Pay-for-performance programs in family practices in the United Kingdom

Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea

AIM

In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD.

METHODS

Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD.

RESULTS

We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%).

CONCLUSIONS

Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.

A new look at physicians' responses to financial incentives: Quality of care, practice characteristics, and motivations

There is considerable controversy about what causes (in)effectiveness of physician performance pay in improving the quality of care. Using a behavioral experiment with German primary-care physicians, we study the incentive effect of performance pay on service provision and quality of care. To explore whether variations in quality are based on the incentive scheme and the interplay with physicians' real-world profit orientation and patient-regarding motivations, we link administrative data on practice characteristics and survey data on physicians' attitudes with experimental data. We find that, under performance pay, quality increases by about 7pp compared to baseline capitation. While the effect increases with the severity of illness, the bonus level does not significantly affect the quality of care. Data linkage indicates that primary-care physicians in high-profit practices provide a lower quality of care. Physicians' other-regarding motivations and attitudes are significant drivers of high treatment quality.

Reducing health inequalities through general practice: a realist review and action framework

Background

Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities.

Objectives

We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice.

Design

Realist review.

Main outcome measures

Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria.

Review methods

Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence.

Results

Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships.

Limitations

The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care.

Conclusions

Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred.

Future work

Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice.

Study registration

This trial is registered as PROSPERO CRD42020217871.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Reducing health inequalities through general practice

Although general practice can contribute to reducing health inequalities, existing evidence provides little guidance on how this reduction can be achieved. We reviewed interventions influencing health and care inequalities in general practice and developed an action framework for health professionals and decision makers. We conducted a realist review by searching MEDLINE, Embase, CINAHL, PsycINFO, Web of Science, and Cochrane Library for systematic reviews of interventions into health inequality in general practice. We then screened the studies in the included systematic reviews for those that reported their outcomes by socioeconomic status or other PROGRESS-Plus (Cochrane Equity Methods Group) categories. 159 studies were included in the evidence synthesis. Robust evidence on the effect of general practice on health inequalities is scarce. Focusing on common qualities of interventions, we found that to reduce health inequalities, general practice needs to be informed by five key principles: involving coordinated services across the system (ie, connected), accounting for differences within patient groups (ie, intersectional), making allowances for different patient needs and preferences (ie, flexible), integrating patient worldviews and cultural references (ie, inclusive), and engaging communities with service design and delivery (ie, community-centred). Future work should explore how these principles can inform the organisational development of general practice.

Does the implementation of pay-for-performance indicators improve the quality of healthcare? First results in France

Background

Pay-for-performance (P4P) models are intended to promote quality of care in both hospitals and primary care settings. They are considered as a means of changing medical practices, particularly in primary care.

Objectives

The first objective of this study was to assess how performance indicators changed over time, measured through “Remuneration on Public Health Objectives” (ROSP) scores, between 2017 and 2020 in a large French region (Grand Est region), and to compare this evolution in the rural vs. urban areas of the region. The second objective was to focus on the area with the least improvement in ROSP scores and to investigate whether the scores and the available sociodemographic characteristics of the area were associated.

Methods

First, we measured the evolution over time of P4P indicators (i.e., ROSP scores) obtained from the regional health insurance system, for GP practices in the Grand Est region between 2017 and 2020. We then compared the scores between the Aube Department and the rest of the region (urban areas). To address the second objective, we focused on the area found to have the least improvement in indicators to investigate whether there was a relationship between ROSP score and sociodemographic characteristics.

Results

More than 40,000 scores were collected. We observed an overall improvement in scores over the study period. The urban area (Grand Est region minus the Aube) scored better than the rural area (Aube) for chronic disease management [median 0.91 (0.84–0.95) vs. 0.90(0.79–0.94), p < 0.001] and prevention [median 0.36 (0.22–0.45) vs. 0.33 (0.17–0.43), p < 0.001], but not for efficiency, where the rural area (Aube) performed better [median 0.67(0.56–0.74) vs. 0.69 (0.57–0.75 in the rest of the Grand Est region, p = 0.004]. In the rural area, we found no significant association between ROSP scores and sociodemographic characteristics, except for extreme rurality in some sub-areas.

Conclusions

At the regional level, the overall improvement in scores observed between 2017 and 2020 suggests that the implementation of ROSP indicators have improved the quality of care, particularly in urban areas. These results also suggest that efforts should be focused on rural areas, which already had the lowest scores at the start of the P4P program.

Predictors and population health outcomes of persistent high GP turnover in English general practices: a retrospective observational study

OBJECTIVE

English primary care faces significant challenges, including 'persistent high turnover' of general practitioners (GPs) in some partnerships. It is unknown whether there are specific predictors of persistent high turnover and whether it is associated with poorer population health outcomes.

DESIGN

A retrospective observational study.

METHODS

We linked workforce data on individual GPs to practice-level data from Hospital Episode Statistics and the GP Patient Survey (2007-2019). We classified practices as experiencing persistent high turnover if more than 10% of GPs changed in at least 3 consecutive years. We used multivariable logistic or linear regression models for panel data with random effects to identify practice characteristics that predicted persistent high turnover and associations of practice outcomes (higher emergency hospital use and patient experience of continuity of care, access to care and overall patient satisfaction) with persistent high turnover.

RESULTS

Each year, 6% of English practices experienced persistent high turnover, with a maximum of 9% (688/7619) in 2014. Larger practices, in more deprived areas and with a higher morbidity burden were more likely to experience persistent high turnover. Persistent high turnover was associated with 1.8 (95% CI 1.5 to 2.1) more emergency hospital attendances per 100 patients, 0.1 (95% CI 0.1 to 0.2) more admissions per 100 patients, 5.2% (95% CI -5.6% to -4.9%) fewer people seeing their preferred doctor, 10.6% (95% CI-11.4% to -9.8%) fewer people reporting obtaining an appointment on the same day and 1.3% (95% CI -1.6% to -1.1%) lower overall satisfaction with the practice.

CONCLUSIONS

Persistent high turnover is independently linked to indicators of poorer service and health outcomes. Although causality needs to be further investigated, strategies and policies may be needed to both reduce high turnover and support practices facing challenges with high GP turnover when it occurs.

What is the value and impact of the adaptation process on quality indicators for local use? A scoping review

BACKGROUND

Quality indicators (QIs) are designed for improving quality of care, but the development of QIs is resource intensive and time consuming.

OBJECTIVE

To describe and identify the impact and potential attributes of the adaptation process for the local use of existing QIs.

DATA SOURCES

EMBASE, MEDLINE, CINAHL and grey literature were searched.

STUDY SELECTION

Literatures operationalizing or implementing QIs that were developed in a different jurisdiction from the place where the QIs were included.

RESULTS

Of 7704 citations identified, 10 out of 33 articles were included. Our results revealed a lack of definition and conceptualization for an adaptation process in which an existing set of QIs was applied. Four out of ten studies involved a consensus process (e.g., Delphi or RAND process) to determine the suitability of QIs for local use. QIs for chronic conditions in primary and secondary settings were mostly used for adaptation. Of the ones that underwent a consensus process, 56.3 to 85.7% of original QIs were considered valid for local use, and 2 to 21.8% of proposed QIs were newly added. Four attributes should be considered in the adaptation: 1) identifying areas/conditions; 2) a consensus process; 3) proposing adapted QIs; 4) operationalization and evaluation.

CONCLUSION

The existing QIs, although serving as a good starting point, were not adequately adapted before for use in a different jurisdiction from their origin. Adaptation of QIs under a systematic approach is critical for informing future research planning for QIs adaptation and potentially establishing a new pathway for healthcare improvement.

Glycemic outcomes in patients with type 2 diabetes after bariatric surgery compared with routine care: a population-based, real-world cohort study in the United Kingdom

BACKGROUND

Clinical trials have shown that bariatric surgery (BS) is associated with better glycemic control and diabetes remission in patients with type 2 diabetes (T2D) compared with routine care.

