EUprimecare: Quality and Costs of Primary Care in Europe

1. 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)

2. Costs • Access Health Care: Iron Triangle • Quality

3. Strong Primary Care What is Strong Primary Care?

4. Background • 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

5. 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

6. Partners • Institute of Health Carlos III. ISCIII. Spain • Universität Bielefeld. UNIBI. Germany • University of Tartu. UTartu. Estonia • National Institute for Strategic Health Research. GYEMSZI. Hungary • OrszágosAlapellátásiIntezet. OALI. Hungary • Institute for health and Welfare. THL. Finland • Kaunas University of Medicine. LSMU. Lithuania • UniversitáCommerciale Luigi Bocconi. UB. Italy

7. WP 5 & 6 WP2 Identify a methodology to measure Quality in PC To measure the Quality in PC COORDINATION WP 1 DISSMINATION WP 8 WP 7 WP 3 & 4 Identify a methodology to measure Costs in PC To measure Costs in PC Evaluation of PC models Conceptualstructure

8. Approach • Costs • Quality

9. 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.

10. Methodology • Literature review: • Structure or process of PC in Europe • Control knobs: financing, regulation, payment, organization, and organizational behavior • Selection of indicators=> template design: • Five variables (Control knobs) to optimize healthcare systems results: • Range of services • DescriptiveAnalysis& Principal Component Analysis

11. Results of Qualitative analysis Functional models • 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 Based on a functional perspective, allowed to proposing 5 models: Direct access to specialist Referral required from GP, mainly solo-practices in PC Referral required from GP, mainly group-practices in PC Health care centers Polyclinics

12. Descriptiveanalysis(I) Mixed model (Hungary) 16% Double coverage FINANCING 7% Uninsured BEVERIDGE NHS (Finland, Italy, Spain) BISMARCK SS (Estonia, Germany, Lithuania) 10,5% Expenditure in HC as GDP 10,6% Private Insurance 18,8% Double coverage Expenditure in PC 6,1% 6,6% 24% 5,7%

13. Descriptive analysis (II) REGULATION • Formal mechanisms to guarantee accessibility, equity and quality of healthcare • Gate-keeping systems, except in Germany ORGANIZATION • 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

14. Descriptiveanalysis(III) ORGANIZATIONAL BEHAVIOUR • 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

15. Framework to define models of Primary Care Financing • Provision of services through national/regional/local health systems (Yes/No) • Private voluntary health insurance (Yes/No) • Geographical distribution of PC services (Yes/No) Regulation • Professional income (Capitation/Salary/Fee for service/Out of pocket) Payment • Gatekeeping for specialist (Yes/No) • Type of facilities (Public/private) • Type of clinical practice (Solo practice/Group practice/ Network) Organization • Improvement programs & Quality management systems (Yes/No) • Continuing clinical education program (Yes/No) • Local adaptation of clinical practice guideline (Yes/No) Organizational behavior

16. Rangeofservices

17. Conclusions • Framework for classification of health systems based on PC • Multidimensional => more complex => more realistic • Healthcare services financing • Basic coverage • Gate-keeping • Private insurances • Professional payment • Type of facilities • Type of practice

18. Costs of Primary Care Systems

19. Methodology Micro-costing • Four clinical vignettes representing the main areas of activity of PC: • Acute care • Chronic care • Health promotion • Prevention (vaccination)

20. Overalltask To identify a methodology for cost measurement in primary 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

21. ChosenMethod Clinical Vignettes= description of a common clinical situation, followed by a synthetic questionnaire to be submitted to professionals • solve the problem of the interpretation of identical questions • are a common denominator in a context of extreme heterogeneity • allow to describe how a certain clinical case is managed in primary care and to estimate all the resources consumed in the delivery

22. STEPS • To choose the vignettes • To translate the vignettes • To validate the vignettes • To submit the vignettes to primary care professionals • To collect questionnaires • To measure resources consumption in the delivery of services involved in the clinical vignettes

23. 1.Choiceofvignettes 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

24. 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.

25. Vignettes V3: 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.

26. STEPS • To choose the vignettes • To translate the vignettes • To validate the vignettes • To submit the vignettes to primary care professionals • To collect questionnaires • To measure resources consumption in the delivery of services involved in the clinical vignettes

27. 4.Submissionofvignettes • personally, by interviewers from each country • 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 • writtenquestionnaire : professionals of each group have been requested to answer the questions related to each vignette in writing

28. 4. Submission of vignettes In total, more than 200 professionals have been interviewed.

29. STEPS • To choose the vignettes • To translate the vignettes • To validate the vignettes • To submit the vignettes to primary care professionals • To collect questionnaires • To measure resources consumption in the delivery of services involved in the clinical vignettes

30. 6. Tomeasureresourcesconsumption • 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

31. 6. To measureresourcesconsumption • 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

32. 6. To measureresourcesconsumption:datacollected Each vignette was structured as to gather information about: • medical and administrative professionals directly involved in the service; • the amount of time spent in the activity by the professionals involved; • medical material directly used in the provision of the service; • medical material and other health care services consumed as a consequence of the service; • other medical professionals involved as a consequence of the service described in the vignette.

33. 6. To measureresourcesconsumption: datacollected Moreover, foreach 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.

34. SOMERESULTSFROMTHE VIGNETTES

35. V2 – A sick 2-year-old boy:Professionals involved

36. V2 – A sick 2-year-old boy:Time spent in the visit

37. V2 – A sick 2-year-old boy:Time - variability within countries

38. V2 – A sick 2-year-old boy:Clinical behaviors

39. V2 – A sick 2-year-old boy:Micro-costing Hourlycost

40. MethodologyMacro-costing Actual costs: Real not estimated Usual accounting principles and practices Indicated in the estimated overall budget

41. Quality of Primary Care Systems

42. 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 Ltd • Donabedian 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.

43. Criteria

44. Criteria

45. Methodology Quality Indicators • 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

46. Methodology Quality Indicators • 60 Quality Indicators (approx) selected to measure Quality of PC in Europe

47. Methodology Quality at the Population Level • Population Survey: • A sample of 3.020 persons • 25-75 years old • 7 countries participating in the project • Domains: Socio-demographic Utilization of services Prevention and health promotion interventions Self-perceived health Satisfaction

48. Methodology Quality at the Clinical Level • Professional survey: • Medical records: • Diabetes and highblood pressure • 9indicators • Specific approach for extracting data in each country (sample)

49. 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

50. Clinicalquality indicators HBP • % Patients < 140/90 mmHg • % Patients with total cholesterol screened within a year