Calidad y Costes en Europa Grant Agreement No. 241595 Euprimecare Modelos de Atención Primaria Calidad y Costes en Europa

Equipo ISCIII Almudena Albertos Sonia García Javier Prado Galbarro Virginia del Pino Patricia García Cediel Ely Parody Xily Martín Mª Angeles Guzmán Carlos Segovia

Triangulo de Hierro Calidad Acceso Coste Para cumplir estos objetivos es esencial entender la relación entre : La calidad de los aspectos que definen un estado de salud Los beneficios de los servicios q presta a la población La distribución de los recursos y costes para la prestación de la asistencia sanitaria Acceso Coste

Triangulo de Hierro Efectividad Equidad Eficiencia Para cumplir estos objetivos es esencial entender la relación entre : La calidad de los aspectos que definen un estado de salud Los beneficios de los servicios q presta a la población La distribución de los recursos y costes para la prestación de la asistencia sanitaria Equidad Eficiencia

Atención primaria “fuerte” Para cumplir estos objetivos es esencial entender la relación entre : La calidad de los aspectos que definen un estado de salud Los beneficios de los servicios q presta a la población La distribución de los recursos y costes para la prestación de la asistencia sanitaria ¿Qué es una Atención Primaria fuerte?

Necesidades de información Modelo conceptual común para describir los modelos de Atención Primaria en Europa Consenso trans-nacional sobre cómo medir Calidad en Atención Primaria Las diferencias en los modelos de financiación y pago dificultan saber los Costes en Atención Primaria

Objetivo Explorar las relaciones que pueden existir entre Calidad y Costes de los Modelos de Atención Primaria en Europa

Partners Institute of Health Carlos III. ISCIII. Spain Universität Bielefeld. UNIBI. Germany University of Tartu. UTartu. Estonia National Institute for Strategic Health Research. GYEMSZI. Hungary Országos Alapellátási Intezet. OALI. Hungary Institute for health and Welfare. THL. Finland Kaunas University of Medicine. LSMU. Lithuania Universitá Commerciale Luigi Bocconi. UB. Italy

COMPORTAMIENTO ORGANIZATIVO Marco Conceptual Desarrollar una metodología y medir Calidad WP 5 & 6 WP 3 & 4 WP 7 WP2 COORDINACION WP 1 DISEMINACION WP 8 MODELOS REGULACION FINANCIACION PAGO ORGANIZACION COMPORTAMIENTO ORGANIZATIVO Desarrollar una metodología y medir Costes

Perspectivas Costes Calidad To define and validate models of Primary Care in Europe For the collection of data on Primary Care a template has been developed considering 5 health system control dimensions: financing, regulation, payment, organization and behaviour. The information from the template will be used for the definition and validation of Primary Care models This will based on coherent relationship between the different aspects explored in the 5 given dimensions. he first step was a literature search which reviewed the exsiting published knowledge regarding PC models in Europe.

Modelos de Atención Primaria

Metodología Revisión de la literatura Selección de indicadores => cuestionario (7 países) Análisis The first step was a literature search which reviewed the exsiting published knowledge regarding PC models in Europe.

Modelos funcionales Results of Qualitative analysis Based on a functional perspective, allowed to proposing 5 models: Direct access to specialist Referral required from GP, mainly solo-practices in PC Referral required from GP, mainly group-practices in PC Health care centers Polyclinics Modelos funcionales Modelo 1, Acceso directo a especialista, AP solos (Alemania) Modelo 2, Derivación al especialista, AP solos (Hungría, Italia) Modelo 3, Derivación al especialista, AP grupos(Estonia, Lituania) Modelo 4, Derivación al especialista, redes (Finlandia, España) Modelo 5, Policlínicos (Shemasko), no necesariamente AP Direct access to any GP or specialist Referral required from GP, mainly solo-practices in PH Referral required from G, mainly group-practices in PHC GPs working mainly in health care centers Polyclinics (Russian Federation, Armenia, Azerbaijan)

