GP JOURNEY THROUGH DECADES The Experience from the Czech Republicc

Bohumil SeifertDepartment of General Practice

1st Faculty of MedicineCharles University in Prague

For University Days, Almaty, Kazahstan, December 2015

The itineraire Personal introduction

A journey through decades: - a little bit of politics, history- health care systems- primary care function

Public Health issues and prevention in general practice

A little bit of politics/history I.

Interval between world wars: The golden time of family medicine in the former Czechoslovakia

Austro-Hungarian empire until 1918 Czech Republic since 1993

Bismarck model

Otto von Bismarck:

Sickness Insurance Law 1883 based on mandatory health insurance paid partly by employee and partly by

employer equity in access to health care:

provided free of charge for all providers are independent contractors

Semashek model Nikolai Semashek, 1874 – 1949

Public health officer in Soviet Union

Model in function in the Czech Republic 1951-1989

directive central management and planning equal access to free of charge care for all low motivation for providers (state employees) low status of health care professionals in society

unfavourable outcomes

Semashek model

A little bit of politics/history II.

1950´s An installation of the Soviet model with polyclinics and dense specialist network in countries of Central and Eastern Europe limited function and development of general practice.

1978: GP as an independent discipline

A little bit of politics/history III.

The CEE countries have experienced dramatical changes,including the changes in the health care and in primary care

1989Velvet revolution

Windak A et al, EJGP 1998 Svab et al, Croat Med J, 1999 Seifert B et al., Family Practice, 2008Oleszyk M et al., BMC Family Practice. 2012

Health care system models: options in 90´

Semaschek model

US model (ver liberal, individual responsibility)

Beveridge model (NHS: UK, Denmark, Portugal)

Bismarck model (Germany, Austria, Switzerland)

Czech health care system: Social health insurance

Insurance paid by employee + employer State pays for children and seniors

8 insurance companies (freedom limited)

Health care is free of charge, small co-payment for medicaments

90´: difficult journey back to Europe Poor background of the GP discipline : - no theory behind - low recognition among other medical professions - low competence - bad image, low attractivity- no international contacts and experience- language barriers- high age averageBUT: - enthusiasm and huge support from Europe

Support from European colleaguesRole of WONCA

In 90´s: new perspectives and possibilities• to travel and to meet colleagues• to participate at courses, conferences • to join WONCA networks, to learn and to adopt• to join research ad quality projects

WONCA Region Europe, Prague 1997: the first meeting in CEE region

GPs in the health care system

Independent insurance contractors List of patients / free choice of doctor Mixed capitation + fee for service payment Bonuses: - teaching (accredited) practices

- appointment systém

- late afternoon office hours

- targets (prevention, screening)

General Practice

in the Czech Republic

Polyclinics solo practices (90´s) Solo practices group practices (25 years later)

Primary care: GP + PED + GYN

- home care, social services

No gatekeeping function but people seek for care first by GP.

Typical General Practice Solo practice team: 1 doctor + 1 nurse Facility: rented or owned Organization: open access/ appointment systém Clinic: common acute problems, chronic disease management ,

systematic prevention + screening, house calls, assessment medicine, social administration

Hardware + software Equipment: POCT LAB (CRP, coagulation control, glucometr, glycHgb),

ECG, ENT examination devices, Doppler, BP 24hours, ABI measurement, spirometry, RHB

35 000 physicians, 18 000 in ambulatory service 5200 GPs, 2200 pediatricians, 1400 gynaecologists

Characteristics of the medicine in the 3rd millenium

• Key challenge: non-communicable diseases

• Fascinating technology development

• Successes in diagnostics, treatment and improvement of prognosis of serious conditions

Further expectations push medicine towards prevention towards pro-active inteventions in asymptomatic

people

Prevention and screening

16

Consequencies:

• Ethics (nature of patient – doctor relation,

individuals v. population )• Safety

• Costs

• Capacity

By Charles Boelen

Prevention and primary care GP is translating population strategies for prevention and health promotion into individualized / personal care

is competentknows patient, his/her personal and family history, place where he lives and works.is able to understand patient´s values and preferenceshas possibility to influence patients systematicallyhas possibility to use every consultation for risk assessment and brief intervention

Prevention Primary prevention:

- actions to promote health prior to the development of diseases or injuries

Secondary prevention:

- actions to detect disease in early (asymptomatic) stages Tertiary prevention:

- actions to reverse, arrest or delay progression of disease

Quaternary prevention (by WONCA):

- actions taken to identify a patient at risk of over-medicalization, to protect him from new medical invasion and to suggest interventions that are ethically acceptable.

Prevention in primary care in the Czech Republic

regular preventive checks (biannualy) systematic screening programs opportunistic brief interventions vaccination

Extraordinary checks (for assessment) Occupational health checks Chronic disease management (follow up) Travel medicine

Personal attitudes to prevention

I am free to make decisions…

I have other preferencies, prevention later

Is it realy quality of my life what matters?

I do not want to became a hostage of doctors and health service .…

30% attendance of preventive checks

Preventive checks and EBM US paradox: In country where the equity in access to health

care is a problem, almost half of contacts in primary care are due to routine preventive check.

