1. WP4.2 Micro-costing: some results from vignettes 11 th and 12 th June 2012, Kuopio Italian team

2. Micro level The main goal of the consortium at the Micro level is to cost specific and relevant clinical cases for which care is provided in the primary care system context, in each partner country

3. WP4 Overall task To measure costs in primary care services in different EU countries Micro-level: Within main categories of primary care, data related to specific services and providers in each participant country are attributed monetary values based on Time- Driven Activity-Based Costing (WP3)

4. Micro level - Methodology STEPS 1.To choose the vignettesV 2.To translate the vignettesV 3.To validate the vignettesV 4.To submit the vignettes to primary care professionals V 5.To collect data V 6.To measure resources consumption in the delivery of services involved in the clinical vignettes 7.To describe how certain primary care cases are managed in different systems

5. WP4.2 – Micro-costing: VIGNETTES RESULTS FROM VIGNETTES DRAFT – NOT FINAL VERSION

6. DIRECT PERSONNEL COSTS – BY COUNTRY HUNGARYITALYFINLAND Physician avarage cost per year 12.100,00 118.930,00 80.900 total amount of hours worked per year192018721639 cost per hour 6,30 63,53 49,36 cost per minute 0,11 1,06 0,82 Nurse avarage cost per year 7.880,00 39.000 42.800 total amount of hours worked per year192017281704 cost per hour 4,10 22,57 25,12 cost per minute 0,07 0,38 0,42 Overheads estimation yearly overheads90%15%21% total cost per minute Physician 0,20 1,22 1,00 total cost per minute Nurse 0,13 0,43 0,51

7. DIRECT PERSONNEL COSTS – BY COUNTRY LITHUANIAESTONIASPAIN Physician avarage cost per year 12.168 18.231 82.474 total amount of hours worked per year191519111533 cost per hour 6,35 9,54 53,80 tariff per activity cost per minute 0,11 0,16 0,90 Nurse avarage cost per year 9.372 11.160 50.086 total amount of hours worked per year191521941533 cost per hour 4,89 5,09 32,67 cost per minute 0,08 0,54 Overheads estimation yearly overheads15%35%21% total cost per minute Physician 0,12 0,21 1,08 total cost per minute Nurse 0,09 0,11 0,66

8. Vignette 1 A 70-years-old man in good health comes to the practice asking to be vaccinated against the seasonal influenza. The patient is known to you.

9. VIGNETTE 1 – ADMINISTRATION OF THE VACCINE: Professionals involved HUNGARYITALYFINLANDLITHUANIA % % % % ADMINISTRATION Total cases33 50 5 30 Physician in the adm.33100,00%50100,00%00,00%30100,00% Nurse in the adm.2678,79%1530,00%5100,00%2893,33% Secretary in the adm.927,27%1428,00%00,00%310,00% Other in the adm.26,06%48,00%00,00%310,00% ESTONIASPAINGERMANYALL COUNTRIES % % % % ADMINISTRATION Total cases27 23 37 205 Physician in the adm.933,33%2295,65%37100,00%18188,29% Nurse in the adm.27100,00%2086,96%00,00%12159,02% Secretary in the adm.27,41%28,70%2772,97%5727,80% Other in the adm.00,00%14,35%513,51%157,32%

10. VIGNETTE 1 – ADMINISTRATION OF THE VACCINE: TIME SPENT (minutes) HUNGARYITALYFINLANDLITHUANIAESTONIASPAINGERMANYALL PHYSICIAN Average time per case8,811,10,08,92,78,67,08,0 Average time per patient8,811,10,08,98,09,07,09,1 NURSE Average time per case3,81,26,66,011,55,00,04,0 Average time per patient4,846,66,411,55,70,06,8 SECRETARY Average time per case0,70,80,00,3 0,23,61,1 Average time per patient2,62,90,03,04,02,05,03,8 OTHER Average time per case0,50,30,00,40,00,10,40,3 Average time per patient7,54,30,03,80,02,03,24,1 TOTAL TIME PER CASE13,713,46,615,614,513,811,113,4

