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Gkiouleka A, Wong G, Sowden S, Kuhn I, Moseley A, Manji S, Harmston RR, Siersbaek R, Bambra C, Ford JA. Reducing health inequalities through general practice: a realist review and action framework. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-104. [PMID: 38551093 DOI: 10.3310/ytww7032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
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.
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Affiliation(s)
- Anna Gkiouleka
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences and Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Sarah Sowden
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Isla Kuhn
- University of Cambridge Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Annie Moseley
- Patient and Public Involvement Representative, Norwich, UK
| | - Sukaina Manji
- Department of Educational Research, Lancaster University, Lancaster, UK
| | | | - Rikke Siersbaek
- Health System Foundations for Sláintecare Implementation, Centre for Health Policy and Management, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John A Ford
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Hayanga B, Stafford M, Ashworth M, Hughes J, Bécares L. Ethnic inequities in the patterns of personalized care adjustments for 'informed dissent' and 'patient unsuitable': a retrospective study using Clinical Practice Research Datalink. J Public Health (Oxf) 2023; 45:e692-e701. [PMID: 37434314 PMCID: PMC10687864 DOI: 10.1093/pubmed/fdad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/02/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND In England, general practitioners voluntarily take part in the Quality and Outcomes Framework, which is a program that seeks to improve care by rewarding good practice. They can make personalized care adjustments (PCAs), e.g. if patients choose not to have the treatment/intervention offered ('informed dissent') or because they are considered to be clinically 'unsuitable'. METHODS Using data from the Clinical Practice Research Datalink (Aurum), this study examined patterns of PCA reporting for 'informed dissent' and 'patient unsuitable', how they vary across ethnic groups and whether ethnic inequities were explained by sociodemographic factors or co-morbidities. RESULTS The odds of having a PCA record for 'informed dissent' were lower for 7 of the 10 minoritized ethnic groups studied. Indian patients were less likely than white patients to have a PCA record for 'patient unsuitable'. The higher likelihood of reporting for 'patient unsuitable' among people from Black Caribbean, Black Other, Pakistani and other ethnic groups was explained by co-morbidities and/or area-level deprivation. CONCLUSIONS The findings counter narratives that suggest that people from minoritized ethnic groups often refuse medical intervention/treatment. The findings also illustrate ethnic inequities in PCA reporting for 'patient unsuitable', which are linked to clinical and social complexity and should be tackled to improve health outcomes for all.
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Affiliation(s)
- Brenda Hayanga
- Department of Global Health and Social Medicine, King’s College London, London WC2B 4BG, UK
| | | | - Mark Ashworth
- Department of Population Health Sciences, King’s College London, London SE1 1UL, UK
| | - Jay Hughes
- The Health Foundation, London EC4Y 8AP, UK
| | - Laia Bécares
- Department of Global Health and Social Medicine, King’s College London, London WC2B 4BG, UK
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Tsang CCS, Wang J. Addressing racial/ethnic disparities associated with Medicare Part D Star Ratings among population with Alzheimer's disease and related dementias. Expert Rev Pharmacoecon Outcomes Res 2023; 23:1067-1075. [PMID: 37551695 PMCID: PMC10592311 DOI: 10.1080/14737167.2023.2245139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 08/01/2023] [Indexed: 08/09/2023]
Abstract
BACKGROUND Previous studies noted that racial/ethnic minority groups were less likely than non-Hispanic White beneficiaries to be included in the assessment of medication utilization measures of Medicare Part D Star Ratings due to restrictive inclusion criteria for measure calculation. This study explored whether adding a measure with less stringent inclusion criteria to Star Ratings can reduce disparities in measure assessment among beneficiaries with Alzheimer's disease and related dementias (ADRD). METHODS This cross-sectional study utilized 2017 Medicare databases linked to Area Health Resources Files. Multivariable logistic regression was used to compare disparities before and after adding the new measure. RESULTS By adding the new measure, disparities in the odds for assessment inclusion between non-Hispanic White beneficiaries and Black, Hispanic, Asian, and Other beneficiaries were respectively reduced by 97% (odds ratio, or OR = 1.97, 95% Confidence Interval or CI = 1.89-2.05), 72% (OR = 1.72, 95% CI = 1.58-1.87), 115% (OR = 2.15, 95% CI = 1.87-2.46), and 44% (OR = 1.44, 95% CI = 1.28-1.62). CONCLUSIONS To improve the selection of medication utilization measures in Star Ratings among beneficiaries with ADRD, policymakers should investigate the optimal composition of measures to better align the interests of patients, providers, and health plans.
