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The Strength of Primary Care in Europe

The Strength of Primary Care in Europe. On behalf of: Dionne Sofia Kringos PhD d.s.kringos@amc.uva.nl Postdoctoral Health Systems Researcher Academic Medical Centre – University of Amsterdam The Netherlands 9 April 2014. Content.

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The Strength of Primary Care in Europe

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  1. The Strength of Primary Care in Europe On behalf of: Dionne Sofia Kringos PhD d.s.kringos@amc.uva.nl Postdoctoral Health Systems Researcher Academic Medical Centre – University of Amsterdam The Netherlands 9 April 2014

  2. Content • How can we measure and compare the strength of European primary care systems • What determines the strength of primary care systems • What is the impact of strong PC on health care system outcomes

  3. Growing demand Rising HC expenditures More complex health care systems Demandside Supplyside Integration of care Prevention Public accountability Multi-morbidity More demanding patients Cultural diversity CHALLENGES IN HEALTH CARE

  4. STRONGER Primary Care … Health outcomes Cost-control Responsiveness (Starfield, 1994; Doescher, 1999; Delnoij, 2000; Shi, 2002; Macinko, 2003)

  5. PC POTENTIAL ….. • Easy access and first contact care • Treatment for most conditions • Opportunities for prevention and health promotion • Coordination & integration of services • Limiting unnecessary care (cost-effectiveness) …. seen from a systems perspective

  6. World Health Report: a need for …. • Monitoring progress • Policy evaluation • Performance assessment

  7. How can we measure and compare the strength of European primary care systems ?

  8. PHAMEU project: measuring the strength of PC systems in Europe - NIVEL (consortium leader)- University of Tartu- IRDES- Heinrich Heine University- University Witten/Herdecke- CERGAS- University of Tromso- Jagiellonian University- University of Ljubljana- IDIAP Jordi Gol- ScHARR- University of Leicester- WHO Europe- European Forum for PC- EUPHA- EGPRN- European Commission

  9. Primary Care System Framework Dimensions of the PC structure Dimensions of the PC Process Dimensions of PC outcomes

  10. PHAMEU MONITOR FRAMEWORK Dimensions of the PC structure Governance of PC system Economic conditions of PC system PC Workforce development Dimensions of the PC Process Access to PC services Comprehensiveness of PC services Continuity of PC Coordination of PC Dimensions of PC outcomes Efficiency of PC Quality of PC

  11. Data Collection 2009/10 1) Primary Care Monitoring Instrument (99 indicators) 2) Supplementary data sources • (Inter)national statistical datasets • Policy documents • Published literature • Expert enquiries • Networks: - PC experts involved in 31 countries - International organizations / networks (WHO-Euro; EUPHA; EFPC; EGPRN

  12. Primary Care Data availability- ranking countries - Bottom 11: GR CY MT IS LU IE IT SE PL RO SI

  13. DIMENSIONS IDENTIFIED

  14. MAPPING THE RELATIVE STRENGTH OF PC

  15. PC Governance Vision Equality access Decentralization Quality mngt infr. Patient advocacy Multidisc. collab.

  16. Economic conditions PC Exp.%THE 25.6 % CH 14.7 % NL 10.3 % HU 4.7 % CZ No data Annual Gross Income GPs Top 5 HIGH LOW LU €150,000 LT €10,782 DK €135,000 MT €10,808 UK €133,000 SK €12,000 TR €27,000 CH €126,006 BG €13,688 FR €125,659 EE €17,500

  17. Workforce Development • 3 types PC Physician Profiles • GPs (FI, NL, NO, PT, RO, UK) • GPs, OBGYN, PAED (BG, MT, SI, ES) • GPs & Specialists (AT, BE, CY, CZ, DK, EE, FR, DE, GR, HU, IS, IT, LV, LT, LU, PL, SK, SE, CH, TR) • GPs average 55+ yrs in 12 countries • 21% med. graduates postgrad. FM • PC Nursing training in 8 countries

  18. Level of PC Orientation at STRUCTURE of 31 Health Care Systems

  19. Opportunities optimise Access to PC services Majority PC prov. specialists Interregional GP density difference >36 GPs per 100,000 pop. GP shortages <2 or 10> GP home visits/wk Never/Occ. telephone consult. Never/Occ. appointm.systems >16% patient GP not affordable

  20. % single handed PC practices 15-20% <5% 90-95% 75-80% <5% 90-95% <10% 36% <10% 25-35% 40-45% 60-65% 20-25% 75-80% 95-100% 100% 70% 65-70% 95-100% 95% 63% 15-20% 45-50% 95-100% <5% 75-80% 40% <5% <5% 65-70% 15-20%

  21. Opportunities optimise Informational continuity of care <85% GPs routinely keep med.records Seldom/Occ. computer usevarious purposes S/Occ. use referral letters Info. transfer >24hrs after hours contacts S/Occ. specialist-GP communication after treatment episode

