Cross-sectional comparison of health care delivery and reimbursement between segregated and nonsegregated communities in Hungary.

Introduction: Spatially segregated, socio-economically deprived communities in Europe are at risk of being neglected in terms of health care. In Hungary, poor monitoring systems and poor knowledge on the health status of people in these segregated areas prevent the development of well-informed effective interventions for these vulnerable communities. Aims: We used data available from National Health Insurance Fund Management to better describe health care performance in segregated communities and to develop more robust monitoring systems. Methods: A cross-sectional study using 2020 health care data was conducted on each general medical practice (GMP) in Hungary providing care to both segregated and nonsegregated (complementary) adult patients. Segregated areas were mapped and ascertained by a governmental decree that defines them as within settlement clusters of adults with low level of education and income. Age, sex, and eligibility for exemption certificate standardized indicators for health care delivery, reimbursement, and premature mortality were computed for segregated and nonsegregated groups of adults and aggregated at the country level. The ratio of segregation and nonsegregation specific indicators (relative risk, RR) was computed with the corresponding 95% confidence intervals (95% CI). Results: Broad variations between GMPs were detected for each indicator. Segregated groups had a significantly higher rate of health care service use than complementary groups (RR = 1.22, 95% CI: 1.219;1.223) while suffering from significantly reduced health care reimbursement (RR = 0.940, 95% CI: 0.929;0.951). The risk of premature mortality was significantly higher among segregated patients (RR = 1.184, 95% CI: 1.087;1.289). Altogether, living in a segregated area led to an increase in visits to health care services by 18.1% with 6.6% less health spending. Conclusion: Adults living in segregated areas use health care services more frequently than those living in nonsegregated areas; however, the amount of health care reimbursement they receive is significantly lower, suggesting lower quality of care. The health status of segregated adults is remarkably lower, as evidenced by their higher premature mortality rate. These findings demonstrate the need for intervention in this vulnerable group. Because our study reveals serious variation across GMPs, segregation-specific monitoring is necessary to support programs sensitive to local issues and establish necessary benchmarks.

Effectiveness of and Inequalities in COVID-19 Epidemic Control Strategies in Hungary: A Nationwide Cross-Sectional Study.

INTRODUCTION: Before the mass vaccination, epidemiological control measures were the only means of containing the COVID-19 epidemic. Their effectiveness determined the consequences of the COVID-19 epidemic. Our study evaluated the impact of sociodemographic, lifestyle, and clinical factors on patient-reported epidemiological control measures. METHODS: A nationwide representative sample of 1008 randomly selected adults were interviewed in person between 15 March and 30 May 2021. The prevalence of test-confirmed SARS-CoV-2 infection was 12.1%, of testing was 33.7%, and of contact tracing among test-confirmed infected subjects was 67.9%. The vaccination coverage was 52.4%. RESULTS: According to the multivariable logistic regression models, the occurrence of infection was not influenced by sociodemographic and lifestyle factors or by the presence of chronic disease. Testing was more frequent among middle-aged adults (aOR = 1.53, 95% CI 1.10-2.13) and employed adults (aOR = 2.06, 95% CI 1.42-3.00), and was more frequent among adults with a higher education (aORsecondary = 1.93, 95% CI 1.20-3.13; aORtertiary = 3.19, 95% CI 1.81-5.63). Contact tracing was more frequently implemented among middle-aged (aOR41-7y = 3.33, 95% CI 1.17-9.45) and employed (aOR = 4.58, 95% CI 1.38-15.22), and those with chronic diseases (aOR = 5.92, 95% CI 1.56-22.47). Positive correlation was observed between age groups and vaccination frequency (aOR41-70y = 2.94, 95% CI 2.09-4.15; aOR71+y = 14.52, 95% CI 7.33-28.77). Higher than primary education (aORsecondary = 1.69, 95% CI 1.08-2.63; aORtertiary = 4.36, 95% CI 2.46-7.73) and the presence of a chronic disease (aOR = 2.58, 95% CI 1.75-3.80) positively impacted vaccination. Regular smoking was inversely correlated with vaccination (aOR = 0.60; 95% CI 0.44-0.83). CONCLUSIONS: The survey indicated that testing, contact tracing, and vaccination were seriously influenced by socioeconomic position; less so by chronic disease prevalence and very minimally by lifestyle. The etiological role of socioeconomic inequalities in epidemic measure implementation likely generated socioeconomic inequality in COVID-19-related complication and death rates.

