De bijdrage van de eerste lijn aan
kwaliteit en betaalbaarheid van
gezondheidszorgsystemen
de resultaten van een Europees onderzoek
Dr. Dionne Sofia Kringos
d.s.kringos@amc.uva.nl
Postdoctoral Health Systems Researcher
Academisch Medisch Centrum – Universiteit van Amsterdam
12 september 2013
Inhoud
1. Hoe kunnen we de sterkte van de eerstelijns
gezondheidszorg in Europese landen meten en
vergelijken?
2. Hoe komt het dat landen hun eerstelijns
gezondheidszorg systeem verschillend structuren en
organiseren?
3. Wat draagt een sterke eerste lijn bij aan de
volksgezondheid en andere belangrijke uitkomsten?
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
Hoe kunnen we de sterkte van de eerstelijns
gezondheidszorg in Europese landen meten
en vergelijken
?
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
Quality of PC
Efficiency of PC
DIMENSIONS IDENTIFIED
PRIMARY CARE STRUCTURE & PROCESS
Dimensions of the PC structure
Governance of PC
system
Economic conditions
of PC system
PC Workforce
development
System goals
Equity in access policies
Collaboration policies
(de)Centralization
Quality management
Patient advocacy
PC expenditures
PC coverage
Employment status
Remuneration system
Income of PC workers
Profile PC workforce
Professional status
Supply and planning
Academic status
Prof. associations
Total: 12 indicators
Total: 11 indicators
Total: 16 indicators
Dimensions of the PC Process
Access
to PC services
Comprehensiveness
of PC services
Continuity of PC
Coordination of PC
Density PC workforce
Geographic availability
Access at practice level
Affordability of services
Patient satisfaction
First contact care
Disease management
Sole GP contacts
Medical procedures
Preventive care
Health promotion
Medical equipment
Longitudinal continuity
Informational continuity
Relational continuity
Gatekeeping system
Skill mix
Collaboration of care
Public health integration
Total: 12 indicators
Total: 10 indicators
Total: 9 indicators
Total: 7 indicators
MAPPING THE RELATIVE STRENGTH OF PC
PC Governance
Vision
Equality access
Decentralization
Quality mngt infr.
Patient advocacy
Multidisc. collab.
0
Turkey
Lithuania
Malta
Slovak Rep.
Bulgaria
Estonia
Greece
40000
Czech Republic
60000
Romania
France
Annual Gross Income GPs
140000
120000
100000
80000
TR €27,000
20000
Austria
Finland
Turkey
Sweden
Portugal
Malta
Luxembourg
Iceland
Germany
25.6 % CH
Denmark
5
160000
Top 5 HIGH
LOW
LU €150,000
DK €135,000
UK €133,000
CH €126,006
FR €125,659
LT €10,782
MT €10,808
SK €12,000
BG €13,688
EE €17,500
Czech Republic
Italy
Norway
Bulgaria
Estonia
Slovak Rep.