  22. Level of PC Orientation at PROCESS of 31 Health Care Systems

  23. CONCLUSION I • PC systems in Europe strongly vary in strength • Common themes to improve PC(e.g. vision, inequity in access, payment systems, workforce shortages, cooperation and coordination) • PC system management requires improved PC information systems at the national level

  24. What determines the strength of primary care systems ?

  25. Governmental Composition Hypothesis 1:Countries that for a longer period have been governed by left-wing parties have a stronger PC system  Independent variables Weighted nr. of years social-democrats or socialists were in power 1993-2008  Confounding variables: PC strength in 1993; Wealth of country in 1993; Health care system in transition  Dependent variables:PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

  26. Governmental Composition – Result • Countries that have predominantly been governed by • (social-) democratic parties have • a stronger PC structure, better PC access, and better coordination of PC

  27. CONCLUSION II • PC systems in Europe strongly vary in strength due to differences in wealth, political composition of government, prevailing values, type of health care system • Strengthening PC is in the end a political decision which can only be taken if it is in line with prevailing values in a country

  28. What is the impact of strong PC on health care system outcomes ?

  29. Health care spending • Hypothesis 1:Health care expenditures are lower and the increase slower in countries that have relatively strong primary care, after adjusting for national income. •  Dependent variables • Total health care expenditure per capita in USD PPP in 2009 • Growth in total health care expenditure per capita in USD PPP in 2000-9 •  Confounding variables: • GDP per capita in USD PPP in 2009; Changes in GDP per capita in USD PPP in 2000-9 •  Independent variables: • PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

  30. Health care spending – Result Total health care expenditures were higher in countries with stronger PC structure But… Countries with more comprehensive PC services delivery had a slower growth in health care expenditures per capita

  31. Population Health Hypothesis 2:Population health is better in countries that have relatively strong primary care, after adjusting for risk factors.  Dependent variables Potential years of life lost, by sex, due to diabetes; ischemic heart disease; stroke; and obstructed airway conditions  Confounding variables: For diabetes: % obese/overweight pop. by sex and age; For ischemic heart disease / stroke: age- and sex standardized hypertension prevalence; For obstructed airway conditions: self-reported smoking prevalence  Independent variables: PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

  32. Population Health – Results • Having a stronger PC structure is associated with a reductionin the potential deathsdue to ischaemic heart disease; also for male patients with stroke; and for female patients with bronchitis, asthma or emphysema • Having a stronger coordination of PC is associated with a reduction in the potential years of life lost for patients with bronchitis, asthma or emphysema • Having a stronger comprehensiveness of PC is associated with a reduction in the potential deaths due to ischemic heart disease and due to stroke

  33. Socio-economic inequality in health Hypothesis 3:Socio-economic inequalities in health are smaller in countries that have relatively strong primary care, after adjusting for inequalities in risk factors  Dependent variables The highest attained educational level in having (very) poor self-perceived health status, asthma, and diabetes (measured with a Concentration Index)  Confounding variables: Age- and sex standardized concentration index for obesity (diabetes), daily smoking (asthma; self-perceived health).  Independent variables: PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

  34. Socio-economic inequality in health – Results • Having a stronger continuity of PC is associated with less socio-economic inequality in poor self-rated health

  35. CONCLUSION III • Strong PC is associated with better population health; lower rates of unnecessary (expensive) hospitalizations; relatively lower socio- economic inequality • More research need to measure contribution of PC to health system outcomes & variation within countries

  36. Further reading…. PhD Thesis:-Kringos DS. The strength of primary care in Europe. Utrecht University/NIVEL, 2012. ISBN: 978-94-6122-154-4.Analysis:- Kringos DS, Boerma WGW, Van der Zee J, Groenewegen PP. Europe’s Strong Primary Care Systems Are Linked To Better Population Health, But Also To Higher Health Spending. Health Affairs April 2013 vol. 32 no. 4, pp. 686-694. • Pelone F, Kringos DS, Valerio L, Romaniello A, Lazzari A, Ricciardi W, de Belvis AG. The measurement of relative efficiency of general practice and the implications for policy makers. Health Policy 107 (2012): 258-268. Measurement instrument: • - Kringos D.S., W.G.W. Boerma, Y. Bourgueil, T. Cartier, T. Hasvold, A. Hutchinson, M. Lember, M. Oleszczyk, D. Rotar Pavlic, I. Svab, P. Tedeschi, A. Wilson, A. Windak, T. Dedeu and S. Wilm. The European Primary Care Monitor: structure, process and outcome indicators. BMC Family Practice 2010,11:81-98. - Kringos DS, Boerma WGW, Hutchinson A, Van der Zee J, Groenewegen PP. The breadth of primary care: a systematic literature review of its core dimensions. BMC HSR 2010, 10 (1):65-78.

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