Utilization of digital primary care in Sweden: Descriptive analysis of claims data on demographics, socioeconomics, and diagnoses

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Abstract

Objective

As digital technologies for health continue to develop, the ability to provide primary care services to patients with new symptoms will grow. In Sweden, two providers of digital primary care have expanded rapidly over the past years giving rise to a heated debate with clear policy implications. The purpose of the study is to present a descriptive review of digital primary care as currently under development in Sweden.

Methods

Descriptive analysis of national coverage data on the utilization of digital care by sex, age, place of residence, socioeconomic status, and most common diagnoses. The data are compared with samples of corresponding data on traditional, office-based primary care, out-of-hours care, and on non-emergency telephone consultations to obtain a comparative analysis of digital care.

Results

Digital primary care in Sweden has increased rapidly over the past two years. Currently, more than 30,000 digital consultations are made per month, equivalent to around two percent of all physician-led primary care. Digital care differs in some ways to that of traditional care as users are generally younger and seek for different conditions compared with office-based primary care. Digital care is also similar to traditional care as utilization is higher in metropolitan areas compared with rural areas. Similar to general health care use, there is a negative correlation between use of digital care and socioeconomic status. User profiles by age and sex of digital care are also similar to those of out-of-hours care and non-emergency telephone medical consultations.

Conclusions

By providing a detailed description of the development of digital primary care the study contributes to a growing understanding of the contributions that digital technologies can make to health care. Based on current trends digital primary care is likely to continue to increase in frequency over the coming years. As technologies develop and the public becomes more familiar to interacting with medical providers over the Internet also the scope of digital care is likely to expand. As the provision of digital primary care expands across Europe and beyond, policy makers will need to develop regulating capacities to ensure its safe, effective and equitable integration into existing health systems.

Introduction

Over the past decade or so, the use of the Internet for health care has moved rapidly from a source of information to consultation to the actual delivery of medical services. Across countries, different types of digital health services have been introduced that link the patient directly with a medical service provider. However, despite the seemingly rapid developments in the area of digital information and communication technologies (ICT), the pace has not been as fast as once expected. For example, a survey of health sector experts in the late 1990s found that respondents predicted that around 20 percent of office-based visits could be replaced by Internet-based ones by 2010 [1]. While some countries have moved faster than others in introducing Internet-based health care models for some groups of patients or types of conditions, in no country has the overall share of total services reached those levels.

However, recent developments may hasten the move toward more Internet-based medical provision also in the field of primary care. Various types of providers have initiated services to supply health care directly to patients through common digital platforms. In the U.S., companies such as American Doctor, Teladoc, and Doctor-on-demand provide a range of health care services, including diagnostics and treatments. In the U.K., GP-at-Hand, a private company using the Babylon platform, has contracted with the NHS to provide primary care services to around 16,000 people in a district in north London [2]. And in Sweden, a country of 10 million people with a publically funded national health service of generally high quality, several private for-profit providers have started offering digital primary care to the public.

As these services are relatively new, in particular in the European context, not much is known about their use or impacts. In a recent systematic review of the evidence base on digital care for emerging symptoms, the authors identify only two studies of relevance and conclude that no firm conclusions can be drawn as to the clinical or economic effects of this type of primary care [3].

In this study, digital care is defined as a primary care physician consultation by means of some digital platform, such as a webpage or mobile application. Interactions between patient and doctor is then made by means of chat or video. Digital care involves both text, sound, and images and can be delivered both synchronously and asynchronously. Due to the ubiquitous nature of digital technologies, digital care is by many seen as a way of improving access to primary care and something that will continue to grow over the coming years.

However, concerns have also been raised in the public debate that digital providers mainly cater to the relatively well-off with minor health problems residing in larger cities. As such, they are seen as not contributing to the overall provision of primary care to those most in need, but mainly cherry-picking patients for short-term gains. This issue has been raised also in the U.K. [4].

Against this background, the purpose of the study is to contribute to a broader understanding of digital care as currently under development in several countries across Europe and beyond. Using national coverage data on digital care and a sample of data on traditional, office-based primary care, we present a descriptive assessment of the recent utilization of digital primary care as currently operating in Sweden. By providing a detailed description of the development of digital primary care the study informs policy makers and health care experts of the contributions that digital technologies can make to health care.

Health care in Sweden is the responsibility of the 21 counties or regions (Regions henceforth; the 290 municipalities are responsible for some elderly care). While the majority of hospitals are public, primary care is supplied by both public and private providers (around 41 percent of all clinics are private). Primary care providers are reimbursed by the Regions through a combination of fee-for-service (FFS) and capitation. The scope of services is regulated in formal agreements between the Regions (as the purchasers of services) and the providers and include digitally based prescriptions.

