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)
Health Care: Iron Triangle
Quality
Access
Costs
Strong Primary Care
What is Strong Primary Care?
Background
to describe Primary Care models
in the EU is not available
 Not yet developed a trans-national consensus on how to
define
are not well identified in national
accounting systems
Objectives
• To contribute to improving the knowledge regarding
:
=> exploring the relationships that could exist
between Quality and Costs of different models and
systems of organizing and delivering PC across
Europe
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
Országos Alapellátási Intezet. OALI. Hungary
Institute for health and Welfare. THL. Finland
Kaunas University of Medicine. LSMU. Lithuania
Universitá Commerciale Luigi Bocconi. UB. Italy
Conceptual structure
WP 5 & 6
WP2
COORDINATION
DISSMINATION
WP 1
WP 8
REGULATION
Identify a methodology
to measure Quality in PC
ORGANIZATIONA
L
BEHAVIOUR
FINANCING
To
measure
the Quality in
PC
ORGANIZATION
OF PRIMARY
CARE IN
EUROPE
WP 7
WP 3 & 4
ORGANIZATION
PAYMENT
Evaluation of PC models
Identify a
methodology to
measure Costs in PC
To measure Costs
in PC
Approach
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.
Methodology
1. Literature review:
 Structure or process of PC in Europe
 Control knobs: financing, regulation, payment,
organization, and organizational behavior
2. Selection of
=> template design:
 Five variables (Control knobs) to optimize healthcare
systems results:
 Range of services
3. Descriptive
& Principal Component Analysis
Results of Qualitative
Functional
modelsanalysis
, Direct access to any GP or specialist
(Germany)
Based
on a functional perspective, allowed to proposing
5 models:
, Referral required
from GP, mainly solopractices in PC (Hungary, Italy)
1.Direct
accessfrom
to specialist
Referral
required
GP, mainly group2.Referral
fromLithuania)
GP, mainly solo-practices in PC
practices
in required
PC (Estonia,
3.Referral required from GP, mainly group-practices in PC
, GPs working
mainly in health care centres
4.Health care centers
(Finland, Spain)
5.Polyclinics
, Polyclinics (Shemasko). Not necessarily GPs at
all
Descriptive analysis (I)
FINANCING
16% Double
coverage
Mixed model
(Hungary)
7% Uninsured
BISMARCK SS
(Estonia, Germany,
Lithuania)
BEVERIDGE NHS
(Finland, Italy,
Spain)
10,5%
Expenditure in HC
as GDP
10,6% Private Insurance
18,8% Double coverage
Public contribution
to HC System
Expenditure in PC
6,1%
77,8%
77,2%
76,9%
24%
5,7%
6,6%
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
Descriptive analysis (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
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
Organizational
behavior
Improvement programs & Quality management systems (Yes/No)
Continuing clinical education program (Yes/No)
Local adaptation of clinical practice guideline (Yes/No)
Range of services
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
Costs of Primary Care
Systems
Methodology Micro-costing
clinical vignettes representing the main
areas of activity of PC:
 Acute care
 Chronic care
 Health promotion
 Prevention (vaccination)
Overall task
To identify a methodology for cost measurement in
primary care services and to apply it.
=> Challenging goal:
• extreme
in terms of professionals involved,
payment mechanisms, services provided across countries
• impossible to develop a one-fits-all method, but need to
provide
Chosen Method
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
STEPS
1.
2.
3.
4.
5.
6.
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
1. Choice of vignettes
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
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.
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 followup 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.
STEPS
1.
2.
3.
4.
5.
6.
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
4. Submission of vignettes
, by interviewers from each country
(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
: professionals of each group
have been requested to answer the questions related to each
vignette in writing
4. Submission of vignettes
In total, more than 200 professionals have been interviewed.
