The Danish Healthcare System and the Danish Registers

Transcription

1 The Danish Healthcare System and the Danish Registers Jens Søndergaard, MD, PhD Professor, family physician, clinical pharmacologist Research Unit for General Practice, Institute of Public Health, University of Southern Denmark

2 Challenges and opportunities in Danish General Practoce Jens Søndergaard, MD, PhD Professor, family physician, clinical pharmacologist Research Unit for General Practice, Institute of Public Health, University of Southern Denmark

3 Denmark square kilometres 5.4 mio inhabitants Very homogeneous population

4 The Danish healthcare system National publicly financed health care with equal access for all One of the highest satisfaction rates in Europe but gatekeeper systems tend to have long hospital waiting lists Life expectancy and other public health parameters better than in the US but could be even better Costs are 50-60% of US costs (8-9% of GDP) Nearly no family physician without contract with the public health insurance Private hospitals growing, but < 5% of national hospital activity

5 Danish Health Insurance 97% choose insurance group 1 registered with a Family Practice (FP). FP is gatekeeper mandatory referral to specialist and hospital no personal copayment for a visit to a doctor 2-3% choose insurance group 2 copayment per visit ( ~ 50 $) no gatekeeping to specialists can choose any doctor for each visit Some people buy an additional private insurance to have (nearly) free access to private clinics and hospitals nearly no waiting lists

6 Antenatal clinics 6

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8 The Danish population and healthcare attendance during 1 year Directly to hospital 2% Gatekeeper Population % Family Physician 4,760,941 14% 19% 17% Hospital 666,990 Hosp. outpat.care 892,670 78% 45% Specialist pract. 826,489 38%?%?%?% Municipality population oriented prev. care and home nurse - care Sundhedsstyrelsen 2007 and Peter Vedsted

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10 Number of GP visits, , 1,000 10

11 General Practice in Denmark Basic conditions We have a patient list system We are gatekeepers Patients do not pay for GP visits Most patients with chronic disease(s) are controlled in general practice GPs have a national contract with renewal every third year

12 General Practice Gate keeper Triage Prevention Treatment: Acute and chronic diseases 80-90% of the medicine consumption in Denmark

13 Danish Family Practice All family physicians are specialists in family medicine 3,600 specialists in family medicine 1 family physician per 1,500 inhabitants 30% capitation fee. 70% fee for service Length of specialist training the same as for other specialists (6.5 years after medical school) They purchase and own their clinics they often work years in the same clinic Work in singlehanded or partnership practices 2 8 doctors An average of one staff member per doctor All have a contract with the public health insurance and the majority of their income comes from the public health insurance.

14 Tasks of a family practice Not a gatekeeper but a gate adviser Reactive diagnostics, treatment and gate advice when people feel ill Proactive chronic care including coordination of care between hospitals, primary care in municipalities and within the family physician s own clinic Preventive tasks Chronic care Childcare and immunizations Antenatal and maternity care In daily clinical work for instance smoking cessation Lifestyle advice etc.

15 Tasks of the family practice -II Family practitioners serve as advisers and coordinators in hospitals and municipalicities Every hospital department and municipality has a part time employed GP who in cooporation with the hospital physicians: Facilitates shared care Develops guidelines for referral Ensures good communication between hospitals and family practitioners Ensures that there is a plan for patients when discharged from hospital

16 The doctor s surgery 50% chronic patients - often several diseases 30% new diseases > 20% MUS: medically unexplained symptoms Maximum 5 days waiting time for an appointment Acute cases must be seen immediately A formal regional out-of-hours service staffed by family physicians. MUS: medically unexplained symptoms Frede Olesen

17 When an entire country is a cohort Frank, Science 2000 The epidemiologist s dream: Denmark Frank, Science 2003

18 Data landscape Clinical databases Statistics Denmark DAMD Danish National Health Service Register Psychiatric diseases registry Statistiscs Denmark socioeconomy (Income, education, marietal status, scik leave etc) PRN register National Danish Prescription registry National biobank Registry of health services Birthregistry Diabetes registry Registry of causes of death Cancer registry

19 Personal Registration Number All Danish citizens are assigned a unique civil registration number (CPR), which enables accurate linkage between these registries.

20 Validity Anafylactic shock Diabetes Febrile seizures Myocardial Infarction Herniated lumbal disc Meningococcal disease Cancer diagnosis Epilepsy Essential hypertension Rheumatic fever Conn's syndrome Traumatic hip luxation Uterine rupture Positive predictive value (%)

21 Danish system of automatic data collection and feedback of structured data in general practice Danish Quality Unit of General Practice The Research Unit for General Practice, University of Southern Denmark

22 Sentinel Data capture Sentinel Data Capture is an IT program designed to collect data from GPs electronic health record system. Data include: ICPC diagnoses National Health Service disbursement codes Laboratory analysis Prescribed drugs Entering an ICPC diagnosis triggers a pop-up screen where additional information can be filled in Data are stored in DAMD Danish General Practice Database.

23 Sentinel Data capture PC in clinic PC in clinic Server in clinic pop-up Danish healthcare data net GPs have access to reports from their patient group through secure logon DAMD Server DAMD Report server Transferring data from DAMD til NIP DAMD generates quality feedback reports NIP National Indicator Project Quality feedback reports are generated individually for each practice on the basis of the accumulated data and available online only for the specific practice. The feedback reports includes a benchmark section which enables the GP to compare his own quality with other GPs locally and nationally.

24 Diabetes pop-up screen Data collection and decision / treatment support: Foot examination within 15 months Eye examination within 30 months Known cardiovascular disease Lifestyle conversation within 15 months Setting individual treatment goals

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26 Pop-up screens There are several pop-up screens: Chronic disease (yearly control for patients, obligatory) Diabetes; COPD; heart failure; CVD, depression Specific projects (voluntary) Fragile elderly; risk of osteoporosis Examples of electronic audit projects Respiratory tract infections, back pain

27 Quality feedback reports Decision / treatment support for GPs: Population overview Benchmark towards own data Benchmark towards other clinics at national, regional and municipality levels Overview of disease for patients

28 Quality feedback reports There are 44 different reports to Danish GPs. Only 5 reports use pop-up Reports in English:

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30 Proportion of diabetes patients, percent HbA1c, median Percent of patients investigated last year Total cholesterol, median Percent of patients investigated last year Systolic blood-pressure, median Percent of patients investigated last year U-Alb/Crea, median Percent of patients investigated last year

31 Disease indicators??

32 Status August 2013 All GPs in Denmark use the system from May million patients are included in DAMD More than 190,000 diabetes patients are included 39 millions patient contacts are registered 142 million lab tests are in the DAMD 54 million prescriptions are registered

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34 Results 50.7% women Mean age was 63.3 years (±SD 10.3) Prescribed antihypertensive medication: 15,056 (40.0%) Diagnosis of hypertension: 22,595 patients (60.0%) 76.9% of the 22,595 were prescribed antihypertensive drugs

35 Results BP control rate 33.2% (CI: ). BP control rate, diabetes: 16.5% (CI: ) BP control rate, comorbidities: 42.9% % for patients with ischemic heart diseases, cerebrovascular or peripheral vascular diseases. Other comorbidities such as cancer, psychiatric disease or chronic obstructive pulmonary diseases, never reduced the odds of BP control

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