Quality follow up programme in primary care. Experiences from Västra Götaland

1. Quality follow up programme in primary care. Experiences from Västra Götaland what have we learned? Staffan Björck, Analysenheten, Regionkansliet, Västra Götalandsregion

2. Region Västra Götaland1.5 mil. Inhab.16% of Sweden Göteborg

3. Västra Götalandsregionen • financing, primary care centres: • Capitation, listed patients • Age and gender • ACG, adjusted clinical groups • CNI, care need index • Distance to hospital • P4P (quality) • initially 3 % with aim to increase • 4,3 % 2011

4. Effect of ACG on reporting of diagnoses Number of patients with diabetes in regional database 70 000 60 000 50 000 40 000 30 000 patients 20 000 10 000 0 2005 2006 2007 2008 2009 2010

5. Effect of ACG on reporting of diagnoses Current prevalence of atrial fibrillation in Västra Götaland =2.44%

6. Follow up quality of care • Identify indicators • System for payment for performance How to do it? Learn from others Develop your own version

7. Learn from others • Reports on Swedish experiences • International experience

8. Most common Indicators for P4P in Sweden, Anell 2009 Counties mått n Adherence to drug recommendations 11 Access by telephone 10 Diabetic patients in national registry 9 Patients visits to own centre 9 Right choice of UTI antibiotics 7 Prescription of physical activity 5 Choice of least expensive BP lowering drug 4 ”It is clear that there is a need for better follow up systems for primary care in Sweden and there is a great potential for cooperation between counties”

9. How to select indicators? Principles 1 Q-indicators Useful informationto centres Payment Medical audit Results to bemade public

10. Principles 2 • Quality indicators • Automated data collection • Evidence based • Avoid ”how”, focus on results • As few as possible but enough to give meaningful information • Enough measures to spread economic risk

11. Principles 3 What do they do in primary care and what is important? Satisfaction, wait times, drug choice etc Chronic disease ≈ 50 % rare visitors ≈ 50 % chronic disease Number of doctors visits during 2 years

13. Quality indicators Primary care Indicators 29 Listed population characteristics 14 Other statistics 5 13 Chronic disease Diabetes 8 Hypertension 8 Ischemic heart disease 2 Heart failure 1 Stroke 4 COP 3 Asthma 9 Psychiatric disorders 1 Others 5 Children's care 3 Prevention 19 Drugs 2 Access to care 9 Patient experience 6 Organisation etc 141

14. Indicators, Diabetes Primary care Indicator 1 Registration national database 2 Blood pressure 3 Smoking registration 4 HbA1c 5 LDL-kolesterol 6 Albuminuria 7 Target for HbA1c 8 Target forHbA1c, recent onset 9 Target forBlood pressure 10 Target forLDL-cholesterol results 11 Patient education 12 Integrated care 13 Influenza immunisation

15. Principles P4Pexample diabetes • Principles • pay for registration • Relative weights • No sharp thresholds • Spread of economic risk Weight High/low limits Limits Relativepoints Registration national database 70 - 90 5 Registration blood pressure 80 - 95 0,5 Registration blood pressure 70 - 90 0,5 Registration HbA1c 80 - 95 0,5 Registration LDL - cholesterol 50 - 80 0,5 Registration albuminuri 70 - 90 0,5 Target for HbA1c 45 - 6 5 0,5 Target for blood pressure 30 - 50 0,5 Target for LDL-cholesterol - 35 - 50 1 sum 9,5 + 4 other indicators without P4P

16. Differences vs NHS example • No exception reporting • Targets more difficult to reach • Much lower financial incentive • Focus on registration to give high quality feed back of results

17. ExamplesResults 80 70 60 50 percent 40 30 20 10 0 P4P range Influenza immunisation, patients 65+ Each dot = a primary care center, with confidence intervals 80 70 Children with antibiotic prescriptions/ year 60 50 percent 40 30 20 10 0

19. Webb access to results 160 000patients

20. Main data sources • National diabetes registry • Regional Primary care quality registry • Drug prescription registry • Regional database for contacts • Swedish vaccination registry • Manual reporting

21. The regional primary care quality registry • Automated data collection from local patient files • Ischemic heart disease • Hypertension • COP • Asthma • Diabetes • Monthly update and back-reporting to centres

22. Interaction between diseases, primary care register Diabetes Hypertension 65 730 198 238 9 % 14 % 58 % 1 % 3 % 6 % 8 % Ischemic. Heart disease Total 44 317 239 349

23. P4P – 41 indicators • How to pay? 3 principles • Decided standard • Professional recommendations • Statistical limits • For example 25 % full payment, 25 % no payment

24. Targets for payment? Statistical limits Diabetes registry. Proportion reaching target for LDL-kolesterol (<2,5 mmol/l) 100 90 80 70 60 50 percent 40 30 20 10 0 Each dot = a primary care center

25. Example of difficulties, P4P • Professional scepticism • Patient groups to small for reliable comparisons • Data sources have to be created • Leads to focus on money, not on results, wrong focus • Resource consuming technical solutions

26. Lessons learned • P4P just one small part of quality improvement programme • Focus on pay for registration, • < 4% of total payment • Involve profession! • Easy access to results • Must be combined with continuous analysis and discussion, reports, seminars etc. Professional dialogue. • Transaction cost • National cooperation • National primary care register • Cooperation between local quality registers