title: Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data.
abstract: 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.
  
  
  RESULTS
  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.
  
  
  CONCLUSIONS
  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.
authors.affiliation: Harvard T.H. Chan School of Public Health, Boston, MA, USA.
authors.forename: Rifat
authors.initials: R
authors.lastname: Atun
authors.affiliation: Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK.
authors.forename: Ipek
authors.initials: I
authors.lastname: Gurol-Urganci
authors.affiliation: Department of Primary Care and Public Health, Imperial College, London, UK.
authors.forename: Thomas
authors.initials: T
authors.lastname: Hone
authors.affiliation: The Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada.
authors.forename: Lisa
authors.initials: L
authors.lastname: Pell
authors.affiliation: NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Stokes
authors.affiliation: Ministry of Social Affairs, Tallinn, Estonia.
authors.forename: Triin
authors.initials: T
authors.lastname: Habicht
authors.affiliation: Estonian Health Insurance Fund, Tallinn, Estonia.
authors.forename: Kaija
authors.initials: K
authors.lastname: Lukka
authors.affiliation: Estonian Health Insurance Fund, Tallinn, Estonia.
authors.forename: Elin
authors.initials: E
authors.lastname: Raaper
authors.affiliation: WHO Country Office in Republic of Kyrgyzstan, World Health Organization.
authors.forename: Jarno
authors.initials: J
authors.lastname: Habicht
mesh_terms: D000328:Adult; D000368:Aged; D000553:Ambulatory Care / Q000706:statistics & numerical data*; D002318:Cardiovascular Diseases / Q000628:therapy; D002908:Chronic Disease / Q000628:therapy*; D015897:Comorbidity; D003695:Delivery of Health Care; D003863:Depression / Q000628:therapy; D003920:Diabetes Mellitus / Q000628:therapy; D019468:Disease Management; D004957:Estonia; D005194:Family Practice; D005260:Female; D018166:Health Care Reform; D006760:Hospitalization; D006761:Hospitals; D006801:Humans; D007297:Inpatients; D008297:Male; D008875:Middle Aged; D010045:Outpatients; D010342:Patient Acceptance of Health Care; D011320:Primary Health Care / Q000706:statistics & numerical data*; D012140:Respiratory Tract Diseases / Q000628:therapy