1
|
Orman Z, Olaiya MT, Thrift AG, Cadilhac DA, Phan T, Nelson MR, Ung D, Srikanth VK, Bladin CF, Gerraty RP, Phillipos J, Kim J. Cost-Effectiveness of an Individualised Management Program after Stroke: A Trial-Based Economic Evaluation. Neuroepidemiology 2024; 58:156-165. [PMID: 38359812 PMCID: PMC11152005 DOI: 10.1159/000535638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/20/2023] [Indexed: 02/17/2024] Open
Abstract
INTRODUCTION Evidence on the cost-effectiveness of comprehensive post-stroke programs is limited. We assessed the cost-effectiveness of an individualised management program (IMP) for stroke or transient ischaemic attack (TIA). METHODS A cost-utility analysis alongside a randomised controlled trial with a 24-month follow-up, from both societal and health system perspectives, was conducted. Adults with stroke/TIA discharged from hospitals were randomised by primary care practice to receive either usual care (UC) or an IMP in addition to UC (intervention). An IMP included stroke-specific nurse-led education and a specialist review of care plans at baseline, 3 months, and 12 months, and telephone reviews by nurses at 6 months and 18 months. Costs were expressed in 2021 Australian dollars (AUD). Costs and quality-adjusted life years (QALYs) beyond 12 months were discounted by 5%. The probability of cost-effectiveness of the intervention was determined by quantifying 10,000 bootstrapped iterations of incremental costs and QALYs below the threshold of AUD 50,000/QALY. RESULTS Among the 502 participants (65% male, median age 69 years), 251 (50%) were in the intervention group. From a health system perspective, the incremental cost per QALY gained was AUD 53,175 in the intervention compared to the UC group, and the intervention was cost-effective in 46.7% of iterations. From a societal perspective, the intervention was dominant in 52.7% of iterations, with mean per-person costs of AUD 49,045 and 1.352 QALYs compared to mean per-person costs of AUD 51,394 and 1.324 QALYs in the UC group. The probability of the cost-effectiveness of the intervention, from a societal perspective, was 60.5%. CONCLUSIONS Care for people with stroke/TIA using an IMP was cost-effective from a societal perspective over 24 months. Economic evaluations of prevention programs need sufficient time horizons and consideration of costs beyond direct healthcare utilisation to demonstrate their value to society.
Collapse
Affiliation(s)
- Zhomart Orman
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia,
| | - Muideen T Olaiya
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Thanh Phan
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Ung
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Velandai K Srikanth
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
| | - Christopher F Bladin
- Eastern Health Clinical School, Monash University, Box Hill, Victoria, Australia
- Victorian Stroke Telemedicine, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Richard P Gerraty
- Department of Medicine, Epworth Healthcare, Richmond, Victoria, Australia
| | - Joseph Phillipos
- Department of General Surgery, Alfred Hospital, Melbourne, Victoria, Australia
| | - Joosup Kim
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Department of Neurology, Monash Medical Centre, Clayton, Victoria, Australia
| |
Collapse
|
2
|
Orman Z, Cadilhac DA, Andrew NE, Kilkenny MF, Olaiya MT, Thrift AG, Ung D, Dalli LL, Churilov L, Sundararajan V, Lannin NA, Nelson MR, Srikanth V, Kim J. Cost-Effectiveness of a Government Policy to Incentivise Chronic Disease Management following Stroke: A Modelling Study. Neuroepidemiology 2024; 58:208-217. [PMID: 38290479 DOI: 10.1159/000536224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
INTRODUCTION Little is known about the cost-effectiveness of government policies that support primary care physicians to provide comprehensive chronic disease management (CDM). This paper aimed to estimate the potential cost-effectiveness of CDM policies over a lifetime for long-time survivors of stroke. METHODS A Markov model, using three health states (stable, hospitalised, dead), was developed to simulate the costs and benefits of CDM policies over 30 years (with 1-year cycles). Transition probabilities and costs from a health system perspective were obtained from the linkage of data between the Australian Stroke Clinical Registry (cohort n = 12,368, 42% female, median age 70 years, 45% had CDM claims) and government-held hospital, Medicare, and pharmaceutical claims datasets. Quality-adjusted life years (QALYs) were obtained from a comparable cohort (n = 512, 34% female, median age 69.6 years, 52% had CDM claims) linked with Medicare claims and death data. A 3% discount rate was applied to costs in Australian dollars (AUD, 2016) and QALYs beyond 12 months. Probabilistic sensitivity analyses were used to understand uncertainty. RESULTS Per-person average total lifetime costs were AUD 142,939 and 8.97 QALYs for those with a claim, and AUD 103,889 and 8.98 QALYs for those without a claim. This indicates that these CDM policies were costlier without improving QALYs. The probability of cost-effectiveness of CDM policies was 26.1%, at a willingness-to-pay threshold of AUD 50,000/QALY. CONCLUSION CDM policies, designed to encourage comprehensive care, are unlikely to be cost-effective for stroke compared to care without CDM. Further research to understand how to deliver such care cost-effectively is needed.
