1. health and fitness

NDPHS
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Remunerating
Primary Health Care
ll e d p r o
Remunerating PHC
ImPrim Work Package 3:
Instruments for improving the financial provisions for Primary Health Care
Incentive payments for high quality PHC performance
Proven Incentive Payment Schemes for PHC Professionals
Quality indicators for high quality PHC performance
Pilot projects on quality indicators in Lithuania and Latvia
Adjusted Clinical Groups (ACG) and co-morbidity
The Swedish Quality Registries and Primary Health Care
Remunerating Primary Health Care
– Instruments for improving the financial provisions for Primary Health Care
© 2012 Contributors and Blekinge Center of Competence, Blekinge County Council, Sweden
Supervising editor: Ingvar Ovhed, Blekinge Center of Competence
Reproduction of the material is permitted provided the source is indicated
Distribution: www.ltblekinge.se/bkc
Printed: BI Reklam
ISBN 978-91-86711-41-2 (printed)
ISBN 978-91-86711-42-9 (pdf)
National Health Service, Riga Latvia
Department of Public Health, Klaipeda University, Klaipeda Lithuania
Family Medicine department, University of Turku, Finland
Blekinge Centre of Competence, Karlskrona, Sweden
November, 2012
Remunerating PHC
ImPrim Work Package 3:
Instruments for improving the financial provisions for Primary Health Care
Incentive payments for high quality PHC performance
Proven Incentive Payment Schemes for PHC Professionals
Quality indicators for high quality PHC performance
Pilot projects on quality indicators in Lithuania and Latvia
Adjusted Clinical Groups (ACG) and co-morbidity
The Swedish Quality Registries and Primary Health Care
Remunerating Primary Health Care
– Instruments for improving the financial provisions for Primary Health Care
© 2012 Contributors and Blekinge Center of Competence, Blekinge County Council, Sweden
Supervising editor: Ingvar Ovhed, Blekinge Center of Competence
Reproduction of the material is permitted provided the source is indicated
Distribution: www.ltblekinge.se/bkc
Printed: BI Reklam
ISBN 978-91-86711-41-2 (printed)
ISBN 978-91-86711-42-9 (pdf)
National Health Service, Riga Latvia
Department of Public Health, Klaipeda University, Klaipeda Lithuania
Family Medicine department, University of Turku, Finland
Blekinge Centre of Competence, Karlskrona, Sweden
November, 2012
Report Remunerating PHC
Content – overall
Acknowledgements
VI
Introduction
VII
Report #1. Incentive payments for high quality PHC performance
A: 1
A. Implementing a Quality Bonus System
A: 19
A. Transnational conclusions for providing cost effective financial incentives A: 41
A. Proven Incentive Payment Schemes for PHC Professionals
A: 60
Report #2. Quality indicators for high quality PHC performance,
B: 1
B. Proposal of recognised quality indicators
B: 32
Report #3. Pilot projects on quality indicators in Lithuania and Latvia
C: 1
C. Pilot project in Latvia
C: 10
C. Pilot project in Lithuania
C: 13
C. Conclusions and recommendations
C: 38
C. Annexes
C: 39
D. Adjusted Clinical Groups (ACG) and co-morbidity
D
E. The Swedish Quality Registries and Primary Health Care
E
V
Acknowledgements
The Flagship project ImPrim, has come to an end.
ImPrim has been one of the flagship projects included in the EU Strategy for the Baltic Sea
Region Action Plan, co-funded by the European Union through the Baltic Sea Region
Programme 2007-2013 and the European Regional Development Fund (ERDF).
As the Lead Partner of ImPrim and on behalf of all Project Partners we hereby express our
gratitude to the Primary Health Care Expert Group of the Northern Dimension Partnership in
Public Health and Social Wellbeing (NDPHS) who originally initiated the project and to the
Swedish Committee for International Health Care Collaboration (SEEC) who was the Lead
Partner from the start until the end of 2010.
We appreciate the invaluable and strong support the ImPrim project has received from the
Ministries of Health of Belarus, Estonia, Finland, Latvia, Lithuania and Sweden.
Special thanks are addressed to the Joint Technical Secretariat, JTS, in Rostock for their
stimulating support and guidance during the whole project period, as well as to the Swedish
Agency for Economic and Regional Growth, for their first level of control, the Regional Council
of Blekinge and the Småland-Blekinge South Sweden Office in Brussels for moral support.
We also thank the Swedish International Development Cooperation Agency, later the Swedish
Institute’s Baltic Sea Unit for their supporting us by funding to help Kaliningrad to take part in
the project, to make the changeover of Lead Partners smooth and to arrange conferences on
parallel important issues associating to the main project objectives.
We are grateful for the profitable cooperation and discussions with the collaborating projects
ICT for Health, Nurse Gudruns full scale lab in Blekinge, Baltic Antibiotic Resistance
collaboration Networks (BARN) and PrimCare IT.
Karlskrona in November 2012
Birgitta Lundberg
Project Director
Lead Partner of ImPrim
VI
Introduction
Instruments for improving the financial provisions for Primary Health
Care
This collection of ImPrim deliverables in the field of remunerating primary health care includes
in the first part incentive payment schemes for high quality PHC performance, focusing on
health promotion and disease prevention. A broad transnational descriptive analysis will be
followed by a set of conclusions for providing cost effective financial incentives within the
remuneration schemes. This work has been carried out from the Latvian National Health Service
in Riga. It is important to balance quantity and quality. Capitation reflects quantity of provided
services, while a Quality Bonus System (QBS), open to family doctors on a voluntary basis, can
promote quality improvements
In the second part will this quality perspective be dicussed and tested. The aim of quality work
can be defined as the best structure, process and outcome of health care consistent with the
patient’s values and preferences, professional knowledge of appropriate and effective care,
possible with given available resources. In this report the authors have collected information of
quality projects in BSR countries as well as information of health care and payments systems.
Information of performance indicators used in respective BSR countries has been collected to
make an initial proposal for quality indicators of PHC performance. These indicators should be
discussed with national stakeholders: financiers, providers, professionals, patients and politicians,
and adapted to the national needs.
In the first short annex is described the ACG Case-Mix System. In combination with
socioeconomic indexes ACG case-mix system could ensure more equitable PHC where patients
with multiple chronic diseases would have good access to PHC resources. The ACG tool will
help stakeholders to allocate resources according to need.
In the last annex are shortly described the Swedish national quality registries has been established
in the Swedish health and medical services in the last decades. All national quality registries
contain individualised data concerning patient problems, medical interventions, and outcomes
after treatment and aggregated the data can be used with the purpose of continuous learning,
quality improvement and management.
VII
ImPrim Report #1
A. Incentive payments for high quality PHC performance
ImPrim Work Package 3:
Instruments for improving the financial provisions for Primary Health Care
Report #1
Incentive payments for high quality PHC performance
- Towards disease prevention and health promotion
in the community
Set of transnational conclusions for providing cost
effective financial incentives within
the remuneration schemes
Editor and author
Aigars Miezitis,
National Health Service, Riga Latvia
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Content
ABSTRACT........................................................................................................................................................... 4
ABBREVIATIONS................................................................................................................................................ 5
2. INTRODUCTION TO PRIMARY HEALTH CARE FINANCING ISSUES ............................................... 7
2.1 THE APPROACH TAKEN IN THE UK ................................................................................................................ 7
2.2 THE APPROACH TAKEN IN ESTONIA ............................................................................................................... 8
2.3 THE CURRENT SITUATION IN LATVIA ............................................................................................................. 9
3. OBJECTIVES WITH THIS REPORT .......................................................................................................... 12
4. OBJECTIVES FOR A QUALITY BONUS SYSTEM ................................................................................ 12
4.1 INDICATOR SHORTLIST ................................................................................................................................ 14
5. IMPLEMENTING A QUALITY BONUS SYSTEM .................................................................................... 19
5.1 FUNDING ..................................................................................................................................................... 19
5.2 ISSUES OF CONCERN .................................................................................................................................... 20
5.3 ADDITIONAL FACTORS ................................................................................................................................ 22
6. CURRENT LATVIAN INDICATOR SYSTEMS ......................................................................................... 32
6.1 QUALITY BONUS SYSTEM INDICATORS ....................................................................................................... 32
7. SET OF TRANSNATIONAL CONCLUSIONS FOR PROVIDING COST EFFECTIVE FINANCIAL
INCENTIVES WITHIN THE REMUNERATION SCHEMES ........................................................................ 41
7.1 CRITIQUE OF EXISTING INDICATORS ............................................................................................................ 41
7.2 INDICATOR SHORTLIST ................................................................................................................................ 42
7.3 MONITORING ............................................................................................................................................... 49
8. RECOMMENDATIONS................................................................................................................................. 49
8.1 REIMBURSEMENT ........................................................................................................................................ 50
8.2 REGIONAL ORGANISATION .......................................................................................................................... 50
8.3 INFORMATION SYSTEMS .............................................................................................................................. 51
8.4 INTEGRATED CARE ...................................................................................................................................... 51
9. CONCLUSION ............................................................................................................................................... 57
REFERENCES ................................................................................................................................................... 59
PART 2: PROVEN INCENTIVE PAYMENT SCHEMES FOR PRIMARY HEALTH CARE
PROFESSIONALS ............................................................................................................................................ 60
ABSTRACT......................................................................................................................................................... 60
1. INTRODUCTION............................................................................................................................................ 60
2. DEFINITIONS ................................................................................................................................................. 61
2.1 PRIMARY CARE INCENTIVE SCHEMES: OBJECTIVES AND KEY ELEMENTS...................................................... 61
2.2 MEASURING THE EFFECTS OF PROVEN INCENTIVE SCHEMES ........................................................................ 61
3. EXISTING INCENTIVE PAYMENT SCHEMES ........................................................................................ 62
3.1 EVIDENCE FROM THE US ............................................................................................................................. 62
3.2 EVIDENCE FROM THE UK ............................................................................................................................ 63
3.3 EVIDENCE FROM OTHER COUNTRIES ............................................................................................................ 67
3.4 PILOT SCHEMES IN BELARUS ....................................................................................................................... 68
4. ANALYSIS FROM CLINICAL AND ECONOMIC PERSPECTIVES ..................................................... 70
4.1 EVIDENCE FROM CLINICAL TRIALS .............................................................................................................. 70
4.2 INCENTIVE EFFECTS AND MEASUREMENT METHODS .................................................................................... 71
5. IMPLICATIONS OF EVIDENCE FOR IMPLEMENTING PROVEN INCENTIVE SCHEMES ............ 72
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Abstract
Across countries in the Baltic region issues concerning quality standards in primary health care (PHC)
service have a two-fold importance: continuing improvement in health outcomes for patients; and
achieving increased efficiency and effectiveness in health systems from primary through to tertiary care.
These are important concerns of the ImPrim project and are explored here both in general terms and with
specific reference to reimbursement for PHC in Latvia (NHS is coordinator of Work Package 3:
‘Instruments for Improving the Financial Provisions for PHC’).
Two principles which have been adopted by ImPrim partners as the basis for a PHC funding process are
quantity and quality. Capitation reflects quantity of provided services, and a Quality Bonus System (QBS),
open to family doctors on a voluntary basis, can drive quality improvements. In developing this approach
partners have drawn on the experience in this area of the UK and Estonia.
This joint report sets out the approach taken in the UK and Estonia (section 1) before going on to
describe the current quality systems in Latvia (section 2). In section 3 we set out general objectives for a
QBS and principles which might underpin it and, in section 4, we put forward a suggested indicator
shortlist based on these principles and existing quality indicators identified in Latvia. We briefly discuss
some implementation issues in section 5. In section 6 we set out general issues of concern, but in section 7
we set out two additional factors emerge from the general issues of concern that are also relevant to any
changes to QBS. In section 8 possible to compare the indicator value of other countries, as well as see the
average indicators values.
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Abbreviations
BSR
Baltic Sea Region
GP
General Practitioner
ND
Northern Dimension
NDPHS
Northern Dimension Partnership in Public Health and Social
Well-being
NDPHS EG
Expert Group of the Northern Dimension Partnership in Public
Health and Social Well-being
NHS
The National Health Service
PC
Primary Care
PHC
Primary Health Care
QBS
Quality Bonus System
EHIF
Estonian Health Insurance Fund
NICE
National Institute for Health and Clinical Excellence
QOF
Quality and Outcomes Framework
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2. Introduction to Primary Health Care financing
issues
2.1 The approach taken in the UK
The Department of Health in England introduced the Quality and Outcomes Framework (QOF) in 2004
as part of a new contract for family doctors. It incentivises them to improve their services to patients,
including improved clinical care and better outcomes. It operates through a system of points which are
awarded for levels of achievement against set criteria and for which they receive financial reward. Over €1
billion is paid out each year to over 8,300 family doctor practices under the QOF. Payments to the family
doctor practices are of three types:

Capitation funding (adjusted for weighted needs of the population such as age);

QOF payments;

Optional payments made for ‘enhanced services’ which might be nationally organized
(such as childhood vaccination), or developed in response to particular local health
initiatives, (eg if there were a large number of homeless people requiring services targeted
towards their needs).
The QOF is a way of rewarding family doctor practices (NB: not individual family doctors) for meeting
higher standards in quality of care; it is not a performance management system. It is voluntary, although
most practices take part. They score points across four areas known as ‘domains’ each with associated sets
of indicators, covering:

Clinical care (with a focus on patients with specified conditions in 11 clinical areas; 76
indicators). For example, hypertension indicators cover whether there is a register of
hypertension patients; whether their blood pressure has been recorded in the previous 9
months; and, if recorded, if it was below 150/90;

Organizational (relating to record keeping, medicines management, education; 56
indicators);

Patient experience (focus on the length of the appointment, patient surveys; 4 indicators);

Additional services (relating to cervical screening, ante-natal care, child health and
contraception; 10 indicators).
Of these, the clinical domain is the largest and is worth up to 697 points out of the maximum 1,000
available (69.7 per cent). Each point is worth €150. Achievement under the QOF has always been high
and from the start was higher than expected – over 90 per cent in the first year against an expected 75 per
cent achievement.
A feature of the QOF is ‘exception reporting’ where – for nine different reasons - a family doctor can
decide to exclude certain patients from the statistics used to construct particular indicators for that
practice. This was built into the QOF system from the outset and was designed to ensure that family
doctors wanting to participate in the QOF would not be penalized under certain circumstances. While
most of these exceptions are for specific clinical conditions and relate to individual indicators, two
exceptions impact on disease registers and the exclusion therefore carries through into the denominators
of all indicators covering that clinical area. These two exceptions are for patients who do not attend for
review (after reminders), or where the family doctor deems it ‘not appropriate’ to review them because
they are, for example, ‘terminally ill’, or ‘extremely frail’. This amounts to a ‘clinical override’ and can
potentially have a significant effect on indicator values (and hence remuneration) for individual practices.
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2.2 The approach taken in Estonia
In Estonia PHC financing is made up of a capitation element (which is age adjusted), a ‘basic allowance’ to
cover accommodation and home visit transport costs and, where over 20km from the nearest hospital,
there is a ‘remote area’ payment. These are paid prospectively once a month. Additionally, there are fee for
service allowances which cover an agreed list of more than 160 diagnostic services (about 32% of the
capitation budget), and which are paid according to invoices submitted. Finally, there is the Quality Bonus
System which is paid once a year retrospectively. This was introduced in 2005 and has been further
developed every year since. The size of the bonus received is based on the number of points obtained and,
typically, pays an equivalent €205 – 320 per month.
The aim of the QBS is to promote active involvement of family doctors in disease prevention, tackle the
spread of infectious diseases, ensure more effective chronic disease management in the community and to
provide a broad range of health services. There are three main indicator domains:
Prevention

Child vaccination across a range of diseases;

Post-natal check-ups at 1, 3, 12 and 24 months;

Pre-school child examination;

Risk-factor screening for cardiovascular disease (eg cholesterol test once every 5
years for 90% of adults aged 40-60).
Chronic disease management

Type 2 diabetes (various tests annually: eg. creatinine, albumin, cholesterol);

Hypertension (health advice, ECG);
 Post myocardial infarction (cholesterol, glucose).
Additional skills from family doctor

Neonatal care;

Gynaecological examinations;

Minor surgery;

Clinical training.
Between 2006 and 2010 the number of family doctors participating each year in the QBS has increased
steadily from around 500 (63%) to over 700 (90%). Of those participating and achieving targets, the
percentage has risen from 6% to 52% (2009), and they increased their involvement in screening and
prevention activities than those who did not participate in QBS. There is no exception reporting (eg for
non-attending patients) as in the UK, and in 2010 the identification of numbers of patients with chronic
diseases moved from being self-reported by practices to being centrally identified from financial databases
(with some increase in resulting estimates).
The two quality incentive systems outlined are quite similar in their overall objectives of incentivising PHC
practice and rewarding family doctors for taking on work designed to support policy objectives, rather
than simply rewarding them on the basis of amount of work undertaken. They both cover a range of PHC
activity embracing organisational development and training as well as clinical areas, and there is a focus on
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public health and long-term conditions management with an aim of maintaining patients in the
community and avoiding unnecessary hospital admissions. In addition, both systems try to extend the
range of services that might be undertaken in PHC rather than ambulatory care locations.
The Estonian system is more ‘top-down’ than the UK system as it is driven by data received by the central
Estonian Health Insurance Fund (EHIF) which manages the contracts with family doctors and so has the
data from invoices submitted for payment.
The UK system is more sophisticated and extensive. The data are electronically abstracted directly from
family doctor practice information systems to the National Institute for Health and Clinical Excellence
(NICE) which is responsible for managing the QOF system and review process. Indicators are calculated
and the data fed back to family doctors. In addition there are annual review meetings on QOF conducted
by the local health authorities who administer the payments under the system.
2.3 The current situation in Latvia
A mixed capitation method of financing has developed since 2000 with the current system adopted
throughout the country from early 2005. Central expenditure on PHC comprises several components
(described in more detail below). An analysis of data supplied by HPC by practice size leads to the
following calculation of expenditure.
Total HPC expenditure
LVL (000)
%
Capitation
13.742
37%
Fixed payment for practice maintenance
3.966
11%
Additional payments
4.377
12%
Payment for manipulations/ procedures
2.367
6%
Patient fees (co-payment reimbursements)
2.835
8%
Payment for the care of ‘temporary patients’
0.074
0%
Payment for nurse and physician assistants
7.486
20%
Quality payment I (monthly payments
0.808
2%
Quality payment II (annual payments)
1.280
3%
Total
36.935
100%
Note that there is a small discrepancy between the total shown and the HPC published total which may be
attributable to the inclusion of different funding elements, or the result of miscounts of practice numbers
relative to those of GPs. The picture is quite complicated in terms of the range of payments and, although
capitation (which is age-weighted) is the most significant, various other allowances and fixed payments can
be large. As in Estonia there are also fee for service payments.
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A total of 5% of the overall HPC expenditure is made under two separate headings related to quality
aspects of care and practice organisation. These indicators are universal in their coverage across family
doctors, although it is up to the individual doctor to decide whether they wish to maximise the potential
income they can derive. This can, at its theoretical maximum, account for up to 15% of a GP’s average
annual income.
Monthly indicators

These are mostly related to practice organisation:

practice reception hours are at least 20 hours per week in practices with fewer than
2000 listed patients or 25 hours in practices with more than 2000 patients;

practice working hours - not less than 40 hours per week with both morning and
evening availability;

at least one hour per day is available for patients without a prior appointment;

a patient can obtain a GP appointment within five days;

home visits are available until at least 15.00.
Annual indicators
The annual indicators involve certain numbers of preventive interventions - check up of patients related
to illness or prevention, preventative check up of children, vaccination of children, examination of
patients with type 2 diabetes, number of emergency calls for patients with primary hypertension and the
quality of care of patients with bronchial asthma.

All practices are divided in two groups depending on the percentage of children: if >70%
then it is a pediatric practice and a separate set of indicators apply (see annex).

If criteria are met then GPs receive the full amount of money available for that indicator;
if they meet only 80-100% of the threshold then the payment for that indicator is
reduced pro rata. There is no payment for performing under the 80% threshold.

The existing quality indicators are now perceived as providing insufficient motivation for
GPs to increase quality of care and, at the same time, there is a growing financial
imperative to improve overall levels of efficiency and effectiveness across the health care
system as a whole (the proportion of the PHC budget on outpatient services, for
example, has increased by 6% between 2009 and 2011)..
This has led to a new Quality Bonus System which was introduced - with involvement of the Family
Doctors’ Association - by the Ministry of Health in July 2011. It is seen as extending the concept of
quality from the existing quality system which focuses solely on care quality between a patient and their
doctor, to one where wider societal values are included through driving improvements in the efficiency
and effectiveness of the health system: for example, reducing unnecessary outpatient referrals or
emergency hospital admissions.
The system is voluntary and open to family doctors registered with the NHS and with a list size of 1,200
patients (or 400 if they are a pediatric practice). It offers the prospect of additional annual payments and,
to date, about 13% of GP practices across the country have signed up.
Within the QBS there are 35 indicators covering areas of process, outcome and resources (see annex).
Each indicator has a certain number of points associated with it and the minimum threshold for receiving
any money at all requires achieving 70% of the total points available.
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There are five compulsory indicators:

doctors and nurses should have separate consulting rooms;

patients should have a medical check-up within a month of registering with the practice;

patient calls for the emergency medical aid service are lower than the national average
rate, or are decreasing;

the hospitalisation rate of a GPs patients is lower than the national average, or is
decreasing;

rate of GP patients' visits to secondary health care specialists is lower than the national
average, or it is decreasing.
PHC can also have a major impact on activity levels and hence costs in secondary care and across the
healthcare system:

by substitution of services that can be delivered more cost-effectively in PHC;

by better management of referrals to specialist outpatients;

by more cost-effective use of diagnostic services;

by more cost-effective prescribing practice.
Therefore, some exploration of secondary care activity and reimbursement is helpful to identify
opportunities to extend the role of PHC. At the same time, any changes to financial incentives across
PHC should be mirrored in secondary care if desired outcomes are to be achieved.
A wide range of medical, surgical and other specialisms are recognised for ambulatory care purposes.
Patients can access these through referral by their GP, or by another specialist. However, partly as a legacy
of the earlier policlinic model, no referrals are needed to access certain specialists directly.
Reimbursement for outpatient services is based on three components: episode (based on a state unified
tariff); manipulations (fee for service undertaken by specialists, and also based on a state unified tariff);
copayment to the specialist by the patient.
Although tariffs are based on detailed analyses of actual costs, these may not provide financial incentives
for desired changes in these practices. In particular: possible priority areas for quality incentives in PHC
(eg diabetes monitoring, cervical screening) are also supported by specialties that allow direct access;
identical courses of treatment in PHC and Specialist Outpatient Health Care (SOHC) is subject to
different reimbursement, as the secondary care provider is paid a fee for the healthcare episode; quality
bonuses in PHC may in part be achieved by treatments provided by secondary care.
There is some evidence that work may have transferred to PHC following the introduction of quality
incentive schemes. There are few incentives for either GPs or specialists to control their volume of
requests for diagnostics or drugs.
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3. Objectives with this report
The general objective of the Joint Transnational Report is to:
identify UK and Estonian approach to KBS;
to present the current situation in Latvia;
show kinds of the KBS indicators;
implementing a QBS in Latvia;
to indicate problematic issues;
determine the average indicators value between different countries.
critique of existing indicators;
make recommendations to improve the QBS
At the same time, the goal is to minimize the existing differences in the socio-economic development
between the western and the eastern parts of the region as well as to resolve issues of common concern
for the countries around the Baltic Sea Region.
4. Objectives for a Quality Bonus System
Quality Bonus Schemes (QBS) to incentivise Primary Health Care (PHC) have been adopted by the UK
and Estonia specifically to reward improved patient outcomes, or at least to encourage care processes that
are expected to lead to improved patient outcomes. This reflects the priorities in those countries when
they were adopted some years ago. In the same way, when considering the design of a QBS for any
country in the Baltic Sea region, we need to identify the priority objectives for primary health care within
the healthcare system as a whole. The major change affecting all countries in the region now, compared to
five or more years ago, is the much bleaker economic climate. In turns this affects the ability of any
healthcare system to improve ‘quality’ and hence the choice of levers within a bonus system, and a need to
focus more widely on cost-effectiveness rather than solely on outcomes.
While the notion of ‘quality’ in a quality bonus system has, from the outset, focused on quality of
healthcare provision and improved clinical outcomes for patients, increasingly there is a desire to
recognize the need for cost-effectiveness in the health care delivery system at the same time. This, in
effect, more explicitly incorporates the health care funders as a major stakeholder in the system, not only
the family doctor and their patients.
This is supported by commentators such as Maynard (2008) who are clear in their view that Western
healthcare systems share a general tendency to inefficiency, and variable quality, in the way they are
delivered, and that there is a need to contract with providers in ways which reward improvements in this.
Incentives - financial or non-financial - if carefully considered, introduced, and monitored can be used to
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steer behaviour in the direction of policy goals. The importance of improving the transparency and
accountability of decision-making and performance - and thereby increasing trust and communication –
can be supported by appropriate use of financial incentives.
Bringing together cost effectiveness and quality in this way suggests to us that the focus of the design of
any QBS needs to be on measures of PHC that indicate whether the value of services is being increased.
The term value is used to describe the outcomes of health care services relative to their costs. This is
discussed in more detail by Porter (2010):
“Since value depends on results, not inputs, value in healthcare is measured by the outcomes achieved, not
the volume of services delivered, and shifting focus from volume to value is a central challenge. Nor is
value measured by the process of care used; process measurement and improvement are important tactics
but are no substitutes for measuring outcomes and costs. Since value is defined as outcomes relative to
costs, it encompasses efficiency. Cost reduction without regard to the outcomes achieved is dangerous and
self-defeating, leading to false ‘savings’ and potentially limiting effective care.”
With relatively constrained budgets, the costs associated with improving quality in health care need to be
recognised and that much of this manifests itself through the impact that PHC can have on other health
and social care systems with which it interacts. So processes which are evidenced to deliver good
outcomes could form part of a QBS for example, for helping to create a shift towards ‘population
management’ as a focus for PHC.
This recognition of the need for value will be a common high-level objective within ImPrim partner
countries together with wanting to have accessible and equitable service provision across the population.
With specific respect to the Latvian situation, these overall objectives of cost-effectiveness and quality
need to be further refined to take account of the particular situation in that country. We have identified
four high level objectives that relate to increasing value, for each of which indicators can be identified to
form the basis of a revised Quality Bonus System for Latvia. The first two are concerned with services
that can be delivered in PHC that will improve outcomes, the other two are primarily concerned with
reducing costs across the system whilst maintaining outcomes:

Prevention activities eg check up, vaccination and immunisation, screening

Management of Chronic Conditions eg diabetes, hypertension

Substitution for Secondary Care eg minor operations, pregnancy care

Avoidance of Demand outside PHC eg better targeted referrals, test requests, prescriptions;
better patient access to family doctors to prevent unnecessary calls on emergency and
inpatient services.
We note that the first three of these categories correspond to the three ‘domains’ already adopted for the
Estonian QBS. It should also be noted that actions within PHC may impact across categories, for example
better control of diabetes will reduce acute exacerbations, also reducing calls on emergency services.
All of the above discussion leads us to propose some basic principles which we believe ought to underpin
a QBS:

A voluntary scheme, and given status as a ‘measure of excellence’ perhaps with a link to an
accreditation process or personal skills development;
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
A single scheme (which, in Latvia, would imply merging the two separate systems which
currently operate).The scheme should only apply to family doctors and not to pediatric only
services. Its measures should all be within the control or influence of the family doctor;

There must be an audit trail of data;

There should be clear and consistent links to other change initiatives where relevant (eg list
size, development of the practice nurse role);

It may be desirable to define qualifying criteria for the scheme (eg separate rooms for doctors
and nurses).

Payments should be linked to potential savings in other tariffs (eg fee for service tariffs in
secondary care);

Patient copayments should reinforce the QBS incentives;

Indicator targets should be ‘absolute’ and not comparative measures based on previous years,
or on other family doctors;

Target ranges should be set based on evidence of what is achievable for the upper bound, and
what is currently achieved to set the lower bound;

There should be no ‘exception reporting’ by doctors to remove ‘difficult’ patients from
indicator calculations.
4.1 Indicator shortlist
This will require more consultation and development but, as a starting point, we can consider groups of
indicators as well as specific examples. It has been suggested that an ‘ideal number’ might be around 30
indicators altogether. While this is not necessarily a fixed limit, it is indicative of the scale expected of it
and reflects the current system.
Using the categories defined above we can identify broad indicator definitions based on those already
introduced in Latvia in the two current systems. Clinical indicators should only be selected if:

PHC has the main ongoing responsibility;

PHC has the potential to improve outcome;
 the disease is a national priority.
The table below shows 16 groups of indicators based on a combination of the existing mandatory system
(M) introduced in 2005, and the QBS system (QBS) introduced in 2011. The proposed indicators can be
directly cross-referenced with the existing ones which are listed in the annex. In the comments column we
describe possible changes that should be considered.
The groups of indicators appear to cover the main areas of interest and concern in the Latvian PHC
system - with a focus on prevention and chronic conditions - and in this respect are very similar to those
covered in the Estonian QBS (with the exception of hypothyroidism). However further discussion of
current objectives in PHC in Latvia is required.
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I
I
I
II
2
3
4
5
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Routine health check
I
Type 2 diabetes monitoring
processes
(where 20+ diabetes patients
on list)
Smoking cessation
Child health (0-18)
Consultation with patient
Short description
Domain
No
.
1
QBS 15
M 4,5
QBS 14
QBS 12,13
M 2,3
M1
QBS 9,10,11
Existing indicators
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50% smokers have had cessation counselling
in previous year
80% have 2+ measured glycated hemoglobin
tests in PHC in previous year
60% have micro albuminuria test in PHC in
previous year
90% of children on list in previous year
90% vaccination rates according to
vaccination calendar
75% children 12-18 have had a check-up in
last 2 years
100% physical and mental evaluation of
children aged 1week – 5 years
All new patients within 1 month of
registration
90% patients 18-40 have had a check-up in
last 5 years
90% patients 40 years and older have had a
check-up in last 3 years
65% of all patients on list in previous year
Current Thresholds
Indicator denominator definition?
Some overlap between current
QBS and Mandatory indicator
systems (between 1 and 2)?
Some overlap between mandatory
and QBS systems?
Some overlap between current
QBS and Mandatory indicator
systems (between 1 and 2)?
Comments
15
II
II
II
II
7
8
9
10
16
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6
COPD monitoring
processes
Hypertension monitoring
processes
Coronary heart disease
monitoring outcomes
Coronary heart disease
monitoring processes
Type 2 diabetes monitoring
outcomes
(where 20+ diabetes patients
on list)
QBS 27
QBS 22, 23, 24, 25,
26
QBS 18, 20
QBS 19, 21
QBS 15, 16, 17
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CV risk determined 100% hypertension
patients during check-up
80% hypertension patients have total
cholesterol test at least once every 3 years
80% hypertension patients have a 12-lead
ECG at least once every 3 years
80% hypertension patients have glycosis test
at least once every 3 years
60% have had life-style consultation with
nurse/ GP asst in previous year
60% have had life-style consultation with
nurse/ GP asst in previous year
60% have one HBA1C measure <7.5% in
previous year
70% received peripheral pulse and foot
examination in previous year
70% have had life-style consultation with
nurse/ GP asst in previous year
70% CHD patients have at least one record
of total cholesterol
60% have had life-style consultation with
nurse/ GP asst in previous year
60% CHD patients have arterial blood
pressure 150/90 or less in previous year
40% CHD patients have total cholesterol
5mmol/L or less in previous year
Indicator denominator definition?
Indicator denominator definition?
Thresholds need review
Indicator denominator definition?
Thresholds need review.
III
IV
IV
IV
IV
12
13
14
15
16
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II
11
Drugs prescribing
Patient hospitalisation
Secondary Health Care visits
Emergency Medical Aid
Service
PHC substitution of services
for secondary care
Asthma monitoring
processes
QBS 32
QBS 30
QBS 29
QBS 28
QBS 31
M 6, 7
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90% asthma patients have 1 measurement of
peak expiratory flow in previous year
90% patients who use inhalers are tested in
accuracy of their use in previous year
Increase in number of minor surgery
procedures
Increase in number of gynecological
examinations
Increase in ante-natal care
Rate of GP’s patient calls for EMAS
(subject to various thresholds relative to the
mean national rate and relative rates of
change in the previous year)
Rate of GP’s patient visits to secondary
health care specialists
(subject to various thresholds relative to the
mean national rate and relative rates of
change in the previous year)
Rate of hospitalisation of GP’s patients
(subject to various thresholds relative to the
mean national rate and relative rates of
change in the previous year)
Number of GP prescriptions for
reimbursable medical drugs/ devices from
List A as a proportion of all prescriptions
has increased 5% over the previous year
Change to a simple % threshold.
Limit number of specialties to
include?
Emergency admissions only?
Could explore absolute measure
of expenditure incurred?
Change to a simple % threshold.
Limit number of specialties to
include?
Change to a simple % threshold.
Emergency calls during normal
GP working hours only?
Current indicator is composite of
very different activities. Are some
already paid as manipulations?
Indicator denominator definition?
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We consider that some of the existing indicators (QBS 1-8, 34-35) do not fall into the four domains we
have identified and instead might be regarded more properly as either:
Admission criteria for entry into the QBS in the first instance;
‘Accreditation’ criteria which, along with the QBS, could be regarded as a mark of ‘quality’ of the
GP practice.
Criteria for admission to QBS
This is about a GP having the necessary elements in place before being eligible to have additional quality
payments. At the very least the practice already needs to be providing consulting hours according to the
regulations and have staffing levels appropriate to the list size. We also believe that the practice space
should be a prerequisite of joining the scheme; not something rewarded by the scheme itself. There
should be a clinical purpose to acquiring additional space and any additional funding should be as a result
of activities that can then be conducted with it, rather than the acquisition of additional space for its own
sake.
The practice has sufficient staffing levels (GP/ nurse/ GP assistant/ receptionist time) to match
the list size. (QBS 2, QBS 3, QBS 6);
The GP practice nurse or GP assistant have a separate room in which to conduct consultations
(QBS 4);
The GP provides consulting hours according to the regulations (QBS 34).
Accreditation criteria
These criteria focus on practice organisation, and they should come about as a result of entry to the QBS
system rather than be a direct reward of that system. Meeting these criteria would not be a condition of
entry to the QBS, but practices would be expected to be “working towards” them over the following few
years.
Patients can contact the practice by email and receive a response within 3 working days (QBS 1a);
The practice has a website (QBS 1b);
Patients can obtain a GP appointment within 4 working days (QBS 5);
Specially designated software is in current use at the GP practice (QBS 7);
PHC staff have education plans and nurse/ GP assistant have postgraduate PHC training (QBS
8);
Organisation of repeat prescriptions for long term conditions (QBS 33);
Local government quality assessment of GP practice (QBS 35).
Of course, similar country-specific lists would need to be developed in each partner ImPrim country
based on the local starting situation and requirements but, in principle, the approach is the same.
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5. Implementing a Quality Bonus System
5.1 Funding
There are a number of ways in which a QBS could be funded which will depend on the extent of the
scheme in terms of eligibility to participate (which family doctors might be included?), scope (what is the
range of services which might be included in the QBS?), and the proportion of family doctor income that
the scheme is expected to represent.
All of these parameters are still up for debate, but suggestions for QBS funding might include:
Within the existing funding framework, absorb the existing PHC funding currently available for the
‘mandatory’ quality indicators introduced in 2005 (see annex).
Making available additional central funding for QBS using savings generated elsewhere. Three specific
funding streams have been identified
There is likely to be a ‘windfall’ from the capitation budget as forecasts of the outcome of the 2011
population census suggest that the population of Latvia will show a decline. If the capitation budget were
maintained at existing levels (rather than adjusted to reflect the population change) then this could
provide funding for QBS;
The Latvian economy is forecast to achieve modest growth in GDP which would enable additional
funding for health care which is seen as a priority sector in the economy (and, within which, there is a
particular commitment to primary health care in the long term). Overall health service funding for 2012 is
estimated at Ls 422million compared with Ls 412million in 2011;
Savings from secondary care where substituted by PHC activity (such as reduced emergency calls and
admissions within normal working hours), and restrictions on current direct access by patients to some
ambulatory care services.
In the future there may be other potential savings that would follow successful developments in PHC eg
more economic prescribing.
More radical approaches in the context of initiatives to increase competition, including the reallocation of
existing PHC budget lines (eg the nurse budget, limit capitation to an upper list size) are considered in
interim report 4 to follow.
Information
On current practice there is substantial information flow to the National Health Service Payment Centre,
and we would support the generation of all indicator values there, as is already the case for the limited
‘mandatory’ system. This will allows proper audit trails to be established.
Equally important will be much greater transfer of key data to family doctors. Currently indicators appear
suspect because the generation of patient population numbers is uncertain, and practices cannot know in
advance what numbers of patients are in any given disease group. Hence they cannot plan to achieve any
given target level of coverage. An essential feature of the new system should be the generation of Patient
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Registers from the outset for all patient groups covered by the scheme. This could be undertaken by the
Payment Centre, based on diagnostic and event data supplied by family doctors, and the additional data
available from the Diabetes Register.
It is possible that such initiatives could be extended over time within PHC to provide a new approach to
eHealth development in primary care, designed around population management.
5.2 Issues of concern
The four issues specified have been raised previously in ImPrim, and substantively discussed in the
Latvian context. They are not likely to be subject to independent resolution and, from the various reviews
of quality initiatives in the UK, Estonia and Latvia, there will be further confounding factors in any local
environment.
a. Competition among family doctors
There is always an element of professional competition between clinicians, but the evidence for the
influence of competition on cost effective practice is limited. If we are looking for structures which
enhance patient choice we need to recognise that those patients that exercise choice of provider in health
care contexts tend to be the best educated and also the healthiest. So other objectives related to targeting
deprivation, for example, may not be progressed - and indeed may be set back - if competition is solely
linked to patient choice.
Even without any administrative restrictions on choosing a family doctor, the knowledge people have as a
basis for their decision making is limited. Rubin et al (2006) in the UK researched whether time to
appointment, choice of appointment time or choice of doctor was most important to a patient. They
found that speed of access, for many, was outweighed by choice of GP or convenience of appointment
(especially if the respondent worked). Other responders, especially those with a chronic illness, valued
seeing their own GP and were willing to wait to see them: in particular older patients were willing to wait
an extra 2.5 days.
Other evidence from the UK (Pike, 2010) suggests that GP practices located close to other rival GP
practices provide a higher quality of care than that provided by GP practices lacking close competitors.
This higher level of quality was QBServed firstly in an indicator of clinical quality (referrals to secondary
care for conditions that are treatable within primary care), and secondly in an indicator of patient
QBServed quality (patient satisfaction scores obtained from GP patient surveys). The first of these
indicators has been adapted in our proposals for a revised Quality Bonus System. The association
between increased competition and higher quality was found for GP practices located within 500 metres
of each other. However it would appear that the magnitude and geographic scope of the relationship are
constrained by restrictions upon patient choice: patients cannot easily move between Family doctors, not
least because list sizes of popular practices rapidly reach agreed maximum levels.
The proximity factor becomes an interesting one to exploit in Latvia and some other Baltic countries,
because of the large numbers of family doctors who practice in locations physically close to each other,
notably in health centres or the old policlinics. The effect will also be more accentuated in areas of higher
density populations such as Riga. Although many doctors work single-handedly, there is potential to
develop services both separately and cooperatively with colleagues, and this could be complementary to
other priority developments.
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b. New doctors entering the labour market
In Latvia a newly qualified doctor wishing to enter PHC has limited opportunities. As a major part of the
funding takes the form of capitation and the majority of the population is already registered with a Family
Doctor, building up a new practice by gradually attracting patients is a long process, and possibly an
unaffordable one.
Most practices are single-handed, and initiatives to encourage Limited Company models of organisation
have not had much success, as it seems that the costs of establishing and maintaining this model are too
great. Within a Limited Company structure it would be relatively easy to take on, or directly employ, a
more junior doctor, but if this is not affordable it would be constructive to explore alternative business
models that could produce a similar end result. There are various opportunities at the regional level
(perhaps within a hospital catchment) to incentivise cooperative working, for example:

direct payments for junior doctors to increase medical cover in practices already serving large
populations per doctor. These junior doctors could possibly be shared between associated family
doctors;

in a similar manner; linking out of hours medical support to particular groups of family doctors;

