Access points to the different levels of health care in a country without a gate-keeping system; numbers and reasons Kathryn Hoffmann 1, K. Viktoria Stein 2, Manfred Maier 1, Anita Rieder 2, Thomas E. Dorner 2 1 Department of General Practice, Centre for Public Health, Medical University of Vienna, Austria 2 Institute for Social Medicine, Centre for Public Health, Medical University of Vienna

The challenges for health care systems become more and more evident in terms of costs, of health equity, and of healthy life expectancy Currently, the most promising way to face these challenges seems to be to strengthen the PHC sector - however, the evidence is not conclusive yet Evident is that accessibility to PHC is an important dimension Normally, a main challenge for health care systems is an existing limitation (e.g. financially, regionally,...) towards the accessibility In Austria, the situation is contrary: Fishbain D.A. et al., 1997; Dorner T.E. et al., 2010 Background

Accessibility to the Austrian health care system is excellent (no financial barriers for patients, 98% of population insured, Bismarck-system) but......with some exceptions patients have free access to both the primary AND secondary level of care  it depends on the estimation of the patient, which level of care she or he consults...Austria has a secondary care focused health care system (and fee-for- service mainly) – e.g. more specialists working in the ambulatory sector than GPs (~9500 specialists and ~6500 GPs) – e.g. no gate-keeping or list system Background

Within this context it was the aim of this study to assess the number of persons consulting a General Practitioner (GP) or specialist in the ambulatory sector, an outpatient department, or had a hospital overnight stay within one year Furthermore, to assess the number and demographic factors of patients that turned to a specialist without consulting a GP concomitantly Finally, to learn about the main reason why these patients turned to a specialist directly Aim and objective

Secondary data analysis The database used for this analysis was the Austrian Health Interview Survey (450 items), with data from 15,474 people > 15 years old (face-to-face interviews) Based on the European Core Health Interview Survey Design Aromaa, A et al., Eur J Public Health 2003;13(Suppl 3):67-72 Stein K.V. et al., Int. J Health Geographics 2011, 10:59

Variables of the utilisation of the healthcare system – Within the last 12 months, did you turn to a GP? (yes – no) – Within the last 12 months, did you consult any specialist in the ambulatory sector/an outpatient department/did you have a hospital overnight-stay? (yes – no) Direct utilisation of specialists – Taking all persons into account that turned to a specialist/outpatient department/hospital and assessing the dichotomised answers to the GP question Demographic variables (gender, age, country of origin, educational level, location, number of chronic diseases surveyed) Design

Main reason for the last direct specialists consultation: – Answer categories: Accident or injury/disease or symptom of a disease/follow-up consultation/preventive check-up/other reasons Statistical analyses included – descriptive statistics – multivariate logistic regression models Analysis

Results (I) GP consultation rate: M 75.6% vs. F 81.8% (p<0.05) Specialist conultation rate: M 54.0% vs. F 79.8% (p<0.05) Outpatient department visit: M 18.3% vs. 18.9% (p>0.05) Hospital stay: M 21.2% vs. 24.3% (p<0.05) Direct specialist consultation rate: M 15.2% vs. F 15.0% (p>0.05) Direct outpatient department contact: 9.5% vs. 7.6% (p>0.05) Direct hospitalisation: 8.6% vs. 7.7% (p>0.05)

Results (II)

Results (III)

Discussion (I) Utilisation rate of GPs is comparable with other Western European countries Utilisation rate of specialists (67.4%) is two-to three-fold higher than in EU-countries with gate-keeping system (e.g. Norway 17%, Ireland 25%) Austria lies beneath the EU27 level for the health indicator „healthy life year expectancy“ Hospitalisation rate is not reduced, in the opposite, it is one of the highest in Europe Nearly every 6 th person who consulted a specialist, every 11 th person who consulted an outpatient department and nearly every 12 th person with a hospital stay ha no GP contact A frequent reason for direct utilisation was a preventive check-up

Strengths Large sample size Comprehensive questionnaire High external validity for Austria Limitations Results based on self-descriptive data (12 months) Cross sectional study No diagnoses  could not analyse the appropriateness of care!!! Discussion (II)

The overall access rates of specialists as well as of specialists without GP consultations are high The high utilisation rate of specialists working in the ambulatory sector is not reflected in low rates of hospital stays or other quality indicators compared with other EU countries The results point into the direction of a benefit through a structurally supported advocacy role for PHC professionals The knowledge gained through this analysis could contribute to the health policy debate on the importance of coordination and continuity at the primary care level Conclusion

Results (III)