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Affiliation(s)
- Chi Chun Steve Tsang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, United States
| | - Junling Wang
- Department of Clinical Pharmacy and Translational Science, University of Tennessee Health Science Center College of Pharmacy, Memphis, TN, United States
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Gkiouleka A, Wong G, Sowden S, Bambra C, Siersbaek R, Manji S, Moseley A, Harmston R, Kuhn I, Ford J. Reducing health inequalities through general practice. Lancet Public Health 2023; 8:e463-e472. [PMID: 37244675 DOI: 10.1016/s2468-2667(23)00093-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 03/30/2023] [Accepted: 04/18/2023] [Indexed: 05/29/2023]
Abstract
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.
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Affiliation(s)
- Anna Gkiouleka
- Department of Public Health and Primary Care, Cambridge, UK
| | - Geoff Wong
- University of Cambridge, Cambridge, UK; Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sarah Sowden
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Rikke Siersbaek
- Centre for Health Policy and Management, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Sukaina Manji
- Department of Educational Research, Lancaster University, Lancaster, UK
| | | | | | - Isla Kuhn
- University of Cambridge Medical Library, School of Clinical Medicine, Cambridge, UK
| | - John Ford
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
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Rasooly A, Pan Y, Tang Z, Jiangjiang H, Ellen ME, Manor O, Hu S, Davidovitch N. Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China. Int J Health Policy Manag 2022; 11:3019-3031. [PMID: 35942954 PMCID: PMC10105207 DOI: 10.34172/ijhpm.2022.6372] [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: 05/17/2021] [Accepted: 05/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation. METHODS In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis. RESULTS Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs. CONCLUSION The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.
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Affiliation(s)
- Alon Rasooly
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yancen Pan
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Zhenqing Tang
- Shanghai Health Development Research Center, Shanghai, China
| | - He Jiangjiang
- Shanghai Health Development Research Center, Shanghai, China
| | - Moriah E. Ellen
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Orly Manor
- Braun School of Public Health and Community Medicine, Hebrew University, Jerusalem, Israel. 5 School of Public Health, Fudan University, Shanghai, China
| | - Shanlian Hu
- School of Public Health, Fudan University, Shanghai, China
| | - Nadav Davidovitch
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
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The role of pay-for-performance in reducing healthcare disparities: A narrative literature review. Prev Med 2022; 164:107274. [PMID: 36156282 DOI: 10.1016/j.ypmed.2022.107274] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/27/2022] [Accepted: 09/18/2022] [Indexed: 11/21/2022]
Abstract
As American healthcare shifts to value-based payment, Pay-for-Performance (P4P) has become an important and controversial topic. One of the main controversies pertains to its potential to narrow or widen existing healthcare disparities depending on how the program is designed and implemented. It is thus imperative to understand which design features are most likely to reduce disparities. We conducted a systematic literature review from 2004 to 2021 of P4P's impact on disparities. Given the interdisciplinary nature of P4P research, multiple search strategies were combined, and many study designs were eligible for analysis. The literature was then qualitatively analyzed, with themes and major findings developed using Grounded Theory. Six major design features emerged as most promising in leveraging P4P to reduce disparities: 1) Risk/Case-Mix Adjustment; 2) Stratified Performance Measures/Stratification; 3) Disparity Reduction Metrics; 4) Exception Reporting; 5) Pay-for-Improvement; and 6) Population-Specific Metrics. Each design feature has its own mechanism, strengths, and weaknesses. We identify and define these features' direct and indirect effects on healthcare disparities. The interaction of each design feature with one another, with P4P as a whole, and within the larger reimbursement system can have considerable effects on disparities. Promising strategies exist to leverage P4P to narrow disparities for clinically and socially complex patients. The six design features discussed in this review help P4P programs address structural disadvantages faced by such patients and their providers. In regard to health equity, these design features can transform P4P from being part of the problem to being part of the solution.
