the imprim project in a nutshell a panel...

Christine Beerepoot, WHO Europe, Copenhagen;

Jakob Kragstrup, University of Copenhagen, Denmark

Teresa Pawlikowska, Warwick university, UK

Ulf Savbäck, Swedish Agency for Economic and Regional Growth

Paula Vainiomäki, University of Turku, Turku Finland

Panel of experts:

The ImPrim Project in a nutshell – a panel discussion Moderator: Paul Forte, Director, Balance of Care Group, UK.

Ruta Markevice

Institute of Hygiene, Vilnius

Ruta Radzeviciene-Jurgute, Chief physician,

Family medicine clinics, Klaipeda

Transnational strategy on how to effectively counteract communicable diseases as part of PHC –

regional activities

• STRAMA like group

• AUDIT center

• REGISTER DATA from SPF registry

Regional activities – STRAMA like group

• The regional management group (Strama like) will help to facilitate an interdisciplinary and locally approved working model, ensuring involvement by concerned authorities, counties, municipalities and non-profit organizations.

• A steering group of 14 persons, mostly doctors, was formed and has started to work. Their first task was to carry out a clinical audit on UTI in PHC as well as hospital care.

Regional activities – AUDIT center

• The audit centre has been established at the department of Public Health at Klaipeda university and has started up.

• Data from a clinical audit on diagnosis and treatment of UTI in both PHC and hospital care are delivered already. An audit report was produced after the first registration phase.

• The follow up meeting gave opportunity for FD and hospital doctors to discuss clinical problems and choose further educational activities. These activities are taking place mostly during year 2012, but are planned to continue in the future.

• Coordinating activities of HAPPY AUDIT 2 with more then 70 FDs participating have started.

Why urinary and respiratory tract infection management?

The key step in the control of antibiotic resistance - improve quality of antibiotics prescription;

• Respiratory and urinary tract infections are the most common reasons for prescribing antibiotic;

• Cost for antibiotics compensation from the SPF:

≈ 10 mln Lt. /year, growth ≈ 5% /year;

• Respiratory tract infections audit was performed in 2008-2009 in HAPPY AUDIT, at the moment HAPPY AUDIT 2 is going on

How to change the prescribing of antibiotics?

Apply internal quality control methods (APO audit

method)

AIM OF REGISTRATION – find out how family doctors and hospital doctors diagnose and treat UTI, improve diagnostic and treatment with A/B skills of participants

Intervention:

- To improve diagnostic quality in primary care;

- To improve knowledge about treatment of UTI;

- To prepare recommendations for treatment of UTI;

APO audit method

Analysis

Planing

First registration

From 2012-04-02 to 2012-04-30

Second

registration

2012-10-22

Intervention:

-follow up meeting

-workshops

-discussions

- methodological

tools

Audit Project Odense

http://fampra.oxfordjournals.org/cgi/content/abstract/cmi090v1

STRAMA

Klaipeda University

Faculty of health

sciences , Public

health department

Institute of Hygiene

(IMPRIM project)

UTI AUDIT

23 family doctors 17 ambulatory and

hospital doctors

Lund University,

Sweden

Blekinge Centre of

Competence,

Sweden

Microbiology laboratories

Regional activities – REGISTER DATA from SPF registry

• Register data issued every half a year for continuous control of resistance pattern and antibiotic use are of basic importance.

• Continuous surveillance of antibiotic consumption using Klaipeda health insurance fund data.

• The list of indicators to monitor antibiotic consumption (prescribing) was set up during Group meetings and training sessions. The main indicators for antibiotic monitoring have been identified as follows:

- number of antibiotic prescriptions / 1000 children (0-18 years) in separate municipalities of Klaipeda region ;

- number of antibiotic prescriptions to children / 1000 children (0-18 years) in different primary care centers of Klaipeda region;

- percentage of phenoxymethylpenicillin prescriptions to children among all penicillin group prescriptions to children in different primary care centers of Klaipeda region.






Panel of experts:

The ImPrim Project in a nutshell – a panel discussion Moderator: Paul Forte, UK

Regional competitiveness: Presentation of a set of transnational conclusions for increasing regional competitiveness via a more even

distribution of resources in PHC.

Vytautas Jurkuvenas, PhD Institute of Hygiene, Vilnius

Ingvar Ovhed, GP, PhD Blekinge Centre of CompetenceKarlskrona

Primary health care …

“…essential health care … universally accessible to individuals and families ... that the community and the country can afford to maintain at every stage of their development …"

WHAT the community and the country can afford ?

