**3.3 Transitions from inpatient to outpatient care**

Many of the diagnostic and treatment procedures that years ago required hospitalization may be performed today on an outpatient basis: day hospital, outpatient surgery, home hospitalization, tele-health, etc. This is a trend that can increase efficiency and lower costs without losing quality.

Secondary care services are provided by specialists' office in hospitals, private specialists with concessions and in health centers on primary level. On average, a patient has 6.7 outpatient contacts per year. Between 2006 and 2015, this number increased by 0.1 contacts or by 1.5%. Slovenia reaches 88.8% of EU23 [16].

The number of acute hospital beds and the average length of stay have consequently been decreasing since the early 2000s. In 2017, Slovenia had 450 acute hospital beds per 100,000 inhabitants (504.3 in EU 28) with the average length of stay 7.0 days (7.5 days in EU15) [16]. There are more reasons for this besides shift from inpatient to outpatient care, among them also the shift from bed-day payments to case-based (DRG) payments, tariff reductions and rationalization during the crisis; however, shifting from inpatient to outpatient care is one of the reasons. To replace inpatient care with outpatient care forms, various financial incentives have been introduced since 2010. The percentage of day-care cases has risen from 11.1% in 2005 to 30% of all hospital cases in 2013. A particular success re transition from inpatient to outpatient care has been a cataract surgery - with 97.9% cases in outpatient care Slovenia is among the highest in the EU [14]. The quality indicator of the share of one-day surgery determines the number of procedures performed as one-day surgeries (excluding overnight hospitalizations) according to the total

#### *Healthcare Access*

number of procedures performed in hospital. One-day surgery helps to redirect resources to less intensive care environments and to reducing the occupancy of hospital beds. At the same time, it brings faster recovery and return to work as well as lower proportion of hospital infections. The indicator shows the shares of one-day surgeries in some selected procedures: the proportion of one-day surgery in knee arthroscopy has increased from 41.3% in 2009 to 54.4% in 2019; in operations of inguinal hernia from 11.6% in 2009 to 15.0% in 2019; tonsillectomy and/or adenoidectomy from 0.25% in 2009 to 0.82% in 2019; cholecystectomy from 0.12% in 2009 to only 0.21% in 2019 and varicose vein surgery from 3,6% in 2009 to 49,2% in 2019 [17].

#### **3.4 RheumaHelper, mobile assistant for rheumatology**

In 2013, the mobile application RheumaHelper was implemented as a tool to easily and quickly check the disease activity and with a classification criterion for main rheumatological diseases. In Slovenia it is used by virtually every rheumatologist.

Each year the application is upgraded with new criteria and disease activity calculators, thus expanding the range of usability. Continuous updates of the application with new criteria and disease activity calculators give the doctor access to the latest treatment guidelines and new methods in practice, leading to faster training of doctors and better-quality care. The doctor's app monitors everywhere, allowing you to make quick but quality decisions regardless of the situation, as the source with verified information is available in your pocket. Care decisions are thus always well supported, ensuring a higher quality of work. In the future, the aim is to add integration with hospital systems, where calculated values could be stored in an electronic medical card.

In Slovenia, the app has been used more than 700,000 times by 2016. The app is translated into 6 languages and active in more than 120 countries. In just 3 years, the app has become a global leader, with more than 4,500 rheumatologists using it in more than 40,000 times a month. Nowadays, it is used by more than 7.000 rheumatologists worldwide.

In 2015, the app also received the portal award Healthline.com in the category of best applications for rheumatoid arthritis [18].

#### **3.5 Patient engagement and empowerment**

There are numerous patient organizations in Slovenia, and they often actively participate in the drafting of policies and regulations in their specific area. All proposed laws and regulations in Slovenia, also in healthcare area, undergo a public debate phase, in which individuals can participate directly. Patient organizations play a crucial role in public debates and often bring issue in the debates, based on own experiences which result in improved legislation.

Decisions about purchasing of healthcare services are made through negotiations between the key partners in healthcare: providers of healthcare services, the HIIS and the Ministry of Health. HIIS acts on behalf of the patients; however, as a main buyer and payer of healthcare services, it often has to follow the goals that may not be completely in line with the patients' interests. Patients hence participate in the process only indirectly, bringing their suggestions and concerns in the debate through any of the partners.

Every person covered by compulsory health insurance has the right to choose a personal physician without administrative and/or territorial constraints within the country. Moreover, insured people also have the right to choose a personal gynecologist and dentist. There is only one insurer offering compulsory health insurance,

the HIIS. Complementary insurance is offered by three insurance companies, which patients can freely choose from. These companies also offer supplementary insurance packages, as do other insurance companies; however, the supplementary insurance market in Slovenia is rather small.