OBJECTIVE

We conducted a real-world population-based study examining the impact of BS on glycemic control and medications in patients with T2D.

SETTING AND METHODS

This was a retrospective, matched, controlled cohort study conducted between January 1, 1990, and January 31, 2018, using IQVIA Medical Research Data, a primary care electronic records database. Adults with body mass index (BMI) ≥30 kg/m² and T2D who had BS (surgical) were matched for age, sex, BMI, and diabetes duration to two controls (with T2D and no BS).

RESULTS

A total of 1126 patients in the surgical group and 2219 patients in the control group were analyzed. Mean (standard deviation) age was 50.0 (9.3) years, 67.6% were women, baseline glycocylated hemoglobin (HbA1C) was 7.8% (1.7 mmol/mol), and diabetes duration was 4.7 years (range, 2.0-8.4 years). Over a median (interquartile range) follow-up of 3.6 years (1.7-5.9 years), a higher proportion of patients in the surgical group achieved an HbA1C of ≤6.0% than the control group (65.8% versus 22.8%). The surgical group showed a decrease in mean HbA1C of 1.5% (95% confidence interval [CI]: 1.4%-1.7%), 1.4% (1.2%-1.5%), and 1.3% (1.1%-1.5%) at 1-, 2-, and 3-year follow-up, respectively, whereas HbA1C increased in the control group. The proportion of patients receiving glucose-lowering medications decreased in the surgical group (92.2% to 66.5%) but increased in the control group (85.3% to 90.2%).

CONCLUSION

BS is associated with significant improvement in glycemic control, achievement of normal HbA1C levels, and reduced need for glucose-lowering therapy in patients with T2D.

The Effects of Cost Containment and Price Policies on Pharmaceutical Expenditure in South Korea

BACKGROUND

Policy-makers have proposed and implemented various cost-containment policies for drug prices and quantities to regulate rising pharmaceutical spending. Our study focused on a major change in pricing policy and several incentive schemes for curbing pharmaceutical expenditure growth during the 2010s in Korea.

METHODS

We constructed the longitudinal dataset from 2008-2017 for 12 904 clinics to track the prescriber behavior before and after the implemented policies. Applying an interrupted time series model, we analyzed changes in trends in overall monthly drug expenditure and antibiotic drug expenditure per prescription for outpatient claims diagnosed with three major diseases before and after the policies' implementation.

RESULTS

Significant price reductions and incentives for more efficient drug prescriptions resulted in an immediate decrease in monthly drug expenditures in clinics. However, we found attenuated effects over the long run. The top-spending clinics showed the highest rate of increase in drug costs.

CONCLUSION

Future policy interventions can maximize their effects by targeting high-spending providers.

Improvement of supportive systems for medically-underserved areas

Background: In order to encourage physicians to work in medically-underserved areas, it is imperative to provide financial incentives and appropriate supportive systems. This paper reviews the concept of medically-underserved areas in Korea is welestablished with reasonable criteria and that the budget and the policy direction of the manpower support are effective.Current Concepts: Some recommendations may be needed to expand the supportive policy for medically-underserved areas. First, the selection criteria for medically-underserved areas should be revised and the evaluation index improved. Second, it is imperative to secure consistency in the legal system by containing overall contents on the definition, criteria, designation procedure, and support matters of medically-underserved areas through the revision of the Public Health and Medical Service Act. This consistency may designate and support medically-underserved areas according to the subject and type through health care resources distribution and condition at the national level. Third, an integrated regional medical service plan should be prepared through the construction of an inter-medical institution cooperation system, effort, and cooperation among parties having diverse interests. Fourth, the incentive system should be improved to secure medical personnel in medically-underserved areas. Fifth, the introduction of untact medical services and related governmental support to the area having insufficient medical personnel is needed.Discussion and Conclusion: The Korean government should seek new supportive measures and models for physicians to continue working in medically-underserved areas.

Efficacy of a theory-driven program to implement alcohol screening and brief interventions in primary health-care: a cluster randomized controlled trial

BACKGROUND AND AIMS

Screening and brief interventions (SBI) in primary health-care practices (PHCP) are effective in reducing reported alcohol consumption, but have not been routinely implemented. Most programs seeking to improve implementation rates have lacked a theoretical rationale. This study aimed to test whether a theory-based intervention for PHCPs could significantly increase alcohol SBI delivery.

DESIGN

Two-arm, cluster-randomized controlled, parallel, 12-month follow-up, trial.

SETTING

PHCPs in Portugal.

PARTICIPANTS

Staff from 12 PHCPs (n = 222, 81.1% women): nurses (35.6%), general practitioners (28.8%), receptionists (26.1%) and family medicine residents (9.5%); patients screened for alcohol use: intervention n = 8062; controls n = 58.

INTERVENTION AND COMPARATOR

PHCPs were randomized to receive a training and support program (n = 6; 110 participants) tailored to the barriers and facilitators for implementing alcohol SBIs following the principles of the Behavior Change Wheel/Theoretical Domains Framework approach, or to a waiting-list control (n = 6; 112 participants). Training was delivered over the first 12 weeks of the trial.

MEASUREMENTS

The primary outcome was the proportion of eligible patients screened (unit of analysis: patient list). Secondary outcomes included the brief intervention (BI) rate per screen-positive patient and the population-based BI rate (unit of analysis: patient list), and changes in health providers' perceptions of barriers to implementation and alcohol-related knowledge (unit of analysis: health provider).

FINDINGS

The implementation program had a significant effect on the screening activity in the intervention practices compared with control practices at the 12-month follow-up (21.7% vs. 0.16%, intention-to-treat analysis, p = 0.003). Although no significant difference was found on the BI rate per screen-positive patient (intervention 85.7% vs. control 63.6%, p = 0.55, Bayes factor = 0.28), the intervention was effective in increasing the population-based BI rate (intervention 0.69% vs. control 0.02%, p = 0.006). Health providers in the intervention arm reported fewer barriers to SBI implementation and higher levels of alcohol-related knowledge at 12-month follow-up than those in control practices.

CONCLUSION

A theory-based implementation program, which included training and support activities, significantly increased alcohol screening and population-based brief intervention rates in primary care.

How do clinical quality and patient satisfaction vary with provider size in primary care? Evidence from English general practice panel data

We examine the relationship between general practice list size and measures of clinical quality and patient satisfaction. Using data on all English practices from 2005/6 to 2016/17, we estimate practice level models with rich data on patient demographics, deprivation, and morbidity. We use lagged list size to allow for potential simultaneity bias from the effect of quality on list size. We compare results from three different estimation methods: pooled ordinary least squares, random practice effects, fixed practice effects. With all three estimation methods increased list size is associated with reductions in all four measures of patient satisfaction. Increases in list size are associated with worse performance on three clinical quality indicators and better performance on three, though the precision and size of the associations varies with the estimation method. The absolute values of the elasticities of the ten quality indicators with respect to list size are small: in all cases a 10% change in list size would change quality by less than 1%. The lack of evidence that large practices have markedly better quality suggests that encouraging practices to form larger, but looser, groupings, may not, in itself, improve their performance.

