From data to decisions? Exploring how healthcare payers respond to the NHS Atlas of Variation in Healthcare in England

Identifying potentially low value surgical care: A national ecological study in England

OBJECTIVES

High variation in clinical practice may indicate uncertainty and potentially low-value care. Methods to identify low value care are often not well defined or transparent and can be time intensive. In this paper we explore the usefulness of variation analysis of routinely-collected data about surgical procedures in England to identify potentially low-value surgical care.

METHODS

This is a national ecological study using Hospital Episode Statistics linked to mid-year population estimates and indices of multiple deprivation in England, 2014/15-2018/19. We identified the top 5% of surgical procedures in terms of growth in standardised procedure rates for 2014/15 to 2018/19 and variation in procedure rates between clinical commissioning groups as measured by the systematic component of variance (SCV). A targeted literature review was conducted to explore the evidence for each of the identified techniques. Procedures without evidence of cost-effectiveness were viewed as of potentially low value.

RESULTS

We identified six surgical procedures that had a high growth rate of 37% or more over 5 years, and four with higher geographical variation (SCV >1.6). There was evidence for two of the 10 procedures that surgery was more cost-effective than non-surgical treatment albeit with uncertainty around optimal surgical technique. The evidence base for eight procedures was less clear cut, with uncertainty around clinical- and/or cost-effectiveness. These were: deep brain stimulation; removing the prostate; surgical spine procedures; a procedure to alleviate pain in the spine; surgery for dislocated joints due to trauma and associated surgery for traumatic fractures; hip joint replacement with cemented pelvic component or cemented femoral component; and shoulder joint replacement.

CONCLUSIONS

This study demonstrates that variation analysis could be regularly used to identify potentially low-value procedures. This can provide important insights into optimising services and the potential de-adoption of costly interventions and treatments that do not benefit patients and the health system more widely. Early identification of potentially low value care can inform prioritisation of clinical trials to generate evidence on effectiveness and cost-effectiveness before treatments become established in clinical practice.

The usage of data in NHS primary care commissioning: a realist evaluation

BACKGROUND

To improve health outcomes and address mounting costs pressures, policy-makers have encouraged primary care commissioners in the British National Health Service (NHS) to increase the usage of data in decision-making. However, there exists limited research on this topic. In this study, we aimed to understand how and why primary care commissioners use data (i.e. quantitative, statistical information) to inform commissioning, and what outcomes this leads to.

METHODS

A realist evaluation was completed to create context-mechanism-outcome configurations (CMOs) relating to the contexts influencing the usage of data in primary care commissioning. Using a realist logic of analysis and drawing on substantive theories, we analysed qualitative content from 30 interviews and 51 meetings (51 recordings and 19 accompanying meeting minutes) to develop CMOs. Purposive sampling was used to recruit interviewees from diverse backgrounds.

RESULTS

Thirty-five CMOs were formed, resulting in an overarching realist programme theory. Thirteen CMOs were identical and 3 were truncated versions of those formed in an existing realist synthesis on the same topic. Seven entirely new CMOs, and 12 refined and enhanced CMOs vis-à-vis the synthesis were created. The findings included CMOs containing contexts which facilitated the usage of data, including the presence of a data champion and commissioners' perceptions that external providers offered new skillsets and types of data. Other CMOs included contexts presenting barriers to using data, such as data not being presented in an interoperable way with consistent definitions, or financial pressures inhibiting commissioners' abilities to make evidence-based decisions.

CONCLUSIONS

Commissioners are enthusiastic about using data as a source of information, a tool to stimulate improvements, and a warrant for decision-making. However, they also face considerable challenges when using them. There are replicable contexts available to facilitate commissioners' usage of data, which we used to inform policy recommendations. The findings of this study and our recommendations are pertinent in light of governments' increasing commitment to data-driven commissioning and health policy-making.

