EUprimecare : Quality and Costs of Primary Care in Europe
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EUprimecare: Quality and Costs of Primary Care in Europe
September 2012, Gothenburg (Sweden)European Forum Primary Care
Grant Agreement no. 241595
Dr. Antonio Sarría-Santamera (ISCIII)Sonia García (ISCIII)
Eleonora Corsalini (UB)
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• The goals of any healthcare system:• Deliver effective, safe, quality personal and non-personal
health interventions to those that need them, when and where needed, with minimum waste of resources
Access
Costs Quality
Background
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• The Tallin Charter • Strengthening of health systems to improve people's health
but keeping equity.
• Primary Care • Basic structure of health system• Eliminating health disparities
Background
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• Common framework to describe Primary Care models in the EU is not available
• Not yet developed a trans-national consensus on how to define quality of Primary Care
• Cost of Primary Care are not well identified in national accounting systems
Background
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Objectives
• To contribute to improving the knowledge regarding Primary Care in Europe:
exploring the relationships that could exist between Quality and Costs of different models and systems of organizing and delivering PC across Europe
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• Institute of Health Carlos III. ISCIII. Spain • Universität Bielefeld. UNIBI. Germany • University of Tartu. UTartu. Estonia • National Institute for Strategic Health Research. ESKI. Hungary • Országos Alapellátási Intezet. OALI. Hungary • Institute for health and Welfare. THL. Finland • Kaunas University of Medicine. KMU. Lithuania• Universitá Commerciale Luigi Bocconi. UB. Italy
Partners
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Conceptual structure
Identify a methodology to measure the PC quality
WP 5 & 6
Identify a methodology to measure costs in PC
WP 3 & 4
WP 7
WP2
Evaluation of PC models
CO
OR
DIN
AT
ION
W
P 1
DIS
SM
INA
TIO
N
W
P 8
To measure the health quality in PC
To measure costs in PC
ORGANIZATION OF PRIMARY CARE IN
EUROPE
REGULATION
FINANCING
PAYMENTORGANIZATION
ORGANIZATIONAL BEHAVIOUR
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• Costs
• Quality:
Approach
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Work package 2: Evaluation of PC models in
EuropeMethodological Approach of a Classification System of PC Models in Europe : Germany, Spain, Estonia, Finland, Hungary, Italia and Lithuania.
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WP2: Methodology
1. Literature review• Structure or process of PC in Europe• Control knobs: financing, regulation, payment, organization, and
organizational behavior
2. Selection of indicators => template design:1. 5 variables (Control knobs) to optimize healthcare systems results:
2. Range of services
3. Descriptive Analysis & Principal Component Analysis
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FINANCING Mixed model
(Hungary)
BISMARCK SS(Estonia, Germany,
Lithuania)
BEVERIDGE NHS(Finland, Italy,
Spain)
7% Uninsured
10,6% Private Insurance18,8% Double coverage
Expenditure in HCas GDP
10,5%
6,1% 6,6%
24%
Expenditure in PC
5,7%
16% Double coverage
Descriptive analysis (I)
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• Formal mechanisms to guarantee accessibility, equity and quality of healthcare
• Gate-keeping systems, except in Germany
• Facilities:• Mostly public: Finland, Spain, Hungary and Lithuania• Totally private: Germany, Estonia and Italy
• Clinical practice: • Integrated network: Finland and Spain• Solo and group practices: Germany, Estonia, Italy, Lithuania, Hungary
REGULATION
ORGANIZATION
Descriptive analysis (II)
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• Process to monitoring and improving the quality of medical practice: • Quality management systems measuring clinical and no clinical
quality indicators• Clinical practices guidelines• Continuing education
ORGANIZATIONAL BEHAVIOUR
Descriptive analysis (III)
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Provision of services through national/regional/local health systems (Yes/No)
Private voluntary health insurance (Yes/No)
Geographical distribution of PC services (Yes/No)
Professional income (Capitation/Salary/Fee for service/Out of pocket)
Gatekeeping for specialist (Yes/No) Type of facilities (Public/private) Type of clinical practice (Solo practice/Group practice/ Network)
Improvement programs & Quality management systems (Yes/No) Continuing clinical education program (Yes/No) Local adaptation of clinical practice guideline (Yes/No)
Financing
Regulation
Organization
Payment
Organizational behavior
Quantitative analysis (PCA)
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Range of services
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Results of Qualitative analysis
Based on a functional perspective, allowed to proposing 5 models:
1.Direct access to specialist
2.Referral required from GP, mainly solo-practices in PC3.Referral required from GP, mainly group-practices in PC
4.Health care centers5.Polyclinics
• Based on a functional perspective, allowed to proposing 5 functional models:
• Model 1: Direct access to any GP or specialist (Germany)• Model 2: Referral required from GP, mainly solo-practices in PC
(Hungary, Italy)• Model 3: Referral required from GP, mainly group-practices in PC
(Estonia, Lithuania)• Model 4: GPs working mainly in health care centres (Finland, Spain)• Model 5: Polyclinics (Shemasko). Not necessarily GPs at all
Results
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Validation models of PC in Europe (24 countries EU )
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COUNTRYGEOGRAPHICAL DISTRIBUTION
OF PRIMARY CARE SERVICES
National system
Regiona/local system
Multiple Insurers
Complementary & suplementary
Duplicative
ESTONIAFINLANDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC
PROVISION SERVICES VOLUNTARY PRIVATE INSURANCE
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Capitation SalaryFee for service
Out of pocket
ESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC
COUNTRYPROFESSIONAL INCOME *
*Predominance
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COUNTRYGATEKEEPING TO
SPECIALISTS TYPE OF
FACILITIES*
Public Solo practice Group practiceIntegrated
networkESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC
TYPE OF PRACTICE*
* Predominance
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COUNTRY
FORMAL QUALITY MANAGEMENT & IMPROVEMENT PROGRAMMES
CONTINUING CLINICAL EDUCATION
PROGRAMMES
LOCAL ADAPTATION OF
CLINICAL GUIDELINES
ESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC
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Framework for classification of health systems based on PCMultidimensional => more complex => more realistic
Healthcare services provision Basic coverageGate-keeping
Private insurances Professional payment
Type of facilities Type of practice
Conclusions
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Work package 3&4: Costs of Primary Care Systems
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4 clinical vignettes representing the main areas of activity of PC: Acute care Chronic care Health promotion Prevention (vaccination)
Methodology Micro-costing
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Methodology Macro-costing
• Actual costs: Real not estimated• Usual accounting principles and practices• Indicated in the estimated overall budget
Incl
udes Personnel Costs
Durable EquipmentConsumables and supplies identifiable
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Work package 5&6: Quality of Primary Care Systems
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• Focus Group Discussion :• Patients (n= 53)• Primary care professionals (n= 64)• 7 countries: Estonia, Finland, Germany, Hungary, Italy, Lithuania, Spain.
• Helped to understand the views about quality in the different partner countries and to set a list of quality criteria.
• Non-clinical indicators for each criteria were identified from the literature review and prioritized by scoring according to importance and measurability.
Methodology Quality Indicators
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60 Quality Indicators (aprox) selected to measure Quality of PC in Europe
Methodology Quality Indicators
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Population Survey:
A sample of 3.020 persons25-75 years old7 countries participating in the projectDomains:
Socio-demographicSatisfactionSelf-perceived healthUtilization of servicesPrevention and health promotion interventions
Methodology Quality at the Population Level
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Professional survey:
Medical records: Diabetes and blood pressure high14 indicators Specific approach for extracting data in each country
(sample)
Methodology Quality at the Clinical Level