Transcript Bild 1

• Quality follow up programme in primary
care. Experiences from Västra Götaland
what have we learned?
Staffan Björck, Analysenheten, Regionkansliet, Västra Götalandsregion
Region Västra Götaland
1.5 mil. Inhab.
16% of Sweden
Göteborg
Västra Götalandsregionen
• financing, primary care centres:
• Capitation, listed patients
•
•
•
•
Age and gender
ACG, adjusted clinical groups
CNI, care need index
Distance to hospital
– P4P (quality)
• initially 3 % with aim to increase
• 4,3 % 2011
Effect of ACG on reporting
of diagnoses
70 000
60 000
50 000
patients
40 000
30 000
20 000
10 000
0
Number of patients
with diabetes in
regional database
Effect of ACG on reporting
of diagnoses
Current prevalence
of atrial fibrillation in
Västra Götaland
40
35
percent
30
25
men
women
20
15
10
5
0
4
49
0
5
5
0-
9
9
6
6
0-
7
0-
9
7
age
9
-8
80
90
T
al=2.44%
t
o
Follow up quality of care
• Identify indicators
• System for payment for performance
How to do it?
Learn from others
Develop your own version
• Learn from others
– Reports on Swedish experiences
– International experience
Most common Indicators for P4P in
Sweden, Anell 2009
mått
Adherence to drug recommendations
Access by telephone
Diabetic patients in national registry
Patients visits to own centre
Right choice of UTI antibiotics
Prescription of physical activity
Choice of least expensive BP lowering drug
Counties
n
11
10
9
9
7
5
4
”It is clear that there is a need for better follow up systems
for primary care in Sweden and there is a great potential
for cooperation between counties”
Principles 1
How to select indicators?
Q-indicators
Useful information
to centres
Payment
Results to be
made public
Medical audit
Principles 2
• Quality indicators
– Automated data collection
– Evidence based
– Avoid ”how”, focus on results
– As few as possible but enough to
give meaningful information
– Enough measures to spread
economic risk
Principles 3
What do they do in primary care and what is
important?
300 000
individer
250 000
200 000
≈ 50 % rare visitors
150 000
≈ 50 % chronic disease
100 000
50 000
0
<1
1
>1-2
>2-4
>3-4
antal läk.besök/år vuxna
>4
Number of doctors visits during 2 years
Quality indicators
Primary care
Indicators
Listed population characteristics
29
Other statistics
14
Children's care
Prevention
5
13
8
8
2
1
4
3
9
1
5
3
Drugs
Access to care
Patient experience
Organisation etc
19
2
9
6
Chronic disease
Diabetes
Hypertension
Ischemic heart disease
Heart failure
Stroke
COP
Asthma
Psychiatric disorders
Others
141
Indicators, Diabetes
Primary care
results
registration
Indicator
1 Registration national database
2
3
4
5
6
7
8
9
10
Blood pressure
Smoking
HbA1c
LDL-kolesterol
Albuminuria
Target for HbA1c
Target for HbA1c, recent onset
Target for Blood pressure
Target for LDL-cholesterol
11 Patient education
12 Integrated care
13 Influenza immunisation
Principles P4P
example diabetes
Weight
High/low limits
Limits
Relative
points
Registration national database
70-90
5
Registration blood pressure
80-95
0,5
Registration blood pressure
Registration HbA1c
Registration LDL-cholesterol
Registration albuminuri
70-90
80-95
50-80
70-90
0,5
0,5
0,5
0,5
Target for HbA1c
Target for blood pressure
Target for LDL-cholesterol
sum
45-65
30-50
35-50
0,5
0,5
1
9,5
+ 4 other indicators without P4P
• Principles
–
–
–
–
pay for registration
Relative weights
No sharp thresholds
Spread of economic
risk
• Differences vs NHS example
– No exception reporting
– Targets more difficult to reach
– Much lower financial incentive
– Focus on registration to give high quality feed
back of results
P4P range
80
70
Examples
Results
percent
60
50
40
30
Influenza
immunisation,
patients 65+
20
10
percent
0
80
70
60
50
40
30
20
10
0
Each dot = a primary
care center, with
confidence intervals
Children with
antibiotic
prescriptions/
year
Webb access to results
160 000
patients
• Main data sources
– National diabetes registry
– Regional Primary care quality registry
– Drug prescription registry
– Regional database for contacts
– Swedish vaccination registry
– Manual reporting
The regional primary care quality
registry
• Automated data collection from local
patient files
– Ischemic heart disease
– Hypertension
– COP
– Asthma
– Diabetes
• Monthly update and back-reporting to
centres
Interaction between diseases, primary
care register
Diabetes
65 730
Hypertension
198 238
9%
14 %
58 %
1% 3%
6%
Ischemic.
Heart disease
44 317
8%
Total
239349
• P4P – 41 indicators
• How to pay? 3 principles
– Decided standard
– Professional recommendations
– Statistical limits
• For example 25 % full payment, 25 % no payment
Targets for payment?
Statistical limits
Diabetes registry. Proportion reaching target for LDL-kolesterol (<2,5
mmol/l)
100
90
80
percent
70
60
50
40
30
20
10
0
Each dot = a primary care
center
• Example of difficulties, P4P
– Professional scepticism
– Patient groups to small for reliable
comparisons
– Data sources have to be created
– Leads to focus on money, not on results,
wrong focus
– Resource consuming technical solutions
• Lessons learned
–
–
–
–
–
–
P4P just one small part of quality improvement programme
Focus on pay for registration,
< 4% of total payment
Involve profession!
Easy access to results
Must be combined with continuous analysis and discussion,
reports, seminars etc. Professional dialogue.
– Transaction cost
– National cooperation
• National primary care register
• Cooperation between local quality registers