WP4.2Micro-costing: some results

from vignettes

11th and 12th June 2012, KuopioItalian team

Micro level

The main goal of the consortium at the Micro level is to cost specific and relevant clinical cases for which care is provided in the primary care system context, in each partner country

WP4 Overall task

To measure costs in primary care services in different EU countries

Micro-level: Within main categories of primary care, data related to specific services and providers in each participant country are attributed monetary values based on Time-Driven Activity-Based Costing (WP3)

Micro level - MethodologySTEPS

1. To choose the vignettes V

2. To translate the vignettes V

3. To validate the vignettes V

4. To submit the vignettes to primary care professionals V

5. To collect data V

6. To measure resources consumption in the delivery of services involved in the clinical vignettes

7. To describe how certain primary care cases are managed in different systems

WP4.2 – Micro-costing: VIGNETTES

RESULTS FROM VIGNETTESDRAFT – NOT FINAL VERSION

DIRECT PERSONNEL COSTS – BY COUNTRY

HUNGARY ITALY FINLAND

Physician

avarage cost per year € 12.100,00 € 118.930,00 € 80.900 total amount of hours worked per year 1920 1872 1639

cost per hour € 6,30 € 63,53 € 49,36

cost per minute € 0,11 € 1,06 € 0,82

Nurse

avarage cost per year € 7.880,00 € 39.000 € 42.800 total amount of hours worked per year 1920 1728 1704

cost per hour € 4,10 € 22,57 € 25,12

cost per minute € 0,07 € 0,38 € 0,42

Overheads estimation

yearly overheads 90% 15% 21%

total cost per minute Physician € 0,20 € 1,22 € 1,00

total cost per minute Nurse € 0,13 € 0,43 € 0,51

DIRECT PERSONNEL COSTS – BY COUNTRY

LITHUANIA ESTONIA SPAIN

Physician

avarage cost per year € 12.168 € 18.231 € 82.474 total amount of hours worked per year 1915 1911 1533

cost per hour € 6,35 € 9,54 € 53,80 tariff per activity

cost per minute € 0,11 € 0,16 € 0,90

Nurse

avarage cost per year € 9.372 € 11.160 € 50.086 total amount of hours worked per year 1915 2194 1533

cost per hour € 4,89 € 5,09 € 32,67

cost per minute € 0,08 € 0,08 € 0,54

Overheads estimation

yearly overheads 15% 35% 21%total cost per minute Physician € 0,12 € 0,21 € 1,08

total cost per minute Nurse € 0,09 € 0,11 € 0,66

Vignette 1

A 70-years-old man in good health comes to the practice asking to be vaccinated against the seasonal influenza. The patient is known to you.

VIGNETTE 1 – ADMINISTRATION OF THE VACCINE: Professionals involved

HUNGARY ITALY FINLAND LITHUANIA % % % %

ADMINISTRATION Total cases 33 50 5 30 Physician in the adm. 33 100,00% 50 100,00% 0 0,00% 30 100,00%Nurse in the adm. 26 78,79% 15 30,00% 5 100,00% 28 93,33%Secretary in the adm. 9 27,27% 14 28,00% 0 0,00% 3 10,00%Other in the adm. 2 6,06% 4 8,00% 0 0,00% 3 10,00%

ESTONIA SPAIN GERMANY ALL COUNTRIES

% % % %ADMINISTRATION Total cases 27 23 37 205 Physician in the adm. 9 33,33% 22 95,65% 37 100,00% 181 88,29%Nurse in the adm. 27 100,00% 20 86,96% 0 0,00% 121 59,02%Secretary in the adm. 2 7,41% 2 8,70% 27 72,97% 57 27,80%Other in the adm. 0 0,00% 1 4,35% 5 13,51% 15 7,32%

VIGNETTE 1 – ADMINISTRATION OF THE VACCINE: TIME SPENT (minutes)

HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL

PHYSICIAN

Average time per case 8,8 11,1 0,0 8,9 2,7 8,6 7,0 8,0

Average time per patient 8,8 11,1 0,0 8,9 8,0 9,0 7,0 9,1

NURSE

Average time per case 3,8 1,2 6,6 6,0 11,5 5,0 0,0 4,0

Average time per patient 4,8 4 6,6 6,4 11,5 5,7 0,0 6,8

SECRETARY

Average time per case 0,7 0,8 0,0 0,3 0,3 0,2 3,6 1,1

Average time per patient 2,6 2,9 0,0 3,0 4,0 2,0 5,0 3,8

OTHER

Average time per case 0,5 0,3 0,0 0,4 0,0 0,1 0,4 0,3

Average time per patient 7,5 4,3 0,0 3,8 0,0 2,0 3,2 4,1

TOTAL TIME PER CASE 13,7 13,4 6,6 15,6 14,5 13,8 11,1 13,4

VIGNETTE 1 – RECORDING: Professionals involved

HUNGARY ITALY FINLAND LITHUANIA % % % %

RECORDING Total cases 33 50 5 30 Cases recorded 33 100,00% 50 100,00% 5 100,00% 29 96,67%Physician in the rec. 11 33,33% 45 90,00% 0 0,00% 29 100,00%Nurse in the rec. 27 81,82% 4 8,00% 5 100,00% 26 89,66%Secretary in the rec. 8 24,24% 0 0,00% 0 0,00% 0 0,00%Other in the rec. 1 3,03% 1 2,00% 0 0,00% 0 0,00%

ESTONIA SPAIN GERMANY ALL COUNTRIES % % % %

REGISTRATION Total cases 27 23 37 205 Cases recorded 27 100,00% 23 100,00% 37 100,00% 204 99,51%Physician in the rec. 0 0,00% 4 17,39% 12 32,43% 101 49,51%Nurse in the rec. 27 100,00% 20 86,96% 0 0,00% 109 53,43%Secretary in the rec. 0 0,00% 0 0,00% 1 2,70% 9 4,41%Other in the rec. 0 0,00% 0 0,00% 30 81,08% 32 15,69%

VIGNETTE 1 – RECORDING: TIME SPENT (minutes)

HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL

PHYSICIAN

Average time per case 0,7 2,1 0,0 2,4 0,0 0,3 0,6 1,1

Average time per patient 2,0 2,4 0,0 2,5 0,0 1,5 1,8 2,3

NURSE

Average time per case 2,5 0,2 1,5 2,6 4,5 2,3 0,0 1,7

Average time per patient 3,0 2,3 1,5 3,0 4,5 2,6 0,0 3,2

SECRETARY

Average time per case 0,9 0,0 0,0 0,0 0,0 0,0 0,1 0,2

Average time per patient 3,6 0,0 0,0 0,0 0,0 0,0 2,0 3,4

OTHER

Average time per case 0,0 0,04 0,0 0,0 0,0 0,0 1,7 0,3

Average time per patient 0,0 2,0 0,0 0,0 0,0 0,0 2,1 2,2

VIGNETTE 1 – MICRO-COSTING

HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANYPHYSICIAN Average time per case 9,4 13,2 0,0 11,4 2,7 8,9 7,6Average cost € 1,88 € 16,11 € - € 1,38 € 0,57 € 9,60 Tariff per activity € 9,54 NURSE Average time per case 6,2 1,4 8,1 8,6 16,0 7,2 0,0Average cost € 0,81 € 0,60 € 4,10 € 0,81 € 1,83 € 4,76 SECRETARY Average time per case 1,6 0,8 0,0 0,3 0,3 0,2 3,7Average cost € 0,16 € 0,25 € - € 0,01 € 0,02 € 0,05 € 0,86 OTHER Average time per case 0,6 0,4 0,0 0,4 0,0 0,1 2,1

Average cost € 0,06 € 0,38 € - € 0,02 € - € - TOTAL LABOUR COST € 2,91 € 17,33 € 4,10 € 2,22 € 2,43 € 14,42 € 9,54

VACCINE - Average price € 6,66 € 5,39 € 2,90 € 5,52 € 5,46 € 5,03 € 21,55 OUT OF POCKET - Average price € 0,52

€ -

€ -

€ -

€ -

€ -

€ -

TOTAL COST € 10,10 € 22,72 € 7,00 € 7,74 € 7,89 € 19,45 € 31,09

Vignette 2

A 2-years-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. The child has drank liquids normally but has poorer appetite than usual. In the doctor’s office he is alert and responsive. He has mild expiratory dyspnea. His breathing rate is 36 times per minute. Diffuse wheezing and rhonchi are heard bilaterally in the lungs. Pharynx is erythematous. Tympanic membranes are otoscopically without signs of inflammation. The boy has had similar episodes of cough, fever and wheezing at the age of 1 year 5 months. He has atopic dermatitis but otherwise has been healthy.