Improving public health

Healthy

At risk

Diseased

Actions: Promotion of healthy behaviors

and environment (universal and targeted

approach)

Actors: Public health, Primary health

care, Other sectors

Actions: Screening, case finding, periodic health

examinations, early intervention, controlling risk

factors, life style and medication

Actors: Primary health care, Public health, Other

sectors

Actions: Treatment and care of acute

and chronic conditions (case

management)

Actors: Primary health care, hospital

care, specialist services, community care

PHC regional planning: WHAT?

Changing financing of health services

Changing scope of

PHC services

Changing quality of PHC

Changing accessibility

to PHC

Regional Planning

Changing financing of health services

Changing scope of

PHC services

Changing quality of PHC

Changing accessibility

to PHC

Regional Planning

Main causes of death, Lithuania, 2011

1 – Heart and circulatory system diseases 2 – Malignant neoplasms

1 1

2

2

Male Female

Screening program performance, Lithuania, 2011

Coverage (% ) CC (1X3) 18; MG (1X2) 21;

HCS (1x1) 28

Knowledge (%) CC 57; MG 55; HCS 38

Participation ever (%) M 36; F 60

Why not (1st cause, %)

RGs motivation - 75; GPs motivation – 34; RGs information - 32

Optimal organization (%)

68

Acr.: CC – cervical cancer; MG – mammography; HCS – hart-circulatory system; RG – risk group; GP – general practitioner

Vytautas Jurkuvenas, Institute of Hygiene

Prescription and cost of AB compensated among children in the pilot region, 2012

PHC institutions Recipes/1000 children assigned Litas for AB prescribed for 1000 children assigned

********** 532 7372,3

********** 500 6975,0

********** 421 7557,2

********** 415 6610,7

********** 358 5383,7

********** 338 4252,6

********** 335 3789,5

********** 320 4522,2

********** 300 4184,1

********** 235 2685,5

********** 220 2123,7

********** 208 1665,4

********** 197 2754,3

********** 191 2454,7

********** 187 2482,1

********** 170 2118,2

********** 150 1437,5

Pilot municipality 313 4 195,2

(Pilot) region 345 5001,0


ImPrim: Building Health Synergy

Regional model for collaboration in primary prevention Regional model for collaboration in secondary prevention Regional model for controlling antimicrobial resistance


Ingvar Ovhed, Blekinge Centre of Competence

Chronic disease management

In the future – NO walls between PHC – Hospital care – community care

Process

of Care

Primary

Health

Care

Hospital

care

Process

of Care

Process

of Care

Community

care

Ingvar Ovhed, Blekinge Centre of Competence

Chronic disease management

In the future with a more qualified PHC –

NO walls between PHC – Hospital care – community care

Process of Care

Primary Health Hospital Community

Care Care Care






Panel of experts:

The ImPrim Project in a nutshell – a panel discussion Moderator: Paul Forte, UK

Cost-effective financial incentives: Presentation of a set of transnational conclusions for providing cost-effective financial

incentives within the remuneration schemes.

Aigars Miezitis National Heatlh Services, Riga, latvia

Liis Rooväli Ministry of Health, Tallinn, Estonia

Cost-effective Financial incentives

AIGARS MIEZITIS, LIIS ROVALI

28 November 2012

eu.baltic.net Part-financed by the European Union

(European Regional Development Fund and European Neighbourhood and Partnership Instrument)

• To strength organization of PHC practice

• To increase accessibility of GP

• To promote the GP active involvement in disease prevention

• To ensure more effective management of patients with chronic diseases

• To tackle the spread of infectious diseases

• To motivate GP-s to provide broad range of health services to patients

Aims of Quality Bonus system in Latvia for PHC

Proposed Approach to QBS

• Objective is to increase Value = outcomes relative to costs

35

Clinical

processesCosts Outcomes

Introduction of new payment model in Latvia

1. Capitation

2. Quality Bonus System (QBS)

Indicator Groups

I. Prevention eg check-up, vaccination, screening

II. Chronic conditions eg diabetes, hypertension

III. Increase of cost efficiency of Health Care system

Increase Minor surgery, pregnancy care,

Reduce referrals, hospitalization rate

IV. Organization Support of use IT solutions, strengthening nurse

role in GP practice

37

OU

TCO

MES

C

OST

S

Principles of a QBS

• Voluntary scheme with status as a ‘measure of excellence’

