Payment systems and hospital length of stay: a bunching-based evidence

Impact of increased reimbursement for ambulance transportation on hospital acceptance in Japan: a difference-in-difference study

OBJECTIVE

Emergency medical services (EMS) often face difficulties in finding accepting hospitals in Japan. The universal medical insurance system in Japan increased the reimbursement for ambulance transportation acceptance at night, and on Sundays and holidays from 1 April 2016. This study investigated the effect of the reimbursement increase on the number of EMS calls, and transportation time from arrival at the scene to arrival at the hospital.

DESIGN

A difference-in-difference study. The treatment group consisted of people who called an ambulance at night while the control group consisted of people who called an ambulance during the daytime.

SETTING

The national ambulance records of the Fire and Disaster Management Agency in Japan from 1 April 2015 to 31 December 2016.

PARTICIPANTS

7 625 463 ambulance dispatches were eligible for inclusion.

PRIMARY AND SECONDARY OUTCOME MEASURES

The changes in EMS calls, transportation time and the number of ambulance transports per 1000 population in one month in a comparison of daytime and night-time transport.

RESULTS

The treatment effect (night-time vs daytime) on the number of EMS calls was -0.013 (95% CI, -0.023 to -0.004), which was significant. The transportation time decreased slightly by 0.080 min (95% CI, -0.157 to -0.004). No impact was observed on the number of ambulance transports per 1000 population per month (0.00; 95% CI, -0.008 to 0.002).

CONCLUSION

An increase in reimbursement for ambulance transportation acceptance was associated with a decrease in the number of EMS calls. Further strategies for decreasing the number of EMS calls are needed to avoid delays in the treatment of emergency patients with critical illness.

Examining organisational responses to performance-based financial incentive systems: a case study using NHS staff influenza vaccination rates from 2012/2013 to 2019/2020

Objective

Financial incentives are often applied to motivate desirable performance across organisations in healthcare systems. In the 2016/2017 financial year, the National Health Service (NHS) in England set a national performance-based incentive to increase uptake of the influenza vaccination among frontline staff. Since then, the threshold levels needed for hospital trusts to achieve the incentive (ie, the targets) have ranged from 70% to 80%. The present study examines the impact of this financial incentive across eight vaccination seasons.

Design

A retrospective observational study examining routinely recorded rates of influenza vaccination among staff in all acute NHS hospital trusts across eight vaccination seasons (2012/2013–2019/2020). The number of trusts included varied per year, from 127 to 137, due to organisational changes. McCrary’s density test is conducted to determine if the number of hospital trusts narrowly achieving the target by the end of each season is higher than would be expected in the absence of any responsiveness to the target. We refer to this bunching above the target threshold as a ‘threshold effect’.

Results

In the years before a national incentive was set, 9%–31% of NHS Trusts reported achieving the target, compared with 43%–74% in the 4 years after. Threshold effects did not emerge before the national incentive for payment was set; however, since then, threshold effects have appeared every year. Some trusts report narrowly achieving the target each year, both as the target rises and falls. Threshold effects were not apparent at targets for partial payments.

Conclusions

We provide compelling evidence that performance-based financial incentives produced threshold effects. Policymakers who set such incentives are encouraged to track threshold effects since they contain information on how organisations are responding to an incentive, what enquiries they may wish to make, how the incentive may be improved and what unintended effects it may be having.

Factors associated with difficulty of hospital acceptance of patients suspected to have cerebrovascular diseases: A nationwide population-based observational study

Although it is essential to shorten the interval to initial treatment in the care of acute ischemic stroke, some hospitals in Japan reject requests for hospital acceptance from on-scene emergency medical service personnel because of limited resources, which can cause delays in care. We aimed to assess the risk factors for difficulty of hospital acceptance of patients suspected to have cerebrovascular diseases. We conducted a retrospective analysis of the national ambulance records of the Fire and Disaster Management Agency in Japan in 2016. Multivariable logistic regression analysis was used to assess the association between difficulty of hospital acceptance of patients suspected to have cerebrovascular diseases and prehospital factors. During the study period, a total of 222,926 patients were included, and 5283 patients (2.4%) experienced difficulties in hospital acceptance. In multivariable analysis, nights (adjusted odds ratio [AOR] 1.54, 95% confidence interval [CI] 1.45–1.64), weekends (AOR 1.32, 95% CI 1.24–1.40), <25 percentile ratio of emergency physicians and neurosurgeons to all physicians (AOR 1.13, 95% CI 1.03–1.23) (AOR 1.36, 95% CI 1.25–1.48), and mean age of physicians (AOR 1.06, 95% CI 1.05–1.07) were significantly associated with difficulties of hospital acceptance of patients suspected to have cerebrovascular disease. There was a marked regional variation in the difficulties of hospital acceptance. Among the national ambulance records of patients suspected to have cerebrovascular diseases, certain prehospital factors such as weekends were positively associated with difficulty of hospital acceptance. A comprehensive strategy for hospital acceptance of patients with cerebrovascular diseases considering regional variation is required.

The Dedicated Emergency Physician Model of emergency care is associated with reduced pre-hospital transportation time: A retrospective study with a nationwide database in Japan

In Japan, the increasing number of patients needing emergency medical care due to population aging is a major public health problem. Recently, emergency medicine in Japan has seen a growth in the number of Dedicated Emergency Physician Model style departments. We aimed to determine whether there is an association between Dedicated Emergency Physician Model emergency care and pre-hospital transportation time. We conducted a secondary analysis of a Japanese national pre-hospital database from 2010 to 2014. Three regions (group 1: Urayasu city and Ichikawa city in Chiba prefecture, group 2: Kamakura city, Chigasaki city, Fujisawa city and Zushi city in Kanagawa prefecture, and group 3: Fukui city in Fukui prefecture) were evaluated as Dedicated Emergency Physician Model emergency medicine areas. We compared transportation times in these areas with all municipalities in the same prefectures, and with a nearby area using multivariate linear regression with cluster adjustment. The variables used for adjustment are the time from Emergency Medical Services activation to the scene, month, day of the month, day of the week, time of day, age, gender, type of injury, severity, and location of call. Compared with all municipalities in each prefecture there were significant reductions in pre-hospital transportation time: 4.2 minutes (95% confidence interval, 0.9 to 7.5, p<0.05) in Group 1, 6.2 minutes (95%CI, 2.9 to 9.6, p<0.01) fin Group 2 and 7.5 minutes (95%CI, 6.0 to 9.0, p<0.01) in Group 3. Compared with nearby areas, there were statistically significant reductions in transportation time in Group 1, 6.8 minutes (95%CI, 0.7 to 12.8, p<0.05) and in Group 2, 6.8 minutes (95%CI, 3.7 to 9.9, p<0.05). There was a trend for reduced transportation time in Group 3, 2.3 minutes, (5.3 to -0.6, p<0.1). Areas with a Dedicated Emergency Physician Model are associated with reduced pre-hospital transportation time.