The usage of data in NHS primary care commissioning: a realist review

BACKGROUND

Primary care has been described as the 'bedrock' of the National Health Service (NHS) accounting for approximately 90% of patient contacts but is facing significant challenges. Against a backdrop of a rapidly ageing population with increasingly complex health challenges, policy-makers have encouraged primary care commissioners to increase the usage of data when making commissioning decisions. Purported benefits include cost savings and improved population health. However, research on evidence-based commissioning has concluded that commissioners work in complex environments and that closer attention should be paid to the interplay of contextual factors and evidence use. The aim of this review was to understand how and why primary care commissioners use data to inform their decision making, what outcomes this leads to, and understand what factors or contexts promote and inhibit their usage of data.

METHODS

We developed initial programme theory by identifying barriers and facilitators to using data to inform primary care commissioning based on the findings of an exploratory literature search and discussions with programme implementers. We then located a range of diverse studies by searching seven databases as well as grey literature. Using a realist approach, which has an explanatory rather than a judgemental focus, we identified recurrent patterns of outcomes and their associated contexts and mechanisms related to data usage in primary care commissioning to form context-mechanism-outcome (CMO) configurations. We then developed a revised and refined programme theory.

RESULTS

Ninety-two studies met the inclusion criteria, informing the development of 30 CMOs. Primary care commissioners work in complex and demanding environments, and the usage of data are promoted and inhibited by a wide range of contexts including specific commissioning activities, commissioners' perceptions and skillsets, their relationships with external providers of data (analysis), and the characteristics of data themselves. Data are used by commissioners not only as a source of evidence but also as a tool for stimulating commissioning improvements and as a warrant for convincing others about decisions commissioners wish to make. Despite being well-intentioned users of data, commissioners face considerable challenges when trying to use them, and have developed a range of strategies to deal with 'imperfect' data.

CONCLUSIONS

There are still considerable barriers to using data in certain contexts. Understanding and addressing these will be key in light of the government's ongoing commitments to using data to inform policy-making, as well as increasing integrated commissioning.

A qualitative study on relationships and perceptions between managers and clinicians and its effect on value-based healthcare within the national health service in the UK

One of the main drivers for change towards delivering value-based healthcare is to improve clinical and managerial culture and engagement within organisations. The relationships between clinicians and managers in an organisation are often considered to be either an enabler or disabler towards successful engagement to develop strategies towards better value healthcare. Successful engagement is dependent on effective and transformational leadership that can impact on organisational value in healthcare. The aim of this research was to explore the relationships, behaviours and perceptions between managers and clinicians towards value-based healthcare in the National Health Service in the United Kingdom. A qualitative research methodology of semi-structured in-depth interviewing on a sample consisting of hospital consultants, senior managers and board executives from a diverse group were conducted. A thematic analysis was used to analyse the data using a systematic approach. The study findings identified areas of potential barriers to engagement for clinicians and managers which were related to regulatory burden, financial challenges and workforce shortages. Key recommendations on what will be required to improve clinicians and managers engagement and the leadership approaches towards improving value-based healthcare are discussed.

Small Area Analysis of Veterans Affairs Mental Health Services Data

OBJECTIVE

To identify geographic variation in mental health service use in the Department of Veterans Affairs (VA), the authors constructed utilization-based VA mental health service areas (MHSAs) for outpatient treatment and mental health referral regions (MHRRs) for residential and acute inpatient treatment.

METHODS

MHSAs are empirically derived geographic groupings of one or more counties containing one or more VA outpatient mental health clinics. For each county within an MHSA, patients received most of their VA-provided outpatient mental health care within that MHSA. MHSAs were aggregated into MHRRs according to where VA users in each MHSA received most of their residential and acute inpatient mental health care. Attribution loyalty was evaluated with the localization index-the fraction of VA users living in each geographic area who used their designated MHSA and MHRR facility. Variation in outpatient mental health visits and in acute inpatient and residential mental health stays was determined for the 2008-2018 period.