• Criteria for entry into scheme

• A single scheme applying only to family doctors

• Indicators within control or influence of the family doctor

• Audit trail

• Targets have to be ‘absolute’ not comparative

• Target ranges based on evidence

• No ‘exception reporting’

38

Belarus Sweden Estonia Lithuania Latvia Average

No Domein Short descriptionIndicator definition

Thresh

oldsWeights Weights Weights Weights Weights

Weightin

g

1 I

Routine

health

check

1.1 Percentage of new patients

with routine health check-up within

1 month of registration

70% -

90%12 - - 20 30 12

1.2 Percentage of patients aged 18-

40 who have had a check-up in

preceding 5 years

70% -

90%30 - - 20 25 15

1.3 Percentage of patients aged 40

years and older who have had a

check-up in preceding 3 years

70% -

90%30 - - 30 25 17

QBS Domein I

2.1 Percentage of children on list in previous 12 months who

have been vaccinated against Diphtheria, Tetanus,

Poliomyelitis, Pertusis, Meningitis, B Hepatitis

80% –

95%31

33

3 ISmoking

cessation

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

40% -

90%14

4 I

Cervical

cancer

screening

4.1. Percentage of patients who have attended cervical cancer

screening according to State programme within the preceding

36 month

40%-

90%22

2 I

Child

health (0-

18)2.2 Percentage of children aged 1week – 5 years who have

had a physical and mental examination according to the State

prevention Programme

75%-

90%

QBS Domein I

5.1 Percentage of patients who have had 2 or more measured

glycated hemoglobin tests (except in an inpatient setting) in the

previous year.

40% –

90%9.4

5.2 Percentage of patients with diabetes who have had a

record of micro-albuminuria testing in preceding 12 months

54% –

90%9.6

5.3 Percentage of patients with diabetes with a record of

neuropathy testing in the preceding 12 months

40% –

90%7.8

5.4 Percentage of patients who have had a life-style

consultation with the nurse/ GP asst in preceding 12 months

40%-

90%10.8

6 II

Diabetes

Mellitus:

monitorin

g

outcomes

6.1 Percentage of patients in whom the most recent HBA1C

measure is <7.5% in preceding 12 months

40% –

70%18

5 II

Diabetes

Mellitus:

monitorin

g

processes

.

QBS Domein II

QBS Domein II

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.

40% -

70%9

7.2 Percentage of hypertension patients who have had a total

cholesterol test at least once every 3 years

60%-

90%6

7.3 Percentage of hypertension patients who have had a 12-

lead ECG at least once every 3 years

40%-

90%5

7.4 Percentage of hypertension patients have glycosis test at

least once every 3 years

60%-

90%6

7.5 Percentage of patients with hypertension who have been

given lifestyle advice in preceding 12 months

60%-

90%8

7 II

Arterial

hypertens

ion

monitorin

g

processes

QBS Domein II

8.1 Percentage of patients with CHD in whom the last blood

pressure reading in the preceding 12 months is 140/90 or less

40% –

80%14

8.2 Percentage of patients with CHD whose last measured

total cholesterol in the preceding 12 months is 5mmol/L or less

40% –

70%15

9.1 Percentage of COPD patients who have had a life-style

consultation in the preceding 12 months

50% –

90%8

9.2 Percentage of patients with COPD with a record of

FEV1 in the preceding 12 months

40%-

70%8

10.1 Percentage of asthma patients who have had at least one

measurement of peak expiratory flow in previous 12 months

40% –

90%8

10.2 Percentage of patients with asthma who have had an

asthma review in preceding 12 months

40%-

70%8

10 II

Asthma

monitorin

g

processes

8 II

Coronary

Heart

Disease:

monitorin

g

outcomes

9 II

COPD

monitorin

g

processes

QBS Domein III

11 III

Emergen

cy

Medical

Aid

Service

11.1 Number of calls/ 100 patients who call for EMAS 6-3 calls 38

12 III

Secondar

y Health

Care

Specialist

visits

12.1 Number of visits / 100 patients of patients who visit

secondary health care specialists

10-6

visits44

13 III

Hospitaliz

ation of

GP’s

patients

13.1 Number of hospital admissions / 100 patients

10-7

hospitaliz

ations

44

QBS Domein IV

14 IV Facilities 14.1 Nurse has a separate consulting room Yes/no 25

14.2 Percentage of nurse working hours per month

when they see patient alone from consultation at the

GP practice

25% - 75% 22

15 IV IT 15.1 Use of IT for clinical audit Yes/no 10

15.3 Use of IT for routine patients consultation Yes/no 21

46

Pros and cons of QOF in UK For…

• Increased quality

• Has led to investment in

organisation and staff

• Better recording of care

• Beginning of patient registers

• May reduce inequity

Against…

• Changes might have happened

anyway

• Initial doctor resistance

• May push up prescribing and

overtreatment

• Has not reduced admissions?

