1. EUprimecare: Quality and Costs of Primary Care in Europe Grant Agreement No. 241595 MD, Antonio Sarría-Santamera (Institute of Health Carlos III) Stefan Scholz (University of Bielefeld) MD Kadri Suija (University of Tartu)

2. Health Care: Iron Triangle CostsQualityAccess

3. Strong Primary Care What is Strong Primary Care?

4. Background

5. Objectives

6. 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 Partners

7. Conceptual structure Identify a methodology to measure Quality in PC WP 5 & 6 Identify a methodology to measure Costs in PC WP 3 & 4 WP 7 WP2 Evaluation of PC models COORDINATION WP 1 DISSMINATION WP 8 To measure the Quality in PC To measure Costs in PC ORGANIZATION OF PRIMARY CARE IN EUROPE REGULATIONFINANCING PAYMENTORGANIZATION ORGANIZATIONA L BEHAVIOUR

8. Approach

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

11. Results of Qualitative analysis Based on a functional perspective, allowed to proposing 5 models: 1.Direct access to specialist 2.Referral required from GP, mainly solo-practices in PC 3.Referral required from GP, mainly group-practices in PC 4.Health care centers 5.Polyclinics Functional models

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

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

14. 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 ORGANIZATIONAL BEHAVIOUR Descriptive analysis (III)

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

16. Range of services

17. 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 Conclusions

18. Costs of Primary Care Systems

19. Methodology Micro-costing

20. Overall task

21. 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

22. STEPS 1.To choose the vignettes 2.To translate the vignettes 3.To validate the vignettes 4.To submit the vignettes to primary care professionals 5.To collect questionnaires 6.To measure resources consumption in the delivery of services involved in the clinical vignettes

23. 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

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 1.To choose the vignettes 2.To translate the vignettes 3.To validate the vignettes 4.To submit the vignettes to primary care professionals 5.To collect questionnaires 6.To measure resources consumption in the delivery of services involved in the clinical vignettes

27. 4. Submission of vignettes

28. In total, more than 200 professionals have been interviewed.

29. STEPS 1.To choose the vignettes 2.To translate the vignettes 3.To validate the vignettes 4.To submit the vignettes to primary care professionals 5.To collect questionnaires 6.To measure resources consumption in the delivery of services involved in the clinical vignettes

30. 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

31. 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

32. 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.

33. 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.

34. SOME RESULTS FROM THE VIGNETTES

35. V2 – A sick 2-year-old boy: Professionals involved CountryTotal casesPaediatrician General PhysicianNurseSecretary Other PC professional Hungary52100,00% 50,00%28,85%30,77% Italy23100,00% 8,70%21,74%0,00% Finland39 100,00%66,67%33,33%10,26% Lithuania30 100,00%60,00%10,00% Estonia23 100,00%69,57%8,70%17,39% Spain21100,00% 47,62%9,52%0,00% Germany23100,00% 0,00%86,96%0,00% All countries211100,00%46,45%28,44%12,80%

36. V2 – A sick 2-year-old boy: Time spent in the visit HungaryItalyFinlandLithuaniaEstoniaSpainGermany Paediat./General Physician Average time per case 13,916,313,815,714,713,412,7 Nurse Average time per case 3,30,76,35,34,06,20,0 Other PC professional Average time per case 2,50,00,80,40,70,0 Total time per case 19,817,020,921,419,319,612,7

37. V2 – A sick 2-year-old boy: Time - variability within countries HungaryItalyFinlandLithuaniaEstoniaSpainGermany Paediat./General Physician Min51011165 Max303830 204030 ST.DEV.6,645,925,825,975,487,705,90 Average time per patient13,8816,3513,8515,6714,6513,3812,65

38. V2 – A sick 2-year-old boy: Clinical behaviors HungaryItalyFinlandLithuaniaEstoniaSpainGermany All countries Pharmacological Treatment94,23%95,65%87,18%76,67%65,22%100,00%95,65%88,15% Categories of drugs Fever reducer24,49%54,55%5,88%26,09%0,00%42,86%9,09%23,12% Bronchodilator81,63%50,00%97,06%73,91%80,00%85,71%100,00%82,26% Antibiotics18,37%36,36%2,94%21,74%20,00%4,76%0,00%14,52% Anti-inflammatory10,20%36,36%0,00%4,35%0,00% 7,53% HungaryItalyFinlandLithuaniaEstoniaSpainGermanyAll countries Diagnostic tests38,46%30,43%46,15%50,00%82,61%0,00%26,09%40,28% Specialist involved40,38%8,70%64,10%23,33%17,39%4,76%0,00%28,44%

39. V2 – A sick 2-year-old boy: Micro-costing HungaryItalyFinlandLithuaniaEstoniaSpainGermany 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 Hourly cost

40. Methodology Macro-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 DIMENSIONSCRITERIA Access  Geographical access  Access via telecommunication tools  Access in time  Appointment system Equity  Waiting time  Human resources  Financial constrains AppropriatenessProfessional training Continuous education Competences in PHC /services Prevention services Long-term care Evidence based practice/guidelines

44. Criteria DIMENSIONSCRITERIA Appropriateness 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 satisfaction/patient centeredeness Safety regarding medical records Hygiene/Infection control Professional satisfaction Equipment (medical/non-medical) Quality management tools (job description, audit) Reporting system of critical incidence

45. 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

47. Methodology Quality at the Population Level Socio-demographicUtilization of services Satisfaction Self-perceived health Prevention and health promotion interventions

48. Methodology Quality at the Clinical Level

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. Clinical quality indicators HBP % Patients < 140/90 mmHg % Patients with total cholesterol screened within a year

51. INDICATOR EstoniaLithuaniaFinlandHungaryGermanyItaly BP for HBP ≤ 140/90 ≤ 140/85≤140/90NA BP for DM2 ≤130/85≤130/80<130/80≤130/80<140/90≤ 130/80 Targets of the clinical indicators in each country

52. INDICATORESTONIALITHUANIAFINLANDHUNGARYGERMANYITALY BP for both, DM2 + HBP ≤130/85≤130/80<130/80≤130/80NA Chol level for DM2 + statin treatment >4.5>4.8>4.5 NA HbA1c level for insulin ≥8.5 ≥7.0 >8.56.5- 7.0? Targets of the clinical indicators in each country