Incentives in primary care and their impact on potentially avoidable hospital admissions

Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis

BACKGROUND

Primary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance.

METHODS

We developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010-2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics.

RESULTS

Countries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider.

CONCLUSIONS

Our results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.

Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China

BACKGROUND

Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation.

METHODS

We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.

RESULTS

A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with  < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.

CONCLUSIONS

Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

Interventions to Prevent Potentially Avoidable Hospitalizations: A Mixed Methods Systematic Review

Background

The demand for healthcare is increasing due to an aging population, more people living with chronic diseases and medical comorbidities. To manage this demand, political institutions call for action to reduce the potentially avoidable hospitalizations. Quantitative and qualitative aspects should be considered to understand how and why interventions work, and for whom. The aim of this mixed methods systematic review was to identify and synthesize evidence on interventions targeting avoidable hospitalizations from the perspectives of the citizens and the healthcare professionals to improve the preventive healthcare services.

Methods and Results

A mixed methods systematic review was conducted following the JBI methodology using a convergent integrated approach to synthesis. The review protocol was registered in PROSPERO, reg. no. CRD42020134652. A systematic search was undertaken in six databases. In total, 45 articles matched the eligibility criteria, and 25 of these (five qualitative studies and 20 quantitative studies) were found to be of acceptable methodological quality. From the 25 articles, 99 meaning units were extracted. The combined evidence revealed four categories, which were synthesized into two integrated findings: (1) Addressing individual needs through care continuity and coordination prevent avoidable hospitalizations and (2) Recognizing preventive care as an integrated part of the healthcare work to prevent avoidable hospitalizations.

Conclusions

The syntheses highlight the importance of addressing individual needs through continuous and coordinated care practices to prevent avoidable hospitalizations. Engaging healthcare professionals in preventive care work and considering implications for patient safety may be given higher priority. Healthcare administers and policy-makers could support the delivery of preventive care through targeted educational material aimed at healthcare professionals and simple web-based IT platforms for information-sharing across healthcare settings. The findings are an important resource in the development and implementation of interventions to prevent avoidable hospitalizations, and may serve to improve patient safety and quality in preventive healthcare services.

Systematic Review Registration:https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=134652, identifier: CRD42020134652.

Supporting efficiency improvement in public health systems: a rapid evidence synthesis

BACKGROUND

Public health systems internationally are under pressure to meet increasing demand for healthcare in the context of increasing financial resource constraint. There is therefore a need to maximise health outcomes achieved with public healthcare expenditure. This paper aims to establish and synthesize the contemporary evidence base for approaches taken at a system management level to improve efficiency.

METHODS

Rapid Evidence Assessment (REA) methodology was employed. A search strategy was developed and applied (PUBMED, MEDLINE) returning 5,377 unique titles. 172 full-text articles were screened to determine relevance with 82 publications included in the final review. Data regarding country, study design, key findings and approaches to efficiency improvement were extracted and a narrative synthesis produced. Publications covering health systems from developed countries were included.

RESULTS

Identified study designs included policy reviews, qualitative reviews, mixed methods reviews, systematic reviews, literature reviews, retrospective analyses, scoping reviews, narrative papers, regression analyses and opinion papers. While findings revealed no comprehensive frameworks for system-wide efficiency improvement, a range of specific centrally led improvement approaches were identified. Elements associated with success in current approaches included dedicated central functions to drive system-wide efficiency improvement, managing efficiency in tandem with quality and value, and inclusive stakeholder engagement.

CONCLUSIONS

The requirement for public health systems to improve efficiency is likely to continue to increase. Reactive cost-cutting measures and short-term initiatives aimed only at reducing expenditure are unlikely to deliver sustainable efficiency improvement. By providing dedicated central system-wide efficiency improvement support, public health system management entities can deliver improved financial, health service and stakeholder outcomes.

GP- and practice-related variation in ambulatory sensitive hospitalisations of older primary care patients

Background

Reducing ambulatory sensitive hospitalisations (ASHs) is a strategy to control spending on hospital care and to improve quality of primary health care. This research investigated whether ASH rates in older people varied by GP and practice characteristics.