introducing care services managed from the hospital, especially for chronic care management,
with individual staff (doctors and, potentially physician assistants or nurses) attached to groups of
family doctors.
The recent survey of family doctors (to be summarised in the final report of this project) found that half
those replying considered themselves already to be working ‘in association with’ other family doctors,
thus there may already be informal groupings that can expedite such changes.
We understand that a common placement for newly qualified doctors in Latvia and some other Baltic
countries is in regional hospitals or policlinic facilities where individuals wishing to develop a career in
PHC can be directly employed as internists. This requires them also to offer out of hours services. Such
postings are seen to offer career progression towards establishing a new family doctor practice, but
further organisational and financial incentives need to be developed to support this.
By way of comparison, the trend in England is towards group practices of family doctors. In 2009, there
were just over 32,000 whole time equivalent family doctors of whom about 1,200 worked in singlehanded practices. This was a reduction of 35% from over 1,900 in 2004. In a related trend, particularly
concerned to improve staffing levels and reduce list sizes in deprived areas, the number of salaried family
doctors rose from fewer than 800 in 1999 to over 7,300 in 2009 (King’s Fund, 2011).
c. Division of large practices
There are no fixed limits in Latvia to practice size. Capitation remains the largest single element of
funding for family doctors, and thus acts as a disincentive for large practices to develop services in the
directions promoted by Quality Bonus Schemes. There are more patients to treat in order to qualify for
bonuses, and these may be outweighed by the gain from a large capitation payment.
Changing the balance between capitation and quality payments could influence behaviour in this area but
as QBS schemes develop it is unlikely that this could avoid various unintended consequences for other
types of practice. Not least we should recognise that small practices are incentivised in the opposite
direction: all practices currently receive a fixed payment regardless of size which forms a larger
component of small practice income.
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d. GP conjunction to the definite territory
The fourth issue that has been under discussion in Latvia relates to the idea that catchment areas could be
defined for Family doctors that were coterminous with those for regional hospitals.
To some degree this would, of course, restrict patient choice in that patients could only choose their GP
from the regional catchment area, and not from Latvia as a whole. However it could improve the
prospects for linking regional employment of new doctors and coordination of out of hours services in
ways that would enhance PHC services to patients. Such an arrangement could also be linked with
attempts to reduce emergency ambulance calls, for which we are currently proposing a performance
indicator relating to daytime emergency calls. Improving the links between Family doctors and the out of
hours service also raises the options for reducing ambulance calls at other times.
Furthermore, a particular attraction of such an alignment would be that the regional hospital could also
have a role in the development of the integrated health care model spanning primary and secondary
health care with a more holistic approach to patient care and health and social care service provision. In
most European countries there is an increasing trend to caring for people in their own homes and
avoiding unnecessary hospital admissions. To be most successful, this model requires good co-ordination
between different health and social care agencies to enable the right integration of services to be delivered
at the right time. The role of a regional hospital - well linked with local Family doctors and nurses in the
surrounding area - as a focus for providing expert advice and ‘outreach’ support in the community in
addition to traditional inpatient care would be a very powerful combination.
A regional focus for PHC development would also provide a potentially strong and clearly focused
context for a redesign of eHealth solutions which have only had limited impact to date. There would be
opportunities for progressive\ implementation of eHealth solutions, and roll-out to individual Family
doctors, within such a framework. The management of patients with chronic conditions, who would be
the major beneficiaries of an integrated approach, requires information sharing between clinicians at all
levels, and a strategy of building from the individual GP data sets required for QBS implementation is a
promising
prospect.
5.3 Additional Factors
Two additional factors emerge from the above discussion that are also relevant to any changes to Quality
Bonus Schemes. These relate to the overall reimbursement arrangements for family doctors, and the
current organisational structure of practices (largely single-handed).
e. Reimbursement
Figure 1 shows the breakdown of all state payments to family doctors in Latvia in 2010. It can be seen
that out of a total expenditure of Ls 37 million, less than half is accounted for by capitation and quality
payments, the two key elements recommended by ImPrim as the basis for GP remuneration. Whilst it is
expected that the quality bonus proportion will increase to some degree, we should also consider the
implication of the other substantial payment types.
Capitation itself is a sensible way to reimburse family doctors for providing a comprehensive PHC
service. However for those doctors with very large list sizes this acts as a disincentive to the development
of ‘quality’ services, and especially those concerned with providing high levels of coverage for particular
patient groups (eg symptom maintenance of diabetic patients, vaccination of children). This is because a
doctor can gain greater income (through capitation) from maintaining a large list size than from providing
enhanced services.
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Figure 1
State Payments to Family Doctors by Type (2010)
Quality bonus
6%
Nurses and
assistants
20%
Capitation
37%
Temporary
patients
0%
Co-payment
reimbursements
8%
Manipulations
6%
Additional
payments
12%
Fixed payment
11%
The next largest element of payment is that for nurses and physician assistants. These expenditures are
paid directly by the NHS to encourage employment of these staff and to maintain their salary levels.
Nurses and physician assistants will play an increasingly important part of the development of enhanced
quality services, so a high level of expenditure is appropriate. In England, for example, between 1995 and
2008, the proportion of general practice consultations undertaken by nurses increased from 21% to 35%.
On the other hand it appears that nurses in Latvia may currently be spending a large part of their time
engaged in administrative support duties, rather than direct patient care. The push for separate rooms for
nurses aims to allow them to undertake more clinical work, but presumably the administrative work will
need to continue and be paid for in some way.
We also note the payments for manipulations. There are 125 manipulations (including vaccinations) on
the unified state tariff which family doctors are eligible to receive as well as specialist doctors. Some of
these are procedures which are included in the 2011 voluntary bonus scheme (eg minor operations,
pregnancy support). Discussion with stakeholders suggests that there is not currently a major impetus for
increasing the range of work undertaken by PHC substituting for specialist services. There would not be
any major cost or quality gains across the health system in them doing so; indeed the incorporation of
quality incentives in PHC could actually increase overall costs for the same outcome. On the other hand,
there are potential benefits in terms of improving patient access to routine procedures (eg reducing
waiting times), and some Family doctors may be keen to develop new skills of services. However we
consider that the current fee for service for manipulations is sufficient incentive for those Family doctors,
and there is always the option of extending the existing list of manipulations if Family doctors are in a
position to extend the range of their services. Maintaining separate payments for manipulations on a
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unified tariff also maintains a ‘level playing field’ between primary and secondary care, in that there is no
financial incentive for manipulations to be performed on cost grounds in one sector rather than the other.
f. Practice Size
There has been some encouragement in Latvia for larger practices similar to the normal organisational
model in the UK. These would allow pooling of nurses, assistants and other staff. However the proposed
business model, a limited company arrangement, has not been widely adopted and it appears that funding
mechanisms do not make this an economic proposition, except for doctors with large private practices.
Figure 2
Doctors in Practices with more than one GP
(2010, N=103)
Number of family doctors
30
25
20
15
10
5
0
2
3
4
5
6
7
8
9
Size of practice
Of 1,329 family doctors listed in 2010 NHS statistics, only 103 were part of an institution shared with
other doctors. The number of doctors working, by size of practice, is shown in figure 2. Practices with 4
or more doctors tend to be in policlinics where, presumably, the doctors are salaried. Most of the
organisations that appear to be limited companies are those with 2 or 3 doctors, 21 practices in all.
Given this very low take up of the limited company model, it is worth considering, for the medium term
at least, whether there are other approaches that could allow doctors to work in larger groups, with
greater sharing of resources, and greater potential for entry of new doctors.
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30
30
30
12
Weights
-
-
-
50
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80% – 95%
70% - 90%
1.3 Percentage of
patients aged 40 years
and older who have had
a check-up in preceding
3 years
Child health (0- 2.1 Percentage of
18)
children on list in
previous 12 months who
have been vaccinated
against Diphtheria,
Tetanus, Poliomyelitis,
Pertusis, Meningitis, B
Hepatitis
70% - 90%
1.2 Percentage of
patients aged 18-40 who
have had a check-up in
preceding 5 years
2 I
70% - 90%
Thresholds
1.1 Percentage of new
patients with routine
health check-up within 1
month of registration
Routine health
check
Indicator definition
1 I
No. Domain Short
description
5. Average of the indicators value
Belarus
Sweden
Weights
Finland
Weights
Estonia
Weights
30
30
20
20
Lithuania
30
25
25
30
Weights
Latvia
23
14
13
10
Weighting
Average
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3 I
Cervical cancer
screening
Smoking
cessation
4.1. Percentage of
patients who have
attended cervical cancer
screening according to
State programme within
the preceding 36 month
preceding 12 months.
Organized list of
smokers in the practice
3.1 Percentage of
patients who smoke and
whose notes contain a
record that smoking
cessation advice or
referral to a specialist
service, where available,
has been offered within
the
2.2 Percentage of
children aged 1week – 5
years who have had a
physical and mental
examination according to
the State prevention
Programme
20
10
30
40
30
60
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40%-90%
40% - 90%
75%-90%
30
20
30
20
10
40
18
12
27
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4 II
Diabetes
Mellitus:
monitoring
processes.
40%-90%
5.4 Percentage of
patients who have had a
life-style consultation
with the nurse/ GP asst
in preceding 12 months
10
10
10
10
Part-financed by the European Union
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and European Neighbourhood and
Partnership Instrument)
10
9
40% – 90%
5.3 Percentage of
patients with diabetes
with a record of
neuropathy testing in the
preceding 12 months
9
15
40% – 90%
5.2 Percentage of
patients with diabetes
who have had a record
of micro-albuminuria
testing in preceding 12
months
5.1 Percentage of
patients who have had 2
or more measured
glycated hemoglobin
tests (except in an
inpatient setting) in the
previous year.
20
10
10
15
10
10
10
10
8
7
8
7
Arterial
hypertension
monitoring
processes
6 II
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Diabetes
Mellitus:
monitoring
outcomes
5 II
60%-90%
40%-90%
60%-90%
7.2 Percentage of
hypertension patients
who have had a total
cholesterol test at least
once every 3 years
7.3 Percentage of
hypertension patients
who have had a 12-lead
ECG at least once every
3 years
7.4 Percentage of
hypertension patients
have glycosis test at least
once every 3 years
7
7
7
8
15
5
5
5
10
20
Part-financed by the European Union
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and European Neighbourhood and
Partnership Instrument)
40% - 705
40% – 70%
7.1 Percentage of
patients who have had a
risk assessment within 3
months of their initial
hypertension diagnosis
and have been newly
diagnosed in the
preceding 12 months.
6.1 Percentage of
patients in whom the
most recent HBA1C
measure is <7.5% in
preceding 12 months
10
5
10
15
30
7
7
7
10
25
5
4
5
7
15
COPD
monitoring
processes
8 II
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Coronary
Heart Disease:
monitoring
outcomes
7 II
40%-70%
9.2 Percentage of
patients with COPD
with a record of FEV1
in the preceding 12
months
20
5
20
20
5
5
15
20
20
15
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and European Neighbourhood and
Partnership Instrument)
50% – 90%
40% – 70%
8.2 Percentage of
patients with CHD
whose last measured
total cholesterol in the
preceding 12 months is
5mmol/L or less
9.1 Percentage of COPD
patients who have had a
life-style consultation in
the preceding 12 months
40% – 80%
60%-905
8.1 Percentage of
patients with CHD in
whom the last blood
pressure reading in the
preceding 12 months is
140/90 or less
7.5 Percentage of
patients with
hypertension who have
been given lifestyle
advice in preceding 12
months
5
10
10
10
10
8
8
25
20
7
6
6
13
12
6
Emergency
Medical Aid
Service
Secondary
Health Care
Specialist visits
Hospitalization
of GP’s
patients
Facilities
10 III
11 III
12 III
13 IV
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Asthma
monitoring
processes
9 II
14.1 Nurse has a separate
consulting room
13.1 Number of hospital
admissions / 100
patients
12.1 Number of visits /
100 patients of patients
who visit secondary
health care specialists
Yes/no
15
30
30
30
5
20
50
60
60
60
20
5
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and European Neighbourhood and
Partnership Instrument)
10-7
hospitalizations
10-6 visits
6-3 calls
40%-70%
10.2 Percentage of
patients with asthma
who have had an asthma
review in preceding 12
months
11.1 Number of calls/
100 patients who call for
EMAS
40% – 90%
10.1 Percentage of
asthma patients who
have had at least one
measurement of peak
expiratory flow in
previous 12 months
30
70
70
40
5
5
30
60
60
60
8
8
21
37
37
32
6
6
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14 IV
IT
15.3 Use of IT for
routine patients
consultation
15.1 Use of IT for
clinical audit
14.2 Percentage of nurse
working hours per
month when they see
patient alone from
consultation at the GP
practice
Yes/no
Yes/no
30
-
-
50
15
50
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
25% - 75%
10
20
30
15
15
30
18
8
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6. Current Latvian indicator systems
6.1 Quality Bonus System indicators
Quality Bonus System indicators (introduced 2011):
GP accessibility
1a) Patient can electronically contact practice; answer to the e-mail is received within 3 working days
1b) GP practice has a website
Contact information and information about opening hours is available (electronically – on the practice’s website; hard copy –
in the GP office)
Minimum requirements for medical staff in the GP practice (must fulfil only one of criteria at the
same time):
2) The GP, a nurse or a GP assistant and another nurse or a receptionist are ensured in the practice with
number of listed patients 1200 - 1999 (pediatrician practice – 400 - 799 +/- 200)
GP practice is the main workplace for the medical staff.
Receptionist’s duties are not managed by the GP, a nurse or a GP assistant (exception – an additional (extra) nurse or GP
assistant)
3) The GP, second GP, a nurse or a GP assistant and second nurse or GP assistant or a receptionist are
ensured in practice, with number of listed patients more than 2000 (pediatrician practice – more than 800)
GP practice has second GP
Working place for a GP practice nurse: Obligatory indicator
4) The GP practice nurse of GP assistant has a separated consulting room
GP consulting hours:
5) The GP provides that patient can get GP reception within 4 working days
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Consulting hours of a GP assistant or a nurse at the GP practice:
6) The GP assistant or nurse provides independent reception time in the GP practice
Reception time of a GP assistant or a nurse at the GP practice is not less than 25% of the GP’s reception time
GP practice resources:
7) Specially designated software is used for the GP practice
GP practice nurse’s and GP assistant's education:
8) A GP practice nurse and a GP assistant has an individual education plan; a nurse and a GP assistant
have completed further education (post-graduate) program in the area of primary health care in
correspondence with the individual education plan
Completed further education (post-graduate) program is at least 20 hours long every year
Individual education plan is being prepared once a year based on individual assessment of knowledge and skills in different
areas of medicine
Evaluation of new registered patients’ state of health: Obligatory indicator
9) The GP has done a checkup and evaluation of the new registered patients’ state of health within the
first month after registration
Organized cancer screening participation rate is 15% higher than mean participation rate in corresponding territory.
Information notice in patient's ambulatory card
Preventive examinations (checkups):
10) Not more than 10% of patients in the age group 18-40 listed at the GP practice haven't had check up
last 5 years
11) Not more than 10% of patients older than 41 listed at the GP practice haven't had a check up last 3
years
12) GP has done checkup for at least 75% of patients in the age group 12-18 listed at the GP practice
once every 2 years
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13) GP has done evaluation of physical and mental development of children in age from 1 week to 5
years using form "Evaluation checklist of physical and mental development of children in age from 1
week to 5 years in accordance to regulations"
GP has done evaluation for at least 90% of patients in the age group 1 week to 5 years listed at the GP practice.
Manipulation "60230 - Evaluation of physical and mental development at children age from 1 week to 5 years in
accordance to regulations" is fixed in patient's ambulatory card.
The smoking-cessation promotion:
14) GP practice has list of smoker patients. At least 50% of listed patients have had smoking cessation
counselling
Manipulation "60231- Consultation on healthy lifestyle (for patients with the 2nd type of diabetes, coronary
heart disease, arterial hypertension, chronic QBStructive pulmonary disease, for smokers)" is used.
ICD-10 diagnostic code Z71.6 "Tobacco abuse counselling" is written down in patient's ambulatory card.
Diabetes patients care:
15) At least 80% of GP's patients with the 2nd type of diabetes have measured glycated hemoglobin
(HbA1c) ; at least 60% of patients at least one of HbA1c measure is less than 7.5%.
There are at least 20 diabetes patients listed in the GP practice and they are registered to the same GP during the period of
evaluation.
16) At least 70 % of GP's diabetes patients receive peripheral pulse examination and recording, and foot
examination once a year.
There are at least 20 diabetes patients listed in the GP practice and they are registered to the same GP during the year.
17) At least 70% of GP's diabetes patients have received consultation on diet, smoking cessation and
physical activities (performed by a nurse or a GP assistant), cover - 70%
Manipulation "60231- Consultation on healthy lifestyle (for patients with the 2nd type of diabetes, coronary heart
disease, arterial hypertension, chronic QBStructive pulmonary disease and for smokers)" is used.
Coronary heart disease patients' care:
18) At least 60% of GP's coronary heart disease patients last arterial blood pressure reading is 150/90
mmHg or less.
Manipulation "60232 - Arterial blood pressure in patients with coronary heart disease is 150/90 mmHg or
less" is used. ICD-10 diagnostical codes, written down in patients' ambulatory cards..
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19) At least 70% of GP's patients with coronary heart disease have record of total cholesterol at least
once.
Manipulation "41056 - Total cholesterol level - concentration 5mmol/L or less" or "41057 - Total cholesterol
level - concentration more than 5mmol/L" is used. ICD-10 diagnostical codes, written down in patients'
ambulatory cards.
20) At least 40% of GP's patients with coronary heart disease have a total cholesterol 5mmol/L or less
Manipulation "41056 - Total cholesterol level - concentration 5mmol/L or less" is used. ICD-10 diagnostical
codes, written down in patients' ambulatory cards.
21) At least 60% of GP's patients with coronary heart disease receive consultation on diet, dangers of
smoking (for smokers) and physical activities performed by a nurse of a GP assistant.
Manipulation "60231- Consultation on healthy lifestyle (for patients with the 2nd type of diabetes, coronary heart
disease, arterial hypertension, chronic QBStructive pulmonary disease and for smokers)" is used. ICD-10
diagnostical codes, written down in patients' ambulatory cards
Arterial hypertension patients’ care:
22) Cardiovascular risk is determinated for all GP's patients with arterial hypertension during checkup.
Manipulation "60233 - Cardiovascular risk determination for patient with arterial hypertension".
Record in patient's ambulatory card. ICD-10 diagnostical codes, written down in patients' ambulatory cards: I10;
I15 I15.0.-I15.9
23) Total cholesterol measuring is provided for at least 80% of GP's patients with arterial hypertension at
least once every 3 years
Manipulation "41056 - Total cholesterol level - concentration 5mmol/L or less" or "41057 - Total cholesterol
level - concentration more than 5mmol/L" is used. ICD-10 diagnostical codes, written down in patients'
ambulatory cards : I10.; I15.-I15.9.
24) Electrocardiogram is provided for at least 80% of GP's patients with arterial hypertension at least
once every 3 years
Manipulation "06003 – 12-lead electrocardiogram recording". ICD-10 diagnostical codes, written down in
patients' ambulatory cards: I10.; I15.-I15.9.
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25) Glycemic control is provided for at least 80% of GP's patients with arterial hypertension at least once
every 3 years
Manipulation „41095 – Glycosis in blood”, ICD-10 diagnostical codes, written down in patients' ambulatory
cards: I10.; I15.-I15.9
26) Consultation on diet (highlighting importance of salt intake reduction), dangers of smoking (for
smokers) and physical activities is provided for at least 60% of GP's patients with arterial hypertension
(performed by a nurse or a GP assistant)
Manipulation "60231- Consultation on healthy lifestyle (for patients with the 2nd type of diabetes, coronary heart
disease, arterial hypertension, chronic QBStructive pulmonary disease and for smokers)" is used. ICD-10
diagnostical codes, written down in patients' ambulatory cards: I10.; I15.-I15.9.
Chronic QBStructive pulmonary disease patients’ health control:
27) At least 60% of GP's patients with chronic QBStructive pulmonary disease have received consultation
on healthy lifestyle and have had smoking cessation counseling for smokers (performed by a nurse or a
GP assistant).
Manipulation "60231- Consultation on healthy lifestyle (for patients with the 2nd type of diabetes, coronary heart
disease, arterial hypertension, chronic QBStructive pulmonary disease and for smokers)" is used. ICD-10
diagnostical codes, written down in patients' ambulatory cards: J44.-J44.9
GP patients’ calls for Emergency Medical Aid Service: Obligatory indicator
28) Rate of GP patients’ calls for Emergency Medical Aid Service is:
1) at least 40% below the state mean rate
2) 25-40% below the state mean rate, by the side of previous year rate decrease is not less than
2%
3) less than 25% below the state mean rate, by the side of previous year rate decrease is not less
than 5%
4) above the state mean rate, but not more than 25%, by the side of previous year rate decrease is
not less than 10%
5) more than 25% above the state mean rate, by the side of previous year rate decrease is not less
than 15%
Patient is registered to the same GP during the year
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GP patients' visits to secondary health care specialists: Obligatory indicator
29) Rate of GP patients' visits to secondary health care specialists is:
1) at least 40% below the state mean rate
2) 25-40% below the state mean rate, by the side of previous year rate decrease is not less than
2%
3) less than 25% below the state mean rate, by the side of previous year rate decrease is not less
than 5%
4) above the state mean rate, but not more than 25%, by the side of previous year rate decrease is
not less than 10%
5) more than 25% above the state mean rate, by the side of previous year rate decrease is not less
than 15%
Patient is registered to the same GP during year
Rate of hospitalization of patients listed in GP practice: Obligatory indicator
30) Rate of hospitalization of patients listed in GP practice is:
1) at least 40% below the state mean rate
2) 25-40% below the state mean rate, by the side of previous year rate decrease is not less than
2%
3) less than 25% below the state mean rate, by the side of previous year rate decrease is not less
than 5%
4) above the state mean rate, but not more than 25%, by the side of previous year rate decrease is
not less than 10%
5) more than 25% above the state mean rate, by the side of previous year rate decrease is not less
than 15%
Patient is registered to the same GP during the year
Quantity of additional manipulations and services performed by the GP practice:
31) GP in practice makes minor surgery, performs medical follow-up and care for pregnant women,
provides gynecological examination. Number of these services (calculated per 100 listed patients) has
increased at least for 5% by the side of previous year.
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Dynamics in number of prescription of reference medical drugs or medical devices (only medical
drugs and medical devices from the list A):
32) Number of GP prescription of reimbursable reference medical drugs or medical devices (from the list
A) from the total number of prescription has increased at least for 5% by the side of previous year.
Prescription of medical drugs receiving in the GP practice:
33) Patient can receive prescription of medical drugs in case of chronic disease without consultation with
the GP within 3 working days
GP consulting hours on holidays:
34) The GP provides consulting hours according to regulations.
Local government opinion on the GP practice:
35) The Centre can receive information about submitted reasoned complaint from inhabitants about
quality of PHC services and working hours of GP practice from local government
Information is submitted from those local governments, where GP provides PHC services
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Mandatory quality indicators (introduced in 2005)
No.
Indicator
Eligibility
Conditions
Evaluation criteria
1A
Health assessment
due to illness or
preventive
from 18 years
GP has evaluated the health
status of at least 65% of listed
patients during the year
45%
2A
Child preventive
examination
from 3 months
to 18 years
GP has evaluated the health
status of at least 90% of listed
patients during the year
45%
3A
Child vaccination
from 3 months
to 14 years
At least 90% of patients have
been vaccinated according to the
vaccination calendar
45%
4B
Glycosylated
hemoglobin tests
for patients with
type 2 diabetes
Diabetes has
been diagnosed
in previous years
and has been on
the same GP list
during the year
At least 60% of patients have had
two or more glycosylated
hemoglobin tests during the year
(excluding any tests carried out as
an inpatient)
15%
5B
Quantitative
determination of
micro albuminuria
for type 2 diabetes
Diabetes has
been diagnosed
in previous years
and has been on
the same GP list
during the year
At least 60% of patients have had
at least 1 examination for micro
albuminuria during the year
(excluding any tests carried out as
an inpatient)
15%
6B
Measurement of
peak expiatory flow
for asthma patients
Patient is aged 6
years + and has
been on the
same GP list
during the year
At least 90% of patients have had
at least 1 measurement of peak
expiratory flow during the year
5%
7B
Training of asthma
patients for correct
use of inhaler
Patient is aged 6
years + and has
been on the
same GP list
during the year
At least 90% of patients who use
inhalers are tested in accuracy of
their usage and training carried
out if necessary
5%
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8C
Ambulance visits to
patients with
primary
hypertension
Primary
hypertension has
been diagnosed
in previous years
and patient has
been on the
same GP list
during the year
At least 90% of patients have not
called ambulance.
15%
For a regular practice - indicators 1, 4, 5, 6, 7, 8 apply
(weightings = 100%)
For pediatric practice (ie where at least 70% of listed patients are less than
18 years old) - indicators no. 2, 3, 6, 7 apply
(weightings = 100%)
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7. Set of transnational conclusions for providing
cost effective financial incentives within the
remuneration schemes
7.1 Critique of existing indicators
We have undertaken consultation with a wide range of stakeholders (which included a workshop attended
by around 30 GPs) to discuss the principles set out above and to review the existing indicators of both
mandatory and voluntary quality systems in Latvia (see summary in annex B). The overall view from this
process was support for our classification of indicators and their scope, and general agreement with the
principle that all indicators should cover areas of work and organisation which are within the direct
control of GPs (or be significantly influenced by them).
The fundamental basis for selecting indicators should be that:

the indicators are coherent and measurable

they appropriately match the current stage of development and capacity of the PHC system to act
on the information they provide

issues they aim to address are seen as important and relate to national priorities in health care and
the health care system.
 the QBS is voluntary
The groups of indicators proposed focused on health monitoring and chronic conditions and, in this
respect, they are similar to those covered in the Estonian QBS and clinical areas which are central to the
UK Quality and Outcomes Framework. In addition, though, there are specific concerns in Latvia about
how the interface between primary and secondary health care is organised and managed and a desire to
see improvements in maximising value for money, in line with the discussion of ‘value’ in section 4.
Annex B includes all existing indicators in Latvia that from both the existing mandatory system (M)
introduced in 2005, and the QBS system (QBS) introduced in 2011 that relate to the four high level
objectives set out in paragraph 4.6. They are grouped into 16 issues which we assume to represent
priorities for change in PHC, and were used as a basis for stakeholder discussions. The groups are crossreferenced with the current indicators as listed in the annex. Not all indicators are included in this table, in
particular all indicators which relate to the organisation and management of practices: these do not fall
into the four high level objectives, and we believe that the organisational changes could best be
encouraged in other ways, as discussed further later in this section.
In the comments column of annex B we describe changes that might be considered based on the
outcome of the stakeholder discussions and in the context of the UK QOF system, in particular where
we looked at the most directly comparable indicators. These potential changes are incorporated in the
recommendations of section 6.
Organisational and Management Indicators
We also consider that some of the existing indicators (QBS 1-8, 34-35) do not fall into any of the four
high level objectives set out in section 4 and instead might be regarded more properly as identifying
criteria which need to be satisfied before a practice can be eligible to join the QBS: in other words that
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the practice is providing a good quality basic service to its patients in terms of its organisation and
management.
At the very least the practice already needs to be providing consulting hours according to the regulations
and have staffing levels appropriate to the list size. We also believe that the practice space should be a
prerequisite of joining the scheme; not something rewarded by the scheme itself. But there should be a
clinical purpose to acquiring additional space and any additional funding should be as a result of activities
that can then be conducted with it, rather than the acquisition of additional space for its own sake.
Current mandatory and voluntary scheme indicators which address these issues of staffing levels, space
and patient access are:
The practice has sufficient staffing levels (GP/ nurse/ GP assistant/ receptionist time) to match the list
size. (QBS 2, QBS 3, QBS 6)

The GP practice nurse or GP assistant have a separate room in which to conduct consultations
(QBS 4)

The GP provides consulting hours according to the regulations (QBS 34)

Patients can obtain a GP appointment within 4 working days (QBS 5)

Patients can contact the practice by email and receive a response within 3 working days (QBS 1a)

The practice has a website (QBS 1b)

Specially designated software is in current use at the GP practice (QBS 7)

PHC staff have education plans and nurse/ GP assistant have postgraduate PHC training (QBS
8)
 Organisation of repeat prescriptions for long term conditions (QBS 33)
Finally, there needs to be a system in place which enables review of patient satisfaction and that eligibility
criterion are being met. The current system has one indicator covering this:
 Local government quality assessment of GP practice (QBS 35
Of course, similar country-specific lists would need to be developed in each partner ImPrim country
based on the local starting situation and requirements but, in principle, the approach would be the same.
7.2 Indicator Shortlist
Table 1 below contains our recommendations for a revised QBS indicator set with relevance of the
indicators being of particular importance. These are based on a combination of our local discussions with
stakeholders in Latvia, and some detailed examination of UK indicators covering similar issues, and in
most instances, incorporate the comments in section 6.
General Principles
We recommend dropping the aggregated ‘Group IIIa’ indicatorin table 1. There does not appear to be
any great appetite in the current primary care environment for GPs to extend their potential workload by
substituting for work presently handled by specialist outpatient clinicians. GPs can already be paid to do
some of this work as a manipulation so there appears to be no overall cost or quality gains to the wider
health care system for more of this work to be done in primary care than as secondary care, other than
the potential to improve patient access and reduce waiting times. This does not preclude reconsideration
of this in the future, however, as GPs develop their competencies to undertake more of this work.
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We recommend that indicators relating to ‘organisational development’ (as listed in sections 5.6 and 5.7
above) remain outside any revised QBS. They are not directly concerned with care processes or clinical
outcomes and, we argue, are better regarded as fundamental standards to which practices might aspire
and would anyway require to have substantially in place in order to maximise their potential for rewards
under the QBS; for example, by having sufficient space available for nurses to run separate clinics for
some long-term conditions, or counselling sessions (note however that this may be possible by sharing of
accommodation where rooms are scarce, or where for much of the time nurses are providing direct
support to doctors and only require occasional independent sessions at the moment).
With regard to the indicators focusing on avoidance of demand outside primary care (Group IIIb in table
1) these are of particular priority for the Health Ministry in the Latvian system. However the current QBS
indicators are not closely defined enough either in their scope, or in their payment thresholds. Recent
work in the UK on GP competitions and quality (Pike, 2010) suggests that a focus on avoiding hospital
admissions for patients with conditions which PHC can handle, or be substantively responsible for
managing, would be helpful. This gives rise to a list of 19 conditions in the UK which are regarded as
‘Ambulatory Care Sensitive’ (ACS). We recommend that indicators focusing on both outpatient and
inpatient utilisation should do so in relation to these conditions only (as recorded as main diagnosis). In
the Latvian case however there are three ACS conditions which relate to services for which patients have
direct access to specialist care – dental conditions, ENT infections and pelvic inflammatory disease – and
should not be included in Latvia at this stage. A list of diagnostic and specialty codes relating to the ACS
conditions will need to be agreed for indicators to be implemented for these groups.
In addition, we consider that patient-initiated EMAS calls and hospital admissions should only apply to
within ‘normal working hours’ - a time period when it might reasonably ne expected that GPs could have
greater influence over handling cases. We note however that, other than with trauma, most acute
conditions necessitating hospitalisation develop over a number of days, and in the long term it will be a
challenge for PHC to increase its influence by pre-emptive involvement during working hours, for
example by earlier action to avoid exacerbation of COPD symptoms.
Other indicators which we recommend dropping because they overlap to some extent with others, or are
difficult to measure accurately include:
General consultation’ with 65% of the patients on the list (as it overlaps considerably with the routine,
age-related health check-up indicators.
Cancer screening. It is not clear what responsibility family doctors are taking here, or whether their
involvement is substantive at this stage. However PHC involvement in screening programmes can have a
major impact and developments to pass responsibility to family doctors should be explored n the future.
The percentage of CHD patients with total cholesterol tests; there is already an indicator more closely
allied to outcomes (cholesterol levels) which covers this area, and the process of cholesterol testing is covered
for the larger hypertension group of patients.
We have also recommended the inclusion of a new indicator of COPD process which is used in the UK:
For, the percentage of COPD patients who have had a record of FEV1 in the previous year.
Following the approach of the UK QOF indicators we also recommend replacing the ‘single threshold’
indicators of the present QBS where a target has to be reached or exceeded, with a ‘threshold range’
where payment is triggered at the lowest point of the range and increases pro rata with the maximum
payment made at the top of the range. This provides an incentive to those practices which may be further
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ImPrim Report #1
A. Incentive payments for high quality PHC performance
behind others and rewards those further advanced accordingly. It also simplifies the currently complex
thresholds for some of the indicators which, because they are related to national averages, will always be
moving upwards and are likely to always be out of reach of those practices the which a QBS system
would want to do most to encourage.
We recommend that, subject to further local review and analysis, the lower bounds of the threshold range
should reflect current levels of achievement, for example the current upper quartile. The upper bound
might reflect best achievable or ideal practice as evidenced elsewhere or in research literature. In this way
there should be incentives for both high and low achieving practices to increase their performance. The
threshold ranges given in table 1 are either taken directly from current UK ranges or based on them.
(Note that, for indicators 10.1, 11.1 and 12.1) ‘better performance’ is the lower threshold value).
As currently set out in table 1 the weightings for each indicator are those which are:
already set out in the QBS
are derived subjectively by us from the mandatory indicator ‘percentage weighting’ of that system
are estimated based on the relative levels of UK QOF indicators. Note that, in the UK, the original
weightings were derived from statistical modelling analyses which are not well documented and have
subsequently been amended subjectively by expert opinion.
These weightings should be viewed as illustrative only and should be reassessed alongside the analyses to
establish threshold ranges.
Another important principle we have adopted – not followed in the UK, but adopted in Estonia – is that
of not allowing GPs to make ‘exceptions’ of patients from their lists for clinical reasons or where the
patient is uncooperative and does not attend the GP when we requested to do so several times, for
example. Excluding patients from the statistics in this way has the effect of reducing the denominator
value of the indicator for a particular practice and thus makes higher scores in the threshold range more
easily achievable. We consider that a sensible threshold range (eg an upper limit of 90%) adequately
allows for this ‘non-compliance’ factor so, for example, in this case 10% of patients could be left out of
the calculation for whatever reason without financial penalty to the practice.
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Routine health check
I
I
I
II
2
3
4
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Diabetes Mellitus:
monitoring processes.
[GP practice must have
at least 20 type II
Smoking cessation
Child health (0-18)
Short description
Domain
15
15
40% – 90%
40% – 90%
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
4.1 Percentage of patients who have had 2 or
more measured glycated haemoglobin tests
(except in an inpatient setting) in the previous
year.
8
10
60% – 90%
10
60% - 90%
20
10
60% - 90%
70% – 95%
12
Weighting
60% - 90%
Thresholds
3.1 Percentage of patients who smoke and whose 40% - 90%
notes contain a record that smoking cessation
advice or referral to a specialist service, where
available, has been offered within the
preceding 12 months.
2.1 Percentage of children on list in previous 12
months who have been vaccinated according to
vaccination calendar
2.2 Percentage of children aged 1week – 5 years
who have had a physical and mental examination
1.1 Percentage of new patients with routine
health check-up within 1 month of registration
1.2 Percentage of patients aged 18-40 who have
had a check-up in preceding 5 years
1.3 Percentage of patients aged 40 years and
older who have had a check-up in preceding 3
years
Indicator definition
Proposed Indicator Definitions, Thresholds and Weightings
No
.
1
Table 1
Definition ‘DM 13’ UK 2011-12
Latvian QBS indicator, threshold based on UK
typical range.
Subject to count of smokers being available
Indicator definition and threshold based on:
‘SMOKING 4’ UK 2011/12
Latvian QBS indicator; no UK equivalent.
Threshold incorporates 90% target in Latvian
system but extended to provide a range.
Latvian QBS indicator; no UK equivalent.
Threshold assumed based on UK ranges
All Latvian QBS indicators; there are no UK
equivalents.
Lower bounds need to be based on current
situation.
Comments
II
II
5
6
eu.baltic.net
Diabetes Mellitus:
monitoring outcomes
[GP practice must have
at least type II diabetes
20 patients.]
Arterial hypertension
monitoring processes
[GP practice must have
at least 50 hypertensive
patients.]
diabetes patients]
8
7
7
7
7
40% – 70%
40% – 90%
40% – 90%
40% – 90%
40% – 70%
30
12
40% – 90%
40% – 70%
12
40% - 90%
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
6.1 Percentage of patients who have had a risk
assessment within 3 months of their initial
hypertension diagnosis and have been newly
diagnosed in the preceding 12 months.
6.2 Percentage of hypertension patients who
have had a total cholesterol test at least once
every 3 years
6.3 Percentage of hypertension patients who
have had a 12-lead ECG at least once every 3
years
6.4 Percentage of hypertension patients have
glycosis test at least once every 3 years
6.5 Percentage of patients with hypertension
who have been given lifestyle advice in preceding
12 months
4.2 Percentage of patients with diabetes who
have had a record of micro-albuminuria testing
in preceding 12 months
4.3 Percentage of patients with diabetes with a
record of neuropathy testing in the preceding 12
months
4.4 Percentage of patients who have had a lifestyle consultation with the nurse/ GP asst in
preceding 12 months
5.1 Percentage of patients in whom the most
recent HBA1C measure is <7.5% in preceding
12 months
Indicator definition, threshold: ‘PP 2’ UK
2011-12
Indicator definition, threshold: ‘PP 1’ UK
2011-12.
Indicator definition based on ‘DM 28’ UK
2011-12.
HBA1C level 7.5% is Latvian measurement.
Indicator definition: Latvian QBS; threshold
based on UK typical range.
Definition ‘DM 10’ UK 2011-12
II
II
II
III
III
7
8
9
10
11
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Secondary Health Care
Specialist visits
Emergency Medical Aid
Service
Asthma monitoring
processes
COPD monitoring
processes
Coronary Heart Disease:
monitoring outcomes
40
40
5
40% – 70%
30% – 10% [to be
determined: eg
lower quartile –
lower decile?]
30% – 10% [to be
determined: eg
lower quartile –
lower decile?]
5
7
40% – 70%
40% – 90%
8
40
40% – 70%
50% – 90%
40
40% – 70%
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
11.1 Number of visits / 100 patients of patients
who visit secondary health care specialists for
any of the following conditions:
1. angina
2. asthma
3. cellulites
4. COPD
5. congestive heart failure
6. convulsions & epilepsy
7. dehydration & gastroenteritis
9.1 Percentage of asthma patients who have had
at least one measurement of peak expiratory flow
in previous 12 months
9.2 Percentage of patients with asthma who have
had an asthma review in preceding 12 months
10.1 Number of calls/ 100 patients who call for
EMAS during normal working hours (Monday –
Friday 08.00 – 18.00)
7.1 Percentage of patients with CHD in whom
the last blood pressure reading in the preceding
12 months is 150/90 or less
7.2 Percentage of patients with CHD whose last
measured total cholesterol in the preceding 12
months is 5mmol/L or less
8.1 Percentage of COPD patients who have had
a life-style consultation in the preceding 12
months
8.2 Percentage of patients with COPD with a
record of FEV1 in the preceding 12 months
Latvian QBS indicator; no equivalent UK.
List of conditions subject to local review. 3
exclusions already made from from
Ambulatory Care Sensitive (ACS) conditions
list (pelvic inflammatory disease; dental
conditions; ENT infections)
Latvian QBS indicator; no equivalent UK.
Need to confirm ‘normal working hours’
Indicator definition, threshold: ‘ASTHMA 6’
UK 2011-12.
Indicator definition, threshold, weight: ‘COPD
10’ UK 2011-12
[Proposed additional indicator to QBS set]
Indicator definition, threshold: ‘COPD 13’ UK
2011-12.
Indicator definition, threshold, weight: ‘CHD
8’ UK 2011-12
Indicator definition, threshold, weight: ‘CHD
6’ UK 2011-12
III
III
12
13
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Drugs prescribing
Hospitalisation of GP’s
patients for processes
which could be
controlled in primary
care (ambulatory care
sensitive conditions
(ACS))
diabetes complications
gangrene
hypertension
influenza and pneumonia
iron deficiency anaemia
nutritional deficiencies
other vaccine
perforated/bleeding ulcer
pyelonephritis
40% – 90%
30% – 10% [to be
determined: eg
lower quartile –
lower decile?]
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
12.1 Number of hospital admissions / 100
patients for whom main diagnosis is:
1. angina
2. asthma
3. cellulites
4. COPD
5. congestive heart failure
6. convulsions & epilepsy
7. dehydration & gastroenteritis
8. diabetes complications
9. gangrene
10. hypertension
11. influenza and pneumonia
12. iron deficiency anaemia
13. nutritional deficiencies
14. other vaccine
15. perforated/bleeding ulcer
16. pyelonephritis
Proportion of GP prescriptions for reimbursable
medical drugs/ devices from List A as a
proportion of all prescriptions
8.
9.
10.
11.
12.
13.
14.
15.
16.
8
40
Rephrased Latvian QBS indicator; assumed
thresholds based on typical UK range.
Latvian QBS indicator; no equivalent UK.
List of conditions subject to local review. 3
exclusions already made from from
Ambulatory Care Sensitive (ACS) conditions
list (pelvic inflammatory disease; dental
conditions; ENT infections)
ImPrim Report #1
A. Incentive payments for high quality PHC performance
7.3 Monitoring
Along with the introduction of relevant and measurable indicators needs to be a formal monitoring
and evaluation system for their operation and use. This does not necessarily have to be as extensive
and complex as that developed in the UK, but the principles it incorporates are valid for other
countries:

A process for validating data submitted and the possibility of checking up on related practice
details, in particular the various organisational and management elements discussed in
section 5.

A proactive use of the indicator data to support and encourage practice development rather
than used as a way of applying penalties or sanctions for performance. This could be in the
form of written or online reports, or it could be more extensive and involve peer review
visits and quality improvement circles. GPs also need to be educated in understanding why
indicators are being used and what is potentially in it for themselves as well as their
patients.
A systematic review process which involves the participation of all stakeholders (eg GPs,
Ministry of Health, etc). This is so the relevance of particular indicators can be reviewed and
aspects (such as threshold values) amended as appropriate. Over time – as experienced in
the UK – some indicators become irrelevant as the majority of practices attain the highest
threshold levels and there might then be a case for dropping an indicator and making its
related activity part of the normal practice contract covered by capitation. Additionally, as
processes become commonplace, related indicators could be amended to address outcomes
instead. Conversely, there may be new priorities to be considered which might require
corresponding incentives and new process indicators to help provide them.
Finally we note that in the UK, the Quality and Outcomes Framework rewards practices rather than
individual GPs and, in this way, encourages and supports PHC team working. We believe the same
philosophy would also apply well in ImPrim partner countries, and issues around competition,
cooperation and integration need to be aligned to individual incentives.