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Lin TK, Werner K, Witter S, Alluhidan M, Alghaith T, Hamza MM, Herbst CH, Alazemi N. Individual performance-based incentives for health care workers in Organisation for Economic Co-operation and Development member countries: a systematic literature review. Health Policy 2022; 126:512-521. [DOI: 10.1016/j.healthpol.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/29/2022] [Accepted: 03/30/2022] [Indexed: 11/04/2022]
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Pillaye J. Covid-19 and ethnic minorities: the Public Health England report distracts from proactive and timely intervention. BMJ 2020; 370:m3054. [PMID: 32763911 DOI: 10.1136/bmj.m3054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Whyte MB, Hinton W, McGovern A, van Vlymen J, Ferreira F, Calderara S, Mount J, Munro N, de Lusignan S. Disparities in glycaemic control, monitoring, and treatment of type 2 diabetes in England: A retrospective cohort analysis. PLoS Med 2019; 16:e1002942. [PMID: 31589609 PMCID: PMC6779242 DOI: 10.1371/journal.pmed.1002942] [Citation(s) in RCA: 58] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 09/11/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Disparities in type 2 diabetes (T2D) care provision and clinical outcomes have been reported in the last 2 decades in the UK. Since then, a number of initiatives have attempted to address this imbalance. The aim was to evaluate contemporary data as to whether disparities exist in glycaemic control, monitoring, and prescribing in people with T2D. METHODS AND FINDINGS A T2D cohort was identified from the Royal College of General Practitioners Research and Surveillance Centre dataset: a nationally representative sample of 164 primary care practices (general practices) across England. Diabetes healthcare provision and glucose-lowering medication use between 1 January 2012 and 31 December 2016 were studied. Healthcare provision included annual HbA1c, renal function (estimated glomerular filtration rate [eGFR]), blood pressure (BP), retinopathy, and neuropathy testing. Variables potentially associated with disparity outcomes were assessed using mixed effects logistic and linear regression, adjusted for age, sex, ethnicity, and socioeconomic status (SES) using the Index of Multiple Deprivation (IMD), and nested using random effects within general practices. Ethnicity was defined using the Office for National Statistics ethnicity categories: White, Mixed, Asian, Black, and Other (including Arab people and other groups not classified elsewhere). From the primary care adult population (n = 1,238,909), we identified a cohort of 84,452 (5.29%) adults with T2D. The mean age of people with T2D in the included cohort at 31 December 2016 was 68.7 ± 12.6 years; 21,656 (43.9%) were female. The mean body mass index was 30.7 ± SD 6.4 kg/m2. The most deprived groups (IMD quintiles 1 and 2) showed poorer HbA1c than the least deprived (IMD quintile 5). People of Black ethnicity had worse HbA1c than those of White ethnicity. Asian individuals were less likely than White individuals to be prescribed insulin (odds ratio [OR] 0.86, 95% CI 0.79-0.95; p < 0.01), sodium-glucose cotransporter-2 (SGLT2) inhibitors (OR 0.68, 95% CI 0.58-0.79; p < 0.001), and glucagon-like peptide-1 (GLP-1) agonists (OR 0.37, 95% CI 0.31-0.44; p < 0.001). Black individuals were less likely than White individuals to be prescribed SGLT2 inhibitors (OR 0.50, 95% CI 0.39-0.65; p < 0.001) and GLP-1 agonists (OR 0.45, 95% CI 0.35-0.57; p < 0.001). Individuals in IMD quintile 5 were more likely than those in the other IMD quintiles to have annual testing for HbA1c, BP, eGFR, retinopathy, and neuropathy. Black individuals were less likely than White individuals to have annual testing for HbA1c (OR 0.89, 95% CI 0.79-0.99; p = 0.04) and retinopathy (OR 0.82, 95% CI 0.70-0.96; p = 0.011). Asian individuals were more likely than White individuals to have monitoring for HbA1c (OR 1.10, 95% CI 1.01-1.20; p = 0.023) and eGFR (OR 1.09, 95% CI 1.00-1.19; p = 0.048), but less likely for retinopathy (OR 0.88, 95% CI 0.79-0.97; p = 0.01) and neuropathy (OR 0.88, 95% CI 0.80-0.97; p = 0.01). The study is limited by the nature of being observational and defined using retrospectively collected data. Disparities in diabetes care may show regional variation, which was not part of this evaluation. CONCLUSIONS Our findings suggest that disparity in glycaemic control, diabetes-related monitoring, and prescription of newer therapies remains a challenge in diabetes care. Both SES and ethnicity were important determinants of inequality. Disparities in glycaemic control and other areas of care may lead to higher rates of complications and adverse outcomes for some groups.