RESULTS

A total of 441 MHSAs were aggregated to 115 MHRRs (representing 3,909,080 patients with 52,372,303 outpatient mental health visits). The mean±SD localization index was 59.3%±16.4% for MHSAs and 67.8%±12.7% for MHRRs. Adjusted outpatient mental health visits varied from a mean of 0.88 per year in the lowest quintile of MHSAs to 3.14 in the highest. Combined residential and acute inpatient days varied from 0.29 to 1.79 between the lowest and highest quintiles.

CONCLUSIONS

MHSAs and MHRRs validly represented mental health utilization patterns in the VA and displayed considerable variation in mental health service provision across different locations.

Understanding unwarranted variation in clinical practice: a focus on network effects, reflective medicine and learning health systems

In the past decades, extensive research has been performed on the phenomenon of unwarranted clinical variation in clinical practice. Many studies have been performed on signaling, describing and visualizing clinical variation. We argue that it is time for next steps in practice variation research. In addition to describing and signaling variation patterns, we argue that a better understanding of causes of variation should be gained. Moreover, target points for improving and decreasing clinical variation should be created. Key elements in this new focus should be research on the complex interaction of networks, reflective medicine, patient beliefs and objective criteria for treatment choices. By combining these different concepts, alternative research objectives and new targets for improving and reducing unwarranted variation may be defined. In this perspective, we reflect on these concepts and propose target points for future research.

Unwarranted clinical variation in health care: Definitions and proposal of an analytic framework

RATIONALE, AIMS, AND OBJECTIVES

Unwarranted clinical variation is a topic of heightened interest in health care systems around the world. While there are many publications and reports on clinical variation, few studies are conceptually grounded in a theoretical model. This study describes the empirical foundations of the field and proposes an analytic framework.

METHOD

Structured construct mapping of published empirical studies which explicitly address unwarranted clinical variation.

RESULTS

A total of 190 studies were classified in terms of three key dimensions: perspective (assessing variation across geographical areas or across providers); criteria for assessment (measuring absolute variation against a standard, or relative variation within a comparator group); and object of analysis (using process, structure/resource, or outcome metrics).

CONCLUSION

Consideration of the results of the mapping exercise-together with a review of adjustment, explanatory and stratification variables, and the factors associated with residual variation-informed the development of an analytic framework. This framework highlights the role that agency and motivation, evidence and judgement, and personal and organizational capacity play in clinical decision making and reveals key facets that distinguish warranted from unwarranted clinical variation. From a measurement perspective, it underlines the need for careful consideration of attribution, aggregation, models of care, and temporality in any assessment.

Peer-pressure and overuse: The effect of a multimodal approach on variation in benzodiazepine prescriptions in a network of public hospitals

BACKGROUND

The epidemic phenomenon leading to a progressive increase in benzodiazepine prescriptions represents a challenge for healthcare systems. In the hospital setting, indicators of prescription variation and potential of overuse are lacking and are rarely monitored. Inter-hospital monitoring/benchmarking, via peer-pressure, can foster the motivation to change. The aim of this investigation was to analyse whether, the reduction in new benzodiazepine prescriptions obtained thanks to a Choosing Wisely campaign, also contributed to reducing inter-hospital variation.

METHODS

Secondary analysis of a multicentre longitudinal intervention in a network of five teaching hospitals in Switzerland. We set out to explore the effect, on inter-hospital benzodiazepine prescription variation, of a continuous monitoring/benchmarking strategy, which was proven effective in reducing the intra-hospital prescription rate. The variance was used to assess inter-hospital variation. To investigate the impact of the intervention a segmented regression analysis of interrupted time series was performed.

RESULTS

A total of 36 299 admissions over 42 months were analysed (1 July 2014 to 31 December 2017). Before the intervention a significant constant upward trend in inter-hospital variability was found (+0.901; SE 0.441; P < .05). After the intervention, the variance trend line significantly changed, decreasing by -0.257 (SE 0.005: P < .001) and producing by December 2017, a 27% absolute reduction.

