musculoskeletal health in europe health services utilisation
TRANSCRIPT
Musculoskeletal Health in Europe Health services utilisation
What impact do musculoskeletal conditions have on health care
resource utilisation across Member States?
Indicators of health services utilisation
• A number of indicators for health services utilisation are included in the eumusc.net core and additional indicator sets.
• These indicators are grouped under the following categories:• Hospital services utilisation • Health services utilisation• Human resources• Drugs
• The following slides present each of these indicators briefly describing the rationale for including the indicator and giving definitions, data sources, relevant data and comments.
Hospital Services Utilisation
Hospital services utilisation core indicator Number in-patient days related to specific
musculoskeletal diagnoses
Rationale:Measure of efficiency of use of health care resources. Indicator often used for health planning.
Definition:Average Length Of Stay (ALOS) total number of occupied hospital bed-days divided by the total number of admissions or discharges. LOS of one patient is date of discharge – date of admission.
Data source:WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT: 1300 (ICD-10 M00-99, ICD-9 0993, 1361, 2794, 446, 710-739).
Comments:All else being equal a short ALOS will reduce the cost per discharge and shift care to less expensive post acute services. But shorter stays could lead to adverse health outcomes. National differences in the type of reimbursement system or health insurance plan may affect the patient length of stay in hospitals.
Average length of stay in days for MSC, 2007 or latest available
Average length of stay in days for musculoskeletal system & connective tissues
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
Denm
ark
United
Kingdom
France
Nether
lands
Luxem
bourg
Spain
Belgiu
m
Irela
nd
Finla
ndIta
ly
Slove
nia
Cypru
s
Avera
ge
Lithuan
ia
Slova
kia
Latvi
a
Austria
Hungar
y
Czech
Repu
blic
Poland
Ger
man
y
Hospital service utilisation core indicatorNumber of hospital in-patient discharges for
musculoskeletal diagnoses
Rationale:Measure of efficiency in use of health care resources. Indicator often used for health planning purposes.
Definition:Number of hospital in-patient discharges from all hospitals during the given calendar year expressed per 1,000 population for diseases of the musculoskeletal system and connective tissue.
Data source:WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT: 1300 (ICD-10 M00-99, ICD-9 0993, 1361, 2794, 446, 710-739).
Comments:International comparisons of hospital discharge statistics are complicated by differences in national health information systems. Most musculoskeletal problems and conditions are managed predominantly in primary care or as outpatients.
Hospital discharges by diagnosis per 100,000 population as percentage of
all discharges 2007Hospital discharges by diagnosis as % all hospital discharges
0 5 10 15 20 25 30
CyprusMalta
IrelandPoland
BulgariaLithuaniaDenmarkRomaniaSlovenia
UnitedItaly
SpainFrance
NetherlandsFinland
HungaryCzech Republic
BelgiumGermany
LuxembourgAustria
Percent of all hospital discharges
Respiratory
Circulatory
Musculoskeletal
Hospital services utilisation indicator Age-standardised admission rates
Rationale:Measure of the utilisation of hospital services for MSC and the burden of MSC on health services.
Definition:Age-standardised admission rates per 1,000 population for musculoskeletal and connective tissue diseases (M00-99).
