The Strength of Primary Care in Europe

On behalf of:Dionne Sofia Kringos PhD

d.s.kringos@amc.uva.nlPostdoctoral Health Systems Researcher

Academic Medical Centre – University of AmsterdamThe Netherlands

9 April 2014

Content

1. How can we measure and compare the strength of European primary care systems

2. What determines the strength of primary care systems

3. What is the impact of strong PC on health care system outcomes

Rising HC expenditures

Integration of care

Growing demand

Multi-morbidity

More demanding patients

Cultural diversity

More complex health care systems

CHALLENGES IN HEALTH CARE

Supplyside

Demandside

Prevention

Public accountability

STRONGER Primary Care …

Health outcomes

Cost-control

Responsiveness

(Starfield, 1994; Doescher, 1999; Delnoij, 2000; Shi, 2002; Macinko, 2003)

PC POTENTIAL …..• Easy access and first contact care• Treatment for most conditions• Opportunities for prevention and health

promotion• Coordination & integration of services• Limiting unnecessary care (cost-

effectiveness)

…. seen from a systems perspective

World Health Report: a need for ….

Policy evaluation

Performance assessment

Monitoring progress

How can we measure and compare the strength of European

primary care systems

?

PHAMEU project: measuring the strength of PC systems in Europe

- NIVEL (consortium leader)- University of Tartu- IRDES- Heinrich Heine University- University Witten/Herdecke- CERGAS- University of Tromso- Jagiellonian University- University of Ljubljana- IDIAP Jordi Gol- ScHARR- University of Leicester- WHO Europe- European Forum for PC- EUPHA- EGPRN- European Commission

Primary Care System FrameworkDimensions of the PC structure

Dimensions of PC outcomes

Dimensions of the PC Process

PHAMEU MONITOR FRAMEWORK

Dimensions of the PC structure

Governance of PC system

Economic conditions of PC

system

PC Workforce development

Dimensions of PC outcomes

Quality of PC Efficiency of PC

Dimensions of the PC Process

Access to PC services

Comprehensiveness of PC services

Continuity of PC Coordination of PC

1) Primary Care Monitoring Instrument (99 indicators)

2) Supplementary data sources

(Inter)national statistical datasets Policy documents Published literature Expert enquiries Networks:

- PC experts involved in 31 countries - International organizations / networks

(WHO-Euro; EUPHA; EFPC; EGPRN

Data Collection 2009/10

Primary Care Data availability- ranking countries -

Bottom 11:

GR CY MT IS LU IE IT SE PL RO SI

Indicators at level:

Ranking of countries on data availability for indicators by level of primary care system (1=No missing values; 2= 2nd country with least missing values... 31=31th country with most missing values)

AT BE BG CH CY CZ DE DK EE ES FI FR GR HU IE IS IT LT LU LV MT NL NO PL PT RO SE SI SK TR UK

Structure of PC system 3 1 1 1 13 1 3 4 1 2 7 1 14 1 4 12 2 1 6 1 15 1 5 5 4 8 10 9 1 11 1

Process of PC system 9 4 1 18 19 11 1 3 3 5 6 3 21 1 14 16 15 1 17 2 20 1 10 8 1 12 13 7 1 4 4

Outcome of PC system 4 8 5 7 22 9 12 14 9 2 6 7 23 14 20 18 19 7 21 10 17 1 13 16 15 10 14 14 11 19 3

Total Ranking 5 4 2 9 18 7 5 7 4 3 6 4 19 5 13 15 12 3 15 4 17 1 9 10 7 10 12 10 4 11 3

DIMENSIONS IDENTIFIED PRIMARY CARE STRUCTURE & PROCESS

Dimensions of the PC structure

Governance of PC system

Economic conditions of PC system

PC Workforce development

Dimensions of the PC Process

Comprehensiveness of PC services

Total: 12 indicators

PC expenditures PC coverage

Employment status Remuneration system Income of PC workers

Profile PC workforce Professional status

Supply and planning Academic status Prof. associations

Total: 10 indicators

System goals Equity in access policies Collaboration policies

(de)Centralization Quality management

Patient advocacy

Total: 11 indicators Total: 16 indicators

First contact care Disease management

Sole GP contacts Medical procedures

Preventive care Health promotion Medical equipment

Access to PC services

Total: 12 indicators

Density PC workforce Geographic availability Access at practice level Affordability of services

Patient satisfaction

Continuity of PC

Total: 9 indicators

Longitudinal continuity Informational continuity

Relational continuity

Coordination of PC

Total: 7 indicators

Gatekeeping system Skill mix

Collaboration of care Public health integration

MAPPING THE RELATIVE STRENGTH OF PC

PC Governance

Vision

Equality access

Decentralization

Quality mngt infr.

Patient advocacy

Multidisc. collab.

