De bijdrage van de eerste lijn aan kwaliteit en betaalbaarheid van gezondheidszorgsystemen de resultaten van een Europees onderzoek Dr. Dionne Sofia Kringos Postdoctoral Health Systems Researcher Academisch Medisch Centrum – Universiteit van Amsterdam 12 september 2013

Inhoud 1. Hoe kunnen we de sterkte van de eerstelijns gezondheidszorg in Europese landen meten en vergelijken? 2. Hoe komt het dat landen hun eerstelijns gezondheidszorg systeem verschillend structuren en organiseren? 3. Wat draagt een sterke eerste lijn bij aan de volksgezondheid en andere belangrijke uitkomsten?

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

Hoe kunnen we de sterkte van de eerstelijns gezondheidszorg in Europese landen meten en vergelijken ?

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

DIMENSIONS IDENTIFIED

MAPPING THE RELATIVE STRENGTH OF PC

PC Governance Vision Equality access Decentralization Quality mngt infr. Patient advocacy Multidisc. collab.

Economic conditions PC Exp.%THE 25.6 % CH 14.7 % NL 10.3 % HU 4.7 % CZ No data Annual Gross Income GPs Top 5 HIGH LOW LU €150,000 DK €135,000 UK €133,000 CH €126,006 FR €125,659 LT €10,782 MT €10,808 SK €12,000 BG €13,688 EE €17,500 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

Access to PC services Majority PC prov. specialists Interregional GP density difference >36 GPs per 100,000 pop. GP shortages GP home visits/wk Never/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% 36% <5% 65-70% 15-20% 40% <5% 75-80% % 75-80% % 20-25% % 95% 60-65% 45-50% 40-45% 70% <10% 90-95% 63% 15-20% 100% 65-70% 90-95%

Level of PC Orientation at PROCESS of 31 Health Care Systems

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)

Hoe komt het dat landen hun eerstelijns gezondheidszorg systeem verschillend structuren en organiseren? ?

Wealth – Result NHS & Social Health Insurance Systems: Wealthier countries in 1993 have weaker PC Strength and less Accessible PC Health care systems in Transitions: Wealthier countries in 1993 have more accessible PC, and more continuity of PC

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

Type of health care system – Result Social Health Insurance Systems: Countries with a SHI have a weaker access to PC, and a weaker continuity of PC Health care systems in Transitions: Countries with a health care system in transition have better access to PC, and more continuity of PC

Values / Culture – Results Countries with a higher ‘desired governmental involvement’ have better access to PC, more continuity of PC, but less coordination of care, and less comprehensive PC Countries with a more family oriented culture have a weaker PC structure; less coordination of care; and less comprehensive PC Transitional countries with a more family oriented culture have better access to PC and more continuity of PC Countries where people rely more on science & technology to improve their health have less access to PC and more comprehensive 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

Wat draagt een sterke eerste lijn bij aan de volksgezondheid en andere belangrijke uitkomsten? ?

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

Potential avoidable hospitalizations – Results Having a stronger structure of PC is associated with a reduction in potentially avoidable hospitalizations for patients with asthma Having a stronger access of PC is associated with a reduction in potentially avoidable hospitalizations for patients with COPD ;  Reductions are even higher among the male population with diabetes Having a stronger coordination of PC is associated with a reduction in potentially avoidable hospitalizations for male patients with COPD

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 – 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, ISBN: 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 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): 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: 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.