EUprimecare : Quality and Costs of Primary Care in Europe

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)

• 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

• 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

• 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

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

• 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

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

ATIO

N

WP

1D

ISSM

INAT

ION

WP

8

To measure the health quality in PC

To measure costs in PC

ORGANIZATION OF PRIMARY

CARE IN EUROPE

REGULATION

FINANCING

PAYMENTORGANIZATION

ORGANIZATIONAL BEHAVIOUR

• Costs

• Quality:

Approach

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.

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

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)

• 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)

• 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)

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)

Range of services

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

Validation models of PC in Europe (24 countries EU )

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

Capitation SalaryFee for service

Out of pocket

ESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC

COUNTRYPROFESSIONAL INCOME *

*Predominance

COUNTRY GATEKEEPING TO SPECIALISTS

TYPE OF FACILITIES*

Public Solo practice Group practiceIntegrated

networkESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC

TYPE OF PRACTICE*

* Predominance

COUNTRY

FORMAL QUALITY MANAGEMENT & IMPROVEMENT PROGRAMMES

CONTINUING CLINICAL EDUCATION

PROGRAMMES

LOCAL ADAPTATION OF

CLINICAL GUIDELINES

ESTONIAFINALNDGERMANYHUNGARYITALY LITHUANIASPAINBELGIUMFRANCELUXEMBURGNETHERLANDSUNITED KINGDOMIRELANDPORTUGALDENMARKGREECENORWAYSWEDENSWITZERLANDAUSTRIACZECH REPUBLICICELANDPOLANDSLOVAK REPUBLIC

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

Work package 3&4: Costs of Primary Care Systems

4 clinical vignettes representing the main areas of activity of PC: Acute care Chronic care Health promotion Prevention (vaccination)

Methodology Micro-costing

Methodology Macro-costing

• Actual costs: Real not estimated• Usual accounting principles and practices• Indicated in the estimated overall budget

IncludesPersonnel CostsDurable EquipmentConsumables and supplies identifiable

Work package 5&6: Quality of Primary Care Systems

• 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

60 Quality Indicators (aprox) selected to measure Quality of PC in Europe

Methodology Quality Indicators

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

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

http://www.brandkit.co/2011/12/15/next-step-chronicles/a-heartfelt-thank-you/attachment/thank-you/

Work package 5&6: QualityPopulation survey-Satisfaction Results

POPULATION SURVEY: SATISFACTION ITEMS

The way how available appointments with Primary Care (PC) suit your needs

The average waiting time for an appointment with PC to get non-urgent care

Waiting time in the waiting room in PC

Appropriate length of consultations with the PC doctor

Ease of talking about all your problems to the PC doctor

Listening skills of your PC doctor

Explanation of tests and treatments by the PC doctor

Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care

Diagnostic test offered in primary care

Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.)

Overall satisfaction

POPULATION SURVEY: OVERALL RESULTS

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

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

Ease of talking about all your problems to the PC doctor 4.25 .894

Listening skills of your PC doctor 4.27 .867

Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.26 .832

OVERALL SATISFATION BY COUNTRY

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

Mean=4.03

Estonia Germany Spain Lithuania Italy Hungary Finland0

10

20

30

40

50

60

70

80

90

100

0.724.02

0.46 1.64 0.70 0.47 2.572.42

8.27

2.557.03

0.70 1.86

5.84

15.70

30.50

18.10

25.53

11.86 12.35

17.52

31.88

40.90

61.25

44.26

33.72 28.44

48.83

49.28

16.31 17.6321.55

53.0256.88

25.23

Overall satisfaction with the attention provided by PC services (%)/Countries

Totally satisfied Very satisfiedSatisfied DissatisfiedVery dissatisfied

OVERALL SATISFACTION WITH THE ATTENTION PROVIDED BY PC SERVICES (%)