Aigars Miezitis

ImPrim Project

[email protected]

The National Health Service Latvia 31 k-3 Cesu Street

Riga, Latvia, LV-1012

mailto:[email protected]

Christine Beerepoot, WHO Europe, Copenhagen





Panel of experts:

The Imprim Project in a nutshell – a panel discussion Moderator: Paul Forte, UK

Maika Kummel, PhD Senior lecturer, Turku University of

Applied Sciences

Arnoldas Jurgutis, GP, PhD Professor, Dept of Public Health,

Klaipeda University

Effectiveness of primary care nursing Introduction

• Nurses are playing important roles in the delivery of primary care

• Variation in the actual tasks, level of responsibility, the extent to which nurse is a true ”partner in care” or more of an assistant to general practitioner

Maika Kummel, Nov 28th, Riga

Effectiveness of primary care nursing

• Systematic review by Keleher et al. 2009

→ What is the impact of the primary care nurse on patients health outcomes compared with usual doctor-led care in primary care settings?

• 31 relevant studies with high-level evidence


Effectiveness of primary care nursing Results

• Modest evidence that nurses can provide effective care and achieve positive health outcomes for patients

• Nurses are effective in care management, enhancing patient knowledge and achieve good patient compliance

• Nurses are also effective in a more diverse range of roles incl. chronic disease management, illness prevention, health promotion


Effectiveness of primary care nursing Results

• Nurse-led care may involve higher levels of patient satisfaction and quality of life was even more evident and stronger

• There is a need for a stronger evidence base for primary nursing


Effectiveness of primary care nursing Conclusion

Primary nursing has much potential for building of knowledge and capacity to enhance nurses’ roles in the health system


Primary Health Care tools to improve community health

.

Arnoldas Jurgutis, PhD , prof.,

Public Health Department Klaipeda University,

ITA, Primary Health Care Expert Group of the Northern Dimension Partnership in Public Health and Social Wellbeing

Klaipėdos

universitetas

Imprim Final Confernce. Riga November 28-29th

Initial step in the development of Imprim project idea

• better health for the population

• at a lower costs

• greater equity in health

Prof Barbara Starfield, Johns Hopkins

University presents a strong scientific

evidence for the benefits of primary helath

care oriented countries in the seminar on

PHC situation in ND countres, Vilnius,

May 2008

• The first contact

• Continuity

• Comprehensiveness

• Co-ordination

• Family orientation

• Community orientation

Klaipeda University


Starfield 09/04 04-167

Source: Starfield B. www.pitt.edu/~super1/lecture/lec8841/index.htm

Starfield 09/04 WC 2957

Areas (within industrial and developing countries) with stronger PHC

have better health outcomes: • total mortality rates, • heart disease mortality rates, • infant mortality, • earlier detection of cancers such as colorectal cancer, breast cancer, uterine/cervical cancer, and melanoma.

the opposite is the case for higher specialist supply, which is associated with worse outcomes.

Klaipeda University


http://www.pitt.edu/~super1/lecture/lec8841/index.htm

Family medicine in BSR – how well we demonstrate core FM competences in the practice?


Klaipeda University

Differences between PHC practices (Klaipeda region 44 practices, year 2011)

• Percentage of listed population not seen by PHC 20% iki 65%

• Prevalence of arterial hypertension min 8,66% max 30,22%

• Hospitalisation due to AH arterinės 0.58 up to 8.33 per 100 inh! (14.4 x)

• Prevalence of DM - 0,13 - 4,37%

• Hospitalisation for DM min 0 max 13,6 per 100 inhab

More: WP3 report N:3, Klaipeda university


Klaipeda University

Comprehensive, patient –centered consultation in primary health care


Solving of the presented problem

Appropriate managemnt chronic problems

Oportunistic screening

Attitudes of patient towards health and health care

Four areas

Stott NCH, Davis RH. The exceptional potential in each primary care consultation. J R Coll Gen Pract 1979:29:201-5 Ovhed I Primary Health care as an Arena for Primary, Secondary and Tertiary Cardiovascular Disease Prevention. PhD Thesis. Malmo.1998

