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Somé NH, Devlin RA, Mehta N, Sarma S. Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis. HEALTH ECONOMICS 2024. [PMID: 38898671 DOI: 10.1002/hec.4872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 03/28/2024] [Accepted: 04/30/2024] [Indexed: 06/21/2024]
Abstract
Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.
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Affiliation(s)
- Nibene Habib Somé
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, Ontario, Canada
| | - Nirav Mehta
- Department of Economics, Western University, London, Ontario, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Wang J, Xu DR, Zhang Y, Fu H, Wang S, Ju K, Chen C, Yang L, Jian W, Chen L, Liao X, Xiao Y, Wu R, Jakovljevic M, Chen Y, Pan J. Development of the China's list of ambulatory care sensitive conditions (ACSCs): a study protocol. Glob Health Res Policy 2024; 9:11. [PMID: 38504369 PMCID: PMC10949688 DOI: 10.1186/s41256-024-00350-5] [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: 12/04/2023] [Accepted: 03/05/2024] [Indexed: 03/21/2024] Open
Abstract
BACKGROUND The hospitalization rate of ambulatory care sensitive conditions (ACSCs) has been recognized as an essential indicator reflective of the overall performance of healthcare system. At present, ACSCs has been widely used in practice and research to evaluate health service quality and efficiency worldwide. The definition of ACSCs varies across countries due to different challenges posed on healthcare systems. However, China does not have its own list of ACSCs. The study aims to develop a list to meet health system monitoring, reporting and evaluation needs in China. METHODS To develop the list, we will combine the best methodological evidence available with real-world evidence, adopt a systematic and rigorous process and absorb multidisciplinary expertise. Specific steps include: (1) establishment of working groups; (2) generations of the initial list (review of already published lists, semi-structured interviews, calculations of hospitalization rate); (3) optimization of the list (evidence evaluation, Delphi consensus survey); and (4) approval of a final version of China's ACSCs list. Within each step of the process, we will calculate frequencies and proportions, use descriptive analysis to summarize and draw conclusions, discuss the results, draft a report, and refine the list. DISCUSSION Once completed, China's list of ACSCs can be used to comprehensively evaluate the current situation and performance of health services, identify flaws and deficiencies embedded in the healthcare system to provide evidence-based implications to inform decision-makings towards the optimization of China's healthcare system. The experiences might be broadly applicable and serve the purpose of being a prime example for nations with similar conditions.
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Affiliation(s)
- Jianjian Wang
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China
| | - Dong Roman Xu
- School of Health Management, Southern Medical University, Guangzhou, China
| | - Yan Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongqiao Fu
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Sijiu Wang
- Vanke School of Public Health, Tsinghua University, Beijing, China
| | - Ke Ju
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Chu Chen
- School of Health Management, Fujian Medical University, Fujian, China
| | - Lian Yang
- School of Public Health, Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University Health Science Center, Beijing, China
| | - Lei Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaoyang Liao
- General Practice Ward/International Medical Center Ward, General Practice Medical Center, West China Hospital, Sichuan University, Chengdu, China
| | - Yue Xiao
- China National Health Development Research Center, Beijing, China
| | - Ruixian Wu
- Center for Health Statistics and Information, National Health Commission, Beijing, China
| | - Mihajlo Jakovljevic
- Institute of Advanced Manufacturing Technologies, Peter the Great St. Petersburg Polytechnic University, St. Petersburg, Russia
- Institute of Comparative Economic Studies, Faculty of Economics, Hosei University, Tokyo, Japan
- Department of Global Health Economics and Policy, Faculty of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Yaolong Chen
- Research Unit of Evidence-Based Evaluation and Guidelines, Chinese Academy of Medical Sciences (2021RU017), School of Basic Medical Sciences, Lanzhou University, Lanzhou, China.