CONCLUSIONS

Thanks to a multimodal approach based on monitoring-benchmarking, a significant reduction in inter-hospital benzodiazepine prescription variation was obtained. Aligning to peer strategy is a spontaneous consequence of open benchmarking that can be used to convert a variation-based suspicion of overuse, into an occasion to actively review prescription habits.

Regional planning for meaningful person-centred care in mental health: context is the signal not the noise

Person-centred care is at the core of a value-based health system. Its transformative potential is to enable and support key policy, planning and service developments across the system even when these go against the self-interest of individual major players. It offers a potent test for decision makers at all levels. It demands responses that are multi-level, empirically grounded, expert-informed and data-driven that must converge on the singularity of individuals in the places that they live. This requires different approaches that recognise, respect and reconcile two necessary but constitutionally disparate perspectives: the bureaucratic, overtly decontextualised, top-down, policy and planning objectives of central governments and the formally complex, dynamic and contextualised experience of individuals in the system. Conflating the latter with the former can lead unwittingly to a pervasive and reductive form of quasi-Taylorism that nearly always creates waste at the expense of value. This has parallel application in the treatment domain where outcomes are non-randomly clustered and partitioned by socioeconomic status, amplifying unwarranted variation by place that is striking in its magnitude and heterogeneity. In this paper, we propose that a combination of (1) relevant, local and sophisticated data planning, collection and analysis systems, (2) more detailed person-centred service planning and delivery and (3) system accountability through co-design and transparent public reporting of health system performance in a manner that is understandable, relevant, and locally applicable are all essential in ensuring planned and provided care is most appropriate to more than merely the 'average' person for whom the current system is built. We argue that only through a greater appreciation of healthcare as a complex adaptive (eco)system, where context is everything, and then utilising planning, analysis and management methodologies that reflect this reality is the way to achieve genuine person-centred care.

Primary care risk stratification in COPD using routinely collected data: a secondary data analysis

Most clinical contacts with chronic obstructive pulmonary disease (COPD) patients take place in primary care, presenting opportunity for proactive clinical management. Electronic health records could be used to risk stratify diagnosed patients in this setting, but may be limited by poor data quality or completeness. We developed a risk stratification database algorithm using the DOSE index (Dyspnoea, Obstruction, Smoking and Exacerbation) with routinely collected primary care data, aiming to calculate up to three repeated risk scores per patient over five years, each separated by at least one year. Among 10,393 patients with diagnosed COPD, sufficient primary care data were present to calculate at least one risk score for 77.4%, and the maximum of three risk scores for 50.6%. Linked secondary care data revealed primary care under-recording of hospital exacerbations, which translated to a slight, non-significant cohort average risk score reduction, and an understated risk group allocation for less than 1% of patients. Algorithmic calculation of the DOSE index is possible using primary care data, and appears robust to the absence of linked secondary care data, if unavailable. The DOSE index appears a simple and practical means of incorporating risk stratification into the routine primary care of COPD patients, but further research is needed to evaluate its clinical utility in this setting. Although secondary analysis of routinely collected primary care data could benefit clinicians, patients and the health system, standardised data collection and improved data quality and completeness are also needed.

Decision making tools for managing waiting times and treatment rates in elective surgery

BACKGROUND

Waiting times for elective treatments, including elective surgery, are a source of public concern and therefore are on policy makers' agenda. The long waiting times have often been tackled through the allocation of additional resources, in an attempt to reduce them, but results are not straightforward. At the same time, researchers have reported wide geographical variations in the provision of elective care not driven by patient needs or preferences but by other factors. The paper analyses the relationship between waiting times and treatment rates for nine high-volume elective surgical procedures in order to support decision making regarding the availability of these services for the citizens. Using the framework already proposed for the diagnostic services, we identify different patterns that can be followed to align the supply with patient needs in the Italian context.

