Using ACSC to monitor quality and equity

1. Using ACSC to monitor quality and equity Supasit Pannarunothai

2. Ambulatory Care Sensitive Condition • Pulmonary tuberculosis, • Gastroenteritis, • Nutritional deficiencies, • Diabetes, • Hypoglycemia, • Angina, • Congestive heart failure (CHF), • Hypertension, etc.

3. Ambulatory Care Sensitive Condition • If the contracting unit for primary care (CUP)is of good quality, admissions of the ACSCs should be low. • Rate of ACSC is used to monitor the project of encouraging primary care unit (PCU) to take care chronic patients instead of hospitals (shifting load from hospital to PCU) • Rate for ACSC presented here: • All conditions • Specific conditions

4. Rural & Urban PCU Out of town district (metropolitan) Town district (metropolitan) Urban PCU District hospital Urban PCU Provincial hospital CUP Rural PCU CUP Shifting load Rural PCU PCU Network (catchment area) Rural PCU PCU Network (catchment area) Rural PCU Rural PCU Rural PCU Rural PCU Rural PCU Rural PCU Rural PCU Rural PCU Rural PCU Sub district in out of town district nonmetropolitan Sub district in town district nonmetropolitan (Reungon 2007)

5. Data requirements • All admission data from hospitals (in 12-file standard dataset) • All ambulatory visits at hospitals (in 12-file standard dataset) • All ambulatory visits at PCUs or health centres (in 18-file standard dataset)

6. Results from 2 provinces • Shifting loads from a regional hospital • Shifting loads from a provincial hospital

7. Regional hospital Mueang Province DM Hypertension

8. Provincial hospital Mueang Province DM Hypertension

9. Key findings • RH admission forDM 5.5%, while 6% share of outpatient visits were at PCUs. • RH admission forHT 1.0%, while 13% share of outpatient visits were at PCUs. • PH admission for DM 11.2%, while 29% share of outpatient visits were at PCUs. • PH admission for HT 6.3%, while 40% share of outpatient visits were at PCUs. ตัวอย่าง ACSC: Pulmonary tuberculosis, Gastroenteritis, Nutritional deficiencies, Diabetes, Hypoglycemia, Angina, Congestive heart failure (CHF), Hypertension, etc.

10. Key findings RW for DRG Diabetes Hypertension If 23% more DM were taken care at PCU, 11m baht saved at OP And 27% more HT at PCU, 27m baht saved at OP

11. Discussions • Can ACSC be used in Thailand? • What target can be set in Thailand? • How can we save hospital outpatient cost as well as inpatient cost? • Ethical aspect: whose saving and whose cost?

12. Primary Care Scores, 1980s and 1990s *Scores available only for the 1990s Starfield 10/02 02-185 Starfield 10/02 IC 2238

13. Primary Care Score vs. Health Care Expenditures, 1997 UK DK NTH FIN SP CAN AUS SWE JAP GER US BEL FR Starfield 10/00 00-133 Starfield 10/00 IC 1731

14. USA GER BEL AUS SWE CAN SP NTH DK FIN UK *1=best 11=worst Relationship between Strength of Primary Care and Combined Outcomes Starfield 1999 IC 1433 Starfield 1999 99-006

15. Primary Care Orientation of Health Systems Health system characteristics (9) Practice characteristics (6) Adapted from Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998, Chapter 15. Starfield 04/99 PC 1475 Starfield 1999 99-147

16. Primary Care Orientation of Health Systems: Rating Criteria • Health System Characteristics • Type of system • Financing • Type of primary care practitioner • Percent active physicians who are specialists • Professional earnings of primary care physicians relative to specialists • Cost sharing for primary care services • Patient lists • Requirements for 24-hour coverage • Strength of academic departments of family medicine Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 04/99 PC 1476 Starfield 1999 99-148

17. Primary Care Orientationof Health Systems:Rating Criteria Each country was rated (scores of 0, 1, or 2) on the strength of 9 characteristics of health policy that are conducive to strong primary care. Starfield 09/02 02-285 Starfield 09/02 PC 2197

18. Primary Care Orientation of Health Systems: Rating Criteria • Practice Characteristics • First-contact • Longitudinality • Comprehensiveness • Coordination • Family-centeredness • Community orientation Source: Starfield. Primary Care: Balancing Health Needs, Services, and Technology. Oxford U. Press, 1998. Starfield 04/99 PC 1477 Starfield 1999 99-150

19. Primary Care Orientationof Health Systems:Rating Criteria The countries were also scored (0, 1, or 2) with regard to the strength of 6 key characteristics of primary care practice. Starfield 09/02 02-286 Starfield 09/02 PC 2198

20. Primary Care Features Consistently Associated with Good/Excellent Primary Care • System features • Regulated resource distribution • Government-provided health insurance • No/low cost-sharing for primary care • Practice features • Comprehensiveness • Family orientation Starfield 10/01 PC 1983 Starfield 10/01 01-174

21. Issues after the conference • ACSC • Primary care score • ACG (Adjusted Clinical Group) vs Thai Out-Patient Group (T-OPG) • ICPC (International Classification for Primary Care)