Access points to the different levels of health care in a country without a gate-keeping system; numbers

and reasons

Kathryn Hoffmann1, K. Viktoria Stein2, Manfred Maier1, Anita Rieder2, Thomas E. Dorner2

1 Department of General Practice, Centre for Public Health, Medical University of Vienna, Austria

2 Institute for Social Medicine, Centre for Public Health, Medical University of Vienna

• The challenges for health care systems become more and more evident in terms of costs, of health equity, and of healthy life expectancy

• Currently, the most promising way to face these challenges seems to be to strengthen the PHC sector - however, the evidence is not conclusive yet

• Evident is that accessibility to PHC is an important dimension • Normally, a main challenge for health care systems is an existing limitation (e.g. financially,

regionally, ...) towards the accessibility

• In Austria, the situation is contrary:

Fishbain D.A. et al., 1997; Dorner T.E. et al., 2010

Background

• Accessibility to the Austrian health care system is excellent (no financial

barriers for patients, 98% of population insured, Bismarck-system) but...

...with some exceptions patients have free access to both the primary AND

secondary level of care it depends on the estimation of the patient, which

level of care she or he consults

...Austria has a secondary care focused health care system (and fee-for-

service mainly)

– e.g. more specialists working in the ambulatory sector than GPs (~9500

specialists and ~6500 GPs)

–e.g. no gate-keeping or list system

Background

• Within this context it was the aim of this study to assess the number of persons consulting a General Practitioner (GP) or specialist in the ambulatory sector, an outpatient department, or had a hospital overnight stay within one year

• Furthermore, to assess the number and demographic factors of patients that turned to a specialist without consulting a GP concomitantly

• Finally, to learn about the main reason why these patients turned to a specialist directly

Aim and objective

• Secondary data analysis

• The database used for this analysis was the Austrian Health Interview Survey 2006-07 (450 items), with data from 15,474 people > 15 years old (face-to-face interviews)

• Based on the European Core Health Interview Survey

Design

Aromaa, A et al., Eur J Public Health 2003;13(Suppl 3):67-72Stein K.V. et al., Int. J Health Geographics 2011, 10:59

• Variables of the utilisation of the healthcare system

– Within the last 12 months, did you turn to a GP? (yes – no)

– Within the last 12 months, did you consult any specialist in the ambulatory

sector/an outpatient department/did you have a hospital overnight-stay? (yes – no)

• Direct utilisation of specialists

– Taking all persons into account that turned to a specialist/outpatient

department/hospital and assessing the dichotomised answers to the GP question

• Demographic variables (gender, age, country of origin, educational level, location, number

of chronic diseases surveyed)

Design

• Main reason for the last direct specialists consultation: – Answer categories: Accident or injury/disease or symptom of a

disease/follow-up consultation/preventive check-up/other reasons

• Statistical analyses included

– descriptive statistics – multivariate logistic regression models

Analysis

Results (I)

• GP consultation rate: M 75.6% vs. F 81.8% (p<0.05)• Specialist conultation rate: M 54.0% vs. F 79.8% (p<0.05)• Outpatient department visit: M 18.3% vs. 18.9% (p>0.05)• Hospital stay: M 21.2% vs. 24.3% (p<0.05)

• Direct specialist consultation rate: M 15.2% vs. F 15.0% (p>0.05)• Direct outpatient department contact: 9.5% vs. 7.6% (p>0.05)• Direct hospitalisation: 8.6% vs. 7.7% (p>0.05)

Results (II)

Results (III)

Discussion (I)• Utilisation rate of GPs is comparable with other Western European

countries• Utilisation rate of specialists (67.4%) is two-to three-fold higher

than in EU-countries with gate-keeping system (e.g. Norway 17%, Ireland 25%)• Austria lies beneath the EU27 level for the health indicator „healthy life

year expectancy“• Hospitalisation rate is not reduced, in the opposite, it is one of the

highest in Europe

• Nearly every 6th person who consulted a specialist, every 11th person who consulted an outpatient department and nearly every 12th person with a hospital stay ha no GP contact

• A frequent reason for direct utilisation was a preventive check-up

• Strengths• Large sample size• Comprehensive questionnaire• High external validity for Austria

• Limitations• Results based on self-descriptive data (12 months)• Cross sectional study• No diagnoses could not analyse the

appropriateness of care!!!

Discussion (II)

• The overall access rates of specialists as well as of specialists without GP consultations are high

• The high utilisation rate of specialists working in the ambulatory sector is not reflected in low rates of hospital stays or other quality indicators compared with other EU countries

• The results point into the direction of a benefit through a structurally supported advocacy role for PHC professionals

• The knowledge gained through this analysis could contribute to the health policy debate on the importance of coordination and continuity at the primary care level

Conclusion

Results (III)