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Feng Y, Gravelle H. Patient Self-Reported Health, Clinical Quality, and Patient Satisfaction in English Primary Care: Practice-Level Longitudinal Observational Study. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2021; 24:1660-1666. [PMID: 34711367 DOI: 10.1016/j.jval.2021.05.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 04/20/2021] [Accepted: 05/12/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To examine the association of self-reported health of patients in general practices, as measured by the EQ-5D-5L, with practice clinical quality and patient-reported satisfaction with accessibility and consultations. METHODS We used data from the General Practitioner (GP) Patient Survey to construct a practice-level EQ-5D-5L index as the health outcome. Key explanatories were patient-reported measures of satisfaction with access and consultations (also derived from the GP Patient Survey) and clinical quality measured by the achievement of clinical quality indicators reported in the Quality and Outcomes Framework. We estimated practice-level linear panel data models with random and fixed practice effects and practice and patient covariates using 2012/13 to 2016/17 data on more than 7500 English general practices. RESULTS Bivariate correlations of the EQ-5D-5L index with quality measures were 0.048 for clinical quality, 0.071 for satisfaction with access, and 0.107 for satisfaction with GP consultations (all with P<.001). In both fixed effects regressions, which allow for unobserved time invariant practice characteristics, and random effects regressions which do not, the EQ-5D-5L index was positively associated with 1-year lags of patient satisfaction with access and GP consultations. Patient-reported health was positively associated with clinical quality in the fixed effects regressions. The implied effects were small in all cases. CONCLUSION Practice-level EQ-5D-5L is positively associated with clinical quality and with 1-year lags of patient-reported satisfaction with access and GP consultations.
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Affiliation(s)
- Yan Feng
- Institute of Population Health Sciences, Queen Mary University of London, England, UK.
| | - Hugh Gravelle
- Centre for Health Economics, University of York, England, UK
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Guha A, Wang X, Harris RA, Nelson AG, Stepp D, Klaassen Z, Raval P, Cortes J, Coughlin SS, Bogdanov VY, Moore JX, Desai N, Miller DD, Lu XY, Kim HW, Weintraub NL. Obesity and the Bidirectional Risk of Cancer and Cardiovascular Diseases in African Americans: Disparity vs. Ancestry. Front Cardiovasc Med 2021; 8:761488. [PMID: 34733899 PMCID: PMC8558482 DOI: 10.3389/fcvm.2021.761488] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 09/21/2021] [Indexed: 12/28/2022] Open
Abstract
Cardiovascular disease (CVD) and cancer often occur in the same individuals, in part due to the shared risk factors such as obesity. Obesity promotes adipose inflammation, which is pathogenically linked to both cardiovascular disease and cancer. Compared with Caucasians, the prevalence of obesity is significantly higher in African Americans (AA), who exhibit more pronounced inflammation and, in turn, suffer from a higher burden of CVD and cancer-related mortality. The mechanisms that underlie this association among obesity, inflammation, and the bidirectional risk of CVD and cancer, particularly in AA, remain to be determined. Socio-economic disparities such as lack of access to healthy and affordable food may promote obesity and exacerbate hypertension and other CVD risk factors in AA. In turn, the resulting pro-inflammatory milieu contributes to the higher burden of CVD and cancer in AA. Additionally, biological factors that regulate systemic inflammation may be contributory. Mutations in atypical chemokine receptor 1 (ACKR1), otherwise known as the Duffy antigen receptor for chemokines (DARC), confer protection against malaria. Many AAs carry a mutation in the gene encoding this receptor, resulting in loss of its expression. ACKR1 functions as a decoy chemokine receptor, thus dampening chemokine receptor activation and inflammation. Published and preliminary data in humans and mice genetically deficient in ACKR1 suggest that this common gene mutation may contribute to ethnic susceptibility to obesity-related disease, CVD, and cancer. In this narrative review, we present the evidence regarding obesity-related disparities in the bidirectional risk of CVD and cancer and also discuss the potential association of gene polymorphisms in AAs with emphasis on ACKR1.
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Affiliation(s)
- Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH, United States
- Division of Cardiology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Xiaoling Wang
- Georgia Prevention Institute, Augusta University, Augusta, GA, United States
| | - Ryan A. Harris
- Georgia Prevention Institute, Augusta University, Augusta, GA, United States
| | - Anna-Gay Nelson
- Department of Chemistry, Paine College, Augusta, GA, United States
| | - David Stepp
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Zachary Klaassen
- Section of Urology, Department of Surgery, Medical College of Georgia at Augusta University, Georgia Cancer Center, Augusta, GA, United States
| | - Priyanka Raval
- Georgia Cancer Center, Augusta University, Augusta, GA, United States
| | - Jorge Cortes
- Georgia Cancer Center, Augusta University, Augusta, GA, United States
| | - Steven S. Coughlin
- Department of Population Health Sciences, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | | | - Justin X. Moore
- Cancer Prevention, Control, and Population Health Program, Georgia Cancer Center, Medical College of Georgia, Augusta University, Augusta, GA, United States
| | - Nihar Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
- Center for Outcomes Research and Evaluation, New Haven, CT, United States
| | - D. Douglas Miller
- Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Xin-Yun Lu
- Department of Neuroscience & Regenerative Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Ha Won Kim
- Division of Cardiology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
| | - Neal L. Weintraub
- Division of Cardiology, Department of Medicine, Medical College of Georgia at Augusta University, Augusta, GA, United States
- Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, United States
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Grigoroglou C, Munford L, Webb R, Kapur N, Doran T, Ashcroft D, Kontopantelis E. Impact of a national primary care pay-for-performance scheme on ambulatory care sensitive hospital admissions: a small-area analysis in England. BMJ Open 2020; 10:e036046. [PMID: 32907897 PMCID: PMC7482460 DOI: 10.1136/bmjopen-2019-036046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world's largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme. SETTING We obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics. RESULTS Hospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition. CONCLUSION Spatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.
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Affiliation(s)
- Christos Grigoroglou
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Luke Munford
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health Organisation, Policy and Economics, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Roger Webb
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Centre for Mental Health and Safety, Division of Psychology & Mental Health, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Navneet Kapur
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Suicide Prevention, Division of Psychology and Mental Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health Trust, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Darren Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine & Health, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, Greater Manchester, UK
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Local Health Departments' Engagement in Addressing Health Disparities: The Effect of Health Informatics. JOURNAL OF PUBLIC HEALTH MANAGEMENT AND PRACTICE 2018; 25:171-180. [PMID: 29975343 DOI: 10.1097/phh.0000000000000842] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
CONTEXT Health disparities and health inequities can lead to poor health outcomes. However, health disparities continue to persist in communities across the United States, presenting a crucial public health challenge. Persisting budget cuts and workforce challenges tend to hinder local health departments' (LHDs') ability to assess and address health disparities. OBJECTIVES To examine the extent to which LHDs' use of informatics effects their engagement in strategies and activities addressing health disparities. METHODS Data from the 2016 Profile of LHDs were used in examining the association of informatics with 9 activities addressing health disparities/inequities. RESULTS Fifty-nine percent of LHDs used data and described health disparities in their jurisdiction, and 12% conducted original research to link health disparities to differences in social or environmental conditions. Less than 40% of LHDs prioritized resources for the reduction of health disparities. LHDs that implemented information systems had increased odds of describing the disparities in their jurisdiction (P < .01) and having prioritized resources for the reduction of disparities (P < .01). Per capita expenditures, participation in a national accreditation program process, and a larger LHD population were also positively associated with 7 of 9 activities for addressing health disparities/inequities. CONCLUSIONS As LHDs advance efforts to reduce health disparities and inequities, leadership will find informatics a useful strategy. National initiatives aimed to boost LHDs' engagement in the reduction of disparities might benefit from our findings, positing a positive influence of informatics.
