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

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

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)

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

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

DIRECT PERSONNEL COSTS – BY COUNTRY HUNGARY ITALY FINLAND Physician avarage cost per year € 12.100,00 € 118.930,00 € 80.900 total amount of hours worked per year 1920 1872 1639 cost per hour € 6,30 € 63,53 € 49,36 cost per minute € 0,11 € 1,06 € 0,82   Nurse € 7.880,00 € 39.000 € 42.800 1728 1704 € 4,10 € 22,57 € 25,12 € 0,07 € 0,38 € 0,42 Overheads estimation yearly overheads 90% 15% 21% total cost per minute Physician € 0,20 € 1,22 € 1,00 total cost per minute Nurse € 0,13 € 0,43 € 0,51

DIRECT PERSONNEL COSTS – BY COUNTRY LITHUANIA ESTONIA SPAIN Physician avarage cost per year € 12.168 € 18.231 € 82.474 total amount of hours worked per year 1915 1911 1533 cost per hour € 6,35 € 9,54 € 53,80 tariff per activity   cost per minute € 0,11 € 0,16 € 0,90 Nurse € 9.372 € 11.160 € 50.086 2194 € 4,89 € 5,09 € 32,67 € 0,08 € 0,54 Overheads estimation yearly overheads 15% 35% 21% total cost per minute Physician € 0,12 € 0,21 € 1,08 total cost per minute Nurse € 0,09 € 0,66

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.

VIGNETTE 1 – ADMINISTRATION OF THE VACCINE: Professionals involved HUNGARY ITALY FINLAND LITHUANIA   % ADMINISTRATION Total cases 33 50 5 30 Physician in the adm. 100,00% 0,00% Nurse in the adm. 26 78,79% 15 30,00% 28 93,33% Secretary in the adm. 9 27,27% 14 28,00% 3 10,00% Other in the adm. 2 6,06% 4 8,00% ESTONIA SPAIN GERMANY ALL COUNTRIES   % ADMINISTRATION Total cases 27 23 37 205 Physician in the adm. 9 33,33% 22 95,65% 100,00% 181 88,29% Nurse in the adm. 20 86,96% 0,00% 121 59,02% Secretary in the adm. 2 7,41% 8,70% 72,97% 57 27,80% Other in the adm. 1 4,35% 5 13,51% 15 7,32%

VIGNETTE 1 – ADMINISTRATION OF THE VACCINE: TIME SPENT (minutes) HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL PHYSICIAN   Average time per case 8,8 11,1 0,0 8,9 2,7 8,6 7,0 8,0 Average time per patient 9,0 9,1 NURSE 3,8 1,2 6,6 6,0 11,5 5,0 4,0 4,8 4 6,4 5,7 6,8 SECRETARY 0,7 0,8 0,3 0,2 3,6 1,1 2,6 2,9 3,0 2,0 OTHER 0,5 0,4 0,1 7,5 4,3 3,2 4,1 TOTAL TIME PER CASE 13,7 13,4 6,6 15,6 14,5 13,8 11,1

VIGNETTE 1 – RECORDING: Professionals involved HUNGARY ITALY FINLAND LITHUANIA   % RECORDING Total cases 33 50 5 30 Cases recorded 100,00% 29 96,67% Physician in the rec. 11 33,33% 45 90,00% 0,00% Nurse in the rec. 27 81,82% 4 8,00% 26 89,66% Secretary in the rec. 8 24,24% Other in the rec. 1 3,03% 2,00% ESTONIA SPAIN GERMANY ALL COUNTRIES   % REGISTRATION Total cases 27 23 37 205 Cases recorded 100,00% 204 99,51% Physician in the rec. 0,00% 4 17,39% 12 32,43% 101 49,51% Nurse in the rec. 20 86,96% 109 53,43% Secretary in the rec. 1 2,70% 9 4,41% Other in the rec. 30 81,08% 32 15,69%

VIGNETTE 1 – RECORDING: TIME SPENT (minutes) HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL PHYSICIAN   Average time per case 0,7 2,1 0,0 2,4 0,3 0,6 1,1 Average time per patient 2,0 2,5 1,5 1,8 2,3 NURSE 0,2 2,6 4,5 1,7 3,0 3,2 SECRETARY 0,9 0,1 3,6 3,4 OTHER 0,04 2,2

VIGNETTE 1 – MICRO-COSTING HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY PHYSICIAN   Average time per case 9,4 13,2 0,0 11,4 2,7 8,9 7,6 Average cost € 1,88 € 16,11 € - € 1,38 € 0,57 € 9,60 Tariff per activity € 9,54 NURSE 6,2 1,4 8,1 8,6 16,0 7,2 € 0,81 € 0,60 € 4,10 € 1,83 € 4,76 SECRETARY 1,6 0,8 0,3 0,2 3,7 € 0,16 € 0,25 € 0,01 € 0,02 € 0,05 € 0,86 OTHER 0,6 0,4 0,1 2,1 € 0,06 € 0,38 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

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 doctor’s 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.