11. VIGNETTE 1 – RECORDING: Professionals involved HUNGARYITALYFINLANDLITHUANIA % % % % RECORDING Total cases33 50 5 30 Cases recorded33100,00%50100,00%5 2996,67% Physician in the rec.1133,33%4590,00%00,00%29100,00% Nurse in the rec.2781,82%48,00%5100,00%2689,66% Secretary in the rec.824,24%00,00%0 0 Other in the rec.13,03%12,00%00,00%0 ESTONIASPAINGERMANYALL COUNTRIES % % % % REGISTRATION Total cases27 23 37 205 Cases recorded27100,00%23100,00%37100,00%20499,51% Physician in the rec.00,00%417,39%1232,43%10149,51% Nurse in the rec.27100,00%2086,96%00,00%10953,43% Secretary in the rec.00,00%0 12,70%94,41% Other in the rec.00,00%0 3081,08%3215,69%

12. VIGNETTE 1 – RECORDING: TIME SPENT (minutes) HUNGARYITALYFINLANDLITHUANIAESTONIASPAINGERMANYALL PHYSICIAN Average time per case0,72,10,02,40,00,30,61,1 Average time per patient2,02,40,02,50,01,51,82,3 NURSE Average time per case2,50,21,52,64,52,30,01,7 Average time per patient3,02,31,53,04,52,60,03,2 SECRETARY Average time per case0,90,0 0,10,2 Average time per patient3,60,0 2,03,4 OTHER Average time per case0,00,040,0 1,70,3 Average time per patient0,02,00,0 2,12,2

13. VIGNETTE 1 – MICRO-COSTING HUNGARYITALYFINLANDLITHUANIAESTONIASPAINGERMANY PHYSICIAN Average time per case9,413,20,011,42,78,97,6 Average cost 1,88 16,11 - 1,38 0,57 9,60 Tariff per activity 9,54 NURSE Average time per case6,21,48,18,616,07,20,0 Average cost 0,81 0,60 4,10 0,81 1,83 4,76 SECRETARY Average time per case1,60,80,00,3 0,23,7 Average cost 0,16 0,25 - 0,01 0,02 0,05 0,86 OTHER Average time per case0,60,40,00,40,00,12,1 Average cost 0,06 0,38 - 0,02 - - TOTAL LABOUR COST 2,91 17,33 4,10 2,22 2,43 14,42 9,54 VACCINE - Average price 6,66 5,39 2,90 5,52 5,46 5,03 21,55 OUT OF POCKET - Average price 0,52 - - - - - - TOTAL COST 10,10 22,72 7,00 7,74 7,89 19,45 31,09

14. Vignette 2 A 2-years-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. The child has drank liquids normally but has poorer appetite than usual. In the doctors office he is alert and responsive. He has mild expiratory dyspnea. His breathing rate is 36 times per minute. Diffuse wheezing and rhonchi are heard bilaterally in the lungs. Pharynx is erythematous. Tympanic membranes are otoscopically without signs of inflammation. The boy has had similar episodes of cough, fever and wheezing at the age of 1 year 5 months. He has atopic dermatitis but otherwise has been healthy.

15. VIGNETTE 2 – VISIT: Professionals involved HUNGARYITALYFINLANDLITHUANIA % % % % VISIT Total cases52 23 39 30 Main Professional involvedPhysician Paediatr. Physician Paediatrician/Physician in the visit52100,00%23100,00%39100,00%30100,00% Nurse in the visit2650,00%28,70%2666,67%1860,00% Secretary in the visit1528,85%521,74%1333,33%310,00% Other in the visit1630,77%00,00%410,26%310,00% ESTONIASPAINGERMANYALL COUNTRIES % % % % VISIT Total cases23 21 23 211 Main Professional involvedPhysician Paediatr. Paediatrician/Physician in the visit23100,00%21100,00%23100,00%211100,00% Nurse in the visit1669,57%1047,62%00,00%9846,45% Secretary in the visit28,70%29,52%2086,96%6028,44% Other in the visit417,39%00,00%0 2712,80%

16. VIGNETTE 2 – VISIT : TIME SPENT - minutes HUNGARYITALYFINLANDLITHUANIAESTONIASPAINGERMANYALL PAEDIATRICIAN/PHYSICIAN Average time per case13,916,313,815,714,713,412,714,3 Average time per patient13,916,313,815,714,713,412,714,3 NURSE Average time per case3,30,76,35,34,06,20,03,9 Average time per patient6,77,59,48,95,813,00,08,3 SECRETARY Average time per case2,01,21,30,20,70,16,61,7 Average time per patient6,85,44,02,38,01,57,66,0 OTHER Average time per case2,50,00,80,40,70,0 0,9 Average time per patient8,307,53,73,80,0 7,0 TOTAL TIME PER CASE21,718,222,221,620,019,719,320,8

