5.4. Specialized ambulatory care / inpatient care

Specialist outpatient care in Lithuania is delivered mainly through polyclinics. In 2011, in addition to 25 free-standing polyclinics that provide primary and secondary care, there were 66 outpatient departments within hospitals, 37 specialized polyclinics and 354 private specialist clinics (Health Information Centre, 2012).

As seen in Fig5.1, the rate of outpatient contacts per capita is close to the EU average. This number (6.9) includes outpatient visits to both primary and specialist physicians rendering care in all types of outpatient facility (including hospital units) as well as emergency care. Visits to medical specialists made up about 34% of all outpatient visits, equivalent to about 2.2 visits per capita in 2011. Specialties with most outpatient attendances were ophthalmology, neurology, ENT, orthopaedics and cardiology (Health Information Centre, 2013).

Fig5.1

The transfer of resources concentrated in specialized hospitals to general hospitals and the outpatient sector over the years has resulted in a reduction of the total number of hospital beds and conversion of facilities to other uses. In 2011, there were 145 hospitals with a total of 26 364 beds. There were 66 general hospitals, 49 nursing inpatient facilities, 26 specialized hospitals and 4 rehabilitation hospitals. The number of hospitals, beds and the average length of stay have decreased substantially since the mid-1990s (see section 4.1). In addition, there are fewer providers as legal entities, mainly as a result of the hospital network restructuring process in 2009–2012, which pursued a merger of smaller and single-profile institutions with larger multiprofile hospitals (see section 6.1). Table5.1 shows the number of beds and average length of stay in public inpatient health-care institutions.

Table 5.1

However, according to the World Bank report in 2009, hospital infrastructure in the country still remained oversized and needed to be better adapted to the needs of the population. Further scope for efficiency gains in inpatient care lies in restructuring of TB care as well as in reducing the number of services provided in small general hospitals.

The private hospital sector in Lithuania is very small. In 2001, there were only 105 private hospitals beds (mostly specialized in rehabilitation, cardiology and surgery), treating approximately 1700 patients. In 2010, there were 14 private medical providers with a total of 180 beds. With the exception of small private nursing hospitals, all private hospitals have the legal status of profit-making publicly traded companies. Some of these hospitals are contracted by the territorial NHIFs, mostly for day surgery. This, together with other conditions for operation (relevance of provision requirements, investment policy, etc.), is a subject of debate among policy-makers and the Ministry of Health Working Group, who question the fairness of contracting and purchasing decisions.

Restructuring of inpatient care in Lithuania has been planned since 2001, with technical support provided under a World Bank loan. It was implemented in three stages over the following 10 years. Goals included restructuring the health-care institution network by reducing inpatient services, accelerating the expansion of a wider range of outpatient services and improving the efficiency of facilities.

While the country’s hospitals were being restructured, day care, day surgery and outpatient rehabilitation services were substantially developed; specialized hospital units (e.g. infectious diseases, psychosomatic disorders, ophthalmology, ENT, gerontology) were closed in many local hospitals, and services were transferred to multiprofile hospitals; in some cities, hospitals were merged.

The first stage (2003–2005) brought a significant decrease in inpatient beds (about 5000 in general and specialized hospitals), hospital admission rates (23.3 to 20.9 per 100 inhabitants) and average length of stay (by 2.2 days) (Baltakis, 2009). Provision of outpatient services increased by 6%; inpatient care volume decreased by 8%; nursing care increased by 15%, and 600 day-care facilities were established (Government of the Republic of Lithuania, 2006). The second stage (2006–2008) was marked by a slight increase in the number of inpatient beds (about 1%) and a 2% increase in hospital admissions due to the expansion of nursing, long-term and palliative care in hospitals, while the number of acute hospital beds further decreased by 2%. In 2010, the National Audit Office of Lithuania reviewed inpatient care provided in 2006–2009 against targets set for the second restructuring stage (3–5% decrease in inpatient services, 10% increase in day care, treatment of common diseases in facilities close to the patient’s home, and a concentration of modern technologies in university clinics). The review concluded that the common target of 18 hospitalizations per 100 inhabitants was not achieved in either the first or second stage of restructuring; there was also an apparent lack of consistency regarding the targets and criteria setting (National Audit Office of Lithuania, 2010). The targets set for the third stage (2009–2012) of the restructuring programme included a minimum 5% increase in outpatient care delivery and an 8% increase in day care in order to facilitate a decrease in the hospitalization rate to 18 hospitalizations per 100 inhabitants. Between 2009 and 2010, the NHIF reported a 2.5% increase in provision of outpatient services, a 14.6% increase in day care, a 9% increase in day surgery and a 5.9% increase in short-term admissions, while inpatient services volume decreased by 2%. Two other criteria (quality, safety and accessibility care, and increased financing) have not been defined in a measurable way.

The vision for the hospital sector of the future envisages the concentration of advanced medical services at the tertiary care level (mostly in university hospitals), of specialized services in regional level hospitals and of general medical services in district or community hospitals. Policy stays focused on the further development of outpatient specialist care and day care. However, concerns have been raised over actual implementation of the reforms on inpatient care planning (e.g. assessment of shortcomings in nationwide needs); on application of service closure criteria (such as requirements for a minimum annual volume of surgery of 600 and of child deliveries of 300, and a maximum distance of 50 km to a hospital providing inpatient surgery), and on the possible impact of the network restructuring on access to care (National Audit Office of Lithuania, 2010).

