Association between fee-for-service expenditures and morbidity burden in primary care.

BACKGROUND: In primary care, fee-for-services (FFS) tariffs are often based on political negotiation rather than costing systems. The potential for comprehensive measures of patient morbidity to explain variation in negotiated FFS expenditures has not previously been examined. OBJECTIVES: To examine the relative explanatory power of morbidity measures and related general practice (GP) clinic characteristics in explaining variation in politically negotiated FFS expenditures. METHODS: We applied a multilevel approach to consider factors that explain FFS expenditures among patients and GP clinics. We used patient morbidity characteristics such as diagnostic markers, multimorbidity casemix adjustment based on resource utilisation bands (RUB) and related GP clinic characteristics for the year 2010. Our sample included 139,527 patients visiting GP clinics. RESULTS: Out of the individual expenditures, 31.6% were explained by age, gender and RUB, and around 18% were explained by RUB. Expenditures increased progressively with the degree of resource use (RUB0-RUB5). Adding more patient-specific morbidity measures increased the explanatory power to 44%; 3.8-9.4% of the variation in expenditures was related to the GP clinic in which the patient was treated. CONCLUSIONS: Morbidity measures were significant patient-related FFS expenditure drivers. The association between FFS expenditure and morbidity burden appears to be at the same level as similar studies in the hospital sector, where fees are based on average costing. However, our results indicate that there may be room for improvement of the association between politically negotiated FFS expenditures and morbidity in primary care.

The Danish Centre for Strategic Research in Type 2 Diabetes (DD2): organization of diabetes care in Denmark and supplementary data sources for data collection among DD2 study participants.

This paper provides a short overview of the Danish health care system and the organization of care for type 2 diabetes patients in Denmark. It also describes the supplementary data sources that are used for collection of baseline data in the nationwide Danish Centre for Strategic Research in Type 2 Diabetes (DD2) Project. The Danish National Health Service provides tax-funded medical care for all 5.6 million Danish residents. The health care system is characterized by extensive individual-level registration of data used for planning, administration, quality improvement, and research. It is estimated that there are currently at least 250,000 individuals with known diabetes in Denmark (approximately 4.5% of the Danish population), of which an estimated 80% are followed and treated by their general practitioners and approximately 20% are followed at hospital specialist outpatient clinics. These health care providers form the basis for recruiting diabetes patients in the DD2 project, and the data sources that these providers use in clinical practice give access to important supplementary patient data. The DD2's patient-enrollment system is designed to be fast and simple, and thus only collects primary interview data that cannot be extracted from already existing data sources. Thus, in addition to an online DD2 questionnaire filled out by general practitioners and hospital physicians at the time of patient enrollment, supplementary data are obtained from the Danish Diabetes Database for Adults, a nationwide clinical quality improvement registry. Both hospital physicians and a growing number of general practitioners routinely report data to this database. For general practitioners, the Danish General Practice Database acts as an important feeder database for the Danish Diabetes Database for Adults and thereby also for the DD2 project.

The danish model for improvement of diabetes care in general practice: impact of automated collection and feedback of patient data.

Background. Sentinel Data Capture is an IT program designed to collect data automatically from GPs' electronic health record system. Data include ICPC diagnoses, National Health Service disbursement codes, laboratory analysis, and prescribed drugs. Quality feedback reports are generated individually for each practice on the basis of the accumulated data and are available online only for the specific practice. Objective. To describe the development of the quality of care concerning drug prescriptions for diabetes patients listed with GPs using the Data Capture module. Methods. In a cohort study, among 8320 registered patients with diabetes, we analyzed the change in the proportion of medication for uncontrolled cases of diabetes. Results. From 2009 to 2010, there was an absolute risk reduction of 1.35% (0.89-1.81: P < 0.001) in proportion of persons not in antidiabetic medication despite an HbA1c above 7.0. Similarly, there was a 4.51% (3.42-5.61: P < 0.001) absolute risk reduction in patients not in antihypertensive treatment despite systolic blood pressure above 130 mm Hg and 4.73% (3.56-5.90: P < 0.001) absolute risk reduction in patients with total cholesterol level above 4.5 mmol/L and not receiving lipid-lowering treatment. Conclusions. Structured collection of electronic data from general practice and feedback with reports on quality of care for diabetes patient seems to give a significant reduction in proportion of patients with no medical treatment over one year for participating GPs. Due to lack of a control group, we are, however, not able to say if the drop in the proportion of uncontrolled cases is a result of participation in collection of electronic data and feedback alone.