Análisis descriptivo FINANCIACION BISMARCK SS (Estonia, Alemania, Mixto (Hungría) BISMARCK SS (Estonia, Alemania, Lituania) BEVERIDGE NHS (Finlandia, Italia, España) 7% Sin seguro 10,6% Seguro privado 18,8% Doble covertura Gasto en AP %GPD 10,5% 6,1% 6,6% 24% Gasto en AP% 5,7% 16% Seguro privado There are 3 countries with Social Security System (Bismarck model): Estonia, Germany and Lithuania. In the other hand there are also 3 countries with National Health System (Beveridge model): Finland, Italy and Spain meanwhile Hungary presents a mixed model. As we can see there are several interesting conclusions to commenting. Finland, Germany and Hungary don´t have basic primary national coverage and Estonia is the country with the highest proportion of uninsured population, 7%. Germany has the highest percentage of population with private insurance, the 10.6% and with Italy both are the countries with higher percentage of double coverage, 18,8% and 16% respectively. The countries with higher share of public contribution to healthcare financing are: Estonia, 77,8%, Italy 77,2% and Germany with the 76,9%. Nevertheless the highest healthcare expenditure as %GDP belong to Germany with the 10,5% meanwhile the lower were Lithuania, the 6,6% and Estonia with the 6,1%. Finally, the highest proportion of overall health expenditures allocated in PC comes from Finland with a 24% while Italy has the lowest percentage, the 5,7%.

Análisis descriptivo REGULACION ORGANIZACION Mecanismos formales para garantizar accessibilidad/equidad, calidad Derivaciones (excepto en Alemania) ORGANIZACION Centros: Mayoritariamente pública: Finlandia, España, Hungría, Lituania Totalmente privada: Alemania, Estonia, Italia Modelos de trabajo: Red integrada: Finlandia y España Solo & grupo: Alemania, Italia Lituania, Hungría In terms of REGULATION, Every country has established formal mechanisms to guarantee accessibility, equity and quality of healthcare. There are differences in terms of the regulation of access both the PC professionals and to specialists. For instance in Germany and although since 2007 there is a specific mechanism establisehd to regulate access to specialists through a gatekeeping system which have some financial advantages. Regarding the Organizational dimension, there are significant differences in terms of how predominant are public and private facilities. In Finland, Spain, Hungary and Lithuania there is a majority of public facilities meanwhile in Germany, Estonia and Italy, they are a 100% private. In terms of models of practice, Finalnd and Spain show integrated networks, while the rest of countries sahre solo and group practices however with different proportions in each country. For instance in Hungary, GPs work in solo practice meanwhile group practices are only in out-of-hours provision.

Servicios en AP This table shows the different range of services which are provided in each country. As we can see, Finalnd, Spain and Lithuania are the countries with more services meanwhile Germany and Italy have the lower quantity of services. Regarding the services which all countries consider as PC activities are: -Diagnosis and treatment of common health problems acute or long term -Provision of individualized preventive service to adults and -ECG examinations

Características para definir modelos de AP Sistema nacional/regiona/loca (SI/NO) Seguro voluntario privado (SI/NO) Planificación de la distribución de servicios de AP (SI/NO) Pago a profesionales (Capitación/Salario/Pago por acto/Pago pacientes) Derivación a especialistas (SI/NO) Centros públicos-privados Forma de trabajo (Solo/Grupo/Redes) Gestión y mejora de calidad (SI/NO) Formación continuada (SI/NO) Guías de práctica clínica locales (SI/NO) FINANCIACION REGULACION ORGANIZACION PAGO CONDUCTA ORGANIZATIVA

Multidimensional => Complejo => Realista Servicios y actividades Conclusiones Multidimensional => Complejo => Realista Servicios y actividades Financiación Pago a profesionales Derivaciones Público-privado Formas de trabajo

Costes

Micro-costes Viñetas clínicas Agudos Crónicos Promoción y educación para la salud Prevención (vacuna)

Viñetas

V2 – Niño de 2 años: Profesionales Country Total cases Paediatrician General Physician Nurse Secretary Other PC professional Hungary 52 100,00%   50,00% 28,85% 30,77% Italy 23 8,70% 21,74% 0,00% Finland 39 66,67% 33,33% 10,26% Lithuania 30 60,00% 10,00% Estonia 69,57% 17,39% Spain 21 47,62% 9,52% Germany 86,96% All countries 211 46,45% 28,44% 12,80%

