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
(Secondary/Tertiary Care)GP
gatekeeperGP or PCGs
(Primary Care) ITALIAN TRENDS Aging of population (1st inEurope 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
(Diabetologist, Rheumatologist, Pulmonologist, Cardiologist)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