Most health care is funded publically through regionally based income taxes and general government block grants. Around 15 percent of health care is paid for out-of-pocket (OOP) to cover user-fees, pharmaceuticals and medical devices [5]. Primary care is free of charge for children below 18 or 20 (varies across Regions) and above 85 years of age. In addition, around six percent of the population have access to private health care insurance, mostly paid for by the employer. However, private insurance only makes up for around one percent of total health expenditures [5].

In contrast to most other OECD countries, primary care in Sweden is mostly provided by multi-professional health care clinics to which the public can freely register. While the quality of care in Sweden is high in an international perspective [5], there is a general perception of reduced access to services, including to primary care [6,7]. For example, recent data show that no Region is able to live up to the national patient guarantee mandates that include being able to see a primary care doctor within seven days after initial contact [8]; compliance rates vary between 77 percent and 95 percent. Furthermore, user satisfaction with traditional services has been going down over the past few years (from 66 percent in 2012 to 60 percent in 2017; www.vantetider.se), and patients frequently express concerns about the difficulty of accessing care and having to navigate a complex system. In contrast, users of digital care are generally highly satisfied (around 90 percent in follow-up surveys; personal communication with the two largest digital providers, Kry and Min Doktor).

Digital care in Sweden is mainly provided by two private, for-profit firms, which initiated operations in 2014 and 2015, respectively. Together, they supply around 90 percent of all digital consultations in the country. In addition to these two large operators there are a number of smaller private providers also offering similar types of digital services. Finally, around five Regions have started offering digital care alongside their regular, in-office services [9]. The digital providers are reimbursed by the Regions on a per-consultation basis and services include those provided by traditional primary care providers, including prescriptions for pharmaceuticals. Around 10 percent of digital consultations is made up of patients with a private health care insurance policy that includes coverage for digital care.

The recent developments in Sweden build on a history of gradual introduction of Internet-based health care services. A decade ago, Umefjord et al. [16] reviewed the introduction of an Internet-based medical consultation system, Ask-the-doctor (2008). Among other things, they looked at the utilization of the service by sex and age finding both differences and similarities compared with traditional care. They concluded that “Asynchronous text-based consultation is likely to expand in the near future.” (p. 120) and that “some of the consultations in established physician–patient relationships are likely to be replaced by online synchronous communication including the use of web cameras.” [9]. The current study is able to assess those predictions by providing a comprehensive review of current developments.

Section snippets

Material and methods

In order to provide a comprehensive review of the development of digital care in Sweden and how it compares with other types of primary care, the study uses data from several different sources. During the study period of June 2016 to December 2017, the majority of digital providers collaborated with existing primary care clinics in the Jönköping Region. The collaboration has enabled the digital providers to operate within the formal structures of the regional systems. As the digital providers

Growth in digital care utilization

Since the start of the study period, when a total of 1459 patients (only 123 of whom were publically funded) were seen, digital care in Sweden has grown rapidly; Fig. 1. In December of 2017, almost 29,000 digital consultations were made, indicating an average monthly growth rate of around 20 percent during this period. The expansion has been driven by an increase in the publically reimbursed consultations while the number of private patients have remained stable. In total, around 265,000

Discussion and conclusions

Digital primary care by means of some digital platform such as a computer, tablet, or smartphone, has increased rapidly in Sweden since its introduction in mid-2016. We find that over the study period some 265,000 digital consultations have been reimbursed by the regional health authorities. The rapid increase and the relatively weak evidence base for the efficacy and safety of digital medical consultations have given rise to a lively debate in Sweden. Similar developments are also occurring in

Authors’ contributions

BE initiated the original idea and led the study. HT and EA provided additional information on primary care in Sweden and on overall approach of the study. OC provided data and information on primary care in one county and provided detailed comments on earlier drafts of the study. JW provided overall information on study approach and on policy implications. AL contributed to the statistical analysis. All authors read and contributed to all parts of the study and approved the final version of

Funding

This research did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

None.

Summary table

What was already known about this subject?

  • Digital primary care has been increasing rapidly over the past two years.

  • The scope of digital care is expanding to several areas of non-emergency care.

  • Concerns have been raised that digital care operates counter to basic principles of prioritization of care.

What did this study add to our knowledge?

  • Digital primary care in Sweden has increased by around 20 percent per month from mid-2016.

  • Utilization of digital primary care in Sweden by

Acknowledgements

The authors acknowledge the comments and suggestions by two anonymous referees on an earlier version of the study.

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