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Asthana S, Moon G, Gibson A, Bailey T, Hewson P, Dibben C. Inequity in cardiovascular care in the English National Health Service (NHS): a scoping review of the literature. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:259-272. [PMID: 27747961 DOI: 10.1111/hsc.12384] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/11/2016] [Indexed: 06/06/2023]
Abstract
There is a general understanding that socioeconomically disadvantaged people are also disadvantaged with respect to their access to NHS care. Insofar as considerable NHS funding has been targeted at deprived areas, it is important to better understand whether and why socioeconomic variations in access and utilisation exist. Exploring this question with reference to cardiovascular care, our aims were to synthesise and evaluate evidence relating to access to and/or use of English NHS services around (i) different points on the care pathway (i.e. presentation, primary management and specialist management) and (ii) different dimensions of inequality (socioeconomic, age- and gender-related, ethnic or geographical). Restricting our search period from 2004 to 2016, we were concerned to examine whether, compared to earlier research, there has been a change in the focus of research examining inequalities in cardiac care and whether the pro-rich bias reported in the late 1990s and early 2000s still applies today. We conducted a scoping study drawing on Arksey & O'Malley's framework. A total of 174 studies were included in the review and appraised for methodological quality. Although, in the past decade, there has been a shift in research focus away from gender and age inequalities in access/use and towards socioeconomic status and ethnicity, evidence that deprived people are less likely to access and use cardiovascular care is very contradictory. Patterns of use appear to vary by ethnicity; South Asian populations enjoying higher access, black populations lower. By contrast, female gender and older age are consistently associated with inequity in cardiovascular care. The degree of geographical variation in access/use is also striking. Finally, evidence of inequality increases with stage on the care pathway, which may indicate that barriers to access arise from the way in which health professionals are adjudicating health needs rather than a failure to seek help in the first place.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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Sonsale A. Do ‘payments for performance’ lead to better or lower quality of services in public service healthcare? INTERNATIONAL JOURNAL OF HEALTHCARE MANAGEMENT 2017. [DOI: 10.1080/20479700.2017.1370858] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Atun R, Gurol-Urganci I, Hone T, Pell L, Stokes J, Habicht T, Lukka K, Raaper E, Habicht J. Shifting chronic disease management from hospitals to primary care in Estonian health system: analysis of national panel data. J Glob Health 2017; 6:020701. [PMID: 27648258 PMCID: PMC5017034 DOI: 10.7189/jogh.06.020701] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background Following independence from the Soviet Union in 1991, Estonia introduced a
national insurance system, consolidated the number of health care providers, and
introduced family medicine centred primary health care (PHC) to strengthen the
health system. Methods Using routinely collected health billing records for 2005–2012, we examine
health system utilisation for seven ambulatory care sensitive conditions (ACSCs)
(asthma, chronic obstructive pulmonary disease [COPD], depression, Type 2
diabetes, heart failure, hypertension, and ischemic heart disease [IHD]), and by
patient characteristics (gender, age, and number of co–morbidities). The
data set contained 552 822 individuals. We use patient level data to test
the significance of trends, and employ multivariate regression analysis to
evaluate the probability of inpatient admission while controlling for patient
characteristics, health system supply–side variables, and PHC use. Findings Over the study period, utilisation of PHC increased, whilst inpatient admissions
fell. Service mix in PHC changed with increases in phone, email, nurse, and
follow–up (vs initial) consultations. Healthcare utilisation for diabetes,
depression, IHD and hypertension shifted to PHC, whilst for COPD, heart failure
and asthma utilisation in outpatient and inpatient settings increased.
Multivariate regression indicates higher probability of inpatient admission for
males, older patient and especially those with multimorbidity, but protective
effect for PHC, with significantly lower hospital admission for those utilising
PHC services. Interpretation Our findings suggest health system reforms in Estonia have influenced the shift of
ACSCs from secondary to primary care, with PHC having a protective effect in
reducing hospital admissions.
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Affiliation(s)
- Rifat Atun
- Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ipek Gurol-Urganci
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Thomas Hone
- Department of Primary Care and Public Health, Imperial College, London, UK
| | - Lisa Pell
- The Centre for Global Child Health, The Hospital for Sick Children, Toronto, Canada
| | - Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK
| | | | - Kaija Lukka
- Estonian Health Insurance Fund, Tallinn, Estonia
| | - Elin Raaper
- Estonian Health Insurance Fund, Tallinn, Estonia
| | - Jarno Habicht
- WHO Country Office in Republic of Kyrgyzstan, World Health Organization
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Santos R, Gravelle H, Propper C. Does Quality Affect Patients' Choice of Doctor? Evidence from England. ECONOMIC JOURNAL (LONDON, ENGLAND) 2017; 127:445-494. [PMID: 28356602 PMCID: PMC5349292 DOI: 10.1111/ecoj.12282] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 01/13/2014] [Indexed: 05/22/2023]
Abstract
Reforms giving users of public services choice of provider aim to improve quality. But such reforms will work only if quality affects choice of provider. We test this crucial prerequisite in the English health care market by examining the choice of 3.4 million individuals of family doctor. Family doctor practices provide primary care and control access to non-emergency hospital care, the quality of their clinical care is measured and published and care is free. In this setting, clinical quality should affect choice. We find that a 1 standard deviation increase in clinical quality would increase practice size by around 17%.
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Affiliation(s)
| | | | - Carol Propper
- University of BristolImperial College London and CEPR
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Lavergne MR, Law MR, Peterson S, Garrison S, Hurley J, Cheng L, McGrail K. A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease. CMAJ 2016; 188:E375-E383. [PMID: 27527484 DOI: 10.1503/cmaj.150858] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/25/2016] [Indexed: 11/01/2022] Open
Abstract
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.
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Affiliation(s)
- M Ruth Lavergne
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine (Lavergne, Law, Peterson, Cheng, McGrail), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC; Department of Family Medicine (Garrison), University of Alberta, Edmonton, Alta.; Department of Economics (Hurley), McMaster University, Hamilton, Ont.
| | - Michael R Law
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine (Lavergne, Law, Peterson, Cheng, McGrail), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC; Department of Family Medicine (Garrison), University of Alberta, Edmonton, Alta.; Department of Economics (Hurley), McMaster University, Hamilton, Ont
| | - Sandra Peterson
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine (Lavergne, Law, Peterson, Cheng, McGrail), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC; Department of Family Medicine (Garrison), University of Alberta, Edmonton, Alta.; Department of Economics (Hurley), McMaster University, Hamilton, Ont
| | - Scott Garrison
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine (Lavergne, Law, Peterson, Cheng, McGrail), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC; Department of Family Medicine (Garrison), University of Alberta, Edmonton, Alta.; Department of Economics (Hurley), McMaster University, Hamilton, Ont
| | - Jeremiah Hurley
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine (Lavergne, Law, Peterson, Cheng, McGrail), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC; Department of Family Medicine (Garrison), University of Alberta, Edmonton, Alta.; Department of Economics (Hurley), McMaster University, Hamilton, Ont
| | - Lucy Cheng
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine (Lavergne, Law, Peterson, Cheng, McGrail), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC; Department of Family Medicine (Garrison), University of Alberta, Edmonton, Alta.; Department of Economics (Hurley), McMaster University, Hamilton, Ont
| | - Kimberlyn McGrail
- Centre for Health Services and Policy Research, School of Population and Public Health, Faculty of Medicine (Lavergne, Law, Peterson, Cheng, McGrail), University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC; Department of Family Medicine (Garrison), University of Alberta, Edmonton, Alta.; Department of Economics (Hurley), McMaster University, Hamilton, Ont
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Asthana S, Gibson A, Bailey T, Moon G, Hewson P, Dibben C. Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04140] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BackgroundA strong policy emphasis on the need to reduce both health inequalities and unmet need in deprived areas has resulted in the substantial redistribution of English NHS funding towards deprived areas. This raises the question of whether or not socioeconomically disadvantaged people continue to be disadvantaged in their access to and utilisation of health care.ObjectivesTo generate estimates of the prevalence of cardiovascular disease (CVD) and common mental health disorders (CMHDs) at a variety of scales, and to make these available for public use via Public Health England (PHE). To compare these estimates with utilisation of NHS services in England to establish whether inequalities of use relative to need at various stages on the health-care pathway are associated with particular sociodemographic or other factors.DesignCross-sectional analysis of practice-, primary care trust- and Clinical Commissioning Group-level variations in diagnosis, prescribing and specialist management of CVD and CMHDs relative to the estimated prevalence of those conditions (calculated using small-area estimation).ResultsThe utilisation of CVD care appears more equitable than the utilisation of care for CMHDs. In contrast to the reviewed literature, we found little evidence of underutilisation of services by older populations. Indeed, younger populations appear to be less likely to access care for some CVD conditions. Nor did deprivation emerge as a consistent predictor of lower use relative to need for either CVD or CMHDs. Ethnicity is a consistent predictor of variations in use relative to need. Rates of primary management are lower than expected in areas with higher percentages of black populations for diabetes, stroke and CMHDs. Areas with higher Asian populations have higher-than-expected rates of diabetes presentation and prescribing and lower-than-expected rates of secondary care for diabetes. For both sets of conditions, there are pronounced geographical variations in use relative to need. For instance, the North East has relatively high levels of use of cardiac care services and rural (shire) areas have low levels of use relative to need. For CMHDs, there appears to be a pronounced ‘London effect’, with the number of people registered by general practitioners as having depression, or being prescribed antidepressants, being much lower in London than expected. A total of 24 CVD and 41 CMHD prevalence estimates have been provided to PHE and will be publicly available at a range of scales, from lower- and middle-layer super output areas through to Clinical Commissioning Groups and local authorities.ConclusionsWe found little evidence of socioeconomic inequality in use for CVD and CMHDs relative to underlying need, which suggests that the strong targeting of NHS resources to deprived areas may well have addressed longstanding concerns about unmet need. However, ethnicity has emerged as a significant predictor of inequality, and there are large and unexplained geographical variations in use relative to need for both conditions which undermine the principle of equal access to health care for equal needs. The persistence of ethnic variations and the role of systematic factors (such as rurality) in shaping patterns of utilisation deserve further investigation, as does the fact that the models were far better at explaining variation in use of CVD than mental health services.