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Affiliation(s)
- Martin B. Whyte
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
- * E-mail:
| | - William Hinton
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | - Andrew McGovern
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | - Jeremy van Vlymen
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | - Filipa Ferreira
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | | | | | - Neil Munro
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
| | - Simon de Lusignan
- Department of Clinical and Experimental Medicine, University of Surrey, Guildford, United Kingdom
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Bisdas T, Bohan P, Lescan M, Zeebregts CJ, Tessarek J, van Herwaarden J, van den Berg JC, Setacci C, Riambau V. Research methodology and practical issues relating to the conduct of a medical device registry. Clin Trials 2019; 16:490-501. [PMID: 31184490 DOI: 10.1177/1740774519855395] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The postmarket research goal is to assess "generalizability" or "external validity" to see if the early results of clinical trials with investigational devices are reproducible in everyday practice in the real world and the longer term. Registries have an important but ambivalent role in achieving this goal. METHODS Although registries are common, in practice they follow the regulatory processes that appear designed primarily for pharmaceutical clinical trials and confirmatory studies. We review the literature to assess different definitions and the role of registries in the hierarchy of scientific evidence. We analyze common characteristics affecting registry design, implementation, and governance as well as safety reporting and off-label use while describing the experience of setting up an international, prospective registry for an endovascular device used to treat abdominal aortic aneurysms. RESULTS Key areas in which to distinguish registries from trials are as follows: eligibility, setting (patients and institutions), device configurations and iterations, the use of design and quality "spaces," a focus on systematic quality checks (rather than source data monitoring), open-ended follow-up, flexibility in the definition of end points and sample sizes, data sharing, and publishing commitments. CONCLUSION Both clinical trials and registries are essential and complementary research methods and the strengths and weaknesses of each need to be recognized. The specific characteristics of registry research deserve to be acknowledged and safeguarded in the regulations governing clinical investigations with medical devices.
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Affiliation(s)
- Theodosios Bisdas
- St. Franziskus-Hospital Münster GmbH, Münster, Germany.,Clinic of Vascular and Endovascular Therapy, Omilos Iatrikou Athinon, Athens, Greece
| | | | - Mario Lescan
- Universitätsklinikum Tübingen Medizinische Universitätsklinik, Tübingen, Germany
| | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jörg Tessarek
- St. Bonifatius Hospital Lingen gGmbH, Lingen, Germany
| | - Joost van Herwaarden
- Department of Vascular Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | | | - Carlo Setacci
- AOU Senese, Vascular and Endovascular Surgery Unit, Department of Medicine, Surgery and Neuroscience, University of Siena, Siena, Italy
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Clement M, Filteau P, Harvey B, Jin S, Laubscher T, Mukerji G, Sherifali D. Organization of Diabetes Care. Can J Diabetes 2018; 42 Suppl 1:S27-S35. [DOI: 10.1016/j.jcjd.2017.10.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Indexed: 02/06/2023]
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Lowrie R, McConnachie A, Williamson AE, Kontopantelis E, Forrest M, Lannigan N, Mercer SW, Mair FS. Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data. BMC Med 2017; 15:77. [PMID: 28395660 PMCID: PMC5387284 DOI: 10.1186/s12916-017-0833-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 03/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. METHODS We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. RESULTS Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices. CONCLUSIONS Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled.
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Affiliation(s)
- Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Andrea E. Williamson
- General Practice and Primary Care, School of Medicine, MVLS, University of Glasgow, Glasgow, Scotland UK
| | - Evangelos Kontopantelis
- The Farr Institute of Health Informatics Research, University of Manchester, Manchester, England UK
| | - Marie Forrest
- East Glasgow Health and Social Care Partnership, Paradise Health Centre, Glasgow, Scotland UK
| | - Norman Lannigan
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Stewart W. Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Frances S. Mair
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
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Kondo KK, Damberg CL, Mendelson A, Motu'apuaka M, Freeman M, O'Neil M, Relevo R, Low A, Kansagara D. Implementation Processes and Pay for Performance in Healthcare: A Systematic Review. J Gen Intern Med 2016; 31 Suppl 1:61-9. [PMID: 26951276 PMCID: PMC4803682 DOI: 10.1007/s11606-015-3567-0] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P. METHODS We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight. RESULTS Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence. DISCUSSION There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input.
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Affiliation(s)
- Karli K Kondo
- Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.