Data sources:WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT 1300 (ICD-10 M00-99; ICD-9 0993,1361, 2794, 446, 710-739)
Age-standardised admission rate for MSC per 1,000 population, 2007 or latest
available
Age-standardised admission rate for diseases of the musculoskeletal system & connective tissue per 1000 population 2007 or latest available
0
5
10
15
20
25
30
Cypru
s
Spain
Irela
nd
Poland
United
Kingdom
Nether
lands
Denm
ark
Italy
Slove
nia
Slova
kia
Avera
ge
Lithuan
ia
France
Finla
nd
Belgiu
mLat
via
Hungar
y
Czech
Repu
blic
Ger
man
y
Austria
In-patients and day cases for MSC per 1,000 population, 2007 or latest
available
0
5
10
15
20
25
30
35
Austri
a
Germ
any
Luxem
bourg
Czech
Rep
ublic
Hungar
y
Finla
nd
Belgiu
m
Latvi
a
France
Lithuan
ia
Slova
kia
Slove
niaIta
ly
Denm
ark
Unite
d Kin
gdom
Nether
lands
Polan
d
Irela
nd
Spain
Cypru
s
In-patients per1,000 population
Day cases per1,000 population
Variation in utilisation of hospital servicesfor MSC
Source: EUROSTAT 2011
Poland
0
2
4
6
8
10
12
14
2003 2004 2005 2006 2007 2008
Year
UK
0
2
4
6
8
10
12
14
2000 2001 2002 2003 2004 2005 2006 2007 2008
Year
In-patients per 1,000
ALOS
Day cases per 1,000
Age standardised admission rateper 1,000
Netherlands
0
2
4
6
8
10
12
14
16
2004 2005 2006 2007 2008
Year
Finland
0
2
4
6
8
10
12
14
16
18
2002 2003 2004 2005 2006 2007 2008
Year
Hospital services utilisation core indicator Number of surgeries hip arthroplasty
Rationale:Volume of surgeries is product of prevalence and severity of condition and availability of appropriate medical resources.
Definition:Number of hip replacements performed in hospital as in-patient surgery per 100,000 population.
Data sources:OECD Health Database 2009 and national arthroplasty registers.
Comments:Arthroplasty registers: Austria, Italy, Denmark, Finland, Romania, Slovakia, Sweden, Hungary, France, England, Scotland Czech Republic, Portugal.
Hip replacement
The number of hip replacement procedures differ significantly across EU Member States. The volume of surgeries is a product of:
• prevalence of the condition • availability of appropriate medical resources• Differences in clinical treatment guidelines and
practices • International mobility across EU borders
Low rates may point to under-treatment or may be due to good control of the underlying systemic disease.
Hip replacement procedures
Hip replacement, procedures per 100,000 population (in-patient) 2007
0
50
100
150
200
250
300
Pro
ced
ure
s
Source: Surgical procedures by ICD-9-CM, Hip replacement, Procedures per 100 000 population (in-patient). OECD Health Data 2009 - Version: November 09
Number of Primary Total Hip Replacements per Diagnosis and Age
Swedish Hip Register 1992-2005
Diagnosis < 50 years 50-59 years 60-75 years > 75 years Total Share
Primary osteoarthritis
53.5% 79.5% 81.6% 68.1% 75.7%
Fracture 3.5% 4.3% 8.2% 21.4% 11.7%
Inflammatory arthritis 17.3% 6.6% 4.2% 2.2% 4.5%
Idiopathic femoral head necrosis
6.3% 2.7% 2.0% 3.8% 2.9%
Childhood disease 13.7% 4.0% 0.8% 0.3% 1.7%
Secondary osteoarthritis 1.5% 0.6% 0.7% 1.4% 0.9%
Tumor 1.1% 0.8% 0.4% 0.3% 0.5%
Secondary arthritis
after trauma 0.8% 0.3% 0.2% 0.3% 0.3%
(missing) 2.3% 1.3% 1.9% 2.2% 1.9%
Total 100% 100% 100% 100% 100%
Hospital services utilisation core indicator Number of surgeries knee arthroplasty
Rationale:Volume of surgeries is product of prevalence and severity of condition and availability of appropriate medical resources.
Definition:Number of knee replacements performed in hospital as in-patient surgery per 100,000 population.
Data sources:OECD Health Database 2009 and national arthroplasty registers.
Comments:Arthroplasty registers: Austria, Italy, Denmark, Finland, Romania, Slovakia, Sweden, Hungary, France, England, Scotland Czech Republic, Portugal
Knee replacement procedures
Knee replacement procedures per 100,000 population 2006
0
20
40
60
80
100
120
140
160
180
200
Health Services Utilisation
MSC in Primary & Community Care
• People with musculoskeletal complaints are frequent visitors to primary health care centres, hospitals, and paramedical institutions (e.g. physiotherapy and chiropractic).
