Ambulatory and Primary Care Related Patient Groups (APR)

Ambulatory and Primary Care Related Patient Groups (APR)

Defining products in ambulatory primary care APR based measurement of primary care activities helps us to evaluate the need of the population s s health care services allocate and organise resources efficiently APR groups all patient related activities to clinically meaningful entities Integrates the total process of care in each episode of illness covers the activities of all employee groups in primary care health centres

APR measures an episode of care APR encompasses a total process of care which may consist of several and separate activities of various professionals to cure a specific illness or health problem The pricing of APR based products is straightforward by summing up the costs of individual activities

APR example: Hypertension Suspected hypertension First visit to registered nurse RR measurement at home Follow up visit to RN Pressure is still high 3 months Follow up visit to physician 1 month First visit to physician Follow up visit to RN Visits, encounters and activities= intermediate products

Ambulatory and Primary Care Related Patient Groups VISIT TYPE and CHARACTERISTICS APR TM AGE and SEX ACTIVITIES Classification of activities (CAAP TM ): Physician Registered nurse Child and maternity clinics HC for school children Physiotherapy Mental care Occupational HC REASON for VISIT Classification of diseases (CDAP TM )* 42 classes *Possible to translate from ICPC and ICD 10

Potential use of APR More detailed description of prevailing diseases, patient case mix and severity adjustments Description of treatment practices Productivity calculations and efficiency comparisons Evaluation of population based need for services Description of total episodes of care including specialized hospital (secondary and tertiary) care

Further examples of APR use Productivity and treatment practise comparisons across employees, units and health centres Benchmarking Performance measurement in time series Productivity differences can be explained by looking more closely at the differences in treatment practices Allocation of resources and identification of required changes in the treatment practices

Further examples of APR use Evaluation of changes in the treatment processes Continuous monitoring of health centre performance APR grouping creates a natural basis for Cost accounting Measuring the effectiveness of care Identification of high risk patients

Profile for disease groups Reasons for encounters in Jyväskylä city health centres at October and November 2002 Jyväskylän tk:n potilaskontaktit sairausluokittain Encounters loka marraskuussa 2002 Encounters Classification of diseases, CDAP PhysiciansR Potilaskontaktit nurses Total Classification of diseases, CDAP Physicians Potilaskontaktit R nurses Total Simple infections Sairausluokka, ASL TM Lääkärit 4 034 Hoitajat 1 408 Yhteensä 5 442 Depression Sairausluokka, ASL TM Lääkärit 442 Hoitajat Yhteensä 442 Hypertension Verenpainetauti 51 404 360 11 2 873 356 16 4 233 760 Muu Allergic tauti reactions tai sairaus 1352 365 51 1 365 403 Healthy Terve 71 520 644 61 560 323 14 2 967 080 Nivelrikko Urethritis, cystitis or nephritis 1285 290 57 83 1 347 368 Skin Helppohoitoiset diseases infektiot 10 1 519 828 864 768 11 2 287 692 Depressio Alcohol or drug abuse 858 275 87 858 362 Diabetes wkomplikaatioineen ith or w ithout complications 4852 190 61 380 261 10 2 113 570 Muu Other neurologinen neurological sairaus diseases 698 350 00 698 350 Injury, Oireet intoxication ja tarkemmin or määrittelemättömät poisoning oireistot 71 035 553 2319 755 91 790 872 Iskeeminen Blood or blood sydänsairaus organ diseases ja sydäninfarkti 631 211 45 113 676 324 Other Ihosairaus musculoskeletal diseases 51 956 723 2 964 81 920 787 Dementia Heart failure ja vanhuudenheikkous or other cardiac diseases 414 217 091 414 308 Female Vamma genitourinary tai myrkytys diseases 61 120 178 1514 236 71 356 692 Veren Cardiac ja arrhythmia verta muodostavien elinten sairaudet 217 282 111 0 328 282 Ear, Muu nose tuki ja and liikuntaelinsairaus throat diseases 61 832 049 256 587 71 088 636 Sydämen Eye diseases rytmihäiriöt 279 257 0 279 257 Symptoms Korva, nenä and ja other kurkkutauti non specific conditions 41 148 421 2 300 0 61 448 421 Silmäsairaus Dementia or senility 248 207 00 248 207 Gastrointestinal Muu endokrinologinen disorders sairaus 51 295 287 630 83 51 925 370 Sydämen Neoplasms vajaatoiminta (malignant diseases) ja muut sydänsairaudet 204 170 0 204 170 Mahavaivat Pregnancy, childbirth and complications of those 51 068 206 368 0 51 436 206 Pahanlaatuinen Peripheral vascular kasvain disease 168 133 00 168 133 Naisten Other endocrinological virtsa ja sukupuolielinsairaus diseases 31 477 075 1127 527 51 004 202 Aivoverenkiertohäiriö Life threatening infections 142 74 00 142 74 Metabolinen Other diseases oireyhtymä or illnesses 1462 875 1494 625 3956 500 Lasten Stroke (thrombotic ja nuorten psyyken or haemorrhagic) ja kehityksen häiriöt 136 72 0 136 72 Reuma Male genitourinary ja sidekudossairaus diseases 1570 235 2314 235 3884 470 Ääreisverenkierron Child psychiatric or sairaudet physiatric development disorders68 125 00 125 68 Selkä Metabolic ja kaularangan syndrome sairaudet 2378 920 334 65 2712 985 Henkeä Other infections uhkaavat infektiot 73 60 00 7360 Krooninen Rheumatoid keuhkosairaus arthritis or connective tissue disease 1253 701 372 458 2711 073 Muut Gall bladder tartuntataudit disease 59 20 0 5920 Päihteiden Chronic pulmonary väärinkäyttö disease 1572 325 430 123 1695 755 Kehitysvamma Mental retardation ja epämuodostumat or congenital disorder 40 19 0 4019 Miesten Ischemic virtsa heart disease ja sukupuolielinsairaus including myocardial infarction 1635 128 624 45 1680 752 Lonkkamurtuma Schizophrenia 27 19 120 3919 Allergiaoireet Back and neck diseases 1594 388 204 13 1607 592 Skitsofrenia Complications of the perinatal period 36 17 0 3617 Muu Arthrosis psyyken sairaus 1440 086 363 123 1563 449 Sappirakon Hip fracturesairaudet 20 9 4 2013 Virtsatieinfektio Other mental illnesses ja munuaistulehdus 1369 112 332 126 1495 444 Perinataaliajan Total ongelmat 2720 713 12 344 40 20057