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Sheena Asthana
- School of Government, University of Plymouth, Plymouth, UK
| | - Alex Gibson
- School of Government, University of Plymouth, Plymouth, UK
| | - Trevor Bailey
- College of Mathematics and Physical Sciences, University of Exeter, Exeter, UK
| | - Graham Moon
- School of Geography and the Environment, University of Southampton, Southampton, UK
| | - Paul Hewson
- School of Computing and Mathematics, University of Plymouth, Plymouth, UK
| | - Chris Dibben
- School of Geosciences, University of Edinburgh, Edinburgh, UK
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McKay AJ, Newson RB, Soljak M, Riboli E, Car J, Majeed A. Are primary care factors associated with hospital episodes for adverse drug reactions? A national observational study. BMJ Open 2015; 5:e008130. [PMID: 26715478 PMCID: PMC4710827 DOI: 10.1136/bmjopen-2015-008130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Revised: 09/15/2015] [Accepted: 10/20/2015] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Identification of primary care factors associated with hospital admissions for adverse drug reactions (ADRs). DESIGN AND SETTING Cross-sectional analysis of 2010-2012 data from all National Health Service hospitals and 7664 of 8358 general practices in England. METHOD We identified all hospital episodes with an International Classification of Diseases (ICD) 10 code indicative of an ADR, in the 2010-2012 English Hospital Episode Statistics (HES) admissions database. These episodes were linked to contemporary data describing the associated general practice, including general practitioner (GP) and patient demographics, an estimate of overall patient population morbidity, measures of primary care supply, and Quality and Outcomes Framework (QOF) quality scores. Poisson regression models were used to examine associations between primary care factors and ADR-related episode rates. RESULTS 212,813 ADR-related HES episodes were identified. Rates of episodes were relatively high among the very young, older and female subgroups. In fully adjusted models, the following primary care factors were associated with increased likelihood of episode: higher deprivation scores (population attributable fraction (PAF)=0.084, 95% CI 0.067 to 0.100) and relatively poor glycated haemoglobin (HbA1c) control among patients with diabetes (PAF=0.372; 0.218 to 0.496). The following were associated with reduced episode likelihood: lower GP supply (PAF=-0.016; -0.026 to -0.005), a lower proportion of GPs with UK qualifications (PAF=-0.035; -0.058 to -0.012), lower total QOF achievement rates (PAF=-0.021; -0.042 to 0.000) and relatively poor blood pressure control among patients with diabetes (PAF=-0.144; -0.280 to -0.022). CONCLUSIONS Various aspects of primary care are associated with ADR-related hospital episodes, including achievement of particular QOF indicators. Further investigation with individual level data would help develop understanding of the associations identified. Interventions in primary care could help reduce the ADR burden. ADRs are candidates for primary care sensitive conditions.
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Affiliation(s)
- Ailsa J McKay
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Roger B Newson
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Michael Soljak
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Elio Riboli
- School of Public Health, Imperial College London, London, UK
| | - Josip Car
- Department of Primary Care and Public Health, Imperial College London, London, UK Department of LKCMedicine, Imperial College London-Nanyang Technological University, Singapore, Singapore
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Kontopantelis E, Springate DA, Ashcroft DM, Valderas JM, van der Veer SN, Reeves D, Guthrie B, Doran T. Associations between exemption and survival outcomes in the UK's primary care pay-for-performance programme: a retrospective cohort study. BMJ Qual Saf 2015; 25:657-70. [PMID: 26628553 PMCID: PMC5013124 DOI: 10.1136/bmjqs-2015-004602] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/01/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The UK's Quality and Outcomes Framework permits practices to exempt patients from financially-incentivised performance targets. To better understand the determinants and consequences of being exempted from the framework, we investigated the associations between exception reporting, patient characteristics and mortality. We also quantified the proportion of exempted patients that met quality targets for a tracer condition (diabetes). DESIGN Retrospective longitudinal study, using individual patient data from the Clinical Practice Research Datalink. SETTING 644 general practices, 2006/7 to 2011/12. PARTICIPANTS Patients registered with study practices for at least one year over the study period, with at least one condition of interest (2 460 341 in total). MAIN OUTCOME MEASURES Exception reporting rates by reason (clinical contraindication, patient dissent); all-cause mortality in year following exemption. Analyses with logistic and Cox proportional-hazards regressions, respectively. RESULTS The odds of being exempted increased with age, deprivation and multimorbidity. Men were more likely to be exempted but this was largely attributable to higher prevalence of conditions with high exemption rates. Modest associations remained, with women more likely to be exempted due to clinical contraindication (OR 0.90, 99% CI 0.88 to 0.92) and men more likely to be exempted due to informed dissent (OR 1.08, 99% CI 1.06 to 1.10). More deprived areas (both for practice location and patient residence) were non-linearly associated with higher exception rates, after controlling for comorbidities and other covariates, with stronger associations for clinical contraindication. Compared with patients with a single condition, odds ratios for patients with two, three, or four or more conditions were respectively 4.28 (99% CI 4.18 to 4.38), 16.32 (99% CI 15.82 to 16.83) and 68.69 (99% CI 66.12 to 71.37) for contraindication, and 2.68 (99% CI 2.63 to 2.74), 4.02 (99% CI 3.91 to 4.13) and 5.17 (99% CI 5.00 to 5.35) for informed dissent. Exempted patients had a higher adjusted risk of death in the following year than non-exempted patients, regardless of whether this exemption was for contraindication (hazard ratio 1.37, 99% CI 1.33 to 1.40) or for informed dissent (1.20, 99% CI 1.17 to 1.24). On average, quality standards were met for 48% of exempted patients in the diabetes domain, but there was wide variation across indicators (ranging from 8 to 80%). CONCLUSIONS Older, multimorbid and more deprived patients are more likely to be exempted from the scheme. Exception reported patients are more likely to die in the following year, whether they are exempted by the practice for a contraindication or by themselves through informed dissent. Further research is needed to understand the relationship between exception reporting and patient outcomes.
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Affiliation(s)
- Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - David A Springate
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, Uk
| | - Jose M Valderas
- Patient Centred Care, APEx Collaboration for Academic Primary Care, Medical School, University of Exeter, Exeter, UK
| | - Sabine N van der Veer
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - David Reeves
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, Uk
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
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Physical health indicators in major mental illness: analysis of QOF data across UK general practice. Br J Gen Pract 2015; 64:e649-56. [PMID: 25267051 DOI: 10.3399/bjgp14x681829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The Quality and Outcomes Framework (QOF) has specific targets for body mass index (BMI) and blood pressure recording in major mental illness (MMI), diabetes, and chronic kidney disease (CKD). Although aspects of MMI (schizophrenia, bipolar disorder, and related psychoses) are incentivised, barriers to care may occur. AIM To compare payment, population achievement, and exception rates for blood pressure and BMI recording in MMI relative to diabetes and CKD across the UK. DESIGN AND SETTING Analysis of 2012/2013 QOF data from 9731 UK general practices 2 years after the introduction of the mental health, BMI, and blood pressure QOF indicators. METHOD Payment, exception, and population achievement rates for the MMI and CKD blood pressure indicators and the MMI and diabetes BMI indicators were calculated and compared. RESULTS UK payment and population achievement rates for BMI recording for MMI were significantly lower than for diabetes (payment: 92.7% versus 95.5% and population achievement: 84.0% versus 92.5%, P<0.001) and exception rates were higher (8.1% versus 2.0%, P<0.001). For blood pressure recording, UK payment and population achievement rates were significantly lower for MMI than for CKD (94.1% versus 97.8% and 87.0% versus 97.1%, P<0.001), while exception rate was higher (6.5% versus 0.0%, P<0.001). This was observed for all countries. Compared with England, Northern Ireland had higher population achievement rates for both mental health indicators, whereas Scotland and Wales had lower rates. There were no cross-jurisdiction differences for CKD and diabetes. CONCLUSION Differences in payment, exception, and population achievement rates for blood pressure and BMI recording for MMI relative to CKD and diabetes were observed across the UK. These findings suggest potential inequalities in the monitoring of physical health in MMI within the UK primary care system.
