Did the expansion of free GP care impact demand for Emergency Department attendances? A difference-in-differences analysis

Does contracting family doctor promote primary healthcare utilization among older adults? - evidence from a difference-in-differences analysis

INTRODUCTION

In 2016, the Chinese government officially scaled up family doctor contracted services (FDCS) scheme to guide patients' health seeking behavior from tertiary hospitals to primary health facilities.

METHODS

This study evaluated the overall gate-keeping effects of this scheme on healthcare utilization of rural residents by using a difference-in-differences (DiD) design. The analysis was based on Shandong Rural Elderly Health Cohort 2019 and 2020. Participants who contracted FDCS in second round and were not contracted with a family doctor in the first round were regarded as treatment group. In total, 310 respondents who have used medical care were incorporated for final study.

RESULTS

Participants who contracted FDCS (treatment group) experienced a significant decline in the mean level of first-contact health-care facilities, decreasing from 2.204 to 1.981. In contrast, participants who did not contract FDCS (control group), showed an increasing trend in the mean level of first-contact health-care facilities, rising from 2.128 to 2.445. Our results showed that contracting FDCS is associated with approximately 0.54 extra lower mean level of first-contact health-care facilities (P = 0.03, 95% CI: -1.03 to 0.05), which suggests an approximately 24.5% reduction in the mean first-contact health-care facility level for participants compared with contracted FDCS than those who did not.

CONCLUSIONS

The study suggested primary healthcare quality should be strengthened and restrictive first point of contact policy should be enacted to establish ordered healthcare seeking behavior among rural residents.

A Quasi-experimental Study on the Effect of Pre-entry Tuberculosis Screening for Immigrants on Treatment Outcomes in South Korea: A Difference-in-Differences Analysis

OBJECTIVE

This study ascertains the effects of the pre-entry tuberculosis (TB) screening policy, which was implemented as a strategy for managing TB among immigrants, on the treatment outcomes of immigrants in South Korea.

METHODS

This study linked three different datasets from 2013 to 2018, namely (1) Korean National Tuberculosis Surveillance System; (2) National Health Information Database for patients diagnosed with TB with ICD code A15-A19, B90, or U84.3; and (3) Statistics Korea database related to cause of deaths. To identify the effect of the policy, cohorts comprising Korean and immigrant TB patients notified before (January 1, 2013-December 31, 2015) and after (September 1, 2016-December 31, 2018), the implementations of the policy were established. A difference-in-differences (DID) analysis of the treatment success and mortality rates was performed.

RESULTS

Data from 100,262 TB patients were included in the analysis (before policy implementation: 1240 immigrants and 65,723 Koreans; after policy implementation: 256 immigrants and 33,043 Koreans). The propensity score matching-DID analysis results showed that the difference in the treatment success rate between immigrants and Koreans decreased significantly, from 16% before to 6% after the policy implementation. The difference in the mortality rate between the two groups decreased from - 3% before to - 1% after the policy implementation; however, this difference was insignificant.

CONCLUSION

The treatment outcomes of immigrant TB patients in South Korea improved after the implementation of the pre-entry active TB screening policy. Future immigrant TB policies should consider establishing active patient support strategies and a healthcare collaboration system between countries.

The role of contextual factors in decision-making by General Practitioners on paediatric referral to the Emergency Department: A Discrete Choice Experiment

A General Practitioner's (GP) decision to refer a patient to the emergency department (ED) requires consideration of a multitude of factors, and significant variation in GP referral patterns to secondary care has been recorded. This study examines the contextual factors that influence GPs when referring a paediatric patient with potentially self-limiting clinical symptoms to the ED. Utilizing a discrete choice experiment, survey data was collected from GPs in Ireland (n = 142) to elicit factors influencing this decision across five attributes: time/day of visit, repeat presentation, parents' capacity to cope, parent requesting a referral, and access to a paediatric outpatient clinic/day unit. Using mixed logit models, all attributes were statistically significant, with repeat presentation and parents lacking the capacity to cope identified as the strongest contextual factors leading to the decision to refer to the ED. There has been limited exploration of this decision-making process and this study uses a robust design to identify and rank contextual attributes. Enhanced awareness of contextual factors on referral decision-making is crucial to understanding patterns of paediatric unscheduled healthcare and to planning services that respond to parent's and children's needs, whilst allowing GPs to make decisions in the best interest of the child.