The Patient Rights Act [19] is mainly concerned with individual rights which must be respected by all healthcare providers, public or private. Patient Rights Act importantly limits these rights by stating that their execution must take into account the right to healthcare services as determined in other laws and by taking into account modern medical doctrine and standards. There are 13 patient rights representatives in Slovenia as well as the Commission for the Protection of Patient Rights. They report regularly to Ministry of Health which monitors the protection of patients' rights.

Health literacy is an important determinant of health. It encompasses the knowledge, motivation, and competencies of individuals to access, understand, judge, and apply health information to day-to-day decisions related to health promotion, disease prevention, and healthcare. Health literacy is a key to empowering and actively participating individuals in caring for their own health.

Since October 2019, the project Raising Health Literacy in Slovenia (ZaPiS) has been running. It is implemented by the Ministry of Health of the Republic of Slovenia and the National Institute of Public Health. The purpose of the project is to raise the health literacy of the population of Slovenia, with an emphasis on connecting all key structures that can contribute to better health of the population. With the planned activities, we will be able to adequately address the changed health needs of people and make better use of new communication opportunities. Project activities will include both the health literacy aspect at the individual level and organizational health literacy. The latter involves the implementation of strategies in healthcare institutions that make it easier for patients to understand health information, navigate their healthcare system, integrate into the healthcare process and take care of their own health [20].

#### **3.6 Accreditation process**

The accreditation procedure of healthcare providers in Slovenia is voluntary. Providers are accredited by internationally recognized organizations independent of the Ministry of Health or the HIIS (e.g. Det Norske Veritas International Accreditation Standards, Accreditation Canada International). The accreditation processes are financially supported by HIIS. The accreditation is valid for three years and then needs to be renewed. All hospitals in Slovenia obtained internationally acquired accreditation; the last hospital obtained it in 2018. Additionally to hospitals, accreditation is becoming more popular also among providers of outpatient care and in healthcare centers at primary level. The data on accreditation is published on the Ministry of Health website [21].

#### **4. Results**

#### **4.1 Quality indicators and PROM**

Slovenia introduced healthcare quality indicators in 2010. The chosen indicators were selected form a number of sources, such as OECD Healthcare Quality Indicators project and WHO Performance Assessment Tool for Quality Improvement in Hospitals. Additionally, some indicators were proposed and developed by the Ministry of Health and the Medical Chamber. The results are published every year in a special report on quality indicators and are publicly accessible on the Ministry of Health webpage; the last report covers year 2019 [15]. Altogether, there are 30 indicators; one in patient-centered care, four in promotion, prevention and primary care (hospital admissions), seven in communicable diseases, 12 in healthcare efficiency, five in patient safety and an indicator for hand hygiene. Patientreported outcome measures have been launched in 2009 and 2010 in National Tender, but later on not systematically introduced [22].

#### *4.1.1 Patient-centered indicators*

The share of exclusively breastfed newborns has decreased significantly, by almost 17 percentage points, in the last decade. In 2019, the share of exclusively breastfed healthy newborns in Slovenian maternity hospitals was thus only 69.9%. The differences between hospitals are large; they range from 16% of exclusively breastfed newborns in Postojna to 96% in Ptuj, while the shares in most of the hospitals range between 60 and 80%.

### *4.1.2 Promotion, prevention and primary care indicators*

Hospital admission rate due to chronic diseases is used in pulmonary disease (COPD), heart failure, asthma and arterial hypertension. These indicators reflect the quality of primary care. In 2019, the hospital admission rate for asthma was 32.7 and has been declining since 2016. The hospital admission rate for COPD was 113.1, heart failure 285.9 and arterial hypertension 47.9. In all chronic disease a general downward trend can be noticed in the last decade.

#### *4.1.3 Communicable diseases*

The indicators on communicable diseases report proportions of vaccinated children against measles, diphtheria, tetanus, whooping cough and hepatitis B. Vaccination against these diseases has been relatively high at the national level for several years in a row, higher than 90% (except for hepatitis B), there are no major deviations. This provides good protection against the spread of the aforementioned infectious diseases in Slovenia. The vaccination of elderly aged 65 years and more reached 12.9%, which is among the lowest levels in EU.

