1. Stephanie Heinemann, MPH Good practices in primary care in Europe: a part of the QUALICOPC project “The Future of Primary Care in Europe IV” Gothenburg conference September 3-4, 2012

2. Stephanie Heinemann 2 A very short bit of QUALICOPC background 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys 2614 No Completed survey 2614 No Completed survey Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs QUALICOPC Funding: European Commission (FP7) PC data: 35 countries, ca. 7000 GPs, 70,000 patients Work packages: patient perceived quality, GP task profiles and GP process quality, access and equity, costs, avoidable hospitalization and “good practices”. The “good practices” work package focuses on identifying…. specific primary care organizational forms which are best fit to address the future challenges of primary care.

3. Stephanie Heinemann 3 How do we address the futures challenges of PC? 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys 2614 No Completed survey 2614 No Completed survey Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs “Strong primary care is often seen as a solution for the challenges that (European) health care systems face.” Peter Groenewegen Is “strong PC”… (Starfield 2012) first contact access and use person-focused care over time a large range of available services timely access to needed services coordination of care …therefore also “good practice”?

4. Stephanie Heinemann 4 “Good practice” organizational forms in the literature 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys 2614 No Completed survey 2614 No Completed survey Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs Objective:Finding health system-level policies (e.g. financing) and practice-level organizational forms (e.g. workforce in PC practices) that are considered to be “good practices” in PC Method:Literature review Medline search Primary care focus Articles self-labeled as “good practices” or “best practices”

5. Stephanie Heinemann 5 Results of Medline search for “good practices” in PC 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys 2614 No Completed survey 2614 No Completed survey Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs 199 self-labeled “good practices” or “best practices” in primary care Most articles refer to a specific sub-specialty seen in primary care e.g. patients with low back pain Some articles refer to meso-level activities e.g. primary/secondary care interface A few articles mention macro-level health policies e.g. impact of primary health care on health systems The searched-for literature on policies such as gatekeeping, capitation payment systems, broad task profiles, etc. could not be found.

6. Stephanie Heinemann 6 What do “good practice” articles have in common? 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys 2614 No Completed survey 2614 No Completed survey Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs 3 common elements of good practice/best practice in PC 1.Recommendation for action outline of care process for ADHD children best-practice diagnostic procedures for GPs 2.Evidence base American Academy of Pediatrics guidelines 3.Underlying policy goal better outcomes for ADHD children less variation in diagnostic procedures Working definition of good practice in primary care: “Recommendations for appropriate action based upon evidence, bringing primary healthcare systems closer to reaching their policy goals” Example from a sub-specialty area

7. Stephanie Heinemann 7 Which challenges and macro-level policy goals? 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys 2614 No Completed survey 2614 No Completed survey Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs Generic health system goals Oliver 2007 National equity of access Cost containment Health improvement Responsiveness Patient choice Questions How does the concept of “strong PC” fit into health policy goals? Should e.g. “large range of services” be regarded as a PC policy goal or rather a variation of PC policy? Strong PC Starfield 2012 First contact access and use Person-focused care over time Large range of available services Timely access to needed services Coordination of care

8. Stephanie Heinemann 8 Case study: Is mandatory GP-gatekeeping a good practice in PC? Systematic reviews Zenter 2010, Velasco Garrido 2011 Health system goalsMandatory GP-gatekeeping National equity of accessNot evaluated Cost containmentGatekeeping reduces costs Health improvementNo evidence ResponsivenessNot evaluated Patient choiceGatekeeping restricts patient choice Question How can we evaluate “good practices” if… evidence is thin? evidence shows that a policy fulfills only some policy goals?

9. Stephanie Heinemann 9 QUALICOPC adds empirical data about PC policy goals Health system goalsQUALICOPC data National equity of accessYES (Ghent) Cost containmentYES (Pisa, RIVM) Health improvementYES (NIVEL, RIVM) ResponsivenessMAYBE (NIVEL, Fulda) Patient choiceYES (NIVEL, Fulda) PC practice organizationYES (Ljubjana)

10. Stephanie Heinemann 10 Further work 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs Identifying good practices in PC will focus upon: 1.Analyzing QUALICOPC data with regards to policy goals 2.Identifying countries coming closest to meeting all goals 3.Contrasting these countries in terms of organizational structure 4.Identifying certain policies/structures universal to good practices

11. Stephanie Heinemann 11 References 2825 GPs contacted by mail 213 Completed GP surveys 213 Completed GP surveys Negative response 20 Negative response 20 Patient survey pending 67 Patient survey pending 67 Consent revoked 23 Consent revoked 23 No address 10 No address 10 Pat. survey complete 113 Pat. survey complete 113 180 participating GPs Oliver A. Inconsistent objectives--reflections on some selective health care policy developments in Europe. Health Econ Policy Law. 2007 Jan;2(Pt 1):93-106. Starfield B. Primary care: an increasingly important contributor to effectiveness, equity, and efficiency of health services. SESPAS report 2012. Gac Sanit. 2012 Jan 20. Velasco Garrido M, Zentner A, Busse R. The effects of gatekeeping: a systematic review of the literature. Scand J Prim Health Care. 2011 Mar;29(1):28-38. Zentner A, Velasco Garrido M, Busse R. [Do primary care physicians acting as gatekeepers really improve health outcomes and decrease costs? A systematic review of the concept gatekeeping]. Gesundheitswesen. 2010 Aug-Sep;72(8-9):e38-44.