- World Health Organization Collaborating Center for Guideline Implementation and Knowledge Translation, Lanzhou University, Lanzhou, China.
| | - Jay Pan
- HEOA Group, West China School of Public Health and West China Fourth Hospital, Sichuan University, Chengdu, China.
- Institute for Healthy Cities and West China Research Center for Rural Health Development, Sichuan University, Chengdu, China.
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Moran V, Suhrcke M, Nolte E. Exploring the association between primary care efficiency and health system characteristics across European countries: a two-stage data envelopment analysis. BMC Health Serv Res 2023; 23:1348. [PMID: 38049793 PMCID: PMC10694950 DOI: 10.1186/s12913-023-10369-y] [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: 05/19/2023] [Accepted: 11/22/2023] [Indexed: 12/06/2023] Open
Abstract
BACKGROUND Primary care is widely seen as a core component of resilient and sustainable health systems, yet its efficiency is not well understood and there is a lack of evidence about how primary care efficiency is associated with health system characteristics. We examine this issue through the lens of diabetes care, which has a well-established evidence base for effective treatment and has previously been used as a tracer condition to measure health system performance. METHODS We developed a conceptual framework to guide the analysis of primary care efficiency. Using data on 18 European countries during 2010-2016 from several international databases, we applied a two-stage data envelopment analysis to estimate (i) technical efficiency of primary care and (ii) the association between efficiency and health system characteristics. RESULTS Countries varied widely in terms of primary care efficiency, with efficiency scores depending on the range of population characteristics adjusted for. Higher efficiency was associated with bonus payments for the prevention and management of chronic conditions, nurse-led follow-up, and a financial incentive or requirement for patients to obtain a referral to specialist care. Conversely, lower efficiency was associated with higher rates of curative care beds and financial incentives for patients to register with a primary care provider. CONCLUSIONS Our results underline the importance of considering differences in population characteristics when comparing country performance on primary care efficiency. We highlight several policies that could enhance the efficiency of primary care. Improvements in data collection would enable more comprehensive assessments of primary care efficiency across countries, which in turn could more effectively inform policymaking.
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Affiliation(s)
- Valerie Moran
- Socio-Economic and Environmental Health and Health Services Research Group, Department of Precision Health, Luxembourg Institute of Health, Luxembourg City, Luxembourg.
- Socio-Economic and Environmental Health and Health Services Research Group, Living Conditions Department, Luxembourg Institute of Socio-Economic Research (LISER), Belval, Esch-sur-Alzette, Luxembourg.
| | - Marc Suhrcke
- Socio-Economic and Environmental Health and Health Services Research Group, Department of Precision Health, Luxembourg Institute of Health, Luxembourg City, Luxembourg
- Socio-Economic and Environmental Health and Health Services Research Group, Living Conditions Department, Luxembourg Institute of Socio-Economic Research (LISER), Belval, Esch-sur-Alzette, Luxembourg
| | - Ellen Nolte
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Hamada S, Iwagami M, Sakata N, Hattori Y, Kidana K, Ishizaki T, Tamiya N, Akishita M, Yamanaka T. Changes in Polypharmacy and Potentially Inappropriate Medications in Homebound Older Adults in Japan, 2015-2019: a Nationwide Study. J Gen Intern Med 2023; 38:3517-3525. [PMID: 37620717 PMCID: PMC10713963 DOI: 10.1007/s11606-023-08364-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND With rising worldwide population aging, the number of homebound individuals with multimorbidity is increasing. Improvement in the quality of home medical care (HMC), including medications, contributes to meeting older adults' preference for "aging in place" and securing healthcare resources. OBJECTIVE To evaluate the changes in drug prescriptions, particularly potentially inappropriate medications (PIMs), among older adults receiving HMC in recent years, during which measures addressing inappropriate polypharmacy were implemented, including the introduction of clinical practice guidelines and medical fees for deprescribing. DESIGN A cross-sectional study. PARTICIPANTS Using data from the national claims database in Japan, this study included older adults aged ≥ 75 years who received HMC in October 2015 (N = 499,850) and October 2019 (N = 657,051). MAIN MEASURES Number of drugs, prevalence of