METHODS

After measuring the waiting times and the treatment rates for nine procedures in the 34 districts in Tuscany, we performed correlation analyses. Then, we plotted the results in a matrix cross-checking waiting times and rates. By doing so, we identified four different contexts that require a second step analysis to tackle unwarranted geographical variations and ensure timely care to patients. Finally, for each district and elective surgical procedure, we measured the economic impact of the different treatment rates in order to evaluate whether there are any supply criticalities and eventually some room for maneuver. We also included active and passive mobility of patients.

RESULTS

The results show a high degree of variation both in treatment rates and waiting times, especially for the orthopaedic procedures: knee replacement, knee arthroscopy and hip replacement. The analysis performed for the nine interventions shows that the 34 districts are in varying positions in the waiting time-treatment rate matrix, suggesting that there is no straightforward relationship between rates and waiting times. Each combination in the matrix may have different determinants that require healthcare managers to adopt diversified strategies. The decision making process needs to be supported by a two-level analysis: the first one to put in place the matrix that cross-checks waiting times and treatment rates, the second one to analyse the characteristics of each quadrant and the improvement actions that can be proposed.

CONCLUSIONS

In Italy, waiting times in elective surgical services are a main policy issue with a relevant geographical variation. Our analysis reveals that this variation is due to multiple elements. In order to avoid simplistic approaches that do not solve the problem but often lead to increased expenditure, policy makers and healthcare managers should follow a two-step strategy firstly identifying the type of context and secondly analysing the impact of elements such as resource productivity, resource availability, patients' preferences and care appropriateness. Only in some cases it is required to increase the service supply.

The international knowledge base for new care models relevant to primary care-led integrated models: a realist synthesis

Background

The Multispecialty Community Provider (MCP) model was introduced to the NHS as a primary care-led, community-based integrated care model to provide better quality, experience and value for local populations.

Objectives

The three main objectives were to (1) articulate the underlying programme theories for the MCP model of care; (2) identify sources of theoretical, empirical and practice evidence to test the programme theories; and (3) explain how mechanisms used in different contexts contribute to outcomes and process variables.

Design

There were three main phases: (1) identification of programme theories from logic models of MCP vanguards, prioritising key theories for investigation; (2) appraisal, extraction and analysis of evidence against a best-fit framework; and (3) realist reviews of prioritised theory components and maps of remaining theory components.

Main outcome measures

The quadruple aim outcomes addressed population health, cost-effectiveness, patient experience and staff experience.

Data sources

Searches of electronic databases with forward- and backward-citation tracking, identifying research-based evidence and practice-derived evidence.

Review methods

A realist synthesis was used to identify, test and refine the following programme theory components: (1) community-based, co-ordinated care is more accessible; (2) place-based contracting and payment systems incentivise shared accountability; and (3) fostering relational behaviours builds resilience within communities.

Results

Delivery of a MCP model requires professional and service user engagement, which is dependent on building trust and empowerment. These are generated if values and incentives for new ways of working are aligned and there are opportunities for training and development. Together, these can facilitate accountability at the individual, community and system levels. The evidence base relating to these theory components was, for the most part, limited by initiatives that are relatively new or not formally evaluated. Support for the programme theory components varies, with moderate support for enhanced primary care and community involvement in care, and relatively weak support for new contracting models.

Strengths and limitations

The project benefited from a close relationship with national and local MCP leads, reflecting the value of the proximity of the research team to decision-makers. Our use of logic models to identify theories of change could present a relatively static position for what is a dynamic programme of change.

Conclusions

Multispecialty Community Providers can be described as complex adaptive systems (CASs) and, as such, connectivity, feedback loops, system learning and adaptation of CASs play a critical role in their design. Implementation can be further reinforced by paying attention to contextual factors that influence behaviour change, in order to support more integrated working.

Future work

A set of evidence-derived ‘key ingredients’ has been compiled to inform the design and delivery of future iterations of population health-based models of care. Suggested priorities for future research include the impact of enhanced primary care on the workforce, the effects of longer-term contracts on sustainability and capacity, the conditions needed for successful continuous improvement and learning, the role of carers in patient empowerment and how community participation might contribute to community resilience.