Further indicators in this category report incidence rates of measles, whooping cough and chronic hepatitis B. While the incidence rate in measles and chronic hepatitis B are low, the incidence rate for whooping cough was relatively high in 2017 and 2018, above 10%. Among the possible causes relatively rapid decline in immunity after vaccination, change in the causative agent, and lower performance of a newer (acellular) whooping cough vaccine are mentioned. Therefore, many countries have introduced boosting doses in adolescence, booster doses at least once in adulthood and vaccination of pregnant women.

#### *4.1.4 Healthcare efficiency*

The pressure ulcer quality indicator shows the rate of hospital ulcers. The differences in the percentage of ulcers acquired differ widely among hospital and ranges from 0 to 23%. Further indicator in this category refer to waiting times for computer tomography – the legal framework for monitoring waiting times was established in 2008 by the Patient Rights Act [19] and the Regulation on maximum waiting times for individual health rights [23]. On 1 May 2011, National Institute for Public Health published data on the waiting lists for selected healthcare services

#### *Structure, Processes and Results in Healthcare System in Slovenia DOI: http://dx.doi.org/10.5772/intechopen.98608*

for the first time. There were 24,819 patients waiting for 60 defined services. The list of 60 services was slightly changed on 1 September 2012, and then there were no further changes until 1 May 2016, when one more service was added to the list. In August 2018, the whole operational system of reporting was replaced, and at the same time, the list of services, their coding and the reporting methodology have been completely changed. For example, data on physiotherapy treatment are no longer monitored and 58 services from previous system now correspond to 400 new services. The service code translator has not yet been officially published; however, the data could potentially be compared if it existed.

Between 1 January 2015 and 1 January 2020, the number of patients waiting for first visit increased by 54.1%. There were total of 403,811 patients on waiting lists on 1 January 2020, among them 165,201 or 40.9% waited longer than allowed. 71.3% of all patients were waiting for outpatient specialist services and the rest were waiting for diagnostic procedures or day care. The estimated financial value for provision of services for all patients on waiting list was 120.4 mio EUR, and the estimated value of service provision for patients waiting longer than allowed was 44.7 mio EUR [24].

A series of indicators on efficiency of the surgical processes include utilization of operating theaters for hospital and outpatient procedures, share of canceled procedures, average length of stay for selected procedures (cholecystectomy, pneumonia, hip replacement etc.), indicators connected to diabetes (hospital admissions because of diabetes, amputations due to diabetes), indicators connected to newborns. The first one is injuries in vaginal delivery: in 2019 a total of 17 cases of third- or fourth-degree of such injuries were reported during childbirth. The share of cesarean sections has increased significantly in the last decade, but remains below EU average. Both the proportion of elective and emergency cesarean sections increased. In 2019, the proportion of Cesarean sections at the gestational age of 37 was 17.2 percent, lowest in general hospital Jesenice (9.1%) and highest at 30.5%, in Trbovlje.

Very important indicators are post-surgical deep vein thrombosis and lung embolism. The rate of cases of pulmonary embolism per 100,000 admissions due to hip or knee endoprosthesis has been decreasing constantly in the last decade while the data on the lung embolism are less clear, stills showing a slight general decreasing trend. The use of antimicrobials is monitored as well.

#### *4.1.5 Patient and personnel safety*

Patient and personnel safety report data on the injuries with sharp objects, falls, foreign bodies in the body after the surgery, methicillin resistant *Staphylococcus aureus* (MRSA) and post-surgical sepsis. Hand hygiene has been improving, but can improve further: overall consistency of hand hygiene has reached 77.5% in 2019.

## **4.2 Quality strategy**

The first National Strategy for Health Quality and Safety was launched in 2010. Its aim was to assure systematic and continuous development of improvements in healthcare system. The strategy defined numerous strategic objectives, such as the development of quality management systems, the development of a clinical culture of safety and quality within and the development and implementation of education programmes in quality and safety. During the period of the strategy, most hospitals and many other providers accredited their quality management systems through one of the international standards. According to the evaluation [25], National Strategy did not play a sufficient role in the practical implementation of other

measures. A new strategy has not yet been formed, also due to a lack of political will. On a positive note, the National Healthcare Plan includes several objectives in the area of quality, such as strengthening of training in quality and safety and patient communication and an update of the quality indicators. Furthermore, several projects, such as ZaPIS [20] or a standardized patient experience measurement in outpatient consultations was set up and survey of patient experiences in hospital care was updated [26].

### **4.3 Registries**

Cancer registries are a service for the systematic collection, storage, analysis, interpretation and presentation of data on cancer patients, their disease and treatment in Slovenia. Cancer reporting is mandatory and legal. More detailed information can be ordered by doctors, researchers and the general public using a special form.