8. Recommendations
In our experience there is seldom one single action that resolves organisational issues such as those
discussed above. Various actions, properly monitored and evaluated as to their consequences are needed
to provide a balanced progression and avoid unintended consequences across the system. The following
proposals have potential to be introduced alongside the Quality Bonus Scheme, and would complement
the financial incentives for change which are its rationale. There are three areas for development relating
to:
Reimbursement components
Regional organisation
Information systems
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A. Incentive payments for high quality PHC performance
These proposals aim to move further towards the focus of PHC funding on the ‘twin pillars’ of capitation
and quality incentives, whilst building on the existing strengths and legacies of the Latvian health system
and support the future direction which seeks to enhance and develop the role of this health care sector.
8.1 Reimbursement
To achieve a PHC system largely funded on capitation allied to performance incentives, whilst addressing
some of the current perverse incentives, requires changes to several aspects of PHC funding. Our
proposals are to:
Set an upper limit on capitation payments in terms of list size; say 2000 per doctor (which would
be consistent with current requirements for the voluntary QBS). This would not restrict a
doctor from continuing to hold more patients than the upper limit, but they would not
receive payment for those beyond the upper limit unless additional medical staff were
available. This could provide an opportunity for new doctors to gain access to patient lists
and there are various ways this might be arranged. For example if the additional doctor was
attached to an Out of Hours service, they could work part time at the practice proportionate
to the extra time required, with the salary proportionately cross-charged to the practice. Or a
new doctor could support two or more practices, possibly linked to other resource sharing.
All this would be simpler to manage if there was a regional catchment arrangement, as out of
hours and funding arrangements could all be aligned, but this would not be essential.
Abolish the separate fixed payment. The sums involved should be incorporated in the capitation
element, and the effect would be to remove the only current incentive for small practice
sizes. As a transitional arrangement there could be a ‘lower bound’ on the capitation
payment, phased out over a few years.
Abolish the separate nursing payment. The earmarked money for this has encouraged high levels
of staffing, but of itself does not encourage the ‘enhanced quality’ activity that is wanted in
PHC. The expenditure could instead be split between capitation and quality payments, and
this would provide an opportunity to substantially increase the funding of the quality bonus
scheme. The reasoning behind this recommendation is that nurses and physician assistants
will be key to delivery of many of the quality targets, but probably not at the levels of staffing
that currently exist. There may be options for doctors working in cooperative groups to
share nurses, or related facilities (eg one room shared between nurses according to direct
patient care workload).
Leave manipulation payments unchanged. The list of manipulations chargeable within PHC could
however be adaptable to changing skills levels amongst Family doctors to allow increased
specialisation as it develops.
These changes would require careful implementation, backed up by detailed analysis to set reallocation of
budget sums in ways that are fully aligned with desired incentives, and that ensure the impacts on
individual practices are fully understood.
8.2 Regional organisation
There are opportunities to adapt the existing regional hospital structure, coupled with the policlinic
legacy, to better meet some of the PHC objectives, as discussed in this interim report. These may also be
important in reinforcing the changes to financial incentives. In particular we recommend:
Secondment of junior doctors from regional hospitals to ‘oversized’ practices (ie with more than
2,000 patients on their list). Potentially these doctors could support more than one practice,
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as well as providing out of hours cover for those practices’ patients. From an analysis of
recorded list sizes at the end of 2010, there were 210 family doctors with more than 2000
patients, with an average excess over this level of 273 patients. If the patients from groups of
family doctors currently over 2000 were reallocated to reduce list sizes to 2000, an additional
29 whole time equivalent doctors could be funded. There may be various permutations to
such an arrangement to incorporate out of hours cover, etc.
Management of shared accommodation. The regional PHC could provide facilities for extended
PHC services, in particular rooms that nurses and doctors’ assistants could use for individual
patient consultations, in line with QBS incentives. The expectation would be that rental
charges for sessional use would be recovered from QBS ?addition payments.
Training of practice nurses. In particular the management of patients with chronic conditions
requires the development of nursing skill sets. Nurses acquiring particular skills and
competencies could provide services to other local practices, and accelerate the achievement
of QBS targets.
The establishment of such regional support might be simpler if GP catchments are aligned with the
regional catchments. However it does not appear essential at this stage and (based on our experience in
the UK) most patients who would benefit from integrated care services across the region are likely to be
registered with a local GP anyway.
8.3 Information systems
Financial and organisational changes linked to a revised QBS provide a platform for a restructuring of the
approach to eHealth. A major element of our proposals for QBS relate to improving the management of
patients with chronic conditions, and the indicators themselves require accurate recording of numbers of
such patients. In turn this allows for patient registers that can be relatively easily generated from NHS
analyses (as already the case for diabetes), and these could form the core of eHealth development at the
regional level. We therefore propose some initial steps:
Calculation and dissemination of patient registers from the NHS.
Development of practice level functionality for monitoring chronic patients
Development of regional facilities for incorporating other clinical and care professional
involvement, coordinated at regional hospital level
These represent initial steps towards the overall architecture required to support integrated care across
primary and secondary care services and beyond.
8.4 Integrated care
Finally we note all the potential changes identified contribute to a move towards a form of integrated care
that can in particular help maintain the health of patients with chronic conditions and reduce dependency
on expensive hospital services. Key characteristics of integrated care are:
It is about shared care, and does not require merging of organisations
It requires coordination of care delivery so that the patient can receive the most appropriate
care at the right time, without necessarily requiring referral to another care professional
It requires the involvement and co-operation of clinicians, organisations, patients and carers.
It requires information sharing which would be expedited by progressive development of
information systems as outlined above.
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I
I
1
2
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Domain
No
.
Consultation with patient
Routine health check
Short description
M1
QBS 10
QBS 9,10,11
Existing indicators
Part-financed by the European Union
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and European Neighbourhood and
Partnership Instrument)
65% of all patients on list in previous year
Notification to patients by GP about the
possibility of having a cancer screening
examination is 15% more than the average in
the definite territory
90% patients 40 years and older have had a
check-up in last 3 years
90% patients 18-40 have had a check-up in
last 5 years
All new patients within 1 month of
registration
Current Thresholds
PROCESS AND OUTCOME INDICATORS IN CURRENT QUALITY BONUS SYSTEMS
ANNEX B
We consider that this indicator overlaps
considerably with the group above and
should be deleted
Specific screening programmes eg cervical
cytology are centrally managed hence
specific targets for GPs are not thought
appropriate. Data on eligible patients for
screening is provided by the Centre. If this
indicator is retained the threshold levels
should be reviewed.
Review thresholds.
Comments
I
I
II
II
3
4
5
6
eu.baltic.net
70% received peripheral pulse and foot
examination in previous year
(where 20+ diabetes patients
on list)
70% have had life-style consultation with
nurse/ GP asst in previous year
60% have one HBA1C measure <7.5% in
previous year
60% have micro albuminuria test in PHC in
previous year
(where 20+ diabetes patients
on list)
Type 2 diabetes monitoring
outcomes
80% have 2+ measured glycated
haemoglobin tests in PHC in previous year
The consultation could be carried out by
any PHC healthcare professional.
Review thresholds.
Review thresholds.
Review thresholds.
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
QBS 15, 16, 17
M 4,5
QBS 15
QBS 14
Review thresholds.
100% physical and mental evaluation of
children aged 1week – 5 years
50% smokers have had cessation counselling
in previous year
Children’s indicators to be part of overall
QBS, with no additional weighting for
‘paediatrician’ practices
M 2,3
90% vaccination rates according to
vaccination calendar
There is some overlap between mandatory
and QBS systems and this set of indicators
should be revised.
75% children 12-18 have had a check-up in
last 2 years
QBS 12,13
90% of children on list in previous year
Type 2 diabetes monitoring
processes
Smoking cessation
Child health (0-18)
II
II
8
9
eu.baltic.net
II
7
Hypertension monitoring
processes
Coronary heart disease
monitoring outcomes
Coronary heart disease
monitoring processes
QBS 22, 23, 24, 25,
26
QBS 18, 20
QBS 19, 21
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
60% have had life-style consultation with
nurse/ GP asst in previous year
80% hypertension patients have glycosis test
at least once every 3 years
80% hypertension patients have a 12-lead
ECG at least once every 3 years
80% hypertension patients have total
cholesterol test at least once every 3 years
CV risk determined 100% hypertension
patients during check-up
40% CHD patients have total cholesterol
5mmol/L or less in previous year
60% CHD patients have arterial blood
pressure 150/90 or less in previous year
60% have had life-style consultation with
nurse/ GP asst in previous year
70% CHD patients have at least one record
of total cholesterol
The consultation could be carried out by
any PHC healthcare professional.
Similar to diabetes, GP practice should
record a minimum number of hypertensive
patients, say 50.
Review thresholds.
Review thresholds.
The consultation could be carried out by
any PHC healthcare professional, though it
represents a good use of nursing resource.
Review thresholds.
The total cholesterol indicator overlaps the
process indicator for hypertension and
could be deleted.
II
II
IIIa
IIIb
10
11
12
13
eu.baltic.net
Emergency Medical Aid
Service
PHC substitution of services
for secondary care
Asthma monitoring
processes
COPD monitoring
processes
(subject to various thresholds relative to the
mean national rate and relative rates of
change in the previous year)
Rate of GP’s patient calls for EMAS
Increase in ante-natal care
Increase in number of gynaecological
examinations
Increase in number of minor surgery
procedures
90% patients who use inhalers are tested in
accuracy of their use in previous year
90% asthma patients have 1 measurement of
peak expiratory flow in previous year
60% have had life-style consultation with
nurse/ GP asst in previous year
The indicator should relate to the time
period when PHC has the greatest potential
to have an impact.
There is currently a complicated series of
thresholds for this indicator which mean
that the target is always changing. We
recommend that this is changed to a
simpler threshold range.
Beyond this the cost and quality arguments
for additional incentives in PHC are limited
at this stage
The current indicator is composite of very
different activities and are already paid for
as manipulations
Review thresholds.
The consultation could be carried out by
any PHC healthcare professional.
Review thresholds.
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
QBS 28
QBS 31
M 6, 7
QBS 27
IIIb
IIIb
15
16
eu.baltic.net
IIIb
14
Drugs prescribing
Patient hospitalisation
Secondary Health Care visits
QBS 32
QBS 30
QBS 29
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Number of GP prescriptions for
reimbursable medical drugs/ devices from
List A as a proportion of all prescriptions
has increased 5% over the previous year
(subject to various thresholds relative to the
mean national rate and relative rates of
change in the previous year)
Rate of hospitalisation of GP’s patients
(subject to various thresholds relative to the
mean national rate and relative rates of
change in the previous year)
Rate of GP’s patient visits to secondary
health care specialists
Review thresholds. Some potential in the future
for consideration of absolute levels of
expenditure both on List A and others, but
more detailed analysis would be needed to
establish robust measures.
The indicator should be restricted to
specialties where PHC can make the most
impact in terms of maintaining patient
health and avoiding admissions. Trauma
should be excluded.
There is currently a complicated series of
thresholds for this indicator which mean
that the target is always changing. We
recommend that this is changed to a
simpler threshold range.
The indicator should relate to conditions
for which PHC has the greatest potential to
treat without specialist referral. In line with
the argument about substitution for
secondary services conditions for which
patients can self refer (eg gynae) should be
excluded in the first instance.
There is currently a complicated series of
thresholds for this indicator which mean
that the target is always changing. We
recommend that this is changed to a
simpler threshold range.
ImPrim Report #1
A. Incentive payments for high quality PHC performance
9. Conclusion
Various actions, properly monitored and evaluated as to their consequences are needed to provide a
balanced progression and avoid unintended consequences across the PHC system. There are three areas
for development relating to:
Reimbursement components;
Regional organisation;
Information systems.
These proposals aim to move further towards the focus of PHC funding on the ‘twin pillars’ of capitation
and quality incentives, whilst building on the existing strengths and legacies of the Latvian health system
and support the future direction which seeks to enhance and develop the role of this health care sector.
To achieve a PHC system largely funded on capitation allied to performance incentives, whilst addressing
some of the current perverse incentives, requires changes to several aspects of PHC funding.
There are opportunities to adapt the existing regional hospital structure, coupled with the policlinic legacy,
to better meet some of the PHC objectives.
Financial and organisational changes linked to a revised QBS provide a platform for a restructuring of the
approach to eHealth.
The above recommendations will be more specifically described in the report “Set of transnational
conclusions for providing costeffective financial incentives with the remuneration schemes.”
In the table of indicators average can be seen that each country has different indicator weights, this means
that there is a little different PHC priorities and needs.
Quality Bonus Schemes to incentivise PHC have been adopted by the UK and Estonia specifically to
reward improved patient outcomes, or at least to encourage care processes that are expected to lead to
improved patient outcomes. This reflects the priorities in those countries when they were adopted some
years ago. In the same way, when considering the design of a QBS for any country in the Baltic Sea
region, we need to identify the priority objectives for primary health care within the healthcare system as a
whole. The major change affecting all countries in the region now, compared to five or more years ago, is
the much bleaker economic climate. In turns this affects the ability of any healthcare system to improve
‘quality’ and hence the choice of levers within a bonus system, and a need to focus more widely on costeffectiveness rather than solely on outcomes.
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A. Incentive payments for high quality PHC performance
Bringing together cost effectiveness and quality in this way suggests to us that the focus of the design of
any QBS needs to be on measures of PHC that indicate whether the value of services is being increased.
The term value is used to describe the outcomes of health care services relative to their costs.
With relatively constrained budgets, the costs associated with improving quality in health care need to be
recognised and that much of this manifests itself through the impact that PHC can have on other health
and social care systems with which it interacts. So processes which are evidenced to deliver good
outcomes could form part of a QBS for example, for helping to create a shift towards ‘population
management’ as a focus for PHC.
This recognition of the need for value will be a common high-level objective within ImPrim partner
countries together with wanting to have accessible and equitable service provision across the population.
With specific respect to the Latvian situation, these overall objectives of cost-effectiveness and quality
need to be further refined to take account of the particular situation in that country. We have identified
four high level objectives (Prevention activities; Management of Chronic Conditions; Substitution for
Secondary Care; Avoidance of Demand outside PHC) that relate to increasing value, for each of which
indicators can be identified to form the basis of a revised QBS for Latvia. The fundamental basis for
selecting indicators should be that: the indicators are coherent and measurable; they appropriately match
the current stage of development and capacity of the PHC system to act on the information they provide;
issues they aim to address are seen as important and relate to national priorities in health care and the
health care system; the QBS is voluntary.
The proposals have potential to be introduced alongside the Quality Bonus Scheme, and would
complement the financial incentives for change which are its rationale. There are three areas for
development relating to: Reimbursement components; Regional organisation; Information systems. These
proposals aim to move further towards the focus of PHC funding on the ‘twin pillars’ of capitation and
quality incentives, whilst building on the existing strengths and legacies of the Latvian health system and
support the future direction which seeks to enhance and develop the role of this health care sector.
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References
Maynard A, 2008. Payment for Performance (P4P): International Experience and a Cautionary Proposal
for Estonia. Health Financing Policy Paper, WHO Regional Office for Europe.
Porter M, 2010. What is Value in Health Care? N Engl J Med 2010; 363:2477-2481
http://www.nejm.org/doi/full/10.1056/NEJMp1011024.
Pike C, 2010. An Empirical Analysis of the Effects of GP Competition. Cooperation and Competition
Panel Working Paper Series, August 2010.
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Part 2: Proven incentive payment schemes for
Primary Health Care professionals
Abstract
In this report we examine available evidence about the impact of incentive schemes on primary health
care quality indicators in the EU and other countries with comparable clinical and financial processes.
This supplements our previous work on developing incentive based reimbursement models for primary
health care (PHC) and provides further support to decisions on their implementation across the Baltic Sea
Region.
The evidence supports the proposition that financial incentives can be used to improve the quality and
quantity of services provided by PHC. Proven incentive payment schemes are those that are based on
clear clinical objectives where processes to deliver desired outcomes are known and measurement of
outcomes may be possible (eg long term management of diabetes patients). Evidence of the effect of
incentive payment schemes is less clear where these factors are less well established (for example health
promotion).
Financial incentives are not the only way to generate quality improvements and in some cases observed
quality gain may be the result of a mix of different types of initiatives and of unrelated trends in clinical
practice. These are examined, together with some findings about possible perverse effects of financial
incentives.
Some further recent material from pilot work undertaken by the ImPrim project in Belarus is included.
1. Introduction
Across countries in the Baltic region issues concerning quality standards in primary health care
(PHC) service have a two-fold importance: continuing improvement in health outcomes for
patients; and achieving increased efficiency and effectiveness in health systems from primary to
tertiary care.
These are important concerns of the Baltic Sea Region transnational cooperation project:
‘Improvement of public health by promotion of equitably distributed high quality primary health care systems’
(ImPrim). The authors have previously reported on these issues both generally and with specific
reference to reimbursement for PHC in Latvia (where the National Health Service is the lead
partner in ImPrim Work Package 3: ‘Instruments for Improving the Financial Provisions for
PHC’).
In this report we examine available evidence about the impact of incentive schemes on primary health
care quality indicators in other EU countries including, where available, assessments of the effects of these
schemes on service quality and availability. Two main aspects are reviewed:
A description of the range and scope of incentive schemes with particular focus on
European examples
Evidence from the research literature which supports or refutes the hypothesis that such
primary care incentive schemes have a measurable impact on patient health care quality.
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Two recently published reports provide substantial summaries of both these aspects: one from
WHO (Elovainio, 2010) which gives an overview of schemes worldwide and a list of key lessons
learned; the other, a Cochrane review by Scott et al (2011), is a comprehensive review of
published literature (2000 – 2009) evaluating the impact of different financial interventions on the
quality of care delivered by primary healthcare physicians. Whilst these go beyond the boundaries
of EU countries, we have also included material from elsewhere that is relevant to the situation
faced by the EU and, in particular, the Baltic Sea Region.
2. Definitions
2.1 Primary care incentive schemes: objectives and key elements
The definition of ‘incentive scheme’ used by Elovainio in his review (2010) is ideal for our
purposes. Noting that performance incentives could be argued as being an integral part of any
health system structure, he chose to focus more specifically on distinct schemes, targeting
providers, which ‘establish a link between provider remuneration and a set of predefined
performance measures’ (Elovainio p2).
Note that these schemes are often referred to in the literature as ‘payment for performance’
(‘P4P’) or provider performance incentives (‘PPI’).
2.2 Measuring the effects of proven incentive schemes
The starting point here is to describe exactly what we mean by a proven incentive scheme. This could be
any scheme where evidence exists that associates the implementation of the scheme with observed
changes in:
health outcomes,
service quality,
behaviour (of care professionals or the public),
In reality, all three elements described above may be present to different degrees and are
interlinked: high quality care is likely to lead to an improvement in health outcomes and, if an
incentive is financially attractive enough, it is likely to be popular with care professionals and
change the nature of their clinical behaviour.
For the purposes of this report we focus on seeking proof of incentive schemes targeted on
primary health care professionals that have had an effect on the quality of care for patients and
positive impacts on health outcomes.
A second issue to address is how it can be ‘proven’ that any changes to quality or outcomes are
solely – or even predominantly - the direct result of an incentive scheme. There will always be
other confounding factors: underlying changes in population morbidity; wider lifestyle and
behaviour changes in society generally; the impacts of other changes taking place in the health
delivery system (to name but three). All or any of these might contribute in some way to changes
in ‘health care quality’ whether or not there are specific incentive payment schemes in operation.
Moreover, the evaluation of incentive scheme ‘effects’ may be subject to varying degrees of
rigour in their assessment - ranging from the use of randomised control trials and formal
statistical testing, through to expert opinion or anecdotal evidence.
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Finally, and more focused on care professional behaviour, incentive schemes could also be said
to be ‘proven’ if they are widely accepted by those they are aimed at. In both Estonia and the UK
– the European countries furthest advanced in adopting PHC incentive schemes – they are
successful in this regard with very high take-up rates of their schemes by primary care physicians.
3. Existing incentive payment schemes
Elovainio (2010) focuses on provider performance incentive schemes in high-income countries
with the aim of identifying lessons that could be used for similar schemes. He notes that
documentation on evaluation of such schemes is limited and mostly confined to studies carried
out in the UK and USA while studies from other countries where schemes have just started or
are being planned (including France, Italy, Estonia, Spain) are only descriptive.
This makes it impossible to provide hard evidence across the board on provider performance
incentives as the available literature often concerns only singular interventions (and then usually
only small scale pilot projects) and that these are based on context-specific arrangements. He also
notes that there are few stable and invariable elements allowing comparison between the different
schemes.
Nevertheless there are now substantial numbers of schemes where changes in behaviour and
performance have been evaluated, and for which evidence has now been published. In the
following sections we look at evidence from the US, UK and elsewhere, and consider also what
can be drawn from the perspectives of clinical trials and economic theory.
3.1 Evidence from the US
Although PPI schemes have existed in the USA for 20 years, it was the publication of the
"Crossing the Quality Chasm" report from the Institute of Medicine (2001) that accelerated
interest and implementation of such schemes. One of the report’s key recommendations was on
the value of P4P to ‘promote effective health care reform’ and this was seminal in a surge of new
schemes (estimated at more than 200). It was also accompanied by a big increase in the use of
‘outcome measures’. In a study of 27 schemes by Rosenthal et al. (2007), only 59% of those
studied had used them in 2003, but this had increased to 94% by 2006. The type of ‘outcomes’
were usually clinical markers related for example to cholesterol or blood pressure levels, and all
schemes included process indicators, especially compliance with asthma and diabetes care
guidelines.
However, P4P schemes in the USA have relatively little value in monetary terms. According to
one survey, the average value of the total bonuses paid to the providers amounted to just
US$1.40 per insured member per month representing only 2.3% of the average reimbursements
to the providers (Rosenthal et al, 2004).
In recent years there has been a push towards a more comprehensive approach where the
performance related payments are included in a wider provider payment reform (Rosenthal, 2008,
cited by Elovainio). These reforms have included, for example, capitation payment modulated by
a performance component; or a savings sharing scheme for fee-for-service beneficiaries, where
integrated physician groups can earn bonuses for demonstrating slower growth in spending
relative to peers and for increased quality (quality and savings have to happen simultaneously)
(Trisolini et al., 2008).
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Elovainio (2010) also describes in more detail the example of the Premier Quality Incentive
Demonstration (PHQID) scheme which was applied to 230 hospitals across the USA. It focused
on five clinical areas including myocardial infarction and hip and knee replacements. Hospitals
were scored in each of these areas, and the average increase in quality scores across all areas
increased by 17% in the four years from the scheme’s inception. The amount of money directly
to the scheme was very small – it averaged $52,000 per hospital per year.
Further ambivalent findings on P4P effects were reported by Chung et al (2010) who explored
the effect of P4P on quality of care measures at a large group practice and found that eight of the
nine measures used showed significant improvement over a one year period, and three of them
had an improved trend over the previous year’s trend. They considered that a small financial
incentive (maximum $5000/year) may have led to continued or enhanced improvement in wellestablished ambulatory care measures. However, they also compared this with other quality
improvement programs having alternative foci for incentives (eg, increasing support for staff
hours) and concluded that the effect of physician-specific incentives was not evident.
3.2 Evidence from the UK
The introduction of the Quality and Outcomes Framework (QOF) in 2004 in the UK has been
the most significant application of P4P scheme in a western health economy both in terms of
scope and ambition and its costs in terms of reimbursement. It covers three main areas: clinical
care; practice organization; and patient experience. We have previously documented features of
the QOF system and its impact on primary care practice in the UK, in reports to the ImPrim
project (Bowen and Forte, 2012). Whilst many specific aspects of QOF were introduced without
a priori evidence of their likely impact, earlier schemes (in particular that for cervical cancer
screening) had led to rapid uptake of screening and substantial associated reductions in mortality.
Figure 1 below shows the immediate change in cervical cytology coverage of the target
population when the financial incentives were introduced in 1992, and the sustained
improvements over several years in the more deprived areas, where it had been particularly
difficult to ensure that many women in the at-risk population came forward and were screened.
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Figure1
Percentage of practices reaching 80% cervical
cytology target
100
Percentage of practices
90
80
70
60
Affluent
50
Neither
40
Deprived
30
20
10
0
1991 1992 1993 1994 1995 1996 1997 1998 1999
Source: Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423
Most evaluation studies (eg Campbell et al., 2007; Doran et al., 2008) seem to indicate that the
QOF initiative has reached some of its objectives. There has been a notable performance
increase for most of the clinical indicators but these do not always represent an acceleration of
the secular trend. For example Campbell et al. (2007) report some acceleration in performance
against QOF indicators for asthma and diabetes following introduction of the scheme, but this
was not observable for coronary heart disease, as illustrated in figure 2.
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Figure 2
Trends in Aggregate Performance for Condition Specific Indicators
Source: Campbell et al. N Engl J Med 2007; 357:181-190
Coleman (2010) also discusses such observational studies that indicate that QOF has led to improvement
in the care of asthma, diabetes and cardiovascular disease although not necessarily at an accelerated rate.
With diabetes care, he points out that the QOF target has a precise and unambiguous definition both in
terms of the target groups of patients with poorer control - which it wants GPs to focus on – and in the
definition of control (a specific HbA1c level). The changing behaviour of GPs with respect to this
indicator means it is not unreasonable to be able to link the indicator to the change in practice and
outcomes.
This may also help explain why there were no significant differences in the rates of improvement between
clinical indicators for which financial incentives were provided as opposed to those for which incentives
were not provided (Campbell et al, 2007).
Coleman argues however, that for some other interventions - particularly in the area of health promotion
and counselling, QOF can have not only little measurable impact but may have unintended consequences.
While there exists evidence that smoking cessation advice by GPs is effective (Ashenden et al, 1997), the
problem lies with the quality of that advice. The QOF indicator for smoking is much more open-ended
than for diabetes because it only seeks data on whether the GP has offered the advice to a percentage of
smokers and does not specify what actually constitutes that advice.
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In an analysis of 4million records in a primary care research database covering the period immediately
before and after the introduction of the QOF, Coleman notes that while GPs recorded a steep rise –
before and after the introduction of QOF – in the number of their patients they ascertained as smokers,
there was no concomitant increase over the same time period in signs of active interventions (eg an
increase in prescriptions for nicotine addiction treatments).
The conclusion he reached from this analysis was that the QOF had been very good at incentivising GPs
to record smoking levels in the population and documenting that they have provided advice. However,
the quality and effectiveness of this advice, and those to whom it has been directed, was more
questionable (ie providing advice in a passive manner through leaflets in the practice surgery, or
concentrating their attention on patients who have already expressed an interest in giving up smoking,
rather than actively targeting and advising strategies for smokers more reluctant to give up of their own
accord).
This points to the importance of testing and considering the impacts of indicator definitions in the first
place; Coleman suggests that an indicator which rewarded GPs for prescribing effective nicotine addiction
treatments would be a much better alternative. By extension he considers that other QOF indicators
focused on health promotion advice-giving may have similarly poor effects.
QOF has been criticised from a variety of perspectives: thresholds for achieving scores being set too low;
lack of baseline data against which to judge whether any effects of QOF were directly attributable to it or
would have happened without it anyway. The cost of QOF is substantial: £1billion per year, or about 15%
of all expenditure on primary care. When introduced it was expected that the score would average 75%
per GP; it turned out to be 96% and has remained around that level ever since.
A significant feature of the QOF is an ‘exclusion mechanism’ that allows GPs to exclude patients
who are not then taken into account when calculating the final QOF scores. These exclusion
criteria can apply to patients who fail to attend after repeated invitations, or patients with
contraindications for the treatments which would otherwise be rewarded by QOF. This ‘clinician
override’ can be significant as it effectively reduces the indicator’s denominator thus increasing its
achievement percentage which, in turn, can directly affect remuneration.
On the other hand there is some evidence of continued improvements in areas where patient compliance
has historically been problematic, especially, as for cervical screening in more deprived areas. For example
Ashworth et al (2008) demonstrate convergence between practice performance in the monitoring of blood
pressure (see figure 3 below), though were unable to report an equivalent convergence in that time period
in related clinical markers.
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Figure 3
Percentage of patients aged > 45
Monitoring of blood pressure
90%
88%
86%
84%
Least deprived
82%
Most deprived
80%
78%
76%
74%
2005
2006
2007
Year
Source: Ashworth et al. BMJ 2008; 337:a2030
3.3 Evidence from other countries
In Australia since 1998 there has been an incentive scheme covering a range of clinical and
organisational practice areas, each one with several indicators. Clinical areas include diabetes and
asthma; organisational areas including teaching and rural practice. Elovainio (2010) reports that
the system is regarded as complex and costly to administer at the local level.
In Spain, in Catalonia, a scheme monitoring quality of care through the contracting system
between the local health administration and providers has led to some provider management
reforms.
In Italy the decentralized health system has led to a variety of initiatives some of which include
performance incentives in the contracts between the local health authorities and GPs (Lippi
Bruni et al., 2009).
In France, a new performance based voluntary contract for French GPs was introduced in 2009
driven by quality of care and efficiency. There are two components: preventive care and follow
up of chronic diseases (60% of the remuneration); and medical prescriptions (40%). The former
focuses on aspects including influenza vaccination and breast cancer screening and covered by
nine indicators, and there are seven indicators covering drug prescriptions. GPs receive a yearend bonus based on their aggregate performance score and number of patients registered.
In addition to the experiences discussed above, there are some high-income countries that are at
the discussion stage regarding the implementation of provider performance incentive schemes;
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this is happening for example in Estonia (Maynard, 2008) and in Canada (Pink et al., 2006). The
current literature is on those countries relates to how provider performance incentive principles
and mechanisms would be applied given the local situation.
Basinga et al (2010) provide a recent example of a thorough evaluation designed to evaluate the
impact of P4P on the use and quality of prenatal, institutional delivery, and child preventive care
in Rwanda. Treatment facilities were enrolled in the P4P scheme in 2006 with comparison
facilities being enrolled in 2008. Their findings were that P4P had a ‘large and significant positive
impact’ on all the service areas investigated, with the greatest effect on those services that had the
highest payment rates and needed the lowest provider effort. The analysis isolated the incentive
effect from the resource effect in P4P and the results showed that the same amount of financial
resources without the incentives would not have achieved the same gain in outcomes (see figure
4 below).
Figure 4
Source: Slide from presentation ‘ What do we get when we pay medical providers for
performance?’ (Gertler P, 2010)
3.4 Pilot schemes in Belarus
Within the ImPrim project there have been several pilot projects undertaken in the Gomel region of south
eastern Belarus aimed at strengthening PHC services in remote rural areas by encouraging physicians to
move there through incentive payments, the inclusion of primary health care into the plans of regional
and local development, professional development by team work organization, and quality indicators.
Of particular interest in the context of this paper is the initial work undertaken on quality indicators
(Tumelevich et al, 2012). The payment system for health care employees system is set centrally, with
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annual standard premiums applied for work experience, qualification, position held, work experience in
rural districts. A bonus payment is considered to be an efficient way of stimulating doctors to become
engaged in primary health care in rural areas. The implementation of indicators aims:
“to make it possible to
- provide material encouragement subject to individual results and working conditions;
- increase efficiency of encouragement in proportion to direct efforts, made by the employees of
primary health care system and results of those efforts.”
Professional development is another area where there has been pilot work and the effects have been
evaluated over a one year period from its start in 2010. This shows decreasing frequencies of both
consultations to the doctors, home visits, ordinary telephone calls, emergency calls and admissions to
hospital as reported in figure 5.
Figure 5
Change of health care activities from 2010 to 2011
Level in 2010, all indicators = 100%
100
Emergency calls
81,6
Ordinary telephone calls
75,4
Admissions to hospital
75,6
Dr.s consultations incl homevisits
82,6
0
20
40
60
80
Per cent
100
120
(Source: Tumelevich et al, 2012).
A satisfaction survey of medical staff was undertaken but the results are not very positive (figure 6).
However, this survey was carried out before the new equipment of two clinics was installed and it would
be expected that on a future re-survey satisfaction levels will increase.
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Figure 6
Degree of satisfaction with the job situation and work load
Per cent
0,0
20,0
40,0
60,0
Enjoy my work
100,0
53,3
Overloaded by
administration
88,2
Want to leave medical work
Relevant paid
80,0
60,0
43,6
(Source: Tumelevich et al, 2012)
4. Analysis from clinical and economic perspectives
4.1 Evidence from clinical trials
Scott et al (2011) examined the evidence from published reports of the effect of changes in the
method and level of payment on the quality of care provided by GPs and aimed to identify:
different types of financial incentives that have improved quality;
characteristics of patient populations for whom quality of care has been improved by
financial incentives; and
characteristics of GPs who have responded to financial incentives.
They identified 2933 potentially relevant studies, out of which seven were chosen based on a
range of assessment criteria. Five of these were in the US, one in the UK, and one in Germany.
However, the evidence was generally judged to be of a low quality because of the risk of bias (due
to either non-randomisation or selection bias, or both). Lack of blinding in the three clusterRCTs reviewed was also an issue.
Three of the studies evaluated single-threshold target payments; one examined a fixed fee per
patient achieving a specified outcome; one study evaluated payments based on the relative
ranking of medical groups’ performance (tournament-based pay); one study examined a mix of
tournament-based pay and threshold payments; and one study evaluated changing from a
blended payments scheme to salaried payment.
Three cluster RCTs examined smoking cessation; one ‘controlled before and after’ (CBA) study
examined patients’ assessment of the quality of care; another CBA examined cervical screening,
mammography screening, and HbA1c; one ‘interrupted time series’ (ITS) study focused on four
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outcomes in diabetes; and one controlled ITS (a difference-in-difference design) examined
cervical screening, mammography screening, HbA1c, childhood immunisation, chlamydia
screening, and appropriate asthma medication.
Six of the seven studies showed positive - but modest - effects on quality of care for some
primary outcome measures, but not all of them; one study found no effect at all on quality of
care. Poor study design led to substantial risk of bias in most studies and, in particular, a key
potential bias issue that was not addressed in any of the studies was that of physician selection
into or out of the incentive schemes. Studies that were randomised and analysed at the level of
the medical group did not report changes in the composition of medical groups (physicians or
their patients) between baseline and follow up, or between the intervention and control groups.
Non-randomised studies did not explicitly account for physician selection. Physicians who
provide poor quality of care may withdraw from the health plans providing these schemes,
choose to contract with health plans that do not have incentive schemes, or choose not to
participate in the study, leaving the ’better performing’ physicians in the study. Observed
improvements in performance may therefore be due to selection rather than any actual changes
in physician behaviour.
In terms of the general findings of weak study designs and moderate effect sizes, the results of
this ‘Cochrane review’ can be seen as largely consistent with previous systematic reviews
discussed in this report.
4.2 Incentive effects and measurement methods
Incentives such as P4P can be very powerful in their effects. Our colleague, Alan Maynard, the
leading health economist, has monitored their development for many years and considers that
they offer the possibility of improving value for money for taxpayers and patients. However he
also advises caution in their design and deployment. He summarised his views in a WHO report
(Maynard, 2008) in support of the introduction of incentive payments in Estonia. We have drawn
some key elements from this report in the following paragraphs.
Maynard points out that incentives can induce behaviours consistent with policy goals, but can
also produce perverse outcomes that frustrate policy objectives. Incentives can be financial and
non-financial. Confucius emphasized the role of trust, without which ‘we cannot stand’. Trust
creates duty, which is a clear non-financial behavioural incentive. O’Neill (2002, cited by
Maynard) elaborated this theme in the context of individual and group behaviour. “Each of us
and every profession and every institution need trust. We need it because we have to be able to
rely on others acting as they say they will, and because we need others to accept that we will act
as we say we will….”
Maynard also notes that another way of looking at the problems associated with exchange
between purchasers and providers is that contracts can never be complete. It is impossible to
identify and include all possible behaviours in a contract, let alone legislate for their policing and
management. As a consequence, trading between buyers and sellers has to be based on trust. The
importance of trust and duty should not be ignored when manipulating financial incentives. It is
necessary to sustain and develop trust by improving information systems, particularly in regard to
measuring and managing outcomes.
In discussion of P4P, there is scope for both non-payment for performance and incentives that
penalize rather than reward. These are sometimes referred to as “reputational” incentives –
rewards and penalties that may be marginal in financial terms but nonetheless provoke significant
behavioural reactions that improve efficiency. Non-reimbursement for failure may have a more
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powerful effect on performance than positive rewards. Indeed, as discussed in economic theory,
a small financial loss may have a larger behavioural effect than a larger financial gain (Kahneman
& Tversky, 1979). This approach, based on prospect theory, is being increasingly considered by
health care reformers. With both rewards and penalties, the emphasis is on the experimental use
of small incentives. The emerging evidence is that this approach, at the margin, may be effective
at eliciting significant changes, in part probably as a result of the effects not just on revenue but
also, via publicity, on public reputation.
Improving the transparency of clinical performance may itself improve accountability and
efficiency. This may facilitate change led by clinicians who are key decision-makers in health care.
Financial incentives can be used marginally to complement trust. Trust and duty, together with
incentives, are the primary determinants of behaviours and have to be carefully balanced as policy
is developed.
The emerging P4P process evidence base is demonstrating effect. However, the initiatives are becoming
increasingly ambitious e.g., Medicare’s 2008 non-payment for medical errors (Rosenthal, 2007). Such
initiatives may not only have high transaction costs, they may also induce increased gaming, and what are
often referred to as ‘unintended consequences’. The incentives literature is full of examples of P4P
mechanisms creating opportunities for “creative” management. Such ubiquitous behavioural responses
have to be policed, further inflating transaction costs. However, such problems have to be seen in light of
the potential gains of knowing more about clinical activity and how this basic information can improve
management and patient care.
Maynard also considers the size of incentive required to induce change in doctors and providers.
Prospect theory and the idea of reputational incentives imply that small negative incentives
(income losses) may produce more change that larger positive incentives (bonuses).The
Medicare–CMS hospital incentives are small and produce change and there is some evidence that
small negative incentives may also affect doctors (Rizzo & Zeckhauser, 2003).
Maynard considers that an essential part of delivering change is the use of patient reported
outcome measures (PROMs) to demonstrate that as processes are improved and clinical practice
variations are reduced, there is an assurance that patients are ‘getting better’, at least in terms of
their own assessment of Quality of Life. Without PROMs, transparency and accountability
become difficult to achieve, and we note that PROMs have been largely absent from the QOF
scheme in the UK. Without them, purchasers operate in the dark, and there is little consumer
protection for the taxpayer and the patient. With PROMs, however, process data can be
complemented and improved clinical and non-clinical management enabled. Cautious,
incremental investment in outcome measurement may cast light on whether patients’ physical
and psychological functioning improves.
5. Implications of evidence for implementing proven
incentive schemes
The review by Elovaino (2010) provides some helpful discussion of the pros and cons of incentive
schemes, and what this might imply for countries developing new schemes. These types of consideration
have mostly been discussed at length within the ImPrim project as proposals have been developed. In the
following paragraphs we summarise some key points arising from his evidence:
i.
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A focus on quality or quantity is strongly related to context, with the focus being
more on increasing utilization in low-income countries and enhancing quality of
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care in high-income countries. Existing payment mechanisms (fee for service etc)
already provide incentives to increase quantity, and incentive schemes do best to
focus on the quality of those services
ii.
Quality is measured in terms of outcomes, but if these are not measurable, or will
take time to change, intermediate measures of process may be more effective in
changing behaviour in desired directions.
iii.
Most performance incentive schemes will increase costs since they introduce new
payments and administrative costs; however, there can be long term savings if other
services can be substituted.
iv.
The performance incentive schemes in high-income countries do not target overall
efficiencies, consequently there is very little literature on their cost-effectiveness or
cost-benefits. Some studies show positive effects (eg hospital admission avoidance)
but the results are highly programme and context specific.
v.
