By Tina Eriksson
The health care system s were designed to handle acute illnesses and thus provide episodic rather than continuous care, transfer responsibility rather than share responsibility between sectors and actors and take responsibility for patients rather than stimulate self care.
The age composition – longevity and changed lifestyle of populations leads to chronic disease. >30% of the Danish population suffer from one or more chronic diseases and >70% of resources in the Danish health care system are spent on care for chronic disease. Moreover there are numerable new possibilities to treat such conditions.
Therefore the National Board of Health (Sundhedsstyrelsen SST) has set out to change the health care system accordingly, with numerous implications for the primary sector.
A new contract between the National Health Insurance and the General Practitioners’ Organisation in Denmark with a new concept for fee combined with quality measurement of diabetes care should be seen as the start of a more basic reform of the sector. The aims are to integrate the care of chronic patients in general practice in a collective strategy for the national health care service of chronic patients.
Diabetes was selected as “model disease” and if the system proves successful, other chronic diseases, e.g. COPD, will be included.
GPs are addressed as the central professional figures – the MAIN COORDINATORS OF CARE
This new contract introduces a new type fee – the annual fee for diabetes care to be introduced in January 2007. It is a fixed annual fee for diabetes care including quality measurement, irrespective of the numbers of diabetes care consultations
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BOX 1: GPs quality indicators for diabetes
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• HbA1c 6-monthly (yearly in 2. sector)
• HbA1c less than 8% (same)
• Blood pressure 6-monthly (yearly in 2. sector)
• Blood pressure less than or equal to135/85 mmHg (same)
• Lipids yearly (every 2nd year in 2. sector)
• Albuminuria yearly (every 2nd year in 2. sector)
• Eye examination every second year (same)
• Foot examination yearly (every 2nd year in 2. sector)
• Life style and self care discussion with patient yearly
• Agreed treatment plan yearly
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Enrolment is voluntary and involves a 3-year period 2007 – 2009. Comprises all diabetics managed in the practice (mainly type 2. diabetes). The practices are now obliged to use electronic patient records. An automatic data capture module must be installed and all diabetes patients have to be coded (ICPC – T90). Data on quality indicators and risk stratification will be sent to a central database. The risk stratification criteria are developed as well as the indicator set for diabetes care.
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Box 2: Risk stratification criteria
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- common to primary and secondary sector
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HgbA1c
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< 7%
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HbA1c > 9 %
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Blood pressure
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<130/80
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>160/90 despite treatment
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Metabolic problems
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No
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Insulin resistance
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Hypoglycaemic incidents
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Diabetic foot
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No
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Wounds
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Arterial insuff., gangrene or amputation
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Retinopathy
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No/simplex
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Oedema
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Proliferative retinopathy
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Cardiovascular disease
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No
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Yes
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Nephropathy
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No
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Micro alb.
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Macro alb./
Nephropathology
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Patients must fulfil all criteria in Level 1 to belong there, in Level 3 patients belong if they only fulfil one criterion. The rest belong in group 2.
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The “old” contract with partly capitation fee and fee for services continue but now extended with specific preventive consultations also useful for chronic care patients but without claim for documentation of the quality. The contract will be gradually adapted to meet society’s increasing demand for chronic care (more older and chronic patients) and the increasing workload in general practice.
The main annual diabetes consultations includes a specified content (guideline), common planned goals (between GP and patient) of treatment in the coming year and planned number of controls in the coming year. The fee is independent of numbers of controls.
The practice will receive feedback of results 6-monthly (quality indicators and risk stratification). The results are anonymous on practice level but public on group level – perhaps on the municipal level.
Practical aspect
All 13 Danish journal systems have now certified to work with the Data-capture module, developed for this purpose. The enrolment of practices started this the first of April. So far it has been a success as 179 practices have enrolled during the first month. It is not the target to enrol all practices the first year – as experience is needed with the system before it is applied full scale.