Can higher spending on primary healthcare mitigate the impact of ageing and non-communicable diseases on health expenditure?

INTRODUCTION

Financing healthcare for ageing populations has become an increasingly urgent policy concern. Primary healthcare (PHC) has been viewed as the cornerstone of health systems. While most research has examined the effects of PHC on population health, there is still a relative paucity of analysis on the effects of PHC on health expenditures, particularly, in low-income and middle-income countries. Knowledge on PHC's potential role in mitigating the impact of ageing and non-communicable diseases (NCDs) on health expenditure remains limited.

METHODS

Using publicly accessible secondary data at country level, this paper examines the impact of ageing and the NCD burden on health expenditures. Regression with the interaction terms is used to explore whether greater expenditures on PHC can mitigate the growing fiscal pressure from ageing and the NCD burden.

RESULTS

The empirical evidence shows that a higher share of PHC spending is correlated with lower per capita non-PHC spending, after controlling for population aged 60 and over and NCD burden, and gross domestic product per capita. However, the mitigating effects of PHC spending to reduce non-PHC expenditure caused by ageing and NCDs are not significant.

CONCLUSIONS

The findings suggest that more PHC spending can potentially lower total health expenditure. However, higher primary health spending cannot fulfil that potential without scrupulous attention to the way it is delivered. More spending on PHC, together with changes in PHC service delivery, highlighting its coordination and referring roles, will put nations on a pathway to achieving universal health coverage more sustainably.

Does the abolition of copayment increase ambulatory care utilization?: a quasi-experimental study in Germany

Due to a problematic situation with public finances, Germany introduced a copayment scheme for ambulatory care visits in 2004. In 2012, Germany achieved a balanced budget, and copayment was abolished on the 1st of January 2013. This policy change offers a rare opportunity to explore the impact of the abolition of copayment, compared to the much more frequently studied introduction of copayment. We therefore investigate the development of ambulatory care and inpatient care utilization following this policy change among people over 50 in Germany, as well as the heterogeneous impacts among vulnerable people, such as the low-income population, the chronically ill and the elderly over the age of 65. We use data from the Survey of Health, Ageing and Retirement in Europe and adopt a difference-in-differences approach with matching. We found that the abolition of copayment only caused an increase in ambulatory care use in the shorter term, while leading to a significant reduction in the longer term. In addition, we find a negative effect on inpatient care use, i.e., the hospitalization offset effect. Finally, we demonstrate that vulnerable people were more sensitive to the abolition of copayment.

Failure to take-up public healthcare entitlements: Evidence from the Medical Card system in Ireland

While population health and welfare can be improved through the provision of non-cash benefits, such as free healthcare, many welfare improving schemes have low rates of take up amongst those eligible for such a benefit. One interesting example of this is the Medical Card scheme in Ireland. Medical Cards are a non-cash benefit that provide free primary, community, and hospital care, as well as heavily subsidised prescriptions drugs, for those below specific income means-test threshold. However, despite the significant benefits afforded by a Medical Card, many people forego entitlement. While this has been of concern to policymakers, the prevalence of, and reason for, non-take up, have to date not been examined in-depth. Using detailed household demographic, healthcare, income and expenditure data, this paper estimates the Medical Card take-up rate, examines the reasons for non-take, and estimates the additional healthcare cost burden to individuals due to non-take-up. The paper estimates that 31% of eligible individuals do not take up a Medical Card. Private health insurance coverage, receipt of social welfare, employment status and health status are all strongly correlated with take up. Results suggest that of a lack of information about eligibility status and social stigma are key factors driving non take up. The paper estimates that families who forego their entitled Medical Card typically spend an additional €202 annually on healthcare. Furthermore, as a consequence of higher purchase rates of, perhaps unnecessary, private health insurance, families not taking up their entitlement spend an additional €489 per annum on PHI premia. Welfare losses are likely to be even higher if forgoing medical care due to cost results in future negative health outcomes.