Are quality promotion initiatives in Austrian and Italian general practices associated with higher patient satisfaction and quality of life? Results from the interventional study 'IQuaB'

The objective was to assess the changes in quality of life (QoL) and patient satisfaction of chronically ill patients in general practices in Salzburg (Austria) and South Tyrol (Italy) after implementation of a combined intervention addressing quality of care of general practitioners (GPs). Furthermore, the correlation between QoL/patient satisfaction and quality of care provided by the GPs (measured by a quality score based on quality indicators [QIs]) was investigated. The non-controlled pre-post study involved GPs and patients with chronic conditions. The intervention consisted of self-audit, benchmarking and quality circles. QIs were extracted in the participating practices in 2012 (preintervention) and 2014 (postintervention). Before and after the intervention, a patient survey was conducted including EQ-5D (measuring health-related QoL), a patient participation scale and parts of the European Task Force on Patient Evaluations of General Practice questionnaire (measuring patient satisfaction). Mann-Whitney U-tests, chi-square tests and Spearman's rank correlation were applied for statistical analysis. Fifty-six GPs participated in the study. 1,710 patients returned the questionnaire in 2012, and 1,374 in 2014. Mean EQ-5D index (QoL) was similar in Salzburg and South Tyrol in both years: 2012 Salzburg 0.85 (95% CI 0.84-0.87), South Tyrol 0.85 (95% CI 0.84-0.86); 2014 Salzburg 0.84 (95% CI 0.83-0.86), South Tyrol 0.84 (95% CI 0.83-0.86). Patient satisfaction was higher in Salzburg than in South Tyrol at baseline (EUROPEP: mean percentage of best response 61.5% vs. 49.1%, p < 0.000) and also at follow-up (61.9% vs. 49.2%; p < 0.000). No significant correlation between quality score and QoL/patient satisfaction was detected. Thus, the impact of the intervention was not significant within the intermediate time periods analysed in the study. Improvements in quality of care do not necessarily also improve patient-relevant outcomes, which are probably more associated with other factors than with medical quality (e.g. availability of the GP, waiting times and communication-related issues).

Explaining variable effects of an adaptable implementation package to promote evidence-based practice in primary care: a longitudinal process evaluation

Background

Implementing evidence-based recommendations is challenging in UK primary care, especially given system pressures and multiple guideline recommendations competing for attention. Implementation packages that can be adapted and hence applied to target multiple guideline recommendations could offer efficiencies for recommendations with common barriers to achievement. We developed and evaluated a package of evidence-based interventions (audit and feedback, educational outreach and reminders) incorporating behaviour change techniques to target common barriers, in two pragmatic trials for four “high impact” indicators: risky prescribing; diabetes control; blood pressure control; and anticoagulation in atrial fibrillation. We observed a significant, cost-effective reduction in risky prescribing but there was insufficient evidence of effect on the other outcomes. We explored the impact of the implementation package on both social processes (Normalisation Process Theory; NPT) and hypothesised determinants of behaviour (Theoretical Domains Framework; TDF).

Methods

We conducted a prospective multi-method process evaluation. Observational, administrative and interview data collection and analyses in eight primary care practices were guided by NPT and TDF. Survey data from trial and process evaluation practices explored fidelity.

Results

We observed three main patterns of variation in how practices responded to the implementation package. First, in integration and achievement, the package “worked” when it was considered distinctive and feasible. Timely feedback directed at specific behaviours enabled continuous goal setting, action and review, which reinforced motivation and collective action. Second, impacts on team-based determinants were limited, particularly when the complexity of clinical actions impeded progress. Third, there were delivery delays and unintended consequences. Delays in scheduling outreach further reduced ownership and time for improvement. Repeated stagnant or declining feedback that did not reflect effort undermined engagement.

Conclusions

Variable integration within practice routines and organisation of care, variable impacts on behavioural determinants, and delays in delivery and unintended consequences help explain the partial success of an adaptable package in primary care.

The effects of an evidence- and theory-informed feedback intervention on opioid prescribing for non-cancer pain in primary care: A controlled interrupted time series analysis

BACKGROUND

The rise in opioid prescribing in primary care represents a significant international public health challenge, associated with increased psychosocial problems, hospitalisations, and mortality. We evaluated the effects of a comparative feedback intervention with persuasive messaging and action planning on opioid prescribing in primary care.

METHODS AND FINDINGS

A quasi-experimental controlled interrupted time series analysis used anonymised, aggregated practice data from electronic health records and prescribing data from publicly available sources. The study included 316 intervention and 130 control primary care practices in the Yorkshire and Humber region, UK, serving 2.2 million and 1 million residents, respectively. We observed the number of adult patients prescribed opioid medication by practice between July 2013 and December 2017. We excluded adults with coded cancer or drug dependency. The intervention, the Campaign to Reduce Opioid Prescribing (CROP), entailed bimonthly, comparative, and practice-individualised feedback reports to practices, with persuasive messaging and suggested actions over 1 year. Outcomes comprised the number of adults per 1,000 adults per month prescribed any opioid (main outcome), prescribed strong opioids, prescribed opioids in high-risk groups, prescribed other analgesics, and referred to musculoskeletal services. The number of adults prescribed any opioid rose pre-intervention in both intervention and control practices, by 0.18 (95% CI 0.11, 0.25) and 0.36 (95% CI 0.27, 0.46) per 1,000 adults per month, respectively. During the intervention period, prescribing per 1,000 adults fell in intervention practices (change -0.11; 95% CI -0.30, -0.08) and continued rising in control practices (change 0.54; 95% CI 0.29, 0.78), with a difference of -0.65 per 1,000 patients (95% CI -0.96, -0.34), corresponding to 15,000 fewer patients prescribed opioids. These trends continued post-intervention, although at slower rates. Prescribing of strong opioids, total opioid prescriptions, and prescribing in high-risk patient groups also generally fell. Prescribing of other analgesics fell whilst musculoskeletal referrals did not rise. Effects were attenuated after feedback ceased. Study limitations include being limited to 1 region in the UK, possible coding errors in routine data, being unable to fully account for concurrent interventions, and uncertainties over how general practices actually used the feedback reports and whether reductions in prescribing were always clinically appropriate.

CONCLUSIONS

Repeated comparative feedback offers a promising and relatively efficient population-level approach to reduce opioid prescribing in primary care, including prescribing of strong opioids and prescribing in high-risk patient groups. Such feedback may also prompt clinicians to reconsider prescribing other medicines associated with chronic pain, without causing a rise in referrals to musculoskeletal clinics. Feedback may need to be sustained for maximum effect.

Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years

INTRODUCTION

Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme.

RESEARCH DESIGN AND METHODS

Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models.

RESULTS

Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels.

CONCLUSIONS

Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.

Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study

National financial incentive schemes for improving the quality of primary care have come under criticism in the United Kingdom, leading to calls for localized alternatives. This study investigated whether a local general practice incentive-based quality improvement scheme launched in 2011 in a city in the North West of England was associated with a reduction in all-cause emergency hospital admissions. Difference-in-differences analysis was used to compare the change in emergency admission rates in the intervention city, to the change in a matched comparison population. Emergency admissions rates fell by 19 per 1,000 people in the years following the intervention (95% confidence interval [17, 21]) in the intervention city, relative to the comparison population. This effect was greater among more disadvantaged populations, narrowing socioeconomic inequalities in emergency admissions. The findings suggest that similar approaches could be an effective component of strategies to reduce unplanned hospital admissions elsewhere.

How did a Quality Premium financial incentive influence antibiotic prescribing in primary care? Views of Clinical Commissioning Group and general practice professionals

BACKGROUND

The Quality Premium (QP) was introduced for Clinical Commissioning Groups (CCGs) in England to optimize antibiotic prescribing, but it remains unclear how it was implemented.

OBJECTIVES

To understand responses to the QP and how it was perceived to influence antibiotic prescribing.

METHODS

Semi-structured telephone interviews were conducted with 22 CCG and 19 general practice professionals. Interviews were analysed thematically.

RESULTS

The findings were organized into four categories. (i) Communication: this was perceived as unstructured and infrequent, and CCG professionals were unsure whether they received QP funding. (ii) Implementation: this was influenced by available local resources and competing priorities, with multifaceted and tailored strategies seen as most helpful for engaging general practices. Many antimicrobial stewardship (AMS) strategies were implemented independently from the QP, motivated by quality improvement. (iii) Mechanisms: the QP raised the priority of AMS nationally and locally, and provided prescribing targets to aim for and benchmark against, but money was not seen as reinvested into AMS. (iv) Impact and sustainability: the QP was perceived as successful, but targets were considered challenging for a minority of CCGs and practices due to contextual factors (e.g. deprivation, understaffing). CCG professionals were concerned with potential discontinuation of the QP and prescribing rates levelling off.

