A World Bank analysis ordered by Estonian Health Insurance Fund says we lack integrated approach to patients – due to ailing cooperation between family doctors and medical specialists, treatment is often insufficient; once home after being hospitalised, people with acute disease conditions may be left alone with their troubles.
Thus, one suffering from infarct, not fully aware of his serious condition and left without decent follow-up treatment and checks, may omit taking needed medicines or fail to see a doctor.
According to the research, 18 percent of all hospitalisations with asthma, chronic obstructive lung disease, diabetes, cardiac insufficiency and high blood pressure could have been avoided by more effective treatment.
On the one hand, we see that the initial level i.e. family doctors should do more to deal with those chronically ill. Meanwhile, the analysis also shows that such hospital-centred approach is facilitated by the Health Insurance Fund (HIF) financing model which motivates hospitals to apply in-patient treatment. On top of that, problems exist with availability of nursing care and rehabilitation, as well as social services.
According to Margus Viigimaa, head of Estonian Society for Cardiology and professor of technical medicine at Tallinn University of Technology, the large percentage of avoidable hospitalisations should not be viewed through dark glasses. «I think that in any country this would be the same. Rather, let’s see the positive: we have room here to make things better,» he observed.
A place of much improvement is, indeed, in what happens after a person leaves hospital – coordination of follow-up treatment is weak. Turns out, only three percent of those hospitalised with acute disease conditions such as stenocardia, infarct or cardiac deficiency, received prescriptions when sent home for all three medicines advised in international treatment guidelines. Also, mere third of the patients studied paid a follow-up visit to family doctor.
Such results show that the health care system has not agreed about follow-up treatment after leaving hospital. Also, information exchange between hospitals and gamily doctors is weak.
It also turned out that despite frequent contacts with family doctors, chronically ill patents are not receiving sufficient preventive services as advised in treatment instructions. To a whopping fifth of diabetics, family doctors apply not one of the diagnostic inspections advisable twice a year.
Estonian Family Doctors’ Society chairman Diana Ingerainen could not tell why. Party, she assumed, it is the overload on the doctors not allowing them to attend trainings and keeping themselves in the know of everything.
Time badly short
In the light of the data, Ms Ingerainen was troubled that very often patients seem to fall between the various levels. «In the hospitals, they assume the family doctors do these things; family doctors hope the hospitals do it. Thus, it is not done. We are obviously lacking in the administration of patients – the organising factor, the logical logistics is weak,» admitted the doctor.
She said that family doctors have tried to have assistants assigned to initial level to see if the patients have paid their visits, and have had the needed analyses and treatment prescribed; however, due to lack of money the idea has not materialised.
Also, she cited time shortage of family doctors as a hindrance to more systemically dealing with chronic sick. «An Estonian family doctor sees an average of 25 patients a day – they enter the door, they have a problem and this then has to be solved. Meanwhile, dealing with the chronically sick takes a lot of planning. It seems to me that our family doctors just don’t have the time.»
When it comes to insufficient consultation, Ms Ingerainen thinks it is also due to the haphazard way Estonian health care is managed. «The roles have been divided in a manner very confusing. A hospital receives a patient nicely enough, but as they finish their part the patient is not under their responsibility at all. Here, patients’ own responsibility should come into play, for them to come see family doctor; often, the doctors at the hospital tell them so, but they do not necessarily show up,» said the doctor. Ms Ingerainen said the family doctors don’t often even know the patient has had an infarct.
According to Margus Viigimaa, a patient having the initial infarct will often fail to comprehend the seriousness of his condition – he may feel he was healthy before and continues to be so now. «But, in reality, his blood vessels are all calcified and the complications will be coming one after another – they start at the heart, then in the brain and someplace else,» explained the professor, adding that such patients need decent treatment, moral support and exercise counselling in order to prevent repeated infarcts.
Resources partly wasted
Prof Viigimaa said patients hospitalised with infarct ought to definitely be monitored by a cardiologist during the first six to eight months. «Together with the family doctor, but regularity is what matters, depending on the severity of the sickness. At the moment, we have no hard and fast system how the infarct patient should proceed, afterwards,» he noted.
At the same time, cardiologists and other medical specialists are often seeing patients who could be easily helped by family doctors alone. As an example of this, Prof Viigimaa cited serial visits by patients with high blood pressure, without complications, with health under control by medicines and in need if simple monitoring.
«But there’s the other problem – for instance, patients with secondary hypertension suspected (the blood pressure resulting from some other disease, such as kidney problems – M. L.) and those severely resistant to treatment – of those, very many will never reach a cardiologist. Meanwhile, some keep visiting for no reason, wasting the medical specialist’s resource.»