Policy of free GP care for children under 6 years: The impact on emergency department attendance

Universal health coverage (UHC) aims to improve child health. Ireland, the only country in the European Union without universal access to primary care, introduced general practitioner (GP) care at no charge for children aged under six in 2015. This paper aims to evaluate the impact of this policy on attendance at the emergency department (ED). A difference-in-difference (DiD) analysis was applied to visit records of 367,000 paediatric patients at five hospitals over a period of five years, with treatment and control differentiated by age. DiD was also used to assess if GP referrals and the severity of presentations altered as a consequence of this policy. While existing research estimates that this policy increased attendance by children aged under six at general practice by over 25%, this policy did not lead to a reduction in ED attendance. Hospital level effects on attendance varied from no impact to increased attendance by children aged under six of 28.9%. While increased GP referrals, particularly for injury and medical reasons, indicated more patients presented to their GP prior to ED attendance, walk-ins without referral did not decrease. Attendance increased at both regional hospitals, which also had the highest proportion of GP referred visits. While the marginal probability of a visit being GP referred increased at four of the five hospitals in this study, only in two of these can the entire effect be attributed to the introduction of this policy (effects 1.4 and 1.8 percentage points). Previous unmet need, capacity constraints in general practice, regional variability in the GP to population ratio, restricted hours of access to GPs, coupled with faster access to diagnostics in the ED setting, may explain variability in the effect and why the expected reduction in ED attendances did not occur.

Do access, quality and cost of general practice affect emergency department use?

Limited access, poor experience, and high out-of-pocket (OOP) costs of primary care services may lead to avoidable emergency department (ED) presentations. But, the evidence has been limited with most of the studies using surveys conducted in EDs. Using detailed health survey data of Australian women linked to multiple administrative datasets, we extend the literature by estimating the effects of access, costs, and experience of general practice (GP) services on the probability of ED attendance while accounting for a large set of health and socioeconomic covariates. Our findings suggest that improvements in access to primary care services can significantly reduce the demand for low acuity ED presentations. We also show that the impact of increased accessibility of GP services is expected to be the highest for socioeconomic vulnerable populations and patients whose access is the poorest. This evidence can be useful for the design of targeted policies aimed at improving access to doctors in particular areas that are socioeconomically disadvantaged and where medical skill shortages are significant. However, policies aimed at reduction in primary care OOP costs or improvement in the perception of GP quality are less likely to be effective in reducing the number of non-urgent ED presentations.

Paediatric attendances of the emergency department in a major Irish tertiary referral centre before and after expansion of free GP care to children under 6: a retrospective observational study

OBJECTIVES

To examine the characteristics of paediatric attendances to the emergency department (ED) in Cork University Hospital (CUH) before and after the expansion of free general practitioner (GP) care to children under the age of 6 years.

DESIGN

This is a retrospective observational study that used a large administrative dataset.

SETTING

The study was conducted in major Irish tertiary referral centre that serves a total population of over 1.1 million. It is a public hospital, owned and managed by the health service executive.

PARTICIPANTS

Children aged 0-15 years who attended CUH ED during the study period of 6 years (2012-2018) were included in this study (n=76 831).

INTERVENTIONS

Free GP care was expanded to all children aged 0-5 years in July 2015.

MAIN OUTCOME MEASURES

Paediatric attendances to CUH ED were examined before (Time Period 1: July 2012-June 2015) and after (Time Period 2: July 2015-June 2018) the expansion of free GP care to children under 6. Changes in GP referral rates and inpatient hospital admissions were investigated.

RESULTS

Paediatric presentations to CUH ED increased from 35 819 during the Time Period 1 to 41 012 during the Time Period 2 (14.5%). The proportion of the CUH ED attendances through GP referrals by children under 6 increased by over 8% in the Time Period 2 (from 10 148 to 14 028). Although the number of all children who attended CUH ED and were admitted to hospital increased in Time Period 2 (from 8704 to 9320); the proportion of children in the 0-5 years group who attended the CUH ED through GP referral and were subsequently admitted to hospital, decreased by over 3%.