VIGNETTE 2 – VISIT: Professionals involved HUNGARY ITALY FINLAND LITHUANIA   % VISIT Total cases 52 23 39 30 Main Professional involved Physician Paediatr. Paediatrician/Physician in the visit 100,00% Nurse in the visit 26 50,00% 2 8,70% 66,67% 18 60,00% Secretary in the visit 15 28,85% 5 21,74% 13 33,33% 3 10,00% Other in the visit 16 30,77% 0,00% 4 10,26% ESTONIA SPAIN GERMANY ALL COUNTRIES   % VISIT Total cases 23 21 211 Main Professional involved Physician Paediatr. Paediatrician/Physician in the visit 100,00% Nurse in the visit 16 69,57% 10 47,62% 0,00% 98 46,45% Secretary in the visit 2 8,70% 9,52% 20 86,96% 60 28,44% Other in the visit 4 17,39% 27 12,80%

VIGNETTE 2 – VISIT : TIME SPENT - minutes HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL PAEDIATRICIAN/PHYSICIAN   Average time per case 13,9 16,3 13,8 15,7 14,7 13,4 12,7 14,3 Average time per patient NURSE 3,3 0,7 6,3 5,3 4,0 6,2 0,0 3,9 6,7 7,5 9,4 8,9 5,8 13,0 8,3 SECRETARY 2,0 1,2 1,3 0,2 0,1 6,6 1,7 6,8 5,4 2,3 8,0 1,5 7,6 6,0 OTHER 2,5 0,8 0,4 0,9 3,7 3,8 7,0 TOTAL TIME PER CASE 21,7 18,2 22,2 21,6 20,0 19,7 19,3 20,8

VIGNETTE 2 – PHARMACOLOGICAL TREATMENT: CATEGORIES OF DRUGS HUNGARY ITALY FINLAND LITHUANIA   % Pharmacological Treatment 49 94,23% 22 95,65% 34 87,18% 23 76,67% Fever reducer 12 24,49% 54,55% 2 5,88% 6 26,09% Bronchodilator 40 81,63% 11 50,00% 33 97,06% 17 73,91% Antibiotics 9 18,37% 8 36,36% 1 2,94% 5 21,74% Anti-inflammatory 10,20% 0,00% 4,35% ESTONIA SPAIN GERMANY ALL COUNTRIES   % Pharmacological Treatment 15 65,22% 21 100,00% 22 95,65% 186 88,15% Fever reducer 0,00% 9 42,86% 2 9,09% 43 23,12% Bronchodilator 12 80,00% 18 85,71% 153 82,26% Antibiotics 3 20,00% 1 4,76% 27 14,52% Anti-inflammatory 14 7,53%

VIGNETTE 2 – TESTS AND SPECIALIST INVOLVED HUNGARY ITALY FINLAND LITHUANIA   % Main Professional involved Physician Paediatr. Pharmacological Treatment 49 94,23% 22 95,65% 34 87,18% 23 76,67% Diagnostic Tests 20 38,46% 7 30,43% 18 46,15% 15 50,00% Specialist involved 21 40,38% 2 8,70% 25 64,10% 23,33% ESTONIA SPAIN GERMANY ALL COUNTRIES   % Main Professional involved Physician Paediatr. Pharmacological Treatment 15 65,22% 21 100,00% 22 95,65% 186 88,15% Diagnostic Tests 19 82,61% 0,00% 6 26,09% 85 40,28% Specialist involved 4 17,39% 1 4,76% 60 28,44%

VIGNETTE 2 – MICRO-COSTING HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY PAEDIATRICIAN/PHYSICIAN   Average time per case 16,3 20,2 17,8 21,6 18,5 17,1 16,6 Average cost € 3,25 € 27,67 € 17,69 € 2,62 € 3,98 € 15,82 Tariff per activity € 42,16 NURSE 4,8 0,7 7,4 5,3 4,0 7,9 0,0 € 0,63 € 0,28 € 3,77 € 0,50 € 0,46 € 5,20 SECRETARY 4,5 2,3 1,3 0,2 0,1 6,6 € 0,69 € 0,56 € 0,01 € 0,04 € 1,54 OTHER 5,7 0,8 0,4 € 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

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.