polypharmacy (≥ 5 regular drugs), major drug categories/classes, and PIMs according to Japanese guidelines were analyzed. Random effects logistic regression models were used to evaluate the differences in medications between 2015 and 2019, considering the correlation within individuals who contributed to the analysis in both years. KEY RESULTS The number of drugs remained unchanged from 2015 to 2019 (median: 6; interquartile range: 4, 9). The prevalence of polypharmacy also remained unchanged at 70.0% in both years (P = 0.93). However, the prescription of some drugs (e.g., direct oral anticoagulants, new types of hypnotics, acetaminophen, proton pump inhibitors, and β-blockers) increased, whereas others (e.g., warfarin, vasodilators, H2 blockers, acetylcholinesterase inhibitors, and benzodiazepines) decreased. Among the frequently prescribed PIMs, benzodiazepines/Z-drugs (25.6% in 2015 to 21.1% in 2019; adjusted odds ratio: 0.52) and H2 blockers (11.2 to 7.3%; 0.45) decreased, whereas diuretics (23.8 to 23.6%; 0.90) and antipsychotics (9.7 to 10.5%; 1.11) remained unchanged. CONCLUSIONS We observed some favorable changes but identified some continuous and new challenges. This study suggests that continued attention to medication optimization is required to achieve safe and effective HMC.
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Affiliation(s)
- Shota Hamada
- Research Department, Institute for Health Economics and Policy, Association for Health Economics Research and Social Insurance and Welfare, Tokyo, Japan.
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan.
- Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Masao Iwagami
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Nobuo Sakata
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
- Heisei Medical Welfare Group Research Institute, Tokyo, Japan
| | - Yukari Hattori
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kiwami Kidana
- Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuro Ishizaki
- Human Care Research Team, Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
| | - Nanako Tamiya
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Tsukuba, Japan
| | - Masahiro Akishita
- Department of Geriatric Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Takashi Yamanaka
- Department of Home Care Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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Skovsgaard CV, Kristensen T, Pulleyblank R, Olsen KR. Increasing capitation in mixed remuneration schemes: Effects on service provision and process quality of care. HEALTH ECONOMICS 2023; 32:2477-2498. [PMID: 37462601 DOI: 10.1002/hec.4736] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Revised: 06/06/2023] [Accepted: 07/01/2023] [Indexed: 10/04/2023]
Abstract
Many health systems apply mixed remuneration schemes for general practitioners, but little is known about the effects on service provision of changing the relative mix of fee for services and capitation. We apply difference-in-differences analyses to evaluate a reform that effectively reversed the mix between fee for services and capitation from 80/20 to 20/80 for patients with type 2 diabetes. Our results show reductions in provision of both the contact services that became capitated and in other non-capitated (still-billable) services. Reduced provision also occurred for guideline-recommended process quality services. We find that the effects are mainly driven by patients with co-morbidities and by general practitioners with high income, relatively many diabetes patients, and solo practitioners. Thus, increasing capitation in a mixed remuneration schemes appears to reduce service provision for patients with type 2 diabetes monitored in general practice with a risk of unwanted quality effects.
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Affiliation(s)
- Christian Volmar Skovsgaard
- Department of Public Health, Danish Centre for Health Economics, University of Southern Denmark, Odense C, Denmark
| | - Troels Kristensen
- Department of Public Health, Danish Centre for Health Economics, University of Southern Denmark, Odense C, Denmark
| | - Ryan Pulleyblank
- Department of Public Health, Danish Centre for Health Economics, University of Southern Denmark, Odense C, Denmark
- Nordic HTA, Copenhagen SV, Denmark
| | - Kim Rose Olsen
- Department of Public Health, Danish Centre for Health Economics, University of Southern Denmark, Odense C, Denmark
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Ride J, Kasteridis P, Gutacker N, Gravelle H, Rice N, Mason A, Goddard M, Doran T, Jacobs R. Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness. HEALTH ECONOMICS 2023; 32:343-355. [PMID: 36309945 PMCID: PMC10092448 DOI: 10.1002/hec.4623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 06/16/2023]
Abstract
A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.