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Gillani SMR, Aziz U, Blundell D, Singh BM. Non elective re-admissions to an acute hospital in people with diabetes: Causes and the potential for avoidance. The WICKED project. Prim Care Diabetes 2015; 9:392-396. [PMID: 25681992 DOI: 10.1016/j.pcd.2015.01.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Revised: 01/05/2015] [Accepted: 01/19/2015] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Managing people with diabetes is a health priority worldwide. Cost benefit attempts at avoiding non elective admissions (NEA) have had some success. To develop an NEA avoidance service, we audited multiple NEA in those with diabetes. METHOD All people with diabetes who had ≥3 NEA to our hospital over 12 months were identified (n=418); 104 (1 in 4) patients were randomly selected and retrospective data collected in 98 subjects on their index (latest, 3rd) admission. RESULTS Of 98 subjects (50 males, 60 Caucasians, 86 type 2 diabetes, aged 69±16 years).Conditions contributing to admission included: Significant co-morbidities in 95 patients (≥2 in 57, ≥4 in 24). Only 14 admission were directly due to diabetes: hypoglycaemia (5); hyperglycaemia (6); DKA (2), Infected foot ulcer (1).97 admissions were justified at the time of presentation. However whilst 78 were unavoidable, 19 were deemed avoidable amongst whom 10 were diabetes related. CONCLUSION The majority of re-admissions were due to multi-morbidity and were often non-diabetes related. The concept of avoidability must be distinguished from point justification at the time of acute need. This would allow the prospective identification of high risk patients and requires an integrated working process to avoid NEA.
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Affiliation(s)
- Syed M R Gillani
- Lea Road Medical Practice, Wolverhampton, UK; Diabetes Centre, New Cross Hospital, Wolverhampton, UK.
| | - Umaira Aziz
- Diabetes Centre, New Cross Hospital, Wolverhampton, UK
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Dusheiko M, Gravelle H, Martin S, Smith PC. Quality of Disease Management and Risk of Mortality in English Primary Care Practices. Health Serv Res 2015; 50:1452-71. [PMID: 25597263 PMCID: PMC4600356 DOI: 10.1111/1475-6773.12283] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To investigate whether better management of chronic conditions by family practices reduces mortality risk. DATA Two random samples of 5 million patients registered with over 8,000 English family practices followed up for 4 years (2004/5-2007/8). Measures of the quality of disease management for 10 conditions were constructed for each family practice for each year. The outcome measure was an indicator taking the value 1 if the patient died during a specified year, 0 otherwise. STUDY DESIGN Cross-section and multilevel panel data multiple logistic regressions were estimated. Covariates included age, gender, morbidity, hospitalizations, attributed socio-economic characteristics, and local health care supply measures. PRINCIPAL FINDINGS Although a composite measure of the quality of disease management for all 10 conditions was significantly associated with lower mortality, only the quality of stroke care was significant when all 10 quality measures were entered in the regression. CONCLUSIONS The panel data results suggest that a 1 percent improvement in the quality of stroke care could reduce the annual number of deaths in England by 782 [95 percent CI: 423, 1140]. A longer study period may be necessary to detect any mortality impact of better management of other conditions.
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Affiliation(s)
- Mark Dusheiko
- Centre for Health Economics, University of York, York, UK
- Institut d'économie et management de la santé, Internef Bureau 532 Université de Lausanne, Lausanne, Switzerland
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Stephen Martin
- Department of Economics and Related Studies, University of York, York, UK
| | - Peter C Smith
- Imperial College Business School, Imperial College, London, UK
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Busby J, Purdy S, Hollingworth W. A systematic review of the magnitude and cause of geographic variation in unplanned hospital admission rates and length of stay for ambulatory care sensitive conditions. BMC Health Serv Res 2015; 15:324. [PMID: 26268576 PMCID: PMC4535775 DOI: 10.1186/s12913-015-0964-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Accepted: 07/16/2015] [Indexed: 12/03/2022] Open
Abstract
Background Unplanned hospital admissions place a large and increasing strain on healthcare budgets worldwide. Many admissions for ambulatory care sensitive conditions (ACSCs) are thought to be preventable, a belief supported by significant geographic variations in admission rates. We conducted a systematic review of the evidence on the magnitude and correlates of geographic variation in ACSC admission rates and length of stay (LOS). Methods We performed a search of Medline and Embase databases for English language cross-sectional and cohort studies on 28th March 2013 reporting geographic variation in admission rates or LOS for patients receiving unplanned care across at least 10 geographical units for one of 35 previously defined ACSCs. Forward and backward citation searches were undertaken on all included studies. We provide a narrative synthesis of study findings. Study quality was assessed using a modified Newcastle-Ottawa scale. Results We included 39 studies comprising 25 on admission rates and 14 on LOS. Studies generally compared admission rates between regions (e.g. states) and LOS between hospitals. Most of the published research was undertaken in the US, UK or Canada and often focussed on patients with pneumonia, COPD or heart failure. 35 (90 %) studies concluded that geographic variation was present. Primary care quality and secondary care access were frequently suggested as drivers of admission rate variation whilst secondary care quality and adherence to clinical guidelines were often listed as contributors to LOS variation. Several different methods were used to quantify variation, some studies listed raw data, failed to control for confounders and used naive statistical methods which limited their utility. Conclusions The substantial geographical variations in the admission rates and LOS of potentially avoidable conditions could be a symptom of variable quality of care and should be a concern for clinicians and policymakers. Policymakers targeting a reduction in unplanned admissions could introduce initiatives to improve primary care access and quality or develop alternatives to admission. Those attempting to curb unnecessarily long LOS could introduce care pathways or guidelines. Methodological work on the quantification and reporting of geographic variation is needed to aid inter-study comparisons. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-0964-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- John Busby
- School of Social and Community Medicine, University of Bristol, Room 2.07, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Sarah Purdy
- Professor of Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - William Hollingworth
- Professor of Health Economics, School of Social and Community Medicine, University of Bristol, Bristol, UK
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Abstract
CONTEXT In its fee-for-service funding model for primary care, British Columbia, Canada, introduced incentive payments to general practitioners as pay for performance for providing enhanced, guidelines-based care to patients with chronic conditions. Evaluation of the program was conducted at the health care system level. OBJECTIVE To examine the impact of the incentive payments on annual health care costs and hospital utilization patterns in British Columbia. DESIGN The study used Ministry of Health administrative data for Fiscal Year 2010-2011 for patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and/or hypertension. In each disease group, cost and utilization were compared across patients who did, and did not, receive incentive-based care. MAIN OUTCOME MEASURES Health care costs (eg, primary care, hospital) and utilization measures (eg, hospital days, readmissions). RESULTS After controlling for patients' age, sex, service needs level, and continuity of care (defined as attachment to a general practice), the incentives reduced the net annual health care costs, in Canadian dollars, for patients with hypertension (by approximately Can$308 per patient), chronic obstructive pulmonary disease (by Can$496), and congestive heart failure (by Can$96), but not diabetes (incentives cost about Can$148 more per patient). The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups. CONCLUSION Although the available literature on pay for performance shows mixed results, we showed that the funding model used in British Columbia using incentive payments for primary care might reduce health care costs and hospital utilization.
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Affiliation(s)
- Marcus J Hollander
- The President of Hollander Analytical Services, Ltd, in Victoria, British Columbia, Canada.
| | - Helena Kadlec
- The Senior Scientist for Hollander Analytical Services, Ltd, in Victoria, British Columbia, Canada.
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del Saz Moreno V, Alberquilla Menéndez-Asenjo Á, Camacho Hernández AM, Lora Pablos D, Enríquez de Salamanca Lorente R, Magán Tapia P. [Analysis of the influence of the process of care in primary health care on avoidable hospitalizations for heart failure]. Aten Primaria 2015; 48:102-9. [PMID: 26087663 PMCID: PMC6877841 DOI: 10.1016/j.aprim.2014.11.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2014] [Revised: 11/05/2014] [Accepted: 11/10/2014] [Indexed: 12/27/2022] Open
Abstract
Objetivo Comprobar si el proceso asistencial en Atención Primaria de Salud (APS), definido por 7 criterios de correcta atención, influye en el riesgo de hospitalizaciones evitables por Ambulatory Care Sensitive Conditions (ACSH) por insuficiencia cardíaca (IC). Diseño Estudio de casos y controles que analizó el riesgo de hospitalización por IC. Factor de exposición: proceso asistencial de APS. Emplazamiento Área sanitaria de la Comunidad de Madrid (n = 466.901). Participantes Pacientes mayores de 14 años con el registro del diagnóstico de IC en la historia clínica electrónica de APS (n = 3.277) antes del 1 de enero de 2007. Los casos fueron pacientes que ingresaron en el hospital de referencia por IC durante 2007. Los controles no requirieron ingreso. Mediciones principales Riesgo de ACSH por IC relacionado con el proceso asistencial considerado tanto de forma conjunta como por cada uno de los criterios. Diferencias en complejidad clínica mediante Adjusted Clinical Group (ACG). Resultados Doscientos veintisiete ingresos por IC frente a un grupo control de 3.050 pacientes. El peso medio de ACG fue mayor en los casos. Los controles tuvieron mayor cumplimentación de criterios, pero ninguno cumplió los 7. Solo en 2 de los criterios se observó menor riesgo de ACSH. A medida que no se cumplimentaba progresivamente cada criterio, el riesgo de ingresar aumentó (OR = 1,33; IC 95%: 1,19-1,49). Conclusión La calidad del proceso asistencial en APS influyó en el riesgo de ingreso por IC.