Study registration

This study is registered as PROSPERO CRD42016039552.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Determinants of initial inhaled corticosteroid use in patients with GOLD A/B COPD: a retrospective study of UK general practice

Initial use of inhaled corticosteroid therapy is common in patients with Global Initiative for Chronic Obstructive Lung Disease (GOLD) A or B chronic obstructive pulmonary disease, contrary to GOLD guidelines. We investigated UK prescribing of inhaled corticosteroid therapy in these patients, to identify predictors of inhaled corticosteroid use in newly diagnosed chronic obstructive pulmonary disease patients. A cohort of newly diagnosed GOLD A/B chronic obstructive pulmonary disease patients was identified from the UK Clinical Practice Research Datalink (June 2005-June 2015). Patients were classified by prescribed treatment, with those receiving inhaled corticosteroid-containing therapy compared with those receiving long-acting bronchodilators without inhaled corticosteroid. In all, 29,815 patients with spirometry-confirmed chronic obstructive pulmonary disease were identified. Of those prescribed maintenance therapy within 3 months of diagnosis, 63% were prescribed inhaled corticosteroid-containing therapy vs. 37% prescribed non-inhaled corticosteroid therapy. FEV1% predicted, concurrent asthma diagnosis, region, and moderate exacerbation were the strongest predictors of inhaled corticosteroid use in the overall cohort. When concurrent asthma patients were excluded, all other co-variates remained significant predictors. Other significant predictors included general practitioner practice, younger age, and co-prescription with short-acting bronchodilators. Trends over time showed that initial inhaled corticosteroid prescriptions reduced throughout the study, but still accounted for 47% of initial prescriptions in 2015. These results suggest that inhaled corticosteroid prescribing in GOLD A/B patients is common, with significant regional variation that is independent of FEV1% predicted.

EARLY-STAGE CHRONIC LUNG DISEASE

OVERUSE OF INHALED STEROIDS IN THE UK: Inhaled steroids are often prescribed to early-stage chronic lung disease patients in the UK despite guidelines to the contrary. Patients newly diagnosed with early-stage chronic obstructive pulmonary disease (COPD) should not be prescribed inhaled corticosteroids (ICS), because they carry an increased risk of side effects such as pneumonia and osteoporosis. ICS should be reserved for patients with severe COPD and frequent exacerbations. James Chalmers at the Scottish Centre for Respiratory Research, Dundee, and co-workers examined prescribed medication data from the UK spanning 10 years, to determine key predictors of ICS prescription during early-stage COPD. Of 29,815 patients identified, an average of 63% were prescribed ICS upon diagnosis, regardless of disease severity. Younger patients were more likely to receive ICS, possibly due to co-morbidity with chronic asthma, and particular UK regions and medical practices prescribed ICS more readily than others.

Diagnostic value of symptoms of oesophagogastric cancers in primary care: a systematic review and meta-analysis

BACKGROUND

Selection of primary care patients for investigation of potential oesophagogastric cancer is difficult, as the symptoms may represent benign conditions, which are also more common.

AIM

To review systematically the presenting features of oesophagogastric cancers in primary care, including open-access endoscopy clinics.

DESIGN AND SETTING

Systematic review and meta-analysis.

METHOD

MEDLINE®, Embase, the Cochrane Library, and CINAHL were searched for studies of adults who were symptomatic and presented in primary care or open-access endoscopy clinics. Exclusions were being asymptomatic, screening, or recurrent cancers. Data were extracted to estimate the diagnostic performance of features of oesophagogastric cancers and summarised in a meta-analysis.