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Affiliation(s)
- Jemimah Ride
- Health Economics UnitMelbourne School of Population and Global HealthUniversity of MelbourneParkvilleVictoriaAustralia
| | | | | | | | - Nigel Rice
- Centre for Health EconomicsUniversity of YorkYorkUK
| | - Anne Mason
- Centre for Health EconomicsUniversity of YorkYorkUK
| | | | - Tim Doran
- Health SciencesUniversity of YorkYorkUK
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Borges MM, Custódio LA, Cavalcante DDFB, Pereira AC, Carregaro RL. Direct healthcare cost of hospital admissions for chronic non-communicable diseases sensitive to primary care in the elderly. CIENCIA & SAUDE COLETIVA 2023; 28:231-242. [PMID: 36629568 DOI: 10.1590/1413-81232023281.08392022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 07/13/2022] [Indexed: 01/11/2023] Open
Abstract
Aging has imposed changes in the epidemiological profile and an increase in the prevalence of chronic non-communicable diseases (CNCDs). The aim was to estimate the direct cost related to hospital admissions of elderly people affected by CNCDs (hypertension, heart failure and diabetes mellitus) sensitive to primary care, in a medium-sized hospital, in the period 2015-2019. Secondly, we investigated whether clinical and demographic factors explain the costs and length of stay. The medical records of 165 elderly people were analyzed. We found a predominance of women with a mean age of 76.9 years. The most frequent cause of hospitalization was heart failure (62%), and the average length of stay was 9.5 days, and 16% of hospitalizations corresponded to rehospitalizations. Of these, 81% were caused by complications from the previous hospitalization. The estimated total cost was R$ 3 million. Male patients had a longer hospital stay compared to female patients. Hypertension and the total number of procedures were significant predictors of cost and length of stay. We found that in 5 years, the costs of hospital admissions for conditions sensitive to primary care in the elderly are considerable, indicating the relevance of investments in primary care.
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Affiliation(s)
- Marina Miranda Borges
- Universidade Federal de São Carlos. Rod. Washington Luiz s/n, Monjolinho. 13565-905 São Carlos SP Brasil.
| | - Luciana Alves Custódio
- Programa de Pós-Graduação em Ciências da Reabilitação, Núcleo de Evidências e Tecnologias em Saúde, Universidade de Brasília. Brasília DF Brasil
| | | | - Antonio Carlos Pereira
- Faculdade de Odontologia de Piracicaba, Universidade Estadual de Campinas. Piracicaba SP Brasil
| | - Rodrigo Luiz Carregaro
- Programa de Pós-Graduação em Ciências da Reabilitação, Núcleo de Evidências e Tecnologias em Saúde, Universidade de Brasília. Brasília DF Brasil
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Borges MM, Custódio LA, Cavalcante DDFB, Pereira AC, Carregaro RL. Direct healthcare cost of hospital admissions for chronic non-communicable diseases sensitive to primary care in the elderly. CIENCIA & SAUDE COLETIVA 2023. [DOI: 10.1590/1413-81232023281.08392022en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Abstract Aging has imposed changes in the epidemiological profile and an increase in the prevalence of chronic non-communicable diseases (CNCDs). The aim was to estimate the direct cost related to hospital admissions of elderly people affected by CNCDs (hypertension, heart failure and diabetes mellitus) sensitive to primary care, in a medium-sized hospital, in the period 2015-2019. Secondly, we investigated whether clinical and demographic factors explain the costs and length of stay. The medical records of 165 elderly people were analyzed. We found a predominance of women with a mean age of 76.9 years. The most frequent cause of hospitalization was heart failure (62%), and the average length of stay was 9.5 days, and 16% of hospitalizations corresponded to rehospitalizations. Of these, 81% were caused by complications from the previous hospitalization. The estimated total cost was R$ 3 million. Male patients had a longer hospital stay compared to female patients. Hypertension and the total number of procedures were significant predictors of cost and length of stay. We found that in 5 years, the costs of hospital admissions for conditions sensitive to primary care in the elderly are considerable, indicating the relevance of investments in primary care.