Methods

We identified ASHs from the national dataset of hospital events for 3755 community-dwelling participants aged 75+ enrolled in a cluster randomised controlled trial involving 60 randomly selected general practices in three regions in New Zealand. Poisson mixed models of 36-month ASH rates were fitted for the entire sample, for complex participants, and non-complex participants. We examined variation in ASH rates according to GP- and practice-level characteristics after adjusting for patient-level predictors of ASH.

Results

Lower rates of ASHs were observed in female GPs (IRR 0.83, CI 0.71 to 0.98). In non-complex participants, but not complex participants, practices in more deprived areas had lower ASH rates (4% lower per deprivation decile higher, IRR 0.96, CI 0.92 to 1.00), whereas main urban centre practices had higher rates (IRR 1.84, CI 1.15 to 2.96). Variance explained by these significant factors was small (0.4% of total variance for GP sex, 0.2% for deprivation, and 0.5% for area type). None of the modifiable practice-level characteristics such as home visiting and systematically contacting patients were significantly associated with ASH rates.

Conclusions

Only a few GP and non-modifiable practice characteristics were associated with variation in ASH rates in 60 New Zealand practices interested in a trial about care of older people. Where there were significant associations, the contribution to overall variance was minimal. It also remains unclear whether lower ASH rates in older people represents underservicing or less overuse of hospital services, particularly for the relatively well patient attending practices in less central, more disadvantaged communities. Thus, reducing ASHs through primary care redesign for older people should be approached carefully.

Trial registration

Australian and New Zealand Clinical Trials Register ACTRN12609000648224.

Incentives to use primary care and their impact on healthcare utilization: Evidence using a public health insurance dataset in China

Large hospitals in China are overcrowded, while primary care tends to be underutilized, resulting in inefficient allocation of resources. This paper examines the impacts of a policy change in a mandatory public employee health insurance program in China designed to encourage the utilization of primary care by reducing patient cost-sharing. We use a unique administrative insurance claim dataset from the Urban Employee Basic Medical Insurance (UEBMI) scheme between 2013 and 2015. The sample includes 40,024 individuals. We conduct an event-study analysis controlling for individual fixed effects and find that the change in cost-sharing increased primary care utilization, decreased non-primary care utilization, and increased total outpatient utilization without impacting total spending. In addition, the policy change did not affect the likelihood of having avoidable inpatient admissions. Further, patients with hypertension or diabetes increased their primary care utilization even when using additional coverage for patients with chronic diseases, the cost-sharing rates for which did not change during the period of our study, rather than their standard UEBMI benefits. This study provides evidence that changes in cost-sharing can affect healthcare utilization, suggesting that supply-side incentives can play an important role in building a primary care-based integrated healthcare delivery system in China.

Effect of a national primary care reform on avoidable hospital admissions (2000-2015): A difference-in-difference analysis

In 2006 a major primary care reform was initiated in Portugal. The most significant aspect of this reform was the creation of a new organizational model of primary care provision: Family Health Units (FHUs), consisting of small voluntarily constituted multidisciplinary teams that have functional autonomy and are partly financed through capitation and pay-for-performance. The creation of FHUs sought to increase access to care and to chronic disease management by improving the long-term relationship between health professionals and patients. The objectives of this study are to evaluate the impact of the FHUs implementation on population health outcomes, measured by the rate of hospitalizations for ambulatory care sensitive conditions (ACSC), i.e. avoidable hospital inpatient admissions, and to explore the effectiveness of the pay-for-performance in primary care by analysing the subset of disease specific hospitalizations for ACSC related to the financial incentives. Using data from 276 Portuguese municipalities from 2000 to 2015 (n = 4416) and exploiting the gradual introduction of the FHUs over time, we used a difference-in-differences approach contrasting the evolution of the hospitalization rate for ACSC in municipalities that implemented or not the FHUs. We then explored heterogeneous effects by incentivized (diabetes and hypertension) and non-incentivized disease-specific rates of hospitalizations for ACSC. During the period under analysis, 448 FHUs were created in 126 municipalities. No significant impact of the FHUs implementation on the reduction of the hospitalization rate for ACSC was found. This result also held for the incentivized hospitalizations for ACSC. We only found a statistically significant effect of the FHUs implementation in the reduction of one non-incentivized area (the rate of urinary tract infection ACSC). Our results question the capacity of this payment mechanism to achieve better health outcomes, and invites a more careful and evidence-based action toward its wider diffusion.