There are no standard procedures for selecting indicators; different types of
organizational and procedural factors will interfere during development and thus it
is likely that implemented schemes cannot replicate the proven indicator sets
vi.
The number of indicators used is necessarily specific to the different schemes,
however there are some indications that as programmes evolve the number of
indicators increases, meaning that the comprehensiveness of the schemes becomes
more of an issues as time goes by and that the financial and administrative burden
becomes less important once the scheme has built up speed.
vii.
The choice between rewarding based on performance targets or improvements in
performance can have a direct influence on how the providers are incentivized:
those with low baseline performance will be more responsive to improvement
related reward while the high performers will be more responsive to rewards for
target attainment. In some cases schemes have resorted to a mixture of the two
methods.
viii.
Similar considerations apply to the use of relative performance indicators eg if
payments are only mage to providers in the upper quartile of an indicator. In theory
a competition based reward mechanism is better for the funding organisation since
costs can be controlled or even predetermined. However because this system
creates winners and losers, it is not easy to get the providers’ acceptance, not least
because the link between changed behaviour and reward cannot be determined in
advance.
ix.
There are some concerns that gaming can be a problem and there is some evidence
of its existence. There is a clear need to put more emphasis on studies that observe
performance incentive schemes from this perspective.
x.
There can be too much emphasis on rewarding one category of staff over another.
In primary care this particularly applies to schemes which reward the GP rather
than other staff groups whose input is key eg the role of nurses in the management
of chronic conditions
There will be further lessons to emerge from the pilot projects in the ImPrim countries. Some of these
pilots are being undertaken in health systems which have had a different historical background and
development path to those mainly presented in this report.
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References
Ashenden R, Silagy C, Weller D, 1997, A systematic review of the effectiveness of promoting lifestyle
change in general practice. Family Practice, 14:160-176.
Ashworth M, Medina J, Morgan M, 2008, Effect of social deprivation on blood pressure
monitoring and control in England: a survey of data from the quality and outcomes framework.
BMJ 2008;337:a2030.
Basinga P, Gertler P, Binagwaho A, Soucat A, Sturdy J, Vermeersch, C, 2010, Paying Primary Health Care
Centers for Performance in Rwanda. Policy Research Working Paper 5190. (The World Bank Human
Development Network, Chief Economist’s Office & Africa Region Health, Nutrition & Population Unit).
Bowen T and Forte P, 2012, Proposals for an Initiative-Based Reimbursement Model for Primary Health
Care
in Latvia. Draft Final Report to ImPrim project (unpublished).
Campbell S, Roland M, Middleton E, Reeves D, 2005, Improvements in quality of clinical care in English
general practice 1998-2003: longitudinal observational study. BMJ, 331:1121.
Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M, 2007, Quality of Primary
Care in England with the Introduction of Pay for Performance. New England Journal of Medicine, 357:18119.
Chung S, Palaniappan L, Trujillo L, Rubin H, Luft H, 2010, Effect of Physician-Specific Pay-forPerformance Incentives in a Large Group Practice. Am J Manag Care, 16(2):e35-e42.
Coleman T, 2010, Do financial incentives for delivering health promotion counselling work? Analysis of
smoking cessation activities stimulated by the quality and outcomes framework. BMC Public Health, 10:167.
Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, Roland M, 2006, Pay-forPerformance Programs in Family Practices in the United Kingdom. N Engl J Med. 355: 375-84.
Elovainio R, 2010, Performance incentives for health in high-income countries – key issues and lessons
learned. World Health Report (2010) Background Paper, No 32 (Geneva, WHO).
Gertler P, 2010, What do we get when we pay medical providers for performance? KDI, Seoul
[http://siteresources.worldbank.org/EXTHDOFFICE/Resources/5485726-1256762343506/65187481292879124539/13.P4P-Korea-KDI.pdf
Kahneman D, Tversky A, 1979, Prospect theory: an analysis of decision under risk. Econometrica,
47:263–292.
.Lippi Bruni M, Nobilio L, Ugolini C, 2009, Economic incentives in general practice: The impact of payfor-participation and pay-for-compliance programs on diabetes care. Health Policy, 90:140-148.
Maynard, A, 2008, Payment for Performance (P4P): International experience and a cautionary proposal
for Estonia. Health Financing Policy Paper, Division of Country Health Systems (Copenhagen, WHO
Regional Office for Europe).
O’Neill, O, 2002, A question of trust. (BBC Reith Lectures). (Cambridge, Cambridge University Press).
eu.baltic.net
74
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ImPrim Report #1
A. Incentive payments for high quality PHC performance
Pink G, Brown A, Studer M, Reiter K, Leatt P, 2006, Pay-for-performance in publicly financed healthcare:
some international experience and considerations for Canada. Healthc Pap.6: 8-26.
Rizzo J, and Zeckhauser R, 2003, Reference incomes, loss aversion and physician behaviour. Review of
Economics and Statistics, 85(4):909–922.
Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, Young D, 2011, The Effect Of
Financial Incentives On The Quality Of Health Care Provided By Primary Care Physicians (Intervention
Review). The Cochrane Collaboration. (Chichester, John Wiley & Sons, Ltd).
Trisolini M, Aggarwal J, Leung M, Pope G, Kautter J, 2008, The Medicare Physician Group
PracticeDemonstration: Lessons Learned on Improving Quality and Efficiency in Health Care. The
Commonwealth Fund.
Tumelevich N, Stribolt W, Ovhed I, 2012, Strengthen Primary Health Care in remote areas in Gomel,
Belarus. ImPrim report no 7 (Karlskrona, Blekinge Centre of Competence).
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ImPrim Report #2
B. Quality indicators for high quality PHC performance
ImPrim Work Package 3:
Instruments for improving the financial provisions for Primary Health Care
Report # 2
Quality indicators for high quality
PHC performance
Operational and tested system of
evidence-based quality indicators
Editors and authors
Arnoldas Jurgutis1, MD, PhD, Paula Vainiomäki2, MD, PhD
1
Public Health department, Faculty of Health Sciences, Klaipeda University, Klaipeda
Lithuania
2
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Family Medicine department, University of Turku, Turku Finland
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Content
ABSTRACT ....................................................................................................................................................... 4
ABBREVIATIONS ............................................................................................................................................. 6
1. BACKGROUND ............................................................................................................................................ 7
2. INTRODUCTION ........................................................................................................................................... 7
3. WHAT IS QUALITY OF CARE AND HOW CAN IT BE MEASURED? ........................................................ 9
3.1. W HAT IS HIGH QUALITY PRIMARY CARE? ................................................................................................... 12
3.2. DEFINITIONS OF GENERAL PRACTICE/FAMILY MEDICINE .............................................................................. 12
4. INTERNATIONAL INITIATIVES ON MEASUREMENT OF QUALITY OF PRIMARY CARE .................... 14
4.1. PHAMEU PROJECT ................................................................................................................................ 14
THE PHAMEU PROJECT ................................................................................................................................ 14
4.2. QUALICOPC PROJECT .......................................................................................................................... 14
4.3. OECD HEALTH CARE QUALITY INDICATOR PROJECT ................................................................................ 15
4.4. EUPHORIC (EUROPEAN PUBLIC HEALTH OUTCOME RESEARCH AND INDICATORS COLLECTION) PROJECT . 16
4.5. MONITORING PERFORMANCE WITH INTERNAL QUALITY IMPROVEMENT TOOLS .............................................. 17
4.6. DEVELOPMENT OF THE QUALITY IMPROVEMENT SYSTEM IN PRIMARY CARE IN ST. PETERSBURG ................ 19
5. REVIEW OF PRIMARY CARE QUALITY IMPROVEMENT SYSTEM IN SELECTED COUNTRIES IN THE
BALTIC SEA REGION .................................................................................................................................... 20
5.1 BELARUS ................................................................................................................................................. 20
5.2 ESTONIA .................................................................................................................................................. 21
5.3 LATVIA ..................................................................................................................................................... 22
5.4 LITHUANIA................................................................................................................................................ 25
5.5 RUSSIA (KALININGRAD REGION) ................................................................................................................ 29
5.6 EXAMPLES FROM NORDIC COUNTRIES: FINLAND, SWEDEN ......................................................................... 30
5.7 DATA COLLECTION.................................................................................................................................... 31
6. PROPOSAL OF RECOGNISED QUALITY INDICATORS FOR MEASUREMENT OF PRIMARY HEALTH
CARE PROFESSIONALS´ PERFORMANCE IN BELARUS, ESTONIA, LATVIA, AND LITHUANIA ......... 32
6.1 W HY IS SETTING PERFORMANCE BASED QUALITY INDICATORS IMPORTANT IN THE BALTIC SEA REGION? ........ 32
6.2 PROPOSED INDICATORS TO MEASURE PHC PERFORMANCE IN BELARUS, ESTONIA, LATVIA, LITHUANIA
(PRESENTED IN TABLE 4) ................................................................................................................................ 32
6.3 RECOMMENDATIONS................................................................................................................................. 32
(6) Retinal photography have been made during last three years ......................................................... 49
7. REFERENCES ............................................................................................................................................ 55
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Abstract
Quality of health care and methods of assessing quality are critically discussed today. The aim of quality
work can be defined as the best structure, process and outcome of health care consistent with patient
values and preferences, professional knowledge of appropriate and effective care, possible with given
available resources. But are we able to assess the quality of primary health care (PHC) concerning
structure, process and health outcomes? To address gaps in the quality Expert Group of PHC of the
Northern Dimension Partnership in Public Health and Social Wellbeing have initiated a project ImPrim
with general objective to promote high quality PHC services in Baltic Sea Region (BSR) to increase cost
efficiency of public health care systems.
There is evidence that health systems with strong PHC have better health outcomes with lower costs
than those with a strong focus on hospital care. Good PHC is comprehensive, manages simultaneously
acute and chronic health problems, health promotion and prevention strategies and has practices with
patient centeredness, holistic approach, coordination of care and teamwork. PHC has features which
are difficult to measure either by counting visits and figures or applying checklists. To measure quality,
valid, measurable, accepted, not easily manipulated and uniform indicators describing relevant features
of care can be used. In pay-for-performance systems professionals’ wages may be connected with these
indicators according to defined target levels
After several decades of Semashko system of health care, intensive reforms have been introduced in
Estonia, Latvia, Lithuania, Poland and also in some Regions of Russia. PHC in Belarus has been in
transition since the late 1990s as the country has experimented with different models of organizing
services. All these countries had same organisational model: centralised health care with predominant
hospital care, exaggerated role of narrow specialists and hospitals leading health care in distinct
territory. Movement towards PHC-oriented health care has changed the systems during last twenty
years, but still there are differences between the countries, when organizational forms of primary health
care, including payment schemes and quality measurement tools are compared.
In this report the authors have collected information of quality projects in BSR countries as well as
information of health care and payments systems. Information of performance indicators used in
respective BSR countries has been collected to make an initial proposal for quality indicators of PHC
performance. These indicators should be discussed with national stakeholders: financiers, providers,
professionals, patients and politicians, and adapted to the national needs.
Authors recommend all the stakeholders to be taken within the discussion, as the applicability of the
indicators may depend on the development and goals of PHC in the country. Quality initiatives should
promote accountability and reflect partnership between patient and health care professionals. Quality
efforts should be applied in a positive, not punitive manner. They should form systematic daily
routines. Gradual implementation with a proper training for quality issues concerning all stakeholders
could help in implementation of indicators. Data collection should give no extra burden for
professionals. Setting indicators connected with wages is a powerful intervention to the work. If just
technical figures are measured, several central characteristics of the PHC tasks are missed.
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In east European countries it is important to balance quality improvement systems from “top-down”
external quality improvement methods, more toward internal “bottom-up” approaches. Other types of
quality assessment should be used simultaneously with pay-for-performance indicators such as patient
satisfaction studies and self assessment of professionals’ work with specially developed tools. Feedback
of the work is needed to improve the quality, and professionals should understand the importance of
quality.
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Abbreviations
APO
Audit Project Odense
BSR
Baltic Sea Region
EURACT
European Academy of Teachers in General Practice
FM
Family Medicine
GP
General Practitioner
MoH
Ministry of Health
ND
Northern Dimension
NDPHS
Northern Dimension Partnership in Public Health and Social Well-being
NDPHS EG
Expert Group of the Northern Dimension Partnership in Public Health
and Social Well-being
PC
Primary Care
PHC
Primary Health Care
PHC EG
Primary Health Care Expert Group
RTI
Respiratory tract infection
WHO
World Health Organization
WONCA
World Organization of National Colleges, Academies and Academic
Associations of General Practitioners/Family Physicians
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1. Background
The ImPrim project is one of the flagship projects included in the EU Strategy for the Baltic Sea
Region Action Plan. Originally initiated by the Primary Health Care Expert Group of the Northern
Dimension Partnership in Public Health and Social Wellbeing (NDPHS), it is mainly sponsored by the
EU Baltic Sea Region Program.
The project is a five-year collaboration involving 13 partners (comprising leading health care
institutions) from Belarus, Estonia, Finland, Latvia, Lithuania and Sweden.
The overall objective is to improve public health (especially in the eastern part of the BSR). Within this
wide field, the project will focus on the role of primary health care and its benefits for the public health
system as well as the regional competitiveness. The specific objective of the PHC project is to promote
the equitable distribution of high quality primary health care services in the BSR in order to increase the
cost-efficiency of the public health system and to efficiently counteract communicable diseases as well
as health problems related to social factors.
2. Introduction
Primary care is the cornerstone of health care systems and measurement of its professionals’
performance is very important to ensure that whole system works effectively, efficiently and for the
benefit of patients and community.
In the secondary and tertiary health care biomedical approach is often used with evidence-based
standards of care, incentives to meet those standards and monitoring progress towards the standards
and goals. Measuring quality within primary health care using same methodology has limitations, as
primary health care has several dimensions not easy the measure.
Good primary health care should not be limited to diagnosis and treatment of presented problems, but
it has to demonstrate a comprehensive approach in order to simultaneously manage multiple
complaints and pathologies, both acute and chronic health problems of the individual and also apply
health promotion and disease prevention strategies appropriately. Strong primary health care practice
includes characteristics, like patient centeredness, holistic approach, coordination of care and
teamwork, which are not so easy to measure applying simple checklists, as in case of clinical
performance.
More and more international evidence is collected that systems with stronger primary care have better
outcomes for less money than those with a strong focus on hospital care (Macinko et al 2007, Starfield
1998, Starfield et al 2005). Nevertheless when comparing different countries, term primary care has
different meanings and there are various organisational forms of primary health care providers. New
public health challenges are ageing of population, burden of chronically ill patients, new expensive
technologies and increased overall costs of health care. Politicians and payers now more than ever are
interested in efficiency of health care systems and have to make decisions which interventions and ways
of working give best value for money.
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Therefore measurement of primary health care (PHC) performance and introduction of new PHC
performance indicators is a hot issue during the last decade in European countries, post-Soviet
Countries included. During last decade all countries in Baltic See Region were trying to improve
primary health care and to implement more or less intensive reforms to rationalise their health care
systems. Most intensive reforms were introduced in Estonia, Latvia, Lithuania, Poland and also in some
Regions of Russia. These countries 20 years ago had the same Semashko organisational model: very
centralised health care with predominant hospital care, exaggerated role of narrow specialists and
hospitals leading health care in distinct territory. All three Baltic countries and Poland from very
beginning of transition declared strong plans to introduce family medicine and primary health care, but
traditions of Semashko systems often served as an obstacle to have coherent reforms. Estonia
demonstrated most successful story of primary health care reform from all former Soviet Union
countries (Atun RA et al, 2006), nevertheless a lot positive lessons could be learned from all other
countries in transitions including Belarus and Russia, where reforms have started relatively later
(NDPHS report PHC in ND countries, 2008).
To address existing gaps in the quality of primary health care Expert group of PHC of the Northern
Dimension Partnership in Public Health and Social Wellbeing have initiated project ImPrim with
general objective to promote high quality PHC services in BSR in order to increase cost efficiency of
public health care systems. 13 Partner organizations, from Belarus, Estonia, Finland, Latvia, Lithuania
and Sweden, are responsible for project implementation in the period 2010 -2012. Work package 3 of
the project should explore how incentives for PHC providers should be organized in order to produce
high quality PHC services. Operational system of evidence based quality indicators should be
developed and tested, verified and/or modified in Lithuania, Latvia, Estonia and Belarus. This report is
the result of the BSR program’s 2007- 2013 project’s “Improvement of public health by promotion of
equitably distributed high quality primary health care systems” (ImPrim) partner Klaipeda university
leaded activities of WP 3: (1) review of systems of quality control in PHC of BSR; (2) elaboration of an
operational system of evidence based and widely recognised quality indicators for PHC performance.
Objective of this document is to make overview of performance indicators used in respective BSR
countries and to make an initial proposal of operational system of evidence based and widely
recognized quality indicators for PHC performance. As the next steps these indicators should be
discussed with national stakeholders, as financers, providers, professionals, patients and politicians, and
adopted to the national needs. Following further activities are defined in the work plan of the ImPrim
project proposal: (1) dissemination of and information about the operational system of recognised
quality indicators to national stakeholders; (2) adoption of the system to the national needs, (3) piloting
of the practical aspects of the operational system of recognised quality indicators in Lithuania, Latvia,
Estonia and Belarus together with GPs, nurses and health authorities; (4) verification/modification of
the system and elaboration of the final product; (5) dissemination of project results via transnational
NDPHS network to National Ministries of Health.
Proposed main indicators should be easy applicable in all four targeted countries, so that it would be
possible to compare between countries and conclude for policy makers on what aspects of PHC could
be strengthen in their respective countries. Optional indicators also will be proposed for consideration
and adoption for use in some countries to measure PHC quality between different PHC providers.
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Initial ideas on widely used PHC quality indicators have been presented during 2 nd Meeting of the BSR
program 2007- 2013 project “Improvement of public health by promotion of equitably distributed high
quality primary health care systems (Imprim) ImPrim Partners meeting in Gomel, October 2010. This
report was prepared using relevant literature, websites, but also several e-mail contacts, phone calls,
workshops, seminars and practices. Report is presented as a proposal document for discussions with
national stakeholders. Nevertheless authors already have had opportunity to adopt the list of proposed
indicators after discussions with partners of and some stakeholders in Latvia and Lithuania. ImPrim
WP3 Workshop February 3 “Instruments for Improving the Financial Provisions for PHC” in Riga
served as opportunity for discussions with Arturs Gravitis, head of Primary health care unit of the
Ministry of Health of Latvia, Aigars Miezitis, project coordinator, Centre of Health Economics of
Latvia (Imprim PP6), Alise Nicmane, Latvian Family Physicians Association (PP7), Ingvar Ovhed and
Jens Wilkens, Blekinge Competence Centrum (PP2). Further discussions on the proposed indicators
took place in Vilnius, February 11th during Ministerial Working group for Imprim Project activities in
Lithuania. During discussions input have received from representatives of Hygiene institute (PP4), Vytautas Jurkuvenas and Romas Gurevicius, chief specialist of Lithuanian MoH Egle Savuliene, head of
health administration of Klaipeda, member of National Health Board – Janina Asadauskiene,
representatives of the Society of Lithuanian General Practitioners Vytautas Kasiulevicius and Sonata
Varvuolyte.
3. What is quality of care and how can it be measured?
Quality of health care may be assessed in quantitative characteristics as number of people, patients,
visits, laboratory tests etc, but it can also be defined from the perspective of greatest health benefits,
least health risks and given available resources. One of the most common definitions for quality in
primary health care is the following: Quality in primary health care is the best health outcomes with
given available resources that are consistent with patient values and preferences.
The WONCA working party for Quality in Family Medicine has addressed for several issues when
supporting family doctors to strive for the best quality. The aim of quality work is the best structure,
process and outcome of health care consistent with patient values and preferences, professional
knowledge of appropriate and effective care, and possible with given available resources. Quality
initiatives should promote accountability and reflect partnership between patient and health care
professionals. Quality efforts should be applied in a positive, not punitive manner. They should be
explicit, systematic daily routines. (Mäkelä et al, 2001)
Øvretveit (1992) has defined the quality of health care by fully meeting the needs of those who need
the service most at the lowest cost to the organisation within limits and directives set by higher
authorities and purchasers
Most professional agree that the target of the patient care is the satisfaction of the patients and a good
professional result of care without wasting resources. At the same time the challenge is often that
professionals are not aware of the quality of their work and they do not have the knowledge, how to
work to achieve the quality they want or is expected from them.
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There are also several viewpoints to the quality: what the patients and their carers want from the
service, does the service meet the professional standards and use effective and accepted technologies,
and is the management working towards the most effective, efficient and productive use of resources,
within limits and directives set by higher authorities/purchasers. It can also be looked the quality from
the point of view of structure, process and outcome.
Several methods of assessing quality of care exist, but in this report we concentrate on measuring the
quality using indicators, even though we are aware of the fact that quantitative measurements mainly
measure the technical part of the professionals’ work in primary health care. It has not been possible to
develop simple and explicit indicators for “soft” issues as humanistic, holistic or comprehensive work.
Quality of performance in primary health care can be measured using quality indicators, chosen to
represent the quality (criterion) and/or show variation in quality. An indicator should measure relevant
features of care, be valid, measurable, accepted, not easily manipulated and be interpreted uniformly. A
target level/standard for individual indicators should be set; and it can be measured what is the
achieved level/standard. Systematically developed clinical practice guidelines are used to assist decisions
for practitioner and patient about appropriate health care for specific clinical circumstances; and these
guidelines also help when choosing the indicators.
Quality is not the end of the process, but it is continuous striving towards the best quality. Deming has
developed a quality circle to describe the continuous process of quality (Figure 1). If we want to achieve
better results, we must change the system. We have to plan an improvement, we have to do according
to our plans, then record and measure if we have moved to the desired direction and act again. The
circle should be continuous.
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ACT
STUDY
PLAN
DO
Figure 1 Model for Quality Improvement by Deming
Indicators are sometimes set according to what is possible to measure: this issue leads to the fact that
we use more quantitative issues (figures, visits etc) than are able to measure basic characteristics
(comprehensiveness, continuity of care, specific problem-solving, multi-morbidity treatment). We
probably may start measuring performance in primary health care by quantitative indicators, but we
have to remember that good primary health care quite often deals with issues that go beyond the
numbers. Instead of focusing on a small number of selected diseases a comprehensive response to
people’s expectations and needs should be emphasized, spanning the range of risks and illnesses. In the
future, methods should be developed for analysing and measuring these “soft issues”. In the current
phase of development, it has to be remembered that indicators measure mainly some minor parts of
general practice/family medicine performance.
There are also suggestions that adhering to current clinical practice guidelines with pay-for-performance
indicators in caring for an older person with several co-morbidities may have undesirable effects. They
may lead to inappropriate judgment of the care provided to the older individuals with complex comorbidities and could create perverse incentives that emphasise the wrong aspects of care for this
population and diminish the quality of their care (Boyd C.M. et al 2005)
It has to be remembered that setting indicators of pay-for-performance system is a strong intervention
for the work. Professionals very easily learn to perform according to the indicators set, if indicators are
connected with the wages. This problem may lead to over-diagnosing and over-treatment and it should
be considered seriously when setting the indicators.
Feedback of the performance of professionals in primary health care is anyway needed to improve and
develop the outcome. Many ways of measuring the performance should be used when trying to assess
the outcome. Other methods have to be used in addition to using indicators and measurements. It is
important to develop tools to self-assess the performance of professionals as well as study patient
satisfaction, but also satisfaction of professionals. Important tool after measurements with indicators is
also peer reviewing the result of measurement, which method often is forgotten.
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3.1. What is high quality primary care?
Organisation of primary health care varies between different countries in BSR. Family Medicine or
General Practice is widely recognized as core discipline of primary health care with specific
competencies which are distinct from other medical specialties. Still family medicine is not finally
introduced in all BSR countries, e.g. up to 30% of population in Lithuania and up to 90% in Belarus
have primary care provided by district internists and paediatricians, not retrained to family doctors.
Despite of different organizational forms primary care should provide functions as defined in
Starfield’s definition (Starfield, 1998): primary care is first contact, continuous, comprehensive and coordinated care
provided to populations undifferentiated by gender, disease, or organ system.
Therefore high quality primary care should include following characteristics:
First contact, easily accessible services for all population groups and addressing all health needs
of the patient
Provision of comprehensive services to meet the need of patients with focus on generalism
rather than specialism
Provision of patient centred rather than disease centred care
Provision of longitudinal relationship with the patients
Coordination of care for individual patients
Holistic approach, i.e. integration of biomedical, psychological and social dimensions of a
patient’s problem;
Focus on health promotion and disease prevention as well as management of established health
problems.
Alma Ata declaration from 1978 http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf
defined primary care in a way, relevant still today. Although it had huge symbolic importance, its effect
in practice was more limited. Community participation and intersectoral action remain challenges for
those working to reduce health inequalities. The changing global burden of diseases and workforce
shortages make effective integration of existing vertical programmes essential. Primary health care is a
key to providing good value for money and enhancing equity. Alma Ata remains relevant for effective
healthcare systems today (Gillam S. 2008).
3.2. Definitions of general practice/family medicine
The World Organisation of Family Doctors defined General Practice /Family medicine in 1991, (World
organisation of Family Doctors, 1991).This document strongly emphasises high level education and
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training. Commitments of the GP to the community are overall objectives (knowledge of the
epidemiology in the community, influence on any health problem, a broad approach, support in the
community). Commitments to the individual are comprehensive care, orientation to the patient, family
focus, doctor-patient relationship.
World Health Organization Regional Office for Europe presented (1998) a document, A Framework
for Professional and Administrative Development of General practice/Family medicine in Europe. In
this document the main characteristics of general practice are: To fulfil these commitments is needed
several requirements, as comprehensive care, coordination with other services, advocacy role,
information base (record-keeping), doctor-patient relationship, accessibility, resource management and
special clinical decision making (undifferentiated problems, not always possible to set diagnosis,
predictive value of prevalence, early stages of diseases, low technology, GP has to protect his/her
patients from unnecessary examinations and measurements etc).
WONCA Europe defined General practice/Family medicine and family doctor’s/general practitioner’s
role in 2005 again. General practitioners/family doctors are specialist physicians trained in the
principles of the discipline. They are personal doctors, primarily responsible for the provision of
comprehensive and continuing care to every individual seeking medical care irrespective of age, sex and
illness. They care for individuals in the context of their family, their community, and their culture,
always respecting the autonomy of their patients. They recognise they will also have a professional
responsibility to their community. In negotiating management plans with their patients they integrate
physical, psychological, social, cultural and existential factors, utilising the knowledge and trust
engendered by repeated contacts. General practitioners/family physicians exercise their professional
role by promoting health, preventing disease and providing cure, care, or palliation. This is done either
directly or through the services of others according to health needs and the resources available within
the community they serve, assisting patients where necessary in accessing these services. They must
take the responsibility for developing and maintaining their skills, personal balance and values as a basis
for effective and safe patient care. (http://www.woncaeurope.org/Definition%20GP-FM.htm)
When comparing these different definitions about primary health care and general practice/family
medicine, the same issues and topics are present in nearly every definition even though the emphasis
may differ from definition to definition. We will meet several characteristics, which are difficult to
measure in quantitative figures.
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4. International initiatives on measurement of quality of
primary care
4.1. PHAMEU project
The PHAMEU project was selected for Funding by DG SANCO in 2006. It aims to establish a
sustainable health information and knowledge system on the state and development of primary care
systems in Europe. 31 European countries have been compared using developed by the project tools.
On the basis of the systematic literature review a provisional set of 55 features and 864 provisional
indicators were collected. After two rounds of elimination, the final set of 41 features, 99 indicators and
44 additional information items have been selected.
PC indicators have been integrated into 9 dimensions:
Governance of the PC system
Economic conditions of the PC system
PC workforce development
Access to PC services
Continuity of care
Coordination of PC services
Comprehensiveness of PC
Quality of PC
Efficiency of PC
Every step of the development process was conducted in agreement with the PHAMEU project
partners from ten countries, to safeguard the importance, scientific soundness, and feasibility of the
resulting PC Monitor. The application of the PC Monitor by the PHAMEU project in the 31
participating countries will ultimately show its feasibility. The PC Monitor offers countries the
opportunity to evaluate their primary care system in the context of their policy aims.
By creating a basis for routine data collection, the PC Monitor could serve the need of various
stakeholder groups for reliable and comparable information. Application of the Monitor will provide
European and national decision makers with comprehensive comparisons of primary care policies and
models of provision that may enable them to improve the effectiveness of primary care. It can serve
future actions in this area, such as health system impact assessments.
4.2. QUALICOPC project
The QUALICOPC project (Evaluating costs and quality of primary care in Europe) is an EC funded
project under the Seventh Framework Programme and carried out by an international network
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of partner institutes (31 countries) and coordinated by NIVEL (Netherlands Institute for Health
Services Research). Duration of the QUALICOPC project is since 1 May 2010 until 1 June 2013.
The project aims to evaluate primary care systems in Europe against criteria of quality, equity and costs.
It will enable to answer questions like, which elements of structure and organisation of primary care are
associated with access to high quality services against affordable costs. And: by what mechanisms
primary care structure and organisation are related to overall health care system goals.
The outcomes of the project aim to help decision makers to shape primary care systems optimally.
Specific objectives relating to Primary Care settings and strategies to:
Generic health care system goals
Indicators of process quality of PC services
Indicators of quality of care as seen by patients
In the project are used existing sources (1) OECD HCQI (avoidable hospitalisation), (2) OECD
Health Equity Project (equity), (3) System of Health Accounts (costs), PHAMEU Database (national
PC structure) and new sources - (1) GP survey (local PC organisation and process quality), (2) Patients
survey (responsiveness; patient perceived outcomes)
The study planning to provide an answer to the question what strong primary care systems entail and
which effects strong primary care systems have on the performance of overall health care systems. To
make insights tangible, good practices will be identified and disseminated. The study results will be
disseminated to the research community, policy makers and other stakeholders in the European health
sector.
4.3. OECD Health Care Quality Indicator Project
The OECD (Organization for Economic Co-operation and Development) Health Care Quality
Indicator Project has started in 2001. The OECD is an intergovernmental economic research
institution headquartered in Paris, France, with a membership of 30 developed countries sharing a
commitment to democratic government and the market economy. Its Health Care Quality Indicators
(HCQI) Project is attempting to bridge this gap by bringing together 23 OECD countries, international
organizations. The long-term objective of the HCQI Project is to develop a set of indicators that reflect
a robust picture of health care quality that can be reliably reported across countries using comparable
data. The HCQI project has built on two pre-existing international collaborations organized by the
Commonwealth Fund of New York (five countries) and the Nordic Group of countries (also five
countries). It now involves 23 countries.
The project initiated its work with two major activities. The first was an effort to build on the set of
indicators proposed by the two existing international collaborations. With additions from the HCQI
participants, a pilot project was undertaken to demonstrate the feasibility of collecting internationally
comparable data that could be released publicly. The second activity was to specify priority areas for
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additional indicator development and to identify specific quality indicators for those priority areas that
would be most appropriate for examination at an international level.
There were identified five priority areas leading to a recommendations of quality or care indicators
already developed and considered suitable for international comparison. 86 indicators were integrated
in the following areas:
Cardiac care (17 indicators),
Mental health care (12 indicators),
Diabetes mellitus (9 indicators),
Patient safety (21 indicators)
Health promotion, prevention, primary care (27 indicators).
The project was started in 2001. According to the Agreement between the European Commission and
OECD, it is an integral part of the activities of the EU in the areas of health indicators and health
systems. The project aims to develop a set of indicators for comparing the quality of health care across
OECD member countries (23 involved). This effort offers policy makers and other stakeholders a
toolkit to stimulate cross-national learning.
These five areas were chosen on the basis of the high impact of the three health areas on the burden of
disease.
The OECD HCQI Project has revealed substantial interest in information on the quality of care that
can be used to compare the performance of different health systems (Mattke S. Et all 2006).
4.4. EUPHORIC (European Public Health Outcome Research and Indicators
Collection) project
The EUPHORIC (European Public Health Outcome Research and Indicators Collection) project is
funded by the European Commission. It is a multidisciplinary project financed as part of the
community programme on public health. The aim is to collect the detailed information about
previously used outcome indicators in Europe, verify the possibility of “harmonizing” them, and
provide political authorities and decision makers with reliable instruments to measure the benefits of
treatments and quality of selected health services.
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The project started in December 2004 and ended in December 2008. The project was guided by a
network of 15 institutions from 10 European countries (Austria, Bulgaria, Finland, France, Germany,
Greece, Italy, Slovak, Spain, and Sweden) and Israel. The network played a crucial role in the
development of a joint effort to provide a valuable source of information. The project was divided into
three phases:
• Survey: to make an inventory of outcome research studies and outcome indicators in
participating countries
• Pilot: to test selected indicators in participating countries
• Dissemination: to make results available to EU authorities, institutions, study participants and
citizens on a multi-language website.
The aim of the first phase of the project, the survey, was to define a list of outcome indicators and to
collect information about the sources of data available in the participating countries in order to
compute the indicators included in the list. The final list of outcome indicators was defined on the basis
of the following selection criteria: availability, relevance to clinical level, relevance to policy level and to
the international scientific community.
EUPHORIC defined a list of 54 outcome indicators in nine areas of disease: (1) Cardiovascular disease
and surgery, (2) Cancer, (3) Infectious disease, (4) Other chronic diseases, (5) Orthopaedics,
(6)Transplantation, (7) Emergency, (8) Neonatal/maternal, (9) Miscellanous.
The second phase of the project, the pilot, provided interesting results in the cardiovascular and
orthopaedic areas and verified the hypothesis that the possibility of developing common outcome
indicators in Europe exists. Efforts were made to identify common European elements suitable for a
political European platform oriented at best practice guarantees for European citizens. Standardized
methodologies were designed and tools developed to assess the quality of care of some selected health
procedures.
The EUPHORIC initial structure considered dissemination as the third and last phase of the project.
This is even more important for projects related to the public health field when not only scientists but
also patients and citizens are interested in the results achieved. To provide the most suitable
information to all the targeted stakeholders, cooperation with people specialized in communication
strategy should be considered when dissemination is organized.
4.5. Monitoring performance with internal quality improvement tools
Quality improvement tools applied differ evidently in ND countries. Nordic countries for many years
are actively involved in international organisations, like European Working Party on Quality in Family
Practice (EQUIP), which contributed to development of various methods and tools for internal quality
assurance. Quality assurance mainly represented in the form of the external control (audit) in Baltic
States, Russia and Belarus contrasts with internal audit experience in the Nordic countries. Internal
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audit tools based on the demand for improvement of personal performance motivate primary care staff
to act better without fear of being externally controlled. One of internal quality improvement tools is
APO (Audit projects Odense) method developed in early 1990th by general practitioners in Odense and
through Nordic audit network involving to use this method a number of family doctors from
Denmark, Sweden, Norway, Iceland and Finland (Munck A et al. 2003). APO audit is method for selfcontrol of your own performance in terms of topic selected by them, using quality indicators defined by
the profession. It is very important that every doctor would feel free to decide if he want to participate
and to choose topic he/she feels is most actual for own quality improvement trying to answer to the
question “am I doing the right thing in the right way?” . Audit process consist of following steps: (1)
defining the problem area, (2) data collection and registration, (2) processing and analysis - very
important to keep confidentiality, that would be visible only average data of the performance and
individual data would be accessible only for respectively individual; (4) comparison and action –
individuals compare their own data with average data. Quality seminar organized to discuss what
changes needed with regards of scientific evidence and better quality for the benefits of the patient.
(Strandberg E-L. 2008).
Participation of Lithuania and Kaliningrad in EU financed project HAPPY AUDIT together with
Sweden, Denmark and other countries have demonstrated possibilities to change attitudes of GPs
towards respiratory infections treatment with antibiotics and serve as an example of international
cooperation for quality improvement. Project also demonstrated that such method could be
successfully used in East European countries, where there are strong traditions of “top-down” quality
control approaches. For spreading of the new approaches and application of APO audit method in the
North West Russia served NDPHS project “Establishing EBM and developing Quality of Care in PHC
through extended networks between PHC doctors and nurses in Northwest Russia” which was
implemented by Blekinge Centre of Competence (project leader Dr. Ingvar Ovhed). General
practitioners from Murmansk, Archangelsk, St Petersburg, Pskov and Kaliningrad have been involved
in different audit circles, targeted to improve (1) performance of nurses in management of hypertension
and lifestyle advise, (2) more appropriate use of antibiotics for respiratory tract infections, (3)
management of Hypertension and Diabetes.
Further strategies is needed to spread such internal quality improvement tools and to foster primary
health care practitioners and nurses to take more their own responsibility for measurement own
performance and for quality improvement. Financial incentives in East Europe countries could be
used to motivate primary health care physicians and nurses to joint such quality improvement circles,
like APO Audit method. Especially actual in East Europe countries would be to focus on such
relatively weak primary health care organisational characteristics like, teamwork and cooperation with
other sectors, strengthening role of nurses, addressing lifestyle related risk factors, organisation of
preventive activities in the practice, empowerment for self-management. These organisational issues are
very important for addressing recent community health needs and to get better quality of overall health
care.
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4.6. Development of the Quality Improvement System in Primary Care in St.
Petersburg
A bilateral project Development of the Quality Improvement System in Primary Care in St. Petersburg between St.
Petersburg Health Committee, and National Research and Development Centre for Welfare and Health
(STAKES), Finland was carried out in 2007-2009. Medical academy for Postgraduate studies in St.
Petersburg (MAPS) was the implementing organization. The purpose of the project was to create and
field-test a model of quality management system for regional level that is based on combination of
indicators, evidence-based guidelines and improved capacity of family physicians and health
administrators to promote changes to improve quality of care. The system of indicators was developed
consisting of 17 indicators of hospitalization due to the ambulatory care sensitive conditions, the set of
indicators has been field-tested, a web-site with the guidelines created (http://pubhealth.spb.ru/SPC/)
and results published.
Evidence-based treatment guidelines for treatment of cardiovascular diseases were selected and analysis
of quality care implemented. Several guidelines on hypertension and diabetes were translated and
published on the web-site, tools for patients’ satisfaction were field-tested, audit was implemented in
the three GP-pilot policlinics and also the system of audit for hypertension was piloted and evaluated.
As a model of quality improvement in family medicine, a series of participatory quality improvement
seminars were organised. During the seminars it was jointly planned, how to improve the quality of care
using the clinical vignettes (diseases selected for the workshops were arterial hypertension and diabetes
mellitus).
Training the trainers, teaching of residents and physicians in training were implemented in several
participatory workshops, seminars and conferences. Also leaders and decision-makers were
participating in the workshops. The book "Family Doctor Journey to Quality" was translated, published
and disseminated and the project results were presented in several articles of the journal "Russian
Family Doctor”. (Grouev AM, Titkov D. 2010).
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5. Review of primary care quality improvement system in
selected countries in the Baltic Sea Region
5.1 Belarus
Primary care in Belarus has been in transition since the late 1990s as the country has experimented with
different models of organizing services. The successful piloting of per capita resource allocation in
Vitebsk oblast (region) led to the nationwide roll out of new financing mechanisms for primary health
care from 2000 and the implementation of per capita financing for services from 2004.
There is now a dual primary health care system in Belarus:

a system of general practitioners in rural areas and on the outskirts of some cities

and the maintenance of the traditional Semashko polyclinic system in urban areas.
In remote rural areas primary care services are provided through FAPs (feldsher-midwife [akusher]
posts) staffed by mid-level medical professionals. A proportion of the remote rural outpatient clinics
have between ten and twenty beds that are mainly used for the care of older people and people with
chronic illnesses. Of the rural outpatient clinics, 70% are staffed by general practitioners (retrained
primary care internists or paediatricians); the remainder still have separate doctors for adults and
children. While the introduction of general practice in rural areas has been deemed a success, there are
no plans to extend general practice into urban areas.
The main categories of narrow specialists for outpatient consultations (surgeons, ear, nose and throat
(ENT) specialists, ophthalmologists, neurologists, endocrinologists, cardiologists, and gynaecologists in
adult polyclinics) are available at these polyclinics and patients can self-refer to the relevant specialist
without a referral from a primary care internist or primary care paediatrician. The urban polyclinics also
have diagnostic facilities: laboratory, X-ray, ultrasound and endoscopy. There are separate parallel
networks of specialists and diagnostic facilities for adults and children which leads to the duplication of
diagnostic facilities at hospitals which also have both adult and paediatric specialists.
The main expansion in primary care in Belarus has been in the workload of primary care doctors,
particularly the need to fulfil a large number of routine annual check-ups, that in many cases has to be
conducted by four to five narrow specialists (oto-rhino-laryngologist, neurologist, surgeon,
ophthalmologist). These check-ups involve extensive paper work and cover large segments of the
population (e.g. all school children twice a year, chronically ill patients, women of reproductive age).
Primary care doctors also are responsible for carrying out annual fluorography screening for
tuberculosis, opportunistic screening (particularly for cancers) and all sick leave authorizations. Primary
health care physicians are salaried – 80-90% of salary, partly dependent on catchment population and
10-50% bonus for selected performance indicators.
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5.2 Estonia
In Estonia, family doctor (FD) is the first contact of a patient and responsible for both prevention and
treatment and, if needed, refers the patient to the appropriate specialist. Family doctors have a limited
gate-keeper role: some specialists can be accessed without a referral. Accessibility time frame criteria
have been established: According to that, an insured person with acute condition should get access to
his/her doctor within the same day and with other cases within 3 working days. PHC is organized
based on practice lists. The size of the practice list is 1600 +/- 400 people, including voluntarily
registered and those, who have been appointed by the county governor based on the permanent place
of living. All people have the right to change their family physician by request and this guarantees
competition between family physicians
Funding of the primary health care is based on the contract between the Family Doctor and the Health
Insurance Fund. The primary health care is free of charge to an insured person. Home visits are an
exception, patient pay a fee. Monthly age-weighted payment per every registered insured patient is paid
according to the calculation twice a year. In addition to in the contract agreed sums, also Quality bonus
system is used.
Quality bonus system was implemented in 2005 and it is voluntary and gives an extra monthly fee (205320 EUR) for a family doctor participating in the system. The main goal have been to promote the
family doctors’ active involvement in disease prevention, to tackle the spread of infectious diseases, to
ensure more effective management of patients with chronic diseases and to motivate family doctors to
provide a broad range of health services to the insured persons. Estonian health Insurance Fond has a
financial database basing on ICD 10 and health services provided by family doctors.
The number of family doctors participating in Quality Bonus system increased from 62% in 2006 to
90% in 2010. Proportion of insured persons who were involved with preventive and follow-up
activities increased for 36% during the period 2006 – 2009. Family doctors who participated in the
project performed more preventive and follow-up activities as compared to those who did not
participate in (for example family nurses’ individual consultations, infant vaccination, management of
diabetes and essential hypertension).The indirect positive impact of the Quality Bonus system is the
improved results of all family doctors (participants as well as non participants) throughout four years.
(Torvand T. 2010)
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Table 1. The Estonian bonus system deals with three domains, presented here.
Prevention
Immunization of the children in FD’s list against has to be at least 90%
Preventive check-up of the children – should be provided according to
the guideline average at least 90 % of the children in the list
Check up of the children before school- 90% coverage from all this age
children in the list
Primary prevention of the CVD (cardiovascular ) risk of all 40-60 year
old patients in the list – 90% of all in this age group during 3 year
Follow-up
of
chronic diseases
the
Patients with hypertension – follow up according the guideline for FDs
Patients with diabetes type 2 (according the guideline)
Patients with myocardial infarction (according to the guideline)
Hypothyreosis (measuring TSH, checking up the medication)
Coverage is calculated each year differently depending what is the average
level in Estonia and adding 10 % more for the next year
Comprehensive care
to stimulate following procedures
Follow-up of pregnancies
Making common gynaecological procedures
Make minor surgery
5.3 Latvia
Latvia has experienced significant declines in numbers of doctors, midwives and nurses, particularly
during the first half of the 1990s. By contrast, numbers of GPs have been continuously increasing, due
to relatively strong support (involving retraining of former primary care internists and paediatricians)
provided to this specialty that forms the basis of family medicine, and which was introduced as a
cornerstone of reforms in the mid-1990s. However Latvia’s inpatient sector till 2009 absorbed high
proportion of overall health care spending. Following data from 2005 - approximately 48% of total
health care spending were spent on in-patient care. This was one of the largest shares of the EU
Member States; only the Republic of Ireland (58% in 1980), Bulgaria (59% in 1995) and Romania (53%
in 2001) account for higher shares of inpatient expenditure (European Observatory. 2008). Financial
shortcuts due to economic crisis served as opportunity in year 2009-2010 to make intensive reforms of
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in-patient services. A number of hospitals have been closed, or received much lower contracting
through Health Payment Centre. Quality of primary health care services became a hot issue in order to
fulfil growing health care needs at the community level. Therefore recent government of Latvia have
ambitious plans to strengthen quality of primary health care using new quality measurement tools and
more advanced payment methods.
Every single PHC practice is regarded as a basic resources allocation unit and are mainly funded based
on age-adjusted capitation of €0.8 per patient per month. Additionally to the capitation fee, practices
getting nurses/assistant allowance, patient fees, fee-for–services payment for specified services, fixed
allocations, bonuses compensation. Average monthly projected income of a GP practice (1600 – 1700
registered patients) is as follows (Health Payment Centre data 2009):
•
Age-adjusted capitation - 36%
•
Nurse/assistant allowance - 21%
•
Fee-for-service specified services - 11%
•
Premiums for quality based indicators – 5 %
•
Fixed allocations and additional payments - 27%
Additionally patients pay patient fee 1.4 EUR per visit in GP practice. The payment for home visits is
not regulated (Miezitis A, 2008).
Quality indicators are approved by the MoH on the annual basis. Depending on the results of the
evaluation undertaken by the Health Payment centre, half of the sum (for activity indicators) may be
paid out monthly and the other half may be paid after a year in accordance with yearly quality
indicators. PHC practices qualify for the monthly bonuses if their activity indicators (appointments per
100 registered patients) fall above the 0.75 minimum of the median calculated monthly for all PHC
practices within the region, in which case they receive 50% of the bonus; and if they satisfy PHC
practice performance assessment criteria (working hours, patient waiting time, information quality) they
receive the remaining 50%. (Latvia HIT 2008).
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Yearly quality indicators involve certain numbers of preventive interventions:
number of registered patients seen during the year (To see 65% population annually of these
registered)
child health check-ups (ages 0 to 7) (at least 90% of registered)
immunizations and vaccinations (90% of these from 3 to 14th vaccinated following plan)
cancer prevention programmes.
diabetes control :
o HbA1c, 60% of patients have got at least two tests per year.
o Micro-albuminuria for Diabetes type II – 60% of patients but (in-patients are excluded.
asthma control:
o Maximum expiration flow – 90 % of patients with asthma long time registered, from 6
year till end
o Teaching inhalator at least 90% of patients
Ambulance visits to hypertension patients – 90% without ambulance calls of these who have
hypertension.
GPs also receive fee-for-service payments for approximately 30 services (for example, strip tests,
streptococcus test, electrocardiograms (ECG), pregnancy monitoring, small surgical procedures, etc.)
and fixed allocations. Among the numerous fixed allocations, the most important are: PHC
nurse/doctor assistant allowance according to number of registered patients. Doctors can choose two
different options to work with one nurse or with two nurses. In case of two nurses doctors getting
higher allowance and also is able to shorten his hours for patients‘ consultation in the office (Lanka I,
2011). There are practice allowances which depend on:
indicator scale-dependent allowances for a number of chronically ill patient visits (from HIT
2008)
density of the population in the catchment area:
o More than 500 inhab/km2 - payment 0/0 LVL/EUR
o 100-499 inhab/km2 - payment 180/256 LVL/EUR
o 20-99 inhab/km2 - payment 300/427 LVL/EUR
o Less than 20 inhab/km2 - payment 480/683 LVL/EUR
distance from practice to emergency post o number of children on the register
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5.4 Lithuania
In Lithuania, Family doctors, after three years of residency, started to be introduced into the primary
health care since 1995. District internists and district paediatricians also have had opportunity to be
retrained into family doctor through discontinuous residency program. Nevertheless, only 70 % of
population are listed to Family doctors. For remaining 30 percent of population primary care is
provided by district internist (for adults) and district paediatricians (for children). In case care is
provided by district internists and district paediatricians, primary health care institution also have to
employ surgeon and gynaecologist (only for adults).
At the end of 2009 primary health care was provided by 1951 family doctors (68 % out of all doctors),
479 district internists (17%) and 447 (15%) district paediatricians. To guarantee wider range of medical
services district internists and paediatricians working in teams with 342 gynaecologists and 218
surgeons.
PHC is generally accepted as the entry point to the health care systems in Lithuania. Family doctors are
gatekeepers and patients need referral to all specialists, with exception of dermato-venaerologist.
Patients have to pay for the visit to secondary health care specialist in case of self referral (i.e. without
referral from primary health care physician).
In Lithuania, implementation of the health care system with private independent contractors was
started in 1999, when EU PHARE project for the support of the PHC reform process announced
competition for family doctors to establish private practices. In year 2008 half of primary health care
institutions were private. Various organisational forms of PHC institutions could be found in Lithuania:
● Primary health care centres
● Family doctor (general practitioner) offices
● Ambulatories
● Medical stations (aid posts)
● Policlinics (PHC and specialists’ care)
Since introduction of new payment scheme from Mandatory Health Insurance in 2007, primary health
care was reimbursed through age adjusted capitation fee. Until 2005 there were used 4 age groups: till 5
year, 5 – 15 year, 16 – 64 year and 65 year and upper. Since 2005 - 7 age groups: till 1 year, 1 – 4 year, 5
– 6 year, 7– 17 year, 18 – 49 year, 50 – 65 year, 65 year and upper.
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Until 2003 t there were 100% age adjusted capitation fee. Incentive payment scheme have been started
to be introduced since 2003. Starting with payment of bonuses (100 Litas=290 Euro) for identification
of first stage of cancer. Following incentive payments for services have been introduced:
Diagnostics of early stages of cancers (2003)
For testing of blood clotting condition (2004): Prothrombin activity test and INR test
Glycosylated hemoglobin test (2005)
Care of pregnant (2005)
Care of children under 1 year (2005)
Care of the disabled (2005)
Imunoprophylaxis of children (2005)
Preventive check -up of schoolchildren (2005)
Nursing at home of chronically ill patients services (2005)
Blood group test, rhesus factor (RH) test, syphilis blood test and HIV antibody test for
pregnant women (2006)
Also paid fee for services for following screening procedures:
Pap smear - for women 25 -60 years once per three years
Mammography - for women 50-65 years once per two years
PSA - for men year 50-75, if risk (family anamnesis) since 45.
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B. Quality indicators for high quality PHC performance
In table 2 is presented quality indicators, for which are paid bonuses. In table 3 quality indicators, which
are monitored without bonus payment.
Table 2. Quality indicators used in Lithuania for bonus payment
Indicator
Numerator
Denominator
Bonus Paula Comments
paid if
Population care coverage
Children care
coverage
Number of children
(under 18) who visited
family doctor at least
once per year
Total number of
listed population
in this age group
90% or I would separate
more preventive services of
treatment of diseases
Adult care
coverage
Number of adults who
visited family doctor at
least once per year 60
Total number of
listed population
in this age group
60% or Thi is not any aim in
more Finland, we want to
keep the population
out of doctors’ offices
Implementation of prevention programmes
Cervical
cancer
prevention
programme
Number of women
participating in this
programme - those who
were informed and got
PAP smear test with
consultation
Total number of
listed women
participated in
this programme
We have a national
and successful
screening
programme. This
might be valid if
programme not exists
Prostate
cancer early
diagnostics
programme
Number of men
participating in this
programme those who
were informed and
checked PSA
Total number of
listed men
participated in
this programme
According to many
studies and recent
information, this is
not valid as a
screening
programme,
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ImPrim Report #2
B. Quality indicators for high quality PHC performance
Table 3. Quality Indicators used for monitoring primary health care performance without
bonus payment
Hospitalization of patients with chronic diseases
Indicator
Numerator
Denominator
Number of hospitalizations due to the
reasons of particular disease during the
reporting cycle
Total number of all listed
patients with this chronic
disease
Arterial hypertension
Diabetes
Asthma
Chronic obstructive
pulmonary disease
(COPD)
The number of specialist consultations provided to patients with chronic diseases
Arterial hypertension
Diabetes
Asthma
Number of consultations concerning to
the cases of particular diseases during
the reporting period
Total number of all listed
patients with this chronic
disease
Chronic obstructive
pulmonary disease
(COPD)
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B. Quality indicators for high quality PHC performance
5.5 Russia (Kaliningrad region)
In Russia, every county has its own Mandatory Health Insurance fund and is able to develop its own
model of purchasing of health care services and to introduce different payment schemes. Since 2007,
out of totally 89 regions 19 pilot regions have been selected where new payment schemes exist or will
be introduced. Five different components of purchasing and payment are piloted and counties can
select how many of these mechanisms they are implementing: (1) capitation based payment with partial
fund-holding; (2) one channel payment (only through Mandatory Health Insurance fund, while other
regions still have payment from budget additionally to the payments from MHI fund; (3) new quality
control system according to developed standards; (4) flexible, special initiative payment schemes are
introduced (up to 30% of salary); (5) salary of administrators not more than 3 times higher than
average.
As an example for other pilot regions a payment scheme based on capitation with partial fund-holding
was introduced in 2005 by Kaliningrad Mandatory Health Insurance. In this pilot funding scheme (until
2008) only PHC physicians who have certificate of family medicine/general practice and have a list of
served population could participate. A contract was made with the head of institution and fee per capita
was revised every month and confirmed by steering committee of MHIF. Fee per capita in 2007 was
around 140 roubles. Institutions have to cover their own expenses (salaries to their staff according to
norms, medicines, other expenses) and to pay for secondary heath care services. Ambulance services,
dispensers of tuberculosis, and oncology were not included in the scheme. Saved amount, so call
"residual profit", could be added to salary fund of the institution, but first a special committee will
evaluate the performance of family doctors. So called "economical sanctions" were used for non-fulfilment
of FD services or for mistakes, e.g.:
 Not full dispensarisation of chronically ill and no proved activity of diabetes, asthma, hypertension
schools ( minus 5% of residual profit)
 Not full provision of prevention activities: fluorography, immunization, health education (minus
5%)
 Ambulance call rate in the district is higher than average (318 calls per 1000 inhabitants annually or
26 calls per 1000 per month in 2007) (minus 5%)
 Late diagnostics of oncologic diseases (for every case minus 10%)
 Late diagnostics of tuberculosis (for every case minus 10%)
 Late hospitalization which caused worsening of patient's status, complications of the disease
(-50% )
 Death due to mistake of family doctor (minus 100%)
 Other, like reasonable complaints of the patients, not qualitative patients' records or bad sanitary
hygiene status in health care institution proved after control of hygienic centre, not fulfilling the
orders of MoH of Russian Federation, MoH of Kaliningrad oblast, chief doctor of Central regional
hospital (minus 5-20%)
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ImPrim Report #2
B. Quality indicators for high quality PHC performance
Withheld money were still kept within the health care institution but could be used only for
improvement of facilities and quality of PHC. A consequence of the new funding scheme was
pronounced increases of salaries of the family doctors who showed better results in their clinical and
preventive activities. The increases for family doctors working in central regional hospitals (in the same
institution as secondary health care specialists) were not equally significant.
5.6 Examples from Nordic countries: Finland, Sweden
Finland has municipally salaried doctors, who will get monthly salary. Currently many different ways of
agreements exist concerning salaries. In the salary, there may be capitation parts, but also part for
procedures performed (e. q. injections to joints, puncture of maxillary sinus, check up for some large
certifications, doing minor surgery, inserting intra-uterine devices etc)
Outcome indicators are used in some primary health care centres, but the quality bonus is usually paid
for the whole primary health care centre, not for individual professionals. These indicators may be
waiting times, electronic communications performed between doctor/nurse and patient, preparing a
suitable abstract of patient records and updating it, mini-interventions performed and recorded for
alcohol abuse or tobacco, group counselling of patients having diabetes and some other chronic
diseases. The quality of care is important, but pay-for-performance system is not generally used.
In Swedish health care, there is a traditional and strong focus on fixed payment to both hospitals and
primary care providers. Pay for performance is already used within Swedish health care, especially
within primary care but to some extent also for hospital services, when the national government
allocates grants to the 21 county councils responsible for health care services (Anell 2009). In general,
all employed doctors have a monthly salary without any components of pay-for-performance. Some of
the counties have started to pay to the primary care units a payment for quality and a percentage as a
payment for availability and number of visits to the primary care unit. This money does not have any
influence on the salary of the doctor.
In Sweden increasing importance has been set to measure the quality of each primary care unit. These
indicators are published on the internet for the patient to compare and for politicians and professionals
to improve the standard of the hospitals and primary care unit.
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B. Quality indicators for high quality PHC performance
5.7 Data collection
Data collection is a critical issue when using performance indicators, and even more critical when they
will be combined with salaries. In best systems, information is collected automatically and electronically
without any extra burden for the professionals, but this is expensive and needs an advanced system.
There are also systems, where it is possible to join in, where e. g. an electronic pop-up screen
concerning e.g. diabetes patients will appear on the screen of a family doctor once a year concerning
every diabetes patient with information collected of the patient records and the doctor cannot pass the
screen without filling in the missing information. This system is voluntary, but very easy for the doctor
to fill in.
It is also possible to measure a cross-section of the level of indicators collecting information during two
weeks time using a special form developed for this issue. As example, data on a form will be collected
concerning all diabetes and cardiovascular patients visiting the primary health care centre during this
time limit annually. When repeated several years, results may be followed and improvement can be
recognised. Also this system has several pros and cons, the result is as reliable as the poorest datacollector is. This is also an extra burden for doctors and nurses, but at the same time it is a powerful
intervention to perform according to what is expected.
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ImPrim Report #2
B. Quality indicators for high quality PHC performance
6. Proposal of recognised quality indicators for measurement
of primary health care professionals´ performance in Belarus,
Estonia, Latvia, and Lithuania
6.1 Why is setting performance based quality indicators important in the Baltic Sea
region?
All the Post-Soviet countries started with the Semashko system but have gone in different directions.
Due to strong traditions of hospital oriented Semashko systems and power of secondary health care
specialists some countries in transition did some steps back from coherent implementation of the PHC
reform. At the same time a global recession has prevailed, and transition time is resources depending
within all the fields of society. There has been rapid changes of PHC organizational forms with very
limited or no comparisons between countries on PHC quality and outcomes
A payment system is perceived as an important part of a wider structure that influences the incentives
and priorities across health care providers. Different understanding of primary health care role,
understanding of what is strong primary care in some countries sometimes is in conflict with
internationally proved characteristics of strong primary health care.
Performance-based quality indicators are a powerful instrument to improve the quality, if they really
measure good quality. The worst case may mean that actual benefits for patients develops to the worse,
while the documented quality at the same time indicate improvements. Health care providers are
rewarded in the belief that improvements are made, in spite of the fact clinical practice develops in the
wrong direction. Examples are when providers avoid complex patients for whom it is more difficult to
reach defined performance targets or if services to patients become dominated by protocols and “boxticking” rather than an interest for the patient’s individual needs (Boyd et al 2005, Anell 2010). Another
example is preventive services and health education activities. Even there are international evidence
that primary health care doctors and nurses could be efficient in healthy behaviour counselling and risk
assessment, often in East Europe countries is met traditional very formal, doctor centred approach in
health education. Many practices disregard health education activities at all, focusing activities of
doctors and nurses merely on diagnostic and treatment activities. In the payment systems, different and
sometimes competing providers got the same payment, irrespective of existing differences in the quality
of services and there are risks also when letting payments stay as they are.
6.2 Proposed indicators to measure PHC performance in Belarus, Estonia, Latvia,
Lithuania (presented in table 4)
6.3 Recommendations
Good quality needs to be assessed from the point of view of structure, process and outcomes. In the
long run, it would be the best to concentrate on outcome measures and patient benefits, rather than
process measures. We, anyhow, considered that performance measure is somewhat different in primary
care than in other parts of health care system.
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B. Quality indicators for high quality PHC performance
1. All the stakeholders should be taken within the development and selection of quality indicators:
patients, health care providers, professionals, financiers and but also decision-makers
(politicians).
2. To propose indicators having evidence will be a difficult and sensitive issue. In this report
proposed indicators should be applied in the national primary health care system, and their
applicability will depend on the phase of development in the PHC in the country concerned. As
an example, Estonia has started with introduction of quality indicators and bonus payment
system much earlier and they have quite developed e-health system. Therefore they ready to use
more quality indicators, than these countries who just start with introduction of quality
indicators and have limited access to the data needed.
3. Gradual implementation would be a good start. The whole package should not be taken in use
at one time, but slow development may be the best. Population health needs with different
priorities in different countries and different regions within the countries should be considered.
4. To provide a general answer to questions about which indicators to choose will be difficult
Following techniques could be used in the selection process: consensus rating procedures,
consensus development workshop, Delphi technique, nominal group technique, RAND
appropriateness method
5. Professionals of all levels of health care, professionals, management and leaders included,
should be trained in quality issues. Training in these issues, especially when provided in a
participatory way, will give commitment and trust in the system. Training sessions also give a
possibility to influence of the coming system and give more commitment. Feedback from the
ground level workers is important.
6. Quite few indicators are applicable, if there does not exist an advanced data collecting system
available. The system should collect the information directly from patient records, national
databases (databases of Patients Funds’ and/or National Health Statistics), ministry of health
and connect the information with the pay for performance system. The family doctor should
not get extra burden of filling in forms for this purpose.
7. Facility exit questionnaires for the patients should be applied to measure essential primary
health care quality aspects, such as accessibility, patient centeredness, holistic approach,
empowerment of the patients for self-care and patient satisfaction.
8. In east Europe countries it is of particular importance to balance quality improvement systems
from “top-down” external quality improvement methods, more toward internal “bottom-up”
approaches. Attitudes of doctors and nurses should be developed so, that they themselves use
other types of quality improvement tools, such as self-assessment with special tools and peer
review groups (e.g. APO audit method). The use of these methods should also be financially
rewarded. Using these other methods many aspects of family doctors work could be possible to
assess, such as comprehensiveness, generalism, holism, continuity of care and patientcenteredness, which are not all measurable with technical figures.
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1. INDICATORS FOR THE
STRUCTURE
Number of family doctors
(after residency) per 10000
population
Average number of population
listed per one PHC physician
1.
1.1.
1.2.
eu.baltic.net
Indicator
No.
Yes
Yes
No
No
Us as an
indicator for
pay for
Yes/no/maybe performance
Use as an
indicator
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Number of
primary health care physicians
(family doctors and/or district
internists and district
Numerator: Inhabitants
Denominator: inhabitants
Numerator: Number of family
doctors x 10 000
Numerator and denominator
Should be collected
information on possible
variations in profiles:
For physicians:
Regional health
administration
Density of population should
be considered
Relevant to be used for
comparison between
countries
Separate urban / rural
(evidence/relevance for
primary care/ example of
countries where it is used)
Comments
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Data sources
Table 4. Proposed quality indicators to measure PHC performance in Lithuania, Latvia, Estonia and Belarus
Total nurses working in
primary health care per 10000
inhabitants
1.4.
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Family medicine (community)
nurses (after special training in
family medicine and/or
community nursing) per 10000
inhabitants
1.3.
Denominator: Inhabitants
Yes
Yes
No
Maybe to pay
bonus for PHC
institution (not
for individual
professionals
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Numerator: Number of nurses
working in primary care X10000
Denominator: Inhabitants
Numerator: Number of nurses
with special primary health care
specialisation x 10000
paediatricians)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
(Belarus)
Auxiliary staff should be
counted as well
Relevant to be used for
comparison between
countries
Maybe additional indicator for
nurses per one FD
3. Private without contract with
National Health Insurance
2. Private in depended
contractors
1. Governmental/municipal
For practice:
3. District paediatrician
2. District internist
1. Family doctor
Density of population around
PHC practice
Geographic accessibility of
primary health care institutions
1.6.
1.7.
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Clinical guidelines for
management of chronic
diseases exist
1.5.
Yes
Yes
No
Part-financed by the European Union
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and European Neighbourhood and
Partnership Instrument)
Geometrical modelling
methodology for the quantitative
determination of the ratios
between the total zone area of
the accessible primary healthcare
institutions and the area of the
respective territory.
Numerator: Number of
inhabitants around PHC
institution
/
Denominator: area (m2 ) served
populations living
Number of chronic conditions
Yes
for which available clinical
guidelines are developed with the
focus on primary health care role
(doctor-nurse-patient)
Special geometrical
modelling research
methodology should
be used (Peciura et al.
2006)
Data from PHC
practice profile
Data available from
MoH and/or
professional
associations of PHC
professionals
Could be difficult to measure,
but would be good for
comparison between countries
and within country for more
equal distribution of PHC
Used in Latvia for practice
allowance
Relevant to be used for
comparison between
countries
Guidelines have to be
developed by PHC doctors and
nurses together with other
experts. They should describe
the seamless chain of treatment
from PHC to secondary care,
but the starting point of PHC.
Role of patient for selfmanagement and role of PHC
nurse particularly should be
emphasized
Official patients fee for the
visits to PHC doctors
Official patients fee for home
visits
INDICATORS FOR THE
PROCESS
Indicators for patients’ visits
1.9.
1.10.
2.
2.1.
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Longest distance to PHC
institution
1.8.
Fee in national currency
(transferred in Euro)
Fee in national currency
(transferred in Euro)
Yes
Yes
Disputable
No
No
Maybe to pay
practice
allowance
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Distance to the most removed
inhabitants listed to km
Regional health
administration(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Data from PHC
practice profile
Relevant to be used for
comparison between countries
Relevant to be used for
comparison between countries
Important indicator for
accessibility and for PHC
development plans to consider
more equal distribution of
practices
Percentage of adult population
seen by family doctors and/or
nurse per year
2.1.2.
eu.baltic.net
Percentage of adult population
seen by their family physician
per year
2.1.1.
Denominator: Total adult
population in the list
Yes
Yes
No
Mo
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Numerator: Number of adults
seen by family doctor and/or
nurse
Denominator: Total number of
inhabitants
Numerator: Number of
inhabitants who at least once
visited doctor annually
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Contra: we have to foster selfcare
Regional health
administration (
Belarus)
Better than previous, because
we have also nurse, but same
problems as in the previous
paragraph may concern.
This may be relatively easy to
manipulate by the
professionals. It is not an aim
to get all the people to visit
doctors, more important is to
invite those whose visit will
give the highest health
outcome! Relevant to be used
for comparison between
countries.
Indicator is used in Latvia,
Lithuania: (paid bonus if 65%
population seen)
Data from Health
Insurance (Estonia,,
Latvia, , Lithuania)
Percentage of adult population
visiting secondary health care
specialist at least once per year
7-17 years children r and/or
nurse
Percentage of children
population seen by their family
doctor and/or nurse Children
below 7 years
7-17 years
below 7 years
Age categories:
Percentage of children
population seen by their family
doctor per year
eu.baltic.net
2.1.5.
2.1.4.
2.1.3.
Yes
Yes
Yes
No
Yes for
prevention
Yes for
prevention
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Total number of
inhabitants
Numerator: Number of
inhabitants who at least once
visited secondary health care
specialists annually
Denominator: Total number of
children
Numerator: Number of children
who at least once visited PHC
doctor or nurse annually
Denominator: Total number of
children
Numerator: Number of children
who at least once visited PHC
doctor annually
Could be applied for
measurement between practices
Regional health
administration
(Belarus)
Visits for ultrasound
examinations, X-ray should be
To see balance between visits
to PHC and visits to secondary
health care
Only preventive check-up
according to the program could
give bonus
Only preventive check-up
according to the program could
give bonus.
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Rate of the visits to primary
health care physicians per one
inhabitant
2.1.7.
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Population in age categories
Proportion of visits to primary
health care from total visits
2.1.6.
Yes
Yes
No
no
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: population (total
and in age categories
Numerator: Number of visits to
primary health care visits (total
and in age cathegories)
Denominator: Total number of
doctor visits
Numerator: Number of visits to
the primary health care doctor
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Relevant to be used for
comparison between
countries
Maybe also separately
adults/children
Should be in two categories :
preventive and for diseases
Relevant to be used for
comparison between
countries
Maybe also could be applied to
compare between practices
Relevant to be used for
comparison between
countries
Adjustment for co morbidity
should be made (patients with
chronic conditions should visit
specialists more often)
omitted
Indicators for accessibility
Waiting time to see doctor if
non-urgent
2.2.
2.3.
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Rate of the visits to secondary
health care physicians per one
inhabitant
2.1.8.
Yes
Yes
Maybe
No
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Answers of the patients to the
question about waiting time
Denominator: Population
Numerator: Number of visits to
secondary health care physician
Facility exit study
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Relevant to be used for
comparison between
Facility exit study will give
opportunity to clarify issues
regarding accessibility, how
were addressed lifestyle issues,
patient involvement, holistic
approach cooperation with
other sectors
Latvia planned national survey
to get data about accessibility.
Relevant to be used for
comparison between
countries
Maybe also could be applied to
compare between practices
INIDCATORS FOR
CLINICAL MANAGEMENT
% of women age 50-60
screened for breast cancer at
least once per three years
3.
3.1.
eu.baltic.net
Waiting time to see doctor if
urgent
2.4.
Yes
Yes
Facility exit study
Regional health
administration
(Belarus)
Maybe, if level of Data from Health
women screened Insurance (Estonia,
is very low
Latvia, Lithuania)
Maybe
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Total women
population age 50-60 in the list
Numerator: Number of women
age 50-60 screened for breast
cancer
Answers of the patients to the
question about waiting time
In Finland the invitation comes
from national register to agreed
age groups, family doctors are
not doing anything with the
invitation.
Screening ethics should be
considered when inviting or
referring patients for screening,
particularly regarding possible
negative effects of screening
for false negative and positive
cases.
Relevant to be used for
comparison between
% of vaccinated against
influenza at age over 65 with
risk conditions
% of vaccinated with
pneumococcal vaccine at age
over 65 with risk conditions
3.3.
3.4.
eu.baltic.net
% of women screened for
cervical cancer at age 25-65 at
least once per three years
3.2.
Yes
Yes
Yes
Data from Health
Finland uses interval of five
Insurance (Est, Latvia, years
Lithuania)
The same remarks concerning
Regional health
ethics as above for breast
administration
cancer screening
(Belarus)
No
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Data from Health
Insurance (Estonia,
(not prioritized Latvia, Lithuania)
as a first level
pay for
Regional health
performance
administration
indicator)
(Belarus)
Yes
Yes
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Total population
over 65 with risk conditions
Numerator: Number of
vaccinated with pneumococcal
vaccine over 65 with risk
conditions
Denominator: Total population
over 65 with risk conditions
Numerator: Number of
vaccinated over 65 with risk
conditions
Denominator: Total women
population age 25-65 in the list
Numerator: Number of women
age 25-65 screened for cervical
cancer
Children and schoolchildren
preventive check-ups, smoking
status of parents recorded
Schoolchildren preventive
check-ups, smoking status of
school pupils recorded
3.6.
3.7.
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% of vaccinated children
according to agreed vaccine
calendar
3.5.
Yes
Maybe
Maybe
Yes
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Total children and
schoolchildren
Numerator: Children and
Yes
schoolchildren, smoking status of
school pupils recorded
Denominator: Total children and
schoolchildren
Numerator: Children and
Yes
schoolchildren, smoking status of
parents recorded
Denominator: Total population
over 65 with risk conditions
Numerator: Number of
vaccinated against influenza over
65 with risk conditions
External audit of
records of preventive
check-ups, if data is
not collected to
centralized database
Would stimulate to address
smoking of schoolchildren
Important, but could be
optional indicator if possible to
get relevant data
Would stimulate to address
smoking in the community
External audit of
Important, but could be
records of preventive optional indicator if possible to
check-ups, if data is get relevant data
not collected to
centralized database
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Schoolchildren preventive
check-ups, BMI during every
check-up recorded
% of population with diagnosis
of AH
3.9.
3.10.
eu.baltic.net
Schoolchildren preventive
check-ups, relation to alcohol
and drugs discussed and
recorded
3.8.
Yes
Yes
Yes
No
Yes
Yes
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Total population
Numerator: Population with
diagnosis of AH
Denominator: Total children and
schoolchildren
Numerator: Children and
schoolchildren, BMI during
every check-up recorded
Denominator: Total children and
schoolchildren
Numerator: Children and
schoolchildren, relation to
alcohol and drugs discussed and
recorded
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Would stimulate to address
risky behaviour
External audit of
Important, but could be
records of preventive optional indicator if possible to
check-ups, if data is get relevant data
not collected to
centralized database
Would stimulate to address
risky behaviour
External audit of
Important, but could be
records of preventive optional indicator if possible to
check-ups, if data is get relevant data
not collected to
centralized database
The percentage of people
diagnosed with hypertension,
who have got lifestyle advice in
the last 12 months for:
increasing physical activity,
smoking cessation, safe
alcohol consumption and
healthy diet.
% of these with diagnosis
ischemic heart disease,
and/or diabetes have recorded
BP in last year
3.12.
3.13.
eu.baltic.net
% of population who are
current smokers and have
received advice on stopping
smoking or nicotine
replacement therapy during
last year.
3.11.
Yes
Maybe
Yes
Yes
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Total population
with diagnosis ischemic heart
disease, and/or diabetes
Numerator: Population with
diagnosis ischemic heart disease,
and/or diabetes have recorded
BP in last year
Denominator: Total population
with diagnosed hypertension
Numerator: Population with
Yes
diagnosis of AH who have got
lifestyle advice in the last 12
months for increasing physical
activity, smoking cessation, safe
alcohol consumption and healthy
diet.
Denominator: Total smokers
(study population)
Numerator: Number of current Yes
smokers and have received advice
on stopping smoking or nicotine
replacement therapy during last
year
This is a powerful intervention
This is important as this
indicator listed is a powerful
intervention for the daily work.
It has to be recorded as other
life style factors (alcohol, diet,
physical activity etc)
How to get relevant data?–
proposal facility exit study
External audit of
Other chronic diseases may be
records of preventive taken within later
check-ups, if data is
not collected to
centralized database
Facility exit
questionnaire
Facility exit
questionnaire
% of those with diagnosis of
Ischemic heart disease and/or
diabetes who are current
smokers who have received
advice on stopping smoking
and/or nicotine replacement
therapy during last year
3.15.
eu.baltic.net
% of those with diagnosis of
Ischemic heart disease and/or
diabetes whose smoking status
recorded during last year
3.14.
Yes
Yes
Yes
Yes
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Total population
with diagnosis ischemic heart
disease, and/or diabetes who are
current smokers
Numerator: Population with
diagnosis ischemic heart disease,
and/or diabetes who are current
smokers who have received
advice on stopping smoking
and/or nicotine replacement
therapy during last year
Denominator: Total population
with diagnosis ischemic heart
disease, and/or diabetes
Numerator: Population with
diagnosis of ischemic heart
disease, and/or diabetes whose
smoking status recorded during
last year
Facility exit
questionnaire
Facility exit
questionnaire
Other chronic diseases may be
taken within later
Proportion of the diabetic
patients whose HbA1C has
been measured during last
year.
3.17.
eu.baltic.net
Management of patients with
diagnosed tuberculosis
3.16.
Denominator: all diabetes
patients
Yes
Yes
Yes
Maybe not
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Numerator: All diabetes patients
for whom HbA1C is measured
during the last year
Denominator: Total number of
registered patients with
confirmed Tuberculosis, in
reporting period
Numerator: Number of patients
with confirmed tuberculosis
subjected to treatment according
to DOTS standard, in reporting
period x100
Practice data on
diabetes patients
monitoring, if data is
not collected to
centralized database
Data on monitoring
patients with
tuberculosis should be
available
Even often is a case (Latvia,
Lithuania) that general
practitioners do not
responsible for prescription of
medicines for tuberculosis, still
strong primary care team
should guarantee proper
cooperation with specialists and
with social workers and to
motivate patients to get
treatment
(8) whose mouth has been
examined during last year
(teeth, gums)
(6) Retinal photography have
been made during last three
years
(5) eyes (visus) have been
examined within the last year
(4) renal function has been
tested within last year (U Alb,
U alb/krea, GFR or krea)
(3) feet have been examined
and result recorded during last
year
(2) body mass index or waist
measurement been recorded
last year
(1) LDL-cholesterol measured
during last year
Proportion of diabetes
patients to whom during last
year have been performed 90%
of tests recommended in
respective guidelines:
eu.baltic.net
3.18.
Yes
Yes
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: all diabetes
patients in practice register during
one year
Numerator: All diabetes patients
for whom have been performed
during last year 90% of tests
recommended in respective
guidelines
Practice data on
diabetes patients
monitoring, if data is
not collected to
centralized database
Emergency hospitalization of
diabetes
3.21.
eu.baltic.net
Emergency hospitalizations for
asthma
Reasonable level:
<40% and of this
>80% ought to be
Penicillin V
Reasonable level:
<40% and of this
>80% ought to be
Penicillin V
Proportion of Acute RTI
treated with antibiotics
3.20.
3.19.
Yes
Yes
No
No
Yes, as optional No
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: all diabetes
patients, registered during one
year (prevalence)
Numerator: Cases of
hospitalization for diabetes
emergency conditions patients
during one year
Denominator: all asthma patients,
registered during one year
(prevalence)
Numerator: Cases of
hospitalization for status
asthmatic and/or for severe
exacerbation of asthma during
one year
Denominator: cases of RTI
registered during one year
Numerator: Number of cases of
RTI for which antibiotics
prescribed during one year
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Still we have to note that the
more technical equipment
available, the more new
examinations available, the
more old age people, the more
visits to hospital as an outcome
Data about
Good indicators, important for
compensated
more rational antibiotic use.
medicines reimbursed
from Health Insurance In Lithuania possible to collect
(Lithuania, Estonia?) responsible in Lithuania to
collect for children, but not
Belarus, Latvia?
possible at all to collect in
Latvia
Rate of ambulance calls per
1000 population
Percentage of population
referred/self-referred to the
secondary health care
specialists
3.23.
3.24.
eu.baltic.net
Emergency hospitalization for
hypertension
3.22.
Yes
Yes
No
No
Maybe
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: Population served
Numerator: Number of primary
visits to the secondary health care
Denominator: Population
Numerator: Number of ambulance Yes
calls per year x1000
Denominator: all hypertensive
patients, registered during one
year (prevalence)
Numerator: Cases of
hospitalization for hypertension
emergency conditions during
one year
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Regional health
administration
(Belarus)
Data from Health
Insurance (Estonia,
Latvia, Lithuania)
Yes, important for comparison
between the countries and also
between the practices
Evidence from Russia and
Lithuania: Up to 50% decrease
when stronger PHC (Jurgutis
2002)
(6) smoking status of parents
recorded
(5) blood glucose measured
(4) BMI of a gravid woman
during the first visit to FD
measured
(3)number of visits to
gynaecologist of normal
pregnancy is between 2 and 4.
(2)number of visits to nurse or
midwife during pregnancy not
less than 9
(1)number of visits to family
doctor during pregnancy not
less than 6
Percentage of pregnant
women, who received 90% of
necessary management
procedures (following evidence
based
recommendations/national