[Resource allocation effectiveness of indicator-based performance monitoring in Hungarian primary care for adults]. / Az indikátoralapú teljesítményértékelésre épülo forráselosztás hatékonysága Magyarországon a felnotteket ellátó háziorvosi praxisokban.

Introduction: The indicator-based performance monitoring and pay-for-performance system for Hungarian primary care was established in 2009, covering the whole country. It is based on a stable legal system and well operating information technology. Although, the health insurance system is able to facilitate the performance improvement only by the financing for general medical practices, the many times modified present system does not take into consideration (apart from the geographical location of practices) factors which determine the performance but cannot be influenced by general practitioners. Aim: The study aimed at renewing the indicator set and evaluation methodology in order to enable the monitoring to evaluate the performance of general medical practices independent of their structural characteristics. Method: Each adult care specific primary care performance indicator from June 2016 covering the whole country has been investigated. Indicators adjusted for structural practice characteristics (age and gender of patients; relative education of people provided; settlement type and county of the practice) have been computed. The difference between adjusted indicators and national reference values has been evaluated by statistical testing. Appropriateness of the present monitoring and financing system has been investigated by comparing the practice level presently applied and adjusted indicators to outline the opportunities to develop the present system. Results: The present monitoring allocates 34.46% of pay-for-performance resources for improving the performance of practices. The majority of resources supports the conservation of performance. Furthermore, the present system is not able to identify each practice with better than reference performance, withholding amount corresponding to 8.83% of pay-for-performance resources. If this financing were restricted to practices with significantly better than reference performance, the maximum of the financing a month in a practice would increase from 176 042 HUF (551 EURO) to 406 604 HUF (1274 EURO). Conclusion: Completing the performance monitoring system operated at present by the National Health Insurance Fund of Hungary with indicators adjusted for structural characteristics of the general medical practices, the resource allocation effectiveness could be improved. Orv Hetil. 2019; 160(39): 1542-1553.

Associations between untreated depression and secondary health care utilization in patients with hypertension and/or diabetes.

PURPOSE: We determined the prevalence of untreated depression in patients with hypertension (HT) and/or diabetes (DM) and estimated the extra health care use and expenditures associated with this comorbidity in a rural Hungarian adult population. We also assessed the potential workload of systematic screening for depression in this patient group. METHODS: General health check database from a primary care programme containing survey data of 2027 patients with HT and/or DM was linked to the outpatient secondary care use database of National Institute of Health Insurance Fund Management. Depression was ascertained by Beck Depression Inventory score and antidepressant drug use. The association between untreated depression and secondary healthcare utilization indicated by number of visits and expenses was evaluated by multiple logistic regression analysis controlled for socioeconomic/lifestyle factors and comorbidity. The age-, sex- and education-specific observations were used to estimate the screening workload for an average general medical practice. RESULTS: The frequency of untreated depression was 27.08%. The untreated severe depression (7.45%) was associated with increased number of visits (OR 1.60, 95% CI 1.11-2.31) and related expenses (OR 2.20, 95% CI 1.50-3.22) in a socioeconomic status-independent manner. To identify untreated depression cases among patients with HT and/or DM, an average GP has to screen 42 subjects a month. CONCLUSION: It seems to be reasonable and feasible to screen for depression in patients with HT and/or DM in the primary care, in order to detect cases without treatment (which may be associated with increase of secondary care visits and expenditures) and to initiate the adequate treatment of them.

Healthcare Utilization and All-Cause Premature Mortality in Hungarian Segregated Roma Settlements: Evaluation of Specific Indicators in a Cross-Sectional Study.

Roma is the largest ethnic minority of Europe with deprived health status, which is poorly explored due to legal constrains of ethnicity assessment. We aimed to elaborate health indicators for adults living in segregated Roma settlements (SRS), representing the most vulnerable Roma subpopulation. SRSs were mapped in a study area populated by 54,682 adults. Records of all adults living in the study area were processed in the National Institute of Health Insurance Fund Management. Aggregated, age-sex standardized SRS-specific and non-SRS-specific indicators on healthcare utilization and all-cause premature death along with the ratio of them (RR) were computed with 95% confidence intervals. The rate of GP appointments was significantly higher among SRS inhabitants (RR = 1.152, 95% CI: 1.136⁻1.167). The proportion of subjects hospitalized (RR = 1.286, 95% CI: 1.177⁻1.405) and the reimbursement for inpatient care (RR = 1.060, 95% CI: 1.057⁻1.064) were elevated for SRS. All-cause premature mortality was significantly higher in SRSs (RR = 1.711, 1.085⁻2.696). Our study demonstrated that it is possible to compute the SRS-specific version of routine healthcare indicators without violating the protection of personal data by converting a sensitive ethical issue into a non-sensitive small-area geographical analysis; there is an SRS-specific healthcare utilization pattern, which is associated with elevated costs and increased risk of all-cause premature death.