The Cancer Registry is one of the oldest population registries in Europe. It was established in 1950 at the Ljubljana Oncology Institute as a special service for collecting and processing data on all new cases of cancer (incidence) and on the survival of cancer patients. The Cancer Registry of the Republic of Slovenia has been a regular member of the International Association of Cancer Registries since its establishment in 1968, and from the very beginning also of the European Cancer Registry Association [27].

The Healthcare Databases Act entered into force in August 2000. The list of databases and registers is defined as an annex, which facilitates the possible amendment of the lists. The annex includes 40 records and 35 registers. Each collection has a defined purpose, reports, data reporter, controller, and data delivery method and data retention time [28].

The endoprosthesis registry contains extended information about the patient, the provider, the prosthesis, the operation, or the reoperation. The collection is managed for: monitoring the survival (time from insertion to removal) of inserted hip and knee endoprostheses, ensuring quality control of endoprosthetic operations, enabling rapid detection of lower quality endoprostheses, indirect reduction of costs of primary and revision hip and knee endoprostheses and as a basis for clinical and epidemiological studies and expert analyzes. The registry manager is hospital Valdoltra, which prepares an annual report on the basis of data sent on an ongoing basis by all providers and other legal and natural persons, regardless of the concession, who perform the arthroplasty medical activity [29].

#### **4.4 National tender and health-related quality of life**

The national tender for hip, hernia, varicose vein and carpal tunnel operations was introduced as a mechanism for lowering prices, measuring outcomes and increasing the efficiency of performed health services. The national tender conducted in 2009 increased the availability of tendered health programs, as 13% more services were provided for the same funds due to lower prices offered by the providers. The effects of the national tender 2009 were the basis for further activities of the HIIS in the implementation of purchasing function. Namely, even in the years of the relative lack of additional financial resources, the HIIS tried to increase the accessibility of insured persons to health services in various ways. Based on the tender HIIS managed to increase the number of the surgeries by 6.6% (increase in the number of surgeries from 12,695 to 13,536) and achieve 4.5% savings. At the same time, national tender enabled control over the safety and quality of health services as for the first time a generic measure for health-related quality of life (EQ-5D) was

used to measure changes in the health status of the patients [30]. Further quality indicators were introduced as well, but were unfortunately never analyzed. The results of the EQ-5D analyses represented a very good concept for national implementation, but could not offer deep enough insight to provide recommendations on the reorganization of the health network or the limitation of the scope of services at an individual provider. Unfortunately, HIIS abandoned the national tender after two years of pressure from public providers, and today it does not monitor the results of treatment and the quality of treatment when distributing funds.

## **4.5 Health technology assessment (HTA)**

HTA framework in Slovenia has not been established at the national level. The need to formalize HTA for all health technologies has been known and various initiatives have been present in the system to introduce it. The most developed level of HTA is present in the area of pharmaceuticals, while with other health technologies, HTA process is much more unclear, irregular and unsystematic [31]. HTA in pharmaceuticals is conducted by HIIS. HIIS passed the Rules on inclusion of medicines in the list [32], which define the types of the analysis that can be used, timelines, and decision criteria that are to be followed in the assessment process. The criteria, according to which the pharmaceuticals are evaluated, are clinical effectiveness, safety and cost-effectiveness. Adaptation of the study results to Slovenian setting is demanded and the analysis should use Slovenian data as much as possible.

Consulting body to HIIS, called Pharmaceutical Reimbursement Commission, makes recommendations on the placement of the pharmaceuticals on the positive or intermediate list [31]. These are based on the presented relative therapeutic value and incremental cost-effectiveness ratio of the drug. The latter must be expressed in marginal costs per quality-adjusted life-year (QALY). The threshold for the acceptance of the pharmaceuticals into the public financing is set to 25,000 EUR [33]. The Pharmaceutical Reimbursement Commission members are physicians and clinical pharmacists as well as other experts with systemic knowledge in the field of drugs. Their recommendations are independent.

Other healthcare technologies, especially healthcare services programmes, are introduced through Health Council. Health Council is the highest advisory body to the Minister of Health. It gives recommendations on introducing new technologies to the Minister, who makes the final decision on their introduction. Upon his decision, the suggestion is made to the HIIS for its public financing and HIIS can make a decision to reimburse the use of new technology or not. The recommendations to the Minister of Health are based on the criteria defined in Procedures on handling the applications for new healthcare programs [34]. The protocol is quite complex and long and consists of several questions on the technology, its safety, target population, clinical effectiveness, costs, and organizational issues. Cost-effectiveness is not included in the protocol.