Encounter comparisons Encounters due to hypertension in Jyäskylä city health centres at October and November 2002 KY KE HU KU SA Jkl tot. Visit type Visit Physician R P RN P RN P RN P RN Physici R characte nurse an nurse r istics Visit Emergency 33 31 35 30 12 0 9 11 3 6 92 78 Visit First 55 124 82 33 147 20 46 11 8 1 338 189 Visit Follow up 194 625 354 914 31 77 69 328 25 96 673 2 040 Phone consultation Emergency 1 1 10 0 12 0 0 0 0 0 23 1 Phone consultation First 9 0 1 0 4 0 2 0 1 0 17 0 Phone consultation Follow up 48 2 146 1 174 0 34 2 14 1 416 6 Total 340 783 628 978 380 97 160 352 51 104 1 559 2 314 Encounters / 1000 habitants 14,1 32,4 21,8 33,9 45,0 11,5 10,4 22,8 14,9 30,3 19,2 28,5

Comparing activities Activities (CAAP) by phys icians due to hypertens ion in Jyväskylä health ce ntres at October and Novem ber 2002 KY KE HU KU SA Jkl tot. Activities Number Index Number Index Number Index Number Index Number Index Number Index No activity 296 12,2 391 13,5 121 14,3 70 2,4 32 9,3 910 11,2 New visit time scheduling 152 6,3 298 10,3 43 5,1 80 2,8 13 3,8 586 7,2 Prescribing or changing medication 162 6,7 246 8,5 53 6,3 96 3,3 20 5,8 577 7,1 Phone time scheduling 115 4,8 257 8,9 29 3,4 62 2,1 22 6,4 485 6,0 w orker 13 0,5 50 1,7 10 1,2 14 0,5 9 2,6 96 1,2 Large examination 8 0,3 46 1,6 0,0 11 0,4 2 0,6 67 0,8 Measurement during visit 5 0,2 31 1,1 6 0,7 5 0,2 0,0 47 0,6 Administrative procedure 11 0,5 14 0,5 5 0,6 12 0,4 1 0,3 43 0,5 Health education 12 0,5 17 0,6 1 0,1 3 0,1 3 0,9 36 0,4 Electrocardiography (emergency) 6 0,2 20 0,7 3 0,4 1 0,0 0,0 30 0,4 Patient monitoring 3 0,1 24 0,8 1 0,1 2 0,1 0,0 30 0,4 Consultation (other HC w orker) 7 0,3 15 0,5 2 0,2 3 0,1 2 0,6 29 0,4 Referral to private provider 3 0,1 20 0,7 1 0,1 3 0,1 1 0,3 28 0,3 Injection/ puncture / evacuation 1 0,0 15 0,5 2 0,2 8 0,3 0,0 26 0,3 Referral to specialist care 9 0,4 6 0,2 1 0,1 1 0,0 1 0,3 18 0,2 care 0,0 11 0,4 0,0 0,0 2 0,6 13 0,2 Therapeutic discussion 2 0,1 4 0,1 1 0,1 4 0,1 0,0 11 0,1 Total 805 33,3 1465 50,7 279 33,0 375 13,0 108 31,5 3032 37,4 Activities / encounter 2,4 2,3 0,7 2,3 2,1 1,9 Index = activities / 1000 inhabitants

Productivity comparisons Productivity of physician labour in Jyväskylä health center 2002 (October November) Unit Output Input Efficiency index(%) Increase/decrease potential in output Increase/decrease potential in input Case mix weighted visits Working hours for physicians (h) Output / input HU 2320,3 197,0 88 271,5 23,0 KJ 1194,3 114,5 78 260,4 25,0 KM 1733,7 121,0 107 128,6 9,0 KS 2816,8 179,0 118 506,4 32,2 KU 3376,6 254,5 99 18,0 1,4 KY 2445,9 174,5 105 124,4 8,9 LH 2851,5 209,5 102 58,2 4,3 NM 2041,2 178,0 86 286,3 25,0 SA 774,0 47,0 123 181,5 11,0