Association between the General Practitioner Workforce Crisis and Premature Mortality in Hungary: Cross-Sectional Evaluation of Health Insurance Data from 2006 to 2014.

The workforce crisis of primary care is reflected in the increasing number of general medical practices (GMP) with vacant general practitioner (GP) positions, and the GPs' ageing. Our study aimed to describe the association between this crisis and premature mortality. Age-sex-standardized mortality for 18⁻64 years old adults was calculated for all Hungarian GMPs annually in the period from 2006 to 2014. The relationship of premature mortality with GPs' age and vacant GP positions was evaluated by standardized linear regression controlled for list size, urbanization, geographical location, clients' education, and type of the GMP. The clients' education was the strongest protective factor (beta = -0175; p < 0.001), followed by urban residence (beta = -0.149; p < 0.001), and bigger list size (beta1601⁻2000 = -0.054; p < 0.001; beta2001-X = -0.096; p < 0.001). The geographical localization also significantly influenced the risk. Although GMPs with a GP aged older than 65 years (beta = 0; p = 0.995) did not affect the risk, GP vacancy was associated with higher risk (beta = 0.010; p = 0.033), although the corresponding number of attributable cases was 23.54 over 9 years. The vacant GP position is associated with a significant but hardly detectable increased risk of premature mortality without considerable public health importance. Nevertheless, employment of GPs aged more than 65 does not impose premature mortality risk elevation.

Exploring quality of care and social inequalities related to type 2 diabetes in Hungary: Nationwide representative survey.

AIMS: The study aimed to launch a T2DM adult cohort that is representative of Hungary through a cross-sectional study, to produce the most important quality indicators for T2DM care, to describe social inequalities, and to estimate the absolute number of T2DM adult patients with uncontrolled HbA1c levels in Hungary. METHODS: A representative sample of the Hungarian T2DM adults (N=1280) was selected in 2016. GPs collected data on socio-demographic status by questionnaire, and on history and laboratory parameters from medical records. The process and outcome indicators used in the international monitoring practice were calculated. The socio-economic status influence was determined by multivariate logistic regression models. RESULTS: Target achievement was 61.66%, 53.48%, and 54.00% for HbA1c, LDL-C, and blood pressure, respectively, in the studied sample (N=1176). In Hungary, 294,534 patients have above target HbA1c value out of 495,801 T2DM adults. The education-dependent positive association with majority of process indicators was not reflected in HbA1c, LDL-C, and blood pressure target achievements. The risk of microvascular complications and requirement of insulin treatment were higher among less educated. CONCLUSIONS: According to our observations, the education-independent target achievement for HbA1c and LDL-C is similar as, for blood pressure is less effective in Hungary than in Europe.

Delivery of cardio-metabolic preventive services to Hungarian Roma of different socio-economic strata.

BACKGROUND: Because the cardiovascular mortality in Hungary is high, particularly among the socio-economically deprived and the Roma, it is implied that primary health care (PHC) has a limited ability to exploit the opportunities of evidence-based preventions, and it may contribute to social health inequalities. OBJECTIVES: Our study investigated the underuse of PHC preventive services. METHODS: Random samples of adults aged 21-64 years free of hypertension and diabetes mellitus were surveyed with participation rate of 97.7% in a cross-sectional study. Data from 2199 adults were collected on socio-demographic status, ethnicity, lifestyle and history of cardio-metabolic preventive service use. Delivery rates were calculated for those aged 21-44 years and those aged 45-64 years, and the influence of socio-demographic variables was determined using multivariate logistic regression. RESULTS: Delivery rates varied between 12.79% and 99.06%, and the majority was far from 100%. Although most preventive service use was independent of education, younger participants with vocational educations underutilized problematic drinking (P = 0.011) and smoking (P = 0.027) assessments, and primary or less educated underutilized blood glucose (P = 0.001) and serum cholesterol (P = 0.005) checks. Health care measures of each lifestyle assessment (P nutrition = 0.032; P smoking = 0.021; P alcohol = 0.029) and waist circumference measurement (P = 0.047) were much less frequently used among older Roma. The blood glucose check (P = 0.001) and family history assessment (P = 0.043) were less utilized among Roma. CONCLUSIONS: The Hungarian PHC underutilizes the cardio-metabolic prevention contributing to the avoidable mortality, not generating considerably health inequalities by level of education, but contributing to the bad health status among the Roma.