0

5

10

15

20

25

30

Sw

itzer

land

Gre

ece

Uni

ted

Kin

gdom

Fra

nce

Bel

gium

Net

herla

nds

Spa

in

Lith

uani

a

Pol

and

Irel

and

Slo

veni

a

Hun

gary

Rom

ania

Cyp

rus

Latv

ia

Slo

vak

Rep

.

Est

onia

Bul

garia

Nor

way Italy

Cze

ch R

epub

lic

Aus

tria

Den

mar

k

Fin

land

Ger

man

y

Icel

and

Luxe

mbo

urg

Mal

ta

Por

tuga

l

Sw

eden

Tur

key

Economic conditionsPC Exp.%THE25.6 % CH

14.7 % NL

10.3 % HU

4.7 % CZNo data

Annual Gross Income GPs Top 5 HIGH LOW

LU €150,000DK €135,000UK €133,000CH €126,006FR €125,659

LT €10,782MT €10,808SK €12,000BG €13,688EE €17,500

0

20000

40000

60000

80000

100000

120000

140000

160000

Luxe

mbo

urg

Denm

ark

Unite

d Ki

ngdo

m

Switz

erla

nd

Fran

ce

Norw

ay

Neth

erla

nds

Irela

nd

Aust

ria

Ger

man

y

Belg

ium

Icel

and

Finl

and

Portu

gal

Cypr

us

Swed

en Italy

Latv

ia

Spai

n

Slov

enia

Pola

nd

Hung

ary

Rom

ania

Turk

ey

Czec

h Re

publ

ic

Gre

ece

Esto

nia

Bulg

aria

Slov

ak R

ep.

Mal

ta

Lith

uani

a

TR €27,000

Workforce Development

3 types PC Physician Profiles GPs (FI, NL, NO, PT, RO, UK) GPs, OBGYN, PAED (BG, MT, SI, ES) GPs & Specialists (AT, BE, CY, CZ, DK, EE,

FR, DE, GR, HU, IS, IT, LV, LT, LU, PL, SK, SE, CH, TR)

GPs average 55+ yrs in 12 countries

21% med. graduates postgrad. FM

PC Nursing training in 8 countries

Level of PC Orientation at STRUCTURE of 31 Health Care Systems

DK ES NL

PT SI UK EE IT LT

NO RO

HIG

H

EE NO DK LT PT IT ES NL RO

SI UK

FI BE DE FR

SE TR AT BG CZ

GR LV

MED

IUM

BG CZ GR AT FR LV SE

TR BE DE FI

CH IE MT HU CY IS LU

PL SK LOW

CY IE IS LU MT PL CH HU SK

PC Workforce development HIGH MEDIUM LOW LOW MEDIUM HIGH

PC Economic conditions

LOW

BG CY CZ

GR IS LU PL AT LV SK

MED

IUM

EE NO FR HU LT

SE TR DE BE IT

RO

HIG

H

IE MT CH DK PT ES FI NL

SI UK

Note: High/Medium/Low= Relatively high/medium/low level of PC orientation at governance / workforce development / economic conditions level. Categories are made based on the relative distribution of data for all indicators of the respective dimension of the PC Monitor .

Figure 3: Level of primary care orientation at structure of health care systems

PC Governance

PC Workforce Development

Access to PC servicesMajority PC prov. specialistsInterregional GP density difference >36 GPs per 100,000 pop.GP shortages

<2 or 10> GP home visits/wkNever/Occ. telephone consult.Never/Occ. appointm.systems>16% patient GP not affordable

Opportunities optimise

% single handed PC practices

15-20%

<10%

<5%

25-35%

75-80%

<5%

<5%

36%

<5%65-70%

15-20%

40%<5%

75-80%

95-100%

75-80%

95-100%

20-25%95-100%

95%

60-65%

45-50%

40-45%

70%

<10%

90-95%

63% 15-20%

100%

65-70%

90-95%

Informational continuity of care<85% GPs routinely keep med.records

Seldom/Occ. computer usevarious purposesS/Occ. use referral letters

Info. transfer >24hrs after hours contactsS/Occ. specialist-GP communication after treatment episode

Opportunities optimise

Level of PC Orientation at PROCESS of 31 Health Care Systems

DK ES LT

NL PL SI UK CZ PT HU

HIG

H

LT NL SI HU PL PT

UK CZ DK ES

SE EE FI IT AT DE IS

NO RO SK

MED

IUM

AT IT SE FI NO RO DE EE IS

SK

GR MT BE CH FR

LU LV BG CY IE

TR LOW

GR LU MT TR

BG CH CY FR BE IE LV

Coordination of care HIGH MEDIUM LOW LOW MEDIUM HIGH

Continuity of care

LO

W

AT TR BG CY HU

NO RO DE IE IS

SK

MED

IUM

IT LU CH FI FR

PT BE CZ EE

LV

HIG

H

GR LT MT NL SE SI PL UK ES DK

Note: High/Medium/Low= Relatively high/medium/low level of PC orientation at access / coordination / continuity of care . Categories are made based on the relative distribution of data for all indicators of the respective dimension of the PC Monitor.

