Efficiency and equity dimensions of Primary Care: the consequences of a changing context

ABSTRACT - Background: Primary care is one of the key features for a sustainable, effective, and comprehensive health system, but its contribution depends on its strength. This dissertation evaluates (i) changes and inequalities in access to primary care in Europe and Portugal, and, (ii) how an important reform of the Portuguese model for providing primary care affected the use of inpatient and emergency care. Methods: First, access to primary care in Europe was measured before (2007) and during (2012) the Great Recession; second, the evolution and financial cost of socioeconomic inequalities in access to primary care in Portugal were estimated from 2000 to 2014; third, the effect of different organizational models of primary care provision on all emergency department visits in Portugal between 2013 and 2015 was measured; and last, the impact of the Portuguese primary care reform on ambulatory care sensitive conditions (ACSC) and on disease specific ACSC related to health conditions targeted in the pay-for-performance were measured from 2000 to 2015. Results: Results show that access to primary care improved during the Great Recession in Europe and that this improvement was greater for people living in countries with higher investment in health. However, socioeconomic inequalities in access to primary care persisted in this period. In Portugal, there are significant and increasing socioeconomic inequalities in ACSC, which possibly reflect inequalities in access and continuity of care in primary care. People assigned to the new organizational model of primary care provision (Family Health Units) had a lower emergency department utilization. Nevertheless, the Family Health Units did not have an impact on the reduction of ACSC, nor on the rate of disease specific ACSC related to health conditions targeted in the pay-for-performance. Conclusion: Supportive health policies for stronger primary care are essential to guarantee access to primary care during economic recession periods, however more attention should be given to the reduction of socioeconomic inequalities in access to primary care. Also, in Portugal there are significant and increasing socioeconomic inequalities in access to primary care. The current primary care reform may have enhanced the asymmetries in the access and quality of services provided at this level, and the capacity of the pay-for-performance mechanism in achieving better health outcomes is questionable.RESUMO - Enquadramento: Os cuidados de saúde primários representam um setor essencial para um sistema de saúde sustentável, eficaz e abrangente, sendo que estas contribuições dependem muito da própria estrutura deste nível de cuidados. Esta tese pretende (i) avaliar as mudanças e desigualdades no acesso aos cuidados de saúde primários na Europa e em Portugal e, (ii) avaliar como uma importante reforma do modelo de prestação de cuidados de saúde primários em Portugal alterou a utilização de cuidados de saúde hospitalares, nomeadamente episódios de internamento e idas aos serviços de urgência. Métodos: Em primeiro lugar, o acesso aos cuidados de saúde primários na Europa foi medido antes (2007) e durante (2012) a Grande Recessão; em segundo lugar, a evolução e o custo financeiro das desigualdades socioeconómicas no acesso aos cuidados de saúde primários em Portugal foram estimados de 2000 a 2014; em terceiro lugar, o efeito de diferentes modelos organizacionais de prestação de cuidados de saúde primários em todos os episódios de urgências foi medido em Portugal entre 2013 e 2015. Por último, foi medido o impacto da reforma portuguesa dos cuidados de saúde primários nos internamentos evitáveis e em grupos de doenças específicas de internamentos evitáveis relacionados com as condições de saúde sobre incluídas no modelo de pagamento por desempenho, entre 2000 e 2015. Resultados: Os resultados indicam que o acesso aos cuidados de saúde primários na Europa melhorou durante a Grande Recessão, e que esta melhoria foi maior para as pessoas que vivem em países com maior investimento em saúde. No entanto, as desigualdades socioeconómicas no acesso aos cuidados de saúde primários persistiram neste período. Em Portugal, existem desigualdades socioeconómicas significativas e crescentes nos internamentos evitáveis (i.e. Internamentos por Causas Sensíveis a Cuidados de Ambulatório) que refletem possivelmente as desigualdades no acesso e na continuidade dos cuidados de saúde primários. As pessoas inscritas no novo modelo organizacional de prestação de cuidados de saúde primários (Unidades de Saúde Familiar) têm uma utilização menor dos serviços de urgências hospitalares. No entanto, as Unidades de Saúde Familiar não tiveram impacto na redução dos internamentos evitáveis nem nos grupos de doenças específicas de internamentos evitáveis relacionadas com as condições de saúde incluídas no modelo de pagamento por desempenho. Conclusão: Políticas de saúde para o reforço dos cuidados de saúde primários são essenciais para garantir o acesso aos cuidados de saúde primários durante os períodos de recessão económica, no entanto, mais ênfase deve ser dada à redução das desigualdades socioeconómicas no acesso a este tipo de cuidados. Também em Portugal, existem desigualdades socioeconómicas no acesso aos cuidados de saúde primários, que têm vindo a aumentar ao longo do tempo. A atual reforma dos cuidados de saúde primários pode ter aumentado as assimetrias no acesso e na qualidade dos serviços prestados neste nível, e a capacidade do mecanismo de pagamento por desempenho em alcançar melhores resultados em saúde é questionável