Collapse
Affiliation(s)
- Zhomart Orman
- Health Economics and Policy Evaluation Research Group, Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Parkville, Victoria, Australia,
- Pharmacoepidemiology and Real-World Evidence Unit, Centre of Cardiovascular Research and Education in Therapeutics, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia,
| | - Dominique A Cadilhac
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Nadine E Andrew
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
- National Centre for Healthy Ageing, Frankston, Victoria, Australia
| | - Monique F Kilkenny
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| | - Muideen T Olaiya
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Amanda G Thrift
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - David Ung
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
- National Centre for Healthy Ageing, Frankston, Victoria, Australia
| | - Lachlan L Dalli
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Leonid Churilov
- Melbourne Medical School, University of Melbourne, Melbourne, Victoria, Australia
| | - Vijaya Sundararajan
- Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Victoria, Australia
| | - Natasha A Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Alfred Health, Melbourne, Victoria, Australia
| | - Mark R Nelson
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia
- National Centre for Healthy Ageing, Frankston, Victoria, Australia
| | - Joosup Kim
- Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
- Stroke Division, Florey Institute of Neuroscience and Mental Health, Parkville, Victoria, Australia
| |
Collapse
|
3
|
Maitra NS, Mahtta D, Navaneethan S, Vaughan EM, Kochar A, Gulati M, Levine GN, Petersen LA, Virani SS. A Mistake Not to Be Repeated: What Can We Learn from the Underutilization of Statin Therapy for Efficient Dissemination of Cardioprotective Glucose Lowering Agents? Curr Cardiol Rep 2022; 24:689-698. [PMID: 35352278 DOI: 10.1007/s11886-022-01694-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/23/2022] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To review the factors contributing to underutilization of guideline-directed therapies, identify strategies to alleviate these factors, and apply these strategies for effective and timely dissemination of novel cardioprotective glucose-lowering agents. RECENT FINDINGS Recent analyses demonstrate underutilization of cardioprotective glucose lowering agents despite guideline recommendations for their use. Major contributors to underutilization of guideline-directed therapies include therapeutic inertia, perceptions about side effects, and factors found at the level of the clinicians, patients, and the healthcare system. The recent emergence of several novel therapies, such as sodium-glucose cotransporter-2 inhibitors and glucagon-like peptide-1 receptor agonists, for use in cardiovascular disease provides a unique avenue to improve patient outcomes. To effectively utilize novel cardioprotective glucose lowering agents to improve cardiovascular outcomes, clinicians must recognize and learn from prior barriers to application of guideline-directed therapies. Further endeavors are prudent to ensure uptake of novel agents.
Collapse
Affiliation(s)
- Neil S Maitra
- Division of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Dhruv Mahtta
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
| | - Sankar Navaneethan
- Section of Nephrology and Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
- Section of Nephrology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Elizabeth M Vaughan
- Division of General Internal Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Ajar Kochar
- Brigham and Women's Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Martha Gulati
- Section of Cardiology, University of Arizona College of Medicine - Phoenix, Phoenix, AR, USA
| | - Glenn N Levine
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Laura A Petersen
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA
- Section of Health Services Research, Baylor College of Medicine, Houston, TX, USA
| | - Salim S Virani
- Section of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations in Quality, Effectiveness, and Safety, Houston, TX, USA.
- Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.
- Michael E. DeBakey Veterans Affairs Medical Center, Health Services Research and Development, 2002 Holcombe Boulevard, Houston, TX, USA.
| |
Collapse
|
4
|
Hafiz N, Hyun K, Knight A, Hespe C, Chow CK, Briffa T, Gallagher R, Reid CM, Hare DL, Zwar N, Woodward M, Jan S, Atkins ER, Laba TL, Halcomb E, Usherwood T, Redfern J. Gender Comparison of Receipt of Government-Funded Health Services and Medication Prescriptions for the Management of Patients With Cardiovascular Disease in Primary Care. Heart Lung Circ 2021; 30:1516-1524. [PMID: 33933363 DOI: 10.1016/j.hlc.2021.04.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 01/11/2021] [Accepted: 04/08/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) and risk factors remains a major burden in terms of disease, disability, and death in the Australian population and mental health is considered as an important risk factor affecting cardiovascular disease. A multidisciplinary collaborative approach in primary care is required to ensure an optimal outcome for managing cardiovascular patients with mental health issues. Medicare introduced numerous primary care health services and medications that are subsidised by the Australian government in order to provide a more structured approach to reduce and manage CVD. However, the utilisation of these services nor gender comparison for CVD management in primary care has been explored. Therefore, the aim is to compare the provision of subsidised chronic disease management plans (CDMPs), mental health care and prescription of guideline-indicated medications to men and women with CVD in primary care practices for secondary prevention. METHODS De-identified data for all active patients with CVD were extracted from 50 Australian primary care practices. Outcomes included the frequency of receipt of CDMPs, mental health care and prescription of evidence-based medications. Analyses adjusted for demography and clinical characteristics, stratified by gender, were performed using logistic regression and accounted for clustering effects by practices. RESULTS Data for 14,601 patients with CVD (39.4% women) were collected. The odds of receiving the CDMPs was significantly greater amongst women than men (preparation of general practice management plan [GPMP]: (46% vs 43%; adjusted OR [95% CI]: 1.22 [1.12, 1.34]). Women were more likely to have diagnosed with mental health issues (32% vs 20%, p<0.0001), however, the adjusted odds of men and women receiving any government-subsidised mental health care were similar. Women were less often prescribed blood pressure, lipid-lowering and antiplatelet medications. After adjustment, only an antiplatelet medication or agent was less likely to be prescribed to women than men (44% vs 51%; adjusted OR [95% CI]: 0.84 [0.76, 0.94]). CONCLUSION Women were more likely to receive CDMPs but less likely to receive antiplatelet medications than men, no gender difference was observed in the receipt of mental health care. However, the receipt of the CDMPs and the mental health treatment consultations were suboptimal and better use of these existing services could improve ongoing CVD management.
Collapse
Affiliation(s)
- Nashid Hafiz
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia. https://twitter.com/HafizNashid
| | - Karice Hyun
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Andrew Knight
- Primary and Integrated Care Unit, South Western Sydney Local Health District, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia
| | - Charlotte Hespe
- The University of Notre Dame, School of Medicine, Sydney, NSW, Australia
| | - Clara K Chow
- Western Sydney Local Health District, Sydney, NSW, Australia; Westmead Applied Research Centre, The University of Sydney, Sydney, NSW, Australia
| | - Tom Briffa
- School of Population and Global Health, Faculty of Health and Medical Sciences, The University of Western Australia, Sydney, NSW, Australia
| | - Robyn Gallagher
- Sydney Nursing School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Christopher M Reid
- School of Public Health, Curtin University, Perth, WA, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - David L Hare
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Vic, Australia; Austin Health, Melbourne, Vic, Australia
| | - Nicholas Zwar
- Faculty of Health Sciences & Medicine, Bond University, Brisbane, Qld, Australia
| | - Mark Woodward
- University of New South Wales, Sydney, NSW, Australia; The George Institute for Global Health, Sydney, NSW, Australia
| | - Stephen Jan
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Emily R Atkins
- The George Institute for Global Health, Sydney, NSW, Australia
| | - Tracey-Lea Laba
- University of Technology Sydney Centre for Health Economics Research and Evaluation, Sydney, NSW, Australia
| | - Elizabeth Halcomb
- School of Nursing, University of Wollongong, Wollongong, NSW, Australia
| | - Timothy Usherwood
- The George Institute for Global Health, Sydney, NSW, Australia; The University of Sydney, Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Julie Redfern
- School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia; The George Institute for Global Health, Sydney, NSW, Australia.