guidelines)
eu.baltic.net
3.25.
Yes
Yes
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: all pregnant women
registered in the practice during one
year
Numerator: Pregnant women who
have received 90% of necessary
procedures and/or interventions
(following evidence based
recommendations/guidelines)
Practice data of
List should be adapted
records on
according to national
management of
guidelines.
pregnant women, if
data is not collected to
centralized database
The rate of stillbirths
eu.baltic.net
3.26.
(9) all laboratory tests are
made following guidelines
(8) Father checked for
tuberculosis
(7) Father (if registered) have
been with the pregnant woman
during the visits to midwife or
FD
(7) risk for alcohol
consumption have been
recorded
Yes
Maybe
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: all pregnant women
registered in the practice during one
year
Numerator: Number of stillbirth
Percentage of women who
were breastfeeding their
newborns 6 months or more
Maybe
Maybe
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
Denominator: number of newborns
survived more than half year
Numerator: Number of women who Yes
were breastfeeding their newborns 6
months or more
Denominator: all pregnant women
registered in the practice during one
year
Rate of women with pregnancy Numerator: Number of women with Yes
and delivery without
pregnancy and delivery without
complications
complications
eu.baltic.net
3.28.
3.27
Practice data of
records on
management of
pregnant women, if
data is not collected to
centralized database
Practice data of
records on
management of
pregnant women, if
data is not collected to
centralized database
ImPrim Report #2
B. Quality indicators for high quality PHC performance
7. References
Anell A. Värden i vården – en ESO-rapport om målbaserad ersättning i hälso- och sjukvården. Rapport
till Expertgruppen för studier i offentlig ekonomi. Finansdepartementet. Regeringskansliet 2010:7
English summary. (Anell A. Values in care- an ESO- report of goal-oriented reimbursement in health
and social care. A report for an expert group in studies of public economy. Financial department,
Government Offices of Sweden 2010:7, English summary).
Atun RA, Menabde N, Saluvere K, Jesse M, Habicht J. Introducing a complex health innovation-primary health care reforms in Estonia (multi-method evaluation). Health Policy. 2006 Nov;79(1):7991. Epub 2006 Jan 6.
Boerma WGW. Profiles of general practice in Europe. An international study of variation in the task of
general practitioners, NIVEL, 2005.
Boyd CM. et al Clinical Practice Guidelines and Quality of Care for Older Patients with Multiple
Comorbid Diseases. Implications for Pay for Performance. JAMA 2005; 294 (6):716-724.
Health Care in Transition, Latvia. European Observatory on Health Care Systems. 2008.
Gillam S. Is the Declaration of Alma Ata still relevant to primary health care. BMJ 2008;336:536-538.
Gilliam S, Siriwardena AN. The Quality Outcomes Framework – transforming general practice.
Radclife Publishing Ltd. UK. 2009.
Grouev A-M, Titkov D. Development of Quality Improvement of Primary Care in St. Petersburg
2007-2009. Final report 12.2. 2010, Terveyden ja hyvinvoinnin laitos (THL), 2010, www.thl.fi
Jurgutis A, Rusovich V, Dotsenko M. (eds). Primary Health Care in the Northern Dimension
Countries. Thematic Report of the NDPHS Expert Group on Primary Health Care. NDPHS Series
No. 4/2008.
Jurgutis A. The evaluation of the efficiency of the model of primary health care center. PhD thesis.
Kaunas 2002
Lanka I. Quality evaluation of Primary Health Care. Factors what affect it. Presentation. Imprim WP3
Workshop “Instruments for Improving the Financial Provisions for PHC”. Riga, February 2011.
Macinko J, Starfield B, Shi L. The contribution of primary care systems to health outcomes within
Organization for Economic Cooperation and Development (OECD) countries, 1970-1998. Health
Serv Res 2003; 38(3):831-865.
Mattke S., Kelley E.,, Scherer P.,Hurst J., Lapetra M.L.G. Health care quality indicators project. Initial
indicators report. OECD health working papers. 2006.
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and European Neighbourhood and
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ImPrim Report #2
B. Quality indicators for high quality PHC performance
Meizitis A. Introduction of GP institution in Latvia. Presentation. Meeting of the Primary Health Care
Expert Group of the NDPHS, Kaliningrad. March 2009.
Munck A., Damstaarg J, Hansen DG., Bjerrum L, Sondergaard J., The Nordic Method for quality
improvement in general practice. Qual Prim Care 2003. 1:73-78.
Mäkelä M, Booth B, Roberts R (eds). Family Doctors´ journey to quality. Stakes 2001.
Peciura R., Jankauskiene D, Gurevicius R. The search for the criteria in reforming health care:
evaluation of the spatial accessibility of primary healthcare service (Lithuania ). Medicina. 2006; 42(11)
Peter C. et al. (eds). Performance Measurement for Health Systems Improvement. WHO. 2009. p. 371405
Starfield, B. Primary Care. Balancing Health Needs, Services, and Technology. New York/Oxford:
Oxford University Press. 1998.
Starfield B., Shi L., Macinko J. Contribution of Primary Care to Health Systems and Health. Milbank
Quarterly. Volume 83, Issue 3, pages 457–502, September 2005.
Strandberg E-L. Developing General Practice: The role of the APO Method. PhD thesis. Lund
university. 2008.
Torvand T. Financing of primary health care and quality bonus system in Estonia Presentation during
Workshop of WP 3. Instruments for Improving the Financial Provisions for PHC, December 13, 2010,
Centre of Health Economics, Riga, Latvia
WHO. Declaration of Alma-Ata. http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf
International Conference on Primary Health Care, Alma-Ata, USSR, 6-12 September 1978
WHO Europe. Framework for Professional and Administrative Development of General
Practice/Family Medicine in Europe, Copenhagen, 1998
WONCA Europe. The European definition of general practice/family medicine. 2005.
http://www.woncaeurope.org/Definition%20GP-FM.htm
WONCA World. World organisation of Family Doctors: The Role of General Practitioner/Family
Physician in Health Care systems WONCA 1991.
Øvretveit, J. Health Service Quality. An Introduction to Quality Methods for Health Services. Oxford:
Blackwell Science Ltd. 1992.
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Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
ImPrim Report #3
C. Pilot projects on quality indicators in Lithuania and Latvia
ImPrim Work Package 3:
Instruments for improving the financial provisions for Primary Health Care
Report # 3
Pilot projects carried out in Lithuania and Latvia
Quality indicators for high quality
PHC performance
Editor
Arnoldas Jurgutis
Authors
Arnoldas Jurgutis , Arvydas Martinkenas , Laura Kubiliute , Vaida Jukneviciute1
Aigars Miezitis2, Jens Wilkens3,
1
1
1
Public Health department,Faculty of Health Sciences, Klaipeda University,
Lithuania
2
National Health Service, Riga, Latvia
3
Blekinge Competence Centre, Blekinge County, Sweden
1
eu.baltic.net
Part-financed by the European Union
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and European Neighbourhood and
Partnership Instrument)
1
ImPrim Report #3
C. Pilot projects on quality indicators in Lithuania and Latvia
eu.baltic.net
2
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
ImPrim Report #3
C. Pilot projects on quality indicators in Lithuania and Latvia
CONTENT
Acknowledgement ............................................................................................................... 4
Abbreviation ......................................................................................................................... 5
Abstract................................................................................................................................ 6
1. INTRODUCTION ............................................................................................................. 8
2. PILOTING OF NEW PRIMARY HEALTH CARE PERFORMANCE INDICATORS:
LATVIA AND LITHUANIA .................................................................................................. 10
2.1. Pilot in Latvia .............................................................................................................. 10
2.1.1. Review of primary care improvement system in Latvia ......................................... 10
2.1.2. Implementation of Pilot project in Latvia ............................................................ 11
2.2. Pilot in Klaipeda region, Lithuania ........................................................................ 13
2.2.1. Review of primary care quality improvement system in Lithuania ..................... 13
2.2.2. . Selection process of quality indicators to be piloted (the Delphi method) ........ 16
2.2.3. Advanced care of patients with NCDs through introduction of consultation and
motivational counselling of patients by nurses ............................................................ 18
2.2.4. Monitoring of consumption of secondary health care services and adjustment for
co-morbidity .................................................................................................................... 23
CONCLUSIONS AND RECOMMENDATIONS .................................................................. 38
ANNEXES.......................................................................................................................... 39
REFERENCES .................................................................................................................. 55
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Part-financed by the European Union
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C. Pilot projects on quality indicators in Lithuania and Latvia
Acknowledgement
The ImPrim project is one of the flagship projects included in the EU Strategy for the Baltic Sea
Region Action Plan. Originally initiated by the Primary Health Care Expert Group of the Northern
Dimension Partnership in Public Health and Social Wellbeing (NDPHS), it is mainly sponsored by the
EU Baltic Sea Region Program.
The project is a three year collaboration involving 13 partners (comprising leading health care
institutions) from Belarus, Estonia, Finland, Latvia, Lithuania and Sweden.
The overall objective is to improve public health (especially in the eastern part of the BSR). Within this
broad field, the project is focussed on the role of primary health care and its benefits for the public
health as well as the regional competitiveness. The specific objective of this report is to report the
process of selection and piloting of new PHC quality indicators in Klaipeda region, Lithuania.
Valuable contribution to the pilot and this report has been provided by the administration and experts
of Klaipeda Regional Sickfund. Authors would like to thank researchers Chad Abrams and Steve Sutch,
Johns Hopkins Bloomberg School of Public Health for valuable collaboration on application the tools
for measurement of comorbidity.
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4
Part-financed by the European Union
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and European Neighbourhood and
Partnership Instrument)
ImPrim Report #3
C. Pilot projects on quality indicators in Lithuania and Latvia
Abbreviation
ACG
BSR
CMI
ECG
GP
HIV
LLC
MoH
ND
NHPD
PHC
RH
RTI
RUB
QBS
WHO
WP
WONCA
eu.baltic.net
Adjusted Clinical Groups
Baltic Sea Region
Case-Mix-Index
Electrocardiogram
General Practitioner
Human Immunodeficiency Virus
Limited Liability Company
Ministry of Health
Northern Dimension
Northern Dimension Partnership in Public Health and Social Well-being
Primary Health Care
Resus factor
Respiratory Tract Infections
Resource Utilisation Bands
Quality Bonus System
World Health Organization
Work Package
World Organization of National Colleges, Academies and Academic
Associations of General Practitioners/Family Physicians
Part-financed by the European Union
(European Regional Development Fund
and European Neighbourhood and
Partnership Instrument)
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ImPrim Report #3
C. Pilot projects on quality indicators in Lithuania and Latvia
Abstract
Quality improvement of primary health care is the topic requiring attention from all stakeholders
throughout all Baltic Sea Region (BSR) countries. There is strong scientific evidence that health systems
with better quality of PHC have better health outcomes, more equity and lower costs. Efforts to
improve the quality of care through development of quality indicators and pay-for-performance
systems become very actual in recent years. Development of quality indicators and more advanced
payment schemes for high quality PHC performance in BSR is one of the most important ImPrim
project1 targets.
Objective of this document is to report the process of selection and piloting of new PHC quality
indicators in Klaipeda region, Lithuania. Proposal document Operational System of Evidence Based and
Widely Recognised Quality Indicators for PHC performance Initial proposal of 30 quality indicators for PHC
performance have been selected based on the proposal document Operational System of Evidence Based and
Widely Recognised Quality Indicators for PHC performance, developed by Imprim project team (Jurgutis,
Vainiomäki, 2011).
The qualitative Delphi method was used for selection process of quality indicators. Experts for the
Delphi study were selected from different local and national stakeholders. The Delphi method
consisted of two rounds. Workshops with various stakeholders have been used to select final
indicators. Representatives of primary health care institutions considered as most important group of
stakeholders. Finally it was agreed to pilot new indicators for monitoring:
Finally it was agreed that there will be piloted indicators to measure following:
1. Advance care of patients with NCDs through provision by nurses services on consultationmotivational counselling of patients with NCDs. As an obstacle - in Lithuania was no
approved methodology for in depended consultation of nurses in primary health care, with
exception of consultation for diabetes patients – approved consultation by nurses, which
was funded through fee for service payment.
2. Avoidable hospitalization of patients with chronic conditions: rates of emergency
hospitalization of asthma, diabetes and hypertension;
3. Consumption of outpatient secondary health care specialists;
4. Prescription of antibiotics for children respiratory tract infections.
1
ImPrim – Improvement of public health by promotion of equitably distributed high quality primary health care systems
Part-financed by the European Union
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(European Regional Development Fund
and European Neighbourhood and
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ImPrim Report #3
C. Pilot projects on quality indicators in Lithuania and Latvia
Consulting and motivation services for NCD patients have been piloted in two PHC institutions in
Klaipeda region by four consulting nurses. The target group were patients with ischemic heart disease,
arterial hypertension, bronchial asthma and chronic obstructive pulmonary disease. Community nurses
training on motivational counselling and chronic disease management was very useful for nurses’
professional development. Gained skills nurses applied in their daily practice and got practical
motivational counselling experience. Positive patients’ evaluation showed high demand of such services
in PHC settings. However, the period of the project was too short to evaluate long-term effect of
consultation and motivation services on NCD patients’ health and significant changes in health
behaviour.
Monitoring of secondary health care consumption (visits to secondary health care level and
hospitalization rates for arterial hypertension, diabetes and asthma) showed existing inequalities in PHC
clinics in Klaipeda region. The consumption of higher health care levels is associated with higher comorbidity. Monitoring of hospitalizations showed high rate of undiagnosed conditions in PHC clinics.
The prevalence of arterial hypertension varied from 8.66% to 30.22% in different PHC clinics. Rate of
hospitalization for arterial hypertension varied from 0.58 to 8.33 per 100 inhabitants.
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C. Pilot projects on quality indicators in Lithuania and Latvia
1. INTRODUCTION
There are evidences that health systems with better PHC have better health outcomes, more equity and
overall lower health care costs. The critical need of primary health care quality improvement is highly
discussed today. Quality of primary health care varies between and within the countries. Good PHC is
comprehensive, manages simultaneously acute and chronic health problems and includes health
promotion and prevention strategies. To indicate recent public health challenges now even more actual
are essential competences of primary health care professionals, like patient centeredness,
comprehensiveness, holistic approach, coordination of care and teamwork (more: Report on Strategy
for continuous professional development of Primary Health Care professionals in order to better
response to changing health needs of the society. Editors: Arnoldas Jurgutis, Paula Vainiomäki)
The indicators for primary health implementation have been adopted in various Baltic Sea Region
countries. It is highly important to select and use quality indicators that are valid, measurable, accepted,
not easily manipulated and equal for describing relevant features of care.
The ImPrim project (“Improvement of public health by promoting of equitably distributed high quality
Primary health care systems”) contributes to the cooperation action “Fight health inequalities through
the improvement of primary health care” and is one of the flagship projects included in the EU strategy
for the Baltic Sea Region Action Plan. One of the project’s work packages WP3 Instruments for Improving
the Financial Provisions for PHC aims to identify, pilot and propose how to improve the allocation of
financial resources to PHC. This work package as one of expected results promotes the use of
recognized quality indicators for PHC performance in countries of BSR and included pilots in Latvia,
Lithuania (Klaipeda region) and Belarus (Gomel region)
Proposal document Operational System of Evidence Based and Widely Recognised Quality Indicators for PHC
performance (Jurgutis, Vainiomäki, 2011) was developed under the leadership of Klaipeda University in
order to make overview of performance indicators used in respective BSR countries and to make an
initial proposal of operational system of evidence based and widely recognized quality indicators for
PHC performance. The proposal document reviews primary health care systems and its improvement
in Latvia, Lithuania and other BSR countries before the pilot implementation.
Proposed quality indicators have been discussed with national and local stakeholders in Latvia,
Lithuania and Belarus. High interest to review system of PHC quality assurance and payment systems
has been demonstrated by Latvian national stakeholders. ImPrim project partner National Health
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ImPrim Report #3
C. Pilot projects on quality indicators in Lithuania and Latvia
Service of Latvia (previous Centre of Health Economics) coordinated WP3 activities and organised a
set of international workshops in Riga to discuss PHC quality assurance and payment methods.
Workshops on quality indicators also took place in Belarus - Gomel (October 2010), Minsk (April
2011) and Klaipeda (September 2011, December 2011, February 2012).
Proposal document of quality indicators also have been discussed with Expert Group of Primary
Health Care and Prison Health Care Systems of the Northern Dimension Partnership in Public Health
and Social Wellbeing during the EG Meeting in Oslo, March 2011 and in Moscow, September 2011.
Comprehensive quality bonus system with incentive payments has been introduced in Latvia. Results of
this pilot were presented in the WP3 report, developed under the leadership by Aigars Miezitis,
National Health Service, Latvia:
Incentive payments for high quality PHC performance - Towards disease
prevention and health promotion in the community. Set of transnational conclusions for providing cost effective financial
incentives within the remuneration schemes.
Objective of this report is to present process of the selection of new PHC quality indicators to be
piloted in Klaipeda region and to present interim results of the pilot. Pilot in Klaipeda region have been
launched in April 2012 and will continue after the end of the project. Some data on indicators to
measure consumption of services of higher health care levels have been collected retrospectively.
Nevertheless period of the pilot was too short to make final evaluation and to make comprehensive
conclusions and recommendations for all piloted indicators.
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2. PILOTING OF NEW PRIMARY HEALTH CARE PERFORMANCE INDICATORS:
LATVIA AND LITHUANIA
2.1. Pilot in Latvia
2.1.1. Review of primary care improvement system in Latvia
Latvia in 2010 had ambitious plans to strengthen quality of primary health care using new quality
measurement tools and more advanced payment methods. Every single PHC practice is regarded as a
basic resources allocation unit and mainly was funded based on age-adjusted capitation of €0.8 per
patient per month. Additionally to the capitation fee, practices getting nurses/assistant allowance,
patient fees, fee-for–services payment for specified services, fixed allocations and bonuses were
compensated. Average monthly projected income of a GP practice (1600 – 1700 registered patients)
was as follows (Health Payment Centre data 2009):
•
Age-adjusted capitation - 36%
•
Nurse/assistant allowance - 21%
•
Fee-for-service specified services - 11%
•
Premiums for quality based indicators – 5 %
•
Fixed allocations and additional payments - 27%
Quality indicators were approved by the MoH on the annual basis. Depending on the results of the
evaluation undertaken by the Health Payment centre, half of the sum (for activity indicators) could be
paid out monthly and the other half could be paid after a year in accordance with yearly quality
indicators. PHC practices qualify for the monthly bonuses: if their activity indicators (appointments per
100 registered patients) fall above the 0.75 minimum of the median calculated monthly for all PHC
practices within the region, they receive 50% of the bonus; and if they satisfy PHC practice
performance assessment criteria (working hours, patient waiting time, information quality) they receive
the remaining 50%.
Yearly quality indicators involve certain numbers of preventive interventions:
Number of registered patients seen during the year (to see 65% population annually of these
registered)
Child health check-ups (ages 0 to 7) (at least 90% of registered)
Immunizations and vaccinations (90% of these from 3 to 14th vaccinated following plan)
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Cancer prevention programmes.
Diabetes control :
o HbA1c, 60% of patients have got at least two tests per year.
o Micro-albuminuria for Diabetes type II – 60% of patients but (in-patients are excluded).
Asthma control:
o Maximum expiration flow – 90 % of patients with asthma long time registered, from 6
year till end
o Teaching inhalator at least 90% of patients
Ambulance visits to hypertension patients – 90% without ambulance calls of these who have
hypertension.
2.1.2. Implementation of Pilot project in Latvia
As a result of ImPrim project activities in Latvia have been introduced Quality Bonus System (QBS).
The aim of the QBS in Latvia was to promote active involvement of family doctors in disease
prevention, tackle the spread of infectious diseases, and ensures more effective chronic disease
management in the community and to provide a broad range of health services. The identified four
objectives of the QBS are concerned with services that can be delivered in PHC to improve outcomes;
the other two are primarily concerned with reducing costs across the system maintaining following
outcomes:
I. Prevention activities e.g. check up, vaccination and immunisation, screening;
II. Management of Chronic Conditions e.g. diabetes, hypertension;
III. Substitution for Secondary Care e.g. minor operations, pregnancy care;
IV. Avoidance of Demand outside PHC e.g. better targeted referrals, test requests, prescriptions; better
patient access to family doctors to prevent unnecessary calls on emergency and inpatient services.
The principles of the QBS:
A voluntary scheme, and given status as a ‘measure of excellence’ perhaps with a link to an
accreditation process or personal skills development
A single scheme (which, in Latvia, would imply merging the two separate systems which currently
operate)
The scheme should only apply to family doctors and not to paediatric only services.
Its measures should all be within the control or influence of the family doctor
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There must be an audit trail of data
There should be clear and consistent links to other change initiatives where relevant (e.g. list size,
development of the practice nurse role)
It may be desirable to define qualifying criteria for the scheme (e.g. separate rooms for doctors and
nurses)
Payments should be linked to potential savings in other tariffs (e.g. fee for service tariffs in
secondary care)
Patient co-payments should reinforce the QBS incentives
Indicator targets should be ‘absolute’ and not comparative measures based on previous years, or on
other family doctors
Target ranges should be set based on evidence of what is achievable for the upper bound, and what
is currently achieved to set the lower bound.
There should be no ‘exception reporting’ by doctors to remove ‘difficult’ patients from indicator
calculations.
There are three main indicator domains:
Prevention
Child vaccination across a range of diseases
Post-natal check-ups at 1, 3, 12 and 24 months
Pre-school child examination
Risk-factor screening for cardiovascular disease (e.g. cholesterol test once every 5 years for 90% of
adults aged 40-60).
Chronic disease management
Type 2 diabetes (various tests annually: e.g. creatinine, albumin, cholesterol)
Hypertension (health advice, ECG)
Post myocardial infarction (cholesterol, glucose)
Additional skills from family doctor
Neonatal care
Gynaecological examinations
Minor surgery
Clinical training
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2.2. Pilot in Klaipeda region, Lithuania
2.2.1. Review of primary care quality improvement system in Lithuania
Primary health care is generally accepted as the entry point to the health care system in Lithuania.
Family doctors are gatekeepers and patients need referral to all specialists, with exception of
dermatovenerologist. Patients have to pay for the visit to secondary health care specialist in case of self
-referral (i.e. without referral from primary health care physician).
Since introduction of new payment scheme from Mandatory Health Insurance in 2007, primary health
care was reimbursed through age adjusted capitation fee. Until 2005 4 age groups were used: till 5 year,
5 – 15 year, 16 – 64 year and 65 year and older. Since 2005 - 7 age groups: till 1 year, 1 – 4 year, 5 – 6
year, 7– 17 year, 18 – 49 year, 50 – 65 year, 65 year and older.
Until 2003 there was 100% age adjusted capitation fee. Incentive payment scheme has been started to
be introduced since 2003. Incentive payments for provided services are those accounted separately and
paid in addition in order to improve various fields of PHC. Following incentive payments for services
have been introduced:
Diagnostics of early stages of cancers;
For testing of blood clotting condition: Prothrombin activity test and INR test;
Glycosylated hemoglobin test;
Care of pregnancy;
Care of children under 1 year;
Care of the disabled;
Immunoprophylaxis of children;
Preventive check -up of schoolchildren;
Nursing at home of chronically ill patients services;
Blood group test, Rhesus factor (RH) test, syphilis blood test and HIV antibody test for pregnant
women.
Also paid fee for services for following screening procedures:
Pap smear - for women 25 – 60 years once per three years
Mammography - for women 50 – 69 years once per two years
PSA - for men year 50 – 75, if risk (family anamnesis) since 45.
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Preventive (screening) services provided in PHC according to established preventive programs are paid
additionally. Currently implementing preventive programs in Lithuania:
Cervical cancer prevention programme (women aged 25 – 60, Pap smear test once per three
years);
Mammographic screening programme (women aged 50 – 69, mammography once per two
years).
Prostate cancer prevention programme (men aged 50 – 75, if risk – since 45, prostate specific
antigen test);
Cardiovascular disease screening programme (men aged 40 – 55 and women aged 50 – 65,
healthy life style counselling, glucose, cholesterol test, electrocardiogram);
Colorectal cancer prevention programme (persons aged 50 – 75, once per two years).
Quality indicators, for which bonuses are paid, are presented in table 1. Different points (0 to 5) are
given according to the reached level of PHC performance.
Table 1. Quality indicators used in Lithuania for bonus payment
Indicator
Numerator
Denominator
Bonus paid
Population care coverage
Children care
coverage
Number of children
(under 18) who visited
family doctor at least
once per year
Total number of listed If 70-85% - 2 points; If
population in this age 85-95% - 4 points; If 95%
group
and more – 5 points
Preventive health
checks
Number of children
(under 18) who visited
family doctor or
paediatrician for
preventive check-ups.
Total number of listed If 60-70% - 1 point; If
population in this age 70-85% - 2 points; If 85%
group
and more – 3 points
Adult care
coverage
Number of adults who
visited family doctor at
least once per year 60
Total number of listed If 45-50% - 2 points; if
population in this age 50-65% - 4 points; if 65%
group
and more – 5 points
Hospitalization of
patients with
arterial
hypertension
Number of
hospitalizations due to
arterial hypertension
during the reporting
cycle
Total number of all
listed patients with
arterial hypertension
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If 1,7-2,19% - 1 point; if
1,4-1,69% - 2 points; if
1,39% or less – 3 points
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Implementation of prevention programmes
Cervical cancer
prevention
programme
Number of women
participating in this
programme - those
who were informed
and got PAP smear
test with consultation
Total number of listed If 15-30% - 1 point; if
women participated in 30-50% - 2 points; if 50%
this programme
and more – 3 points
Prostate cancer
early diagnostics
programme
Number of men
participating in this
programme those who
were informed and
checked PSA
Total number of listed If 15-25% - 1 point; if
men participated in
25-35% - 2 points; if 35%
this programme
and more – 3 points
PHC are reimbursed through:
1. Age adjusted capitation fee;
2. Incentive payments for services provided;
3. Incentive payments for preventive (screening) programs;
4. Bonus payments for good performance.
The distribution of components of PHC payment system in Lithuania (Klaipeda region) is shown in
diagram 1. Capitation fee represents 80 -85 % of the total payment to PHC facilities. The remaining 15
- 20 % is based on incentive payments for services and bonus payments.
Diagram 1. The components of PHC reimbursement system (period – 6 months: JulyDecember, 2011; 22 PHC clinics. Source: Territorial Sickness Fund, Klaipeda).
1,277,445.81 Lt,
9%
1,577,640.25 Lt,
11%
Bonus payments
11,770,960.59
Lt, 80%
Incentive payments
for services
Capitation
Current PHC payment system does not enough motivate family doctors and nurses to provide more
comprehensive services and more focus towards disease prevention and health promotion in the
community.
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2.2.2. . Selection process of quality indicators to be piloted (the Delphi method)
Initial proposal of 30 quality indicators for PHC performance have been selected based on the proposal
document Operational System of Evidence Based and Widely Recognised Quality Indicators for PHC performance.
The respective quality indicators were divided into following categories: structural indicators (number
of family doctors, community nurses), process indicators (percentage of population seen by family
doctor, rates of visits to secondary health care specialists) and indicators for clinical management
(screening, vaccination rates, preventive check-up). Detailed list of quality indicators used for the first
Delphi round is available in Annex 1.
The qualitative Delphi method was used for selection process of quality indicators. The Delphi
technique is a widely used and accepted method for achieving convergence of opinion within certain
topic areas. Experts for the Delphi study were selected from different local and national stakeholders
(Table 2). The Delphi method consisted of two rounds.
Table 2. Experts of the Delphi study.
No
Level
1.
Local (Klaipeda
region)
2.
National
Institutions
Family doctors
Community nurses
Offices of Public Health
Representatives of Municipality
Health Departments
FM association
National and Territorial Health
Insurance Funds, Ministry of
Health
Others
No of experts (1st
Delphi round)
9
4
3
3
No of experts (2nd
Delphi round)
8
4
2
3
3
6
2
6
5
33
5
30
Total:
During the first round experts have selected 5 to 15 out of 32 quality indicators. Experts also had an
opportunity to propose new indicators. The results of the first Delphi round are presented in Annex 3.
According the experts’ responses to the first Delphi round, the following changes was made in the list
of quality indicators before launching the second Delphi round:
Excluded majority of structural indicators;
Excluded the indicators that already receive incentive payments;
A few quality indicators were merged (e.g. rates of hospitalization);
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A new quality indicator was added (Waiting time to GP‘s reception according the time written
in a voucher).
The list of quality indicators used for the second Delphi round is available in Annex 2. In the second
Delphi round experts received feedback from the first round (group responses), selected 5 out of 22
quality indicators and rated their importance 1 to 5 points. The top six quality indicators selected by
experts are the following (Annex 3):
1. Rates of hospitalization of patients with chronic conditions (emergency hospitalization of
asthma, diabetes and hypertension);
2. Percent of children with an overweight and obesity to whom a plan for procedures and
treatment has been provided (glycemic control, B.holest; consultations on nutrition, physical
activity) by an endocrinologist, GP or nurse;
3. The primary care nurse provides independent reception time in the GP practice;
4. Percent of women age 50-69 screened for breast cancer at least once per two years;
5. Rate of the visits to secondary health care specialists per 100 listed inhabitants (depending on
possibilities to separate referrals made by GPs, self-referrals and obligatory referrals for the
patients with chronic conditions);
6. Percent of children with Acute RTI treated with antibiotics.
Delphi results have been presented and discussed during several workshops targeted to different
stakeholders. Project have emphasised importance of bottom up approach so primary health care
professionals considered as most actual target group. During several meetings with primary health care
physicians and nurses it was agreed that most actual would be to strengthen competences of primary
health care nurses to work more independently in consultation and motivational counselling of nurses.
Primary health care physicians also agreed that there is unequal consumption of secondary health care
services, which often is inappropriate to real needs. Result of inappropriate use of secondary health care
services is increasing waiting times to get specialist consultation. Nonetheless there were arguments that
referral rate depend on morbidity level of population and some health care institutions have sicker
population. Also there exist some formal requirements for referrals, e.g. some medicines cannot be
prescribed without consultation of specialist. MoH supported the initiative to introduce the new
motivational counselling services for nurses.
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Finally it was agreed that there will be piloted indicators to measure following:
5. Advance care of patients with NCDs through provision by nurses services on consultationmotivational counselling of patients with NCDs. As an obstacle - in Lithuania was no
approved methodology for in depended consultation of nurses in primary health care, with
exception of consultation for diabetes patients – approved consultation by nurses, which
was funded through fee for service payment.
6. Avoidable hospitalization of patients with chronic conditions: rates of emergency
hospitalization of asthma, diabetes and hypertension;
7. Consumption of outpatient secondary health care specialists;
8. Prescription of antibiotics for children respiratory tract infections.
Also it was agreed that consumption of more expensive levels of care should be adjusted for level of
morbidity of population. Tools for measurement of co-morbidity in population should be applied to
make conclusions on appropriateness of referrals to more expensive levels of care.
In this report we have described the piloting process and results of these quality indicators: consulting
and motivational services for NCD patients, hospitalization rates of patients with chronic conditions
and visits to secondary health care specialists. The results of use of antibiotics for children RTI will be
presented in upcoming report.
2.2.3. Advanced care of patients with NCDs through introduction of consultation and
motivational counselling of patients by nurses
1) Planning and organisation of new services
Rapid need assessment. Interviews with primary health care nurses and doctors have been made for
identification of the needs for introduction of services. The following limitations have been identified:
-
lack of information and skills – lack of knowledge and reliable information of nurses and patients; lack
of communication skills of nurses; insufficient management capabilities;
-
lack of awareness – unfavourable/passive patients attitude; inadequate adherence to treatment; lack of
patients responsibility for their own health and for self-care; lack of patients and nurses motivation;
-
fear and reluctance to change – too much prominence is given to technical work and procedures; lack of
innovation in the organisation; patients reluctance to change;
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-
Technical and structural obstacles – patients’ affluence, variety of treatment possibilities; lack of
methodological aids; insufficient financing; shortage of nurses.
These issues were used when setting further directions of methodology of the services.
Methodology of the counselling services. The methodology was designed on purpose to address the
most substantial priorities that would give the biggest benefit for the patients suffering from chronic
diseases, for the community nurses’ professional development through practical work with this type of
patients, and in general for health care costs, through reduced health care usage for these patients.
Methodology was developed for independent motivational consultations provided by nurses, has been
approved by Ministry of health Methodology.
Methodology of the services is attached in the annex 4.
The selection of PHC institutions ready to introduce motivational counselling services of NCD
patients. As it was mentioned above, MoH agreed on methodology of new services to be provided by
PHC nurses. Nevertheless, there was not planned any incentive payment for year 2012. Therefore, it
was necessary to find institutions which were willing to introduce services on voluntary basis. The
proposal was submitted to seven PHC institutions in Klaipeda city and district. These institutions are
listed below:
Public primary health care institution: Senamiestis Primary Health Care Centre (Senamiesčio
pirminės sveikatos priežiūros centras);
Public primary health care institution: Jurininkai Primary Health Centre (Jūrininkų pirminės
sveikatos priežiūros centras);
Public primary health care institution: Paupiai Primary Health Care Centre (Paupių pirminės
sveikatos priežiūros centras);
Public primary health care institution: Klaipeda Primary Health Care Centre (Klaipėdos
pirminės sveikatos priežiūros centras);
Public primary health care institution: Gargzdai Primary Health Care Centre (Gargždų pirminės
sveikatos priežiūros entras)
Private primary health care institution: LLC “My Family Doctor” (UAB “Mano Šeimos
Gydytojas”
Private primary health care institution: LLC “Nefrida” Clinic (UAB “Nefridos” klinika)
All PHC institutions were very interested in mentioned services, only five of them refused to participate
in the pilot due to financial difficulties. However, representatives of these institutions were still
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interested in introducing this type of services in PHC setting in the future, when incentive payment is
performed. Despite of the financial limitations, two PHC institutions accepted to implement
counselling services without additional funding from external resources (table 3).
Table 3. List of PHC institutions providing consultation and motivational counselling of NCD
patients in community nurse practice
Nr.
PHC institution
1.
Private primary health care institution: LLC “My
Family Doctor” (UAB “Mano Šeimos Gydytojas”
2.
Public primary health care institution: Gargzdai
Primary Health Care Centre (Gargždų pirminės
sveikatos priežiūros entras)
Place of the
institution
Number of
nurses providers
Klaipeda city
2
Klaipeda district
2
Training and preparation of community nurses for the consulting of NCD patients. According
to complexity of this type of patients consulting, the need to prepare nurses was manifest. Thus, nurses’
trainings were organised.
The main training workshop took place in Klaipeda, May 2012. The report of the training workshop is
in annex 5. In the training participated 18 community nurses from 7 PHC institutions (mentioned
above) from Klaipeda city and district. The training lasted three days. In each day nurses were trained
on different topics: the first training day included chronic disease management, the second training day
was dedicated to theoretical and practical aspects of motivational counselling, and the last training day
included practical exercises and role-play related to previous two days topics: chronic disease
management combined with motivational counselling and patient empowerment skills.
Nurses’ positive evaluation, active participation and interest in all the topics during training period
revealed high motivation of the nurses for chronic diseases management, motivational counselling and
patient’s empowerment. This knowledge and skills gained during this training is required for their
professional development permanently. The skills, however, have been also improved later during the
period of services provision in their practice.
The second training workshop was organised on the 1st of August, 2012. The aim of this training was
to present the main behavioural change models2 and repeat acquired on the daily practice main
The main theoretical health behavioural change models presented in the training: Transtheoretical Model of Behavioural
change, 5 A’s Behaviour Change Model
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communication skills through role play (analysing cases prepared by workshop participants). In this
training only four nurses participated– those who have already started NCD patients counselling.
2) Implementation and monitoring of consultation and motivational counselling of NCD
patients
Implementation process. The services have been launched on the 1st of July in both PHC institutions:
in “My Family Doctor” clinic (in Klaipeda city), and in Gargzdai PHC centre (in Klaipeda district). In
Gargzdai nurses provided services 10 hours per week as part of their routine work, whereas in Klaipeda
nurses planned their consultation time out of hours, according to their work schedule. In both
institutions the provision of the consultations was different, but the provision of consultation and
motivation services was still carried out quite successfully.
Information was disseminated to the patients seeking to attract more patients to come to the
consultation: the article in local newspaper about consultation services provided by nurses (in
Gargzdai); the informal leaflets and nurses visit cards were handed out to patients in the PHC
institutions. Additionally, but also very important, the workshops were organised on purpose to
improve collaboration between community nurses and family doctors.
Methodology of results monitoring. The monitoring process was very important for the evaluation of
the pilot project, so that results could be disseminated and serve as an opportunity to introduce
motivational counselling countrywide. Therefore, the monitoring of the services was foreseen during all
implementation process. Results of monitoring were grouped to intermediate process indicators and
further outcome indicators, which are shown in the table below.
Outcome indicators were measured using the data from National sickness fund database. Changes in
hospitalization rate due to NCD exacerbation was measured before and after the consultation started.
The data was collected only about the patients who had more than one consultation, and hospitalisation
rate were compared between the periods before the implementation of mentioned services and after.
The intermediate results were measured using patients satisfaction questionnaire and interview of
nurses’ focus group. Patients’ satisfaction questionnaire consisted of questions about the quality and
benefits of counselling and motivation services, self-management capabilities, and changes in patients’
life style. Focus group interview for consulting nurses was used to reveal changes in nurses’ attitudes
towards their competences and possibilities in counselling NCD patients.
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Table 4. Measures planned to be used to monitor results of introduced new services –
motivational counselling of NCD patients by nurses
Group of indicators
for monitoring new
services
Further, outcome
indicators
Measures
1. Changes in hospitalisation rates due
to NCD exacerbation;
2. Changes in rate of visits to general
practice physicians and secondary
health care specialists/emergency
services due to NCD exacerbation;
Intermediate,
process indicators
1. Increase in patient self-management
capabilities;
2. Patients satisfaction with services
provided in primary health care;
3. Patients satisfaction of services
provided by community nurses;
4. Nurses’ attitudes towards provided
facilities for NCD patients.
Monitoring
process/measures
1. Investigation of patients
pathways within health system
before and after introduction of
new services;
2. Comparison of health care
services utilization of the
patients who have been
counselled by the nurses with
the patients who have not been
counselled.
Patients’ focus group interview
and patient satisfaction
questionnaire
Focus group interviews for
nurses
3) Analysis of the results and dissemination countrywide
Future plans of counselling and motivation services for NCD patients after the pilot project.
This pilot project period was too short to achieve significant results which could indicate outcomes of
these newly introduced services. However, the services piloted in Lithuania PHC settings and the
intermediate results revealed that such services are very actual for addressing primary health care
challenges related to spread of NCDs. Many uncontrolled problems came out after the pilot: patients’
non-adherence to treatment plan, lack of support for NCD patients in terms of risk management and
health promotion. Thus, continuity of these services is essential to improve NCD patients’ health care
and reduce health care costs related to expensive health care services utilisation. Continuity of these
activities would be useful for nurses’ professional development, PHC institutions work effectiveness
and reduced family doctors workload, patients’ satisfactions with health care systems and for health
care system as a whole.
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2.2.4. Monitoring of consumption of secondary health care services and adjustment for comorbidity
The following quality indicators for monitoring consumption of secondary health care services have
been selected:
Visits to secondary health care specialists without bonus payments;
Hospitalizations rate of patients with chronic conditions (emergency hospitalization of asthma,
diabetes, arterial hypertension)”. These quality indicator aims to reveal and compare the existing
inequalities in health care consumption among various PHC clinics.
During the organized workshops with general practitioners was considered that morbidity of
population is unequal – some PHC institutions have listed only easy-to-treat patients. It was agreed that
consumption of higher levels health care services should be adjusted to population‘s co-morbidity
burden. The international studies revealed that a higher co-morbidity burden is associated with
increasing consumption of health care services. Increasing co-morbidity is associated with ageing, thus
the increasing life expectancy is an important factor leading to a higher prevalence of chronic noncommunicable diseases and augmented health care consumption.
The data of presented research studies revealed that 2% of population with very high level of comorbidity consume up to 30% of overall health care resources. Study carried out in the USA revealed
that 82% of aged population had 1 or more chronic conditions, and 65% had multiple chronic
conditions. In-patient admissions for ambulatory care sensitive conditions and hospitalizations with
preventable complications increased with the number of chronic conditions. For example, patients with
4 or more chronic conditions were 99 times more likely to have an admission for an ambulatory care
sensitive condition than a person without any chronic conditions. Per capita health care expenditures
increased with the number of types of chronic conditions from $211 for patients without a chronic
condition to $13 973 for patients with 4 or more types of chronic conditions (Wolff, 2002). These
findings show that increasing burden of co-morbidities is one of most challenging issue for health care
