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Presentations prepared by Franz Pirbauer at the EUPHA conference 2005 in Graz



Replacing illusions with explicit targets after 30 years of a nationwide Periodic Health Examination in Austria

Christian Temml

Temml C 1, Piribauer F 2, Schmid D 3, Maier M 4, Klima G 5, Pueringer U 6, Gray JAM 7
1. Preventive Medicine Center Vienna; 2. Center for applied Epidemiology and Health Policy Vienna; 3. AGES Vienna; 4. Public Health Center – Medical University Vienna; 5. Styrian Sickfund, Graz; 6. VAEB – Prevention Center, Graz, Austria; 7. National Screening Committee, UK
Contact details: office[at]zaeg.at

Background:
From 1974 – 2003 a total of 12 million and 400 thousand periodic health examinations (PHEs) were performed in a standardised way, regulated by a fill-in form, in Austria (pop. 8 million). In order to evaluate the effectiveness of the different screening manoeuvres within the PHEs the preventive purposes must be explicitly defined. Such target disease - screening manoeuvre links (TSL) have been published in recommendations for the PHE in Canada, Australia and the USA. Our aim was to identify or establish such TSLs also for the Austrian PHE programme, which seemed to lack, despite almost 30 years of standardised preventive activities at the primary care level.

Methods:
We conducted a systematic literature review, including hand-searches, and interviews with local experts. We elicited implicit assumptions about the target disease-screening manoeuvre-links among local PHE experts. We critically assessed these assumptions with representative physician panels, which were involved in the Austrian PHE reform project between 2002 and 2004. Subsequently we compared the final list of the assumed target diseases with the target diseases of the PHE–recommendations made by the Canadian and United States Preventive Services Task Forces.

Results:
Among 208 eligible medical publications there was none reporting on the TSLs for the Austrian PHE. In the Austrian legal documents we found 12 target conditions and 149 screening manoeuvres for the PHE, but no link between them. These 149 screening manoeuvres were allocated to 80 conditions. Twenty-three of these 80 disorders are covered by the USA- or Canadian- PHE recommendations.

Conclusions:
The majority of the implicit target diseases (57 of 80 conditions) of the Austrian PHE programme are not considered to be included or even discussed in internationally acknowledged, evidence based PHE programmes. A substantial number of the Austrian screening manoeuvres are not based on scientific evidence and are therefore candidates for removal within the reform of the Austrian PHE programme.


Overcoming barriers to change a 30 years lasting annual medical check up practice in Austria.

Franz Piribauer

Piribauer F 1, Schmid D 2, Klima G 3, Pueringer U 4, Temml C 5, Maier M 6, Gray JAM 7
1. PiCo – Health Consulting Vienna; 2. AGES, Vienna; 3. Styrian Sickfund, Graz; 4. VAEB – Prevention Center, Graz; 5. Preventive Medicine Center Vienna; 6. Public Health Center - Med. Univ. Vienna, Austria; 7. National Screening Committee, UK
Contact details: pico[at]pico.at

Issue:
Recommendations to reorient preventive services in primary care have been made in international research already 25 years ago. However, the recommended switch from annual general medical check ups to disease targeted periodic health examinations (PHEs) offered in age- and sex specific intervals, has proven to be difficult to implement in Europe and Northern America. Between 1974 and 2003 12 million and 400 thousand periodic health examinations were performed in a standardised way, regulated by a fill-in form, in Austria (pop. 8 million) .To overcome barriers to change such a widespread practice we applied internationally published barrier models in Austria.

Description:
We found three barrier models suitable for PHE in the primary care setting. The two Canadian models (Cabana, Hodon) provided causal factors for improving guideline adherence, and Grol’s model taught us the additional dimensions of marketing, social interaction, organisational change and coercion. As proposed by Grol, all dimensions were addressed at once during a PHE reform project from 2001 to 2005 in Austria.

Lessons:
The guideline adherence model was helpful as no explicit guideline has existed for 30 years. Preparing, publishing, disseminating the first evidence based PHE guideline should enable physicians for the first time to clearly understand the manoeuvre- prevention target link, - the “why I am doing this”. Increasing the financial reward to 75 Euro/PHE, and redesigning completely the documentation forms based on a published analysis by the Netherlands Institute for Health Service Research, an institution beyond the influence of any special local interest group, have proven to be key change factors (Grol´s organisational change plus coercion). The new Austrian PHE, comparable with evidence based PHE programmes in Canada, the US, Australia and New Zealand is due to be started on June 1st 2005.

Conclusions:
Public Health professionals trained to base their decisions on internationally accumulated scientific knowledge could make good use of models of barriers when reforming PHE programmes. All barrier dimensions should be addressed at once, even when resources are limited on the side of the professionals.

European Public Health Ethical Network

Franz Piribauer

Shickle D 1, Piribauer F 2, Czabanowska K 3, Loewy EH 4
1. School of Health and Related Research, University of Sheffield, UK; 2. Centre of applied Epidemiology and Health Policy Vienna, Austria; 3. Institute of Public Health, Jagiellonian University Krakow, Poland; 4. Institute of Bioethics, University of California, Davies, Sacramento, United States
Contact details: office[at]zaeg.at

Background:
Tensions exist between the private and public interest when Public Health acts. From traditional fields like immunization to new ones like consumers preferences in health care financing a balance is found for the ethical tradeoffs involved when health policy is formulated. There may be substantial differences of preferences where to set the ethical tradeoffs among European populations.

Methods:
The variance of Public Health policy and practice and ethical preferences of lay – populations are analysed in 16 EU countries. Partners from each country report on their Public Health structure, processes and laws in pre-selected public health action fields. Among several hundred EU citizens elicited tensions when faced with the same Public Health policy ethical tradeoffs were recorded on 120 hours of video – taped/ transcribed Focus Group discussions. Analysis of the ethical principles in all findings will be performed in an additional steps by Ethicists in the EU funded project (started 2003, ends 2006).

Results:
The organisational structure of Public Health services varies to a great extent within Europe. Variation in Public Health is surprisingly strongly related to the political history of each nation. The difference influences the reactions to acute or long-time challenges like virus pandemics or delivery and outcomes of immunizations. An astonishing EU – wide awareness among the lay - citizens for the “US vs. Swedish” model of public/ private ethical tradeoffs exists.

Conclusions:
European policy makers may take in account the differences in ethical preferences among their citizens when public health policy is formulated. European wide plans for public health actions, like in the case of a spread of a viral disease, may consider the quite high variance in Public Health service structures and processes.
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