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Affiliation(s)
| | - Ángel Alberquilla Menéndez-Asenjo
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Unidad Docente Multiprofesional de Atención Familiar y Comunitaria, Dirección Asistencial Centro, Madrid, España
| | - Ana M Camacho Hernández
- Dirección General de Sistemas de Información, Unidad Sistemas de Información de Atención Primaria, Madrid, España
| | - David Lora Pablos
- Unidad de Investigación Clínica (imas12-CIBERESP), Hospital Universitario 12 de Octubre, Madrid, España
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Gutacker N, Mason AR, Kendrick T, Goddard M, Gravelle H, Gilbody S, Aylott L, Wainwright J, Jacobs R. Does the quality and outcomes framework reduce psychiatric admissions in people with serious mental illness? A regression analysis. BMJ Open 2015; 5:e007342. [PMID: 25897027 PMCID: PMC4410123 DOI: 10.1136/bmjopen-2014-007342] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND The Quality and Outcomes Framework (QOF) incentivises general practices in England to provide proactive care for people with serious mental illness (SMI) including schizophrenia, bipolar disorder and other psychoses. Better proactive primary care may reduce the risk of psychiatric admissions to hospital, but this has never been tested empirically. METHODS The QOF data set included 8234 general practices in England from 2006/2007 to 2010/2011. Rates of hospital admissions with primary diagnoses of SMI or bipolar disorder were estimated from national routine hospital data and aggregated to practice level. Poisson regression was used to analyse associations. RESULTS Practices with higher achievement on the annual review for SMI patients (MH9), or that performed better on either of the two lithium indicators for bipolar patients (MH4 or MH5), had more psychiatric admissions. An additional 1% in achievement rates for MH9 was associated with an average increase in the annual practice admission rate of 0.19% (95% CI 0.10% to 0.28%) or 0.007 patients (95% CI 0.003 to 0.01). CONCLUSIONS The positive association was contrary to expectation, but there are several possible explanations: better quality primary care may identify unmet need for secondary care; higher QOF achievement may not prevent the need for secondary care; individuals may receive their QOF checks postdischarge rather than prior to admission; individuals with more severe SMI may be more likely to be registered with practices with better QOF performance; and QOF may be a poor measure of the quality of care for people with SMI.
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Affiliation(s)
- Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Anne R Mason
- Centre for Health Economics, University of York, York, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | | | | | - Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
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Jacobs R, Gutacker N, Mason A, Goddard M, Gravelle H, Kendrick T, Gilbody S, Aylott L, Wainwright J. Do higher primary care practice performance scores predict lower rates of emergency admissions for persons with serious mental illness? An analysis of secondary panel data. HEALTH SERVICES AND DELIVERY RESEARCH 2015. [DOI: 10.3310/hsdr03160] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundSerious mental illness (SMI) is a set of chronic enduring conditions including schizophrenia and bipolar disorder. SMIs are associated with poor outcomes, high costs and high levels of disease burden. Primary care plays a central role in the care of people with a SMI in the English NHS. Good-quality primary care has the potential to reduce emergency hospital admissions, but also to increase elective admissions if physical health problems are identified by regular health screening of people with SMIs. Better-quality primary care may reduce length of stay (LOS) by enabling quicker discharge, and it may also reduce NHS expenditure.ObjectivesWe tested whether or not better-quality primary care, as assessed by the SMI quality indicators measured routinely in the Quality and Outcomes Framework (QOF) in English general practice, is associated with lower rates of emergency hospital admissions for people with SMIs, for both mental and physical conditions and with higher rates of elective admissions for physical conditions in people with a SMI. We also tested the impact of SMI QOF indicators on LOS and costs.DataWe linked administrative data from around 8500 general practitioner (GP) practices and from Hospital Episode Statistics for the study period 2006/7 to 2010/11. We identified SMI admissions by a mainInternational Classification of Diseases, 10th revision (ICD-10) diagnosis of F20–F31. We included information on GP practice and patient population characteristics, area deprivation and other potential confounders such as access to care. Analyses were carried out at a GP practice level for admissions, but at a patient level for LOS and cost analyses.MethodsWe ran mixed-effects count data and linear models taking account of the nested structure of the data. All models included year indicators for temporal trends.ResultsContrary to expectation, we found a positive association between QOF achievement and admissions, for emergency admissions for both mental and physical health. An additional 10% in QOF achievement was associated with an increase in the practice emergency SMI admission rate of approximately 1.9%. There was no significant association of QOF achievement with either LOS or cost. All results were robust to sensitivity analyses.ConclusionsPossible explanations for our findings are (1) higher quality of primary care, as measured by QOF may not effectively prevent the need for secondary care; (2) patients may receive their QOF checks post discharge, rather than prior to admission; (3) people with more severe SMIs, at a greater risk of admission, may select into practices that are better organised to provide their care and which have better QOF performance; (4) better-quality primary care may be picking up unmet need for secondary care; and (5) QOF measures may not accurately reflect quality of primary care. Patient-level data on quality of care in general practice is required to determine the reasons for the positive association of QOF quality and admissions. Future research should also aim to identify the non-QOF measures of primary care quality that may reduce unplanned admissions more effectively and could potentially be incentivised.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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Kasteridis P, Mason AR, Goddard MK, Jacobs R, Santos R, McGonigal G. The influence of primary care quality on hospital admissions for people with dementia in England: a regression analysis. PLoS One 2015; 10:e0121506. [PMID: 25816231 PMCID: PMC4376688 DOI: 10.1371/journal.pone.0121506] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 02/01/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To test the impact of a UK pay-for-performance indicator, the Quality and Outcomes Framework (QOF) dementia review, on three types of hospital admission for people with dementia: emergency admissions where dementia was the primary diagnosis; emergency admissions for ambulatory care sensitive conditions (ACSCs); and elective admissions for cataract, hip replacement, hernia, prostate disease, or hearing loss. METHODS Count data regression analyses of hospital admissions from 8,304 English general practices from 2006/7 to 2010/11. We identified relevant admissions from national Hospital Episode Statistics and aggregated them to practice level. We merged these with practice-level data on the QOF dementia review. In the base case, the exposure measure was the reported QOF register. As dementia is commonly under-diagnosed, we tested a predicted practice register based on consensus estimates. We adjusted for practice characteristics including measures of deprivation and uptake of a social benefit to purchase care services (Attendance Allowance). RESULTS In the base case analysis, higher QOF achievement had no significant effect on any type of hospital admission. However, when the predicted register was used to account for under-diagnosis, a one-percentage point improvement in QOF achievement was associated with a small reduction in emergency admissions for both dementia (-0.1%; P=0.011) and ACSCs (-0.1%; P=0.001). In areas of greater deprivation, uptake of Attendance Allowance was consistently associated with significantly lower emergency admissions. In all analyses, practices with a higher proportion of nursing home patients had significantly lower admission rates for elective and emergency care. CONCLUSION In one of three analyses at practice level, the QOF review for dementia was associated with a small but significant reduction in unplanned hospital admissions. Given the rising prevalence of dementia, increasing pressures on acute hospital beds and poor outcomes associated with hospital stays for this patient group, this small change may be clinically and economically relevant.
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Affiliation(s)
| | - Anne R Mason
- Centre for Health Economics, University of York, York, United Kingdom
| | - Maria K Goddard
- Centre for Health Economics, University of York, York, United Kingdom
| | - Rowena Jacobs
- Centre for Health Economics, University of York, York, United Kingdom
| | - Rita Santos
- Centre for Health Economics, University of York, York, United Kingdom
| | - Gerard McGonigal
- Department of Medicine for the Elderly, York Teaching Hospital NHS Foundation Trust, York, United Kingdom
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Kontopantelis E, Springate DA, Ashworth M, Webb RT, Buchan IE, Doran T. Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study. BMJ 2015; 350:h904. [PMID: 25733592 PMCID: PMC4353289 DOI: 10.1136/bmj.h904] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework. DESIGN Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA). SETTING 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012. PARTICIPANTS 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care. INTERVENTION National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators. MAIN OUTCOME MEASURES All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality. RESULTS All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality. CONCLUSIONS Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.