• Comparison of GP utilisation between countries is limited because in some countries the GP has much more of a gatekeeping function than in others. In Spain, Portugal, Italy, Finland, Denmark, Norway, United Kingdom, Ireland and the Netherlands the GP has an explicit gatekeeping role. (Kroneman et al., 2006) In Luxemburg, Belgium, Germany, Austria, France, Sweden and Greece direct access to most other services is possible (Kroneman et al., 2006).
Health services utilisation core indicator Primary care visits related to diagnostic
codeRationale:Provides information on the burden of MSC on health services. Necessary for planning of prevention and health care policy.
Definition:% of annual primary care visits (all causes) that are due to MSC (as defined by ICD10 or ISHMT).
Data sources:National routinely collected data on primary care visits by ICD10 or ISHMT.
Comments:Availability of national health statistics on primary care patient visits by diagnosis very variable between countries. Comparability problematic because of differences in nature and use of primary care services between countries.
Primary care visits for musculoskeletal conditions
• In one UK study one in seven of all recorded consultations during 2006 was for a musculoskeletal problem. One in four of the registered population consulted for a musculoskeletal problem in that year, rising to more than one in three of older adults. The back was the most common reason for consultation, followed by the knee, chest and neck (Jordan et al 2010).
• Data from the second Dutch national survey of general practice indicate neck and upper extremity symptoms are common in Dutch general practice with GPs consulted approximately seven times per week for a complaint relating to the neck or upper extremity (Bot et al 2005).
• In Italy the frequency of visits to GPs for musculoskeletal conditions ranges between 10% and 18% of total consultations (Cimmino 2007).
The burden of MSC on primary care in the UK – consultation rates 2003
The burden of MSC on primary care in the UK – consultation rates for non-
infectious disease 2003
Non-infectious GP consultations per 100,000 population
Netherlands: the number of persons diagnosed by the GP as having a musculoskeletal disease or
complaint per 1,000 registered patients
Total musculoskeletal disorders 133
Sprain 15
Low back pain with radiation 15
Arthrosis 15
Shoulder syndrome / PHS 14
Osteoporosis 7
Rheumatoid arthritis 4
Other disorders 77
Percentage of adults visiting GP for MSC, UK 2006
The table below presents the percentage and estimated number in the adult UK population who visit their general practitioner at least once during a year with any musculoskeletal complaint. These rates have been consistent over the past 6 years.
How many adults consult GP with MSC per annum UK, 2006 Gender Percentage consulting No patients who visit per
annum (million) Male 17 4.1 Female 23 6.0 Total 20 10.1
GP consultations for MSC by age and gender, UK 2006
Percentage of registered patients consulting GP for MSC per annum, UK 2006
0
5
10
15
20
25
30
35
40
15-24 25-44 45-64 65-74 75+
Age
Per
cen
t
Male
Female
Other providers of MSC care
• Occupational therapists, physiotherapists and chiropractors provide care for those with MSC.
• It is very difficult to obtain comparable data across the EU on consultations for MSC with these professionals.
• One source of data is the European Health Interview Survey (EHIS) which asks a general questions about visits to physiotherapists, occupational therapists and chiropractors.
Percent respondents visited health provider in past 12 months
Percent respondents visited health provider in past 12 months
0 2 4 6 8 10 12 14
Belgium
Latvia
Cyprus
Hungary
Malta
Austria
Wales
Slovenia
Czech Repub.
Percent
Physiotherapist
Chiropodist
Occupationaltherapist
Health services utilisation indicator Outpatient / ambulatory consultations with physician or surgeon related to diagnostic
code
Rationale:Provides information on the burden of MSC on health services. Necessary for planning of prevention and health care policy. Provides information on how far recommended standards of care in MSC health services are being met.
Definition:Number of outpatient visits per 100,000 population per year for MSC.
Data sources:National routinely collected data on out-patient visits, RA, OA, Back Pain, SPA.
Comments:Availability of national health statistics on out patient visits by diagnosis is variable between countries. Variability between countries on what is treated on an outpatient basis therefore needs to be considered together with national in-patient data.