OVERALL SATISFACTION ACCORDING TO SOCIO-DEMOGRAPHIC CHARACTERISTICS

Categories Mean SD

GenderMan 4.00 .90

Woman 4.05 .92

Age

25-34 3.91 .89

35-49 3.92 .94

50-64 4.05 .90

65-75 4.26 .84

City/town of residence

Rural (10.000 people or less) 4.09 .89

Urban (10.000 people or more) 3.99 .92

OVERALL SATISFATION ACCORDING TO CLINICAL CONDITIONS

Mean SD

Diabetes 4.24 .88

Hypertension 4.12 .93

Hypercholesterolemia 4.05 .89

Asthma 3.93 .00

Chronic bronchitis 3.95 .91

Mean=4.03

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 p<0.001

Appropriate length of consultations with the PC doctor 4.25 4.02 p<0.001

Ease of talking about all your problems to the PC doctor 4.33 4.14 p<0.001

Listening skills of your PC doctor 4.39 4.11 p<0.001

Explanation of tests and treatments by the PC doctor 4.19 4.5 p<0.001

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 4.12 p<0.001

Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.35 4.11 p<0.001

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

ORGANIZATIONAL FEATURES

Countries

Gatekeeping and Integrated Network FinlandSpain

Gatekeeping Italy LithuaniaEstoniaHungary

No gatekeeping. no Integrated Network Germany

OVERALL SATISFACTION ACCORDING TO ORGANIZATIONAL FEATURES

Gatekeeping + Integrated Network

Mean (SD) No Gatekeeping Mean (SD)

Gatekeeping Mean (SD)

The way how available appointments with Primary Care (PC) suit your needs 3.81 (0.94) 4.01 (0.92) 4.19 (1.01)

The average waiting time for an appointment with PC to get non-urgent care 3.60 (1.01) 4.00 (0.88) 3.88 (1.15)

Waiting time in the waiting room in PC 3.63 (0.98) 3.64 (1.02) 3.73 (1.14)

Appropriate length of consultations with the PC doctor 3.90 (0.86) 3.97 (0.92) 4.32 (0.87)

Ease of talking about all your problems to the PC doctor 3.97 (0.89) 4.26 (0.81) 4.38 (0.88)

Listening skills of your PC doctor 3.95 (0.87) 4.24 (0.84) 4.44 (0.83)

Explanation of tests and treatments by the PC doctor 3.90 (0.83) 4.08 (0.85) 4.26 (0.95)

Preventive activities and services to prevent illnesses (vaccines. counseling. diagnostic tests) offered in primary care 3.75 (0.93) 3.64 (1.01) 3.97 (1.08)

Diagnostic test offered in primary care 4.00 (0.85) 3.78 (0.96) 3.98 (1.08)

Helpfulness of staff of primary care (not including the PC doctor. but nurses. patient service staff. etc.) 4.01 (0.82) 4.35 (0.76) 4.37 (0.83)

Overall satisfaction (SD) 3.91 (0.83) 3.57 (0.99) 4.20 (0.88)

Gatekeeping + Integrated Network

Mean (SD)

3.81 (0.94)

3.60 (1.01)

3.63 (0.98)

3.90 (0.86)

3.97 (0.89)

3.95 (0.87)

3.90 (0.83)

3.64 (1.01)

3.78 (0.96)

4.01 (0.82)

4.00 (0.88)

Gatekeeping Mean (SD)

4.19 (1.01)

3.73 (1.14)

4.32 (0.87)

4.38 (0.88)

4.44 (0.83)

4.26 (0.95)

3.97 (1.08)

3.98 (1.08)

4.37 (0.83)

4.20 (0.88)

OVERALL SATISFACTION ACCORDING TO UTILIZATION

Categories Mean SD

Number of visits to GP

1 visit 3.96 .92

2-3 visits 3.99 .90

4-6 visits 4.03 .94

7-9 visits 4.15 .86

>9 visits 4.24 .86

Number of visits to specialist

1 visit 3.98 .94

2-3 visits 3.99 .93

4-6 visits 3.89 .94

7-9 visits 4.29 .74

>9 visits 4.06 1.02

Work package 7:Trade offs between PC Models, Quality

and PC expenditure

PERCENTAGE OF PATIENTS DIAGNOSED BY THEIR PC DOCTORS ACCORDING TO FINANCING FEATURES

Chronic Bronchitis Hypertension Hypercholesterolemia Asthma Diabetes 0

10

20

30

40

50

60

70

80

90

NHS SS

PERCENTAGE OF PATIENTS WHO ARE DIAGNOSED BY THEIR PC DOCTOR ACCORDING TO ORGANIZATIONAL FEATURES

Diabetes Hypertension Hypercholesterolemia Asthma Chronic Bronchitis 0

10

20

30

40

50

60

70

80

90

100

Gatekeeping & Integrated NetworkGatekeeping No Gatekeeping no Integrated Network

FRECUENCY OF PREVENTION AND COUNSELING ACTIVITIES ACCORDING TO FINANCING FEATURES

NHS SS NHS SS NHS SS NHS SS NHS SSWeight measure Cholesterol measure Blood sugar measure Blood preasure measure Smoking counselling