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Affiliation(s)
- Evangelos Kontopantelis
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester
| | - David A Springate
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester Centre for Biostatistics, Institute of Population Health, University of Manchester
| | - Mark Ashworth
- Primary Care and Public Health Sciences, King's College London, London, UK
| | - Roger T Webb
- Centre for Mental Health and Risk, University of Manchester
| | - Iain E Buchan
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
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Feng Y, Ma A, Farrar S, Sutton M. The tougher the better: an economic analysis of increased payment thresholds on the performance of general practices. HEALTH ECONOMICS 2015; 24:353-371. [PMID: 24391074 DOI: 10.1002/hec.3022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 08/14/2013] [Accepted: 11/12/2013] [Indexed: 06/03/2023]
Abstract
We investigate whether and how a change in performance-related payment motivated General Practitioners (GPs) in Scotland. We evaluate the effect of increases in the performance thresholds required for maximum payment under the Quality and Outcomes Framework in April 2006. A difference-in-differences estimator with fixed effects was employed to examine the number of patients treated under clinical indicators whose payment schedules were revised and to compare these with the figures for those indicators whose schedules remained unchanged. The results suggest that the increase in the maximum performance thresholds increased GPs' performance by 1.77% on average. Low-performing GPs improved significantly more (13.22%) than their high-performing counterparts (0.24%). Changes to maximum performance thresholds are differentially effective in incentivising GPs and could be used further to raise GPs' performance across all indicators.
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Affiliation(s)
- Yan Feng
- Office of Health Economics, London, UK
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Harrison MJ, Dusheiko M, Sutton M, Gravelle H, Doran T, Roland M. Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study. BMJ 2014; 349:g6423. [PMID: 25389120 PMCID: PMC4228282 DOI: 10.1136/bmj.g6423] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
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.
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Affiliation(s)
- Mark J Harrison
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, UK Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada Centre for Health Evaluation and Outcome Sciences, St Paul's Hospital, Vancouver, BC, Canada
| | - Mark Dusheiko
- Centre for Health Economics, University of York, York, UK Institute for Health Economics and Management, University of Lausanne, Lausanne, Switzerland
| | - Matt Sutton
- Manchester Centre for Health Economics, Institute of Population Health, University of Manchester, UK
| | - Hugh Gravelle
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Tim Doran
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, BC, Canada
| | - Martin Roland
- Cambridge Centre for Health Services Research, University of Cambridge, Forvie Site, Robinson Way, Cambridge, CB2 0SR, UK
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MacCarthy D, Hollander MJ. RISQy business (Relationships, Incentives, Supports, and Quality): evolution of the British Columbia Model of Primary Care (patient-centered medical home). Perm J 2014; 18:43-8. [PMID: 24867550 DOI: 10.7812/tpp/13-083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In 2002, the British Columbia Ministry of Health and the British Columbia Medical Association (now Doctors of BC) came together to form the British Columbia General Practice Services Committee to bring about transformative change in primary care in British Columbia, Canada. This committee's approach to primary care was to respond to an operational problem--the decline of family practice in British Columbia--with an operational solution--assist general practitioners to provide better care by introducing new incentive fees into the fee-for-service payment schedule, and by providing additional training to general practitioners. This may be referred to as a "soft power" approach, which can be summarized in the abbreviation RISQ: focus on Relationships; provide Incentives for general practitioners to spend more time with their patients and provide guidelines-based care; Support general practitioners by developing learning modules to improve their practices; and, through the incentive payments and learning modules, provide better Quality care to patients and improved satisfaction to physicians. There are many similarities between the British Columbian approach to primary care and the US patient-centered medical home.
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Affiliation(s)
- Dan MacCarthy
- Medical Advisor for Practice Support and Quality, Doctors of BC, formerly the British Columbia Medical Association, in Vancouver, British Columbia, Canada. He was actively involved in the development, implementation, and ongoing work for the General Practice Services Committee.
| | - Marcus J Hollander
- President of Hollander Analytical Services, Ltd, in Victoria, British Columbia, Canada.
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Spatio-temporal variation and prediction of ischemic heart disease hospitalizations in Shenzhen, China. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2014; 11:4799-824. [PMID: 24806191 PMCID: PMC4053872 DOI: 10.3390/ijerph110504799] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/11/2014] [Revised: 04/28/2014] [Accepted: 04/29/2014] [Indexed: 01/09/2023]
Abstract
Ischemic heart disease (IHD) is a leading cause of death worldwide. Urban public health and medical management in Shenzhen, an international city in the developing country of China, is challenged by an increasing burden of IHD. This study analyzed the spatio-temporal variation of IHD hospital admissions from 2003 to 2012 utilizing spatial statistics, spatial analysis, and space-time scan statistics. The spatial statistics and spatial analysis measured the incidence rate (hospital admissions per 1,000 residents) and the standardized rate (the observed cases standardized by the expected cases) of IHD at the district level to determine the spatio-temporal distribution and identify patterns of change. The space-time scan statistics was used to identify spatio-temporal clusters of IHD hospital admissions at the district level. The other objective of this study was to forecast the IHD hospital admissions over the next three years (2013–2015) to predict the IHD incidence rates and the varying burdens of IHD-related medical services among the districts in Shenzhen. The results show that the highest hospital admissions, incidence rates, and standardized rates of IHD are in Futian. From 2003 to 2012, the IHD hospital admissions exhibited similar mean centers and directional distributions, with a slight increase in admissions toward the north in accordance with the movement of the total population. The incidence rates of IHD exhibited a gradual increase from 2003 to 2012 for all districts in Shenzhen, which may be the result of the rapid development of the economy and the increasing traffic pollution. In addition, some neighboring areas exhibited similar temporal change patterns, which were also detected by the spatio-temporal cluster analysis. Futian and Dapeng would have the highest and the lowest hospital admissions, respectively, although these districts have the highest incidence rates among all of the districts from 2013 to 2015 based on the prediction using the GM (1,1). In addition, the combined analysis of the prediction of IHD hospital admissions and the general hospital distributions shows that Pingshan and Longgang might experience the most serious burden of IHD hospital services in the near future, although Futian would still have the greatest number and the highest incidence rate of hospital admissions for IHD.
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Honeyford K, Baker R, Bankart MJG, Jones D. Modelling factors in primary care quality improvement: a cross-sectional study of premature CHD mortality. BMJ Open 2013; 3:e003391. [PMID: 24154516 PMCID: PMC3808822 DOI: 10.1136/bmjopen-2013-003391] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To identify features of primary care quality improvement associated with improved health outcomes using premature coronary heart disease (CHD) mortality as an example, and to determine impacts of different modelling approaches. DESIGN Cross-sectional study of mortality rates in 229 general practices. SETTING General practices from three East Midlands primary care trusts. PARTICIPANTS Patients registered to the practices above between April 2006 and March 2009. MAIN OUTCOME MEASURES Numbers of CHD deaths in those aged under 75 (premature mortality) and at all ages in each practice. RESULTS Population characteristics and markers of quality of primary care were associated with variations in premature CHD mortality. Increasing levels of deprivation, percentages of practice populations on practice diabetes registers, white, over 65 and male were all associated with increasing levels of premature CHD mortality. Control of serum cholesterol levels in those with CHD and the percentage of patients recalling access to their preferred general practitioner were both associated with decreased levels of premature CHD mortality. Similar results were found for all-age mortality. A combined measure of quality of primary care for CHD comprising 12 quality outcomes framework indicators was associated with decreases in both all-age and premature CHD mortality. The selected models suggest that practices in less deprived areas may have up to 20% lower premature CHD mortality than those with median deprivation and that improvement in the CHD care quality from 83% (lower quartile) to 86% (median) could reduce premature CHD mortality by 3.6%. Different modelling approaches yielded qualitatively similar results. CONCLUSIONS High-quality primary care, including aspects of access to and continuity of care, detection and management, appears to be associated with reducing CHD mortality. The impact on premature CHD mortality is greater than on all-age CHD mortality. Determining the most useful measures of quality of primary care needs further consideration.