| |
Collapse
|
5
|
Mahtta D, Rodriguez F, Jneid H, Levine GN, Virani SS. Improving adherence to cardiovascular guidelines: realistic transition from paper to patient. Expert Rev Cardiovasc Ther 2020; 18:41-51. [PMID: 31941396 DOI: 10.1080/14779072.2020.1717335] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: The emphasis on clinical trials to inform evidence-based medicine remains paramount within the cardiovascular community. Although such high-quality evidence is often translated into national and international guidelines, there exists a large gap between guideline development and guideline implementation into daily clinical practice.Areas covered: This article outlines barriers that impede guideline adherence and possible strategies to overcome such barriers. Barriers intrinsic and extrinsic to clinicians are discussed. The structured process of guideline implementation including guideline adoption, diffusion, and dissemination is discussed. Lastly, the authors review in detail the current and potential future elements of guideline diffusion and dissemination.Expert opinion: Improving guideline adherence remains challenging as it requires understanding of and navigation through various barriers. However, further research specific to cardiovascular medicine guidelines is necessary to better understand the objective effectiveness of various strategies employed by guideline writers and medical societies to improve adherence. The cost-effectiveness of nationwide dissemination strategies in improving guideline adherence and patient outcomes is also necessary but is largely unknown.
Collapse
Affiliation(s)
- Dhruv Mahtta
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, TX, USA
| | - Fatima Rodriguez
- Division of Cardiovascular Medicine and the Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | - Hani Jneid
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Glenn N Levine
- Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Salim S Virani
- Health Policy, Quality & Informatics Program, Michael E. DeBakey VA Medical Center Health Services Research & Development Center for Innovations, Houston, TX, USA.,Department of Medicine, Section of Cardiology, Baylor College of Medicine, Houston, TX, USA.,Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA.,Section of Cardiovascular Research, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
6
|
Cost-effectiveness of optimized adherence to prevention guidelines in European patients with coronary heart disease: Results from the EUROASPIRE IV survey. Int J Cardiol 2018; 272:20-25. [PMID: 30172478 DOI: 10.1016/j.ijcard.2018.06.104] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 06/13/2018] [Accepted: 06/27/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND This study aims to assess the cost-effectiveness of optimized guideline adherence in patients with a history of coronary heart disease. METHODS An individual-based decision tree model was developed using the SMART risk score tool which estimates the 10-year risk for recurrent vascular events in patients with manifest cardiovascular disease (CVD). Analyses were based on the EUROASPIRE IV survey. Outcomes were expressed as an incremental cost-effectiveness ratio (ICER). RESULTS Data from 4663 patients from 13 European countries were included in the analyses. The mean estimated 10-year risk for a recurrent vascular event decreased from 20.13% to 18.61% after optimized guideline adherence. Overall, an ICER of 52,968€/QALY was calculated. The ICER lowered to 29,093€/QALY when only considering high-risk patients (≥20%) with decreasing ICERs in higher risk patients. Also, a dose-response relationship was seen with lower ICERs in older patients and in those patients with higher risk reductions. A less stringent LDL target (<2.5 mmol/L vs. <1.8 mmol/L) lowered the ICER to 32,591€/QALY and intensifying cholesterol treatment in high-risk patients (≥20%) instead of high-cholesterol patients lowered the ICER to 28,064€/QALY. An alternative method, applying risk reductions to the CVD events instead of applying risk reductions to the risk factors lowered the ICER to 31,509€/QALY. CONCLUSION Depending on the method used better or worse ICERs were found. In addition, optimized guidelines adherence is more cost-effective in higher risk patients, in patients with higher risk reductions and when using a less strict LDL-C target. Current analyses advice to maximize guidelines adherence in particular patient subgroups.
