Quality follow up programme in primary

• 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 – P 4 P (quality) • initially 3 % with aim to increase • 4, 3 % 2011

Effect of ACG on reporting of diagnoses Number of patients with diabetes in regional database 70 000 60 000 50 000 30 000 20 000 10 20 09 20 08 20 07 20 06 20 05 0 20 patients 40 000

Effect of ACG on reporting of diagnoses Current prevalence of atrial fibrillation in Västra Götaland =2. 44%

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 P 4 P 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 e as se di ic on hr C Sa tim tis et e fa c s, ct dr ion ug , ch wai oi t ce What do they do in primary care and what is important? ≈ 50 % rare visitors ≈ 50 % chronic disease 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 Hb. A 1 c LDL-kolesterol Albuminuria Target for Hb. A 1 c, recent onset Target for Blood pressure Target for LDL-cholesterol 11 Patient education 12 Integrated care 13 Influenza immunisation

Principles P 4 P 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 Hb. A 1 c Registration LDL-cholesterol Registration albuminuri 70 -90 80 -95 50 -80 70 -90 0, 5 Target for Hb. A 1 c Target for blood pressure Target for LDL-cholesterol sum 45 -65 30 -50 35 -50 0, 5 1 9, 5 + 4 other indicators without P 4 P • 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

P 4 P 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 % 1% 3% 6% Ischemic. Heart disease 44 317 58 % 8% Total 239349

• P 4 P – 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, P 4 P – 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 – – – P 4 P 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