For many years, ministerial agencies such as the Medical Audit Inspectorate and the SHCAA were in charge of external quality assurance in health care; the former institution mostly dealt with investigation of likely malpractice cases and the latter addressed facility licensing issues. While licensing of medical professionals and facilities are obligatory, accreditation is a voluntary procedure. In September 2011, the Medical Audit Inspectorate was combined with the SHCAA. Its renewed statute stipulated responsibility for both patient safety and quality assurance of health care (mostly through enforcing compliance with legislation and regulations). In addition, the regional branches of the NHIF are responsible for verifying health-care providers’ compliance with contractual agreements.

Between 1998 and 2008, internal quality control at provider level was organized under local audit provisions. A study published in 2006 found that the system was operating successfully in about a third of small local hospitals but more frequently in larger hospitals. Lack of financial resources, information and training were cited as barriers to implementation of quality assurance programmes (Legido-Quigley et al., 2008). This framework was replaced by the introduction of minimum quality requirements set by the Ministry of Health: a list of documentation (e.g. description of patient complaints and provision of essential care); an obligation to register, analyse and implement preventive measures for adverse events; a requirement to follow the ministry’s approved diagnostic and treatment guidelines as well as the rules of the local medical audit; and the maintenance of overall responsibility for quality control being in the hands of the director of the facility.

There were a few attempts (commonly underfinanced and inconsistent) to develop and implement national quality assurance programmes based on different approaches. For example, a Hospital Infections Management Programme for 2007–2011 was adopted with the main goal of reducing prevalence of hospital infections by 15% through improvements in surveillance (covering 80% of hospitals), regulation and training. However, between 2005 and 2011, the occurrence of hospital infections in patients increased from 3.4% (data from 35 hospitals) to 4.2% (data from 76 hospitals) (Minister of Health, 2007b; Health Information Centre, 2011).

In 2007, the National Audit Office of Lithuania concluded that there was no single comprehensive system for quality assurance in health care. Although more than 40 health-care providers voluntarily have adopted quality management systems (mostly ISO-9001 standards), there still are no clear nationwide incentives for quality improvement at health-care facilities. The Committee on Development of the National Patient Safety Platform (2009) noted that there was no central agency collecting statistics on adverse events and patient complaints and referred to a survey conducted in 2008 that found that one-tenth of medical professionals did not know about adverse events and that 5% of medical professionals reported that they occurred quite frequently (several times per month). In response, at the end of 2012, the Ministry of Health adopted a set of indicators aiming to improve the quality of service and performance evaluation in inpatient care (Minister of Health, 2012).

Another important aspect of improving health-care provision, raised as a high priority issue (National Health Board, 2009), relates to continuity of care, considering the increasing burden of chronic disease and comorbidities. Lithuania, similarly to Estonia and Latvia, has not yet established chronic disease management as a distinct concept. Instead, chronic care is embedded within the primary care system (Elissen et al., 2013). Attempts have been made to improve the integration between primary and secondary care (e.g. provision of guidelines for family physicians for treatment of mild depression). However, most treatment guidelines and standards address specialist care, in part because of its relatively high cost.

5.4.1. Day care

In 1997, the Ministry of Health issued a list of day-care services to be provided in public hospitals and reimbursed by the NHIF. It included interventions (haemodialysis, cataract) and services (obstetrics, adult oncology, paediatrics, trauma and orthopaedics). By 2009, the list contained three specialties for children (including onco-haematology) and seven specialties for adults (including dermatology/venereology and haematology). A separate list has been created for surgical interventions treated in day care (first approved by the Ministry of Health in 2003).

The reference prices for day surgery were initially set at approximately 50% of the price for similar inpatient services, and there were not sufficient incentives for the implementation of day surgery in hospitals. The latest (2009) edition of the list covers six groups with 141 procedures that can only be performed in health-care institutions licensed to provide health services at secondary level or higher, with intensive care arrangements. The reimbursement rate (reference price paid by the NHIF) varies 10-fold between the easiest and the most complex group.

Increase in day-care service volume is considered one of the most important objectives in delivery of health-care services. A 10% increase in day surgery was a target for the second stage of health-care restructuring (see section 5.4). Between 2006 and 2009, the total number of day-care procedures increased from 27 791 to 86 440. Despite this rapid increase, day surgery still has a minor share in the total hospital service provision. In 2010, hospital inpatient services represented 45% of total hospital services (Fig5.2).

Fig5.2

Incentives to increase day-care volume are currently financed through capital investments, a share of a World Bank loan allocated to establishment of day surgery centres, and a portion of EU structural funds allocated to equipment of day surgery and mental health day-care units in public and private hospitals. Markedly, as private hospitals are mostly engaged in day surgery provision, administrations of public hospitals have raised issues regarding the fairness of regulatory and funding arrangements.

Another important aspect of improving health-care provision, raised as a high priority issue (National Health Board, 2009), relates to continuity of care, considering the increasing burden of chronic disease and comorbidities. Lithuania, similarly to Estonia and Latvia, has not yet established chronic disease management as a distinct concept. Instead, chronic care is embedded within the primary care system (Elissen et al., 2013). Attempts have been made to improve the integration between primary and secondary care (e.g. provision of guidelines for family physicians for treatment of mild depression). However, most treatment guidelines and standards address specialist care, in part because of its relatively high cost.