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Affiliation(s)
- Kate Honeyford
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - M John G Bankart
- Insitute of Primary Care and Health Sciences, Keele University, Keele, UK
| | - David Jones
- Department of Health Sciences, University of Leicester, Leicester, UK
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Freund T, Campbell SM, Geissler S, Kunz CU, Mahler C, Peters-Klimm F, Szecsenyi J. Strategies for reducing potentially avoidable hospitalizations for ambulatory care-sensitive conditions. Ann Fam Med 2013; 11:363-70. [PMID: 23835823 PMCID: PMC3704497 DOI: 10.1370/afm.1498] [Citation(s) in RCA: 114] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2012] [Revised: 10/04/2012] [Accepted: 10/25/2012] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Hospitalizations for ambulatory care-sensitive conditions (ACSCs) are seen as potentially avoidable with optimal primary care. Little is known, however, about how primary care physicians rate these hospitalizations and whether and how they could be avoided. This study explores the complex causality of such hospitalizations from the perspective of primary care physicians. METHODS We conducted semistructured interviews with 12 primary care physicians from 10 primary care clinics in Germany regarding 104 hospitalizations of 81 patients with ACSCs at high risk of rehospitalization. RESULTS Participating physicians rated 43 (41%) of the 104 hospitalizations to be potentially avoidable. During the interviews the cause of hospitalization fell into 5 principal categories: system related (eg, unavailability of ambulatory services), physician related (eg, suboptimal monitoring), medical (eg, medication side effects), patient related (eg, delayed help-seeking), and social (eg, lack of social support). Subcategories frequently associated with physicians' rating of hospitalizations for ACSCs as potentially avoidable were after-hours absence of the treating physician, failure to use ambulatory services, suboptimal monitoring, patients' fearfulness, cultural background and insufficient language skills of patients, medication errors, medication nonadherence, and overprotective caregivers. Comorbidities and medical emergencies were frequent causes attributed to ACSC-based hospitalizations that were rated as being unavoidable. CONCLUSIONS Primary care physicians rated a significant proportion of hospitalizations for ACSCs to be potentially avoidable. Strategies to avoid these hospitalizations may target after-hours care, optimal use of ambulatory services, intensified monitoring of high-risk patients, and initiatives to improve patients' willingness and ability to seek timely help, as well as patients' medication adherence.
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Affiliation(s)
- Tobias Freund
- Department of General Practice and Health Services Research, University Hospital Heidelberg, Heidelberg, Germany.
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Harris M. Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework. Rev Saude Publica 2012; 46:577-82. [DOI: 10.1590/s0034-89102012005000032] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 12/13/2011] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.
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Doran T, Kontopantelis E, Fullwood C, Lester H, Valderas JM, Campbell S. Exempting dissenting patients from pay for performance schemes: retrospective analysis of exception reporting in the UK Quality and Outcomes Framework. BMJ 2012; 344:e2405. [PMID: 22511209 PMCID: PMC3328418 DOI: 10.1136/bmj.e2405] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To examine the reasons why practices exempt patients from the UK Quality and Outcomes Framework pay for performance scheme (exception reporting) and to identify the characteristics of general practices associated with informed dissent. DESIGN Retrospective analysis. SETTING Data for 2008-9 extracted from the clinical computing systems of general practices in England. PARTICIPANTS 8229 English family practices. MAIN OUTCOME MEASURES Rates of exception reporting for 37 clinical quality indicators, associations of patient and general practice factors with exception rates, and financial gain for practices relating to their use of exception reporting. RESULTS The median rate of exception reporting was 2.7% (interquartile range 1.9-3.9%) overall and 0.44% (0.14-1.1%) for informed dissent, but variation in rates was wide between practices and across indicators. Common reasons for exception reporting were logistical (40.6% of exceptions), clinical contraindication (18.7%), and patient informed dissent (30.1%). Higher rates of informed dissent were associated with: higher numbers of registered patients, higher levels of local area deprivation, and failure of the practice to secure maximum remuneration in the previous year. Exception reporting increased the cost of the scheme by £30,844,500 (€36,877,700; $49,053,200) (£0.58 per patient), with two indicators accounting for a quarter of this additional cost. CONCLUSIONS The provision to exception report enables practices to exempt dissenting patients without being financially penalised. Relatively few patients were excluded for informed dissent, however, suggesting that the incentivised activities were broadly acceptable to patients.
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Affiliation(s)
- Tim Doran
- Health Sciences Research Group-Primary Care, University of Manchester, Manchester M13 9PL, UK.
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The effect of improving processes of care on patient outcomes: evidence from the United Kingdom's quality and outcomes framework. Med Care 2012; 50:191-9. [PMID: 22329994 DOI: 10.1097/mlr.0b013e318244e6b5] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Despite the extensive use of process of care measures in pay-for-performance programs, little is known about the effect of improving process performance on patient outcomes. METHODS Retrospective longitudinal analysis of data extracted from 7228 family practices in the United Kingdom's Quality and Outcomes Framework pay-for-performance program. We estimated the proportion of the change in outcome performance over time which was attributable to change in process performance for 5 chronic conditions (diabetes, coronary heart disease, stroke, epilepsy, and hypertension). Our analytic strategy accounted for bias resulting from unmeasured processes of care and severity of illness. RESULTS The estimated improvement in composite outcomes that was attributable to improved process was 29.6% for diabetes, 25.6% for coronary heart disease, 34.7% for stroke, 29.1% for epilepsy, and 17.7% for hypertension. The relationship between processes and outcomes varied little across patient and practice characteristics. CONCLUSIONS Improvement in process performance in English family practices led to improvements in patient outcomes. Although the effect was modest at the practice-level, process improvements seem to have led to substantial improvements in population health.
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Chauhan M, Bankart MJ, Labeit A, Baker R. Characteristics of general practices associated with numbers of elective admissions. J Public Health (Oxf) 2012; 34:584-90. [PMID: 22448040 DOI: 10.1093/pubmed/fds024] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In England both emergency (unplanned) and non-emergency (elective) hospital admissions have been increasing. Some elective admissions are potentially avoidable. AIM to identify the characteristics of general practices and patients associated with elective admissions. METHODS A cross-sectional study, in Leicestershire, England, was conducted using admission data (2006-07 and 2007-08). Practice characteristics (list size, distance from principal hospital, quality and outcomes framework score and general practitioner (GP) patient access survey data) and patient characteristics (age, ethnicity and deprivation and gender) were used as predictors of elective hospital admissions in a negative binomial regression model. RESULTS Practices with a higher proportion of patients aged 65 years or greater and of white ethnicity had higher rates of elective hospital admissions. Practices with more male patients and with more patients reporting being able to consult a particular GP had fewer elective hospital admissions. For 2007-08 practices with a larger list size were associated with higher elective hospital admissions. Quality and outcomes framework performance did not predict admission numbers. CONCLUSIONS As for unplanned admissions, elective admissions increase as being able to consult a particular GP declines. Interventions to improve continuity should be investigated. Practices face major problems in managing the increased need for planned care as the population ages.
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Affiliation(s)
- Mitum Chauhan
- Department of Health Sciences, University of Leicester, Leicester, UK
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Dusheiko M, Gravelle H, Martin S, Rice N, Smith PC. Does better disease management in primary care reduce hospital costs? Evidence from English primary care. JOURNAL OF HEALTH ECONOMICS 2011; 30:919-932. [PMID: 21893358 DOI: 10.1016/j.jhealeco.2011.08.001] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2010] [Revised: 08/01/2011] [Accepted: 08/01/2011] [Indexed: 05/31/2023]
Abstract
We apply cross-sectional and panel data methods to a database of 5 million patients in 8000 English general practices to examine whether better primary care management of 10 chronic diseases is associated with reduced hospital costs. We find that only primary care performance in stroke care is associated with lower hospital costs. Our results suggest that the 10% improvement in the general practice quality of stroke care between 2004/5 and 2007/8 reduced 2007/8 hospital expenditure by about £130 million in England. The cost savings are due mainly to reductions in emergency admissions and outpatient visits, rather than to lower costs for patients treated in hospital or to reductions in elective admissions.