CONCLUSION

The expansion of free GP care has upstream health service utilisation implications, such as increased attendances at ED, and should be considered and costed by policy-makers.

Does formal home care reduce inpatient length of stay?

Formal home care is an appropriate substitute for acute hospital care for many older people. However, limited empirical evidence exists on the extent of substitution between the supply of home care and hospital use. This study examines whether patients from areas with a better supply of home care have lower inpatient length of stay (LOS). We link administrative data on over 300,000 public hospital inpatient admissions in Ireland between 2012 and 2015 to region-year panel data on public home care supply. In addition to modeling average LOS, we estimate unconditional quantile regressions to examine whether home care supply has a disproportionately strong impact on long LOS. We find that inpatients from areas with higher per capita home care supply have lower average LOS; a 10% increase in home care is associated with a 1.2%-2.1% reduction in LOS. This result is driven by the subset of patients with the longest LOS, likely delayed discharges. Stronger results were found for stroke and hip fracture patients, who might be expected to have higher than average propensity to use home care services, and for patients from a region that experienced an unusually large increase in home care supply.

Factors influencing general practitioners decisions to refer Paediatric patients to the emergency department: a systematic review and narrative synthesis

BACKGROUND

Clinical guidelines are integral to a general practitioner's decision to refer a paediatric patient to emergency care. The influence of non-clinical factors must also be considered. This review explores the non-clinical factors that may influence general practitioners (GPs) when deciding whether or not to refer a paediatric patient to the Emergency Department (ED).

METHODS

A systematic review of peer-reviewed literature published from August 1980 to July 2019 was conducted to explore the non-clinical factors that influence GPs' decision-making in referring paediatric patients to the emergency department. The results were synthesised using a narrative approach.

RESULTS

Seven studies met the inclusion criteria. Non-clinical factors relating to patients, GPs and health systems influence GPs decision to refer children to the ED. GPs reported parents/ caregivers influence, including their perception of severity of child's illness, parent's request for onward referral and GPs' appraisal of parents' ability to cope. Socio-economic status, GPs' aversion to risk and system level factors such as access to diagnostics and specialist services also influenced referral decisions.

CONCLUSIONS

A myriad of non-clinical factors influence GP referrals of children to the ED. Further research on the impact of non-clinical factors on clinical decision-making can help to elucidate patterns and trends of paediatric healthcare and identify areas for intervention to utilise resources efficiently and improve healthcare delivery.

Children's unscheduled primary and emergency care in Ireland: a multimethod approach to understanding decision making, trends, outcomes and parental perspectives (CUPID): project protocol

INTRODUCTION

The aim of this project is to determine the patterns, decision-making processes and parental preferences associated with unscheduled paediatric healthcare utilisation in Ireland. Unscheduled paediatric healthcare is outpatient care provided within primary care settings by general practitioners (GPs), emergency departments (EDs) located in paediatric and general hospitals, and out-of-hours services provided by cooperatives of GPs operating on a regional basis. This project will take a multimethod approach to analysing the utilisation of unscheduled paediatric healthcare nationally within the context of a significant change to the provision of healthcare for young children in Ireland-the introduction of free at the point of delivery GP care for all children aged under 6.

METHODS AND ANALYSIS

A multimethod approach consisting of three work packages will be employed. Using patient-level data, work package 1 will describe patterns of attendance at primary care, out-of-hours medical services and at EDs. Applying a difference-in-difference methodology, the impact of the introduction of free GP care for children under 6 on attendance will be assessed. Work package 2 will explore geospatial trends of attendance at EDs, identifying disparities in ED attendance by local area and demographic characteristics. Work package 3 will employ two discrete choice experiments to examine parental preferences for unscheduled paediatric healthcare and GP decision making when referring a child to the ED. The insights gained by each of the work packages individually and collectively will inform evidence-based health policy for the organisation of paediatric care and resource allocation.

ETHICS AND DISSEMINATION

Ethical approval for this research has been granted by University College Dublin, The Irish College of General Practitioners and the five participating hospitals. Results will be disseminated via publication in peer-reviewed journals, national and international conferences, and to relevant stakeholders and interest groups.