17. VIGNETTE 2 – PHARMACOLOGICAL TREATMENT: CATEGORIES OF DRUGS HUNGARYITALYFINLANDLITHUANIA % % % % Pharmacological Treatment4994,23%2295,65%3487,18%2376,67% Fever reducer1224,49%1254,55%25,88%626,09% Bronchodilator4081,63%1150,00%3397,06%1773,91% Antibiotics918,37%836,36%12,94%521,74% Anti-inflammatory510,20%836,36%00,00%14,35% ESTONIASPAINGERMANYALL COUNTRIES % % % % Pharmacological Treatment1565,22%21100,00%2295,65%18688,15% Fever reducer00,00%942,86%29,09%4323,12% Bronchodilator1280,00%1885,71%22100,00%15382,26% Antibiotics320,00%14,76%00,00%2714,52% Anti-inflammatory00,00%0 0 147,53%

18. VIGNETTE 2 – TESTS AND SPECIALIST INVOLVED HUNGARYITALYFINLANDLITHUANIA % % % % Main Professional involvedPhysician Paediatr. Physician Pharmacological Treatment4994,23%2295,65%3487,18%2376,67% Diagnostic Tests2038,46%730,43%1846,15%1550,00% Specialist involved2140,38%28,70%2564,10%723,33% ESTONIASPAINGERMANYALL COUNTRIES % % % % Main Professional involvedPhysician Paediatr. Pharmacological Treatment1565,22%21100,00%2295,65%18688,15% Diagnostic Tests1982,61%00,00%626,09%8540,28% Specialist involved417,39%14,76%00,00%6028,44%

19. VIGNETTE 2 – MICRO-COSTING HUNGARYITALYFINLANDLITHUANIAESTONIASPAINGERMANY PAEDIATRICIAN/PHYSICIAN Average time per case16,320,217,821,618,517,116,6 Average cost 3,25 27,67 17,69 2,62 3,98 15,82 Tariff per activity 42,16 NURSE Average time per case4,80,77,45,34,07,90,0 Average cost 0,63 0,28 3,77 0,50 0,46 5,20 SECRETARY Average time per case4,52,31,30,20,70,16,6 Average cost 0,46 0,69 0,56 0,01 0,04 1,54 OTHER Average time per case5,70,00,80,40,70,0 Average cost 0,59 - 0,77 0,02 0,07 - TOTAL LABOUR COST 4,94 28,64 22,78 3,15 4,56 21,06 42,16 DRUGS - Average cost 5,44 12,20 11,61 3,35 2,83 4,54 14,47 TESTS - Average cost 2,18 4,85 3,66 2,81 3,57 - 16,58 TOTAL COST 12,57 45,69 38,05 9,32 10,95 25,59 73,20

20. Vignette 3 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.

21. VIGNETTE 3 – VISITS IN 12 MONTHS: PC Professionals involved HUNGARYITALYFINLANDLITHUANIA % % % % PC VISITS in 12 months Total cases32 27 38 30 Physician in the visit32100,00%27100,00%38100,00%30100,00% Nurse in the visit3196,88%1140,74%3489,47%2893,33% Secretary in the visit1031,25%1037,04%1436,84%413,33% ESTONIASPAINGERMANYALL COUNTRIES % % % % PC VISITS in 12 months Total cases23 33 206 Physician in the visit23100,00%23100,00%33100,00%206100,00% Nurse in the visit23100,00%23100,00%33100,00%18388,83% Secretary in the visit14,35%521,74%00,00%4421,36%

22. VIGNETTE 3 – VISITS : TIME SPENT in 12 months - minutes HUNGARYITALYFINLANDLITHUANIAESTONIASPAINGERMANYALL PHYSICIAN Average time per visit1118251519131216 Average number of visits per patient63254244 Average time per case65,957,445,374,573,327,347,555,8 Average time per patient65,957,445,374,573,327,347,555,8 NURSE Average time per visit81145101513719 Average number of visits per patient83354466 Average time per case61,511,8108,649,257,256,340,257,4 Average time per patient63,529,0121,352,757,256,340,264,6 SECRETARY Average time per contact47784303 Average number of contacts per patient84444302 Average time per case9,47,99,23,00,71,50,04,9 Average time per patient30,021,425,122,516,06,80,022,8 TOTAL TIME PER CASE in 12 months - minutes136,877,1163,1126,7131,285,187,8118,1