Out-patient visits for MSC (ICD10 codes M00-99)
It is difficult to obtain comparative data on out-patients visits for MSC. The number of out-patient visits can differ significantly between countries. For example in Romania in 2010 the number of outpatient visits per 1,000 population per year for musculoskeletal conditions was 22.4 while in Spain for 2009 the comparable number was 2.8:
Health services utilisation indicator Day cases related to diagnostic
codeRationale:Provides information on the burden of MSC on health services. Necessary for planning of prevention and health care policy.
Definition:Number of hospital day cases from all hospitals during the given calendar year expressed per 1,000 population for diseases of the musculoskeletal system and connective tissue.
Data sources:WHO European Hospital Morbidity database Diseases of the musculoskeletal system and connective tissue. ISHMT 1300 (ICD-10 M00-99; ICD-9 0993,1361, 2794, 446, 710-739)
Comments:Variability may exist between countries on what is treated as a day case.
Human Resources
• A range of practitioners, manage musculoskeletal problems. These include specialists, general practitioner, community pharmacists, physical therapists (chiropractors, osteopaths and physiotherapists), behavioural therapists (counsellors, psychologists and psychotherapists) and complementary medicine practitioners (for example, acupuncturists and aromatherapists).
• Measuring human resources is problematic because concepts used for medical specialities differ across the EU Member States. In particular there are differences in the roles carried out by associated health professionals such as Occupational Therapists which makes direct comparison of human resources between countries problematic.
• Whilst on a national level there may be good access to health professionals there may be large regional variations. This regional variation in availability may affect the equity of access.
Human resources core indicator Number of rheumatologists
Rationale:Assessment of availability (not necessarily accessibility) of health care services.
Definition:Number Rheumatology specialists per 100,000 inhabitants
Data sources:Eurostat indicator; Data obtained from national administrative sources.
Comments:Practising physicians provide services directly to patients, tasks include: conducting medical examination and making diagnosis, prescribing medication and giving treatment for diagnosed illnesses, disorders or injuries, giving organized medical or surgical procedures. It describes availability of staff for the whole country; may differ by region.
Rheumatology physicians per 100,000 inhabitants 2006
EUROSTAT
Practising rheumatology physicians per 100,000 inhabitants, 2006
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
Franc
e
Eston
ia
Luxem
bourg
Denm
ark
Belgi
um
Greec
e
Poland
Sweden
Slova
kia
UK (Engl
and
only)
Avera
ge
Malt
a
Bulgar
ia
Czech
Rep
ublic
Lithua
nia
Nethe
rlands
Roman
ia
Portuga
l
Cypru
s
Latvi
a
Irela
nd
Human resources core indicatorNumber of orthopaedic surgeons
Rationale:Assessment of availability (not necessarily accessibility) of health care services.
Definition:Number orthopaedic surgeons per 100,000 inhabitants
Data sources:National statistics and professional organisations
Comments:Some problems in obtaining comparable data between countries, some collect practising, others licensed etc. Availability of staff may differ by region.
Orthopaedic specialists per 100,000 inhabitants 2010
Number orthopaedic specialists per 100,000 inhabitants
0
2
4
6
8
10
12
14
16
18
France
Nether
lands UK
Czech
Repub
lic
Estonia
Finlan
d
Austria
Portugal
Belgiu
mSpai
n
Germ
any
Sweden
Number of practising Occupational Therapists per 100,000 inhabitants 2011
COTECNumber of practising occupational therapists per 100,000
inhabitants 2011
0
20
40
60
80
100
120
Italy
Luxem
bourg
Latvia
Czech
Repub
lic
Spain
Greece
Cyprus
France
Portugal
Nether
lands
Austria
Sloven
ia UK
Finlan
d
Germ
any
Belgiu
m
Denmar
k
Sweden
Physiotherapists
Number of Physiotherapists per 100,000 inhabitants 2005
0
50
100
150
200
250
Irela
nd
Greece
Spain UK
Italy
Austria
France
Germ
any
Nether
lands
Sweden
Belgiu
m
Denmar
k
Finlan
d
Number of diagnostic DXA scanners in EU
Drug use• In recent years, for the majority of MSC, there has been
considerable progress in medical and surgical management techniques leading to a reduction in the pain and disability arising from these conditions. In particular there have been significant advances in the effectiveness of treatments for RA and there is evidence to suggest that the improvement in the health status of those with RA can be attributed to the more aggressive use of and increased accessibility to, these treatments (Heiberg et al 2005;Krishnan et al 2003; Uhlig et al 2008).