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Chen S, Fu H, Jian W. Trends in avoidable hospitalizations in a developed City in eastern China: 2015 to 2018. BMC Health Serv Res 2022; 22:856. [PMID: 35788227 PMCID: PMC9252061 DOI: 10.1186/s12913-022-08275-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/30/2022] [Indexed: 11/18/2022] Open
Abstract
Objective This study aimed to measure the avoidable hospitalization rate and the treatment cost per hospitalization in large cities of eastern China. Methods In this study, the hospital discharge data of all inpatients in the city from 2015 to 2018 were collected. In accordance with the organization for Economic Cooperation and Development (OECD) definition of avoidable hospitalizations, five diseases were selected as the measurement objects, including hypertension, diabetes, asthma, chronic obstructive pulmonary disease (COPD), as well as congestive heart failure (CHF). We described the avoidable hospitalization rate, average cost and length of stay for avoidable hospitalization cases. Linear probability model and log-linear model were used to control the basic characteristics and disease severity of patients, and to measure the trend of the avoidable hospitalization rate and expenditure of avoidable hospitalizations. Results From 2015 to 2018, the absolute number of avoidable hospitalizations in the city increased while fluctuating, which reached 125,372 in 2018. Among the five avoidable hospitalizations, the number of hospitalizations for diabetes increased continuously in the 4-year period. Congestive heart failure showed the most significant increase over the four years. Avoidable hospitalizations in the city have remained at a high level, while avoidable hospitalizations of hypertension and asthma fell to levels lower than those in 2015 in 2017 and 2018 after rising in 2016. The cost per hospitalization and length of stay per hospitalization decreased. Conclusions Avoidable hospitalizations in the city remain at a high level, and more effective policies should be formulated to guide patients with avoidable hospitalizations, so as to more effectively exploit outpatient services and continuously improve the quality of primary health care services. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-022-08275-w.
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Affiliation(s)
- Siyuan Chen
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China
| | - Hongqiao Fu
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
| | - Weiyan Jian
- Department of Health Policy and Management, School of Public Health, Peking University, No. 38, Xueyuan Road, Haidian District, Beijing, 100191, China.
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Gravelle H, Liu D, Santos R. How do clinical quality and patient satisfaction vary with provider size in primary care? Evidence from English general practice panel data. Soc Sci Med 2022; 301:114936. [PMID: 35367906 DOI: 10.1016/j.socscimed.2022.114936] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 03/11/2022] [Accepted: 03/18/2022] [Indexed: 11/26/2022]
Abstract
We examine the relationship between general practice list size and measures of clinical quality and patient satisfaction. Using data on all English practices from 2005/6 to 2016/17, we estimate practice level models with rich data on patient demographics, deprivation, and morbidity. We use lagged list size to allow for potential simultaneity bias from the effect of quality on list size. We compare results from three different estimation methods: pooled ordinary least squares, random practice effects, fixed practice effects. With all three estimation methods increased list size is associated with reductions in all four measures of patient satisfaction. Increases in list size are associated with worse performance on three clinical quality indicators and better performance on three, though the precision and size of the associations varies with the estimation method. The absolute values of the elasticities of the ten quality indicators with respect to list size are small: in all cases a 10% change in list size would change quality by less than 1%. The lack of evidence that large practices have markedly better quality suggests that encouraging practices to form larger, but looser, groupings, may not, in itself, improve their performance.
