Retrained from district internists and district pediatricians 1997 - separation of primary health care and secondary health care, Free choice of primary health care provider gate keeping role for PHC 2000 – private PHC started to be introduced into the system

3. Goal of the reform – to get more efficient health care model III III II II > 50 % health problems <20 % health problems FD DI DP I I New model Soviet model Small oriented to local community family doctor’s offices Polyclinic District internists and pediatricians with some specialists Family doctors

4. Focus during the training in Family Medicine residency to wider extent gain the ability to solve common health problems related to different organ systems learn to use a more comprehensive approach to patient care develop patient-centered consultation skills increased attention towards disease prevention in the community

5. Which type of PHC specialist is more efficient in providing care to patients with high morbidity? 2007 European ACG Conference, Karlskrona, Sweden 18-19 Sep, 2007 • There are two types of PHC physicians in Lithuania: • Family Physicians (population all ages) • primary care givers for 70% of the population) • District internist (adults over 18 years) and district pediatricians (serving children population) • primary care givers for 30% of the population

6. Aim of the study • To compare and contrast visits rates to primary and secondary health care for selected chronic conditions with high level of co morbidity, and by specialty of primary health care physician.

7. Methodology (1) • Study objects - patients who had registered in 2005 with primary health care institutions in Klaipeda city and the Klaipeda region (in total 244425 inhabitants) and with selected chronic conditions (37823 patients) • Children: • asthma • hypertension • Adults: • asthma • diabetes • hypertension • ischemic heart disease

8. Methodology (2) • Data obtained from database of sickness fund: • All visits of study population to primary and out-patient secondary health care in 2005 • All diagnoses coded in IDC 10 • Type of PHC specialist (family doctor or district physician) • The Johns Hopkins ACG Case Mix system was used to select patients with targeted chronic conditions and to group them into three comorbidity groups: • Low comorbidity (RUB 2) • Medium comorbidity (RUB 3) • High comorbidity (RUB 4 and RUB5) • Statistical analyses were done with SPSS software version 12 8

9. Family Doctor and District Physician Primary Care Total visits to primary health care specialistsby patients with index conditions and high morbidity who registered with Family Doctors and District Physicians *p<0,05 **p<0,01 ***p<0,001

10. Family Doctor and District Physician Secondary Care Total visits for index conditions to secondary health specialistsby patients with high morbidity who registered with Family Doctors and District Physicians *p<0,05 **p<0,01 ***p<0,001

11. Family Doctor and District Physician Primary Care Visits for selected specific conditions to primary health care specialistsby patients with high morbidity who registered with Family Doctors and District Physicians *p<0,05

12. Family Doctor and District Physician Secondary Care Visits for selected specific conditions to secondary health specialistsby patients with high morbiditywho registered with Family Doctors and District Physicians *p<0,05

13. Family Doctor and District Physician Primary Care Visits for other conditions to primary health care specialistsby patients with high morbidity who registered with Family Doctors and District Physicians *p<0,05 **p<0,01 ***p<0,001

14. Family Doctor and District Physician Secondary Care Visits for other conditions to secondary health specialistsby patients with high morbidity who registered with Family Doctors and District Physicians *p<0,05 **p<0,01 ***p<0,001

15. Conclusions (1) • Patients with high comorbidity who have registered with family physicians more often visit their primary health care physicians, and need specialist care less often, comparedto patients who registered with district physicians • consistent finding for adults with several chronic conditions,including asthma, diabetes, hypertension, and IHD • similar finding for children with hypertension, but not for children with asthma

16. Conclusions (2) Main explanation for differences: Patients who registered with family doctors are more often visiting their primary health care physician, and are less often referred to specialists for solving other (not index) problems With the exception of adults with diabetes, there are no differences when comparing visits for index conditions 16

17. Efficient management of patients with high co-morbidity • A new type of interface between primary care and secondary health care for patients with co-morbidity: • Specialists of secondary health care – specialists in diagnosis • Primary health care (PHC) physicians – specialists in patients

18. Implications • Patient-centered training of family doctors appears to raise the level of primary care and reduce the level of secondary care for complex patients. This has implications for the efficient use of resources when delivering care to the population in Lithuania. • Measurement of comorbidity could be a valid tool for improving the planning of health care resources for distinct populations.