systems.
During the pilot project in Klaipeda region it was decided to investigate health care consumption
patterns and existing health care inequalities in various PHC clinics during the years 2011-2012. Johns
Hopkins University ACG system was selected as a tool to assess the population‘s co-morbidity burden.
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High interest to reveal inequalities of health care consumption in different PHC clinics was presented
by administration of Klaipeda Territorial Sickness Fund and also such idea was supported by MoH. To
get more relevant results about existing inequalities it was decided to collect retrospective data about
population’s morbidity burden and visits to secondary health care during years 2011 – 2012.
The necessary data for the pilot (non-personalized population data and the use of out-patient health
services) was provided by Klaipeda Territorial Sickness Fund. The population included 415 241
inhabitants (women – 218870 (52.7%), men – 196371 (47.3%)) from all Klaipeda city and district. This
population was listed in 18 public (65% enlisted inhabitants) and 26 private (35%) PHC clinics. All
included population of 2012 year listed in PHC institutions in Klaipeda region consisted of 241 936
inhabitants (women – 128006 (52.9%), men – 113936 (47.1%)). The population according to their
living area was divided into 2 categories: urban – 212010 (87.6%) of inhabitants, rural – 29926 (12.4%).
Johns Hopkins ACG system was used to assess population’s co-morbidity level. According to the ACG
methodology, the population was grouped into six Resource Utilization Bands (RUB) which provided a
simple means of arraying the population from “healthy” to “very high” morbidity and range from nonusers (RUB 0) to a very high comorbidity group (RUB 5).
The application of the ACG System for Klaipeda pilot was performed in collaboration with experts
Chad Abrams and Steve Sutch from Johns Hopkins Bloomberg School of Public Health (USA). The
experts provided technical support in developing analysis in applying the ACG System. The ACG
system was used as a tool to compare inequalities in referral rates among PHC clinics in Klaipeda city
and district and to define main factors influencing higher referral rates.
There were found inequalities in co-morbidity level in different PHC populations (see diagram 2).
Populations were unequally distributed in different PHC clinics according to their morbidity burden.
For example, the non-users (RUB 0) in different PHC clinics ranged from 17.5% to 68.3% or 3.9 times.
Multimorbid patients (RUB 5) ranged from 0.04% to 2.11% in different PHC clinics.
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Diagram 2. Distribution of inhabitants enlisted in 18 public and 26 private PHC clinics into Resource
Utilisation Bands (RUBs), year 2011.
Private PHC 24
Private PHC 23
Private PHC 5
Private PHC 22
Private PHC 21
Private PHC 20
Private PHC 19
Private PHC 18
Private PHC 17
Private PHC 16
Private PHC 15
Private PHC 14
Private PHC 13
Public PHC 19
Private PHC 12
Private PHC 11
Private PHC 10
Private PHC 9
Private PHC 8
Private PHC 7
Private PHC 6
Public PHC 18
Public PHC 17
Public PHC 15
Private PHC 26
Private PHC 4
Private PHC 25
Public PHC 14
Private PHC 2
Private PHC 1
Public PHC 13
Private PHC 3
Public PHC 12
Public PHC 11
Public PHC 10
Public PHC 9
Public PHC 8
Public PHC 7
Public PHC 6
Public PHC 5
Public PHC 4
Public PHC 3
Public PHC 2
Public PHC 1
RUB 0
RUB 1
RUB 2
RUB 3
RUB 4
RUB 5
0%
20%
40%
60%
80%
100%
These results showed that morbidity burden has an impact on consumption of higher level medical care
services (see diagram 3). For example, patients with a very high co-morbidity burden (RUB5) visited
secondary health care specialists 16 times more often comparing with “healthy” users (RUB1) and 6
times more often than low morbidity burden (RUB2).
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Diagram 3. Number of visits to primary, secondary and tertiary health care levels in different Resource
Utilisation Bands (RUBs) per 1 inhabitant, 2011, N= 415241.
The higher co-morbidity group is associated with higher needs for out-patient heath care services.
Thus, measuring population co-morbidity allows planning health care resources. Special attention
should be drawn to the high multiborbidity group of patient as this group consume the main part of
health care resources.
There were 560 (0.2%) inhabitants assigned to a high multimorbidity group (RUB5) in Klaipeda city
and district in year 2012: 54 of them lived in rural (0.18% overall rural population) and 506 - in urban
areas (0.24% overall urban population). High multimorbidity (RUB5) distribution according to gender
was: women – 378 (0.30% overall women population) and men – 182 (0.16% overall men population)
(Table 6).
Table 6. Distibution into RUBs (Resoucre Utilization Bands), year 2012.
Gender
Female
Male
RUB
0
1
2
3
4
5
42602
17727
21153
42325
3821
378
(33.28%) (13.85%) (16.53%) (33.06%) (2.99%) (0.30%)
51811
17789
18237
24029
1882
182
(45.48%) (15.61%) (16.01%) (21.09%) (1.65%) (0.23%)
Total
128006
(100%)
113930
(100%)
150774 (62.3%) inhabitants were listed in 7 public PHC and 91162 (37.7%) – in 19 private PHC clinics
in Klaipeda region. There were inequalities in co-morbidity level found in different PHC populations
(see diagram 4). For example, the non-users (RUB 0) ranged from 15.5% to 47.4% or 3 times in
different PHC clinics.
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Diagram 4. Distribution of inhabitants enlisted in 7 public and 19 private PHC clinics into Resource
Utilisation Bands (RUBs), year 2012.
Private PHC 29
Private PHC 28
Private PHC 27
Private PHC 24
Private PHC 23
Private PHC 21
Private PHC 19
Private PHC 15
Private PHC 13
Public PHC 19
Private PHC 12
Private PHC 11
Private PHC 10
Private PHC 9
Private PHC 8
Private PHC 6
Private PHC 26
Private PHC 25
Private PHC 1
Public PHC 13
Private PHC 3
Public PHC 10
Public PHC 9
Public PHC 7
Public PHC 2
Public PHC 1
RUB 0
RUB 1
RUB 2
RUB 3
RUB 4
RUB 5
0%
20%
40%
60%
80%
100%
The consumption of health care levels (according to the number of visits per 1 inhabitant) was analysed
in Klaipeda region. Patients assigned to a higher co-morbidity burden had higher care needs (Diagram
5).
Diagram 5. Number of visits to primary, secondary and tertiary health care levels in different Resource
Utilisation Bands (RUBs) per 1 inhabitant, 2012, N= 241936.
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The visits to primary, secondary and tertiary care levels were analysed using the following “weights”:
O/E (Observed/Expected visits), CMI (Case-Mix Index). The term “weight” was used to represent a
relative value for resource use with respect to some population average and is generally expressed as a
numeric value with a mean of 1.0.
The O/E ratio is an indication of observed to expected resource use or, in other words, how much
resources the Clinic expended as compared to what it was expected to utilize with the given morbidity
level of their patients. In this instance, scores greater than 1.0 indicate the Clinic is spending more than
expected, less than 1.0 they are spending less than expected. For example, lowest O/E values were in
private PHC clinics (private PHC 1, 3, 8 and 13) and the highest O/E rates were in public PHC 7 and
10, private PHC 25 and 26 (Table 7).
Case mix is by definition a system that classifies people into groups that are homogeneous in their use
of resources. A good case-mix system also gives meaningful clinical descriptions of these individuals.
The case-mix index is calibrated around 1.0 for the population. Scores greater than 1.0 indicate the
population is sicker than average, less than 1.0 indicate healthier than average. For example, lowest
CMI values were in public PHC 19 and in private PHC 1, 25 and 28 and highest CMI values were in
private PHC 3 and 11 and in public PHC 7 and 13 (Table 7).
Method for calculating ACG Expected visits and O/E ratio is as follows.
Every patient is assigned to specific ACG code which is assigned based on patients gender, age and all
conditions that were diagnosed.
First, an expected visit rate for each ACG was calculated. This is counted simply as the sum of visits
divided by the number of patients for each ACG category. This was done taking all population (not a
single PHC) into account.
Second, we calculated an ACG expected visits for each clinic according to the following formula:
ACG Expected Visits for jth clinic,
E
j
n x
ij
i
i
where
x
n
Average visits for ith ACG &
i
ij
Number of patients in jth clinic, with ith ACG.
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Having this formula, we were able to calculate what are ACG Expected Visits for every PHC, based on
average ACG visit rate (mean) for overall population.
Observed visits are simply considered as actual visits. Having observed and Expected visits, O/E ratio
was calculated.
CMI for visits is the ACG Expected visits divided by the total average observed visits.
It is important to note, that having total cost data, method of calculating O/E ratio could be more
accurate and easier to interpret.
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Table 7. Visits to different health care levels, year 2012.
PHC
Public PHC 1
Public PHC 2
Public PHC 7
Public PHC 9
Public PHC 10
Private PHC 3
Public PHC 13
Private PHC 1
Private PHC 25
Private PHC 26
Private PHC 6
Private PHC 8
Private PHC 9
Private PHC 10
Private PHC 11
Private PHC 12
Public PHC 19
Private PHC 13
Private PHC 15
Private PHC 19
Private PHC 21
Private PHC 23
Private PHC 24
Private PHC 27
Public PHC 19
Private PHC 28
Total
Observed visits
Level 1 Level 2 Level 3
106191
35203
5054
144575
59694
6554
83416
28539
2100
6557
2221
356
17009
2854
464
2817
1359
152
22465
12130
1808
8069
7557
1080
2733
824
98
3073
864
68
19070
7011
906
14839
8567
1153
40967
24109
1635
8710
4758
471
13029
7644
742
7479
3132
641
2823
991
156
8957
5073
602
17944
7902
904
13914
6597
822
6375
3891
309
706
361
44
1844
589
134
538
292
59
184
72
9
2210
1030
60
556494 233264
26381
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Expected visits
Level 1 Level 2 Level 3
97810
38938
5036
141229
60019
6454
70088
28204
2203
6730
2470
357
12439
3285
488
3588
1440
144
24997
11156
1915
12855
6670
1021
2193
775
93
2426
946
89
19534
7685
866
19777
8713
1119
44954
20941
1516
10293
4682
486
16031
7083
735
7978
3178
622
3007
989
151
11443
5050
609
20538
8389
919
15380
6671
788
7836
3659
320
731
317
43
1761
655
131
614
295
56
203
63
11
2059
995
67
556494 233268
26239
Level 1
1,09
1,02
1,19
0,97
1,37
0,79
0,90
0,63
1,25
1,27
0,98
0,75
0,91
0,85
0,81
0,94
0,94
0,78
0,87
0,90
0,81
0,97
1,05
0,88
0,91
1,07
1,00
O/E ratio
Level 2 Level 3
0,90
1,00
0,99
1,02
1,01
0,95
0,90
1,00
0,87
0,95
0,94
1,06
1,09
0,94
1,13
1,06
1,06
1,05
0,91
0,76
0,91
1,05
0,98
1,03
1,15
1,08
1,02
0,97
1,08
1,01
0,99
1,03
1,00
1,03
1,00
0,99
0,94
0,98
0,99
1,04
1,06
0,97
1,14
1,02
0,90
1,02
0,99
1,05
1,14
0,82
1,04
0,90
1,00
1,01
Total
1,03
1,02
1,13
0,96
1,25
0,84
0,96
0,81
1,19
1,16
0,96
0,83
0,99
0,90
0,90
0,96
0,96
0,86
0,90
0,93
0,90
1,02
1,01
0,92
0,96
1,06
1,00
Level 1
1,06
0,98
1,09
0,95
0,95
1,16
1,09
0,72
0,81
0,92
1,09
0,92
0,94
0,80
1,11
0,97
0,80
0,83
1,00
1,15
0,94
1,26
0,98
1,13
0,82
1,61
1,00
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CMI
Level 2
1,01
1,00
1,05
0,84
0,60
1,11
1,16
0,89
0,68
0,86
1,02
0,97
1,04
0,86
1,17
0,92
0,62
0,88
0,98
1,19
1,05
1,30
0,87
1,30
0,61
1,86
1,00
Level 3
1,15
0,95
0,73
1,07
0,79
0,98
1,76
1,21
0,73
0,71
1,02
1,10
0,67
0,79
1,07
1,59
0,84
0,93
0,95
1,24
0,81
1,56
1,54
2,18
0,94
1,11
0,99
Total
1,05
0,98
1,07
0,92
0,84
1,14
1,13
0,79
0,77
0,90
1,06
0,94
0,96
0,82
1,12
0,97
0,75
0,85
0,99
1,16
0,97
1,28
0,97
1,21
0,77
1,66
1,00
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The regression analysis in order to define the factors that can explain the consumption of health care
was used. Variables selected for regression analysis:
1. dependent – referral rates (that includes referrals to both secondary and tertiary health care
levels)
2. independent:
CMI (overall for every PHC institution, 1,2 and 3 health care level together)
[ACGExpected/(Total_visits_per_1*Total_PHC_population)];
Age_average.
Table 8. Correlation matrix, 2011.
Referral_Rate
Referral_Rate
Pearson
Correlation
1
Sig. (2-tailed)
CMI
N
Pearson
Correlation
Sig. (2-tailed)
N
44
,697**
,000
44
CMI
Age_average
**
,076
,000
,626
44
1
44
,242
44
,114
44
,697
**. Correlation is significant at the 0.01 level (2-tailed).
*. Correlation is significant at the 0.05 level (2-tailed).
The Sig. (2-tailed) cells in the table reveal there is no age and referral rate correlation. Thus, age does
not sufficiently explain the consumption of health care. This can be simply explained by newborns
having a significant amount of referrals in their first year, thus increasing consumption of resources and
reflecting on overall population morbidity. Here we have non linear referral rates dependency on age.
Therefore age alone can’t explain population health. More variables (gender, ACG code, comorbidity
index) should be taken into account.
2.2.5. Hospitalization rates of patients with chronic conditions (emergency hospitalization for
asthma, diabetes and arterial hypertension)
This quality indicator was selected for monitoring hospitalizations for arterial hypertension, diabetes
and asthma. It is very important to diagnose the mentioned conditions in early stages in order to
prevent unnecessary hospitalizations.
The necessary data for the pilot was provided by Klaipeda Territorial Sickness Fund from which
hospitalizations for three conditions were selected: arterial hypertension (with the following codes from
International classification of diseases (TLK-10-AM): I 11.0 and I 11.9), diabetes (E 10.02, E 10.11, E
10.16, E 10.21, E 10.22, E 10.22, E 10.32, E 10.33, E 10.35, E 10.42, E 10.64, E 10.65, E 10.71, E
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10.73, E 10.8, E 10.9, E 11.01, E 11.11, E 11.15, E 11.21, E 11.22, E 11.33, E 11.35, E 11.42, E 11.43,
E 11.51, E 11.52, E 11.64, E 11.65, E 11.71, E 11.72, E 11.73 and E 11.9), asthma (J 45.0, J 45.1, J 45.8
and J 45.9). The population included 241 936 inhabitants listed in PHC institutions in Klaipeda region
in year 2012. 150774 (62.3%) of inhabitants were listed in 7 public PHC and 91162 (37.7%) – in 19
private PHC clinics.
During the six months of hospitalizations monitoring (2012), 49249 hospitalizations were performed:
35819 hospitalizations in hospitals of Klaipeda district, 12789 - in Klaipeda city and 641 - in other
regions. 15420 persons were hospitalised: 214 persons for diabetes, 188 for asthma and 399 for arterial
hypertension.
The following tables (8-10) and diagrams (6-8) demonstrate the hospitalization data of the three
conditions (diabetes, asthma and arterial hypertension) in different PHC clinics in Klaipeda city and
district.
Rate of arterial hypertension and rate of hospitalizations for this condition were not related (Table 11).
Concerning received our data, the prevalence of mentioned condition varies from 8.66% to 30.22% or
3.5 times in different PHC clinics of Klaipeda city and district. Rate of hospitalization rate for arterial
hypertension varies from 0.58% to 8.33% per 100 inhabitants or 14.4 times. According to the USA
data, the prevalence of arterial hypertension is 29.6% in the population (Ong et al., 2007).
Table 9. Rates of hospitalizations for arterial hypertension, year 2012.
Number of
hospitalizations
for arterial
hypertension
Number of
hospitalized
patients
Patients with
arterial
hypertension
Number of
inhabitants
Rate of arterial
hypertension
per 100
inhabitants
PHC code
Public PHC 1
148
61
7166
39991
17,92
Rate of
hospitalization
per 100 patients
with arterial
hypertension
0,85
Public PHC 2
234
94
7990
62561
12,77
1,18
Public PHC 7
165
62
4341
27854
15,58
1,43
Public PHC 9
16
4
424
3065
13,83
0,94
Public PHC 10
13
6
820
5697
14,39
0,73
Private PHC 3
9
3
208
1341
15,51
1,44
Public PHC 13
104
40
1968
9964
19,75
2,03
Private PHC 1
29
11
670
7738
8,66
1,64
Private PHC 25
14
5
184
1175
15,66
2,72
Private PHC 26
2
1
172
1143
15,05
0,58
Private PHC 6
28
14
1277
7823
16,32
1,10
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Private PHC 8
25
9
1089
9299
11,71
0,83
Private PHC 9
30
16
2097
20875
10,05
0,76
Private PHC 10
17
6
545
5615
9,71
1,10
Private PHC 11
17
8
774
6296
12,29
1,03
Private PHC 12
18
5
547
3582
15,27
0,91
Public PHC 19
5
3
185
1642
11,27
1,62
Private PHC 13
22
7
692
5981
11,57
1,01
Private PHC 15
31
15
1232
8911
13,83
1,22
Private PHC 19
32
12
1160
5830
19,90
1,03
Private PHC 21
23
7
348
3620
9,61
2,01
Private PHC 23
3
1
52
252
20,63
1,92
Private PHC 24
2
1
113
782
14,45
0,88
Private PHC 27
5
2
32
236
13,56
6,25
Private PHC 28
1
1
12
107
11,21
8,33
Private PHC 29
14
5
168
556
30,22
2,98
1007
399
34266
241936
14,16
1,16
Total
Average number of days spent in hospital for arterial hypertension was 7.3, varying from 2 to 17,3 days
(Diagram 6).
Diagram 6. Average number of days spent in hospital for arterial hypertension.
Private PHC 11
Private PHC 1
Public PHC 7
Private PHC 6
Public PHC 9
Private PHC 21
Public PHC 10
Private PHC 13
Public PHC 2
Public PHC 13
Average of all clinics
Private PHC 12
Private PHC 19
Public PHC 1
Private PHC 25
Private PHC 23
Public PHC 19
Private PHC 29
Private PHC 8
Private PHC 15
Private PHC 9
Private PHC 10
Private PHC 27
Private PHC 26
Private PHC 3
Private PHC 28
Private PHC 24
2,0
2,0
0
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3,3
4,0
4
8,2
7,9
7,9
7,9
7,8
7,7
7,3
7,3
7,3
7,1
6,9
6,3
6,1
6,0
5,6
5,2
5,2
5,2
5,2
5,1
5,0
6
8
17,3
12,3
10
12
14
16
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Our data showed that PHC clinics with higher rates of diabetes had less hospitalised patients (Table
10). For example, there were the highest number of patients with diabetes diagnosis but not
hospitalized for this condition in private PHC clinics No. 24, 27, 28 and 29. Prevalence of diabetes
varies from 0.13% to 4.37% or 33.6 times in different PHC clinics.
Table 10. Rates of hospitalizations for diabetes, 2012.
PHC code
Number of
hospitalizations
for diabetes
Number of
hospitalized
patients
Patients with
diabetes
Number of
inhabitants
39991
Rate of
diabetes per
100
inhabitants
2,16
Rate of
hospitalization
per 100 patients
with diabetes
5,21
Public PHC 1
186
45
864
Public PHC 2
220
65
993
62561
1,59
6,55
Public PHC 7
16
3
437
27854
1,57
0,69
Public PHC 9
3
2
33
3065
1,08
6,06
Private PHC 3
16
2
20
1341
1,49
10,00
Public PHC 13
26
8
250
9964
2,51
3,20
Private PHC 1
20
4
54
7738
0,70
7,41
Private PHC 6
35
12
193
7823
2,47
6,22
Private PHC 8
30
9
72
9299
0,77
12,50
Private PHC 9
71
17
367
20875
1,76
4,63
Private PHC 10
15
6
44
5615
0,78
13,64
Private PHC 11
26
9
95
6296
1,51
9,47
Private PHC 12
21
5
34
3582
0,95
14,71
Private PHC 13
2
1
41
5981
0,69
2,44
Private PHC 15
47
13
228
8911
2,56
5,70
Private PHC 19
28
7
139
5830
2,38
5,04
Private PHC 21
39
5
38
3620
1,05
13,16
Private PHC 23
1
1
1
252
0,13
100,00
Public PHC 10
0
0
82
5697
1,44
0,00
Private PHC 25
0
0
21
1175
1,79
0,00
Private PHC 26
0
0
17
1143
1,49
0,00
Public PHC 19
0
0
3
1642
0,18
0,00
Private PHC 24
0
0
11
782
4,37
0,00
Private PHC 27
0
0
7
236
2,97
0,00
Private PHC 28
0
0
3
107
2,80
0,00
Private PHC 29
0
0
23
556
4,14
0,00
Total/Average
802
214
4070
241936
1,68
5,32
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The average number of days spent in hospital for diabetes was 11.7, varying from 4.3 to 17.9 days
(Diagram 7).
Diagram 7. Average number of days spent in hospital for diabetes.
Public PHC 2
Private PHC 19
Private PHC 13
Private PHC 12
Average of all clinics
Private PHC 15
Private PHC 21
Private PHC 11
Private PHC 10
Public PHC 7
Private PHC 1
Private PHC 6
Public PHC 13
Private PHC 9
Public PHC 1
Private PHC 3
Private PHC 8
Private PHC 23
Public PHC 9
4,3
0
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4
6,0
10,1
10,0
9,4
9,3
9,1
8,7
8,5
8,3
8,3
7,9
7,8
8
12,6
11,7
11,4
12
15,0
16
16,9
17,9
20
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Concerning asthma, higher rates of diagnosed asthma in some PHC clinics could be related with lower
rates of hospitalizations (private PHC No. 27 and 29) (Table 11). Prevalence of asthma varies from 0%
to 5.16% in different PHC clinics, but hospitalizations for asthma – from 0% to 16.67%.
Table 11. Rates of hospitalizations for asthma, 2012.
Number of
hospitalizations
for asthma
Number of
hospitalized
patients
Listed patients
with asthma
Listed
number of
inhabitants
Rate of asthma
per 100
inhabitants
68
26
449
39991
1,12
Rate of
hospitalization
per 100 patients
with asthma
5,79
169
47
824
62561
1,32
5,70
115
29
392
27854
1,41
7,40
5
1
40
3065
1,31
2,50
39
8
56
5697
0,98
14,29
9
1
12
1341
0,89
8,33
65
21
203
9964
2,04
10,34
24
7
68
7738
0,88
10,29
5
2
12
1175
1,02
16,67
6
2
14
1143
1,22
14,29
16
3
117
7823
1,50
2,56
8
4
109
9299
1,17
3,67
40
10
244
20875
1,17
4,10
11
1
62
5615
1,10
1,61
21
3
78
6296
1,24
3,85
8
2
44
3582
1,23
4,55
1
1
12
1642
0,73
8,33
7
3
58
5981
0,97
5,17
34
8
135
8911
1,51
5,93
13
3
100
5830
1,72
3,00
14
4
35
3620
0,97
11,43
3
2
13
252
5,16
15,38
0
0
4
782
0,51
0,00
Private PHC 27
0
0
5
236
2,12
0,00
Private PHC 28
0
0
0
107
0,00
-
Private PHC 29
0
0
12
556
2,16
0,00
681
188
3098
241936
1,28
6,07
PHC code
Public PHC 1
Public PHC 2
Public PHC 7
Public PHC 9
Public PHC 10
Private PHC 3
Public PHC 13
Private PHC 1
Private PHC 25
Private PHC 26
Private PHC 6
Private PHC 8
Private PHC 9
Private PHC 10
Private PHC 11
Private PHC 12
Public PHC 19
Private PHC 13
Private PHC 15
Private PHC 19
Private PHC 21
Private PHC 24
Private PHC 23
Total
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Average number of days spent in hospital for asthma condition was 7.6, varying from 4.4 to 9.7 days
(Diagram 8).
Diagram 8. Average number of days spent in hospital for asthma.
Private PHC 26
Public PHC 7
Private PHC 24
Public PHC 1
Public PHC 10
Private PHC 15
Public PHC 13
Average of all
Private PHC 6
Private PHC 13
Public PHC 19
Public PHC 9
Private PHC 11
Private PHC 25
Public PHC 2
Private PHC 3
Private PHC 12
Private PHC 1
Private PHC 21
Private PHC 9
Private PHC 19
Private PHC 10
Private PHC 8
4,4
0
2
4
7,0
7,0
7,0
7,0
6,8
6,8
6,7
6,4
6,3
6,3
6,1
6,0
5,3
6
8,0
7,8
7,6
7,6
8
9,0
8,9
8,8
9,7
9,4
10
The data of our pilot study revealed variations in diagnosing arterial hypertension, diabetes and asthma
in different PHC clinics: prevalence of arterial hypertension varied from 8.66% to 30.22%; prevalence
of diabetes varied from 0.13% to 4.37%; prevalence of asthma varied from 0% to 5.16%. Also there
were inequalities in hospitalization rate in different PHC clinics: hospitalization for arterial hypertension
varied from 0.58% to 8.33% per 100 inhabitants; hospitalization for asthma – from 0% to 16.67% per
100 inhabitants.
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CONCLUSIONS AND RECOMMENDATIONS
Community nurses training on motivational counselling and chronic disease management was very
useful for nurses’ professional development. Gained skills nurses applied in their daily practice and got
practical motivational counselling experience. Positive patients’ evaluation showed high demand of
such services in PHC settings. However, the period of the project was too short to evaluate long-term
effect of consultation and motivation services on NCD patients’ health and significant changes in
health behaviour. Thus, the continuity of NCD patients motivational counselling is essential to monitor
the impact of these services on NCD patients’ lifestyle and health changes.
Monitoring of secondary health care consumption (visits to secondary health care level and
hospitalization rates for arterial hypertension, diabetes and asthma) showed existing inequalities in PHC
clinics in Klaipeda region. The consumption of higher health care levels is associated with higher comorbidity. Therefore, it is important to measure population’s morbidity burden for more appropriate
allocation of health care resources and more rational use of health care. The use of health care services
is inappropriate in many PHC clinics. Monitoring of hospitalizations showed that there is a high rate of
undiagnosed conditions in PHC clinics which can lead to higher hospitalization rates.
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ANNEXES
Annex 1
THE SELECTION OF QUALITY INDICATORS FOR PRIMARY HEALTH CARE
PERFORMANCE TO BE PILOTED IN KLAIPEDA
First round
Please select from 5 to 15 the most important PHC quality indicators. Mark “Yes” or “No” in the
column “Indicators to be piloted”.
If you think that the selected indicators should be linked to incentive payment, mark “Yes” in the
column “Linked to a financial incentive”.
You can add other quality indicators that you consider relevant in the end of this list (No 33 – 37).
Please send your responses until 9 November by e-mail: laurakubiliute@yahoo.com.
No
1.
Indicator
INDICATORS FOR THE
STRUCTURE
Number of family doctors per
10000 population
2.
Total nurses working in
primary health care per 10000
3.
Family medicine (community)
nurses (after special training in
family medicine and/or
community nursing) per
10000 inhabitants
The primary care nurse has a
separated consulting room
4.
5.
6.
The primary care nurse
provides independent
reception time in the GP
practice
INDICATORS FOR THE
PROCESS
% of adult population seen by
family doctors and/or nurse
during last 3 years
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Conditions
After residency
Indicators
to be
piloted
(Yes/No)
Linked
to a
financial
incentive
(Yes/No
)
Rationale
Family doctors are
important for
PHC quality
Nurses are
important for
PHC quality
Community
nurses should take
more
responsibilities
Reception time of a
nurse is not less than
25% of the GP’s
reception time
Not more than 10% of
patients have not been
seen by family doctor
or nurse
Nurse should
have a separated
consulting room
Nurse should
have special hours
for consulting
Not only patients
but all community
should be in focus
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7.
8.
9.
10.
11.
12.
% of children below 7 years
seen by their family doctor
and/or nurse per year
% of children 8-17 years seen
by their family doctor and/or
nurse per year
% of adult population visiting
secondary health care
specialist at least once per year
(excluding the obligatory
referrals for patients with
chronic conditions)
INDICATORS FOR
CLINICAL
MANAGEMENT
% of women age 50-69
screened for breast cancer at
least once per two years
% of women screened for
cervical cancer at age 25-60 at
least once per three years
14.
% of vaccinated against
influenza at age over 65 and
persons with risk conditions
(depending on amount of
vaccines received)
% of children with an
overweight and obesity to
whom a plan for procedures
and treatment has been
provided (glycemic control,
B.holest; consultations on
nutrition, physical activity) by
an endocrinologist, GP or
nurse
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Prevention ability
Not less than 95% of
children
Prevention ability
Rate of visits to
secondary health care
specialists is:
1. at least 40% below
the state mean rate
2. above the state mean
rate, but not more than
25%, by the side of
previous year rate
decrease is not less
than 10%
High quality PHC
should decrease
visits to secondary
health care
Rate of the visits to secondary
health care specialists with
referral per 100 listed
inhabitants
Rate of the self-referred visits
to secondary health care
specialists
13.
15.
Not less than 95% of
children
High quality PHC
should decrease
visits to secondary
health care
High quality PHC
should decrease
visits to secondary
health care
Organized cancer
screening participation
rate is 15% higher than
mean participation rate
in corresponding
territory
Organized cancer
screening participation
rate is 15% higher than
mean participation rate
in corresponding
territory
Evaluate the
implementation of
preventive breast
cancer program
Evaluate the
implementation of
preventive
cervical cancer
program
Evaluate the
influenza
prevention
A plan for procedures
and treatment at least
for 90% of the
children;
BMI greater than 85
percentile (overweight)
and 95 (obesity)
Overweight
prevention for
children
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16.
17.
18.
19.
20.
% of population with
diagnosis of AH
% of AH patients to whom
total cholesterol measuring
has been provided during last
year
% of AH patients to whom
glycemic control has been
provided during last year
% of these with diagnosis
coronary heart disease,
and/or diabetes have recorded
blood pressure during last year
% of patients with coronary
heart disease to whom total
cholesterol measuring has
been provided during last year
21.
% of diabetic patients who
HbA1C has been measured 4
times during last year
22.
% of diabetic patients who
had the HbA1C measured,
HbA1C is less than 7%
% of diabetic patients who
renal function has been tested
during last year
23.
24.
% of children with Acute RTI
treated with antibiotics
25.
% of children with Acute RTI
treated with Penicillin V (% of
total antibiotics)
Rates of hospitalization of
patients with chronic
conditions
26.
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At least 80% of AH
patients
Evaluate the
prevalence of AH
Appropriate AH
patients’ care
At least 80% of AH
patients
Appropriate AH
patients’ care
At least 70% of
patients with coronary
heart disease
At least 90% of
diabetic patients; there
are at least 20 diabetes
patients listed in the
GP practice
At least 60% of
diabetic patients
At least 90% of the
diabetic patients
There are at least 20
diabetes patients listed
in the GP practice
Reasonable level is less
than 30%
Reasonable level is
60%
1.at least 40% below
the state mean rate
2. 25-40% below the
state mean rate, by the
side of previous year
rate decrease is not less
than 2% 3.less than
25% below the state
mean rate, by the side
of previous year rate
decrease is not less
than 5%
4. above the state mean
rate, but not more than
25%, by the side of
previous year rate
decrease is not less
Evaluate the
effectiveness of
chronic disease
management
Appropriate care
for patients with
ischemic heart
disease
Appropriate care
for diabetes
patients
Appropriate care
for diabetes
patients
Appropriate care
for diabetes
patients
Revels the
antibiotics
prescribing rates
Revels the
antibiotics
prescribing rates
High quality PHC
reduces the
hospitalization
rates
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than 10%
5. more than 25%
above the state mean
rate, by the side of
previous year rate
decrease is not less
than 15%
27.
Emergency hospitalizations
for asthma
28.
Emergency hospitalization of
diabetes
29.
Emergency hospitalization for
hypertension
30.
Rate of ambulance calls per
1000 population
31.
% of pregnant women, who
had visits to family doctor or
midwife and gynaecologist
(according to the guidelines)
% of women who were
breastfeeding their newborns
32.
Evaluate the
management of
chronic
conditions
Evaluate the
management of
chronic
conditions
Evaluate the
management of
chronic
conditions
Evaluate the
performance of
family doctor’s
institution
1.at least 25-40% below
the state mean rate
2.above the state mean
rate, but not more than
25%, by the side of
previous year rate
decrease is not less
than 10%
Appropriate care
for pregnant
women
Duration of
breastfeeding is 6
months or more
Long
breastfeeding
period has a
positive effect on
child’s health
In the second Delphi round the respondents will receive the feedback – results of this round (how
experts evaluated PHC quality indicators). All personal data is confidential.
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Annex 2
THE SELECTION OF QUALITY INDICATORS FOR PRIMARY HEALTH CARE
PERFORMANCE TO BE PILOTED IN KLAIPEDA
Second round
According the experts’ responses to the first Delphi round and foreign experts, the following changes
were made in the list of quality indicators:
1. Excluded the following PHC quality indicators: structural indicators (no 1-3), screenings for
cervical cancer (no 13, already exists), children check-ups (no 7 and 8, already exists), visits of
adults to secondary health care specialists (no 9);
2. The following indicators were merged: visits to secondary health care specialists (no 10 and
11),, hospitalization rates (no 26-29);
3. A new indicator was added (Waiting time to family doctor‘s reception according the time
written in a voucher).
Please select 5 the most important PHC quality indicators and rate them by giving points from 1 to 5: 5
– the most important indicator, 1 – least important indicator. Write points 1, 2, 3, 4 or 5 in the column
“Indicators to be piloted”.
If you think that the selected indicators should be linked to incentive payment, mark “Yes” in the
column “Linked to a financial incentive”.
Please send your responses until 18 November by e-mail: laurakubiliute@yahoo.com.
No
Indicator
1.
The primary care nurse has a separated consulting room
2.
The primary care nurse provides independent reception time in the GP
Indicators to
Linked to a
be piloted
financial
(1,2,3,4 or 5
incentive
points)
(Yes/No)
practice
3.
% of adult population seen by family doctors and/or nurse during last 3
years
4.
Rate of the visits to secondary health care specialists per 100 listed
inhabitants (depending on possibilities to separate referrals made by GPs,
self-referrals and obligatory referrals for the patients with chronic
conditions)
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5.
% of women age 50-69 screened for breast cancer at least once per two
years
6.
% of vaccinated against influenza at age over 65 and persons with risk
conditions (depending on amount of vaccines received)
7.
% of children with an overweight and obesity to whom a plan for
procedures and treatment has been provided (glycemic control, B.holest;
consultations on nutrition, physical activity) by an endocrinologist, GP or
nurse
8.
% of population with diagnosis of AH
9.
% of AH patients to whom total cholesterol measuring has been provided
during last year
10.
% of AH patients to whom glycemic control has been provided during
last year
11.
% of these with diagnosis coronary heart disease, and/or diabetes have
recorded blood pressure during last year
12.
% of patients with coronary heart disease to whom total cholesterol
measuring has been provided during last year
13.
% of diabetic patients who HbA1C has been measured at least once during
last year
14.
% of diabetic patients who had the HbA1C measured, HbA1C is less than
7%
15.
% of diabetic patients who renal function has been tested during last year
16.
% of children with Acute RTI treated with antibiotics
17.
% of children with Acute RTI treated with Penicillin V (% of total
antibiotics)
18.
Rates of hospitalization of patients with chronic conditions (emergency
hospitalization of asthma, diabetes and hypertension)
19.
Rate of ambulance calls per 1000 population
20.
% of pregnant women, who had visits to family doctor or midwife and
gynaecologist (according to the guidelines)
21.
% of women who were breastfeeding their newborns
22.
Waiting time to GP‘s reception according the time written in a voucher
The respondents will receive a feedback on the results of the second Delphi round. All personal data is
confidential.
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Annex 3
THE RESULTS ON THE SELECTION PROCESS OF PHC QUALITY INDICATORS
(DELPHI STUDY)
Delphi first round
The experts selected 5 to 15 out of 32 quality indicators.
No
Indicator
1.
% of women age 50-69 screened for breast cancer at least once per two years
No of
experts
30
2.
% of women screened for cervical cancer at age 25-60 at least once per three
30
years
3.
Rates of hospitalization of patients with chronic conditions
24
4.
Number of family doctors per 10000 population
21
5.
The primary care nurse has a separated consulting room
20
6.
The primary care nurse provides independent reception time in the GP
20
practice
7.
% of adult population seen by family doctors and/or nurse during last 3 years
20
8.
% of children with Acute RTI treated with antibiotics
20
9.
% of children below 7 years seen by their family doctor and/or nurse per year
19
10.
Rate of ambulance calls per 1000 population
19
11.
% of children 8-17 years seen by their family doctor and/or nurse per year
18
12.
% of AH patients to whom total cholesterol measuring has been provided
18
during last year
13.
% of children with Acute RTI treated with Penicillin V (% of total antibiotics)
18
14.
% of pregnant women, who had visits to family doctor or midwife and
18
gynaecologist (according to the guidelines)
15.
% of women who were breastfeeding their newborns
18
16.
% of children with an overweight and obesity to whom a plan for procedures
17
and treatment has been provided (glycemic control, B.holest; consultations
on nutrition, physical activity) by an endocrinologist, GP or nurse
17.
% of diabetic patients who HbA1C has been measured at least once during
16
last year
18.
% of diabetic patients who had the HbA1C measured, HbA1C is less than 7%
16
19.
Total nurses working in primary health care per 10000 inhabitants
15
20.
Family medicine (community) nurses (after special training in family medicine
14
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and/or community nursing) per 10000 inhabitants
21.
% of AH patients to whom glycemic control has been provided during last
14
year
22.
% of these with diagnosis coronary heart disease,
and/or diabetes have
14
recorded blood pressure during last year
23.
% of diabetic patients who renal function has been tested during last year
14
24.
Emergency hospitalization of diabetes
14
25.
% of vaccinated against influenza at age over 65 and persons with risk
13
conditions (depending on amount of vaccines received)
26.
% of patients with coronary heart disease to whom total cholesterol measuring
13
has been provided during last year
27.
Emergency hospitalizations of asthma
13
28.
Emergency hospitalization of hypertension
13
29.
% of adult population visiting secondary health care specialist at least once per
12
year (excluding the obligatory referrals for patients with chronic conditions)
30.
Rate of the visits to secondary health care specialists with referral per 100
12
listed inhabitants
31.
% of population with diagnosis of AH
9
32.
Rate of the self-referred visits to secondary health care specialists
7
The PHC quality indicators suggested by experts
No Indicator
1.
Population listed per one family doctor (calculated
not per „physical persons“ but per one staff
member (100 % working)
Problem is that we have many doctors who work less than
100% in one institution (AJ)
2.
Mortality rate of chronic patients in PHC
3.
4.
5.
6.
The number of avoidable hospitalizations for
chronic patients listed in PHC centers
Population distribution in all age groups, to define
how it reflect normal distribution in the population
Waiting time to family doctor‘s reception in
according the time written in a voucher
The number of practising family doctors per 10000
inhabitants
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Rationale
Reveals the family
doctor‘s work load
Expert
Representative of
Municipality Health
Department
Evaluates quality of
work of family doctor
Evaluates work quality of
family doctor
Reveals the family
doctor‘s work load
Indicate accessibility to
primary health care
doctor
Public health
specialist
Public health
specialist
Public health
specialist
Family doctor
National expert
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7.
8.
9.
Nursing services at home
The indicator of population density
Ratio of nurses to doctors in the practice
Important in rural areas
Family doctor
Family doctor
Family doctor
Delphi second round
The experts selected 5 out of 22 quality indicators and rated their importance 1 to 5 points.
No
Indicator
1.
Rates of hospitalization of patients with chronic conditions (emergency
hospitalization of asthma, diabetes and hypertension)
% of children with an overweight and obesity to whom a plan for procedures and
treatment has been provided (glycemic control, B.holest; consultations on nutrition,
physical activity) by an endocrinologist, GP or nurse
The primary care nurse provides independent reception time in the GP practice
% of women age 50-69 screened for breast cancer at least once per two years
Rate of the visits to secondary health care specialists per 100 listed inhabitants
(depending on possibilities to separate referrals made by GPs, self-referrals and
obligatory referrals for the patients with chronic conditions)
% of children with Acute RTI treated with antibiotics
% of adult population seen by family doctors and/or nurse during last 3 years
Waiting time to GP‘s reception according the time written in a voucher
% of these with diagnosis coronary heart disease, and/or diabetes have recorded
blood pressure during last year
% of vaccinated against influenza at age over 65 and persons with risk conditions
(depending on amount of vaccines received)
% of women who were breastfeeding their newborns
Rate of ambulance calls per 1000 population
% of diabetic patients who had the HbA1C measured, HbA1C is less than 7%
% of pregnant women, who had visits to family doctor or midwife and gynaecologist
(according to the guidelines)
The primary care nurse has a separated consulting room
% of children with Acute RTI treated with Penicillin V (% of total antibiotics)
% of patients with coronary heart disease to whom total cholesterol measuring has
been provided during last year
% of diabetic patients who HbA1C has been measured at least once during last year
% of population with diagnosis of AH
% of AH patients to whom glycemic control has been provided during last year
% of AH patients to whom total cholesterol measuring has been provided during
last year
% of diabetic patients who renal function has been tested during last year
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
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Point
s
54
No of
experts
17
44
13
43
40
40
12
12
13
36
24
20
18
11
7
10
6
18
7
15
15
15
14
6
7
6
5
11
10
6
6
4
4
5
5
1
1
5
3
1
1
0
0
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Annex 4
Patients with chronic non-infectious diseases consultation and motivation incentive services
methodology
I. General provisions
1. The methodology of patients with chronic noncommunicable diseases (further NCD) consultation
and motivation services determines services provision for patients with NCD, which are included in
services provision program, procedures and requirements for services providers.
2. NCD to be included in patients’ consultation and motivation services programme: ischemic heart
disease, arterial hypertension, chronic obstructive pulmonary disease, and bronchial asthma.
3. The aim of consultation and motivation services – to reduce chronic patients acute disease
exacerbations, complications and hospitalisations, after physicians consultation, providing knowledge
and skills for the patients, which would help positively change life style, helping to manage the main
risk factors, and promoting independent and responsible self-care.
4. Patients with NCD consultation and motivation services will be provided in primary health care
institutions (further PHCI).
5. Patients with NCD consultation and motivation services are provided independently from physicians
by community nurses, if necessary in collaboration with other health care specialists.
6. Consultation and motivation services are provided to PHCI patients with NCD, determined in the
2nd subsection.
7. Community nurses provide NCD patients consultation and motivation services consistently
following services implementation procedures determined in the description.
8. Consultation and motivation services were determined referring to scientifically based evidences,
practice and recommendations; health professionals and other experts recommendations; also referring
to Lithuanian Medical Norm MN 57:2011: „Community nurse, rights, duties and responsibilities“; The
Order of Lithuania Minister of Health Nr. V-982: „The approval of the description of care provision
requirements for patients with diabetes“;Order of Lithuania Minister of Health Nr. V-913: „The
approval of screening and prevention funding program for persons in cardiovascular diseases high-risk
group“;The Order of Lithuania Minister of Health Nr. 301: „For preventive health checks in health
care institutions“.
II. The procedure of consultation and motivation services provision
9. Primary and continuous support has to be provided by the community nurses for the patients with
NCD.
10. Patient’s health curriculum consists of five main stages:
10.1. the determination and evaluation of the main risk factors: community nurse determines personal
health education needs for each patient with NCD through major risk factors identification
(malnutrition, lack of physical activity, harmful habits, and stress); additionally, evaluates patient’s
adherence to treatment examination and plan, using evaluation tool – risk factors assessment
questionnaire.
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10.2. information provision to the patient and health curriculum development: after the patient received
the information about the effect and consequences of risk factors, health curriculum have to be
developed, considering individual patient’s characteristics and needs, willingness and readiness to
change life style, social environment factors, socio-economic state, existing chronic disease(s) care
aspects, and identified risk factors;
10.3. management of identified risk factors: according described risk factors evaluation and health
curriculum development requirements, described in 10.1 and 10.2 subsections, community nurses
implement risk factors management, which were identified as the most influential and harmful for the
patient. The management includes:
10.3.1. malnutrition correction: if malnutrition was identified as the most harmful, or one of the most
harmful risk factors for the patient’s NCD exacerbation, community nurse identifies and register
patient’s nutrition features and monitor the changes; additionally, provide healthy diet
recommendations, which also have to be provided in a written form (informational leaflet);
10.3.2. increase of physical activity: if lack of physical activity was identified as the most harmful, or one
of the most harmful risk factors for patient’s NCD exacerbation, community nurse identifies and
register patient’s physical activity level and monitor the changes; additionally, patient have to be
stimulated to be more physically active or do physical exercises, that correspond patient’s physical
condition, age and other special features; the recommendations for physical activity also have to be
provided in a written form (informational leaflet);
10.3.3. reduction and/or refusal of harmful habits: if smoking and/or alcohol consumption were
identified as the most harmful, or one of the most harmful risk factors for NCD exacerbations,
community nurse identifies and register the duration and complexity of harmful habits; independently
from amount and duration of smoking community nurse questions smoking patients about their
attitude and interest in smoking cessation and offers quite smoking; in the case of excessive alcohol
consumption community nurse offers to reduce and/or refuse alcohol consumption;
10.3.4. stress management: if high stress level was identified as the most harmful, or one of the most
harmful risk factors for NCD disease(s) exacerbation, community nurse helps to cope with stress, that
are related to existing disease(s) and other social/environmental factors; additionally community nurse
have to inform the patient about two major stress coping methods: problem focused and emotion
focused coping strategies; the recommendations have to be provided according to individual patient’s
needs;
10.3.5. motivational counselling and patient’s behavioural change: community nurse has to follow
motivational counselling and behavioural change model principles. After risk factors management
development, patient’s stage of change have to be assessed. Considering patient’s stage of change,
community nurse consult the patient about the most appropriate issues, necessary particularly for
individual patient; in the consultation community nurse apply the major behavioural change principles:
appropriate strategies for each stage of behavioural change, patient’s motivation aspects, adaptation of
recommendations and multiple interventions, patient’s resistance management;
10.4. ensuring patient’s adherence to treatment plan: community nurse provides practical advices and
recommendations about adequate and timely use of medications, and supports the patients in order to
ensure adequate adherence to treatment regimen and avoid disease(s) exacerbation;
10.5. patient’s self management promotion: community nurse promotes patient’s self management, and
assists to control the disease(s) by their selves, at the same time maintaining active social life; helps to
overcome frustration, fatigue, pain and social exclusion. For this purpose nurse have to apply self
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management strategies and recommend to the patient how to maintain and strengthen health; helps to
integrate in social environment, and helps to evaluate applied new treatment methods.
11. The primary community nurse consultations lasts 45 minutes and have to be provided once per year
regarding to patient’s health curriculum requirements described in 10, 11, 12 subsections.
12. Community nurse works in collaboration with general practitioners, nurses and other health care
specialists that works in the institution, and, if necessary, has to consult about patient’s health
condition, medical history and other important issues.
III. Health curriculum analysis, assessment and sustainability
13. After the end of patient’s health curriculum implementation period, community nurse analyses and
evaluates achieved results of individual patients. For the assessment community nurse uses
questionnaire for NCD patients, that has to be delivered to the patient after health curriculum
implementation.
14. Community nurse, also, has to monitor chronic disease(s) markers during and after health
curriculum period (blood pressure, cholesterol level in the blood, urine test results, body mass index,
and lung function).
15. After the evaluation of patient’s results, community nurse, taking into account the results and in
collaboration with the patient, provides continuous support through secondary consultation, and, if
necessary, more consultations. Secondary community nurse consultations lasts 30 minutes and have to
be provided according to individual patient’s demand.
16. Continuous support has to be provided in the case of:
16.1. according to risk factors management provided in the health curriculum, patient fails to improve
nutrition habits; increase physical activity; reduce or quite smoking; reduce or refuse alcohol
consumption; overcome stress; consistently follow the treatment plan;
16.2. ineffective patient’s self-management;
