Background
Efficiency is considered a key measure of health system performance [
1]. Assessments of overall system efficiency might conceal important variation between different parts of the health system, and it is important to understand how the various sectors perform in order to effectively inform decision-making by mangers and policymakers [
2]. Related research has tended to focus on hospitals (including different types of ownership), not least due to the availiability of data [
3‐
5] and because the hospital setting has clear boundaries [
6]. Efficiency in primary care is less well understood and the imprecise boundaries and wide range of outputs mean that efficiency is more difficult to assess [
2,
7,
8]. Yet, primary care is recognised to be at the core of resilient and sustainable health systems [
9], with evidence pointing to its key role in improving health outcomes, health system efficiency and health equity [
10,
11]. Primary care also plays an important role in the effective prevention and integrated management of the rising burden of chronic disease globally [
12]. It is against this background that assessing the performance and efficiency of primary care has become ever more important [
13].
Most studies of efficiency in primary care have been conducted in European countries, with a focus on technical efficiency of primary care providers, such as general practices, primary care centres or primary care teams within countries [
8,
14,
15]. Only one study [
16] specifically examined primary care efficiency across [
22] European countries, finding that countries varied considerably in terms of their efficiency in translating care structures into processes and care processes into quality outcomes. The study provided important insights into technical efficiency as measured by primary care structures, such as governance, financing or workforce; processes (e.g. access, continuity of care) and outcomes (quality, efficiency, equity). However, it did not explore the factors that could explain variation between countries in terms of primary care efficiency. Such an analysis would allow for inferences about the likely contribution of national-level policies to improve efficiency [
2].
This paper seeks to address this important research gap by investigating the relationship between health system characteristics and primary care efficiency across European countries. Specifically, we seek to explore whether a given characteristic is associated with higher or lower primary care efficiency. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment, much of which can be delivered in primary care [
17]. Diabetes has been proposed as a useful tracer condition to assess health system performance [
18]. As efficiency analysis is inherently a comparative exercise, focusing on a single condition can enhance the comparability of efficiency measures across countries [
2] and may facilitate the identification of outputs attributable to primary care.
Discussion
In this paper, we investigated the efficiency of primary care systems in European countries and explored the associations between efficiency and health system characteristics. Primary care efficiency scores improved when a range of population characteristics were taken into account. We found that bonus payments, nurse-led follow-up of people with chronic conditions, and an incentive or requirement for patients to have a referral from primary to specialist care were associated with increased efficiency whereas the number of curative care beds and incentives for patients to register with a primary care provider reduced efficiency. For other health system variables, associations were less consistent.
Our finding that bonus payments were associated with higher efficiency aligns with other evidence suggesting that incentive payments in primary care, such as pay-for-performance schemes targeted at the management of chronic conditions, is associated with reduced resource use [
58,
59] and gains in efficiency [
60]. Likewise, the positive association between nurse-led follow-up of people with chronic conditions and efficiency, and task-shifting from physicians to nurses in primary care is also reflected in the wider literature suggesting that substitution of physicians by nurses in primary care can have a positive effect on health outcomes and patient satisfaction, although the effect on costs, health system outcomes, and quality of life is less conclusive [
61‐
64]. Similarly, the association of a requirement to obtain a primary care referral to specialist care with higher efficiency aligns with previous studies [
65,
66] that reported higher efficiency scores for OECD countries that had primary care gatekeeping arrangements in place.
Somewhat counterintuitively, evidence of an association between patient registration with a primary care provider and efficiency was mixed, with compulsory registration significantly positive only in the model that adjusted for income while voluntary registration using incentives was negatively associated with primary care efficiency in all models. Patient registration has been linked to enhancing care continuity and coordination [
67], which, in turn, has been linked to improved patient outcomes [
68] and lower service use and cost [
69]. However, the nature and extent of how countries define and implement ‘patient registration’ varies substantially [
70], and it is likely that the variable as conceptualized in the data source [
44] used in this study captures some other mechanism that would explain our finding.
We also found some evidence that EHR availability and use may be associated with improved efficiency, although this applied to certain models in our study only. There is limited evidence, mostly from the United States, which points to the potential of EHR to increase efficiency in some contexts [
71] while other studies have highlighted the negative impacts of inadequate design of EHR systems [
72,
73].
A higher rate of curative care beds was associated with reduced efficiency. This finding is perhaps unsurprising as hospital beds built are likely to be used (‘Roemer’s Law’ [
74‐
77]) although the relationship between hospital bed capacity and use is more complicated. For example, in an international comparative study Van Loenen et al. [
78] found hospital bed supply to be strongly associated with admission rates for uncontrolled diabetes and long-term complications. They also highlighted the possibility of reverse causation, finding that countries that had a stronger primary care orientation also had lower hospital bed supply. Moreover, the price of hospital services varies widely across countries [
79], which may have implications for efficiency.
We further found a negative association between efficiency and the organisation of out-of-hours primary care using a rota of physicians in all models except those that adjusted for alcohol consumption and smoking. A physician rota for out-of-hours primary care was the most common organisational model in our sample. Alternative approaches such as general practice co-operatives may be more efficient [
80], but this model was not widespread and there may be insufficient statistical power to detect a positive association. A recent review [
81] of national diabetes registries found that most registries served to monitor and improve the quality of diabetes care and that national registries may also help to achieve efficiency gains by identifying the causes of variation in outcomes. We did not find evidence to support this observation.