Figure 4: Level of primary care orientation at process of services delivery of health care systems

Coordination of care

PC Access

CONCLUSION I PC systems in Europe strongly vary in strength

PC system management requires improved PC information systems at the national level

Common themes to improve PC (e.g. vision, inequity in access, payment

systems, workforce shortages, cooperation and coordination)

What determines the strength of primary care systems

?

Governmental Composition

Hypothesis 1: Countries that for a longer period have been governed by left-wing parties have a stronger PC system

Independent variables

Weighted nr. of years social-democrats or socialists were in power 1993-2008

Confounding variables: PC strength in 1993; Wealth of country in 1993; Health care system in transition

Dependent variables:PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

Governmental Composition – Result

Countries that have predominantly been governed by (social-) democratic parties have

a stronger PC structure, better PC access, and better coordination of PC

CONCLUSION II

PC systems in Europe strongly vary in strength due to differences in wealth, political composition of government, prevailing values, type of

health care system Strengthening PC is in the end a political decision which can only be

taken if it is in line with prevailing values in a country

What is the impact of strong PC on health care system outcomes

?

Health care spending

Hypothesis 1: Health care expenditures are lower and the increase slower in countries that have relatively strong primary care, after adjusting for national income.

Dependent variables1) Total health care expenditure per capita in USD PPP in 20092) Growth in total health care expenditure per capita in USD PPP in 2000-

9

Confounding variables: GDP per capita in USD PPP in 2009; Changes in GDP per capita in USD PPP in

2000-9

Independent variables:

PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

Health care spending – Result

Total health care expenditures were higher in countries with stronger PC structure

But…

Countries with more comprehensive PC services delivery had a slower growth in health care expenditures per capita

Population Health

Hypothesis 2: Population health is better in countries that have relatively strong primary care, after adjusting for risk factors.

Dependent variablesPotential years of life lost, by sex, due to diabetes; ischemic heart disease;

stroke; and obstructed airway conditions

Confounding variables: For diabetes: % obese/overweight pop. by sex and age; For ischemic heart disease /

stroke: age- and sex standardized hypertension prevalence; For obstructed airway conditions: self-reported smoking prevalence

Independent variables: PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

Population Health – Results

• Having a stronger PC structure is associated with a reduction in the potential deaths due to ischaemic heart disease; also for male patients with stroke; and for female patients with bronchitis, asthma or emphysema

• Having a stronger coordination of PC is associated with a reduction in the potential years of life lost for patients with bronchitis, asthma or emphysema

• Having a stronger comprehensiveness of PC is associated with a reduction in the potential deaths due to ischemic heart disease and due to stroke

Socio-economic inequality in health

Hypothesis 3: Socio-economic inequalities in health are smaller in countries that have relatively strong primary care, after adjusting for inequalities in risk factors

Dependent variablesThe highest attained educational level in having (very) poor self-perceived

health status, asthma, and diabetes (measured with a Concentration Index)

Confounding variables: Age- and sex standardized concentration index for obesity (diabetes), daily smoking

(asthma; self-perceived health).

Independent variables: PC Structure; PC Access; PC Continuity; PC Coordination;PC Comprehensiveness

Socio-economic inequality in health – Results

• Having a stronger continuity of PC is associated with less socio-economic inequality in poor self-rated health

CONCLUSION III

More research need to measure contribution of PC to health system outcomes & variation within countries

Strong PC is associated with better population health; lower rates of unnecessary (expensive) hospitalizations; relatively lower socio- economic inequality

Further reading….PhD Thesis:- Kringos DS. The strength of primary care in Europe. Utrecht University/NIVEL, 2012. ISBN: 978-94-6122-154-4.Analysis:- Kringos DS, Boerma WGW, Van der Zee J, Groenewegen PP. Europe’s Strong Primary Care Systems Are Linked To Better Population Health, But Also To Higher Health Spending. Health Affairs April 2013 vol. 32 no. 4, pp. 686-694.

- Pelone F, Kringos DS, Valerio L, Romaniello A, Lazzari A, Ricciardi W, de Belvis AG. The measurement of relative efficiency of general practice and the implications for policy makers. Health Policy 107 (2012): 258-268. Measurement instrument:

- Kringos D.S., W.G.W. Boerma, Y. Bourgueil, T. Cartier, T. Hasvold, A. Hutchinson, M. Lember, M. Oleszczyk, D. Rotar Pavlic, I. Svab, P. Tedeschi, A. Wilson, A. Windak, T. Dedeu and S. Wilm. The European Primary Care Monitor: structure, process and outcome indicators. BMC Family Practice 2010,11:81-98.

- Kringos DS, Boerma WGW, Hutchinson A, Van der Zee J, Groenewegen PP. The breadth of primary care: a systematic literature review of its core dimensions. BMC HSR 2010, 10 (1):65-78.