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1year

<1-2year

>2year

FRECUENCY OF PREVENTION AND COUNSELING ACTIVITIES ACCORDING TO ORGANIZATIONAL FEATURES

GTK+INY GTK No GTK/INT





Weight measure Cholesterol measure Blood sugar measure Blood preasure measure Smoking counselling

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1year

<1-2year

>2year

SELF-PERCEIVED HEALTH STATUS ACCORDING TO FINANCING FEATURES

95.6

4.4

NHS

89.5

10.5

SS

SELF-PERCEIVED HEALTH STATUS ACCORDING TO ORGANIZATIONAL FEATURES

96.1

3.9

GTK+INT

89.8

10.2

GTK

93.5

6.5

No GTK/INT

UTILIZATION ACCORDING TO FINANCING FEATURES

UTILIZATION ACCORDING TO ORGANIZATIONAL FEATURES

PERCENTAGE OF PATIENTS WHO ARE DIAGNOSED BY THEIR PC DOCTOR ACCORDING TO LEVEL OF EXPENDITURE

Diabetes Hypertension Hypercholesterolemia Asthma Chronic Bronchitis 0

10

20

30

40

50

60

70

80

90

100

LowMedium High

FRECUENCY OF PREVENTION AND COUNSELING ACTIVITIES ACCORDING TO LEVEL OF EXPENDITURE

Low Medium High Low Medium High Low Medium High Low Medium High Low Medium HighWeight measure Cholesterol measure Blood sugar measure Blood preasure measure Smoking counselling

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1year

<1-2year

>2year

SELF-PERCEIVED HEALTH STATUS ACCORDING TO LEVEL OF EXPENDITURE

88.1

11.9

Low

94.6

5.4

Medium

96.5

3.5

High

UTILIZATION ACCORDING TO EXPENDITURE LEVEL

Final remarks

The use of clinical vignettes in costing primary care services in

7 EU countries

3rd September 2012, EFPC Conference - Gothenburg

E. Corsalini, G. Fattore, A. Compagni

Overall task

To identify a methodology for cost measurement in primary care services and to apply it.

Challenging goal:• extreme variability in terms of professionals involved,

payment mechanisms, services provided across countries

• impossible to develop a one-fits-all method, but need to provide a common and defined framework

Chosen MethodClinical Vignettes= description of a common clinical

situation, followed by a synthetic questionnaire to be submitted to professionals

• solve the problem of the interpretation of identical questions

• are a common denominator in a context of extreme heterogeneity

• allow to describe how a certain clinical case is managed in primary care and to estimate all the resources consumed in the delivery

STEPS

1. To choose the vignettes2. To translate the vignettes3. To validate the vignettes4. To submit the vignettes to primary care professionals5. To collect questionnaires6. To measure resources consumption in the delivery of

services involved in the clinical vignettes

1. Choice of vignettes

Criteria taken into account:• Main areas of primary care systems:

- Disease prevention area- Care of acute but common problems- Care of chronic conditions- Health promotion services

• Primary care activities/services common to all the partners of the consortium

VignettesV1: A 70-year-old man in good health comes to the practice

asking to be vaccinated against the seasonal influenza

V2: A 2-year-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. […] He has mild expiratory dyspnea. His breathing rate is 36 times per minute. […] He has atopic dermatitis but otherwise has been healthy.

VignettesV3: 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.

V4: 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.

STEPS



4. Submission of vignettesVignettes have been 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 was 20-30 and different vignettes have been submitted to the same group

• through a written questionnaire: professionals of each group have been requested to answer the questions related to each vignette in writing

4. Submission of vignettesIn total, more than 200 professionals have been interviewed.

Professionals Number Professionals Number Professionals Number Professionals Number

HUNGARY GP 33 Paediatrician 52 GP 32 GP 29

ITALY GP 50 Paediatrician 23 GP 27 GP 50

FINLAND Nurse 5 GP 39 GP 38 GP 39

LITHUANIA GP 30 GP 30 GP 30 GP 30

ESTONIA Nurse 27 GP 23 GP 23 Nurse 24

GP 20 GP 20

Nurse 3 Nurse 3

GERMANY GP 37 Paediatrician 23 GP 33 GP 33

TOTAL 205 211 206 228

4

SPAIN GP 23Paediatrician 21

VIGNETTES

COUNTRY1 2 3

STEPS



6. To measure resources consumption

• Data collected through questionnaires by each partner have been put together and synthesized in four different databases, specific per each vignette/questionnaire, by the Bocconi University team

