Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data

Rifat Atun, Ipek Gurol-Urganci, Thomas Hone, Lisa Pell, Jonathan Stokes, Triin Habicht, Kaija Lukka, Elin Raaper, Jarno Habicht

    Research output: Contribution to journalArticlepeer-review


    Background Following independence from the Soviet Union in 1991,
    Estonia introduced a national insurance system, consolidated the
    number of health care providers, and introduced family medicine
    centred primary health care (PHC) to strengthen the health system.
    Methods Using routinely collected health billing records for 2005–
    2012, we examine health system utilisation for seven ambulatory care
    sensitive conditions (ACSCs) (asthma, chronic obstructive pulmonary
    disease [COPD], depression, Type 2 diabetes, heart failure, hypertension,
    and ischemic heart disease [IHD]), and by patient characteristics
    (gender, age, and number of co–morbidities). The data set contained
    552 822 individuals. We use patient level data to test the
    significance of trends, and employ multivariate regression analysis to
    evaluate the probability of inpatient admission while controlling for
    patient characteristics, health system supply–side variables, and PHC
    Findings Over the study period, utilisation of PHC increased, whilst
    inpatient admissions fell. Service mix in PHC changed with increases
    in phone, email, nurse, and follow–up (vs initial) consultations.
    Healthcare utilisation for diabetes, depression, IHD and hypertension
    shifted to PHC, whilst for COPD, heart failure and asthma utilisation
    in outpatient and inpatient settings increased. Multivariate regression
    indicates higher probability of inpatient admission for males, older
    patient and especially those with multimorbidity, but protective effect
    for PHC, with significantly lower hospital admission for those utilising
    PHC services.
    Interpretation Our findings suggest health system reforms in Estonia
    have influenced the shift of ACSCs from secondary to primary
    care, with PHC having a protective effect in reducing hospital admissions
    Original languageEnglish
    Article number020401
    JournalJournal of global health
    Issue number2
    Publication statusPublished - 26 Apr 2016


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