CONCLUSIONS

CCG and practice professionals expressed positive views of the QP and associated prescribing targets and feedback. The QP helped influence change mainly by raising the priority of AMS and defining change targets rather than providing additional funding. To maximize impact, behavioural mechanisms of financial incentives should be considered pre-implementation.

Quality improvement in chronic care by self-audit, benchmarking and networking in general practices in South Tyrol, Italy: results from an interventional study

BACKGROUND

Systematic strategies promoting quality of care in general practice are yet under-represented in several European countries.

OBJECTIVE

This interventional study assessed whether a combined intervention (self-audit, benchmarking, quality circles) improved quality of care in Salzburg, Austria and South Tyrol, Italy. The present publication reports the Italian results.

METHODS

We developed quality indicators for general practice in a consensus process based on pre-existing quality programmes. The indicators addressed diagnosis and treatment regarding eight common chronic conditions. A quality score comprising 91 indicators was calculated (0-5 points per indicator depending on fulfilment, maximum 455 points). We collected anonymous data from the electronic health records of the participating physicians in 2012, 2013 and 2014. Wilcoxon signed-rank tests were used for pre-post analysis.

RESULTS

Thirty-six GPs participated in the study. The median quality score increased significantly from 177.0 points at baseline to 272.0 points at the second follow-up (P = 0.000). Improvements concerned process and intermediate outcome indicators particularly between baseline and the first follow-up.

CONCLUSION

Performance was relatively low at baseline and improved considerably, mainly in the first study period. The intervention investigated in this study can serve as a model for future quality programmes. A customized electronic health record for the implementation of this intervention as well as standardized and consistent documentation by GPs is a prerequisite. Use of a limited set of quality indicators (QIs) and regular QI modification is probably advisable to increase the benefits. Long-term prospective studies should investigate the impact of QI-based interventions on end-result outcomes.

Obesity Without Metabolic Abnormality and Incident CKD: A Population-Based British Cohort Study

RATIONALE & OBJECTIVE

Metabolically healthy obesity (obesity without any metabolic abnormality) is not considered to be associated with increased risk of morbidity and mortality. We examined and quantified the association between metabolically healthy overweight/obesity and the risk of incident chronic kidney disease (CKD) in a British primary care population.

STUDY DESIGN

Retrospective population-based cohort study.

SETTING & PARTICIPANTS

4,447,955 of the 5,182,908 adults in The Health Improvement Network (THIN) database (United Kingdom, 1995-2015) with a recorded body mass index (BMI) at the time of registration date who were free of CKD and cardiovascular disease.

EXPOSURE

11 body size phenotypes were created, defined by BMI categories (underweight, normal weight, overweight, and obesity) and 3 metabolic abnormalities (diabetes, hypertension, and dyslipidemia).

OUTCOME

Incident CKD defined as a recorded code for kidney replacement therapy, a recorded diagnosis of CKD, or by an estimated glomerular filtration rate of<60mL/min/1.73m² for≥90 days, or a urinary albumin-creatinine ratio>3mg/mmol for≥90 days.

RESULTS

Of the 4.5 million individuals, 1,040,921 (23.4%) and 588,909 (13.2%) had metabolically healthy overweight and metabolically healthy obesity, respectively. During a mean follow-up interval of 5.4±4.3 (SD) years, compared with individuals with a metabolically healthy normal weight (n=1,656,231), there was a higher risk of incident CKD among those who had metabolically healthy overweight (adjusted HR, 1.30 [95% CI, 1.28-1.33]) and metabolically healthy obesity (adjusted HR, 1.66 [95% CI, 1.62-1.70]). The association was stronger in those younger than 65 years of age. In all BMI categories, there was greater risk of incident CKD with a greater number of metabolic abnormalities in a graded manner.

LIMITATIONS

Potential misclassification of metabolic status due to delayed diagnosis and residual confounding due to unmeasured factors.

CONCLUSIONS

Overweight and obesity without metabolic abnormality are associated with a higher risk of incident CKD compared with those with normal body weight and no metabolic abnormality.

Measured Performance and Vaccine Administration After Decision Support and Office Workflow Changes for Influenza Vaccination

Influenza vaccination is underused. We examined changes in vaccination following decision support and workflow changes in a cross-sectional analysis of three vaccination seasons among adult primary care patients from 21 practices. Interventions included clinical decision support changes to facilitate documentation; changes to rooming workflow for medical assistants and licensed practical nurses to promote vaccination, prepare orders, document care done elsewhere; and record patient refusals. We measured rates for a national vaccination performance measure and receipt of onsite vaccination. Approximately 120,000 patients were eligible each season. Performance on the quality measure increased each year (40.6% to 62.5% to 76.4%). Corresponding rates of onsite vaccination were 27.7%, 28.8%, and 31.5%. The adjusted odds ratio for onsite vaccination in the second season compared with the first was 0.94 (95% confidence interval [CI] 0.92, 0.96). Onsite vaccination was more likely in the third season compared with either previous season-adjusted odds ratio for third versus second 1.14 (95% CI, 1.12, 1.16) or adjusted odds ratio for third versus first 1.07 (95% CI 1.05-1.09). Sequential changes in decision support and patient rooming process workflows were associated with large improvements in measured performance and with a significant increase in clinic-administered influenza vaccination by the third season.

Sex, Age, and Socioeconomic Differences in Nonfatal Stroke Incidence and Subsequent Major Adverse Outcomes

Supplemental Digital Content is available in the text.

Data about variations in stroke incidence and subsequent major adverse outcomes are essential to inform secondary prevention and prioritizing resources to those at the greatest risk of major adverse end points. We aimed to describe the age, sex, and socioeconomic differences in the rates of first nonfatal stroke and subsequent major adverse outcomes.

An adaptable implementation package targeting evidence-based indicators in primary care: A pragmatic cluster-randomised evaluation

BACKGROUND

In primary care, multiple priorities and system pressures make closing the gap between evidence and practice challenging. Most implementation studies focus on single conditions, limiting generalisability. We compared an adaptable implementation package against an implementation control and assessed effects on adherence to four different evidence-based quality indicators.

METHODS AND FINDINGS

We undertook two parallel, pragmatic cluster-randomised trials using balanced incomplete block designs in general practices in West Yorkshire, England. We used 'opt-out' recruitment, and we randomly assigned practices that did not opt out to an implementation package targeting either diabetes control or risky prescribing (Trial 1); or blood pressure (BP) control or anticoagulation in atrial fibrillation (AF) (Trial 2). Within trials, each arm acted as the implementation control comparison for the other targeted indicator. For example, practices assigned to the diabetes control package acted as the comparison for practices assigned to the risky prescribing package. The implementation package embedded behaviour change techniques within audit and feedback, educational outreach, and computerised support, with content tailored to each indicator. Respective patient-level primary endpoints at 11 months comprised the following: achievement of all recommended levels of haemoglobin A1c (HbA1c), BP, and cholesterol; risky prescribing levels; achievement of recommended BP; and anticoagulation prescribing. Between February and March 2015, we recruited 144 general practices collectively serving over 1 million patients. We stratified computer-generated randomisation by area, list size, and pre-intervention outcome achievement. In April 2015, we randomised 80 practices to Trial 1 (40 per arm) and 64 to Trial 2 (32 per arm). Practices and trial personnel were not blind to allocation. Two practices were lost to follow-up but provided some outcome data. We analysed the intention-to-treat (ITT) population, adjusted for potential confounders at patient level (sex, age) and practice level (list size, locality, pre-intervention achievement against primary outcomes, total quality scores, and levels of patient co-morbidity), and analysed cost-effectiveness. The implementation package reduced risky prescribing (odds ratio [OR] 0.82; 97.5% confidence interval [CI] 0.67-0.99, p = 0.017) with an incremental cost-effectiveness ratio of £1,359 per quality-adjusted life year (QALY), but there was insufficient evidence of effect on other primary endpoints (diabetes control OR 1.03, 97.5% CI 0.89-1.18, p = 0.693; BP control OR 1.05, 97.5% CI 0.96-1.16, p = 0.215; anticoagulation prescribing OR 0.90, 97.5% CI 0.75-1.09, p = 0.214). No statistically significant effects were observed in any secondary outcome except for reduced co-prescription of aspirin and clopidogrel without gastro-protection in patients aged 65 and over (adjusted OR 0.62; 97.5% CI 0.39-0.99; p = 0.021). Main study limitations concern our inability to make any inferences about the relative effects of individual intervention components, given the multifaceted nature of the implementation package, and that the composite endpoint for diabetes control may have been too challenging to achieve.