VIGNETTES
COUNTRY
1
2
3
4
Professionals
Number
Professionals
Number
Professionals
Number
Professionals
Number
HUNGARY
GP
33
Paediatrician
52
GP
32
GP
29
ITALY
GP
50
Paediatrician
23
GP
27
GP
50
Nurse
5
GP
39
GP
38
GP
39
GP
30
GP
30
GP
30
GP
30
Nurse
27
GP
23
GP
23
Nurse
24
GP
20
Paediatrician
21
GP
20
GP
23
Nurse
3
Nurse
3
GP
37
GP
33
GP
33
FINLAND
LITHUANIA
ESTONIA
SPAIN
GERMANY
TOTAL
205
Paediatrician
23
211
206
228
STEPS
1.
2.
3.
4.
5.
6.
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
6. To measure resources
consumption
•
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
6. To measure resources
consumption
•
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
6. To measure resources
consumption: data collected
Each vignette was structured as to gather information about:
1. medical and administrative professionals directly involved in the
service;
2. the amount of time spent in the activity by the professionals
involved;
3. medical material directly used in the provision of the service;
4. medical material and other health care services consumed as a
consequence of the service;
5. other medical professionals involved as a consequence of the
service described in the vignette.
6. To measure resources
consumption: data collected
Moreover, for each 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.
SOME RESULTS FROM THE
VIGNETTES
V2 – A sick 2-year-old boy:
Professionals involved
General
Paediatrician Physician
Country
Total cases
Hungary
52
100,00%
50,00%
28,85%
30,77%
Italy
23
100,00%
8,70%
21,74%
0,00%
Finland
39
100,00%
66,67%
33,33%
10,26%
Lithuania
30
100,00%
60,00%
10,00%
10,00%
Estonia
23
100,00%
69,57%
8,70%
17,39%
Spain
21
100,00%
47,62%
9,52%
0,00%
Germany
23
100,00%
0,00%
86,96%
0,00%
All countries
211
46,45%
28,44%
12,80%
100,00%
Nurse
Other PC
Secretary professional
V2 – A sick 2-year-old boy:
Time spent in the visit
Hungary
Italy
Finland
Lithuania
Estonia
Spain
Germany
13,9
16,3
13,8
15,7
14,7
13,4
12,7
3,3
0,7
6,3
5,3
4,0
6,2
0,0
Average time per case
2,5
0,0
0,8
0,4
0,7
0,0
0,0
Total time per case
19,8
17,0
20,9
21,4
19,3
19,6
12,7
Paediat./General
Physician
Average time per case
Nurse
Average time per case
Other PC professional
V2 – A sick 2-year-old boy:
Time - variability within countries
Hungary
Italy
Finland Lithuania
Estonia
Spain
Germany
Min
5
10
1
1
1
6
5
Max
30
38
30
30
20
40
30
ST.DEV.