V2 – Niño de 2 años: Tiempos Hungary Italy Finland Lithuania Estonia Spain Germany Paediat./General Physician   Average time per case 13,9 16,3 13,8 15,7 14,7 13,4 12,7 Nurse 3,3 0,7 6,3 5,3 4,0 6,2 0,0 Other PC professional 2,5 0,8 0,4 Total time per case 19,8 17,0 20,9 21,4 19,3 19,6

V2 – Niño de 2 años: Variabilidad   Hungary Italy Finland Lithuania Estonia Spain Germany Paediat./General Physician Min 5 10 1 6 Max 30 38 20 40 ST.DEV. 6,64 5,92 5,82 5,97 5,48 7,70 5,90 Average time per patient 13,88 16,35 13,85 15,67 14,65 13,38 12,65

V2 – Niño de 2 años: Patrones clínicos Hungary Italy Finland Lithuania Estonia Spain Germany All countries Pharmacological Treatment 94,23% 95,65% 87,18% 76,67% 65,22% 100,00% 88,15%   Categories of drugs Fever reducer 24,49% 54,55% 5,88% 26,09% 0,00% 42,86% 9,09% 23,12% Bronchodilator 81,63% 50,00% 97,06% 73,91% 80,00% 85,71% 82,26% Antibiotics 18,37% 36,36% 2,94% 21,74% 20,00% 4,76% 14,52% Anti-inflammatory 10,20% 4,35% 7,53% Hungary Italy Finland Lithuania Estonia Spain Germany All countries Diagnostic tests 38,46% 30,43% 46,15% 50,00% 82,61% 0,00% 26,09% 40,28%   Specialist involved 40,38% 8,70% 64,10% 23,33% 17,39% 4,76% 28,44%

V2 – Niño de 2 años: Micro-costes Hungary Italy Finland Lithuania Estonia Spain Germany Paediat./General Physician € 3,86 € 26,83 € 14,13 € 4,17 € 5,05 € 16,24 € 59,51   Nurse € 0,74 € 0,27 € 3,01 € 0,79 € 0,58 € 5,34 Secretary € 0,55 € 0,67 € 0,45 € 0,02 € 0,06 € 0,04 Assistant/Trainee € 0,70 € - € 0,61 € 0,03 € 0,09 TOTAL LABOUR COST € 5,86 € 27,78 € 18,20 € 5,01 € 5,78 € 21,62 DRUGS COST € 8,47 € 11,83 € 9,28 € 5,11 € 3,59 € 4,66 € 13,07 TESTS COST € 3,40 € 4,71 € 2,92 € 4,29 € 4,52 € - € 16,03 OUT-OF-POCKET TOTAL COST € 17,72 € 44,32 € 30,39 € 14,41 € 13,88 € 26,27 € 88,62 Hourly cost

Calidad

Metodología Grupos Focales: Pacientes (n= 53) Profesionales (n= 64) 7 países Identificar sus perspectivas sobre la calidad y proponer una lista de criterios de calidad Revisión de la literatura para buscar Indicadores no-clínicos para cada criterio priorizados de acuerdo a su importancia y factibilidad Consenso entre los investigadores

Methodology Quality Indicators 60 Indicadores

Medida de calidad a nivel poblacional Encuesta poblacional: 3.020 persons 25-75 años de edad 7 países DominiosDomains: Socio-demográficos Utilización Prevención y promoción de la salud Estado de salud Satisfacción

INDICADORES DE SATISFACCION Mean SD The way how available appointments with Primary Care (PC) suit your needs 4.05 .993 The average waiting time for an appointment with PC to get non-urgent care 3.81 1.078 Waiting time in the waiting room in PC 3.69 1.080 Appropriate length of consultations with the PC doctor 4.15 .898 Ease of talking about all your problems to the PC doctor 4.25 .894 Listening skills of your PC doctor 4.27 .867 Explanation of tests and treatments by the PC doctor 4.13 .918 Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care 3.86 1.034 Diagnostic test offered in primary care 3.96 1.004 Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.26 .832 Overall satisfaction with the attention provided by PC services 4.03 .911