VIGNETTE 2 – VISIT: Professionals involved

HUNGARY ITALY FINLAND LITHUANIA % % % %

VISIT Total cases 52 23 39 30 Main Professional involved Physician Paediatr. Physician Physician Paediatrician/Physician in the visit 52 100,00% 23 100,00% 39 100,00% 30 100,00%Nurse in the visit 26 50,00% 2 8,70% 26 66,67% 18 60,00%Secretary in the visit 15 28,85% 5 21,74% 13 33,33% 3 10,00%Other in the visit 16 30,77% 0 0,00% 4 10,26% 3 10,00%

ESTONIA SPAIN GERMANY ALL COUNTRIES % % % %

VISIT Total cases 23 21 23 211

Main Professional involved Physician Paediatr. Paediatr. Paediatrician/Physician in the visit 23 100,00% 21 100,00% 23 100,00% 211 100,00%Nurse in the visit 16 69,57% 10 47,62% 0 0,00% 98 46,45%Secretary in the visit 2 8,70% 2 9,52% 20 86,96% 60 28,44%Other in the visit 4 17,39% 0 0,00% 0 0,00% 27 12,80%

VIGNETTE 2 – VISIT : TIME SPENT - minutes

HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL

PAEDIATRICIAN/PHYSICIAN

Average time per case 13,9 16,3 13,8 15,7 14,7 13,4 12,7 14,3

Average time per patient 13,9 16,3 13,8 15,7 14,7 13,4 12,7 14,3

NURSE

Average time per case 3,3 0,7 6,3 5,3 4,0 6,2 0,0 3,9

Average time per patient 6,7 7,5 9,4 8,9 5,8 13,0 0,0 8,3

SECRETARY

Average time per case 2,0 1,2 1,3 0,2 0,7 0,1 6,6 1,7

Average time per patient 6,8 5,4 4,0 2,3 8,0 1,5 7,6 6,0

OTHER

Average time per case 2,5 0,0 0,8 0,4 0,7 0,0 0,0 0,9

Average time per patient 8,3 0 7,5 3,7 3,8 0,0 0,0 7,0

TOTAL TIME PER CASE 21,7 18,2 22,2 21,6 20,0 19,7 19,3 20,8

VIGNETTE 2 – PHARMACOLOGICAL TREATMENT: CATEGORIES OF DRUGS

HUNGARY ITALY FINLAND LITHUANIA

% % % %Pharmacological Treatment 49 94,23% 22 95,65% 34 87,18% 23 76,67%Fever reducer 12 24,49% 12 54,55% 2 5,88% 6 26,09%Bronchodilator 40 81,63% 11 50,00% 33 97,06% 17 73,91%Antibiotics 9 18,37% 8 36,36% 1 2,94% 5 21,74%

Anti-inflammatory 5 10,20% 8 36,36% 0 0,00% 1 4,35%

ESTONIA SPAIN GERMANY ALL COUNTRIES % % % %

Pharmacological Treatment 15 65,22% 21 100,00% 22 95,65% 186 88,15%

Fever reducer 0 0,00% 9 42,86% 2 9,09% 43 23,12%

Bronchodilator 12 80,00% 18 85,71% 22 100,00% 153 82,26%

Antibiotics 3 20,00% 1 4,76% 0 0,00% 27 14,52%Anti-inflammatory 0 0,00% 0 0,00% 0 0,00% 14 7,53%

VIGNETTE 2 – TESTS AND SPECIALIST INVOLVED

HUNGARY ITALY FINLAND LITHUANIA % % % %

Main Professional involved Physician Paediatr. Physician Physician

Pharmacological Treatment 49 94,23% 22 95,65% 34 87,18% 23 76,67%

Diagnostic Tests 20 38,46% 7 30,43% 18 46,15% 15 50,00%

Specialist involved 21 40,38% 2 8,70% 25 64,10% 7 23,33%

ESTONIA SPAIN GERMANY ALL COUNTRIES % % % %

Main Professional involved Physician Paediatr. Paediatr.

