• Quality follow up programme in primary care. Experiences from Västra Götaland

what have we learned?

Staffan Björck, Analysenheten, Regionkansliet, Västra Götalandsregion

Region Västra Götaland1.5 mil. Inhab.16% of Sweden

Göteborg

Västra Götalandsregionen

• financing, primary care centres:

• Capitation, listed patients• Age and gender• ACG, adjusted clinical groups• CNI, care need index• Distance to hospital

– P4P (quality)• initially 3 % with aim to increase• 4,3 % 2011

Number of patients with diabetes in regional database

Effect of ACG on reporting of diagnoses

0

10 000

20 000

30 000

40 000

50 000

60 000

70 000

2005

2006

2007

2008

2009

2010

patie

nts

Current prevalence of atrial fibrillation in Västra Götaland

Effect of ACG on reporting of diagnoses

0

5

10

15

20

25

30

35

40

40-

49

50-

59

60-

69

70-

79

80-

89 90-

Total

age

pe

rcen

t

menwomen

=2.44%

Follow up quality of care

• Identify indicators

• System for payment for performance

How to do it?Learn from others

Develop your own version

• Learn from others– Reports on Swedish experiences– International experience

Most common Indicators for P4P in Sweden, Anell 2009

måttCounties

nAdherence to drug recommendations 11Access by telephone 10Diabetic patients in national registry 9Patients visits to own centre 9Right choice of UTI antibiotics 7Prescription of physical activity 5Choice of least expensive BP lowering drug 4

”It is clear that there is a need for better follow up systems for primary care in Sweden and there is a great potential for cooperation between counties”

How to select indicators?

Q-indicators

PaymentResults to bemade public Medical audit

Useful informationto centres

Principles 1

Principles 2

• Quality indicators– Automated data collection– Evidence based– Avoid ”how”, focus on results – As few as possible but enough to

give meaningful information– Enough measures to spread

economic risk

Principles 3 What do they do in primary care and what is

important?

0

50 000

100 000

150 000

200 000

250 000

300 000

<1 1 >1-2 >2-4 >3-4 >4

antal läk.besök/år vuxna

ind

ivid

er

Satis

fact

ion, w

ait

times

, dru

g choic

e

etc

Chronic

dis

ease

≈ 50 % rare visitors

≈ 50 % chronic disease

Number of doctors visits during 2 years

Quality indicators

Primary care

29

14

5138821439153

19296

141

Indicators

Listed population characteristics

Other statistics

Chronic disease DiabetesHypertensionIschemic heart diseaseHeart failureStrokeCOPAsthmaPsychiatric disordersOthers

Children's care Prevention

Drugs Access to carePatient experience Organisation etc

Indicators, Diabetes Primary care

regi

stra

tion

resu

ltsIndicator

1 Registration national database

2 Blood pressure3 Smoking4 HbA1c5 LDL-kolesterol6 Albuminuria7 Target for HbA1c8 Target for HbA1c, recent onset9 Target for Blood pressure

10 Target for LDL-cholesterol

11 Patient education

12 Integrated care

13 Influenza immunisation

Principles P4Pexample diabetes

High/low limits

Weight

Limits Relativepoints

Registration national database 70-90 5

Registration blood pressure

80-95 0,5

Registration blood pressure 70-90 0,5 Registration HbA1c 80-95 0,5 Registration LDL-cholesterol 50-80 0,5 Registration albuminuri 70-90 0,5

Target for HbA1c 45-65 0,5 Target for blood pressure 30-50 0,5 Target for LDL-cholesterol- 35-50 1 sum 9,5

• Principles– pay for registration– Relative weights– No sharp thresholds– Spread of economic

risk

+ 4 other indicators without P4P

• Differences vs NHS example– No exception reporting– Targets more difficult to reach– Much lower financial incentive– Focus on registration to give high quality feed

back of results

0

10

20

30

40

50

60

70

80

perc

ent

0

10

20

30

40

50

60

70

80p

erc

en

t

ExamplesResults

Influenza immunisation, patients 65+

Children with antibiotic prescriptions/ year

P4P range

Each dot = a primary care center, with confidence intervals

Webb access to results

160 000patients

• Main data sources– National diabetes registry– Regional Primary care quality registry – Drug prescription registry – Regional database for contacts– Swedish vaccination registry– Manual reporting

The regional primary care quality registry

• Automated data collection from local patient files– Ischemic heart disease– Hypertension– COP– Asthma– Diabetes

• Monthly update and back-reporting to centres

Interaction between diseases, primary care register

Hypertension

198 238

Diabetes 65 730

Ischemic. Heart disease

44 317

58 %

9 %

14 %

6 %

1 % 3 %

8 %

Total 239 349

• P4P – 41 indicators

• How to pay? 3 principles – Decided standard– Professional recommendations– Statistical limits

• For example 25 % full payment, 25 % no payment

Diabetes registry. Proportion reaching target for LDL-kolesterol (<2,5 mmol/l)

Targets for payment?

Statistical limits

0

10

20

30

40

50

60

70

80

90

100

pe

rce

nt

Each dot = a primary care center

• Example of difficulties, P4P– Professional scepticism– Patient groups to small for reliable

comparisons– Data sources have to be created– Leads to focus on money, not on results,

wrong focus– Resource consuming technical solutions

• Lessons learned– P4P just one small part of quality improvement programme – Focus on pay for registration, – < 4% of total payment– Involve profession!– Easy access to results– Must be combined with continuous analysis and discussion,

reports, seminars etc. Professional dialogue. – Transaction cost– National cooperation

• National primary care register• Cooperation between local quality registers