Integrated or not integrated? Which future for Primary Care Groups (PCGs)?

Integrated or not integrated? Which future

for Primary Care Groups (PCGs)?

Emanuela Foglia, Emanuele Porazzi, Umberto Restelli, Francesca Scolari,

Daniela Malnis, Giovanni Beghi, Antonino Mazzone, Carla Dotti

Agenda

•

Primary Care: Evidence from international and national

literature

•

Research Problems

•

Study’s Objective

•

The Italian Background

•

Lombardy Region

•

LHA Milano 1 and HA “Ospedale Civile di Legnano”: a case of

Hospital - Primary Care integration

•

Methods

•

Results

•

Conclusions

•

References

Primary Care: Evidence from International and National Literature

PRIMARY CARE



Ensuring the continuity of patient care (Bodenheimer

et al.

, 2002; Fioravanti

et al.,

2007, Longo, 2007; Fattore

et al.

2009)



Increasing the appropriateness, effectiveness and efficiency of care (Berg

et al

., 2006;

Heath

et al.

, 2009; Solberg

et al.

, 2009)



Reducing socioeconomic and geographic disparities across the population (Ferrer

et

al.,

2005)

ASSOCIATIVE MEDICINE



Evidence of effectiveness of associative models of primary care in chronic diseases

(Bodenheimer

et al.

, 2002; Olivarius, 2001; Soulberg

et al.,

2009; Mehrotra

et al.,

2009; Mascia

et al.,

2008)



Better performances in the case of GPs networks/groups, than for individual

practitioners (Longo 2007; Mannino

et al

., 2009; Fantini

et al.

, 2010)



Discontinuity of care at the interface between inpatient and outpatient management

can lead to increased morbidity and mortality (Tandjung

et al

., 2011)

Research Questions

THE IDENTIFIED PROBLEMS - BACKGROUND



Low diffusion of PC Associative Models in Italy and Lombardy Region

(IRER, 2010; Damiani, 2007; AGENAS, 2009; Mannino, 2009)



Lack of territorial performance indicators for evaluating performance of

different organizational models (McElduff, 2004; Mascia, 2008; Eath,

2009; Fattore, 2009)

RESEARCH QUESTIONS

1. How to assess the efficiency of PCGs?

The Study’s objective

The Study investigated the impact of PCGs introduction on

the overall performance of District 4 (and LHA Milano1) in

terms of:

1. rate of hospitalization

efficiency

2. mortality rate

effectiveness

Primary Care: The Italian Background

Hospital

GP

GP or PCGs

Europe with people > 65 years – European Commission, 2011)

 Complexity of Health Care demand: increasing of chronic diseases and fragile patients

 Lack of economic resources

Responsibile for providing comprehensive healthcare (health prevention, primary and community care)

Primary Care: The Italian Background

In the last 20 years Healthcare Reforms in Italy and all Western Europe have

reshaped Primary Care and the role of GPs:

•

Legislative Decree 502/1992: first reference to Associative Medicine

•

Legislative Decree 229/1999: District as citizens’ reference point for the access to

Primary Primary Care (through Local Health Authority)

•

Italian National Healthcare Plan 2006-2008: new strategic guidelines for the

empowerment of Primary Care as the introduction of new financial inventive

schemes, ICT support, the development of a first network for integrating hospital

and territorial assistance (Primary Care Unit – UTAP)

•

“State – Regions” National Agreement (2004 and 2006): innovative models of

Associative Medicine in Primary Care (from the experience of PCGs in the UK) in

order to ensure the continuity of patients’ care

•

The GPs National Collective Agreement of 2009: empowerment of GPs role in order

to

achieve

greater

functional

integration

between

the

professionals.