Pharmacological Treatment 15 65,22% 21 100,00% 22 95,65% 186 88,15%

Diagnostic Tests 19 82,61% 0 0,00% 6 26,09% 85 40,28%

Specialist involved 4 17,39% 1 4,76% 0 0,00% 60 28,44%

VIGNETTE 2 – MICRO-COSTING

HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANYPAEDIATRICIAN/PHYSICIAN Average time per case 16,3 20,2 17,8 21,6 18,5 17,1 16,6Average cost € 3,25 € 27,67 € 17,69 € 2,62 € 3,98 € 15,82 Tariff per activity € 42,16 NURSE Average time per case 4,8 0,7 7,4 5,3 4,0 7,9 0,0Average cost € 0,63 € 0,28 € 3,77 € 0,50 € 0,46 € 5,20 SECRETARY Average time per case 4,5 2,3 1,3 0,2 0,7 0,1 6,6Average cost € 0,46 € 0,69 € 0,56 € 0,01 € 0,04 € 0,04 € 1,54 OTHER Average time per case 5,7 0,0 0,8 0,4 0,7 0,0 0,0Average cost € 0,59 € - € 0,77 € 0,02 € 0,07 € - TOTAL LABOUR COST € 4,94 € 28,64 € 22,78 € 3,15 € 4,56 € 21,06 € 42,16

DRUGS - Average cost € 5,44 € 12,20 € 11,61 € 3,35 € 2,83 € 4,54 € 14,47

TESTS - Average cost € 2,18 € 4,85 € 3,66 € 2,81 € 3,57 € - € 16,58 TOTAL COST € 12,57 € 45,69 € 38,05 € 9,32 € 10,95 € 25,59 € 73,20

Vignette 3

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.

VIGNETTE 3 – VISITS IN 12 MONTHS: PC Professionals involved

HUNGARY ITALY FINLAND LITHUANIA

% % % %PC VISITS in 12 months Total cases 32 27 38 30 Physician in the visit 32 100,00% 27 100,00% 38 100,00% 30 100,00%Nurse in the visit 31 96,88% 11 40,74% 34 89,47% 28 93,33%

Secretary in the visit 10 31,25% 10 37,04% 14 36,84% 4 13,33%

ESTONIA SPAIN GERMANY ALL COUNTRIES

% % % %

PC VISITS in 12 months

Total cases 23 23 33 206

Physician in the visit 23 100,00% 23 100,00% 33 100,00% 206 100,00%

Nurse in the visit 23 100,00% 23 100,00% 33 100,00% 183 88,83%

Secretary in the visit 1 4,35% 5 21,74% 0 0,00% 44 21,36%

VIGNETTE 3 – VISITS : TIME SPENT in 12 months - minutes

HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALLPHYSICIAN Average time per visit 11 18 25 15 19 13 12 16Average number of visits per patient 6 3 2 5 4 2 4 4Average time per case 65,9 57,4 45,3 74,5 73,3 27,3 47,5 55,8Average time per patient 65,9 57,4 45,3 74,5 73,3 27,3 47,5 55,8NURSE Average time per visit 8 11 45 10 15 13 7 19Average number of visits per patient 8 3 3 5 4 4 6 6Average time per case 61,5 11,8 108,6 49,2 57,2 56,3 40,2 57,4Average time per patient 63,5 29,0 121,3 52,7 57,2 56,3 40,2 64,6SECRETARY Average time per contact 4 7 7 8 4 3 0 3Average number of contacts per patient 8 4 4 4 4 3 0 2Average time per case 9,4 7,9 9,2 3,0 0,7 1,5 0,0 4,9Average time per patient 30,0 21,4 25,1 22,5 16,0 6,8 0,0 22,8

TOTAL TIME PER CASE in 12 months - minutes 136,8 77,1 163,1 126,7 131,2 85,1 87,8 118,1