• Treatment of RA focuses on the suppression of inflammation. It is treated with non-steroid anti-inflammatory drugs (NSAIDs) usually in combination with disease modifying antirrheumatic drugs (DMARDs). In the late 1990s so called ‘biologics’ such as TNF inhibitors were introduced. They have a strong effect on inflammation and can prevent or slow the progression of joint erosion. These drugs are expensive. A 2007 study estimated the costs at between 9,000- 18,000 Euros per patient per year ( Engel-Nitz 2007).
Variations in drug use
• Across the EU in recent decades there has been an upward trend in expenditure on pharmaceuticals.
• There is a wide variation between different countries• Factors in variation include:
• Differences in the demography and health status of the population e.g. proportion of elderly in the population.
• Differences in organization and financing of pharmaceuticals supplies e.g. reimbursement policies.
• Cultural differences in the use of medication.• Differences in clinical practice e.g. differences in prescribing
practice. • Differences in service organisation and delivery e.g. access
to specialists.
Drug use indicator Self-reported medication use for
MSC
Rationale:Health resources utilization - relates to accessibility, quality of care and costs
Definitions:Percent of population who report having used medication prescribed by a physician during the past 2 weeks for pain in joints, neck or back
Percent of population who report having used medication NOT prescribed by a physician during the past 2 weeks for pain in joints, neck or back
Data sources:EHIS and National Health Interview Surveys
Reasons for long-term medical treatment
Longterm treatment because of longstanding troubles with muscles, bones
and joints (arthritis, rheumatism)
% reporting medical long term treatment for troubles with muscles, bones and joints
0
5
10
15
20
25
30
35
40
45
Pe
rce
nta
ge
Percentage of all respondents taking medication for MSC in past
2 weeks Percentage of respondents taking prescribed and non-prescribed
medications for MSC in past 2 weeks
0
2
4
6
8
10
12
14
16
18
Cyprus Malta Slovenia Latvia Austria CzechRepub
Hungary
Per
cen
t
Prescribed painin joints
Prescribed painin back
Non-prescribedpain in joints
Drug use indicatorPharmaceuticals consumption for
MSCRationale:Health resources utilization - relates to accessibility, quality of care and costs
Definitions:Amount of medicine use (based on sales statistics) per day per 1,000 population for treatment of MSC (ATC codes M) expressed in Defined Daily Doses (DDDs) per day.
Amount of medicine use (based on sales statistics) per day per 1,000 population for Antiinflammatory and antirheumatic products (ATC codes M01) expressed in Defined Daily Doses (DDDs) per day.
Data sources:OECD Health database - data obtained from national medicine sales register
Comments:There are a number of possible sources of under-reporting of drug sales in different countries. Most drugs in this area can be used for different non MSC conditions therefore difficult to interpret.