Disease management in diabetes care: When involving GPs improves patient compliance and health outcomes

Although the study of the association between interventions in primary care and health outcomes continues to produce mixed findings, programs designed to promote the greater compliance of General Practitioners and their diabetic patients with guidelines have been increasingly introduced worldwide, in an attempt to achieve better quality diabetes care through the enhanced standardisation of patient supervision. In this study, we use clinical data from the Diabetes Register of one large Local Health Authority (LHAs) in Italy's Emilia-Romagna Region for the period 2012-2015. Firstly, we investigate whether GPs' participation in the local Diabetes Management Program (DMP) leads to improved patient compliance with regional guidelines. Secondly, we test whether the monitoring activities prescribed for diabetics by the Regional diabetes guidelines have a positive impact on patients' health outcomes and increase appropriateness in health care utilization. Our results show that such a Program, which aims to increase GPs' involvement and cooperation in following the Regional guidelines, achieves its goal of improved patient compliance with the prescribed actions. In turn, through the implementation of the DMP and the greater involvement of physicians, Regional policies have succeeded in promoting better health outcomes and improved appropriateness of health care utilization.

A Spatial Analysis of Preventable Hospitalization for Ambulatory Care Sensitive Conditions and Regional Characteristics in South Korea

Hospitalization rates for ambulatory care sensitive conditions (ACSCs) can indicate the accessibility of a community’s primary care. We examined regional variation in ACSC hospitalization rates and identified associated factors. ACSC hospitalization rates in the 232 districts in 2013 ranged from 4.08 to 101.53 per 1000 adults. Spatial analysis showed that none of the 24 highest rate districts were located near Seoul, whereas 80% of the 45 lowest rate districts were, suggesting health care inequality between people living near Seoul and in other areas. Regression analysis showed significantly higher ACSC hospitalization rates in districts with higher elderly (β = 0.94) and low-income populations (β = 2.25), more remote areas (β = 0.29), and more hospital beds (β = 0.03). The number of primary care clinics was negatively associated with ACSC hospitalization (β = −1.37). For these variables, geographically weighted regression analysis provided local regression coefficients, useful for developing region-specific strategies to reduce ACSC hospitalization.

Can external interventions crowd in intrinsic motivation? A cluster randomised field experiment on mandatory accreditation of general practice in Denmark

Motivation crowding studies have demonstrated that external interventions can harm effort and performance through crowding out of intrinsic motivation, when interventions are perceived as lack of trust. However, motivation crowding theory also presents a much less investigated crowding in effect, which occurs when external interventions increase intrinsic motivation. This study empirically tests the motivational effect of a specific external intervention and its associations with the perception of the intervention. We draw on a cluster randomised stepwise introduction of a mandatory accreditation system in general practice in Denmark combined with baseline and follow-up questionnaires of 1146 GPs. Based on a series of mixed effects multilevel models, we find no evidence of motivation crowding out among surveyed GPs, although most GPs perceived accreditation as a tool for external control prior to its implementation. Rather, our results indicate that being accredited crowds in intrinsic motivation. This is especially the case when GPs perceive accreditation as an instrument for quality improvement. External interventions can therefore, at least in some cases, foster intrinsic motivation of health care professionals.

The effect of a hepatitis pay-for-performance program on outcomes of patients undergoing antiviral therapy

Background

To examine the effect of a participatory pay-for-performance (P4P) program in Taiwan on health outcomes for patients with severe hepatitis B or C.

Methods

This study adopted 4-year panel data from the databases of the National Health Insurance Administration (NHIA) in Taiwan. Using the caliper matching method to match patients in the P4P (experimental) group with those in the potential comparison group on a one-to-one basis for the year 2010, we tracked patients up to the year 2013 and employed Cox proportional-hazards regression models to evaluate the effect on patient outcomes.

Results

The P4P group did not have a lower risk (HR = 0.44, P = 0.05) of hospital admission for severe hepatitis patients (i.e. need antiviral therapy). The risk of developing liver cirrhosis was also lower, but the reduction was not statistically significant (HR = 0.92, P = 0.77).

Conclusions

This study found that participatory-type P4P has not resulted in reduced hospital admission of hepatitis B or C patients who need antiviral therapy. The means by which the participatory P4P program could strengthen patient-centered care to achieve better patient health outcomes is discussed in detail.

