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

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
use.
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