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Affiliation(s)
- Hugh Gravelle
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York, YO10 5DD, United Kingdom.
| | - Dan Liu
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York, YO10 5DD, United Kingdom; Centre for Health Economics Research and Evaluation, University of Technology Sydney, PO Box 123, Broadway, NSW, 2007, Australia.
| | - Rita Santos
- Economics of Social and Health Care Research Unit, Centre for Health Economics, University of York, York, YO10 5DD, United Kingdom.
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Lau YS, Malisauskaite G, Brookes N, Hussein S, Sutton M. Complements or substitutes? Associations between volumes of care provided in the community and hospitals. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:1167-1181. [PMID: 34138375 PMCID: PMC8526459 DOI: 10.1007/s10198-021-01329-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 05/27/2021] [Indexed: 06/12/2023]
Abstract
Policymakers often suggest that expansion of care in community settings may ease increasing pressures on hospital services. Substitution may lower overall health system costs, but complementarity due to previously unidentified needs might raise them. We used new national data on community and primary medical care services in England to undertake system-level analyses of whether activity in the community acts as a complement or a substitute for activity provided in hospitals. We used two-way fixed effects regression to relate monthly counts of community care and primary medical care contacts to emergency department attendances, outpatient visits and admissions for 242 hospitals between November 2017 and September 2019. We then used national unit costs to estimate the effects of increasing community activity on overall system expenditure. The findings show community care contacts to be weak substitutes with all types of hospital activity and primary care contacts are weak substitutes for emergency hospital attendances and admissions. Our estimates ranged from 28 [95% CI 21, 45] to 517 [95% CI 291, 7265] community care contacts and from 34 [95% CI 17, 1283] to 1655 [95% CI - 1995, 70,145] GP appointments to reduce one hospital service visit. Primary care and planned hospital services are complements. Increases in community services and primary care activity are both associated with increased overall system expenditure of £34 [95% CI £156, £54] per visit for community care and £41 [95% CI £78, £74] per appointment in general practice. Expansion of community-based services may not generate reductions in hospital activity and expenditure.
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Affiliation(s)
- Yiu-Shing Lau
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK.
| | | | - Nadia Brookes
- Centre for Health Services Studies, University of Kent, Kent, UK
| | - Shereen Hussein
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK
- Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Melbourne, Australia
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Das-Munshi J, Schofield P, Ashworth M, Gaughran F, Hull S, Ismail K, Robson J, Stewart R, Mathur R. Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years. BMJ Open Diabetes Res Care 2021; 9:e002118. [PMID: 34497046 PMCID: PMC8438718 DOI: 10.1136/bmjdrc-2021-002118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/29/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme. RESEARCH DESIGN AND METHODS Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models. RESULTS Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels. CONCLUSIONS Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.