Quality of diabetes follow-up care and hospital admissions

Diabetes may lead to severe complications. For this reason, disease prevention and improvement of medical follow-up represent major public health issues. The aim of this study was to measure the impact of adherence to French follow-up guidelines on hospitalization of people with diabetes. We used insurance claims data from the years 2010 to 2013 collected for 52,027 people aged over 18, affiliated to a French social security provider and treated for diabetes. We estimated panel data models to explore the association between adherence to guidelines and different measures of hospitalization, controlling for socioeconomic characteristics, diabetes treatment and density of medical supply. The results show that adherence to four guidelines was associated with a significant decrease in hospital admissions, up to approximatively 30% for patients monitored for a complete lipid profile or microalbuminuria during the year. In addition, our analyses confirmed the strong protective effect of income and a significant positive correlation with good supply of hospital care. In conclusion, good adherence to French diabetes guidelines seems to be in line with the prevention of health events, notably complications, that could necessitate hospitalization.

Using Weighted Hospital Service Area Networks to Explore Variation in Preventable Hospitalization

Objective

To demonstrate the use of multiple‐membership multilevel models, which analytically structure patients in a weighted network of hospitals, for exploring between‐hospital variation in preventable hospitalizations.

Data Sources

Cohort of 267,014 people aged over 45 in NSW, Australia.

Study Design

Patterns of patient flow were used to create weighted hospital service area networks (weighted‐HSANs) to 79 large public hospitals of admission. Multiple‐membership multilevel models on rates of preventable hospitalization, modeling participants structured within weighted‐HSANs, were contrasted with models clustering on 72 hospital service areas (HSAs) that assigned participants to a discrete geographic region.

Data Collection/Extraction Methods

Linked survey and hospital admission data.

Principal Findings

Between‐hospital variation in rates of preventable hospitalization was more than two times greater when modeled using weighted‐HSANs rather than HSAs. Use of weighted‐HSANs permitted identification of small hospitals with particularly high rates of admission and influenced performance ranking of hospitals, particularly those with a broadly distributed patient base. There was no significant association with hospital bed occupancy.

Conclusion

Multiple‐membership multilevel models can analytically capture information lost on patient attribution when creating discrete health care catchments. Weighted‐HSANs have broad potential application in health services research and can be used across methods for creating patient catchments.

Spatial effects in hospital expenditures: A district level analysis

We use spatial econometric methods to analyse spillovers in hospital expenditures across Health Districts of the Emilia-Romagna Region (Italy). We estimate spatial models that allow for global spillovers and distinguish between the expenditures associated with potentially inappropriate hospitalizations and those associated with complex medical procedures. We also investigate the relative contribution of geographical and institutional proximity in explaining spatial dependence, by explicitly modelling different connectivity structures and exploiting them to build alternative spatial weight matrices. We find that interactions largely differ between types of expenditures, with positive spatial effects for potentially inappropriate admissions, the effect being generally not significant for high-complexity expenditure. Relying on the estimated direct and indirect effects, we also test for the presence of spatial spillovers across districts. Finally, the paper draws policy implications for the public health planner.

The influence of welfare systems on pay-for-performance programs for general practitioners: A critical review

While pay-for-performance (P4P) programs are increasingly common tools used to foster quality and efficiency in primary care, the evidence concerning their effectiveness is at best mixed. In this article, we explore the influence of welfare systems on four P4P-related dimensions: the level of healthcare funders' commitment to P4Ps (by funding and length of program operation), program design (specifically target-based vs. participation-based program), physicians' acceptance of the program and program effects. Using Esping-Andersen's typology, we examine P4P for general practitioners (GPs) in thirteen European and North American countries and find that welfare systems contribute to explain variations in P4P experiences. Overall, liberal systems exhibited the most enthusiastic adoption of P4P, with significant physician acceptance, generous incentives and positive but modest program effects. Social democratic countries showed minimal interest in P4P for GPs, with the exception of Sweden. Although corporatist systems adopted performance pay, these countries experienced mixed results, with strong physician opposition. In response to this opposition, health care funders tended to favour participation-based over target-based P4P. We demonstrate how the interaction of decommodification and social stratification in each welfare regime influences these countries' experiences with P4P for GPs, directly for funders' commitment, program design and physicians' acceptance, and indirectly for program effects, hence providing a framework for analyzing P4P in other contexts or care settings.