Collapse
|
7
|
Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, Greenhalgh J, Roland M. Outpatient services and primary care: scoping review, substudies and international comparisons. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04150] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.
Collapse
Affiliation(s)
| | | | | | | | - Ellen Nolte
- RAND Europe, Cambridge, UK
- European Observatory on Health Systems and Policies, London School of Economics and Political Science and London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanne Greenhalgh
- Faculty of Education, Social Sciences and Law, University of Leeds, Leeds, UK
| | - Martin Roland
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| |
Collapse
|
8
|
Pitchforth E, Roland M. Specialist services in the community: a qualitative study of consultants holding novel types of employment contracts in England. Future Hosp J 2015; 2:173-179. [PMID: 31098115 DOI: 10.7861/futurehosp.2-3-173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
The aim of this study was to understand, from consultants' experiences, the potential benefits and limitations of specialists being employed by a community organisation. We carried out a qualitative study using semi-structured interviews with consultants holding novel contracts across three specialties: geriatric, respiratory and palliative medicine. Consultants in our study reported that community-based roles offered a number of potential benefits. They felt better able to take a population perspective, to treat patients in a holistic sense and to form good working relationships with community-based colleagues. A number of challenges were also evident, including a lack of clarity about their role, professional isolation and, for those in geriatric and respiratory medicine, a lack of training and career development opportunities. Our study suggests that community-based consultant posts are often taken up by highly motivated individuals who report the benefits in terms of being able to provide more appropriate care for patients but that the long-term development of these posts may be constrained by a number of factors. Their idiosyncratic nature, the lack of clarity around the role, challenges to professional identity and lack of training opportunities or professional development suggest that current approaches to their development may not be sustainable.
Collapse
Affiliation(s)
| | - Martin Roland
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| |
Collapse
|
9
|
Becker C, Holle R, Stollenwerk B. The excess health care costs of KardioPro, an integrated care program for coronary heart disease prevention. Health Policy 2015; 119:778-86. [PMID: 25656962 DOI: 10.1016/j.healthpol.2015.01.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 12/17/2014] [Accepted: 01/19/2015] [Indexed: 11/16/2022]
Abstract
Coronary heart disease (CHD) is a major cause of death and important driver of health care costs. Recent German health care reforms have promoted integrated care contracts allowing statutory health insurance providers more room to organize health care provision. One provider offers KardioPro, an integrated primary care-based CHD prevention program. As insurance providers should be aware of the financial consequences when developing optional programs, this study aims to analyze the costs associated with KardioPro participation. 13,264 KardioPro participants were compared with a propensity score-matched control group. Post-enrollment health care costs were calculated based on routine data over a follow-up period of up to 4 years. For those people who incurred costs, KardioPro participation was significantly associated with increased physician costs (by 33%), reduced hospital costs (by 19%), and reduced pharmaceutical costs (by 16%). Overall costs were increased by 4%, but this was not significant. Total excess costs per observation year were €131 per person (95% confidence interval: [€-36.5; €296]). Overall, KardioPro likely affected treatment as the program increased costs of physician services and reduced costs of hospital services. Further effects of substituting potential inpatient care with increased outpatient care might become fully apparent only over a longer time horizon.
Collapse
Affiliation(s)
- Christian Becker
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany.