CONCLUSIONS

In this study, we observed that a multifaceted implementation package was clinically and cost-effective for targeting prescribing behaviours within the control of clinicians but not for more complex behaviours that also required patient engagement.

TRIAL REGISTRATION

The study is registered with the ISRCTN registry (ISRCTN91989345).

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis

AIM

To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care.

DESIGN

Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points.

SETTING

England.

PARTICIPANTS

Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723).

MEASUREMENTS

The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption.

FINDINGS

There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month.

CONCLUSIONS

Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.

Temporal trends in the incidence, treatment patterns, and outcomes of coronary artery disease and peripheral artery disease in the UK, 2006–2015

Aims

Most reports estimating national incidence rates of coronary (CAD) and peripheral arterial disease (PAD) have focused on stable outpatients or acute or elective hospital admissions, but not on the overall burden of disease. In this study, we report the changing trends in the population-level incidence of CAD and PAD, respectively from 2006 to 2015, statin utilization for secondary prevention and survival outcomes using multiple nationally representative data sources from the UK (primary care encounters, hospital admissions, and procedure-level data).

Methods and results

A nationally representative study of linked primary and secondary care electronic health records of 4.6 million individuals from the UK. We calculated crude and standardized annual incidence rates separately for CAD and PAD. Statin use for secondary prevention, trends in annual major vascular event rates, and mortality between 2006 and 2015, were estimated for CAD and PAD, respectively. We identified 160 376 and 70 753 patients with incident CAD and PAD, respectively. The age- and sex-standardized incidence of CAD was similar in 2006 (443 per 100 000 person-years) and 2015 [436 per 100 000 person-years; adjusted incidence rate ratio (IRR) 0.98, 95% confidence interval (CI) 0.96–1.00]. In contrast, there was a 15% decline in the standardized incidence of PAD (236 per 100 000 person-years in 2006 to 202 per 100 000 person-years in 2015; adjusted IRR 0.85, 95% CI 0.82–0.88). The proportion of incident CAD and PAD patients prescribed long-term statins, was only 66% and 55%, respectively and was less common amongst women, patients aged &gt;70 years, with heart failure, chronic lung disease, or depression. Cardiovascular mortality declined by 43% for incident CAD (adjusted IRR 0.57, 95% CI 0.50–0.64) between 2006 and 2015 but did not decline for incident PAD (adjusted IRR 0.84, 95% CI 0.70–1.00).

Conclusion and relevance

In the UK, the standardized incidence of CAD appears stable but mortality rates are falling, whereas the standardized incidence of PAD is falling but mortality rates are not.

New funding for a new Brazilian Primary Health Care

This paper aims to present a debate on the new Brazilian Primary Health Care (PHC) funding policy. We consulted the national and international literature, and we involved municipal, state, and federal PHC managers to develop the payment method. The proposed final model is based on weighted capitation, payment-for-performance, and incentive for strategic actions. Capitation is weighted by the socioeconomic vulnerability, demographic aspects, and municipal adjustment, the payment-for-performance consists of an entire set of 21 indicators, and incentives for strategic actions were facilitated from the maintenance of some specific programs. The results of the simulations pointed to low registration (90 million Brazilians) for the currently estimated coverage (148,674,300 Brazilians). Moreover, they showed an immediate increase in financial resources for 4,200 Brazilian municipalities. We observed that the funding proposal brings Brazilian PHC into the 21st century, points to the strengthening of PHC attributes, and materializes the principles of universality and equity of the Unified Health System.

Spatial competition and quality: Evidence from the English family doctor market

We examine whether family doctor firms in England respond to local competition by increasing their quality. We measure quality in terms of clinical performance and patient-reported satisfaction to capture its multi-dimensional nature. We use a panel covering 8 years for over 8000 English general practices. We measure competition as the number of rival doctors within a small distance and control for a large number of potential confounders. We find that increases in local competition are associated with increases in patient satisfaction and to a lesser extent in clinical quality. However, the magnitude of the effect is small.

Quality indicators and community pharmacy services: a scoping review

BACKGROUND

Quality indicators are a commonly used improvement tool in health care. There is growing interest and activity in the use of quality indicators to improve community pharmacy practice.

OBJECTIVES

To conduct a scoping review of the use of quality indicators for community pharmacy practice, including their methods of development and evaluation.

METHODS

Electronic databases (EMBASE and PubMed) were searched to identify papers published between January 2008 and April 2018. No limits were applied for language of publication or country of origin. Studies were included if they reported empirical data regarding the development or evaluation of quality indicators. All study designs were eligible for inclusion. Duplicate independent screening was undertaken of the search results. Data extraction was performed by one reviewer.

RESULTS

Of the 988 records identified from the database search, 15 articles were included. The studies were conducted in 12 countries from six continents. Eleven studies described the development of quality indicators, eight of which included the evaluation of the psychometric properties of the indicators developed. Four studies examined the impact of quality indicators on practice all of which reported improvements in some aspects of quality, mainly with structure indicators rather than those relating to process and outcome.

CONCLUSIONS

Whilst there is a growing emphasis on promoting improvement in community pharmacy services, evidence is lacking of the effect of indicators on improving quality. Measurable process and outcome indicators are needed. The future development of quality indicators would also benefit from a multi-stakeholder approach.

Organisational factors associated with safety climate, patient satisfaction and self-reported medicines adherence in community pharmacies

BACKGROUND

Evidence suggests that community pharmacy service quality varies, and that this may relate to pharmacy ownership. However little is known about wider organisational factors associated with quality.

OBJECTIVE

To investigate organisational factors associated with variation in safety climate, patient satisfaction and self-reported medicines adherence in English community pharmacies.

METHODS

Multivariable regressions were conducted using data from two cross-sectional surveys, of 817 pharmacies and 2124 patients visiting 39 responding pharmacies, across 9 diverse geographical areas. Outcomes measured were safety climate, patient satisfaction and self-reported medicines adherence. Independent variables included service volume (e.g. dispensing volume), pharmacy characteristics (e.g. pharmacy ownership), patient characteristics (e.g. age) and areal-specific demographic, socio-economic and health-needs variables.