RESULTS

Fourteen studies were identified. The strongest summary sensitivity and specificity estimates were for: dyspepsia 0.42 (95% confidence interval [CI] 0.29 to 0.56) and 0.48 (95% CI = 0.31 to 0.65); pain 0.41 (95% CI = 0.24 to 0.62) and 0.75 (95% CI = 0.51 to 0.89); and dysphagia 0.32 (95% CI = 0.17 to 0.52) and 0.92 (95% CI = 0.81 to 0.97). Summary positive likelihood ratios (LR+) and diagnostic odds ratios were: dyspepsia 0.79 (95% CI = 0.55 to 1.15) and 0.65 (95% CI = 0.32 to 1.33); pain 1.64 (95% CI = 1.20 to 2.24) and 2.09 (95% CI = 1.57 to 2.77); and dysphagia 4.32 (95% CI = 2.46 to 7.58) and 5.91 (95% CI = 3.56 to 9.82). Sensitivity was lower for: anaemia 0.12 [95% Cl = 0.08 to 0.19] with specificity 0.97 [95% Cl = 0.94 to 0.99]; nausea/vomiting/bloating 0.17 [95% Cl = 0.05 to 0.46] and 0.84 [95% Cl = 0.60 to 0.94] respectively; reflux 0.23 [95% Cl = 0.10 to 0.46] and 0.70 [95% Cl = 0.59 to 0.80]; weight loss 0.25 [95% Cl = 0.12 to 0.43] and 0.96 [95% Cl = 0.88 to 0.98]. [corrected]. Corresponding LR+ were: anaemia 4.32 (95% CI = 2.64 to 7.08); nausea/vomiting/bloating 1.07 (95% CI = 0.52 to 2.19); reflux 0.78 (95% CI = 0.47 to 1.78) and; weight loss 5.46 (95% CI = 3.47 to 8.60).

CONCLUSION

Dysphagia, weight loss, and anaemia show the strongest association but with relatively low sensitivity and high specificity. The findings support the value of investigation of these symptoms, but also suggest that, in a population of patients who are low risk but not no-risk, investigation is not currently recommended.

Examining regional variation in health care spending in British Columbia, Canada

Examining regional variation in health care spending may reveal opportunities for improved efficiency. Previous research has found that health care spending and service use vary substantially from place to place, and this is often not explained by differences in the health status of populations or by better outcomes in higher-spending regions, but rather by differences in intensity of service provision. Much of this research comes from the United States. Whether similar patterns are observed in other high-income countries is not clear. We use administrative data on health care use, covering the entire population of the Canadian province of British Columbia, to examine how and why health care spending varies among health regions. Pricing and insurance coverage are constant across the population, and we adjust for patient-level age, sex, and recorded diagnoses. Without adjusting for differences in population characteristics, per-capita spending is 50% higher in the highest-spending region than in the lowest. Adjusting for population characteristics as well as the very different environments for health service delivery that exist among metropolitan, non-metropolitan, and remote regions of the province, this falls to 20%. Despite modest variation in total spending, there are marked differences in mortality. In this context, it appears that policy reforms aimed at system-wide quality and efficiency improvement, rather than targeted at high-spending regions, will likely prove most promising.

Equity of utilisation of cardiovascular care and mental health services in England: a cohort-based cross-sectional study using small-area estimation

Background

A 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.

Objectives

To 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.

Design

Cross-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).

Results

The 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.

Conclusions

We 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.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

'Seizure First Aid Training' for people with epilepsy who attend emergency departments, and their family and friends: study protocol for intervention development and a pilot randomised controlled trial

INTRODUCTION

People with chronic epilepsy (PWE) often make costly but clinically unnecessary emergency department (ED) visits. Offering them and their carers a self-management intervention that improves confidence and ability to manage seizures may lead to fewer visits. As no such intervention currently exists, we describe a project to develop and pilot one.