a repeated cross-sectional study

© The Author(s) 2018. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.Background: The strengthening of primary care (PC) has been encouraged as a strategy to achieve more efficient and equitable health systems. However, the Great Recession may have reduced access to PC. This paper analyses the change in access to PC and its patterning in 28 European countries between 2007 and 2012. Methods: We used data from the 2007 and 2012 waves of the EU-SILC questionnaire (n = 687 170). The dependent variable was the self-reported access to PC ('easy' vs. 'difficult'). We modelled the access to PC as a function of the year and individual socioeconomic and country-level health system variables, using a mixed effects logistic regression, adjusting for sex, age, civil status, country of birth, chronic condition and self-reported health. Additionally, we interacted the year with socioeconomic and country-level variables. Results: The probability of reporting difficult access to PC services was 4% lower in 2012, in comparison with 2007 (OR = 0.96, P < 0.01). People with the lowest educational level (OR = 1.63, P < 0.01), high difficulty to make ends meet (OR = 1.94, P < 0.01) and with material deprivation (OR = 1.25, P < 0.01) experienced a significantly higher likelihood of difficult access. The better access in 2012 was significantly higher in people living in countries with higher health expenditures, a greater number of generalist medical practitioners, and with stronger gatekeeping. Conclusion: Access to PC improved between 2007 and 2012, and this improvement was greater for people living in countries with a higher investment in health and PC. However, the poor access amongst low-SE status people was stable over the period.publishersversionpublishe

Análise comparativa de sistemas de classificação de doentes de reabilitação

RESUMO - Caracterização do problema: A inadequação e ineficácia do sistema de financiamento ―por diária‖ dos cuidados de reabilitação resultaram na necessidade de criação de sistemas de classificação de doentes de reabilitação em regime de internamento, em muitos países. Também em Portugal é necessário implementar um sistema de financiamento, baseado num sistema de classificação de doentes, ajustado pela complexidade e necessidade de cuidados destes doentes. Objectivos: Caracterização dos cuidados de reabilitação em Portugal, e do actual sistema de financiamento destes doentes; realização de uma revisão de literatura dos sistemas de classificação de doentes de reabilitação já existentes, de modo a compreender quais as variáveis de agrupamento utilizadas e qual a capacidade de previsão dos custos destes mesmos sistemas; perceber a importância da implementação de um dos sistemas de classificação em Portugal, e quais as suas vantagens. Metodologia: Da revisão de literatura efectuada, foram encontrados quatro sistemas de classificação de doentes implementados e/ou em vias de serem implementados como base para um sistema de financiamento, nos EUA, Austrália e Canadá. Foi efectuada uma extensa caracterização e análise crítica dos mesmos. Conclusões: Podemos concluir, que dos poucos sistemas de classificação de doentes de reabilitação existentes, optou-se pelo estudo de uma possível adopção do sistema norte-americano para a realidade portuguesa, por ser o único sistema de classificação já utilizado para fins de financiamento para todos os doentes de reabilitação desde 2002, o que inclui mais variáveis de decisão na classificação dos doentes, e o que permite a maior previsão dos custos dos doentes em termos percentuais.ABSTRACT - Background: The inadequacy and inefficiency of the “per diem” funding system of rehabilitation care resulted in the need to create classification systems for inpatient rehabilitation, in many countries. Also in Portugal it´s necessary to implement a funding system based on a patient classification system, adjusted by complexity and need for care of these patients. Aims: Characterization of rehabilitation care in Portugal, and the current funding system of these patients; conducting a literature review of patient classification systems for rehabilitation, in order to understand which are the grouping variables used and what is the ability of costs prediction in each of the systems; understand the importance of implementing a classification system in Portugal, and its advantages. Methods: A literature search was performed, and four patient classification systems were found in the U.S., Australia and Canada. Some are already implemented, and others are about to be implemented as the basis for a new funding system. An extensive description and critical analysis of these systems was performed. Conclusions: After the analysis of the existing patient classification systems for rehabilitation, we chose to study a possible adoption of the American system for the Portuguese reality, because it´s the only classification system already used for funding purposes for all rehabilitation patients since 2002, it includes more decision variables for the classification of patients, and which allows the highest cost estimate