- Oregon Health and Science University, Portland, OR, USA.
| | | | | | - Makalapua Motu'apuaka
- Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA
| | - Michele Freeman
- Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA
| | - Maya O'Neil
- Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA
- Oregon Health and Science University, Portland, OR, USA
| | - Rose Relevo
- Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA
| | - Allison Low
- Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA
| | - Devan Kansagara
- Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA
- Oregon Health and Science University, Portland, OR, USA
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Lin Y, Yin S, Huang J, Du L. Impact of pay for performance on behavior of primary care physicians and patient outcomes. J Evid Based Med 2016; 9:8-23. [PMID: 26667492 DOI: 10.1111/jebm.12185] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Accepted: 07/23/2015] [Indexed: 02/05/2023]
Abstract
BACKGROUND AND OBJECTIVES Pay-for-performance is a financial incentive which links physicians' income to the quality of their services. Although pay-for-performance is suggested to be an effective payment method in many pilot countries (ie the UK) and enjoys a wide application in primary health care, researches on it are yet to reach an agreement. Thus, a systematic review was conducted on the evidence of impact of pay-for-performance on behavior of primary care physicians and patient outcomes aiming to provide a comprehensive and objective evaluation of pay-for-performance for decision-makers. METHODS Studies were identified by searching PubMed, EMbase, and The Cochrane Library. Electronic search was conducted in the fourth week of January 2013. As the included studies had significant clinical heterogeneity, a descriptive analysis was conducted. Quality Index was adopted for quality assessment of evidences. RESULTS Database searches yielded 651 candidate articles, of which 44 studies fulfilled the inclusion criteria. An overall positive effect was found on the management of disease, which varied in accordance with the baseline medical quality and the practice size. Meanwhile, it could bring about new problems regarding the inequity, patients' dissatisfaction and increasing medical cost. CONCLUSIONS Decision-makers should consider the baseline conditions of medical quality and the practice size before new medical policies are enacted. Furthermore, most studies are retrospective and observational with high level of heterogeneity though, the descriptive analysis is still of significance.
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Affiliation(s)
- Yifei Lin
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Senlin Yin
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jin Huang
- West China School of Medicine/West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Liang Du
- Periodical Press of West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Roland M. Should doctors be able to exclude patients from pay-for-performance schemes? BMJ Qual Saf 2015; 25:653-6. [PMID: 26717988 DOI: 10.1136/bmjqs-2015-005003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2015] [Indexed: 12/25/2022]
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Kontopantelis E, Springate DA, Ashcroft DM, Valderas JM, van der Veer SN, Reeves D, Guthrie B, Doran T. Associations between exemption and survival outcomes in the UK's primary care pay-for-performance programme: a retrospective cohort study. BMJ Qual Saf 2015; 25:657-70. [PMID: 26628553 PMCID: PMC5013124 DOI: 10.1136/bmjqs-2015-004602] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 11/01/2015] [Indexed: 01/24/2023]
Abstract
OBJECTIVES The UK's Quality and Outcomes Framework permits practices to exempt patients from financially-incentivised performance targets. To better understand the determinants and consequences of being exempted from the framework, we investigated the associations between exception reporting, patient characteristics and mortality. We also quantified the proportion of exempted patients that met quality targets for a tracer condition (diabetes). DESIGN Retrospective longitudinal study, using individual patient data from the Clinical Practice Research Datalink. SETTING 644 general practices, 2006/7 to 2011/12. PARTICIPANTS Patients registered with study practices for at least one year over the study period, with at least one condition of interest (2 460 341 in total). MAIN OUTCOME MEASURES Exception reporting rates by reason (clinical contraindication, patient dissent); all-cause mortality in year following exemption. Analyses with logistic and Cox proportional-hazards regressions, respectively. RESULTS The odds of being exempted increased with age, deprivation and multimorbidity. Men were more likely to be exempted but this was largely attributable to higher prevalence of conditions with high exemption rates. Modest associations remained, with women more likely to be exempted due to clinical contraindication (OR 0.90, 99% CI 0.88 to 0.92) and men more likely to be exempted due to informed dissent (OR 1.08, 99% CI 1.06 to 1.10). More deprived areas (both for practice location and patient residence) were non-linearly associated with higher exception rates, after controlling for comorbidities and other covariates, with stronger associations for clinical contraindication. Compared with patients with a single condition, odds ratios for patients with two, three, or four or more conditions were respectively 4.28 (99% CI 4.18 to 4.38), 16.32 (99% CI 15.82 to 16.83) and 68.69 (99% CI 66.12 to 71.37) for contraindication, and 2.68 (99% CI 2.63 to 2.74), 4.02 (99% CI 3.91 to 4.13) and 5.17 (99% CI 5.00 to 5.35) for informed dissent. Exempted patients had a higher adjusted risk of death in the following year than non-exempted patients, regardless of whether this exemption was for contraindication (hazard ratio 1.37, 99% CI 1.33 to 1.40) or for informed dissent (1.20, 99% CI 1.17 to 1.24). On average, quality standards were met for 48% of exempted patients in the diabetes domain, but there was wide variation across indicators (ranging from 8 to 80%). CONCLUSIONS Older, multimorbid and more deprived patients are more likely to be exempted from the scheme. Exception reported patients are more likely to die in the following year, whether they are exempted by the practice for a contraindication or by themselves through informed dissent. Further research is needed to understand the relationship between exception reporting and patient outcomes.