Latvia
Cyprus
Romania
Hungary
Slovenia
Ireland
Poland
Lithuania
Spain
Netherlands
Belgium
10
Hungary
Poland
Slovenia
Spain
Latvia
Italy
Sweden
Cyprus
Portugal
Greece
United Kingdom
15
Finland
Iceland
Belgium
Germany
Austria
Ireland
0
Netherlands
Switzerland
30
Norway
France
Switzerland
United Kingdom
Denmark
Luxembourg
Economic conditions
25
PC Exp.%THE
20
14.7 % NL
10.3 % HU
4.7 % CZ
No data
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
Level of PC Orientation at
STRUCTURE of 31 Health Care Systems
PC Workforce
development
HIGH
MEDIUM
LOW
HIGH
CY IS LU
PL SK
IT ES NL RO
SI UK
MEDIUM
HU
DK LT PT
BG CZ GR
AT FR LV SE
TR
BE DE FI
CY IE IS LU
CH HU SK
MT PL
LOW
LOW
CH IE MT
BE DE FR AT BG CZ
SE TR
GR LV
EE NO
MEDIUM
HIGH
BG CY CZ
AT LV SK
GR IS LU PL
MEDIUM
FI
EE IT LT
NO RO
EE NO
FR HU LT
SE TR
DE BE IT
RO
HIGH
DK ES NL
PT SI UK
LOW
PC Governance
IE MT
CH DK PT
ES FI NL
SI UK
PC Workforce
Development
PC Economic
conditions
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
% single handed PC practices
15-20%
<5%
90-95%
75-80%
90-95%
<10%
<5%
36%
25-35%
20-25%
40-45% 60-65%
75-80%
70%
45-50%
<10%
95-100% 100%
95-100% 95%
63% 15-20%
75-80%
<5%
<5%
65-70%
65-70%
95-100%
40%
<5%
15-20%
Level of PC Orientation at
PROCESS of 31 Health Care Systems
AT DE IS
NO RO SK
GR MT
BE CH FR
LU LV
BG CY IE
TR
HIGH
MEDIUM
LOW
HIGH
EE FI IT
HU PL PT
UK
CZ DK ES
MEDIUM
SE
LT NL SI
AT IT SE
FI NO RO
DE EE IS
SK
GR LU MT
TR
BG CH CY
FR
BE IE LV
LOW
MEDIUM
HIGH
AT TR
BG CY HU
NO RO
DE IE IS
SK
IT LU
CH FI FR
PT
BE CZ EE
LV
HIGH
HU
MEDIUM
CZ PT
LOW
Coordination
of care
DK ES LT
NL PL SI UK
LOW
PC Access
GR LT MT
NL SE SI
PL UK
ES DK
Coordination
of care
Continuity of
care
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
Hoe komt het dat landen hun eerstelijns
gezondheidszorg systeem verschillend
structuren en organiseren?
?
Wealth – Result
NHS & Social Health Insurance Systems:
Wealthier countries in 1993 have weaker PC Strength and
less Accessible PC
Health care systems in Transitions:
Wealthier countries in 1993 have more accessible PC, and
more continuity of PC
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
Type of health care system – Result
Social Health Insurance Systems:
Countries with a SHI have a weaker access to PC, and a
weaker continuity of PC
Health care systems in Transitions:
Countries with a health care system in transition have better
access to PC, and more continuity of PC
Values / Culture – Results
Countries with a higher ‘desired governmental involvement’
have better access to PC, more continuity of PC, but
less coordination of care, and less comprehensive PC
Countries with a more family oriented culture have
a weaker PC structure; less coordination of care; and less
comprehensive PC
Transitional countries with a more family oriented culture have
better access to PC and more continuity of PC
Countries where people rely more on science & technology to
improve their health have less access to PC and more
comprehensive PC
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
Wat draagt een sterke eerste lijn bij aan de
volksgezondheid en andere belangrijke
uitkomsten?
?
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
Potential avoidable hospitalizations – Results
•
Having a stronger structure of PC is associated with a
reduction in potentially avoidable hospitalizations for
patients with asthma
•
Having a stronger access of PC is associated with a
reduction in potentially avoidable hospitalizations for
patients with COPD ;
 Reductions are even higher among the male population
with diabetes
•
•
Having a stronger coordination of PC is associated with a
reduction in potentially avoidable hospitalizations for male
patients with COPD
Population Health – Results
•
Having a stronger PC structure is associated with a
reduction in the potential deaths due 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
Socio-economic inequality in health – Results
•
Having a stronger continuity of PC is associated with less
socio-economic inequality in poor self-rated health
CONCLUSION III
 Strong PC is associated with better population health; lower rates of
unnecessary (expensive) hospitalizations; relatively lower socioeconomic inequality
 More research need to measure contribution of PC to
health system outcomes & variation within countries
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.