| | - Rolf Holle
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| | - Björn Stollenwerk
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München - German Research Center for Environmental Health, Neuherberg, Germany
| |
Collapse
|
10
|
James EL, Ewald B, Johnson N, Brown W, Stacey FG, Mcelduff P, Booth A, Yang F, Hespe C, Plotnikoff RC. Efficacy of GP referral of insufficiently active patients for expert physical activity counseling: protocol for a pragmatic randomized trial (The NewCOACH trial). BMC FAMILY PRACTICE 2014; 15:218. [PMID: 25543688 PMCID: PMC4305254 DOI: 10.1186/s12875-014-0218-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 12/17/2014] [Indexed: 11/23/2022]
Abstract
Background Physical inactivity is fourth in the list of risk factors for global mortality. General practitioners are well placed to offer physical activity counseling but insufficient time is a barrier. Although referral to an exercise specialist is an alternative, in Australia, these allied health professionals are only publicly funded to provide face-to-face counseling to patients who have an existing chronic illness. Accordingly, this trial aims to determine the efficacy of GP referral of insufficiently active patients (regardless of their chronic disease status) for physical activity counseling (either face-to-face or predominately via telephone) by exercise specialists, based on patients’ objectively assessed physical activity levels, compared with usual care. If the trial is efficacious, the equivalence and cost-effectiveness of face-to-face counseling versus telephone counseling will be assessed. Methods This three arm pragmatic randomized trial will involve the recruitment of 261 patients from primary care clinics in metropolitan and regional areas of New South Wales, Australia. Insufficiently active (less than 7000 steps/day) consenting adult patients will be randomly assigned to: 1) five face-to-face counseling sessions, 2) one face-to-face counseling session followed by four telephone calls, or 3) a generic mailed physical activity brochure (usual care). The interventions will operationalize social cognitive theory via a behavior change counseling framework. Participants will complete a survey and seven days of pedometry at baseline, and at three and 12 months post-randomization. The primary analyses will be based on intention-to-treat principles and will compare: (i) mean change in average daily step counts between baseline and 12 months for the combined intervention group (Group 1: face-to-face, and Group 2: telephone) and usual care (Group 3); (ii) step counts at 3 months post-randomization. Secondary outcomes include: self-reported physical activity, sedentary behavior, quality of life, and depression. Discussion If referral of primary care patients to exercise specialists increases physical activity, this process offers the prospect of systematically and sustainably reaching a large proportion of insufficiently active adults. If shown to be efficacious this trial provides evidence to expand public funding beyond those with a chronic disease and for delivery via telephone as well as face-to-face consultations. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12611000884909.
Collapse
Affiliation(s)
- Erica L James
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW, Australia.
| | - Ben Ewald
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW, Australia.
| | - Natalie Johnson
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW, Australia.
| | - Wendy Brown
- School of Human Movement Studies, University of Queensland, St Lucia, QLD, Australia.
| | - Fiona G Stacey
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre for Health Behaviour, University of Newcastle, Callaghan, NSW, Australia. .,Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW, Australia.
| | - Patrick Mcelduff
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.
| | - Angela Booth
- School of Medicine and Public Health, University of Newcastle, Callaghan, NSW, Australia.
| | - Fan Yang
- Inner West Sydney Medicare Local, Ashfield, NSW, Australia.
| | - Charlotte Hespe
- General Practice Research, School of Medicine, Sydney, The University of Notre Dame, Darlinghurst, NSW, Australia.
| | - Ronald C Plotnikoff
- Priority Research Centre in Physical Activity and Nutrition, University of Newcastle, Callaghan, NSW, Australia. .,Hunter Medical Research Institute, University of Newcastle, Callaghan, NSW, Australia.
| |
Collapse
|
11
|
Understanding claims-based quality profiles in primary care practice: the role of office system tools and health information technology. Health Care Manage Rev 2013; 39:293-304. [PMID: 24042963 DOI: 10.1097/hmr.0b013e31829fc9f1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND Claims-based quality profiles are increasingly used by third-party payers as a means of monitoring and remunerating physician performance. As traditional approaches to assessing performance yield to electronically generated data, identifying practice tools capable of influencing the behavior of these measures becomes essential to effectively managing medical practices. PURPOSE The aim of this study was to examine the effect of using office system tools (i.e., patient registries, physician reminders, and flow sheets) and health information technology (HIT) on claims-based quality profile scores in primary care practices. METHODOLOGY We analyzed survey responses from primary care physicians (n = 191) regarding their use of office system tools and HIT. These responses were linked to quality profile scores obtained from a Blue Cross Blue Shield of Texas claims-based data set. FINDINGS Elevated quality profile scores were associated with physicians who reported higher use of HIT. In addition, the influence of one office system tool, physician reminders, was contingent upon the availability and use of HIT. PRACTICE IMPLICATIONS Our findings indicate that primary care practices that fail to implement or use HIT appropriately will fare poorly in systems that monitor and reward performance based on measures derived from claims data. Linking prompts or reminders directly to clinical actions that influence quality indicators endorsed by payers should be a component of quality assurance programs.