Implementation of economic incentives by LHAs for group practices, encouraging

GPs to participate in collaborative arrangements

Primary Care: The Italian Background

Characteristics: GPs Simple Association GPs Network GPs Group

Professional

Associates Min. 3 – Max.10

Min. 3 – Max. 10 (not

compulsory) Min. 3 – Max. 8

Location Not bound to a single

location

Not bound to a single location, but possibility to rotate to different locations

Single location divided into several medical studios

Sharing of therapeutic, diagnostic and clinical guidelines or pathway

Yes Yes Yes

Common use of ICT Support No No

Yes (computer links and files sharing)

Common use of

administrative personnel No

Yes (specific Agreement with Regions and in the face

of economic incentive)

Yes (specific Agreement with Regions and in the face

of economic incentive)

High Low

Source: Art. 40 –NCA2000

Lombardy Region

DIFFUSION OF ASSOCIATIVE MODELS FOR GPs IN LOMBARDY REGION

Despite health care reform Legislation, which has focused national and

regional attention on the central role GPs and team based care, institutional

research has shown poor implementation of Primary Care innovative

organizational models

32%

15% 29%

24%

Associative Models Diffusion in Lombardy Region (2010)

Single GP

GPs in Simple Association GPs Network

GPs Groups

Local Health Authority Milano 1

GPs ASSOCIATIVE MODELS DISTRIBUTIONS PER DISTRICT (LHA MILANO 1)

LHA Milano 1, Strategic Planning Document, 2012

Single GPs Simple Association Netowork Group

District GPs No. % No. % No. % No. %

District 1 121 25 21% 19 16% 57 47% 20 17% District 2 110 27 25% 3 3% 31 28% 49 45% District 3 76 25 33% 3 4% 33 43% 15 20% District 4 119 27 23% - - 32 27% 60 50% District 5 46 12 26% 4 9% 23 50% 7 15% District 6 80 16 20% - - 34 43% 30 38% District 7 48 25 52% 3 6% 13 27% 7 15% TOT GPs in LHA Milano 1 600 157 26% 32 5% 223 37% 188 31% TOT Pop. 808.523 181.072 44.686 316.997 265.768

A Case of Hospital - Primary Care Integration

The project of LHA Milano 1 and Hospital Autority “Ospedale

Civile di Legnano”

GPs ORGANIZATIONAL MODEL

Mission:

provide users with the delivery of primary care, in collaboration and

constant comparison with Specialists, in order to ensure continuity of care and

promote greater appropriateness

Hours

: “Extended” hours (late afternoon or Saturday morning)

How often?

Once every week Specialists go to PCG



to carry out the scheduled

visit/consultation

Characteristics of patients selected to be examined by Specialists:

‘fragile’ patients,

with comorbidity, not yet hospitalized, who need multidimensional approach to care

Territory characteristics:

medium-large Municipalities close to each other,

high-medium income and education, the majority of population commute to bigger

cities

A Case of Hospital - Primary Care Integration

Organisational model of reference

Hospital

PC Groups

Specialist

LHA Milano 1

Agreement

Health District 4 - Legnano

GPs

The GPs select patients

Methods

DATA SOURCES

•

LHA Milano 1 Dataset (Department of Primary Care): Data used in the

study were provided by the LHA Milano 1 administrative dataset

•

Hospital Authority “Ospedale Civile” of Legnano: Discharge records

•

ISTAT (

Italian National Institute of Statistics

): demographic and

performance (mortality rate) data

PERIOD OF STUDY

•

2008 – 2010 (3 years)

POPULATION

•

3 PCGs: 30,240 patients

•

LHA Milano 1: 940,767 residents

Results

Hospitalization Rate (*1,000)

in PCGs: a comparison between

the PCGs, District 4 and LHA Milano 1

140,00 145,00 150,00 155,00 160,00 165,00 170,00 2008 2009 2010 PCG A+B+C

DISTRICT 4 (no A+B+C)

LHA MILANO 1 (no A+B+C and District 4)

p value < 0.05 p value < 0.01

Results

Mortality Rate (*1,000)

in PCGs compared with LHA Milano 1

6,00 6,50 7,00 7,50 8,00 8,50 9,00 9,50 10,00 2008 2009 2010 PCGs A+B+C

DISTRICT 4 (no A+B+C)