RESULTS

Valid response rates were 277/800 (34.6%) and 971/2097 (46.5%) for pharmacy and patient surveys respectively. Safety climate was associated with pharmacy ownership (F_8,225 = 4.36, P < 0.001), organisational culture (F_{4, 225} = 12.44, P < 0.001), pharmacists' working hours (F_{4, 225} = 2.68, P = 0.032) and employment of accuracy checkers (F_{4, 225} = 4.55, P = 0.002). Patients' satisfaction with visit was associated with employment of pharmacy technicians (β = 0.0998, 95%CI = [0.0070,0.1926]), continuity of advice-giver (β = 0.2593, 95%CI = [0.1251,0.3935]) and having more reasons for choosing that pharmacy (β = 0.3943, 95%CI = [0.2644, 0.5242]). Satisfaction with information received was associated with continuity of advice-giver (OR = 1.96, 95%CI = [1.36, 2.82]), weaker belief in medicines overuse (OR = 0.92, 95%CI = [0.88, 0.96]) and age (OR = 1.02, 95%CI = [1.01, 1.03]). Regular deployment of locums by pharmacies was associated with poorer medicines adherence (OR = 0.50, 95%CI = [0.30, 0.84]), as was stronger patient belief in medicines overuse (OR = 0.88, 95%CI=[0.81, 0.95]) and younger age (OR = 1.04, 95%CI = [1.01, 1.07]). No patient outcomes were associated with pharmacy ownership or service volume.

CONCLUSIONS

This study characterised variation in the quality of English community pharmacy services identifying the importance of skill-mix, continuity of care, pharmacy ownership, organisational culture, and patient characteristics. Further research is needed into what constitutes and influences quality, including the development of validated quality measures.

Thyroid replacement therapy, thyroid stimulating hormone concentrations, and long term health outcomes in patients with hypothyroidism: longitudinal study

OBJECTIVE

To explore whether thyroid stimulating hormone (TSH) concentration in patients with a diagnosis of hypothyroidism is associated with increased all cause mortality and a higher risk of cardiovascular disease and fractures.

DESIGN

Retrospective cohort study.

SETTING

The Health Improvement Network (THIN), a database of electronic patient records from UK primary care.

PARTICIPANTS

Adult patients with incident hypothyroidism from 1 January 1995 to 31 December 2017.

EXPOSURE

TSH concentration in patients with hypothyroidism.

MAIN OUTCOME MEASURES

Ischaemic heart disease, heart failure, stroke/transient ischaemic attack, atrial fibrillation, any fractures, fragility fractures, and mortality. Longitudinal TSH measurements from diagnosis to outcomes, study end, or loss to follow-up were collected. An extended Cox proportional hazards model with TSH considered as a time varying covariate was fitted for each outcome.

RESULTS

162 369 patients with hypothyroidism and 863 072 TSH measurements were included in the analysis. Compared with the reference TSH category (2-2.5 mIU/L), risk of ischaemic heart disease and heart failure increased at high TSH concentrations (>10 mIU/L) (hazard ratio 1.18 (95% confidence interval 1.02 to 1.38; P=0.03) and 1.42 (1.21 to 1.67; P<0.001), respectively). A protective effect for heart failure was seen at low TSH concentrations (hazard ratio 0.79 (0.64 to 0.99; P=0.04) for TSH <0.1 mIU/L and 0.76 (0.62 to 0.92; P=0.006) for 0.1-0.4 mIU/L). Increased mortality was observed in both the lowest and highest TSH categories (hazard ratio 1.18 (1.08 to 1.28; P<0.001), 1.29 (1.22 to 1.36; P<0.001), and 2.21 (2.07 to 2.36; P<0.001) for TSH <0.1 mIU/L, 4-10 mIU/L, and >10 mIU/L. An increase in the risk of fragility fractures was observed in patients in the highest TSH category (>10 mIU/L) (hazard ratio 1.15 (1.01 to 1.31; P=0.03)).

CONCLUSIONS

In patients with a diagnosis of hypothyroidism, no evidence was found to suggest a clinically meaningful difference in the pattern of long term health outcomes (all cause mortality, atrial fibrillation, ischaemic heart disease, heart failure, stroke/transient ischaemic attack, fractures) when TSH concentrations were within recommended normal limits. Evidence was found for adverse health outcomes when TSH concentration is outside this range, particularly above the upper reference value.

Association Between Idiopathic Intracranial Hypertension and Risk of Cardiovascular Diseases in Women in the United Kingdom

IMPORTANCE

Cardiovascular disease (CVD) risk has not been previously evaluated in a large matched cohort study in idiopathic intracranial hypertension (IIH).

OBJECTIVES

To estimate the risk of composite cardiovascular events, heart failure, ischemic heart disease, stroke/transient ischemic attack (TIA), type 2 diabetes, and hypertension in women with idiopathic intracranial hypertension and compare it with the risk in women, matched on body mass index (BMI) and age, without the condition; and to evaluate the prevalence and incidence of IIH.

DESIGN, SETTING, AND PARTICIPANTS

This population-based matched controlled cohort study used 28 years of data, from January 1, 1990, to January 17, 2018, from The Health Improvement Network (THIN), an anonymized, nationally representative electronic medical records database in the United Kingdom. All female patients aged 16 years or older were eligible for inclusion. Female patients with IIH (n = 2760) were included and randomly matched with up to 10 control patients (n = 27 125) by BMI and age.

MAIN OUTCOMES AND MEASURES

Adjusted hazard ratios (aHRs) of cardiovascular outcomes were calculated using Cox regression models. The primary outcome was a composite of any CVD (heart failure, ischemic heart disease, and stroke/TIA), and the secondary outcomes were each CVD outcome, type 2 diabetes, and hypertension.

RESULTS

In total, 2760 women with IIH and 27 125 women without IIH were included. Age and BMI were similar between the 2 groups, with a median (interquartile range) age of 32.1 (25.6-42.0) years in the exposed group and 32.1 (25.7-42.1) years in the control group; in the exposed group 1728 women (62.6%) were obese, and in the control group 16514 women (60.9%) were obese. Higher absolute risks for all cardiovascular outcomes were observed in women with IIH compared with control patients. The aHRs were as follows: composite cardiovascular events, 2.10 (95% CI, 1.61-2.74; P < .001); heart failure, 1.97 (95% CI, 1.16-3.37; P = .01); ischemic heart disease, 1.94 (95% CI, 1.27-2.94; P = .002); stroke/TIA, 2.27 (95% CI, 1.61-3.21; P < .001); type 2 diabetes, 1.30 (95% CI, 1.07-1.57; P = .009); and hypertension, 1.55 (95% CI, 1.30-1.84; P < .001). The incidence of IIH in female patients more than tripled between 2005 and 2017, from 2.5 to 9.3 per 100 000 person-years. Similarly, IIH prevalence increased in the same period, from 26 to 79 per 100 000 women. Incidence increased markedly with BMI higher than 30.

CONCLUSIONS AND RELEVANCE

Idiopathic intracranial hypertension in women appeared to be associated with a 2-fold increase in CVD risk; change in patient care to modify risk factors for CVD may reduce long-term morbidity for women with IIH and warrants further evaluation.

Diagnostic tests, drug prescriptions, and follow-up patterns after incident heart failure: A cohort study of 93,000 UK patients

BACKGROUND

Effective management of heart failure is complex, and ensuring evidence-based practice presents a major challenge to health services worldwide. Over the past decade, the United Kingdom introduced a series of national initiatives to improve evidence-based heart failure management, including a landmark pay-for-performance scheme in primary care and a national audit in secondary care started in 2004 and 2007, respectively. Quality improvement efforts have been evaluated within individual clinical settings, but patterns of care across its continuum, although a critical component of chronic disease management, have not been studied. We have designed this study to investigate patients' trajectories of care around the time of diagnosis and their variation over time by age, sex, and socioeconomic status.