Cost-effectiveness of the endovascular repair of Abdominal Aortic Aneurysm in Portugal

AbstractEndovascular Aneurysm Repair (EVAR) for the treatment of aortic abdominal aneurism has been shown to improve short-term survival and quality of life as compared to Open Repair (OR), while reducing the rate of serious complications and allowing for the treatment of more patients.ObjectivesTo examine the cost-effectiveness of EVAR compared to OR in the treatment of aortic abdominal aneurism in the Portuguese context using a model previously developed in the UK.MethodologyWe adapted an international economic evaluation model to the Portuguese situation, assuming that the health benefits of EVAR observed in clinical trials would also apply to Portuguese patients. We carried out an expert panel survey to calculate the resource use associated with the intervention and its short and long-term consequences, valued with Portuguese prices.ResultsThe major cost difference in the primary intervention (difference of 3,064 € in favor of OR) is related to the cost of the endograft/graft. No major differences are observed in the total cost of complications and re-interventions between the two procedures. EVAR represents a cost of 16,709 € over lifetime compared to 12,130 € for OR. Using data from the literature we show that EVAR allows for 0.17 additional undiscounted years of life and 0.091 additional undiscounted quality-adjusted life years. The incremental cost-effectiveness ratio (ICER) of EVAR is of 65,605 €/QALY.ConclusionEndovascular repair of aortic abdominal aneurysm represents an effective alternative and has been used increasingly in Portugal and elsewhere. Our study shows that its cost-effectiveness is currently above the commonly accepted threshold in Portugal, but that the economic value of EVAR would greatly improve if benefits were confirmed in the long run after the intervention. Under these circumstances, EVAR would become an economically valuable intervention that could be adopted on a large scale in Portugal

CENTRALIZED PURCHASING IN HEALTH

The centralization of purchases has been increasingly a strategic trend, particularly in the health sector. In Portugal, the SPMS, Serviços Partilhados do Ministério da Saúde, E.P.E., was established in 2010 as a central purchasing entity for the health sector. Centralized purchasing can bring advantages, such as increasing the efficiency of the purchasing process, but also disadvantages, such as the possibility of oligopoly by suppliers, generated by imperfect competition, and a diminished response to the most decentralized units. This theme was the subject of a reflection meeting, which aimed to promote a debate on the national framework aspects of this process, challenges of implementation for hospital medicines and suggestions for improvement of this process. The main ideas generated for a successful centralized purchasing indicate that the central purchasing entity should be dynamic and facilitator, should ensuring equity, safety, accessibility and quality of drugs. There should be better planning and rigorous procurement of drugs, and an integrated information system that allows sharing and networking among the central purchasing and the various health institutions, fostering a proximity policy, should be created. Professionals should be trained in the necessary technical procedures for the completion of the acquisition of drugs, and hospital pharmacists should be included as consultants in the development of specific procedures of centralized procurement, according to the hospital’s needs. Finally, this entire process must be followed by constant monitoring through an annual assessment of the economic and financial feasibility. The benefits of the activity performed annually should adequately quantify the quality and efficiency gains that demonstrate the financial impact achieved in scope of the reduction of expense in the National Health Service

“Evolution and financial cost of socioeconomic inequalities in ambulatory care sensitive conditions: an ecological study for Portugal, 2000–2014”

