1. Micro level: submission of vignettes and collection of data
WP3
Micro level: submission of vignettes and collection of data
3rd November 2011, Milan
Italian team

2. WP3: Overall task
To identify a methodology for cost measurement in primary care both at Macro and at Micro level

3. 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

4. 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
To collect data
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

5. Translation of vignettes
To translate the vignettes
The translation procedure consisted of three steps:
Translation of the vignettes and questionnaires from English to Local language, involving a language expert
Translation of the vignettes and questionnaires from Local language to English, involving a different language expert
Comparison between the original English version of the vignettes and the one resulting from the double translation

6. Translation of vignettes
To translate the vignettes: results from back translations
Vignette 1
Vignette 2
Vignette 3
Vignette 4
Spain ok
minor differences
Germany
minor differences + additional questions
Finland
Hungary
Lithuania
Estonia

7. Validation of vignettes
To validate the vignettes
After having properly translated the vignettes and the questionnaires, the four scenarios have to be validated by professionals.
The validation requires the involvement of 3 to 5 professionals, to be chosen among those who mainly follows the patient in the specific scenarios described. Obviously, the same professional will validate more than one vignettes.
Italy did the validation by interviewing 2 general practitioners and 1 paediatrician: the GPs answered on vignettes 1, 3 and 4, while the paediatrician answered on vignette 2.
Partners were supposed to validated vignettes by 17th October  NO PROBLEMS HAVE OCCURED

8. Submission of vignettes
To submit the vignettes to primary care professionals
Once validated and translated, vignettes are to be submitted to primary care professionals in each country. The choice of respondents for each vignette is based on types of professionals mainly involved.
Which Professionals? GP
Paediatrician
PC nurse
Specialist
Other
V.1 - Vaccination 6 5 1
V.2 - Child bronchitis 4
V.3 - Diabetic patient 7 3
V.4 - Health promotion -Smoking cessation

9. Submission of vignettes
To submit the vignettes to primary care professionals
Vignettes have to be submitted:
personally, by interviewers from each country
to a group of professionals of the same kind (e.g., a group of GPs, a group of paediatricians, a group of nurses): the number of the members for each group will be 25 to 30 and different vignettes could be submitted to the same group
through a written questionnaire: professionals of each group will be requested to answer to the questions related to each vignette in writing

10. Submission of vignettes
To submit the vignettes to primary care professionals
Recommendations
each country has to abide to the minimum number of professionals to be interviewed for each professional figure involved (= 25). However, professionals can be cluster in smaller groups that interviewers meet at different time (for instance, you can interview 2 groups of 15 general practitioners each)  Italy: we have already submitted vignettes to 24 GPs of the Emilia-Romagna region, clustered in groups of 4 in the same day. Our goal is to interview 30 GPs
it is extremely important that each vignette is submitted only to a group of professionals; on the contrary, more than one vignette could be submitted to the same group  Italy: we have submitted vignette 1, 3 and 4 to the 24 GPs

11. Submission of vignettes
To submit the vignettes to primary care professionals
Recommendations :
meetings should be organized in “neutral” places, in order to not influence interviewees  Italy: we did not organize the meeting in Bocconi University, nor in GPs practices. We met GPs on a Saturday, in their medical association’s base
at the beginning of each meeting the meaning of the Project should be explained to the respondents, spending at least 10 minutes; then, a brief introduction of the vignettes has to be provided, paying attention not to add any comments that could somehow influence the professionals  Italy: we gave an overview of the main goals of the project and did not mention any content of the vignettes

12. Submission of vignettes
To submit the vignettes to primary care professionals
Recommendations
before distributing the vignettes and questionnaires, respondents have to be asked to answer the questions autonomously, avoiding to talk with their neighbors; also, professionals have to be informed that questionnaires are anonymous and that they would have 15 minutes per vignette to answer the questionnaire
after the introduction and the illustration of the rules, a paper copy of vignettes, along with the related questionnaires, has to be distributed. Please note: it is very important to distribute one vignette and questionnaire at a time
it could be kind and useful to give the respondents a little present to thank them: Italy we did it and the GPs appreciated it!

13. Submission of vignettes
To submit the vignettes to primary care professionals
Other suggestions from Italian first experience:
Try not to stress too much on the goal of costing the activities described in the vignettes: doctors do not love costing objectives and, most of all, they do not like to be evaluated on the basis of costs  on the contrary, try to underline the international value of the project and the extreme utility of the information they are going to give you through the questionnaires
Doctors tend to ask very specific questions, especially regarding clinical details. For the sake of homogeneity, we had to describe clinical cases in general terms  try to suggest them to think to the “average” patient

14. Submission of vignettes
To submit the vignettes to primary care professionals
Other suggestions from Italian first experience:
Try to distribute each questionnaire simultaneously to all the respondents of the group: if someone completes the questionnaire earlier he/she will kindly wait for the others to finish
On our experience, doctors are very interested on the final results of the project  it could be useful to assure that you will provide deliverables/final reports, especially regarding PC models, overall costs of the system, quality dimensions and quality indicators.

15. Collection of data EXAMPLE  DATABASE for VIGNETTE 1 To collect data
After the submission of vignettes is completed, each partner will be asked to summarize the information collected into a database that we will provide by early December.
EXAMPLE  DATABASE for VIGNETTE 1

16. GANTT September October November December TRANSLATION 10th October
VALIDATION
17th October
SUBMISSION
9th December
COLLECTION
20th December

17. Next steps
To measure resources consumption in the delivery of services involved in the clinical vignettes
One of the most accredited methods to cost health care services/activities is the Time-Driven Activity-Based Costing (TDABC). Besides the time to carry out an activity, additional resources -e.g. drugs, tests- consumed in the management of that case will be collected through the vignettes and then monetized. We have provided guidance on how to carry out this step in the WP3 Deliverable (30th June) and we will improve the process with more details after having analyzed data collected through vignettes  Next year

18. Next steps
To describe how certain primary care cases are managed in different systems
This is an indirect achievement coming from Micro costing: we could think about how to use the valuable information regarding the delivery process of certain services

19. Thank you