METHODS AND FINDINGS

For this retrospective population-based study, we used linked primary and secondary health records from a representative sample of the UK population provided by the Clinical Practice Research Datalink (CPRD). We identified 93,074 individuals newly diagnosed with heart failure between 2002 and 2014, with a mean age of 76.7 years and of which 49% were women. We examined five indicators of care: (i) diagnosis care setting (inpatient or outpatient), (ii) posthospitalisation follow-up in primary care, (iii) diagnostic investigations, (iv) prescription of essential drugs, and (v) drug treatment dose. We used Poisson and linear regression models to calculate category-specific risk ratios (RRs) or adjusted differences and 95% confidence intervals (CIs), adjusting for year of diagnosis, age, sex, region, and socioeconomic status. From 2002 to 2014, indicators of care presented diverging trends. Outpatient diagnoses and follow-up after hospital discharge in primary care declined substantially (ranging from 56% in 2002 to 36% in 2014, RR 0.64 [0.62, 0.67] and 20% to 14%, RR 0.73 [0.65, 0.82], respectively). Primary care referral for diagnostic investigations and appropriate initiation of beta blockers and angiotensin-converting-enzyme inhibitors (ACE-Is) or angiotensin receptor blockers (ARBs) both increased significantly (37% versus 82%, RR 2.24 [2.15, 2.34] and 18% versus 63%, RR 3.48 [2.72, 4.43], respectively). Yet, the average daily dose prescribed remained below guideline recommendations (42% for ACE-Is or ARBs, 29% for beta blockers in 2014) and was largely unchanged beyond the first 30 days after diagnosis. Despite increasing rates of treatment initiation, the overall dose prescribed to patients in the 12 months following diagnosis improved little over the period of study (adjusted difference for the combined dose of beta blocker and ACE-I or ARB: +6% [+2%, +10%]). Women and patients aged over 75 years presented significant gaps across all five indicators of care. Our study was limited by the available clinical information, which did not include exact left ventricular ejection fraction values, investigations performed during hospital admissions, or information about follow-up in community heart failure clinics.

CONCLUSIONS

Management of heart failure patients in the UK presents important shortcomings that affect screening, continuity of care, and medication titration and disproportionally impact women and older people. National reporting and incentive schemes confined to individual clinical settings have been insufficient to identify these gaps and address patients' long-term care needs.

Patient consultation rate and clinical and NHS outcomes: a cross-sectional analysis of English primary care data from 2.7 million patients in 238 practices

BACKGROUND

Primary care workload is high and increasing in the United Kingdom. We sought to examine the association between rates of primary care consultation and outcomes in England.

METHODS

Cross sectional observational study of routine electronic health care records in 283 practices from the Clinical Practice Research Datalink from April 2013 to March 2014. Outcomes included mortality rate, hospital admission rate, Quality and Outcomes Framework (QOF) performance and patient satisfaction. Relationships between consultation rates (with a general practitioner (GP) or nurse) and outcomes were investigated using negative binomial and ordinal logistic regression models.

RESULTS

Rates of GP and nurse consultation (per patient person-year) were not associated with mortality or hospital admission rates: mortality incidence rate ratio (IRR) per unit change in GP/ nurse consultation rate = 1.01, 95% CI [0.98 to 1.04]/ 0.97, 95% CI [0.93 to 1.02]; hospital admission IRR per unit change in GP/ nurse consultation rate = 1.02, 95% CI [0.99 to 1.04]/ 0.98, 95% CI [0.94 to 1.032]. Higher rates of nurse but not GP consultation were associated with higher QOF achievement: OR = 1.91, 95% CI [1.39 to 2.62] per unit change in nurse consultation rate vs. OR = 1.04, 95% CI [0.87 to 1.24] per unit change in GP consultation rate. The association between the rates of GP/ nurse consultations and patient satisfaction was mixed.

CONCLUSION

There are few associations between primary care consultation rates and outcomes. Previously identified demographic and staffing factors, rather than practice workload, appear to have the strongest relationships with mortality, admissions, performance and satisfaction. Studies with more detailed patient-level data would be required to explore these findings further.

The Push and Pull of Self-Managing Mild COPD: An Evaluation of Participant Experiences of a Nurse-Led Telephone Health Coaching Intervention

Health coaching is a novel population intervention to support self-management but it is untested in people with mild disease. People with chronic obstructive pulmonary disease with mild dyspnea are a population excluded from supported self-management and whose illness might progress without intervention. We explored participants' experiences about how health coaching motivated behavior change. Interviews were conducted with 21 intervention and 10 control participants at 6 months, and 20 intervention participants at 12 months. Participants were identified from a randomized controlled trial of telephone health coaching. Data were analyzed using the framework method. Participants positively enacted behavior change to become more physically active. Participants took advantage of environmental affordances to pull themselves toward activity targets, or relied on being pushed to be more active by the health coach or significant others. Behavior change was maintained where efforts to be more active were built into the everyday lifeworld of participants.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Use of medicine pricing and reimbursement policies for universal health coverage in Indonesia

OBJECTIVES

This study aimed to define the problems of the current use of the e-Catalogue and the national formulary (NF)-two elements of medicine pricing and reimbursement policies in Indonesia for achieving universal health coverage (UHC)-by examining the knowledge and attitudes of stakeholders. Specifically, to investigate (1) the perceived challenges involved in the further implementation of the e-Catalogue and the NF, (2) reasons of prescribing medicines not listed in the NF, and (3) possible improvements in the acceptance and use of the e-Catalogue and the NF.

METHODS

Semi-structured interviews were conducted with stakeholders (policymakers, healthcare providers, a pharmaceutical industry representative, and experienced patients) to collect the qualitative data. The data was analysed using directed content analysis, following the guidelines of the COnsolidated criteria for REporting Qualitative studies (COREQ) in reporting the findings.

RESULTS

Interestingly, 20 of 45 participants decided to withdraw from the interview due to their lack of knowledge of the e-Catalogue and the NF. All 25 stakeholders who fully participated in this research were in favor of the e-Catalogue and the NF. However, interviewees identified a range of challenges. A major challenge was the lack of harmonization between the lists of medicines in the e-Catalogue and the NF. Several system and personal reasons for prescribing medicines not listed in the NF were identified. Important reasons were a lack of incentives for physicians as well as a lack of transparent and evidence-based methods of selection for the medicines to be listed in the NF.

CONCLUSIONS

The e-Catalogue and the NF have not been fully utilized for achieving UHC in Indonesia. Some possible improvements suggested were harmonization of medicines listed in the e-Catalogue and the NF, restructuring incentive programs for prescribing NF medicines, and increasing the transparency and evidence-based approach for selection of medicines listed in the e-Catalogue and the NF.

Influence of financial and reputational incentives on primary care performance: a longitudinal study

BACKGROUND

The Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time.

AIM

To determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme.

DESIGN AND SETTING

Observational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013.

METHOD

The authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards.

RESULTS

Both the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from -0.121 percentage points per quality point (95% CI = -0.220 to -0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013.

CONCLUSION

In the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.

Epilepsy and associated mortality in patients with multiple sclerosis

BACKGROUND AND PURPOSE

We aimed to determine the prevalence of epilepsy in patients with multiple sclerosis (MS) at diagnosis, the risk of developing epilepsy after the diagnosis of MS and the relative risk of mortality associated with epilepsy.

METHODS

We used the UK Clinical Practice Research Data-link to identify 2526 patients with incident MS and 9980 age-, sex- and index year-matched non-MS controls from 1997 to 2006. Logistic regression was used to estimate odds ratios [95% confidence interval (CI)] for epilepsy and Cox regression was used to estimate hazard ratios (HRs) (95% CI) for epilepsy and mortality.

RESULTS

Patients with incident MS were on average 45 years old and 70.9% were female. At diagnosis, the prevalence of epilepsy in patients with MS was 1.30% compared with 0.57% in non-MS controls. At diagnosis, MS was associated with an adjusted odds ratio (95% CI) of 2.11 (1.36-3.27) for pre-existing epilepsy. Among epilepsy-free patients, the cumulative probabilities of developing epilepsy, first recorded within 10 years of the index date, were 2.77% for patients with MS and 0.90% for controls. MS was associated with an adjusted HR (95% CI) of 6.01 (2.94-12.29) for epilepsy. Among patients with MS, epilepsy was associated with an HR (95% CI) of 2.23 (1.02-4.84) for all-cause mortality.