23. VIGNETTE 3 – DRUGS PRESCRIPTION HUNGARYITALYFINLANDLITHUANIA % % % % Pharmacological Treatment3093,75%2696,30%3386,84%2893,33% Metformin2376,67%2596,15%3090,91%28100,00% ESTONIASPAINGERMANYALL COUNTRIES % % % % Pharmacological Treatment23100,00%1773,91%2575,76%18288,35% Metformin2295,65%1694,12%25100,00%16992,86%

24. VIGNETTE 3 – TESTS PRESCRIPTION HUNGARYITALYFINLANDLITHUANIA % % % % Diagnostic Tests2887,50%27100,00%3694,74%30100,00% HbA1C932,14%2281,48%2877,78%2893,33% Eye visit/ Fundus28100,00%2696,30%1438,89%2686,67% ECG/Cardiologist1450,00%1555,56%1541,67%620,00% Lipid profile/triglyc.310,71%1659,26%1027,78%413,33% Creatinine/kidney func.27,14%27,41%2055,56%1136,67% Microalbum.13,57%933,33%1027,78%00,00% Blood sugar310,71%1970,37%2569,44%1653,33% ESTONIASPAINGERMANYALL COUNTRIES % % % % Diagnostic Tests23100,00%23100,00%33100,00%20097,09% HbA1C2295,65%730,43%2472,73%14070,00% Eye visit/ Fundus1773,91%2295,65%3090,91%16381,50% ECG/Cardiologist00,00%1147,83%618,18%6733,50% Lipid profile/triglyc.1252,17%521,74%618,18%5628,00% Creatinine/kidney func.2086,96%28,70%1442,42%7135,50% Microalbum.1669,57%417,39%412,12%4422,00% Blood sugar417,39%00,00%1133,33%7839,00%

25. VIGNETTE 3 – SPECIALISTS INVOLVED HUNGARYITALYFINLANDLITHUANIA % % % % Specialist involved3093,75%2592,59%1231,58%2996,67% Diabetologist/Endocr. 2583,33%1456,00%325,00%2793,10% Eye doctor 2893,33%25100,00%1191,67%2689,66% Cardiologist 2480,00%2392,00%216,67%724,14% ESTONIASPAINGERMANYALL COUNTRIES % % % % Specialist involved1773,91%2191,30%3193,94%16580,10% Diabetologist/Endocr. 529,41%314,29%1238,71%8953,94% Eye doctor 17100,00%21100,00%31100,00%15996,36% Cardiologist 00,00%0 825,81%6438,79%

26. Vignette 4 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. Note: Each country is free to decide the specific reason for the encounter. It should be as much neutral as possible (it should not be for a clinical reason).

27. VIGNETTE 4 – TIME SPENT IN THE VISIT BY THE PHYSICIAN HUNGARYITALYFINLANDLITHUANIAESTONIASPAINGERMANYALL Total cases29503930242333228 Total time410755368,5294392,52573942871 TIME SPENT PER CASE14,115,19,49,816,411,211,912,6

28. VIGNETTE 4 – PC Professionals Behavior HUNGARYITALYFINLANDLITHUANIA % % % % VISIT Total cases29 50 39 30 Advice on smoking29100,00%4794,00%3794,87%30100,00% Ask in the future29100,00%4998,00%3794,87%2686,67% Recording29100,00%4998,00%3794,87%2480,00% ESTONIASPAINGERMANYALL COUNTRIES % % % % VISIT Total cases24 23 33 228 Advice on smoking24100,00%23100,00%33100,00%22397,81% Ask in the future24100,00%23100,00%3193,94%21996,05% Recording2291,67%23100,00%2472,73%20891,23%

29. Next steps We are planning to do some more analysis, in particular: Variability in each country in terms of: - Time -Prescription (both drugs and tests) -Costs Comparison across countries of costs expressed in PPP (total values and drivers of cost)

30. Next steps – Suggestions for publications Possibility to write two papers on WP 4.2 – micro- costing part: 1.Patterns of treatment for 4 primary care cases: comparison across 7 EU countries 2.Micro-costing of specific PC activities in 7 EU countries: methodology and results

31. Thank you