6,64
5,92
5,82
5,97
5,48
7,70
5,90
Average time per
patient
13,88
16,35
13,85
15,67
14,65
13,38
12,65
Paediat./General
Physician
V2 – A sick 2-year-old boy:
Clinical behaviors
Finland Lithuania Estonia
Spain
All
Germany countries
Hungary
Italy
Pharmacological
Treatment
94,23%
95,65%
87,18%
76,67%
65,22% 100,00% 95,65%
88,15%
Categories of drugs
Fever reducer
Bronchodilator
Antibiotics
Anti-inflammatory
24,49%
81,63%
18,37%
10,20%
54,55%
50,00%
36,36%
36,36%
5,88%
97,06%
2,94%
0,00%
26,09%
73,91%
21,74%
4,35%
0,00%
80,00%
20,00%
0,00%
23,12%
82,26%
14,52%
7,53%
Hungary
Italy
Diagnostic tests
38,46%
Specialist involved
40,38%
42,86%
85,71%
4,76%
0,00%
9,09%
100,00%
0,00%
0,00%
Finland Lithuania Estonia
Spain
Germany All countries
30,43%
46,15%
50,00%
82,61%
0,00%
26,09%
40,28%
8,70%
64,10%
23,33%
17,39%
4,76%
0,00%
28,44%
V2 – A sick 2-year-old boy:
Micro-costing
Hourly cost
Hungary
Italy
Finland Lithuania Estonia
Spain
Germany
Paediat./General Physician €
3,86 € 26,83 € 14,13 €
4,17 €
5,05 € 16,24 € 59,51
Nurse
€
0,74 €
0,27 €
3,01 €
0,79 €
0,58 €
5,34
Secretary
€
0,55 €
0,67 €
0,45 €
0,02 €
0,06 €
0,04
Assistant/Trainee
€
0,70
€
0,61 €
0,03 €
0,09
TOTAL LABOUR COST
€
5,86 €
27,78 €
18,20 €
5,01 €
5,78 €
21,62 €
59,51
DRUGS COST
€
8,47 €
11,83 €
9,28 €
5,11 €
3,59 €
4,66 €
13,07
TESTS COST
€
3,40 €
4,71 €
2,92 €
4,29 €
4,52 €
- €
16,03
OUT-OF-POCKET
€
-
€
-
TOTAL COST
€ 17,72
€
€
-
-
€ 44,32
€
-
€ 30,39
€
-
€ 14,41
€
-
€ 13,88
€
€
-
-
€ 26,27
€ 88,62
Methodology Macro-costing
Includes
• Actual costs: Real not estimated
• Usual accounting principles and practices
• Indicated in the estimated overall budget
Personnel Costs
Durable Equipment
Consumables and supplies identifiable
Quality of Primary Care
Systems
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.
Criteria
DIMENSIONS
CRITERIA
Access
Geographical access
Access via telecommunication tools
Access in time
Appointment system
Equity
Waiting time
Human resources
Financial constrains
Appropriateness
Professional training
Continuous education
Competences in PHC /services
Prevention services
Long-term care
Evidence based practice/guidelines
Criteria
DIMENSIONS
Appropriateness
CRITERIA
•Usual source of care
•Referral system
•Continuity of care and medical information in
PHC and across providers
•Team-work in PHC
•Clinical criteria related to preventive activities
and management of chronic diseases
Patient
•Safety regarding medical records
satisfaction/patient •Hygiene/Infection control
centeredeness
Professional
satisfaction
•Equipment (medical/non-medical)
•Quality management tools (job description,
audit)
•Reporting system of critical incidence
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
Methodology Quality Indicators
selected to measure
Quality of PC in Europe
Methodology Quality at the
Population Level
 A sample of 3.020 persons
 25-75 years old
 7 countries participating in the project
 Domains:
Socio-demographic
Prevention and
health promotion
interventions
Utilization of services
Self-perceived
health
Satisfaction
Methodology Quality at the
Clinical Level
Diabetes and high blood pressure
9 indicators
Specific approach for extracting data in each country
(sample)
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
Clinical quality indicators HBP
• % Patients < 140/90 mmHg
• % Patients with total cholesterol screened
within a year
Targets of the clinical
indicators in each country
INDICATOR
Estonia
Lithuania
Finland
Hungary
Germany
Italy
≤ 140/90
≤140/90
≤ 140/85
≤140/90
NA
NA
≤130/85
≤130/80
<130/80
≤130/80
<140/90
≤ 130/80
BP for HBP
BP for DM2
Targets of the clinical
indicators in each country
INDICATOR
ESTONIA
LITHUANIA
FINLAND
HUNGARY
GERMANY
ITALY
BP for both,
DM2 + HBP
≤130/85
≤130/80
<130/80
≤130/80
NA
NA
Chol level
for DM2 +
statin
treatment
>4.5
>4.8
>4.5
>4.5
NA
NA
HbA1c level
for insulin
≥8.5
≥8.5
≥7.0
≥7.0
>8.5
6.57.0?