Insulin therapy in type 2 diabetes is no longer a secondary care activity in the Netherlands

AIM

Because Dutch health care organisations did want to establish well-defined diabetes shared care groups, we investigated the organisation of insulin therapy in general practice in the Netherlands and assessed factors that were associated with providing insulin therapy in type 2 diabetes (DM2) patients.

METHODS

Questionnaire to half of the Dutch general practitioners (GPs) (n=3848). We compared GPs who both start insulin treatment and monitor the dosages with those who always refer patients requiring insulin therapy or only monitor insulin dosages.

RESULTS

Total response was 42% (n=1621). 67% of the GPs start insulin therapy in patients with DM2, especially male GPs and those above the age of 40, as well as GPs working in a health centre and those working together with a practice nurse. GPs working in urban regions less often start insulin. The most often mentioned barriers for starting and/or monitoring insulin therapy are lack of knowledge of insulin therapy, lack of time and insufficient financial incentives.

CONCLUSION

This nation-wide overview shows that insulin therapy is no longer a secondary care based activity. However, there is still need to enlarge the practice staff and to overcome the perceived skills deficit.

Data integrity: the quest for meaningful, usable data is accelerating as a P4P surge sweeps healthcare

Improving data integrity will be a necessity for the industry going forward, especially as P4P programs link clinical performance to reimbursement. The challenge will be long-term. Most hospitals and health systems are just beginning to work on the problem, and even the most advanced organizations are admittedly in early stages. Progress in clinical-quality performance improvement work will depend on progress with data integrity, both from the standpoint of valid data analysis and in the context of clinician buy-in on outcomes measurement.

The changing reimbursement landscape: nurses' role in quality and operational excellence

Operational excellence, care quality, and financial performance are increasingly linked as key drivers of hospital performance. This environment may be seen as a challenge, but it is also an excellent opportunity for nursing services to further demonstrate their value in patient care outcomes and support financial performance. Nursing contributions toward reduced complications, reductions in length of stay, and lower costs per case should be measured, rewarded, and made transparent to the public. Staff nurses should not view quality as simply another task on which to focus their attention, but rather a continuous process that requires critical thinking about how care is delivered and its effect on the entire care progression of a patient. Nursing management must focus on continually educating their staff on appropriate care, as well as developing and supporting a culture of safety and accountability. Nursing leadership must improve nurse retention and recruiting efforts, encourage interdisciplinary collaboration and, most importantly, demonstrate to the rest of the organization the value nursing brings to the organization through consistently tracking quality and financial indicators and tying them to nursing initiatives.

Physician perception of reimbursement for outpatient procedures among managed care patients with diabetes mellitus

OBJECTIVE

To examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus.

STUDY DESIGN

Cross-sectional analysis.

METHODS

Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans.

RESULTS

Patients of physicians who reported reimbursement for electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement.

CONCLUSIONS

Reimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.

Why financial incentives did not reach the poor tuberculosis patients? A qualitative study of a Fidelis funded project in Shanxi, China

BACKGROUND

A project implemented in 50 counties of Shanxi province provided incentives to poor TB patients for their first trip to tuberculosis (TB) dispensaries. Incentives were also given to doctors for referring and supervising TB patients. A previous quantitative evaluation identified no improvement on TB case detection and management. This qualitative study was then conducted to explore reasons for project failure.

OBJECTIVE

To understand how the incentives were distributed to and viewed by their recipients and the implications for TB and health systems.

METHODS

Qualitative in-depth interviews were conducted with 32 TB patients, 13 village doctors, 12 village leaders, 8 TB doctors and 8 TB programme managers.

RESULTS

The study revealed a lack of operational tools on how to evaluate patients' economic status and how to publicise the incentives. As a result, patients did not know the level of incentives in advance and regarded the amount as inadequate. Patients faced a huge financial burden and a long delay in treating TB, dwarfing the benefits of travel incentives. The referral and case supervision incentives were not implemented. Doctors did not receive any referral and supervision incentives in addition to those already existing.

CONCLUSIONS

Strategies to address health system and TB programme issues should be implemented before or alongside financial incentives. Operational details and tools for any intervention should be developed, field-tested and revised prior to wide-scale use.

Association of patient case-mix adjustment, hospital process performance rankings, and eligibility for financial incentives

CONTEXT

While most comparisons of hospital outcomes adjust for patient characteristics, process performance comparisons typically do not.

OBJECTIVE

To evaluate the degree to which hospital process performance ratings and eligibility for financial incentives are altered after accounting for hospitals' patient demographics, clinical characteristics, and mix of treatment opportunities.

DESIGN, SETTING, AND PATIENTS

Using data from the American Heart Association's Get With the Guidelines program between January 2, 2000, and March 28, 2008, we analyzed hospital process performance based on the Centers for Medicare & Medicaid Services' defined core measures for acute myocardial infarction. Hospitals were initially ranked based on crude composite process performance and then ranked again after accounting for hospitals' patient demographics, clinical characteristics, and eligibility for measures using a hierarchical model. We then compared differences in hospital performance rankings and pay-for-performance financial incentive categories (top 20%, middle 60%, and bottom 20% institutions).

MAIN OUTCOME MEASURES

Hospital process performance ranking and pay-for-performance financial incentive categories.

RESULTS

A total of 148,472 acute myocardial infarction patients met the study criteria from 449 centers. Hospitals for which crude composite acute myocardial infarction performance was in the bottom quintile (n = 89) were smaller nonacademic institutions that treated a higher percentage of patients from racial or ethnic minority groups and also patients with greater comorbidities than hospitals ranked in the top quintile (n = 90). Although there was overall agreement on hospital rankings based on observed vs adjusted composite scores (weighted kappa, 0.74), individual hospital ranking changed with adjustment (median, 22 ranks; range, 0-214; interquartile range, 9-40). Additionally, 16.5% of institutions (n = 74) changed pay-for-performance financial status categories after accounting for patient and treatment opportunity mix.

CONCLUSION

Our findings suggest that accounting for hospital differences in patient characteristics and treatment opportunities is associated with modest changes in hospital performance rankings and eligibility for financial benefits in pay-for-performance programs for treatment of myocardial infarction.