UK: NHS preventive checks since 2009 The Netherlands, Denmark: No!

While we are not sure about the benefit of preventive checks, we know that they can harm; cause useless diagnosis, useless treatment, risk of invasive tests, stress from false positive results, false assurance from false negative tests, psychosocial consequences of disease labelling, increase of expenses,……

B. Starfield, Epidemiol Community Health Med 2008;62:580-583

Preventive checks and EBMCOCHRAN REVUE14 studies, 182 880 persons (76 403 PP, 106 477 controls)

Follow up 1-22 let Results RR 95% conf.interval Total mortality 0,99 (0,95-1,03)Cardiovascular mortality 1,03 (0,9-1,17)Cancer mortality 1,01 (0,92-1,12)

0 effect: morbidity, hospitalization rate, invalid benefits, practice visits, sick days 20% increase in number of diagnosis in 6 years v. controlsMore hypertensions and hyperlipidemia

There is no evidence on the usefulness of preventive checks

Co-referates

Systematic prevention increases the chance for equity in access to health and therefore a reduction of the risk of CV and oncological diseases.

The effect of prevention depends on participation rate. New Zeland reports participation rate 75%.

Good health policy must take in account both public health priorities and medical research based evidence.

Cardiovascular prevention issues

Participation paradox People at low risk are more likely to participate at the prevention, while people at high risk less likely.

The preventive examination of low risk is not effective while the interventions in people with high risk is effective.

Thresholds: hypertension, serum cholesterol, blood sugar-97% of US adults aged 50 and over have one or more these three risk factors

GPs at the frontline of cancer prevention

Primary prevention

Early diagnostics in symptomatic

Secondary prevention: - screening programmes for high risk persons - screening programmes for average risk p.

Care for cancer patients

• The principal method of identification of colorectal cancer stays symptomatic presentation to GPs who are source of referral to secondary care ………………………90-95% of colorectal cancers

Key Issues: - Help-seeking behaviour - GP performance - Access to diagnostics

Early diagnostics of cancer

Delay processes on patient´s side: - cognitive: low recognition of seriousness of the

symptom - emotional: fear of recieving a cancer diagnosis - behavioural: a reluctance to interact with the HC system

Forbes et al, Brit Jour of Cancer 2013

Simon et al, Cancer Epid Biomarkers and Prevention, 2010

Quaife et al, Brit Jour of Cancer 2014

Whitaker et al, Brit Jour of GP, 2015

Early diagnostics of cancer: Help-seeking behaviour

Clinical decision making in primary care is based on risk estimation.

The aim is to identify in a timely way those patients with a high risk of serious disease

Winkens et al. BMJ 2002, Elstein et al, BMJ 2002

Symptoms are common, but cancer is rare. Concept of alarm symtoms (rectal bleeding, weight loss,

anemia, abdominal pain, apetite loss, alteration in bowel habit). Probability of cancer increases with a combination of

symptoms. Jellema et al, BMJ 2010, Astin et al, BJGP 2011, Olde Bekkink et al, BJC 2010

Early diagnostics of cancer.GP performance

Early diagnostics of cancer.Access to diagnostics

capacity organization of referrals waiting times quality of services

CRC: Due to increasing demand of screening colonoscopies optimalization of referrals for colonoscopy is necessary.

Waiting times 6-12 weeks

interdisciplinary cooperation.

The principles of screening

The aim of screening is to lower the burden of cancer in the population by discovering disease in its early latent stages

SAVING LIVES, IMPROVING QUALITY OF LIFEUSING OF APPROPRIATE METHODS - NO HARMRATIONAL FUNDING: COST EFFECTIVITY

European guidelines, Segnan, Patnick, Karsa, 2010

GPs should be educated in screening in order to:

understand prevention and screening communicate prevention and screening increase uptake in prevention and screening provide balanced information for informed choice

perform screening or recruite for screening interprete results, deal appropriately with

findings support a patient in surveillance programs

Promote healthy life style

Communicate prevention and screening

Organize practice in order to have time and capacity for prevention and screening

Identify high risk patients (CV, Ca)

Do not miss a symptomatic cancer/refer in time.

Prevention Imperatives for primary care physicians

Global emerging challenges in general practice in Europe

• Effective strategies on CV and cancer prevention

• Chronic disease management

• Aging of people – integrated social-health care - primary care preparedness

• Quality and Patient safety

• International professional mobility – standardized curriculum. Sustainable attractivity of the discipline.

• Multicultural medicine

 International conference on

PATIENT SAFETY EQuiP is an international network of experts and people interesting in quality

and safety improvement in primay care.It is one of principal WONCA networks.

The conference will také place in a beautiful Kaiserstein palace

in the old part of Prague.   

Conference Secretariat GUARANT InternationalNa Pankráci 17140 21 Prague 4Czech Republic E-mail: equip2016@guarant.czWebpage: www.equip2016.cz  

 

49th EQuiP Assembly Meeting 2016

Praha 22-23.4.2016

GP yourney continues…..

Thank you for your attention