CONCLUSIONS

This population-based study found an increased prevalence of epilepsy in patients with MS at diagnosis when compared with non-MS controls and the risk of developing epilepsy was also higher following the MS diagnosis. Patients with MS with epilepsy had a higher risk of mortality compared with those without.

Physicians' and nurses' attitudes towards performance-based financial incentives in Burundi: a qualitative study in the province of Gitega

Background: Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners.

Objective: To elicit physicians’ and nurses’ experiences and views on how PBF influenced and helped them in healthcare delivery.

Methods: A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data.

Results: Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery.

Conclusions: PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes.

Modelling the cost-effectiveness of pay-for-performance in primary care in the UK

BACKGROUND

Introduced in 2004, the United Kingdom's (UK) Quality and Outcomes Framework (QOF) is the world's largest primary-care pay-for-performance programme. Given some evidence of the benefits and the substantial costs associated with the QOF, it remains unclear whether the programme is cost-effective. Therefore, we assessed the cost-effectiveness of continuing versus stopping the QOF.

METHODS

We developed a lifetime simulation model to estimate quality-adjusted life years (QALYs) and costs for a UK population cohort aged 40-74 years (n = 27,070,862) exposed to the QOF and for a counterfactual scenario without exposure. Based on a previous retrospective cross-country analysis using data from 1994 to 2010, we assumed the benefits of the QOF to be a change in age-adjusted mortality of -3.68 per 100,000 population (95% confidence interval -8.16 to 0.80). We used cost-effectiveness thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY to determine the optimal strategy in base-case and sensitivity analyses.

RESULTS

In the base-case analysis, continuing the QOF increased population-level QALYs and health-care costs yielding an incremental cost-effectiveness ratio (ICER) of £49,362/QALY. The ICER remained >£30,000/QALY in scenarios with and without non-fatal outcomes or increased drug costs, and under differing assumptions about the duration of QOF benefit following its hypothetical discontinuation. The ICER for continuing the programme fell below £30,000/QALY when QOF incentive payments were 36% lower (while preserving QOF mortality benefits), and in scenarios where the QOF resulted in substantial reductions in health-care spending or non-fatal cardiovascular disease events. Continuing the QOF was cost-effective in 18%, 3% and 0% of probabilistic sensitivity analysis iterations using thresholds of £30,000/QALY, £20,000/QALY and £13,000/QALY, respectively.

CONCLUSIONS

Compared to stopping the QOF and returning all associated incentive payments to the National Health Service, continuing the QOF is not cost-effective. To improve population health efficiently, the UK should redesign the QOF or pursue alternative interventions.

Taking the measure of the profession: Physician associations in the measurement age

Systematic measurement of healthcare services enables evaluation of health professionals' quality of work. Whereas policy makers find measurement a useful mechanism for quality improvement, a public choice perspective implies that physicians would resent such an initiative, which undermines their professional autonomy. In this article, we compare two healthcare systems of economically developed countries - Israel and the UK. Both systems share common features such as universal coverage, strong state intervention, and enthusiasm for New Public Management. In both countries, quality measurement was introduced in acute care hospitals at around the same time. However, while the UK succeeded in establishing a framework of surgical outcome measures during the 2000s, a similar initiative in Israel failed completely during the 1990s. We also refer to subsequent quality indicator efforts in Israel, in both community and hospital frameworks, that were more successful, but in a way that reinforces our central thesis. We contend that differences in reform outcomes stem from the medical profession's reaction to government's endeavors. This response, in turn, hinges on the professional organizations' relative institutional position vis-a-vis state authorities. This study constitutes a unique investigation of the medical profession's response to critical quality measurement reforms. Most importantly, it stresses the institutional position of medical associations as the primary factor in explaining cross-case variation in government's success in introducing quality measurement.

Long term extension of a randomised controlled trial of probiotics using electronic health records

Most randomised controlled trials (RCTs) are relatively short term and, due to costs and available resources, have limited opportunity to be re-visited or extended. There is no guarantee that effects of treatments remain unchanged beyond the study. Here, we illustrate the feasibility, benefits and cost-effectiveness of enriching standard trial design with electronic follow up. We completed a 5-year electronic follow up of a RCT investigating the impact of probiotics on asthma and eczema in children born 2005–2007, with traditional fieldwork follow up to two years. Participants and trial outcomes were identified and analysed after five years using secure, routine, anonymised, person-based electronic health service databanks. At two years, we identified 93% of participants and compared fieldwork with electronic health records, highlighting areas of agreement and disagreement. Retention of children from lower socio-economic groups was improved, reducing volunteer bias. At 5 years we identified a reduced 82% of participants. These data allowed the trial’s first robust analysis of asthma endpoints. We found no indication that probiotic supplementation to pregnant mothers and infants protected against asthma or eczema at 5 years. Continued longer-term follow up is technically straightforward.

Current practice of usual clinic blood pressure measurement in people with and without diabetes: a survey and prospective 'mystery shopper' study in UK primary care

OBJECTIVES

Hypertension trials and epidemiological studies use multiple clinic blood pressure (BP) measurements at each visit. Repeat measurement is also recommended in international guidance; however, little is known about how BP is measured routinely. This is important for individual patient management and because routinely recorded readings form part of research databases. We aimed to determine the current practice of BP measurement during routine general practice appointments.

DESIGN

(1) An online cross-sectional survey and (2) a prospective 'mystery shopper' study where patients agreed to report how BP was measured during their next appointment.

SETTING

Primary care.

PARTICIPANTS

Patient charity/involvement group members completing an online survey between July 2015 and January 2016. 334 participants completed the prospective study (51.5% male, mean age=59.3 years) of which 279 (83.5%) had diabetes.

PRIMARY OUTCOME

Proportion of patients having BP measured according to guidelines.

RESULTS

217 participants with (183) and without diabetes (34) had their BP measured at their last appointment. BP was measured in line with UK guidance in 63.7% and 60.0% of participants with and without diabetes, respectively. Initial pressures were significantly higher in those who had their BP measured more than once compared with only once (p=0.016/0.089 systolic and p<0.001/p=0.022 diastolic, in patients with/without diabetes, respectively).

CONCLUSIONS

Current practice of routine BP measurement in UK primary care is often concordant with guidelines for repeat measurement. Further studies are required to confirm findings in broader populations, to confirm when a third repeat reading is obtained routinely and to assess adherence to other aspects of BP measurement guidance.

Socioeconomic inequality in medication persistence in primary and secondary prevention of coronary heart disease - A population-wide electronic cohort study

Background

Coronary heart disease (CHD) mortality in England fell by 36% between 2000 and 2007 and it is estimated that approximately 50% of the fall was due to improved treatment uptake. Marked socio-economic inequalities in CHD mortality in the United Kingdom (UK) remain, with higher age-adjusted rates in more deprived groups. Inequalities in the persistence of medication for primary and secondary prevention of CHD may contribute to the observed social gradient and we investigated this possibility in the population of Wales (UK).

Methods and findings

An electronic cohort of individuals aged over 20 (n = 1,199,342) in Wales (UK) was formed using linked data from primary and secondary care and followed for six years (2004–2010). We identified indications for medication (statins, aspirin, ACE inhibitors, clopidogrel) recommended in UK National Institute for Clinical Excellence (NICE) guidance for CHD (high risk, stable angina, stable angina plus diabetes, unstable angina, and myocardial infarction) and measured the persistence of indicated medication (time from initiation to discontinuation) across quintiles of the Welsh Index of Multiple Deprivation, an area-based measure of socio-economic inequality, using Cox regression frailty models. In models adjusted for demographic factors, CHD risk and comorbidities across 15 comparisons for persistence of the medications, none favoured the least deprived quintile, two favoured the most deprived quintile and 13 showed no significant differences.

Conclusions

During our study period (2004–2010) we found no significant evidence of socio-economic inequality in the persistence of recommended medication for primary and secondary prevention of CHD.