Pharmaceutical consumption, Musculoskeletal System, Defined daily dosage per 1000 inhabitants per day
Pharmaceutical consumption musculoskeletal system, DDD per 1000 inhabitants
0.0
20.0
40.0
60.0
80.0
100.0
120.0
140.0
160.0
1999 2000 2001 2002 2003 2004 2005 2006 2007
DD
D p
er 1
000
inh
abit
ants
per
day
Czech Repub
Denmark
Finland
Germany
Hungary
Netherlands
Portugal
Slovakia
Sweden
Pharmaceutical consumption, M01A-Antiinflammatory,antirheumatic prod. non-steroids, Defined daily dosage per 1000 inhabitants per day
Pharmaceutical consumption M01A antiinflam. antirheumatic prod. non-steroids, DDD per 1000 inhabitants
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
1999 2000 2001 2002 2003 2004 2005 2006 2007
DD
D p
er 1
000
inh
abit
ants
per
day
Czech Republic
Denmark
Finland
Germany
Hungary
Netherlands
Portugal
Slovak Republic
Sweden
Drug use indicatorPharmaceuticals sales for MSC
Rationale:Health resources utilization - relates to accessibility, quality of care and costs
Definitions:Sales of pharmaceutical products for MSC (ATC codes M) or sales of pharmaceutical products for Antiinflammatory and antirheumatic non-steroid products (ATC codes M01) on the domestic market based on retail prices (the final price paid by the customer). Expressed as: i. % Total sales ii. US$ Purchasing Power Parity (PPP) per annum.
Data sources:OECD Health database - data obtained from national medicine sales register
Comments:There are a number of possible sources of under-reporting of drug sales in different countries. Most drugs in this area can be used for different non MSC conditions therefore difficult to interpret.
Pharmaceutical sales, Musculoskeletal system per capita US$ PPP
Pharmaceutical sales musculoskeletal system per capita US$ PPP
0
5
10
15
20
25
30
35
1999 2000 2001 2002 2003 2004 2005 2006 2007
per
cap
ita
US
$ P
PP
Czech Republic
Denmark
Finland
Germany
Hungary
Netherlands
Portugal
Slovak Republic
Sweden
Pharmaceutical sales, M01A Antiinflam, antirheumatic prod. Non-steroids per capita
US$ PPP
Pharmaceutical sales M01A antiinflam antirheumatic prod. non-steroids per capita US$ PPP
0
5
10
15
20
25
1999 2000 2001 2002 2003 2004 2005 2006 2007
per
cap
ita
US
$ P
PP
Czech Republic
Denmark
Finland
Germany
Hungary
Netherlands
Portugal
Slovak Republic
Sweden
Pharmaceutical sales musculoskeletal system, % total
salesPharmaceutical sales musculoskeletal system, % total sales
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
1999 2000 2001 2002 2003 2004 2005 2006 2007
% t
ota
l sa
les
Czech Republic
Denmark
Finland
Germany
Hungary
Netherlands
Portugal
Slovak Republic
Sweden
Pharmaceutical sales M01A Antiinflam, antirheumatic prod. non-steroids % total
salesPharmaceutical sales M01A antiinflammatory, antirheumatic prod.
Non-steroids % total sales
0
1
2
3
4
5
6
7
8
9
Germ
any
Sweden
France
Denmar
k
Belgiu
m
Slovak
Rep
ublic
Czech
Repub
lic
Finlan
d
Portugal
% t
ota
l sa
les
2002
2007
International variation in use of TNF inhibitors & DMARD
• Jonsson et al (2008) examined international variation in the use of TNF inhibitors and of conventional DMARDS for the treatment of rheumatoid arthritis for the period 2000-2006.
• High uptake was observed for Sweden, the Netherlands and Finland, France Spain and the UK were around the EU 13 average. Germany Italy and countries of central and eastern Europe were below this average.
• Possible reasons for differences proposed by the authors were:• Differences in GDP (although there were large differences
between countries with similar GDP) • Differences in relative price levels• Differences in national preferences and priorities• Variations in access to rheumatologists
• Variations in clinical guidelines have also been suggested as a reason for variation in usage of biological treatments (Kobelt & Kasteng 2009).
eumusc.net is an information and surveillance network promoting a comprehensive European strategy to optimise musculoskeletal health. It addresses the prevention and management of MSC’s which is neither equitable nor a priority within most EU member states. It is focused on raising the awareness of musculoskeletal health and harmonising the care of rheumatic and musculoskeletal conditions.It is a 3 year project that began in February 2010. It is supported by the European Community (EC Community Action in the Field of Health 2008-2013), the project is a network of institutions, researchers and individuals in 22 organisations across 17 countries, working with and through EULAR.
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