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Affiliation(s)
- Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - David A Springate
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, Uk
| | - Jose M Valderas
- Patient Centred Care, APEx Collaboration for Academic Primary Care, Medical School, University of Exeter, Exeter, UK
| | - Sabine N van der Veer
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
| | - David Reeves
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, Uk
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
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Multimorbidity and Patient Safety Incidents in Primary Care: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0135947. [PMID: 26317435 PMCID: PMC4552710 DOI: 10.1371/journal.pone.0135947] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 07/29/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Multimorbidity is increasingly prevalent and represents a major challenge in primary care. Patients with multimorbidity are potentially more likely to experience safety incidents due to the complexity of their needs and frequency of their interactions with health services. However, rigorous syntheses of the link between patient safety incidents and multimorbidity are not available. This review examined the relationship between multimorbidity and patient safety incidents in primary care. METHODS We followed our published protocol (PROSPERO registration number: CRD42014007434). Medline, Embase and CINAHL were searched up to May 2015. Study design and quality were assessed. Odds ratios (OR) and 95% confidence intervals (95% CIs) were calculated for the associations between multimorbidity and two categories of patient safety outcomes: 'active patient safety incidents' (such as adverse drug events and medical complications) and 'precursors of safety incidents' (such as prescription errors, medication non-adherence, poor quality of care and diagnostic errors). Meta-analyses using random effects models were undertaken. RESULTS Eighty six relevant comparisons from 75 studies were included in the analysis. Meta-analysis demonstrated that physical-mental multimorbidity was associated with an increased risk for 'active patient safety incidents' (OR = 2.39, 95% CI = 1.40 to 3.38) and 'precursors of safety incidents' (OR = 1.69, 95% CI = 1.36 to 2.03). Physical multimorbidity was associated with an increased risk for active safety incidents (OR = 1.63, 95% CI = 1.45 to 1.80) but was not associated with precursors of safety incidents (OR = 1.02, 95% CI = 0.90 to 1.13). Statistical heterogeneity was high and the methodological quality of the studies was generally low. CONCLUSIONS The association between multimorbidity and patient safety is complex, and varies by type of multimorbidity and type of safety incident. Our analyses suggest that multimorbidity involving mental health may be a key driver of safety incidents, which has important implication for the design and targeting of interventions to improve safety. High quality studies examining the mechanisms of patient safety incidents in patients with multimorbidity are needed, with the goal of promoting effective service delivery and ameliorating threats to safety in this group of patients.
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Impact of 'stretch' targets for cardiovascular disease management within a local pay-for-performance programme. PLoS One 2015; 10:e0119185. [PMID: 25811487 PMCID: PMC4374919 DOI: 10.1371/journal.pone.0119185] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Accepted: 01/28/2015] [Indexed: 12/03/2022] Open
Abstract
Pay-for-performance programs are often aimed to improve the management of chronic diseases. We evaluate the impact of a local pay for performance programme (QOF+), which rewarded financially more ambitious quality targets (‘stretch targets’) than those used nationally in the Quality and Outcomes Framework (QOF). We focus on targets for intermediate outcomes in patients with cardiovascular disease and diabetes. A difference-in-difference approach is used to compare practice level achievements before and after the introduction of the local pay for performance program. In addition, we analysed patient-level data on exception reporting and intermediate outcomes utilizing an interrupted time series analysis. The local pay for performance program led to significantly higher target achievements (hypertension: p-value <0.001, coronary heart disease: p-values <0.001, diabetes: p-values <0.061, stroke: p-values <0.003). However, the increase was driven by higher rates of exception reporting (hypertension: p-value <0.001, coronary heart disease: p-values <0.03, diabetes: p-values <0.05) in patients with all conditions except for stroke. Exception reporting allows practitioners to exclude patients from target calculations if certain criteria are met, e.g. informed dissent of the patient for treatment. There were no statistically significant improvements in mean blood pressure, cholesterol or HbA1c levels. Thus, achievement of higher payment thresholds in the local pay for performance scheme was mainly attributed to increased exception reporting by practices with no discernable improvements in overall clinical quality. Hence, active monitoring of exception reporting should be considered when setting more ambitious quality targets. More generally, the study suggests a trade-off between additional incentive for better care and monitoring costs.