Does the extension of primary care practice opening hours reduce the use of emergency services?

Overcrowding in emergency departments generates potential inefficiencies. Using regional administrative data, we investigate the impact that an increase in the accessibility of primary care has on emergency visits in Italy. We consider two measures of avoidable emergency visits recorded at list level for each General Practitioner. We test whether extending practices' opening hours to up to 12 hours/day reduces the inappropriate utilization of emergency services. Since subscribing to the extension program is voluntary, we account for the potential endogeneity of participation in a count model for emergency admissions in two ways: first, we use a two-stage residual inclusion approach. Then we exploit panel methods on data covering a three-year period, thus accounting directly for individual heterogeneity. Our results show that increasing primary care accessibility acts as a restraint on the inappropriate use of emergency departments. The estimated effect is in the range of a 10-15% reduction in inappropriate admissions.

Financial Incentives to Encourage Value-Based Health Care

This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.

Visualising linked health data to explore health events around preventable hospitalisations in NSW Australia

OBJECTIVE

To explore patterns of health service use in the lead-up to, and following, admission for a 'preventable' hospitalisation.

SETTING

266 950 participants in the 45 and Up Study, New South Wales (NSW) Australia

METHODS

Linked data on hospital admissions, general practitioner (GP) visits and other health events were used to create visual representations of health service use. For each participant, health events were plotted against time, with different events juxtaposed using different markers and panels of data. Various visualisations were explored by patient characteristics, and compared with a cohort of non-admitted participants matched on sociodemographic and health characteristics. Health events were displayed over calendar year and in the 90 days surrounding first preventable hospitalisation.

RESULTS

The visualisations revealed patterns of clustering of GP consultations in the lead-up to, and following, preventable hospitalisation, with 14% of patients having a consultation on the day of admission and 27% in the prior week. There was a clustering of deaths and other hospitalisations following discharge, particularly for patients with a long length of stay, suggesting patients may have been in a state of health deterioration. Specialist consultations were primarily clustered during the period of hospitalisation. Rates of all health events were higher in patients admitted for a preventable hospitalisation than the matched non-admitted cohort.

CONCLUSIONS

We did not find evidence of limited use of primary care services in the lead-up to a preventable hospitalisation, rather people with preventable hospitalisations tended to have high levels of engagement with multiple elements of the healthcare system. As such, preventable hospitalisations might be better used as a tool for identifying sicker patients for managed care programmes. Visualising longitudinal health data was found to be a powerful strategy for uncovering patterns of health service use, and such visualisations have potential to be more widely adopted in health services research.

A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease

BACKGROUND

In 2007, the province of British Columbia implemented incentive payments to primary care physicians for the provision of comprehensive, continuous, guideline-informed care for patients with 2 or more chronic conditions. We examined the impact of this program on primary care access and continuity, rates of hospital admission and costs.

METHODS

We analyzed all BC patients who qualified for the incentive based on their diagnostic profile. We tracked primary care contacts and continuity, hospital admissions (total, via the emergency department and for targeted conditions), and cost of physician services, hospital care and pharmaceuticals, for 24 months before and 24 months after the intervention.

RESULTS

Of 155 754 eligible patients, 63.7% had at least 1 incentive payment billed. Incentive payments had no impact on primary care contacts (change in contacts per patient per month: 0.016, 95% confidence interval [CI] -0.047 to 0.078) or continuity of care (mean monthly change: 0.012, 95% CI -0.001 to 0.024) and were associated with increased total rates of hospital admission (change in hospital admissions per 1000 patients per month: 1.46, 95% CI 0.04 to 2.89), relative to preintervention trends. Annual costs per patient did not decline (mean change: $455.81, 95% CI -$2.44 to $914.08).

INTERPRETATION

British Columbia's $240-million investment in this program improved compensation for physicians doing the important work of caring for complex patients, but did not appear to improve primary care access or continuity, or constrain resource use elsewhere in the health care system. Policymakers should consider other strategies to improve care for this patient population.

The Dynamics of Hospital Use among Older People Evidence for Europe Using SHARE Data

OBJECTIVE

Hospital services use, which is a major driver of total health expenditures, is expected to rise over the next decades in Europe, especially because of population aging. The purpose of this article is to better understand the dynamics of older people's demand for hospital care over time in a cross-country setting.