Multimorbidity and blood pressure control in 37 651 hypertensive patients from Danish general practice.

BACKGROUND: Patients with hypertension are primarily treated in general practice. However, major studies of patients with hypertension are rarely based on populations from primary care. Knowledge of blood pressure (BP) control rates in patients with diabetes and/or cardiovascular diseases (CVDs), who have additional comorbidities, is lacking. We aimed to investigate the association of comorbidities with BP control using a large cohort of hypertensive patients from primary care practices. METHODS AND RESULTS: Using the Danish General Practice Database, we included 37 651 patients with hypertension from 231 general practices in Denmark. Recommended BP control was defined as BP <140/90 mm Hg in general and <130/80 mm Hg in patients with diabetes. The overall control rate was 33.2% (95% CI: 32.7 to 33.7). Only 16.5% (95% CI: 15.8 to 17.3) of patients with diabetes achieved BP control, whereas control rates ranged from 42.9% to 51.4% for patients with ischemic heart diseases or cerebrovascular or peripheral vascular diseases. A diagnosis of cardiac heart failure in addition to diabetes and/or CVD was associated with higher BP control rates, compared with men and women having only diabetes and/or CVD. A diagnosis of asthma in addition to diabetes and CVD was associated with higher BP control rates in men. CONCLUSION: In Danish general practice, only 1 of 3 patients diagnosed with hypertension had a BP below target. BP control rates differ substantially within comorbidities. Other serious comorbidities in addition to diabetes and/or CVD were not associated with lower BP control rates; on the contrary, in some cases the BP control rates were higher when the patient was diagnosed with other serious comorbidities in addition to diabetes and/or CVD.

[Data collection perspectives from patient care in general practice]. / Perspektiver ved dataindsamling i almen praksis.

GPs in Denmark have a unique civil registration system with personal ID-numbers, a patient list system and a gatekeeper function. A piece of software (Data Capture) has been developed to automatically collect and send prescriptions, lab tests, expense items and diagnosis information from the physician's patient files to the Danish General Practice Database (DAMD). Furthermore, project-related information can be captured by a pop up screen. Data about the GPs' own quality in the field of patient care are sent back to the GP. Many research projects are currently being initiated on the basis of DAMD data.

Estimating incidence and prevalence of episodes of care in general practice.

OBJECTIVES: To develop methods for prospective registration and analysis of episodes of care (one or more contacts about the same health problem). To compare estimates of point prevalence and incidence of hypertension among a group of elderly patients by means of an elaborate coding of episodes and a new method based on routine coding of contact diagnoses. DESIGN: Prospective longitudinal cohort study. SETTING: General practice in Denmark. SUBJECTS: 31 GPs and 1722 patients 70+ years of age. MAIN OUTCOME MEASURES: During the course one year, data were registered in the doctors' electronic medical record systems. Registration included ICPC diagnoses and codes for diagnostic and therapeutic procedures. Individual contacts were linked into episodes of care by the recording physician. Prevalence and incidence were calculated from the GPs' registration of episodes of care and from contact registration by means of a new method, "the waiting time distribution". RESULTS: Estimates of incidence (2.1 per 100 patient years) and point prevalence (21.2 per 100 patients) of episodes of hypertension care could be calculated when the GPs actively linked contacts into episodes. Based on simple contact registration it was possible to calculate similar estimates. CONCLUSION: A full registration of episodes of care is time-consuming and complicated. Incidence and point prevalence of chronic conditions, however, may be estimated from simple coding of contact diagnoses.