METHODS AND ANALYSIS

To develop the intervention, an existing group-based seizure management course that has been offered by the Epilepsy Society within the voluntary sector to a broader audience will be adapted. Feedback from PWE, carers and representatives from the main groups caring for PWE will help refine the course so that it addresses the needs of ED attendees. Its behaviour change potential will also be optimised. A pilot randomised controlled trial will then be completed. 80 PWE aged ≥16 who have visited the ED in the prior 12 months on ≥2 occasions, along with one of their family members or friends, will be recruited from three NHS EDs. Dyads will be randomised to receive the intervention or treatment as usual alone. The proposed primary outcome is ED use in the 12 months following randomisation. For the pilot, this will be measured using routine hospital data. Secondary outcomes will be measured by patients and carers completing questionnaires 3, 6 and 12 months postrandomisation. Rates of recruitment, retention and unblinding will be calculated, along with the ED event rate in the control group and an estimate of the intervention's effect on the outcome measures.

ETHICS AND DISSEMINATION

Ethical approval: NRES Committee North West-Liverpool East (Reference number 15/NW/0225). The project's findings will provide robust evidence on the acceptability of seizure management training and on the optimal design of a future definitive trial. The findings will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

ISRCTN13 871 327.

Using clinical practice variations as a method for commissioners and clinicians to identify and prioritise opportunities for disinvestment in health care: a cross-sectional study, systematic reviews and qualitative study

Background

NHS expenditure has stagnated since the economic crisis of 2007, resulting in financial pressures. One response is for policy-makers to regulate use of existing health-care technologies and disinvest from inefficiently used health technologies. A key challenge to disinvestment is to identify existing health technologies with uncertain cost-effectiveness.

Objectives

We aimed to explore if geographical variation in procedure rates is a marker of clinical uncertainty and might be used by local commissioners to identify procedures that are potential candidates for disinvestment. We also explore obstacles and solutions to local commissioners achieving disinvestment, and patient and clinician perspectives on regulating access to procedures.

Methods

We used Hospital Episode Statistics to measure geographical variation in procedure rates from 2007/8 to 2011/12. Expected procedure numbers for each primary care trust (PCT) were calculated adjusting for proxies of need. Random effects Poisson regression quantified the residual inter-PCT procedure rate variability. We benchmarked local procedure rates in two PCTs against national rates. We conducted rapid systematic reviews of two high-use procedures selected by the PCTs [carpal tunnel release (CTR) and laser capsulotomy], searching bibliographical databases to identify systematic reviews and randomised controlled trials (RCTs). We conducted non-participant overt observations of commissioning meetings and semistructured interviews with stakeholders about disinvestment in general and with clinicians and patients about one disinvestment case study. Transcripts were analysed thematically using constant comparison methods derived from grounded theory.

Results

There was large inter-PCT variability in procedure rates for many common NHS procedures. Variation in procedure rates was highest where the diffusion or discontinuance was rapidly evolving and where substitute procedures were available, suggesting that variation is a proxy for clinical uncertainty about appropriate use. In both PCTs we identified procedures where high local use might represent an opportunity for disinvestment. However, there were barriers to achieving disinvestment in both procedure case studies. RCTs comparing CTR with conservative care indicated that surgery was clinically effective and cost-effective on average but provided limited evidence on patient subgroups to inform commissioning criteria and achieve savings. We found no RCTs of laser capsulotomy. The apparently high rate of capsulotomy was probably due to the coding inaccuracy; some savings might be achieved by greater use of outpatient procedures. Commissioning meetings were dominated by new funding requests. Benchmarking did not appear to be routinely carried out because of capacity issues and concerns about data reliability. Perceived barriers to disinvestment included lack of collaboration, central support and tools for disinvestment. Clinicians felt threshold criteria had little impact on their practice and that prior approval systems would not be cost-effective. Most patients were unaware of rationing.

Conclusions

Policy-makers could use geographical variation as a starting point to identify procedures where health technology reassessment or RCTs might be needed to inform policy. Commissioners can use benchmarking to identify procedures with high local use, possibly indicating overtreatment. However, coding inconsistency and limited evidence are major barriers to achieving disinvestment through benchmarking. Increased central support for commissioners to tackle disinvestment is needed, including tools, accurate data and relevant evidence. Early engagement with patients and clinicians is essential for successful local disinvestment.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.