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Nishino Y, Gilmour S, Shibuya K. Inequality in diabetes-related hospital admissions in England by socioeconomic deprivation and ethnicity: facility-based cross-sectional analysis. PLoS One 2015; 10:e0116689. [PMID: 25705895 PMCID: PMC4338138 DOI: 10.1371/journal.pone.0116689] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 12/06/2014] [Indexed: 11/19/2022] Open
Abstract
Objective To investigate the effect of social deprivation and ethnicity on inpatient admissions due to diabetes in England. Design Facility-based cross-sectional analysis. Setting National Health Service (NHS) trusts in England reporting inpatient admissions with better than 80% data reporting quality from 2010–2011 (355 facilities). Participants Non-obstetric patients over 16 years old in all NHS facilities in England. The sample size after exclusions was 5,147,859 all-cause admissions. Main Outcome Measures The relative risk of inpatient admissions and readmissions due to diabetes adjusted for confounders. Results There were 445,504 diabetes-related hospital admissions in England in 2010, giving a directly (age-sex) standardized rate of 1049.0 per 100,000 population (95% confidence interval (CI): 1046.0–1052.1). The relative risk of inpatient admission in the most deprived quintile was 2.08 times higher than that of the least deprived quintile (95% CI: 2.02–2.14), and the effect of deprivation varied across ethnicities. About 30.1% of patients admitted due to diabetes were readmitted at least once due to diabetes. South Asians showed 2.62 times (95% CI: 2.51 – 2.74) higher admission risk. Readmission risk increased with IMD among white British but not other ethnicities. South Asians showed slightly lower risk of readmission than white British (0.86, 95% CI: 0.80 – 0.94). Conclusions More deprived areas had higher rates of inpatient admissions and readmissions due to diabetes. South Asian British showed higher admission risk and lower readmission risk than white British. However, there was almost no difference by ethnicity in readmission due to diabetes. Higher rates of admission among deprived people may not necessarily reflect higher prevalence, but higher admission rates in south Asian British may be explained by their higher prevalence because their lower readmission risk suggests no inequality in primary care to prevent readmission. Better interventions in poorer areas, are needed to reduce these inequalities.
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Affiliation(s)
- Yoshitaka Nishino
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
- * E-mail:
| | - Stuart Gilmour
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
| | - Kenji Shibuya
- Department of Global Health Policy, Graduate School of Medicine, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan
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Ödesjö H, Anell A, Gudbjörnsdottir S, Thorn J, Björck S. Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study. Scand J Prim Health Care 2015; 33:291-7. [PMID: 26671067 PMCID: PMC4750739 DOI: 10.3109/02813432.2015.1118834] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed. DESIGN AND SETTING Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county. SUBJECTS A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units. MAIN OUTCOME MEASURES Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL). RESULTS In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register - they had higher HbA1c (54.9 [54.5-55.4] vs. 53.7 [53.6-53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs -1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001). CONCLUSION P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes. Key points A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden. Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure. Newly entered patients and data during the incentive programme were less well controlled. Missing data in a quality register can cause performance to be overestimated.
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Affiliation(s)
- H. Ödesjö
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Primary Health Care, Region Västra Götaland, Sweden
- CONTACT Helena Ödesjö Resident Physician, Primary Health Care Västra Götaland Region, Närhälsan Torslanda Vårdcentral, Nordhagsvägen 2A, 423 34 Torslanda, Sweden
| | - A. Anell
- Lund University School of Economics and Management, Sweden
| | - S. Gudbjörnsdottir
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - J. Thorn
- Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Primary Health Care, Region Västra Götaland, Sweden
| | - S. Björck
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
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Performance-based financial incentives for diabetes care: an effective strategy? Can J Diabetes 2014; 39:83-7. [PMID: 25444683 DOI: 10.1016/j.jcjd.2014.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/10/2014] [Accepted: 06/11/2014] [Indexed: 01/02/2023]
Abstract
The use of financial incentives provided to primary care physicians who achieve target management or clinical outcomes has been advocated to support the fulfillment of care recommendations for patients with diabetes. This article explores the characteristics of incentive models implemented in the context of universal healthcare systems in the United Kingdom, Australia, Taiwan and Canada; the extent to which these interventions have been successful in improving diabetes outcomes; and the key challenges and concerns around implementing incentive models. Research in the effect of incentives in the United Kingdom demonstrates some improvements in process outcomes and achievement of cholesterol, blood pressure and glycated hemoglobin (A1C) targets. Evidence of the efficacy of programs implemented outside of the United Kingdom is very limited but suggests that physicians participating in these enhanced billing incentive programs were already completing the guideline-recommended care prior to the introduction of the incentive. A shift to pay-for-performance programs may have important implications for professionalism and patient-centred care. In the absence of definitive evidence that financial incentives drive the quality of diabetes management at the level of primary care, policy makers should proceed with caution. It is important to look beyond simply modifying physicians' behaviours and address the factors and systemic barriers that make it challenging for patients and physicians to manage diabetes in partnership.
