Abstract
BackgroundFollowing independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system.MethodsUsing routinely collected health billing records for 2005–2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co–morbidities). The data set contained 552 822 individuals. We use patient level data to test the significance of trends, and employ multivariate regression analysis to evaluate the probability of inpatient admission while controlling for patient characteristics, health system supply–side variables, and PHC use.FindingsOver the study period, utilisation of PHC increased, whilst inpatient admissions fell. Service mix in PHC changed with increases in phone, email, nurse, and follow–up (vs initial) consultations. Healthcare utilisation for diabetes, depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure and asthma utilisation in outpatient and inpatient settings increased. Multivariate regression indicates higher probability of inpatient admission for males, older patient and especially those with multimorbidity, but protective effect for PHC, with significantly lower hospital admission for those utilising PHC services.InterpretationOur findings suggest health system reforms in Estonia have influenced the shift of ACSCs from secondary to primary care, with PHC having a protective effect in reducing hospital admissions.
Highlights
Following independence from the Soviet Union in 1991, Estonia introduced a national insurance system, consolidated the number of health care providers, and introduced family medicine centred primary health care (PHC) to strengthen the health system
Interpretation Our findings suggest health system reforms in Estonia have influenced the shift of ambulatory care sensitive conditions (ACSCs) from secondary to primary care, with PHC having a protective effect in reducing hospital admissions
We examine how the Estonian health system reforms have affected service utilisation across 2005–2012 in family medicine clinics and outpatient departments, and admissions to hospital for selected ambulatory–care sensitive conditions (ACSCs); conditions which should be effectively managed in PHC [11,12]
Summary
Using routinely collected health billing records for 2005– 2012, we examine health system utilisation for seven ambulatory care sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2 diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by patient characteristics (gender, age, and number of co–morbidities). 2012: Tariffs increased to pre–crisis level, with the differential between PHC and hospitals introduced in 2011 maintained; Centralization of planning and regulatory functions, with PHC management functions centralized from country governors to the National Health Board; Amendment to Health Insurance Act to strengthen the gatekeeping function of PHC by reducing the number of directly accessible specialties in outpatients; Age–adjusted capitation payment scheme strengthened to motivate family doctors to treat more patients with chronic conditions and improve management of chronic conditions. We examine how the Estonian health system reforms have affected service utilisation across 2005–2012 in family medicine clinics and outpatient departments, and admissions to hospital for selected ambulatory–care sensitive conditions (ACSCs); conditions which should be effectively managed in PHC [11,12]. Estonia transitioned to an insurance–based financing model in 1991 with the creation of regional sickness funds [6], followed by the establishment of the independent Estonian
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