Collapse
|
12
|
Banham D, Lynch J, Karnon J. An equity-effectiveness framework linking health programs and healthy life expectancy. Aust J Prim Health 2012; 17:309-19. [PMID: 22112699 DOI: 10.1071/py11034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 09/01/2011] [Indexed: 11/23/2022]
Abstract
South Australia's Strategic Plan includes a target to improve the population's healthy life expectancy. A common question among health policy and service planners is: 'How do health programs and services in the community relate to healthy life expectancy?' In response, this paper outlines an effectiveness and equity framework (EEF) for evaluating health interventions in applied settings. Using the example of coronary heart disease (CHD) management in general practice in South Australia, the EEF: (1) applies an internally consistent approach to accounting for population healthy life expectancy at state and smaller geographic levels; (2) estimates average population health gains from health programs, and gains across different socioeconomic subgroups within the community; (3) conducts economic evaluation by equating health gains against health system costs in population subgroups; (4) summarises relevant information about candidate intervention programs within a multi-criteria performance matrix for presentation to decision makers; (5) reassesses outcomes (and processes) following the implementation of a program and iteratively adds to the relevant knowledge and evidence base. The EEF offers a practical approach to selecting and evaluating intervention programs. The challenge is to develop system culture and data capture methods clearly focussed on linking health system activities to population health outcomes.
Collapse
Affiliation(s)
- David Banham
- Research and Ethics Policy Unit, SA Health, Adelaide, SA 5000, Australia.
| | | | | |
Collapse
|
13
|
|
14
|
Passey ME, Shrestha RN, Bertram MY, Schofield DJ, Vos T, Callander EJ, Percival R, Kelly SJ. The impact of diabetes prevention on labour force participation and income of older Australians: an economic study. BMC Public Health 2012; 12:16. [PMID: 22225701 PMCID: PMC3295674 DOI: 10.1186/1471-2458-12-16] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 12/13/2011] [Accepted: 01/06/2012] [Indexed: 12/20/2022] Open
Abstract
Background Globally, diabetes is estimated to affect 246 million people and is increasing. In Australia diabetes has been made a national health priority. While the direct costs of treating diabetes are substantial, and rising, the indirect costs are considered greater. There is evidence that interventions to prevent diabetes are effective, and cost-effective, but the impact on labour force participation and income has not been assessed. In this study we quantify the potential impact of implementing a diabetes prevention program, using screening and either metformin or a lifestyle intervention on individual economic outcomes of pre-diabetic Australians aged 45-64. Methods The output of an epidemiological microsimulation model of the reduction in prevalence of diabetes from a lifestyle or metformin intervention, and another microsimulation model, Health&WealthMOD, of health and the associated impacts on labour force participation, personal income, savings, government revenue and expenditure were used to quantify the estimated outcomes of the two interventions. Results An additional 753 person years in the labour force would have been achieved from 1993 to 2003 for the male cohort aged 60-64 years in 2003, if a lifestyle intervention had been introduced in 1983; with 890 person years for the equivalent female group. The impact on labour force participation was lower for the metformin intervention, and increased with age for both interventions. The male cohort aged 60-64 years in 2003 would have earned an additional $30 million in income with the metformin intervention, and the equivalent female cohort would have earned an additional $25 million. If the lifestyle intervention was introduced, the same male and female cohorts would have earned an additional $34 million and $28 million respectively from 1993 to 2003. For the individuals involved, on average, males would have earned an additional $44,600 per year and females an additional $31,800 per year, if they had continued to work as a result of preventing diabetes. Conclusions In addition to improved health and wellbeing, considerable benefits to individuals, in terms of both additional working years and increased personal income, could be made by introducing either a lifestyle or metformin intervention to prevent diabetes.
Collapse
Affiliation(s)
- Megan E Passey
- University Centre for Rural Health--North Coast, School of Public Health, University of Sydney, 61 Uralba St, Lismore, NSW 2480, Australia.
| | | | | | | | | | | | | | | |
Collapse
|