Kathryn Hoffmann 1 , K . Viktoria Stein 2 , Manfred Maier 1 , Anita Rieder 2 , Thomas E. Dorner 2

1. Access points to the different levels of health care in a country without a gate-keeping system; numbers and reasons Kathryn Hoffmann1, K. Viktoria Stein2, Manfred Maier1, Anita Rieder2, Thomas E. Dorner2 1 Department of General Practice, Centre for Public Health, Medical University of Vienna, Austria 2 Institute for Social Medicine, Centre for Public Health, Medical University of Vienna

2. Background • The challenges for health care systems become more and more evident in terms of costs, of health equity, and of healthy life expectancy • Currently, the most promising way to face these challenges seems to be to strengthen the PHC sector - however, the evidence is not conclusive yet • Evident is that accessibility to PHC is an important dimension • Normally, a main challenge for health care systems is an existing limitation (e.g. financially, regionally, ...) towards the accessibility • In Austria, the situation is contrary: Fishbain D.A. et al., 1997; Dorner T.E. et al., 2010

3. Background • Accessibility to the Austrian health care system is excellent (no financial barriers for patients, 98% of population insured, Bismarck-system) but... ...with some exceptions patients have free access to both the primary AND secondary level of care  it depends on the estimation of the patient, which level of care she or he consults ...Austria has a secondary care focused health care system (and fee-for-service mainly) • e.g. more specialists working in the ambulatory sector than GPs (~9500 specialists and ~6500 GPs) • e.g. no gate-keeping or list system

4. Aim and objective • Within this context it was the aim of this study to assess the number of persons consulting a General Practitioner (GP) or specialist in the ambulatory sector, an outpatient department, or had a hospital overnight stay within one year • Furthermore, to assess the number and demographic factors of patients that turned to a specialist without consulting a GP concomitantly • Finally, to learn about the main reason why these patients turned to a specialist directly

5. Design • Secondary data analysis • The database used for this analysis was the Austrian Health Interview Survey 2006-07 (450 items), with data from 15,474 people > 15 years old (face-to-face interviews) • Based on the European Core Health Interview Survey Aromaa, A et al., Eur J Public Health 2003;13(Suppl 3):67-72 Stein K.V. et al., Int. J Health Geographics 2011, 10:59

6. Design • Variables of the utilisation of the healthcare system • Within the last 12 months, did you turn to a GP? (yes – no) • Within the last 12 months, did you consult any specialist in the ambulatory sector/an outpatient department/did you have a hospital overnight-stay? (yes – no) • Direct utilisation of specialists • Taking all persons into account that turned to a specialist/outpatient department/hospital and assessing the dichotomised answers to the GP question • Demographic variables (gender, age, country of origin, educational level, location, number of chronic diseases surveyed)

7. Analysis • Main reason for the last direct specialists consultation: • Answer categories: Accident or injury/disease or symptom of a disease/follow-up consultation/preventive check-up/other reasons • Statistical analyses included • descriptive statistics • multivariate logistic regression models

8. Results (I) • GP consultation rate: M 75.6% vs. F 81.8% (p<0.05) • Specialist conultation rate: M 54.0% vs. F 79.8% (p<0.05) • Outpatient department visit: M 18.3% vs. 18.9% (p>0.05) • Hospital stay: M 21.2% vs. 24.3% (p<0.05) • Direct specialist consultation rate: M 15.2% vs. F 15.0% (p>0.05) • Direct outpatient department contact: 9.5% vs. 7.6% (p>0.05) • Direct hospitalisation: 8.6% vs. 7.7% (p>0.05)

9. Results (II)

10. Results (III)

11. Discussion (I) • Utilisation rate of GPs is comparable with other Western European countries • Utilisation rate of specialists (67.4%) is two-to three-fold higher than in EU-countries with gate-keeping system (e.g. Norway 17%, Ireland 25%) • Austria lies beneath the EU27 level for the health indicator „healthy life year expectancy“ • Hospitalisation rate is not reduced, in the opposite, it is one of the highest in Europe • Nearly every 6th person who consulted a specialist, every 11th person who consulted an outpatient department and nearly every 12th person with a hospital stay ha no GP contact • A frequent reason for direct utilisation was a preventive check-up

12. Discussion (II) • Strengths • Large sample size • Comprehensive questionnaire • High external validity for Austria • Limitations • Results based on self-descriptive data (12 months) • Cross sectional study • No diagnoses  could not analyse the appropriateness of care!!!

13. Conclusion • The overall access rates of specialists as well as of specialists without GP consultations are high • The high utilisation rate of specialists working in the ambulatory sector is not reflected in low rates of hospital stays or other quality indicators compared with other EU countries • The results point into the direction of a benefit through a structurally supported advocacy role for PHC professionals • The knowledge gained through this analysis could contribute to the health policy debate on the importance of coordination and continuity at the primary care level

14. Results (III)