The study period covers six years (2010–2016), which coincided with primary care reform efforts in several countries that may be associated with efficiency. For example, in 2010, the Netherlands introduced a bundled payment for diabetes care provided in primary care settings. Evaluations showed that the reform led to improved care coordination and adherence to quality guidelines, improvements in clinical outcomes, and a reduction in the use of specialist care and associated costs [
82]. Since the introduction of a new payment system for GPs in 2015, the bundled payment accounts for around 15% of GP income [
83]. Similarly, Denmark introduced a bundled payment system in primary care for diabetes patients in 2007, but this was discontinued in 2014 due to low participation by GPs [
84]. Evaluations have found that bundled payment models were associated with increased efficiency compared to separate payment for different services [
85]. Therefore, we might expect that bundled payment would be positively associated with primary care efficiency. However, we are unable to test this hypothesis based on available data.
The implementation of austerity measures, following the 2007–08 financial crisis and subsequent global recession, may have affected primary (and secondary) care access and efficiency. However, it is difficult to investigate these changes given the diversity of responses across countries, encompassing changes to public funding, health coverage and health service planning, purchasing and delivery [
86]. Additionally, an examination of the relationship between efficiency and quality regulations and regulatory actors was beyond the scope of this study.
While we included a variable measuring task-shifting from physicians to nurses in primary care, we did not consider the substitution of specialist care to primary care. A review of interventions involving the transfer of (elements of) services from specialist to primary care found some evidence of a reduction in the utilisation of specialist care but a lack of information on costs [
87]. Evidence suggests that the relocation of specialists to primary care settings is associated with shorter waiting lists and times and improved patient satisfaction [
88] as well as lower costs [
89].
Not all countries in our study provide universal access to primary care. In Ireland, eligibility for free primary care services is based on age and income and less than half of the population meet the relevant criteria. Evidence suggests that people not eligible for free primary care are more likely to report unmet need for health care [
90], and to forgo preventative [
91], and chronic care [
92]. While Irish government policy has prioritised universal primary care, modelling suggests that significant numbers of additional GPs would be needed to meet the increased demand arising from the introduction of universal primary care. One proposed solution to address the potential shortage of GPs is increased nurse substitution [
93] and our findings of a positive relationship between task-shifting and efficiency would lend support to this policy.
While the time period of our study does not cover the COVID-19 pandemic, some of our results have relevance for the changes in health care delivery that were adopted in response to the pandemic. For example, the use of digital health tools increased substantially during the pandemic [
94]. We found that the availability and use of one such tool (EHR) was associated with increased efficiency. A key finding of our study, namely that task-shifting from physicians to nurses in primary care was associated with increased efficiency, is very likely to remain significant given the continued efforts of countries to move to more systematic use of the non-physician workforce in primary care.
Strengths and limitations
We used two indicators on the quality of primary care for diabetes, admissions and lower extremity amputation for diabetes. These are widely used in health system performance comparisons as indicators of the quality of diabetes care [
95] and have also been used in a previous study [
96] measuring the efficiency of diabetes care at a national level. National studies have also used more refined measures of diabetes care including diabetes-related medication [
97,
98], the number of diabetic patients with a complete diabetes annual review [
97] and a composite indicator of diabetes prevention and quality [
96]. However, data on such indicators across countries and over time are currently unavailable. While focusing on a single condition facilitated the identification of appropriate outputs and cross-country comparisons, it is important to note that it does not reflect the wide range of activity undertaken in primary care and therefore our results would not be representative of primary care as a whole. Nevertheless, our results on the positive relationship between certain health system characteristics and efficiency may be relevant for other chronic conditions managed in primary care. Bonus payment and nurse-led follow-up are measured in relation to chronic illness in general and not specifically diabetes. Similarly, an incentive or requirement to receive a referral from primary to specialist care, and task-shifting from physicians to nurses are not restricted to a certain disease or patient population. While the OECD collects data on generalist medical practitioners according to a standardized definition, countries may differ in the extent to which their national data collection systems adhere to this definition, which may contribute to some of the differences across countries. As highlighted in our conceptual framework, nurses and other health care professionals play an important role in the care of people with diabetes, including in primary care settings. The OECD Health Statistics database includes data on nurses and pharmacists but does not distinguish between care settings. The lack of comparable data on nurses and other health professionals working in primary care settings, across countries and over time should be addressed in international databases. The exclusion of other primary care professions as inputs in the DEA models may have led to potential bias arising from the underestimation of the efficiency estimates [
99,
100]. Many countries are implementing new models of delivering primary care using a team-based approach [
11] and research suggests that collaborative and team-based care may improve clinical outcomes for diabetes care [
101], and reduce the use of acute care for patients with chronic illness [
102]. However, heterogeneity in the composition of primary care teams and the lack of comparable data across countries restricted consideration of the relationship between team-based care and efficiency. We pooled data over time in order to increase the sample size and the reliability of our results but a potential drawback is that we overlook change in efficiency over time. Nevertheless, our approach is in line with previous studies in the healthcare context [
3,
103,
104].
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