VIGNETTE 3 – DRUGS PRESCRIPTION

HUNGARY ITALY FINLAND LITHUANIA

% % % %Pharmacological Treatment 30 93,75% 26 96,30% 33 86,84% 28 93,33%

Metformin 23 76,67% 25 96,15% 30 90,91% 28 100,00%

ESTONIA SPAIN GERMANY ALL COUNTRIES

% % % %Pharmacological Treatment 23 100,00% 17 73,91% 25 75,76% 182 88,35%

Metformin 22 95,65% 16 94,12% 25 100,00% 169 92,86%

VIGNETTE 3 – TESTS PRESCRIPTION

HUNGARY ITALY FINLAND LITHUANIA % % % %

Diagnostic Tests 28 87,50% 27 100,00% 36 94,74% 30 100,00%HbA1C 9 32,14% 22 81,48% 28 77,78% 28 93,33%Eye visit/ Fundus 28 100,00% 26 96,30% 14 38,89% 26 86,67%ECG/Cardiologist 14 50,00% 15 55,56% 15 41,67% 6 20,00%Lipid profile/triglyc. 3 10,71% 16 59,26% 10 27,78% 4 13,33%Creatinine/kidney func. 2 7,14% 2 7,41% 20 55,56% 11 36,67%Microalbum. 1 3,57% 9 33,33% 10 27,78% 0 0,00%Blood sugar 3 10,71% 19 70,37% 25 69,44% 16 53,33%

ESTONIA SPAIN GERMANY ALL COUNTRIES % % % %

Diagnostic Tests 23 100,00% 23 100,00% 33 100,00% 200 97,09%HbA1C 22 95,65% 7 30,43% 24 72,73% 140 70,00%Eye visit/ Fundus 17 73,91% 22 95,65% 30 90,91% 163 81,50%ECG/Cardiologist 0 0,00% 11 47,83% 6 18,18% 67 33,50%Lipid profile/triglyc. 12 52,17% 5 21,74% 6 18,18% 56 28,00%Creatinine/kidney func. 20 86,96% 2 8,70% 14 42,42% 71 35,50%Microalbum. 16 69,57% 4 17,39% 4 12,12% 44 22,00%Blood sugar 4 17,39% 0 0,00% 11 33,33% 78 39,00%

VIGNETTE 3 – SPECIALISTS INVOLVED

HUNGARY ITALY FINLAND LITHUANIA % % % %

Specialist involved 30 93,75% 25 92,59% 12 31,58% 29 96,67%

Diabetologist/Endocr. 25 83,33% 14 56,00% 3 25,00% 27 93,10%

Eye doctor 28 93,33% 25 100,00% 11 91,67% 26 89,66%

Cardiologist 24 80,00% 23 92,00% 2 16,67% 7 24,14%

ESTONIA SPAIN GERMANY ALL COUNTRIES % % % %

Specialist involved 17 73,91% 21 91,30% 31 93,94% 165 80,10%Diabetologist/Endocr. 5 29,41% 3 14,29% 12 38,71% 89 53,94%Eye doctor 17 100,00% 21 100,00% 31 100,00% 159 96,36%Cardiologist 0 0,00% 0 0,00% 8 25,81% 64 38,79%

Vignette 4

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.

Note: Each country is free to decide the specific reason for the encounter. It should be as much neutral as possible (it should not be for a clinical reason).

VIGNETTE 4 – TIME SPENT IN THE VISIT BY THE PHYSICIAN

HUNGARY ITALY FINLAND LITHUANIA ESTONIA SPAIN GERMANY ALL

Total cases 29 50 39 30 24 23 33 228

Total time 410 755 368,5 294 392,5 257 394 2871

TIME SPENT PER CASE 14,1 15,1 9,4 9,8 16,4 11,2 11,9 12,6

VIGNETTE 4 – PC Professionals’ Behavior

HUNGARY ITALY FINLAND LITHUANIA

% % % %VISIT Total cases 29 50 39 30 Advice on smoking 29 100,00% 47 94,00% 37 94,87% 30 100,00%Ask in the future 29 100,00% 49 98,00% 37 94,87% 26 86,67%

Recording 29 100,00% 49 98,00% 37 94,87% 24 80,00%

ESTONIA SPAIN GERMANY ALL COUNTRIES % % % %

VISIT Total cases 24 23 33 228 Advice on smoking 24 100,00% 23 100,00% 33 100,00% 223 97,81%Ask in the future 24 100,00% 23 100,00% 31 93,94% 219 96,05%Recording 22 91,67% 23 100,00% 24 72,73% 208 91,23%

Next steps

We are planning to do some more analysis, in particular:

Variability in each country in terms of:- Time- Prescription (both drugs and tests)- Costs

Comparison across countries of costs expressed in PPP (total values and drivers of cost)

Next steps – Suggestions for publications

Possibility to write two papers on WP 4.2 – micro-costing part:

1. Patterns of treatment for 4 primary care cases: comparison across 7 EU countries

2. Micro-costing of specific PC activities in 7 EU countries: methodology and results

Thank you