Main findings
Our analysis demonstrated that screenings for hypertension and diabetes are much less intensive than recommended; and the implementation of influenza vaccination is critically neglected in Hungary. The proportion of subjects taken up hypertension screening in Hungary was similar to that from Poland [39] less than in Italy [40], and much less than reported in England, in Canada and in the United States [41,42,43]. The diabetes mellitus screening proportion in Denmark and in the UK was higher [44], in Poland was similar [39], and among Dutch with Asian origin [45] was much less than in Hungary. The Hungarian observations for influenza vaccination correspond to reports from Portugal [46]. The vaccination coverage was higher than the Hungarian in France [47], in Spain [48], and in the UK [49] in both studied target groups.
Hypertension screening had the highest implementation ratio, and it increased slightly between the survey years (66.1 to 68.0%). (Table 2) The lower estimate of the role of providers who were not GPs but who implemented the inventions was relatively high (7.9%). Because the 3,484,552 implemented screenings in 2 years were accompanied by 561,098 in 2 years opportunistic SAPI and 1,150,321 in 2 years organised SAPI (Table 3), the gain potentially achievable by improvement in screening implementation is larger for organised approaches.
Almost two-thirds of the target population underwent diabetes mellitus screening (Table 2). The lower approximation for the role of non-GPs is only 4.0%. The SAPI of the opportunistic approach (363,270/2 years) is remarkably higher than that of the organised approach (227,543/2 years) (Table 3).
The influenza vaccination for the < 60 HR group is an underused service in Hungary. Furthermore, the already very low implementation ratio showed a slight decrease between survey collections (10.6 to 9.1%) (Table 2). The role of GPs is not replaced by other physicians, as is reflected in the lower estimate of 0.6% for non-GP contributions. The highly negligent attitude of GPs is reflected in the larger opportunistic SAPI (2,784,072/2 years) compared to the organised SAPI (380,033/2 years) (Table 3).
The decreasing implementation ratio of influenza vaccination between data collection time points (29.0 to 22.8%) is very low but considerably higher among the < 60 group (Table 2). The role of non-GPs seems to be smaller than for the < 60 HR group. The opportunistic SAPI (3,029,700/2 years) is also much larger than the organised SAPI (494,150/2 years) for this vaccination target group (Table 3).
Altogether, the preventive interventions that can be delivered at the PHC level showed a small but slightly increased implementation ratio (43.6% vs 45.3%) (Table 2). The majority of the missed interventions (8,990,187/2 years) belong to the opportunistic SAPI (6,738,140/2 years). The organised SAPI is estimated to be 2,252,047/2 years. The role of GPs is not taken over by other physicians, as is reflected by the 3.7% lower estimation of non-GP contributions to the delivery of the investigated preventive interventions (Table 3).
Implications
The unexploited SAPI of opportunistic prevention is much larger for influenza vaccination than for organised vaccination programmes. For diabetes screening, these SAPIs are similar. The organised SAPI is the dominant for hypertension screening.
As shown by our analysis, GPs delivered the majority of the investigated prevention services. More precisely, a minority of the interventions were delivered per year to adults who did not visit a GP in the previous year. Because it could not be excluded that an intervention was delivered by a non-GP physician, a lower approximation could be calculated in our analyses for the role of non-GPs. Since PHC service development is the key factor for both opportunistic and organised approaches, the workload of the GP determines the feasibility of any further development of PHC services.
At the time of the study period, 655 interventions were missed among patients of an average-sized GMP who visited GP in the previous year. This opportunistic SAPI corresponds to 12–13 extra interventions per week. The SAPI for organised approaches is 219 interventions a year (4–5 interventions per week). The whole SAPI is 16–18 extra interventions per week in an average-sized GMP.
The increase in the necessary workload is significant. Therefore, PHC service development requires a capacity increase in Hungarian GMPs. At present, a typical PHC staff consists of a GP (who is the owner of the GMP) and a nurse [50]. This minimal staff seems to be an obstacle for the development of effective preventive services irrespective of the nature of the preventive approach. Larger staffs with broader professional expertise are needed both for guideline-based opportunistic service delivery and for population-level, call-based organised service delivery [10].
Strengths and limitations
The surveys on which our analysis is based were supervised by Eurostat with respect to the questionnaire content, sampling, and data collection. Eurostat’s involvement established the reliability of the investigation. The questionnaires used in the two surveys had the same questions on the parameters we investigated. Furthermore, the sample sizes from both surveys were large enough to ensure high statistical power.
The response rates of the surveys were not particularly high, jeopardizing the survey’s representativeness. This weakness was partly handled by weighting in statistical analyses, which took into consideration age, sex, and settlement type-specific response rates. All the estimations for the populations of the whole country and of the GMPs are approximations of numbers of interventions.
The morbidity status of participants was assessed by self-reporting. This could result in underreporting. Since screening interventions (measurement of blood pressure and checking glucose levels) are regularly applied as a part of chronic care for other than hypertension and diabetes mellitus, the proportion of screenings in the target groups could be overestimated. Consequently, the observed poor screening performance could be even worse.
The interventions among adults who visited a GP in the previous year were considered to be implemented by a GP. Even though subjects of our investigation were apparently healthy, few interventions could be implemented by non-GPs. This led to some overestimation of GP contribution to intervention delivery, but it did not influence the SAPI of organised prevention at PHC.