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Boeckxstaens P, Smedt DD, Maeseneer JD, Annemans L, Willems S. The equity dimension in evaluations of the quality and outcomes framework: a systematic review. BMC Health Serv Res 2011; 11:209. [PMID: 21880136 PMCID: PMC3182892 DOI: 10.1186/1472-6963-11-209] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2010] [Accepted: 08/31/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pay-for-performance systems raise concerns regarding inequity in health care because providers might select patients for whom targets can easily be reached. This paper aims to describe the evolution of pre-existing (in)equity in health care in the period after the introduction of the Quality and Outcomes Framework (QOF) in the UK and to describe (in)equities in exception reporting. In this evaluation, a theory-based framework conceptualising equity in terms of equal access, equal treatment and equal treatment outcomes for people in equal need is used to guide the work. METHODS A systematic MEDLINE and Econlit search identified 317 studies. Of these, 290 were excluded because they were not related to the evaluation of QOF, they lacked an equity dimension in the evaluation, their qualitative research focused on experiences or on the nature of the consultation, or unsuitable methodology was used to pronounce upon equity after the introduction of QOF. RESULTS None of the publications (n = 27) assessed equity in access to health care. Concerning equity in treatment and (intermediate) treatment outcomes, overall quality scores generally improved. For the majority of the observed indicators, all citizens benefit from this improvement, yet the extent to which different patient groups benefit tends to vary and to be highly dependent on the type and complexity of the indicator(s) under study, the observed patient group(s) and the characteristics of the study. In general, the introduction of QOF was favourable for the aged and for males. Total QOF scores did not seem to vary according to ethnicity. For deprivation, small but significant residual differences were observed after the introduction of QOF favouring less deprived groups. These differences are mainly due to differences at the practice level. The variance in exception reporting according to gender and socio-economic position is low. CONCLUSIONS Although QOF seems not to be socially selective at first glance, this does not mean QOF does not contribute to the inverse care law. Introducing different targets for specific patient groups and including appropriate, non-disease specific and patient-centred indicators that grasp the complexity of primary care might refine the equity dimension of the evaluation of QOF. Also, information on the actual uptake of care, information at the patient level and monitoring of individuals' health care utilisation tracks could make large contributions to an in-depth evaluation. Finally, evaluating pay-for-quality initiatives in a broader health systems impact assessment strategy with equity as a full assessment criterion is of utmost importance.
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Hospitalizations for ambulatory care sensitive conditions and quality of primary care: their relation with socioeconomic and health care variables in the Madrid regional health service (Spain). Med Care 2011; 49:17-23. [PMID: 20978453 DOI: 10.1097/mlr.0b013e3181ef9d13] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Hospitalizations for ambulatory care sensitive conditions (ACSH) have been proposed as an indirect indicator of the effectiveness and quality of care provided by primary health care. OBJECTIVE To investigate the association of ACSH rates with population socioeconomic factors and with characteristics of primary health care. RESEARCH DESIGN Cross-sectional, ecologic study. Using hospital discharge data, ACSH were selected from the list of conditions validated for Spain. SETTING All 34 health districts in the Region of Madrid, Spain. SUBJECTS Individuals aged 65 years or older residing in the region of Madrid between 2001 and 2003, inclusive. MEASURES Age- and gender-adjusted ACSH rates in each health district. RESULTS The adjusted ACSH rate per 1000 population was 35.37 in men and 20.45 in women. In the Poisson regression analysis, an inverse relation was seen between ACSH rates and the socioeconomic variables. Physician workload was the only health care variable with a statistically significant relation (rate ratio of 1.066 [95% CI; 1.041-1.091]). These results were similar in the analyses disaggregated by gender. In the multivariate analyses that included health care variables, none of the health care variables were statistically significant. CONCLUSIONS ACSH may be more closely related with socioeconomic variables than with characteristics of primary care activity. Therefore, other factors outside the health system must be considered to improve health outcomes in the population.
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Purdy S, Griffin T, Salisbury C, Sharp D. Emergency admissions for coronary heart disease: A cross-sectional study of general practice, population and hospital factors in England. Public Health 2011; 125:46-54. [DOI: 10.1016/j.puhe.2010.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 06/16/2010] [Accepted: 07/13/2010] [Indexed: 12/21/2022]
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Griffiths P, Murrells T, Dawoud D, Jones S. Hospital admissions for asthma, diabetes and COPD: is there an association with practice nurse staffing? A cross sectional study using routinely collected data. BMC Health Serv Res 2010; 10:276. [PMID: 20858245 PMCID: PMC2955649 DOI: 10.1186/1472-6963-10-276] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2010] [Accepted: 09/21/2010] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Delivering good quality primary care for patients with chronic conditions has the potential to reduce non-elective hospital admissions. Practice nurse staffing levels in England have been linked to attainment of general practice performance targets for some chronic conditions. The aim of this study was to examine whether practice nurse staffing level is similarly associated with non-elective hospital admissions in three clinical areas: asthma, Chronic Obstructive Pulmonary Disease (COPD) and diabetes. METHODS This observational study used cross sectional analysis of routinely collected data. Hospital admissions data for the period 2005-2006 (for asthma, COPD and diabetes) were linked with a database of practice characteristics, nurse staffing data and data on population characteristics for the same period. Statistical modelling explored the relationship between non-elective hospital admission rates for the three conditions and the list size per full time equivalent (FTE) practice nurse. RESULTS Higher practice nurse staffing levels were significantly associated with lower rates of admission for asthma (p < 0.001) and COPD (p < 0.001). A similar association was seen for patients with two or more admissions (p < 0.05 for asthma and p < 0.001 for COPD). For diabetes, higher practice nurse staffing level was significantly associated with higher admission rates (p < 0.05), but this association was not significant in case of patients with two or more admissions. Across all models, increasing deprivation was associated with higher admission rates for all conditions. CONCLUSIONS The inconsistent relationship between nurse staffing and patient outcomes across the different conditions and the fact that for diabetes the relationship between staffing and outcomes was in a different direction from the association between staffing and care quality, highlights the need to avoid making a simple causal interpretation of these findings and reduces the possible confidence in such conclusions. There is a need for more research into the organisation and delivery of diabetes care services in general practice, preferably using patient level data; in order to better understand the impact of the different staffing configurations on patient outcomes.
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Affiliation(s)
- Peter Griffiths
- King's College London, National Nursing Research Unit, 57 Waterloo Road, London, UK.
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Doran T, Roland M. Lessons From Major Initiatives To Improve Primary Care In The United Kingdom. Health Aff (Millwood) 2010; 29:1023-9. [DOI: 10.1377/hlthaff.2010.0069] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Tim Doran
- Tim Doran ( ) is Harkness Fellow in Health Care Policy at the Harvard School of Public Health in Boston, Massachusetts
| | - Martin Roland
- Martin Roland is a professor of health services research at the University of Cambridge in England
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Barnett R, Malcolm L. Practice and ethnic variations in avoidable hospital admission rates in Christchurch, New Zealand. Health Place 2010; 16:199-208. [DOI: 10.1016/j.healthplace.2009.09.010] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2009] [Revised: 08/20/2009] [Accepted: 09/23/2009] [Indexed: 10/20/2022]
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Biswas R, Joshi A, Joshi R, Kaufman T, Peterson C, Sturmberg JP, Maitra A, Martin CM. Revitalizing primary health care and family medicine/primary care in India--disruptive innovation? J Eval Clin Pract 2009; 15:873-80. [PMID: 19811603 DOI: 10.1111/j.1365-2753.2009.01271.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
CONTEXT India has rudimentary and fragmented primary health care (PHC) and family medicine systems, yet it also has the policy expectation that PHC should meet the needs of extremely large populations with slums and difficult to reach groups, rapid social and epidemiological transition from developing to developed nation profiles. Historically, the system has lacked impetus to achieve PHC. OBJECTIVE To provide an overview of PHC approaches and the current state of PHC and family medicine in India in order to assess the opportunities for their revitalization. METHODS A narrative review of the published and grey literature on PHC, family medicine, Web2.0 and health informatics key papers and policy documents, pertinent to India. OUTCOMES A conceptual framework and recommendations for policy makers and practitioner audiences. FINDINGS PHC is constructed through systems of local providers who address individual, family and local community basic health needs with strong community participation. Successful PHC is a pre-eminent strategy for India to address the determinants of health and the almost chaotic of massive social transition in its institutions and health care sector. There is a lack of an articulated comprehensive framework for the publicly stated goals of improving health and implementing PHC. Also, there exists a very limited education and organization of a medical and PHC workforce who are trained and resourced to address individual, family and local community health and who have become increasingly specialized. However, emerging technology, Health2.0 and user generated health care informatics, which are largely conducted through mobile phones, are co-evolving patient-driven health systems, and potentially enhance PHC and family medicine workforce development. CONCLUSIONS In order to improve health outcomes in an equitable manner in India, there is a pressing need for a framework for implementing PHC. The co-emergence of information technologies accessible to the mass population and user-driven health care provide a potential catalyst or innovation for this transition.
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Affiliation(s)
- Rakesh Biswas
- Department of Medicine, People's College of Medical Sciences, Bhopal, India.
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Martin CM, Kaufman T. Addressing health inequities: a case for implementing primary health care. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2008; 54:1515-1517. [PMID: 19005107 PMCID: PMC2592308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- Carmel M Martin
- Northern Ontario School of Medicine, Clinical Sciences Division, 238 Bruyère St, Ottawa, ON.
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