VIGNETTE 3 – VISITS IN 12 MONTHS: PC Professionals involved HUNGARY ITALY FINLAND LITHUANIA   % PC VISITS in 12 months Total cases 32 27 38 30 Physician in the visit 100,00% Nurse in the visit 31 96,88% 11 40,74% 34 89,47% 28 93,33% Secretary in the visit 10 31,25% 37,04% 14 36,84% 4 13,33% ESTONIA SPAIN GERMANY ALL COUNTRIES   % PC VISITS in 12 months Total cases 23 33 206 Physician in the visit 100,00% Nurse in the visit 183 88,83% Secretary in the visit 1 4,35% 5 21,74% 0,00% 44 21,36%

VIGNETTE 3 – VISITS : TIME SPENT in 12 months - minutes HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL PHYSICIAN   Average time per visit 11 18 25 15 19 13 12 16 Average number of visits per patient 6 3 2 5 4 Average time per case 65,9 57,4 45,3 74,5 73,3 27,3 47,5 55,8 Average time per patient NURSE 8 45 10 7 61,5 11,8 108,6 49,2 57,2 56,3 40,2 63,5 29,0 121,3 52,7 64,6 SECRETARY Average time per contact Average number of contacts per patient 9,4 7,9 9,2 3,0 0,7 1,5 0,0 4,9 30,0 21,4 25,1 22,5 16,0 6,8 22,8 TOTAL TIME PER CASE in 12 months - minutes 136,8 77,1 163,1 126,7 131,2 85,1 87,8 118,1

VIGNETTE 3 – DRUGS PRESCRIPTION HUNGARY ITALY FINLAND LITHUANIA   % Pharmacological Treatment 30 93,75% 26 96,30% 33 86,84% 28 93,33% Metformin 23 76,67% 25 96,15% 90,91% 100,00% ESTONIA SPAIN GERMANY ALL COUNTRIES   % Pharmacological Treatment 23 100,00% 17 73,91% 25 75,76% 182 88,35% Metformin 22 95,65% 16 94,12% 169 92,86%

VIGNETTE 3 – TESTS PRESCRIPTION HUNGARY ITALY FINLAND LITHUANIA   % Diagnostic Tests 28 87,50% 27 100,00% 36 94,74% 30 HbA1C 9 32,14% 22 81,48% 77,78% 93,33% Eye visit/ Fundus 26 96,30% 14 38,89% 86,67% ECG/Cardiologist 50,00% 15 55,56% 41,67% 6 20,00% Lipid profile/triglyc. 3 10,71% 16 59,26% 10 27,78% 4 13,33% Creatinine/kidney func. 2 7,14% 7,41% 20 11 36,67% Microalbum. 1 3,57% 33,33% 0,00% Blood sugar 19 70,37% 25 69,44% 53,33% ESTONIA SPAIN GERMANY ALL COUNTRIES   % Diagnostic Tests 23 100,00% 33 200 97,09% HbA1C 22 95,65% 7 30,43% 24 72,73% 140 70,00% Eye visit/ Fundus 17 73,91% 30 90,91% 163 81,50% ECG/Cardiologist 0,00% 11 47,83% 6 18,18% 67 33,50% Lipid profile/triglyc. 12 52,17% 5 21,74% 56 28,00% Creatinine/kidney func. 20 86,96% 2 8,70% 14 42,42% 71 35,50% Microalbum. 16 69,57% 4 17,39% 12,12% 44 22,00% Blood sugar 33,33% 78 39,00%

VIGNETTE 3 – SPECIALISTS INVOLVED HUNGARY ITALY FINLAND LITHUANIA   % Specialist involved 30 93,75% 25 92,59% 12 31,58% 29 96,67% Diabetologist/Endocr. 83,33% 14 56,00% 3 25,00% 27 93,10% Eye doctor 28 93,33% 100,00% 11 91,67% 26 89,66% Cardiologist 24 80,00% 23 92,00% 2 16,67% 7 24,14% ESTONIA SPAIN GERMANY ALL COUNTRIES   % Specialist involved 17 73,91% 21 91,30% 31 93,94% 165 80,10% Diabetologist/Endocr. 5 29,41% 3 14,29% 12 38,71% 89 53,94% Eye doctor 100,00% 159 96,36% Cardiologist 0,00% 8 25,81% 64 38,79%

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).

VIGNETTE 4 – TIME SPENT IN THE VISIT BY THE PHYSICIAN HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL Total cases 29 50 39 30 24 23 33 228 Total time 410 755 368,5 294 392,5 257 394 2871 TIME SPENT PER CASE 14,1 15,1 9,4 9,8 16,4 11,2 11,9 12,6

VIGNETTE 4 – PC Professionals’ Behavior HUNGARY ITALY FINLAND LITHUANIA   % VISIT Total cases 29 50 39 30 Advice on smoking 100,00% 47 94,00% 37 94,87% Ask in the future 49 98,00% 26 86,67% Recording 24 80,00% ESTONIA SPAIN GERMANY ALL COUNTRIES   % VISIT Total cases 24 23 33 228 Advice on smoking 100,00% 223 97,81% Ask in the future 31 93,94% 219 96,05% Recording 22 91,67% 72,73% 208 91,23%

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)

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

Thank you