1. Micro-costing: some results from vignettes
WP4.2
Micro-costing: some results from vignettes
11th and 12th 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
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

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

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

7. DIRECT PERSONNEL COSTS – BY COUNTRY
LITHUANIA
ESTONIA
SPAIN
Physician
avarage cost per year € € €
total amount of hours worked per year
1915
1911
1533
cost per hour
€ ,35
€ ,54
€ ,80
tariff per activity
cost per minute
€ ,11
€ ,16
€ ,90
Nurse € € €
2194
€ ,89
€ ,09
€ ,67
€ ,08
€ ,54
Overheads estimation
yearly overheads
15%
35%
21%
total cost per minute Physician
€ ,12
€ ,21
€ ,08
total cost per minute Nurse
€ ,09
€ ,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
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%

10. 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

11. 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%

12. 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

13. 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
€ ,88
€ ,11 €
€ ,38
€ ,57
€ ,60
Tariff per activity
€ ,54
NURSE
6,2
1,4
8,1
8,6
16,0
7,2
€ ,81
€ ,60
€ ,10
€ ,83
€ ,76
SECRETARY
1,6
0,8
0,3
0,2
3,7
€ ,16
€ ,25
€ ,01
€ ,02
€ ,05
€ ,86
OTHER
0,6
0,4
0,1
2,1
€ ,06
€ ,38
TOTAL LABOUR COST
€ ,91
€ ,33
€ ,10
€ ,22
€ ,43
€ ,42
€ ,54
VACCINE - Average price
€ ,66
€ ,39
€ ,90
€ ,52
€ ,46
€ ,03
€ ,55
OUT OF POCKET - Average price
€ ,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 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.

15. 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%

16. 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

17. 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%

18. 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%

19. 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
€ ,25
€ ,67
€ ,69
€ ,62
€ ,98
€ ,82
Tariff per activity
€ ,16
NURSE
4,8
0,7
7,4
5,3
4,0
7,9
0,0
€ ,63
€ ,28
€ ,77
€ ,50
€ ,46
€ ,20
SECRETARY
4,5
2,3
1,3
0,2
0,1
6,6
€ ,69
€ ,56
€ ,01
€ ,04
€ ,54
OTHER
5,7
0,8
0,4
€ ,59 €
€ ,77
€ ,02
€ ,07
TOTAL LABOUR COST
€ ,94
€ ,64
€ ,78
€ ,15
€ ,56
€ ,06
€ ,16
DRUGS - Average cost
€ ,44
€ ,20
€ ,61
€ ,35
€ ,83
€ ,54
€ ,47
TESTS - Average cost
€ ,18
€ ,85
€ ,66
€ ,81
€ ,57
€ ,58
TOTAL COST
€ 12,57
€ 45,69
€ 38,05
€ ,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
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%

22. 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

23. 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%

24. 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%

25. 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%

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
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

28. 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%

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:
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

31. Thank you