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Clement M, Harvey B, Rabi DM, Roscoe RS, Sherifali D. Organisation des soins du diabète. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
Pay-for-performance schemes explicitly link provider remuneration to the quality of care provided, with the aims of modifying provider behavior and improving patient outcomes. If successful, pay-for-performance schemes could drive improvements in quality and efficiency of care. However, financial incentives could also erode providers' intrinsic motivation, narrow their focus, promote unethical behavior, and ultimately increase health care inequalities. Evidence from schemes implemented to date suggests that carefully designed pay-for-performance schemes that align sufficient rewards with clinical priorities can produce modest but significant improvements in processes of diabetic care and intermediate outcomes. There is limited evidence, however, on whether improvements in processes of care result in improved outcomes, in terms of patient satisfaction, reduced complications, and greater longevity. The lack of adequate control groups has limited research findings to date, and more robust studies are needed to explore both the potential long-term benefits of pay-for-performance schemes and their unintended consequences.
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Affiliation(s)
- Tim Doran
- Institute of Population Health, University of Manchester, Williamson Building Oxford Road, Manchester, M13 9PL, UK.
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Cheung NW. Individualising type 2 diabetes management: new treatment options and models of care. Med J Aust 2012; 197:196-7. [DOI: 10.5694/mja12.11041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- N Wah Cheung
- Department of Diabetes and Endocrinology, Westmead Hospital, Sydney, NSW
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Watnick S, Weiner DE, Shaffer R, Inrig J, Moe S, Mehrotra R. Comparing mandated health care reforms: the Affordable Care Act, accountable care organizations, and the Medicare ESRD program. Clin J Am Soc Nephrol 2012; 7:1535-43. [PMID: 22626961 DOI: 10.2215/cjn.01220212] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In addition to extending health insurance coverage, the Affordable Care Act of 2010 aims to improve quality of care and contain costs. To this end, the act allowed introduction of bundled payments for a range of services, proposed the creation of accountable care organizations (ACOs), and established the Centers for Medicare and Medicaid Innovation to test new care delivery and payment models. The ACO program began April 1, 2012, along with demonstration projects for bundled payments for episodes of care in Medicaid. Yet even before many components of the Affordable Care Act are fully in place, the Medicare ESRD Program has instituted legislatively mandated changes for dialysis services that resemble many of these care delivery reform proposals. The ESRD program now operates under a fully bundled, case-mix adjusted prospective payment system and has implemented Medicare's first-ever mandatory pay-for-performance program: the ESRD Quality Incentive Program. As ACOs are developed, they may benefit from the nephrology community's experience with these relatively novel models of health care payment and delivery reform. Nephrologists are in a position to assure that the ACO development will benefit from the ESRD experience. This article reviews the new ESRD payment system and the Quality Incentive Program, comparing and contrasting them with ACOs. Better understanding of similarities and differences between the ESRD program and the ACO program will allow the nephrology community to have a more influential voice in shaping the future of health care delivery in the United States.
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Robertson C, Rose S, Kesselheim AS. Effect of financial relationships on the behaviors of health care professionals: a review of the evidence. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2012; 40:452-466. [PMID: 23061573 DOI: 10.1111/j.1748-720x.2012.00678.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This paper explores the empirical evidence regarding the impact financial relationships on the behavior of health care providers, specifically, physicians. We identify and synthesize peer-reviewed data addressing whether financial incentives are causally related to patient outcomes and health care costs. We cover three main areas where financial conflicts of interest arise and may have an observable relationship to health care practices: (1) physicians' roles as self-referrers, (2) insurance reimbursement schemes that create incentives for certain clinical choices over others, and (3) financial relationships between physicians and the drug and device industries. We found a well-developed scientific literature consisting of dozens of empirical studies, some that allow stronger causal inferences than others, but which altogether show that such financial conflicts of interests can, and sometimes do, impact physicians' clinical decisions. Further research is warranted to document the causal relationship of such changes on health outcomes and the cost of care, but the current base of evidence is sufficiently robust to motivate policy reform.
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