LHA MI 1 (no District 4 and A+B+C)

ITALY MORTALITY RATE

p value < 0.01 p value < 0.01

Conclusions



The study demonstrates the importance to focus on new organisational

models, with pathways that link General Practitioners and hospitals

Specialists, in order to ensure continuity and better quality of care



Although the per thousand hospitalization rate reveals a better

performance for the District in terms of efficiency, the situation

changes when considering the results in terms of effectiveness



After 3 years of implementation, GPs have better performance in terms

of mortality rate, followed by LHA and District 4 for major chronic

diseases (per thousand mortality rate as the hard endpoint to study the

imporvement)

References

Agenas, Stato di attuazione dei modelli innovativi di assistenza primaria nelle Regioni italiane, Progetto di ricerca corrente finanziato dal Ministero del Lavoro, della Salute e delle Politiche Sociali negli anni 2007-2008, Maggio 2009

Berg M., De Brantes F., Schellekens W., “The right incentives for high-quality, affordable care: a new form of regulated competition”, International Journal for Quality in Health Care, 18 (4), 2006, pp. 261-263

Bodenheimer T., Wagner E.H., Grumbach K., “Improving Primary Care for Patients with Chronic Illness”,JAMA, 288(14), 2002, pp. 1775-1779

Damiani G., Venditti A., Palumbo D., Rizzato E., Guzzanti E., Assistenza Primaria: significato e prospettive di sviluppo organizzativo, Organizzazione Sanitaria, 2, 2007, pp. 3-16

Fantini M.P., Carretta S., Mimmi S., Beletti M., Rucci P., Cavazza G., Di Martini M., Longo F., “L’impatto delle caratteristiche e dell’organizzazione dei MMG sulla qualità assistenziale delle malattie croniche”,Mecosan, 2010, 73, pp. 73-92

Ferrer R.L., Hmabidge S.J., Maly R.C., The essential role of generalists in health care systems, Annals of Internal Internal Medicine, 2005; 142(8): 691-9

Fioravanti L., Spandonaro F., Continuità assistenziale dal principio alla realizzazione: cosa insegna il

References

Heath I., Rubistein A., Stange K.C., Van Driel M.L., “Quality in primary health care: a multidimensional approach to complexity”,BMJ, 338, 2009, pp. 911-913

IRER – Istituto Regionale di Ricerca di Regione Lombardia, Definizione di nuovi modelli di gestione dei Medici di Medicina Generale (MMG), differenziati in base alle specificità territoriali e coerenti con i bisogni dei cittadini e con il modello gestionale basato sul consulto formativo, Milano, Marzo 2010

Longo F., “Implementing managerial innovation in Primary Care: Can we rank change drivers in complex adoptive organizations?”, Health Care Management Review, n. 3, pp. 1-13, 2007

Mannino S., Villa M., Lucchi S., Brunelli G., Locatelli G.W., Zenoni S., Longo F., “Variazioni delle performance dei MMG in relazione dalle forme associative”, Mecosan, 70, 2009, pp. 75-97

Olivarius N.F., Beck-Nielsen H., Andreasen A.H., Hørder M., Pedersen P.A., “Randomised Controlled Trial of Structured Personal Care of Type 2 Diabetes Mellitus”, British Medical Journal, 323(7391), 2001, pp. 970-975

Solberg L.I., Asches S.E., Shortell S.M., Gillies R.R., Taylor N., Pawlson L.G., Scholles S.H., Young M.R., “Is Integration in Large Medical Groups Associated With Quality?”, American Journal of Managed Care, 15(6), 2009, pp. 34-41

Vendramini E., Lega F., Budgeting and performance management in the Italian National Healt System: assessment and constructive criticism, Journal of Health Organization and Management, 2008, 22 ()1), pp. 11-22