DATA SOURCE

We used data from the Survey on Health, Ageing, and Retirement in Europe (SHARE), in 10 countries between 2004 and 2011.

STUDY DESIGN

We estimated a dynamic panel model of hospital admission for respondents aged 50 years or more.

PRINCIPAL FINDINGS

Following prior research, we found evidence of state dependence in hospital use over time. We also found that rise in frailty-among other health covariates-is a strong predictor of increased hospital use. Progression by one point on the frailty scale [0;5] is associated with an additional risk of about 2.1 percent on average.

CONCLUSIONS

Our results support promotion of early detection of frailty in primary care, and improvement of coordination between actors within the health system, as potential strategies to reduce avoidable or unnecessary hospital use among frail elderly.

Dealing with minor illnesses: The link between primary care characteristics and Walk-in Centres' attendances

The reformulation of existing boundaries between primary and secondary care, in order to shift selected services traditionally provided by Emergency Departments (EDs) to community-based alternatives, has determined a variety of organisational solutions. One innovative change has been the introduction of fast-track systems for minor injuries or illnesses, whereby community care providers are involved in order to divert patients away from EDs. These facilities offer an open-access service for patients not requiring hospital treatments, and may be staffed by nurses and/or primary care general practitioners operating within, or alongside, the ED. To date little research has been undertaken on such experiences. To fill this gap, we analyse a Walk-in Centre (WiC) in the Italian city of Parma, consisting of a minor injury unit located alongside the teaching hospital's ED. We examine the link between the utilisation rates of the WiC and primary care characteristics, focusing on the main organisational features of the practices and estimating panel count data models for 2007-2010. Our main findings indicate that the extension of practice opening hours significantly lowers the number of attendances, after controlling for General Practitioner's and practice's characteristics.

Sociodemographic and health characteristics, rather than primary care supply, are major drivers of geographic variation in preventable hospitalizations in Australia

Supplemental Digital Content is available in the text.

Background:

Geographic rates of preventable hospitalization are used internationally as an indicator of accessibility and quality of primary care. Much research has correlated the indicator with the supply of primary care services, yet multiple other factors may influence these admissions.

Objective:

To quantify the relative contributions of the supply of general practitioners (GPs) and personal sociodemographic and health characteristics, to geographic variation in preventable hospitalization.

Methods:

Self-reported questionnaire data for 267,091 participants in the 45 and Up Study, Australia, were linked with administrative hospital data to identify preventable hospitalizations. Multilevel Poisson models, with participants clustered in their geographic area of residence, were used to explore factors that explain geographic variation in hospitalization.

Results:

GP supply, measured as full-time workload equivalents, was not a significant predictor of preventable hospitalization, and explained only a small amount (2.9%) of the geographic variation in hospitalization rates. Conversely, more than one-third (36.9%) of variation was driven by the sociodemographic composition, health, and behaviors of the population. These personal characteristics explained a greater amount of the variation for chronic conditions (37.5%) than acute (15.5%) or vaccine-preventable conditions (2.4%).

Conclusions:

Personal sociodemographic and health characteristics, rather than GP supply, are major drivers of preventable hospitalization. Their contribution varies according to condition, and if used for performance comparison purposes, geographic rates of preventable hospitalization should be reported according to individual condition or potential pathways for intervention.

[Pay-for-performance in health care services: a review of the best evidence available]

Pay-for-performance (P4P) has been widely used around the world seeking to improve health outcomes, and in Brazil it is the basis of the National Program for Improving Access and Quality (PMAQ). The literature published between 1998 and January 2013 that evaluated the effectiveness of P4P to produce results or patterns of access and quality in health was scrutinized. A total of 138 studies, with the inclusion of a further 41 studies (14 systematic reviews, 07 clinical trials and 20 observational studies) were retrieved and analyzed Among the more rigorous studies, favorable conclusions for P4P were less frequent, whereas observational studies were more favorable to positive effects of P4P on the quality of, and access to, health services. Methodological limitations of observational studies may have contributed to these results, but the range of results is more linked to the conceptual and contextual aspects of the use of the P4P schemes reviewed, the heterogeneity of P4P models and results. P4P can be helpful in promoting the achievement of objectives in health care systems, especially in the short term and for specific actions requiring less effort of health care providers, but should be used with caution and with a rigorous planning model, also considering undesirable or adverse effects.