Klaipeda University

Community oriented primary health care Case: 42 year men risky drinking, smoking, overweight, low physical activity. Living in a family with three children (4, 8, 14 years), they are often ill with respiratory infection. Often they visit doctor with mother, also doctor and nurse visits their family. Man never visit doctor, avoid preventive check-ups. How big risk for this man is premature death? What tools are available in PHC to motivate him for change? What features of primary health care you need? family orientation! community orientation!

Klaipeda University


Extended Primary health care team

Extended

team

Individuals

Families

Community

Family

physician

Local

administration

Public health

speciasts

Rehabilitation

nurse

Teachers,

NGO,

Etc.

Midwife

Family

nurse

Social

worker


KLAIPEDA UNIVERSITY

Motivational counseling of patients with NCDs by specially trained PHC nurses

Aim - to improve management of NCD in

primary care through enhanced cooperation and shared responsibility between doctor and nurse

Description of new services have been accepted by MoH, but no incentive payment in 2012

Volunteer PHC institutions have been included in the pilot (two institutions, four nurses)

E–monitoring tools developed


Klaipeda University

Traditional Semashko PHC: nurse in the same consulting room with FD

Motivational counseling of patients with NCDs by specially trained PHC nurses (2)

Intermediate results of the services:

• Better evaluated and corrected behavioral risk factors

• Better understanding of disease and treatment plan

• Empowered for self-care

International evidence:

• 15 min. motivational counseling, if also have continuous meeting is efficient in modifying risky behavior(Rubak et al., 2005)

• Motivational counseling helps to understand risk of the disease, to decrease anxiety, increase satisfaction with health care services and empower for decision making and sefcare (Koelewijn-van Loon et al., 2010)


Klaipeda University

Obstacles need to overcome to increased focus towards preventive care (1)

• Related to traditional education of doctors and nurses

– Priority to clinical medicine, particularly in CME (comercial influence of technology producers)

– Traditional hospital oriented education, lack of training in the community

– Lack of training in motivational counseling and behavioral change

– Lack of multi-professional training to enhance teamwork – Education of nurses often are far away from PHC-related

needs for competences – Lack of management skills to introduce organizational

changes

Klaipeda University


• Related to the health care organization: – Threat for continuity due to increased market of out-

patient specialized services (lobbying for first contact care)

– Lack of financial incentives to increase focus toward prevention

– Difficult to find relevant indicators to measure quality of preventive work, teamwork

– Lack of (due to attitudes, training) internal tools for quality control

– Lack of tools to reach vulnerable population groups

Klaipeda University

Obstacles need to overcome to increased focus towards preventive care (2)


• More reading: WP4 report N5:

Strategy for continuous professional development of PHC professionals in order to better response to changing health needs of the society

Authors: Paula Vainiomaki, Arnoldas Jurgutis, Jacek Putz, Vaida Jukneviciute

PP14 Klaipeda University & PPHS EG of NDPHS

Christine Beerepoot, WHO Europe, Copenhagen





Panel of experts:

The Imprim Project in a nutshell – a panel discussion Moderator: Paul Forte, UK

As anyone knows who has worked in the field, implementation of new practices is the biggest challenges of all.

Hollin & McMurran 2011

ImPrim is closing, but we should not – we (partners) are just in the middle or start of implementation.

Implementation, what it may be

Diffusion – Passive distribution e.g. scientific publications or internet

Dissemination – Focused distribution towards a target audience

Implementation – Active procedures and interventions

Knowledge translation (KT), quality improvement

How to implement our experiences

• What should be transferred

• To whom should be transferred

• By whom should our experiences be transferred

• How should we transfer

• To what effect our experiences should be transferred

Lavis et al 2003

What could we use as tools? • Printed educational material • Educational meetings • Educational outreach • Local opinion leaders • Audit and feedback • Computerised reminders (best, if at the point of care) • Tailored intervention • P4P -methodology • Incentives -> not big effect sizes by any of these, but we have to facilitate the change

Grimshaw et al 2012, Campbell et al NEJM 2009, Doran et al. BMJ 2011, Flodgren et al. Cochrane 2011

the imprim project in a nutshell a panel...

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