• This last part of the exercise had two different purposes:- to measure resources consumption in the delivery of certain primary care activities to which monetary values could be attributed;- to collect data/information useful to carry out an analysis of variation of how the same case is managed within and between countries

6. To measure resources consumption

• Measuring resource consumption Methodology: Time-Driven Activity-Based-Costing = it is a particular development of the better known Activity-Based Costing (ABC) that allows to design cost models in very complex contexts, such as service organizations

The TDABC requires two parameters: the time required to provide/perform the activity the unit cost of supplying capacity

6. To measure resources consumption: data collected

Each vignette was structured as to gather information about:1. medical and administrative professionals directly involved in

the service;2. the amount of time spent in the activity by the professionals

involved;3. medical material directly used in the provision of the service;4. medical material and other health care services consumed as

a consequence of the service;5. other medical professionals involved as a consequence of the

service described in the vignette.

6. To measure resources consumption: data collected

Moreover, for each vignette, partner countries have provided:• cost of the professionals directly involved;• cost of administrative staff involved;• cost of the medical material directly used;• cost of the medical material and other health care services

consumed as a consequence of the service;• cost of other medical professionals involved as a consequence

of the service;• direct cost paid by patients for the provision of the service;• estimation of overheads costs.

SOME RESULTS FROM THE VIGNETTES

V2 – A sick 2-year-old boy:Professionals involved

Country Total cases PaediatricianGeneral

Physician Nurse SecretaryOther PC

professional

Hungary 52 100,00% 50,00% 28,85% 30,77%

Italy 23 100,00% 8,70% 21,74% 0,00%

Finland 39 100,00% 66,67% 33,33% 10,26%

Lithuania 30 100,00% 60,00% 10,00% 10,00%

Estonia 23 100,00% 69,57% 8,70% 17,39%

Spain 21 100,00% 47,62% 9,52% 0,00%

Germany 23 100,00% 0,00% 86,96% 0,00%

All countries 211 100,00% 46,45% 28,44% 12,80%

V2 – A sick 2-year-old boy:Time spent in the visit

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 12,7Nurse

Average time per case 3,3 0,7 6,3 5,3 4,0 6,2 0,0Other PC professional

Average time per case 2,5 0,0 0,8 0,4 0,7 0,0 0,0

Total time per case 19,8 17,0 20,9 21,4 19,3 19,6 12,7

V2 – A sick 2-year-old boy:Time - variability within countries

Hungary Italy Finland Lithuania Estonia Spain Germany

Paediat./General Physician

Min 5 10 1 1 1 6 5

Max 30 38 30 30 20 40 30

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 – A sick 2-year-old boy:Clinical behaviors

Hungary Italy Finland Lithuania Estonia Spain GermanyAll

countriesPharmacological Treatment 94,23% 95,65% 87,18% 76,67% 65,22% 100,00% 95,65% 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% 100,00% 82,26%Antibiotics 18,37% 36,36% 2,94% 21,74% 20,00% 4,76% 0,00% 14,52%Anti-inflammatory 10,20% 36,36% 0,00% 4,35% 0,00% 0,00% 0,00% 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% 0,00% 28,44%

V2 – A sick 2-year-old boy:Micro-costing

Hungary Italy Finland Lithuania Estonia Spain GermanyPaediat./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 € 59,51

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

Hou

rly c

ost

Some costs data:Labour cost (in PPP)

Hungary Italy Finland Lithuania Estonia SpainGeneral Physician average cost in PPP

per year € 18.818 € 115.354 € 64.617 € 18.549 € 23.106 € 84.675

Paediatrician average cost in PPP per year € 18.818 € 129.910 N.A. N.A. N.A. € 72.148

Nurse average cost in PPP per year € 12.255 € 37.827 € 34.185 € 14.287 € 14.144 € 51.423

Secretary average cost in PPP per year € 4.821 € 29.098 € 27.676 € 7.811 € 7.180 € 22.972

Assistant/Trainee average cost in PPP per year € 9.720 € 92.601 N.A € 7.811 € 14.144 N.A

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EUprimecare : Quality and Costs of Primary Care in Europe

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