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study

OBJECTIVE

To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs).

DESIGN

Controlled longitudinal study.

SETTING

English National Health Service between 1998/99 and 2010/11.

PARTICIPANTS

Populations registered with each of 6975 family practices in England.

MAIN OUTCOME MEASURES

Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs.

RESULTS

Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11.

CONCLUSIONS

The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

Organizational aspects of primary care related to avoidable hospitalization: a systematic review

BACKGROUND

Often used indicators for the quality of primary care are hospital admissions rates for conditions which are potentially avoidable by well-functioning primary care. Such hospitalizations are frequently termed as ambulatory care sensitive conditions (ACSCs).

OBJECTIVE

We aim to investigate which characteristics of primary care organization influence avoidable hospitalization for chronic ACSCs.

METHODS

MEDLINE, Embase and SciSearch were searched for publications on avoidable hospitalization and primary care. Studies were included if peer reviewed, written in English, published between January 1997 and November 2013, conducted in high income countries, identified hospitalization for ACSC as outcome measures and researched organization characteristics of primary care. A risk of bias assessment was performed to assess the quality of the articles.

FINDINGS

A total of 1778 publications were reviewed, of which 49 met inclusion criteria. Twenty-two primary care factors were found. Factors were clustered into four primary care clusters: system-level characteristics, accessibility, structural and organizational characteristics and organization of the care process. Adequate physician supply and better longitudinal continuity of care reduced avoidable hospitalizations. Furthermore, inconsistent results were found on the effectiveness of various disease management programs in reducing hospitalization rates.

CONCLUSIONS

Available evidence suggests that strong primary care in terms of adequate primary care physician supply and long-term relationships between primary care physicians and patients reduces hospitalizations for chronic ACSCs. There is a lack of evidence for the positive effects of many other organizational primary care aspects, such as specific disease management programs.

The role of GP's compensation schemes in diabetes care: evidence from panel data

We investigate the impact of the implementation of Diabetes Management Programs with financial incentives in the Italian Region Emilia-Romagna between 2003 and 2005. We focus on avoidable hospitalisations for diabetic patients for whom GPs receive additional payments exceeding capitation. We estimate a panel count data model to test the hypothesis that those patients under the responsibility of GPs receiving a higher share of their income through ad-hoc payments, are less likely to experience avoidable hospitalisations. Our findings indicate that financial transfers may help improve the quality of care, even when they are not based on the ex-post verification of performance. The estimated effect indicates that, at sample averages, an increase of 100 Euros of the financial incentives paid to GPs (around 17% of the yearly payment received by GPs for diabetes programmes) is expected to reduce the number of diabetic ACSCs by 1%, around 100 cases when projected on the entire region.

Group versus single handed primary care: a performance evaluation of the care delivered to chronic patients by Italian GPs

OBJECTIVES

In family medicine contrasting evidence exists on the effectiveness of team practice compared with solo practice on chronic disease management. In Italy, several experiences of team practice have been introduced since the late 1990s but few studies detail their impact on the quality of care. The aim of this paper is to evaluate the impact of team practice in family medicine in six Italian regions using chronic disease management process indicators as a measure of outcome.

METHODS

Cross-sectional studies were performed to assess impact on quality of care for diabetes, congestive heart failure and ischaemic heart disease. The impact of team vs. solo practice was approximated through performance comparison of general practitioners (GPs) adhering to a team with respect to GPs working in a solo practice. Among the 2082 practitioners working in the 6 regions those assisting 300+ patients were selected. Quality of care towards 164,267 patients having at least one of three chronic conditions was estimated for the year 2008 using administrative databases. Quality indicators (% of patients receiving appropriate care) were selected (4 for diabetes, 4 for congestive heart failure, 3 for ischaemic heart disease) and a total score was computed for each patient. For each disease the response variable associated to each physician was the average score of the patients on his/her list. A multilevel model was estimated assessing the impact of team vs. solo practice.

RESULTS

No impact was found for diabetes and heart failure. For ischaemic heart disease a slightly significant impact was observed (0.040; 95% CI: 0.015, 0.065).

CONCLUSIONS

No significant difference was found between team practice and solo practice on chronic disease management in six Italian regions.

Pay for Performance in Health Care

Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.