INDICADORES DE SATISFACCION Mean SD The way how available appointments with Primary Care (PC) suit your needs 4.05 .993 The average waiting time for an appointment with PC to get non-urgent care 3.81 1.078 Waiting time in the waiting room in PC 3.69 1.080 Appropriate length of consultations with the PC doctor 4.15 .898 Ease of talking about all your problems to the PC doctor 4.25 .894 Listening skills of your PC doctor 4.27 .867 Explanation of tests and treatments by the PC doctor 4.13 .918 Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care 3.86 1.034 Diagnostic test offered in primary care 3.96 1.004 Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.26 .832 Overall satisfaction with the attention provided by PC services 4.03 .911 The average waiting time for an appointment with PC to get non-urgent care 3.81 1.078 Waiting time in the waiting room in PC 3.69 1.080 Ease of talking about all your problems to the PC doctor 4.25 .894 Listening skills of your PC doctor 4.27 .867 Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care 3.86 1.034 Diagnostic test offered in primary care 3.96 1.004 Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.26 .832

SATISFACCION SEGÚN PAISES Country Mean SD Hungary 4.39 .81 Italy 4.38 .77 Estonia 4.27 .86 Spain 3.93 .70 Finland 3.88 .94 Lithuania 3.77 .92 Germany 3.57 0.99 Media=4.03

SATISFACCION (%)

OVERALL SATISFACTION ACCORDING TO SOCIO-DEMOGRAPHIC CHARACTERISTICS Categories Mean SD Sexo Hombres 4.00 .90 Mujeres 4.05 .92 Edad 25-34 3.91 .89 35-49 3.92 .94 50-64 65-75 4.26 .84 Lugar de residencia Rural (<10.000) 4.09 Urbano (10.000+) 3.99

OVERALL SATISFACTION ACCORDING TO FINANCING FEATURES SS NHS p value The way how available appointments with Primary Care (PC) suit your needs 4.12 3.95 p<0.001 The average waiting time for an appointment with PC to get non-urgent care 3.85 3.77 p=0.004 Waiting time in the waiting room in PC 3.75 3.61 Appropriate length of consultations with the PC doctor 4.25 4.02 Ease of talking about all your problems to the PC doctor 4.33 4.14 Listening skills of your PC doctor 4.39 4.11 Explanation of tests and treatments by the PC doctor 4.19 4.5 Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care 3.81 3.92 p=0.019 Diagnostic test offered in primary care 3.82 Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.35 Overall satisfaction (SD) 4.00 (0.96) 4.06 (0.84) p<0.301

SATISFACCION SEGÚN MODELOS DE FINANCIACION SS NHS p value The way how available appointments with Primary Care (PC) suit your needs 4.12 3.95 p<0.001 The average waiting time for an appointment with PC to get non-urgent care 3.85 3.77 p=0.004 Waiting time in the waiting room in PC 3.75 3.61 Appropriate length of consultations with the PC doctor 4.25 4.02 Ease of talking about all your problems to the PC doctor 4.33 4.14 Listening skills of your PC doctor 4.39 4.11 Explanation of tests and treatments by the PC doctor 4.19 4.5 Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care 3.81 3.92 p=0.019 Diagnostic test offered in primary care 3.82 Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.35 Overall satisfaction (SD) 4.00 (0.96) 4.06 (0.84) p<0.301 Explanation of tests and treatments by the PC doctor 4.19 Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care 3.81 Diagnostic test offered in primary care 3.82

UTILIZACION SEGÚN MODELOS DE FINANCIACION

UTILIZACIÓN DE SERVICIOS SEGÚN MODELO DE FINANCIACIÓN   NHS SS % Toma de tensión 67,7 81,6 % Medida colesterol 42,6 53,4 % Medida azúcar 43,3 58,1 % Consejos sobre dieta (alcohol, menos de un año) 8,5 5,4 % Consejos sobre ejercicio (menos de un año) 43,1 29,6 % Mamografías (menos de un año) 32,4 24,1 % Citología (menos de un año) 39,1 37,8

Medida de calidad a nivel poblacional Encuesta a profesionales: Historias clínicas: Diabetes e hipertensión 9 indicadores Metodología específicas en cada país

Diferencias entre países INDICADOR Estonia Lituania Finlandia Hungría Alemania Italia TA EN HTA ≤ 140/90 ≤140/90 ≤ 140/85 NA TA EN DM2 ≤130/85 ≤130/80 <130/80 <140/90 ≤ 130/80

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