16.3. in the case of chronic disease(s) exacerbation.
17. According to patient’s results, the continuous support must be provided for the patient, and health
curriculum has to be amended, attempting to eliminate existing drawbacks and apply new counselling
and motivation strategies.
18. Patient’s consultation and motivation services performance evaluation criteria:
18.1. objective results:
18.1.1. reduction in extra hospitalisations due to NCD exacerbation;
18.1.2. decrease of emergency medical services utilization due to NCD exacerbation;
18.1.3. reduction of visits to general practice physicians due to NCD exacerbation;
18.2. subjective results:
18.2.1. increase in patient self-management capabilities;
18.3.3. patients satisfaction of services provided in their PHCI;
18.3.4. patients satisfaction of services provided by community nurses;
Patients with chronic non-infectious diseases
consultation and motivation incentive services
description
Annex
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Incentive services remunerations
1. Nurses daily workload: full-time – 38 h. per week, part-time – 19 h. per week.
2. Community nurse can consult not more than 10 patients per day.
3. Patients with NCD consultation and motivation services basic costs:
Nr.
Service
1.
Primary individual
community nurse
consultation
2.
Continuous individual
community nurse
consultation
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Remuneration conditions
Provided to adult patients with ischemic
heart disease, arterial hypertension, chronic
obstructive pulmonary disease, and bronchial
– not more than 1 consultation per year.
Duration – 45 minutes.
Provided to adult patients with ischemic
heart disease, arterial hypertension, chronic
obstructive pulmonary disease, and bronchial
– not more than 5 consultation per year.
Duration – 30 minutes.
Basic cost (litai)
25
20
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Annex 5
The report of community training workshop (2012, 14-16 of May)
1st day training. The first training day was about chronic disease management. The main aim of the
day was to provide nurses knowledge and practical skills about chronic disease management in primary
care practice, precisely in community nurses’ daily practice. In the first part of the day the lecturer
cardiologist (Sigute Norkiene) provided knowledge in ischemic heart disease and arterial hypertension
management. Nurses gained knowledge about these diseases care aspects in clinical practice and
through practical exercises got practical skills when encountering this type of patients in the daily
practice. Nurses actively participated in the discussions initiated by the lecturer. During the training
lecturer cardiologist introduced practical situations for the nurses about the possible situations when
confronting with patients with IHD or AH. Visual education material (medical posters and other
educational stuff about cardiovascular diseases) was provided for the nurses during the training.
On the other part of the day the lecturer pulmonologist (Indre Butiene) provided knowledge for nurses
in chronic obstructive pulmonary disease and bronchial asthma management. Nurses gained knowledge
about these diseases care aspects in clinical practice. The lecturer nurses how correctly use inhaler for
the patients with bronchial asthma. Visual education material was, also, provided for the nurses: video
clips about correct use of inhaler, and they also had a chance to try to use correctly by their self after
the clips and lecturer explanations. Due to time limitations practical exercises when confronting
patients with pulmonary diseases were provided in the 3rd day training.
Evaluation of the day. To evaluate training days the evaluation questionnaire was used for each topic
of the day. The 1st day was evaluated by all nurses’ participants (18). Nurses evaluated the training on
cardiovascular disease and on pulmonary disease management separately. Generally, the evaluation was
high on both topics. From possible 270 scores the first part of the day (cardiovascular diseases
management) was assessed by 266 scores, and the other part of the day (pulmonary disease
management) by 260 scores. Nearly all training parts (presentation form, content, and organisation)
were assessed as a very good (5 scores) on both topics. Overall evaluation of the day, scoring from 1 to
10, was mostly 9 or 10. Community nurses also expressed the opinion in open questions. Most of the
answers are shown in the table below.
-
2nd day training. The second training day was about motivational counselling theoretical and practical
aspects. The aim of the day was to provide nurses theoretical knowledge about motivational counselling
strategies in community nurses practice. Motivational counselling lecturer (Milda Dambrauskiene –
expert of the “Crisis Research Centre”) provided knowledge for the nurses about motivational
counselling principles and strategies in community nurse practice with short practical trainings and
discussions. Nurses were tasked with exercises in small groups about theoretical motivational
counselling and patient empowerment aspects, attempting to absorb received information more deeply.
Lecturer, also, provided visual material – short movies related to the training topics and the discussions
after each movie. Nurses were active during all the training day and shared their experience and
received knowledge with each other.
Evaluation of the day. The 2nd day was also evaluated by all training participants (18). Nurses
evaluated the training on motivational counselling and patient empowerment separately. The evaluation
was very high on both topics: from 270 scores both topics were assessed by 270 scores. All training
parts (presentation form, content, and organisation) were assessed as a very good (5 scores) on both
topics. Overall evaluation of the day, scoring from 1 to 10, was also very high: all nurses gave 10 scores.
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Moreover, there were no negative evaluations in open questions. Most of the answers to open
questions are shown in the table given in the table below.
-
3rd day training. The last training day included practical exercises and role-play related to past two days
topics: chronic disease management combined with motivational counselling and patient empowerment
skills. The aim of the day was to train nurses to adapt received knowledge in daily practise situations
though role-play. The 3rd training day was led by lecturer pulmonologist (Indre Butiene) and
motivational counselling lecturer (Arnoldas Jurgutis). The training started with practical situations for
the nurses on pulmonary diseases management: COPD and bronchial asthma management in person’s
daily life and risk factors management, combining with patients’ motivation and empowerment
strategies. After short introduction, Arnoldas Jurgutis continued with role-plays. First of all, two nurses
played a situation in front of the other participants (one of the nurses was consulting nurse, and the
other – the patient). After the role-play lecturer initiated the discussion and stimulated all participants
discuss actively. The situation was analysed in detail with positive and negative assessment of all
participants, and suggestions to improve the consultation. Afterwards, all the nurses were grouped into
pairs and got the situations to play by their own similarly as it was done of the first two nurses. After
the first role-play the nurses changed in pairs and continued to play. When the role-plays were finished,
the lecturer led the discussion and nurses shared their experience received during the role-plays.
Evaluation of the day. The 3rd day was also evaluated by all training participants (18). Nurses
evaluated the training on chronic disease management combined with motivational counselling and
patient empowerment skills. Similarly as on the 2nd, the evaluation of 3rd days was very high as well:
both parts of the day (practical situations on pulmonary disease management and role-plays) were
assessed by 270 scores. All training parts (presentation form, content, and organisation) were assessed
as a very good (5 scores). Overall evaluation of the day, scoring from 1 to 10, was very high as well: all
nurses gave 10 scores. Most of the nurses’ answers to open questions are given in the table below.
Nurses’ answers to training evaluation questionnaire open questions
1st day evaluation
Positive evaluation:
Negative evaluation:
What are three the most useful issues that you
What was useless and
learned today?
unnecessary?
Cardiovascular
Risk factors influence on health;
Knowledge about
and pulmonary Arterial hypertension management;
diseases diagnosis;
diseases
Differences between COPD and asthma;
Information about drugs
management
Healthy human code;
prescribing;
Communication skills;
How to avoid IHD;
IHD management;
How to recognise and manage IHD;
What care is necessary for patients with AH;
How patients should be questioned to
ascertain more about the disease;
Appropriate use of medications;
Consequences of AH;
Knowledge about the cholesterol;
How to recognise myocardial infarction,
angina pectoris, COPD an bronchial asthma;
How to provide information for the patient;
Prevention of chronic diseases;
Symptoms of bronchial asthma and COPD;
Topic of the
day
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Suggestions to
improve the
training
Longer
training
period
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Topic of the
day
Motivational
counselling
theoretical and
practical aspects
Topic of the
day
Practical
exercises and
role-play
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2nd day evaluation
Positive evaluation:
Negative evaluation:
What are three the most useful issues that you
What was useless and
learned today?
unnecessary?
Communication skills between nurse and
–
patient;
Information provision;
Knowledge appliance in practice;
How to motivate the patient;
How to recognise stages of change;
How to know the patient;
Differences between stages of change;
Help patient make decisions;
Know more about patient’s disease and help
to change behaviour;
How to listen actively;
The importance of the motivation;
How to help to change behaviour for
patients with chronic diseases;
How to receive adequate information from
the patient through appropriate questions;
How to manage patient’s resistance and
relapse;
Open/close questions formulation in
communication process;
The benefits of motivational counselling;
Principles of patient empowerment;
Possible patient’s reactions to life changes;
3rd day evaluation
Positive evaluation:
Negative evaluation:
What are three the most useful issues that you
What was useless and
learned today?
unnecessary?
Bronchial asthma an COPD treatment and
–
management;
Work in groups;
Patients counselling and motivation;
Adequate questions for the patients;
Use gained knowledge in the daily practice
situations;
Implement motivational counselling in the
practice;
Shared decision making benefits;
How to gain patient’s confidence;
The benefit of appropriate counselling for
the results of the patient;
Communication skills.
Suggestions to
improve the
training
Longer
training
period
Suggestions to
improve the
training
More work in
groups;
To introduce more
training on how to
manage patients’
resistance
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REFERENCES
1. World Health Organization (2008). The World Health Report 2008: Primary Health Care – Now More
than Ever. (Report). Geneva: World Health Organisation.
2. North Dimension Partnership in Public Health and Social Well-being. (2008). Primary health
care in the North dimension countries (Thematic report).
3. Jurgutis A., Vainiomäki P (2011). Operational System of Evidence Based and Widely
Recognised Quality Indicators for PHC performance. Proposal document for discussions with
stakeholders.
4. Anstiss T. (2009). Motivational interviewing in primary care. Journal of Clinical Psychology in Clinical
Settings, 16: 87–93
5. Laurant M., Reeves D., Hermens R. et al. (2009). Substitution of doctors by nurses in primary
care (Review). Cohrane Database of Systematic Reviews, Issue 1.
6. Runciman P., Watson H., McIntosh J., Tolson D. (2006). Community nurses’ health promotion
work with older people. Journal of Advanced Nursing, 55(1): 46-57.
7. Rice V., H., Stead L., F. (2009). Nursing interventions for smoking cessation (Review). Cohrane
Database of Systematic Reviews, Issue 1.
8. Stenner K., L., Courtenay M., Carey N. (2011). Consultations between nurse prescribers and
patients with diabetes in primary care: A qualitative study of patient views. International Journal of
Nursing Studies, 48: 37–46.
9. Koelewijn-van Loon M., S., Weijden T., Ronda G. et al. (2010). Improving lifestyle and risk
perception through patient involvement in nurse-led cardiovascular risk management: A clusterrandomized controlled trial in primary care. Preventive Medicine, 50: 35–44.
10. Hernandez J., Anderson S. (2012). Storied experiences of nurse practitioners managing
prehypertension in primary care. Journal of the American Academy of Nurse Practitioners, 24 : 89–96.
11. Holmqvist M., Bendtsen P., SpakF. et al. (2008). Asking patients about their drinking A national
survey among primary health care physicians and nurses in Sweden. Addictive Behaviors, 33: 301–
314.
12. LR Sveikatos apsaugos ministro įsakymas “Dėl Lietuvos medicinos normos MN 57:2011
„Bendruomenės slaugytojas. Teisės, pareigos, kompetencijos ir atsakomybės“ patvirtinimo.
2011 m. birželio 30 d. Nr. V-650, Vilnius
13. LR Sveikatos apsaugos ministro įsakymas “Dėl sergančiųjų cukriniu diabetu slaugos paslaugų
teikomo reikalavimų aprašo patvirtinimo”. 2008 m. spalio 10 d. Nr. V-982, Vilnius.
14. LR Sveikatos apsaugos ministro įsakymas “Dėl asmenų, priskirtinų širdies ir kraujagyslių ligų
didelės rizikos grupei, atrankos ir prevencijos priemonių programos patvirtinimo”. 2005 m.
lapkričio 25 d. Nr. V-913, Vilnius.
15. LR Sveikatos apsaugos ministro įsakymas “Dėl profilaktinių sveikatos tikrinimų sveikatos
priežiūros įstaigose”. 2000 m. gegužės 31 d. Nr.301, Vilnius.
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16. Queensland Government. (2005). Queensland strategy for chronic diseases 2004-2015.
Brisbone: Queensland Health.
17. Department of Health. (2005). Supporting people with long term conditions: An NHS and social care
model to support local innovations and integration. Quarry Hill: Department of Health.
18. The Royal College of General practitioners. (2009). Guidelines for preventive activities in general
practice (7th edition). South Melburne, Victoria: The Royal College of General practitioners.
19. Laws R. A., Chan B. C., Williams A. E. Et al. (2010). An efficacy trial of brief lifestyle
intervention delivered by generalist community nurses (CN SNAP trial). BMC Nursing, 9:4.
20. Garcia J., Beyers J., Uetrecht C. Et al. (2010). Healthy eating, physical activity, and healthy weights
guideline for public health in Ontario. Ontario: Cancer Care Ontario.
21. Glasgow et al, Whitlock et al. (2002). 5 A’s Behavior Change Model Adapted for Self-Management
Support
Improvement.
Retrieved
from:
http://www.improvingchroniccare.org/downloads/3.5_5_as_behaviior_change_model.pdf
22. Bundy C. (2004). Changing behaviour: using motivational interviewing techniques. Journal of The
Royal Society of Medicine, 97(44): 43-47.
23. Wolff J. L., Starfield B., Anderson G. (2002). Prevalence, expenditures, and complications of multiple
chronic conditions in the elderly. Archives of Internal Medicine; 162. p. 2269-2276.
24. Ong K.L., Cheung B.M., Man Y.B., Lau C.P., Lam K.S. (2007). Prevalence, awareness, treatment, and
control of hypertension among United States adults 1999-2004. Hypertension; 49(1):69-75.
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D. Adjusted Clinical Groups (ACG) and co-morbidity
Adjusted Clinical Groups (ACG)
and co-morbidity
Economic steering owing to the burden of sickness in the population – recent
experiences from Sweden
Andrzej Zielinski1, Bengt Ardenvik2, Ingvar Ovhed1,
Blekinge Centre of Competence, Sweden, 2Centre for Development, Region Skåne, Sweden
1
Background
PHC plays an important role in the health care system by delivering more efficient, equitable and
effective care(1). The two major challenges to PHC are managing co-morbidity and improving
equity in health care services. Thus patients with co-morbidity often need complex treatment and
account for a high proportion of resource use in health care.
An ageing population and co-morbidity
The demographic curve has changed markedly during the last century in Sweden and the number
of elderly individuals has increased. One of the emerging problems in an ageing population is comorbidity. With increasing life expectancy in society, the number of patients with multiple
chronic diseases occurring simultaneously increases. Patients with co-morbidity are the norm
rather than the exception in PHC practices(2,3). Their health needs should be recognized. This is
important for those who organize PHC and for planning and deciding about reimbursement in
PHC. Due to the increasing number of patients with multiple chronic diseases in PHC(4), the
problem of assessing co-morbidity seems to be very important. Co-morbidity increases the risk
of mortality (5), leads to longer stays in hospital (6), increases health care utilization (3)and
deteriorates physical functioning (7). Although co-morbidity is a common condition among PHC
patients, it is not so often the subject of studies as single diseases, such as for example asthma or
hypertension (8).
Measuring co-morbidity
Patients with co-morbidity require a comprehensive health assessment and treatment taking into
account all of the diseases. Co-morbidity and multimorbidity are the concepts which are often
used to describe individuals with more than one chronic condition.
The studies with indices of co-morbidity are based on different sources such as self reports
(Seattle Index of Comorbidity), medical records (Kaplan-Feinstein Index, Charlson Index) or
administrative data (Chronic Diseases Score). It is important to have complete data. Data
collected with use of interviews or questionnaires depend on the patients’ ability to give an
adequate answer, which is a weakness of such studies. The risk of using self-reported diagnoses is
that patients can forget to inform about some of diagnoses or confuse symptoms.
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D. Adjusted Clinical Groups (ACG) and co-morbidity
ACG- Case-Mix System
Another way to measure co-morbidity in PHC is the Adjusted Clinical Groups Case-Mix System
(ACG Case-Mix System) (9). The ACG Case-Mix System not only describes the presence of
disease but also gives a measure of co-morbidity on an ordinal scale. The ACG Case-Mix System
takes into account all possible diagnoses and calculates groups of individuals with the same level
of morbidity. This method makes it possible for us to compare patients with different diagnoses.
The Adjusted Clinical Groups Case-Mix System (ACG Case-Mix System) was designed to
measure co-morbidity level. It was developed in the 1980s at Johns Hopkins University. Primarily
the system was created to analyse the relationship between morbidity and the use of health care
by children over a time. Diagnoses were grouped in categories dependent on the diagnoses’ selflimitation, likelihood to recur over time or chronic character and need of specialist’s consultation.
It was then modified for use in adults.
The first step in building an ACG group is gathering all the diagnoses in one of 32 ADGs. Each
ADG includes a diagnosis with similar severity and likelihood of the health condition’s
persistence over time. There are five criteria of ADG which are based on the opinions of expert
physicians concerning:
the duration of the condition (acute, recurrent, chronic)
the severity of the condition (e.g. minor and stable versus major and unstable)
diagnostic certainty (symptom versus disease)
aetiology of the condition (infectious, injury or other)
specialty care involvement (e.g. medical, surgical, obstetric.)
One patient can have more than one ADG as he or she can have more than one disease. The
next step is to group each individual in one specific ACG by a branching algorithm. ACG
categories are based on empirical analysis and clinical judgement and are calculated by combining
ADGs, gender and age but not the number of visits or episodes. Individuals who are grouped in
the same ACG have a similar pattern of morbidity and resource consumption during a given
period.
PHC in Sweden today
According to the Swedish Health and Medical Services Act from 1982, PHC should ensure basic
medical treatment, care, prevention and rehabilitation which do not require specialist or hospital
resources.
Family medicine has been a separate specialty in Sweden since 1982. PHC is organized in small
health care centres with physicians, mostly specialists in family medicine, nurses, physiotherapists
and midwives with responsibility for patients within geographically limited areas. This system has
changed in recent years with a tendency towards smaller PHC practices consisting of physicians
and nurses only.
In Sweden health care can be provided by both public and private care givers. Both public and
private driven health care are publicly financed by county councils. Most PHC is public, but the
privatization of PHC under contract from county councils is increasing. This means a higher
level of competition between PHC centres/practices but at the same time should ensure better
access to PHC. Expansion of the private sector in PHC caused by reforms in Swedish health care
resulted in more private PHC practices being established, mostly in major cities.
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D. Adjusted Clinical Groups (ACG) and co-morbidity
Costs in primary health care and how they relate to co-morbidity
Health care costs depend on the development of technology. The use of new high-tech medical
devices or drugs increases the costs of health care. SHC doctors are used to meeting selected
patients who need advanced diagnosis and treatment. This means that the specialists more readily
use more expensive methods in order to diagnose and begin treatment after a short time of
observation. Most PHC patients’ health condition is not so severe and GPs can assess their
health care needs and treat them with easier and cheaper methods. It saves costs and protects
patients from unnecessary and sometimes potentially harmful diagnostics. In one study in the
USA the costs of health care were lower and the quality of care higher in states with a higher
supply of general practitioners in comparison to states with a higher supply of specialists (10).
Whittle et al. found that among patients who were treated for pneumonia and did not die, those
whose attending doctor was a family physician had the lowest costs of treatment (11). Patients
with co-morbidity are common PHC patients, and many studies show that co-morbidity is
associated with higher health care costs (3,12).
Rational use of resources can ensure health service for all who need it, and conversely if we use
resources irrationally or inadequately there is a risk that there will not be enough for everyone in
need. In Sweden the capitation was based mainly on the age of the inhabitants, but only about
11% of the variation in PHC costs could be explained by age and gender (12). People of the same
age can have different needs of health care, and relying only on age or gender when allocating
resources or deciding about reimbursement is not enough.
Socioeconomic factors and equity in health care
Social stratification in society partly explains the unequal distribution of wealth. This can be
significant for differences in health between different groups. Some diseases are equally
distributed regardless of socioeconomic status (SES) whereas others more often exist in affluent
groups or poor groups. Worse socioeconomic circumstances often lead to worse health status
(13) with higher morbidity and mortality both in Sweden and in other countries (14, 15, 16).
Unequal distribution of resources in society results in different exposures, and this can result in
unequal distribution of diseases. Therefore the confounding effect of socioeconomic conditions
is so important to take into consideration when analysing other factors. Even though Sweden is
known as an egalitarian society, socioeconomic differences in mortality are found here (14).
Although some studies have found that socioeconomic differences were not as large as in other
countries (17, 18), other research suggests that they were higher (16).
A number of indicators are used to measure SES, but all the different indicators are correlated
with each other and they describe particular aspects of social stratification.
One of these indexes is CNI – Care Need Index, using seven factors, developed by Swedish
researchers (19).
1. Degree of unemployness
2. Proportion of children below 5 years
3. Proportion of population born outside EU
4. Single parents with children below 17 years
5. Single people over 65 years
6. Moved last year
7. Low educational level
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D. Adjusted Clinical Groups (ACG) and co-morbidity
The Skåne model for Reimbursement of PHC
In Skåne region in Southern Sweden, with a population of 1,25 million, a combination of ACGweights and CNI was introduced in 2010 as a model for reimbursement for needs.
Primary care allowance moves as patient chooses health centre
Primary care allowance (more than 90% of the reimbursement).
Target-related reimbursement (linked to degree of coverage and quality criteria).
Special reimbursement for interpreter and socioeconomic factors.
Reimbursement for special assignments
Reimbursement for needs, also including pharmaceuticals. PHC has the cost responsibility for
common essential drugs, which means 75% of the total budget.
If you attract sick individuals you need more resources, because of that;
- 80 % of the amount is determined by age, gender and ACG care weighting
If you attract groups at risk for sickness you need more resources for preventive care, therefor;
- 20 % of the amount is determined by socioeconomic determinants, Care Need Index, based on
unemployment, income, education level etc.
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D. Adjusted Clinical Groups (ACG) and co-morbidity
Figure 1. Combined weigths for four PHC centres with different sickness and socioeconomic
burdens.
Combination of ACG- and CNI-weights for some PHC
centres in Skåne region, Sweden 2010
2,50
2,00
1,50
1,00
0,50
0,00
PHCC A
PHCC B
PHCC C
PHCC D
1. ACG-weight
0,72
0,69
0,85
1,30
2. CNI-weight
0,86
1,23
2,21
1,09
3. ACG*0,8+CNI*0,2
0,75
0,80
1,12
1,26
1. ACG weight (individual based)
2. CNI-weight (population based)
3. Combined basis for payment
PHCC A: Low needs – urban population, low sickness good socioeconomy
PHCC B: Rather low needs – student families, low sickness but worse socioeconomic
situation
PHCC C: High needs: low sickness, most worse socioeconomic situation
PHCC D: Highest needs: Highest individual sickness, old rural population, not so good
socioeconomic situation
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D. Adjusted Clinical Groups (ACG) and co-morbidity
Figure 2: Degree of explanation of costs in PHC, up to gender, gender and age, PHC district and
gender, age, PHC district and ACG-weights.
Degree of explanation of costs in PHC
100,00%
90,00%
80,00%
70,00%
60,00%
50,00%
40,00%
30,00%
20,00%
10,00%
0,00%
degree of explanation
1. gender
1.+age
2.+ PHC
district
3+ACGweights
1,87%
14,25%
14,88%
63,41%
after Zielinski (20)
Comments: In figure 2 can be seen that age explains much more than gender up to costs.
However, when adding the burden of sickness in a population you will explain lmost 2/3 of the
total costs. It may be expected that if pharmaceutical costs and costs for sick-leave are added the
degree of explanation will be still higher.
Discussion and conclusions
Although co-morbidity is a very common condition, not much is known about how to organize
PHC in order to ensure the best health care for this patient group. The importance of comorbidity should be made more visible for health care managers. Their decisions about
reimbursement or organization changes of health care system can be more appropriate for
improving the care of older patients with co-morbidity.
Co-morbidity level measured as ACG or RUB explains patients’ costs to a high degree and much
higher than demographic data such as age and gender. The usefulness of measuring co-morbidity
lies in the possibility of creating a model for more adequate resource allocation in Swedish PHC.
This could ensure more equitable PHC where patients with multiple chronic diseases would have
good access to PHC resources. The ACG Case-Mix System has shown to be an important tool to
help to allocate resources according to need (21).
In Sweden in 2012 an increasing proportion of county councils are implementing this tool for
reimbursement of PHC.
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D. Adjusted Clinical Groups (ACG) and co-morbidity
References
1. Starfield B, Shi L, Macinko J: Contribution of primary care to health systems and health.
Milbank Q 2005, 83(3):457-502.
2. Fortin M, Bravo G, Hudon C, Vanasse A, Lapointe L: Prevalence of multimorbidity among
adults seen in family practice. Ann Fam Med 2005, 3(3):223-228.
3. Wolff JL, Starfield B, Anderson G: Prevalence, expenditures, and complications of multiple
chronic conditions in the elderly. Arch Intern Med 2002, 162(20):2269-76.
4. Uijen AA, van de Lisdonk EH: Multimorbidity in primary care: prevalence and trend over the
last 20 years. Eur J Gen Pract 2008, 14 Suppl 1:28-32.
5. Newman AB, Boudreau RM, Naydeck BL, Fried LF, Harris TB: A physiologic index of
comorbidity: relationship to mortality and disability. J Gerontol A Biol Sci Med Sci 2008,
63(6):603-609.
6. Librero J, Peiro S, Ordinana R: Chronic comorbidity and outcomes of hospital care: length of
stay, mortality, and readmission at 30 and 365 days. J Clin Epidemiol 1999, 52(3):171-179.
7. Marengoni A, von Strauss E, Rizzuto D, Winblad B, Fratiglioni L: The impact of chronic
multimorbidity and disability on functional decline and survival in elderly persons. A communitybased, longitudinal study. J Intern Med 2009, 265(2):288-295.
8. Fortin M, Lapointe L, Hudon C, Vanasse A: Multimorbidity is common to family practice: is it
commonly researched? Can Fam Physician 2005, 51:244-245.
9. Starfield B, Weiner J, Mumford L, Steinwachs D: Ambulatory care groups: a categorization of
diagnoses for research and management. Health Serv Res 1991, 26(1):53-74.
10. Baicker K, Chandra A: Medicare spending, the physician workforce, and beneficiaries' quality
of care. Health Aff (Millwood) 2004, Suppl Web Exclusives:W4-184-97.
11. Whittle J, Lin CJ, Lave JR, Fine MJ, Delaney KM, Joyce DZ, Young WW, Kapoor WN:
Relationship of provider characteristics to outcomes, process, and costs of care for communityacquired pneumonia. Med Care 1998, 36(7):977-987.
12. Engstrom SG, Carlsson L, Ostgren CJ, Nilsson GH, Borgquist LA: The importance of
comorbidity in analysing patient costs in Swedish primary care. BMC Public Health 2006, 6:36.
13. Dalstra JA, Kunst AE, Mackenbach JP, EU Working Group on Socioeconomic Inequalities
in Health: A comparative appraisal of the relationship of education, income and housing tenure
with less than good health among the elderly in Europe. Soc Sci Med 2006, 62(8):2046-2060.
14. Sundquist J, Johansson SE: Indicators of socio-economic position and their relation to
mortality in Sweden. Soc Sci Med 1997, 45(12):1757-1766.
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ImPrim Report
D. Adjusted Clinical Groups (ACG) and co-morbidity
15. Gerber Y, Weston SA, Killian JM, Therneau TM, Jacobsen SJ, Roger VL: Neighborhood
income and individual education: effect on survival after myocardial infarction. Mayo Clin Proc
2008, 83(6):663-669.
16. Mackenbach JP, Kunst AE, Cavelaars AE, Groenhof F, Geurts JJ: Socioeconomic
inequalities in morbidity and mortality in western Europe. The EU Working Group on
Socioeconomic Inequalities in Health. Lancet 1997, 349(9066):1655-1659.
17. Vagero D, Lundberg O: Health inequalities in Britain and Sweden. Lancet 1989, 2(8653):3536.
18. Yngwe MA, Diderichsen F, Whitehead M, Holland P, Burstrom B: The role of income
differences in explaining social inequalities in self rated health in Sweden and Britain. J Epidemiol
Community Health 2001, 55(8):556-561.
19. Sundquist K, Malmstrom M, S Johansson S, Sundquist J:Care Need Index, a useful tool for
the distribution of primary health care resources. J Epidemiol Community Health. 2003
May;57(5):347-52
20. Zielinski A, Kronogård M, Lenhoff H, Halling A. Validation of ACG Case-mix for equitable
resource allocation in Swedish primary health care. BMC Public Health 2009:9:347
21. Zielinski A. Analysing performance of primary health care using the ACG Case-Mix System.
Thesis Lund university 2011
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ImPrim Report
E. The Swedish Quality Registries and PHC
The Swedish Quality Registries and Primary Health
Care
Rut F Öien1, Ingvar Ovhed1
Blekinge Centre of Competence
1
A system of national quality registries has been established in the Swedish health and medical
services in the last decades. There are about 73 registries and seven competence centres that
receive central funding in Sweden. All national quality registries contain individualised data
concerning patient problems, medical interventions, and outcomes after treatment and
aggregated the data can be used with the purpose of continuous learning, quality improvement
and management.
Definition of quality registers in Sweden
A national quality registry contains individualised data concerning patient problems, medical
interventions, and outcomes after treatment; within all healthcare production. It is annually
monitored and approved for financial support by an Executive Committee.
Vision
The vision for the quality registries and the competence centres is to constitute an over-all
knowledge system that is actively used on all levels for continuous learning, quality improvement
and management of all healthcare services.
A catalogue that describes the National Healthcare Quality Registries in Sweden was published
2007. The catalouge also describes the organization of the Quality Registries and the Swedish
healthcare system.
Competence centres
Seven competence centers for the National Quality Registries has been established. In a
competence center, several registries share the costs for staff and systems that a single registry
could not bear. Hence, a continued development of the registries can be assured although the
system follows a decentralized model, i.e. each register is governed by a professional
collaboration.
Competence centers aim to promote the development of new registries, create synergy effects by
collaboration among registries (eg, in technical operations, analytical work, and use of registry
data to support clinical quality improvement), and helping to make registry data beneficial for
different users.
EyeNet
One of the very first centers is Eyenet,
EyeNet Sweden was instituted January 2003 as a centre of competence within the field of quality
registries. The Swedish National Cataract Register, NCR, with its long experience of data
collection and research, formed the framework of this new developing centre. EyeNet Sweden
now works with and supports registries from all parts of health care, including dental care.
EyeNet Sweden is located in Blekinge Hospital in Karlskrona Sweden close connected to
Blekinge Centre of Competence, LP of the ImPrim project.
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E. The Swedish Quality Registries and PHC
The principal recipients of the feedback of procesed and analyzed data from the National Quality
registries are the local profession and the units that participate in the registry. It is there that they
best can analyse data as well as take measures for improvement. In pace with the increasingly
open reporting of results by the registries, other interested parties have also arisen such as
patients/the public and politicians as well as client organizations. A Handbook for establishing
quality registries was published by EyeNet and will be accessible on the web.
Primary Health Care and Quality registries
In PHC the value of quality registries has been lively discussed. The arguments against have been
that the management of old patients with co-morbidity seldom will follow guidelines. However
there are general practitioners who have developed quality registries for PHC. One of these are
Rut F Oien, MD PhD, coordinator of the national quality registry Rikssår or RUT (Registry of
Ulcer Treatment). She started this work 15 years ago and is now the coordinator on national
level.
Her description of this register follows;
Registering Ulcer Treatment through a national quality registry:
RUT – a winning concept for both patients and the health care sector
Rut F Öien
RUT (Registry of Ulcer Treatment) is a web-based national quality registry on hard-to-heal ulcers
developed to meet the demands of modern ulcer care in providing reliable diagnosis, adequate
strategies for ulcer care and a structured follow up to ulcer healing. RUT was the first primary
care quality registry in Sweden initiated by a general practitioner, Rut F Öien, since most leg
ulcers patients are treated in primary or community care in Sweden. RFÖ is also the registry
manager.
National registries
A system of national quality registers has been established in the Swedish health and medical
services in the last decades. RUT (Registry of Ulcer Treatment) has been running since May 1st,
2009. The Swedish national registers cover different areas of medicine such as diabetes mellitus
(NRD), dementia (SweDEM), Swedish intensive care (SIR) and acute coronary care (RIKS-HIA).
There are currently 73 registers and 27 registry candidates that receive central funding from Salar,
the Swedish Association of Local Authorities and Regions www.skl.se. Salar publishes reports
from the registers to enable the participant clinics to compare their outcome results with other
clinics in Sweden for optimising medical care.
RUT was developed in cooperation with EyeNet Sweden www.eyenetsweden.se, one of the
competence centres (1) and is also the first primary care register in Sweden initiated by a general
practitioner Rut F Öien (RFÖ).
Research in wound management
In Blekinge county there are 150,000 inhabitants and we have 25 years’ experience of quality
improvement and clinical research within the field
of wound management (2, 3) resulting in the establishment of Blekinge Wound Healing Centre in
2003. The Centre is a GP-led (RFÖ), primary care based specialist centre covering the treatment
and follow up of the majority of ulcer patients in the whole county. Ten per cent of the patients
treated at the Centre are referred from physicians at the hospital.
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When the need for a web-based quality register became obvious, RUT was developed to meet the
demands of modern ulcer care. Introducing
a structured team management of ulcer care with the emphasis on diagnosis and documentation
and treatment was the key to success for an improved
wound management programme. Over the last years, RUT has been adjusted and evaluated at
Blekinge Wound Healing Centre in order to determine the clinical parameters. RUT has been
operational since May 1st, 2009.
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ImPrim Report
E. The Swedish Quality Registries and PHC
Registrations in RUT
Patients with hard-to-heal leg, foot and pressure ulcers are registered at two occasions. The first
registration, assessment of the ulcer, is to guarantee the diagnosis. The second registration is at
follow up, i.e. at ulcer healing.
It should be noted that all patients with a non-healed ulcer remain on the register until the ulcer
is healed no matter how long this takes. Therefore, at follow up the patient can either have a
healed ulcer, be deceased, have had an amputation and thus no longer an ulcer, moved to another
geographical area or no longer wishes to stay on the register.
At the first registration the following parameters are noted: patient’s social security number,
which is linked and matched to the Population Statistics at The Council for Official Statistics of
Sweden; gender; age; date of diagnosis;
profession or former profession; smoking habits; civil status; number of children; mobility;
exercises habits and Body Mass Index.
In addition, details are also taken regarding the nurse responsible for ulcer care; if the ulcer is a
recurrent, new or traumatic ulcer; actual or earlier concomitant diseases; actual medication with
particular interest in analgesics and
antibiotics, and ulcer related pain. In the anamnesis (patient history) we focus on the following
parameters: DVT (Deep Vein Thrombosis), varicose veins; arterial or venous surgery, history of
recurrent leg ulcers, ulcer localisation: foot, leg, sacrum/hip and lateral or medial localisation.
Ulcer size is also measured by digital planimeter (Visitrak®) and number of ulcers is noted.
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During this evaluation we also assess patient circulation by means of palpation of arteria dorsalis
pedis and arteria tibialis posterior as well as measuring the blood pressure by a hand-held Doppler,
which is also used for measuring
deep or superficial venous insufficiency (vena saphena magna, vena saphena parva and vena poplitea).
The diagnosis is set by using these parameters together with the clinical examination. The
following ulcer diagnoses are used: venous, arterial, venous-arterial, diabetic foot ulcer, pressure
ulcer, traumatic ulcer, skin malignancy, hypostatic eczema or other diagnosis.
The strategy for wound management includes prescribed care for the skin surrounding the ulcer,
the ulceredges and the ulcer bed, as well as treatment for oedema. A photo gallery is linked to the
register for visualizing the healing
process .
Follow up at complete ulcer healing includes date of healing; time for healing (weeks); estimated
number of weekly dressing changes to healing; compression therapy; treatment with antibiotics;
pain relief; the most used dressing material, and if advice was given on smoking cessation,
exercises and diet. Adverse events are recorded at follow-up i.e. amputation, venous or arterial
surgery and death.
Every unit registers and has access to its own patients and visits. Registration can be done at any
moment and follow-up can be carried out when all the mandatory parameters are registered.
Reports
Every unit or user can at any time receive data from their own unit which can be used to
compare the unit’s quality of wound management to the whole country.
Technical support is performed by EyeNet Sweden, www.eyenetsweden.se.
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ImPrim Report
E. The Swedish Quality Registries and PHC
Results 2009-2012
An earlier study demonstrated a significant improvement in the care of hard-to-heal leg and foot
ulcers in the county of Blekinge during the period 1994 to 2005 with reduction of treatment time,
prevalence and significant costs
savings (3).
Treatment time decreased from 1.7 hours per patient per week in 1994 to 1.3 hours in 2005.
Estimated prevalence of hard-to-heal leg and foot ulcers reduced from 0.22% in 1994 to 0.15%
in 2005. These results led to a significant reduction of annual costs by SEK 6.96 million
(approximately 1 million Euro) in the study area.
Another explanation for the improved results of leg and foot ulcer care is the more frequent use
of compression therapy (71% in 1994 and 90% in 2005), a key to successful treatment of venous
leg ulcers.
A further indicator of improved leg and foot ulcer care is the reduction in daily dressing changes
(20% in 1994 to 10% in 2005) and the increase in weekly changes (12% in 1994 to 32% in 2005),
which is also acknowledged in
a recent Swedish study (4).
Basic data from the adjusted register in 2012 (n=1162) show a mean age of 73 years (13-97 years)
with 60% women. Fiftyfour percent of the patients suffered from heart disease and eleven
percent had rheumatoid arthritis or other
inflammatory disease.
Ulcer healing
0.00 0.25 0.50 0.75 1.00
Ulcer healing per year
0
Number at risk
2009 111
2010 258
2011 260
2012 106
100
200
300
400
Days
500
600
700
800
69
134
114
26
43
64
39
4
27
39
16
0
22
24
5
0
20
12
0
0
12
5
0
0
4
3
0
0
2
2
0
0
2009
2011
2010
2012
Data from RUT show that in 2009 the median healing time was 135 days for ulcers of any
etiology compared with 61 days in 2012.
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Another result is the reduction of treatment with antibiotics from 78% in 2006 (5) compared
with 24.6% in 2012.
RUT has been implemented regionally and is in use in primary, community and hospital care,
namely dermatological departments, throughout the country. RUT has proved to be a guarantee
for good clinical practice as well as for evaluation of quality, more participants are joining the
register.
Discussion
The leg ulcer patient’s right to receive optimal treatment has been limited during the last decades
due to lack of diagnosis by the physician and continuity of ulcer care to complete healing.(2,6,7)
Dressing changes throughout weeks, months and even years have been carried out by the nurse
often without a proper diagnosis.(2) The physician has often been absent in the team work
around the patient, leading to missed diagnosis and hence the leg ulcer patient is not given
optimal treatment for healing. It is well known that understanding the aetiology of leg ulceration
is a prerequisite to systematic and sound clinical assessment and to planning and implementing
appropriate wound management (8, 9). Furthermore research results have proven that hard-toheal leg and foot ulcers, being symptoms of underlying chronic circulatory disease, have an
adverse effect on the patients’ quality of life (10, 11).
RUT, as a diagnostic quality registry, provides information on both the outcome and process
quality needed to provide high quality leg ulcer care. Several problem areas such as injuries caused
by the health care sector can easily be identified in RUT leading to correction of treatment while
also focusing on education of staff (12). Improvements in leg and foot ulcer care lead to a better
quality of life and a reduction of pain in patients with ulcers (13-15). These aspects and the cost
savings would be substantial if the quality register RUT were to be introduced in any department
where ulcer care is given.
A shift in paradigm has occurred, where “ulcer care” with accurate diagnosis and effective
treatment evolved to “ulcer healing”. A national quality registry has been found to be imperative
in achieving better conditions for leg
ulcer patients.
Hard-to-heal leg and foot ulcers have an adverse effect on the patients’ quality of life. Giving
these patients an early and adequate diagnosis and hence more effective treatment will not only
improve ulcer care but also reduce the costs for the health care sector. The success of wound
management will be based on ensuring that the patient and staff have the knowledge and
understanding of the
ulcer’s aetiology and how specific types of treatment work.
RUT would appear to have the potential to improve the quality of care, ensure appropriate
diagnosis and treatment, and eventually improve health outcomes nationwide.
Conclusion
To optimise treatment of hard-to-heal ulcers nationwide there is a need for a webbased quality
registry to compare care, needs, costs and outcomes. RUT would appear to fulfill these demands
and can also be used to identify problem areas such as injuries caused by the health care sector.
Acknowledgement:
Part of this article was published in EWMA journal
Öien RF. RUT – a winning concept for both patients and the health care sector. EWMA Journal
2009;9(2):41-4.
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E. The Swedish Quality Registries and PHC
References
1. Lundström M (ed.), Albrecht S, Serring I, Svensson K, Wendel E. Handbook for establishing
quality registries. EyeNet Sweden, Karlskrona, Sweden 2005.
ISBN 91-631- 8585-7.
2. Öien RF, Håkansson A, Ovhed I, Hansen BU. Wound management for 287 patients with
chronic leg ulcers demands 12 full-time nurses. Leg ulcer epidemiology and care in a well-defi
ned population in Southern Sweden. Scand J Prim Health Care 2000;18:220-5.
3. Öien RF, Ragnarson Tennvall G. Accurate diagnosis and effective treatment of leg ulcer
reduce prevalence, care time and costs. J Wound Care
2006;15:259-62.
4. Ragnarson Tennvall G, Hjelmgren J, Öien R. The cost of treating hard-to-heal venous leg
ulcers: results from a Swedish survey. World Wide Wounds [serial
on the internet]. 2006 November [about 8 p.]. Available from
www.worldwidewounds.com/2006/ november
5. André M, Eriksson M, Odenholt I. Treatment of patients with skin and soft tissue infections.
Results from the STRAMA survey of diagnoses and prescriptions among general practitioners.
Lakartidningen. 2006 Oct 18-24;103(42):3165-7. [Article in Swedish]
6. Husband LL. Shaping the trajectory of patients with venous ulceration in primary care. Health
Expect 2001 Sep;4(3):189-98.
7. Phillips T, Stanton B, Provan A, Lew R. A study of the impact of leg ulcers on quality of life: fi
nancial, social, and psychological implications. J Am Acad
Dermatol, 1994;31:49-53.
8. Kjaer, ML, Sorensen LT, Karlsmark T, Mainz J, Gottrup F. Evaluation of the quality of
venous leg ulcer care given in a multidisciplinary specialist centre. J Wound Care 2005
Apr;14(4):145-50.
9. Dowsett C. Assessment and management of patients with leg ulcers. Nurs Stand 2005 Apr 2026;19(32):65-6, 68, 70
10. Lindholm C, Bjellerup M, Christensen OB, Zederfeldt B. Quality of life in chronic leg ulcer
patients. An assessment according to the Nottingham Health Profi le. Acta Derm Venereol
(Stockh) 1993; 73:440-3.
11. Ragnarson Tennvall G, Apelqvist J. Health-related quality of life in patients with diabetes
mellitus and foot ulcers. J Diabetes Complications 2000;
14(5):235-41.
12. Simon DA, Dix FP, McCollum CN. Management of venous leg ulcers. BMJ 2004 Jun
5;328(7452): 1358-62.
13. Boulton AJ, Vileikyte L, Ragnarson-Tennvall G, Apelqvist J. The global burden of diabetic
foot disease. Lancet 2005;366(9498):1719-24.
14. Öien RF, Håkansson A, Hansen BU. Leg ulcers in patients with rheumatoid arthritis– a
prospective study of aetiology, wound healing and pain reduction
after pinch grafting. Rheumatology 2001;40:816-20.
15. Rolandsson O, Hasselström J, Öien R, Säwe J. Peripheral arterial disease in primary health
care. Occurrence and care. Läkartidningen 2006 Sep
13-19;103(37):2645-6, 2648- In Swedish.
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NDPHS
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Remunerating
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