Abstract Background Hospitalizations for Ambulatory Care Sensitive Conditions (ACSC) are specific conditions for which hospitalization is thought to be avoidable through patient education, health promotion initiatives, early diagnosis and by appropriate chronic disease management, and have been shown to be greatly influenced by socioeconomic (SE) characteristics. We examined the SE inequalities in hospitalization rates for ACSC in Portugal, their evolution over time (2000–2014), and their associated financial burden. Methods We modeled municipality-level ACSC hospitalization rates per 1000 inhabitants and ACSC hospitalization-related costs per inhabitant, for the 2000–2014 period (n = 4170), as a function of SE indicators (illiteracy and purchasing power, in quintiles), controlling for the proportion of elderly, sex, disease specific mortality rate, population density, PC supply, and time trend. The evolution of inequalities was measured interacting SE indicators with a time trend. Costs attributable to ACSC related hospitalization inequalities were measured by the predicted values for each quintile of the SE indicators. Results Hospitalization rate for ACSC was significantly higher in the 4th quintile of illiteracy compared with the 1st quintile (beta = 1.97; p < 0.01), and significantly lower in the 5th quintile of purchasing power, compared with the 1st quintile (beta = − 1.19; p < 0.05). ACSC hospitalization-related costs were also significantly higher in the 4th quintile of illiteracy compared with the 1st quintile (beta = 4.04€; p < 0.05), and significantly lower in the 5th quintile of purchasing power, compared with the 1st quintile (beta = − 4,69€; p < 0.01). The SE gradient significantly increased over the 2000–2014 period, and the annual cost of inequalities were estimated at more than 15 million euros for the Portuguese NHS. Conclusion There was an increasing SE patterning in ACSC related hospitalizations, possibly reflecting increasing SE inequalities in early and preventive high-quality care, imposing a substantial financial burden to the Portuguese NHS

Results of the Web-Delphi process to INAMI stakeholders (three rounds)

IMPACT HTA, WP7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 3 (Testing the framework with empirical applications), Results of the Web-Delphi process to INAMI stakeholders (three rounds), about the views of stakeholders regarding “The relevance of the following value aspects for the evaluation of new medicines in this disease context is” (2020) For details on the Web-Delphi process, see: IMPACT HTA, Work Package 7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 3, Deliverable 7.3 (Testing the framework with empirical applications), Testing the IMPACT-HTA Value Framework in collaboration with HTA agencies: Case studies on Non-Small Cell Lung Cancer and Spinal Muscular Atrophy (2021), Aris Angelis (LSHTM, LSE), Mónica Oliveira (IST), Teresa Rodrigues (IST), Liliana Freitas (IST), Carlos Bana e Costa (IST), Panos Kanavos (LSE

Results of the Web-Delphi process to YLV stakeholders (three rounds)

IMPACT HTA, WP7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 3 (Testing the framework with empirical applications), Results of the Web-Delphi process to TLV stakeholders (three rounds), about the views of stakeholders regarding “The relevance of the following value aspects for the evaluation of new medicines in this disease context is” (2020) For details on the Web-Delphi process, see: IMPACT HTA, Work Package 7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 3, Deliverable 7.3 (Testing the framework with empirical applications), Testing the IMPACT-HTA Value Framework in collaboration with HTA agencies: Case studies on Non-Small Cell Lung Cancer and Spinal Muscular Atrophy (2021), Aris Angelis (LSHTM, LSE), Mónica Oliveira (IST), Teresa Rodrigues (IST), Liliana Freitas (IST), Carlos Bana e Costa (IST), Panos Kanavos (LSE

IMPACT HTA, WP7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 2 (Multi-criteria evaluation framework), Results of the 1st Web-Delphi process to HTA stakeholders, organized into 6 separate parallel panels

IMPACT HTA, WP7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 2 (Multi-criteria evaluation framework), Results of the 1st Web-Delphi process to HTA stakeholders, organized into 6 separate parallel panels (one panel per stakeholder group, 2 rounds), about the views of stakeholders regarding “This aspect should be considered in the evaluation of new medicines on a common basis” (2019) For details on the Web-Delphi process, see: IMPACT HTA, Work Package 7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 2, Deliverable 7.2 (Multi-criteria evaluation framework), Advancing knowledge and MCDA tools to assist HTA agencies in evaluating medicines on a common basis (2021) Oliveira, M.D. (IST), Panos Kanavos (LSE), Bana e Costa, C. (IST

IMPACT HTA, WP7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 2 (Multi-criteria evaluation framework), Results of the 2nd Web-Delphi process to HTA stakeholders, organized in a single panel

IMPACT HTA, WP7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 2 (Multi-criteria evaluation framework), Results of the 2nd Web-Delphi process to HTA stakeholders, organized in a single panel (all stakeholder groups in a single panel, 2 rounds), about the views of stakeholders regarding “This aspect should be considered in the evaluation of new medicines on a common basis” (2019) For details on the Web-Delphi process, see: IMPACT HTA, Work Package 7 (Methodological tools using multi-criteria value methods for HTA decision-making), Task 2, Deliverable 7.2 (Multi-criteria evaluation framework), Advancing knowledge and MCDA tools to assist HTA agencies in evaluating medicines on a common basis (2021) Oliveira, M.D. (IST), Panos Kanavos (LSE), Bana e Costa, C. (IST