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Affiliation(s)
- Jayati Das-Munshi
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
- ESRC Centre for Society and Mental Health, King's College London, London, UK
| | - Peter Schofield
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Mark Ashworth
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Fiona Gaughran
- South London and Maudsley (SLaM) NHS Trust, London, UK
- Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
| | - Sally Hull
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Khalida Ismail
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - John Robson
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - Rohini Mathur
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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Russo LX, Powell-Jackson T, Maia Barreto JO, Borghi J, Kovacs R, Gurgel Junior GD, Gomes LB, Sampaio J, Shimizu HE, de Sousa ANA, Bezerra AFB, Stein AT, Silva EN. Pay for performance in primary care: the contribution of the Programme for Improving Access and Quality of Primary Care (PMAQ) on avoidable hospitalisations in Brazil, 2009-2018. BMJ Glob Health 2021; 6:bmjgh-2021-005429. [PMID: 34244203 PMCID: PMC8273460 DOI: 10.1136/bmjgh-2021-005429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 06/18/2021] [Indexed: 01/13/2023] Open
Abstract
Background Evidence on the effect of pay-for-performance (P4P) schemes on provider performance is mixed in low-income and middle-income countries. Brazil introduced its first national-level P4P scheme in 2011 (PMAQ-Brazilian National Programme for Improving Primary Care Access and Quality). PMAQ is likely one of the largest P4P schemes in the world. We estimate the association between PMAQ and hospitalisations for ambulatory care sensitive conditions (ACSCs) based on a panel of 5564 municipalities. Methods We conducted a fixed effect panel data analysis over the period of 2009–2018, controlling for coverage of primary healthcare, hospital beds per 10 000 population, education, real gross domestic product per capita and population density. The outcome is the hospitalisation rate for ACSCs among people aged 64 years and under per 10 000 population. Our exposure variable is defined as the percentage of family health teams participating in PMAQ, which captures the roll-out of PMAQ over time. We also provided several sensitivity analyses, by using alternative measures of the exposure and outcome variables, and a placebo test using transport accident hospitalisations instead of ACSCs. Results The results show a negative and statistically significant association between the rollout of PMAQ and ACSC rates for all age groups. An increase in PMAQ participating of one percentage point decreased the hospitalisation rate for ACSC by 0.0356 (SE 0.0123, p=0.004) per 10 000 population (aged 0–64 years). This corresponds to a reduction of approximately 60 829 hospitalisations in 2018. The impact is stronger for children under 5 years (−0.0940, SE 0.0375, p=0.012), representing a reduction of around 11 936 hospitalisations. Our placebo test shows that the association of PMAQ on the hospitalisation rate for transport accidents is not statistically significant, as expected. Conclusion We find that PMAQ was associated with a modest reduction in hospitalisation for ACSCs.
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Affiliation(s)
- Letícia Xander Russo
- Department of Economics, Federal University of Grande Dourados, Dourados, Brazil
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | - Roxanne Kovacs
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London, UK
| | | | | | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraiba, Joao Pessoa, Brazil
| | - Helena Eri Shimizu
- Department of Collective Health, University of Brasilia, Brasilia, Brazil
| | | | | | - Airton Tetelbom Stein
- Department of Public Health, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
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Khedmati Morasae E, Rose TC, Gabbay M, Buckels L, Morris C, Poll S, Goodall M, Barnett R, Barr B. Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study. Med Care Res Rev 2021; 79:394-403. [PMID: 34323143 PMCID: PMC9052704 DOI: 10.1177/10775587211035280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
National financial incentive schemes for improving the quality of primary care
have come under criticism in the United Kingdom, leading to calls for localized
alternatives. This study investigated whether a local general practice
incentive-based quality improvement scheme launched in 2011 in a city in the
North West of England was associated with a reduction in all-cause emergency
hospital admissions. Difference-in-differences analysis was used to compare the
change in emergency admission rates in the intervention city, to the change in a
matched comparison population. Emergency admissions rates fell by 19 per 1,000
people in the years following the intervention (95% confidence interval [17,
21]) in the intervention city, relative to the comparison population. This
effect was greater among more disadvantaged populations, narrowing socioeconomic
inequalities in emergency admissions. The findings suggest that similar
approaches could be an effective component of strategies to reduce unplanned
hospital admissions elsewhere.
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Affiliation(s)
| | | | | | - Laura Buckels
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Sharon Poll
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Rob Barnett
- Liverpool Local Medical Committee, Liverpool, UK
| | - Ben Barr
- University of Liverpool, Liverpool, UK
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15
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Liang LL, Tussing AD, Huang N, Tsai SL. Incentives for physician teams: Effectiveness of performance feedback and payment distribution methods. Health Policy 2021; 125:1377-1384. [PMID: 34334226 DOI: 10.1016/j.healthpol.2021.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 07/19/2021] [Accepted: 07/20/2021] [Indexed: 11/29/2022]
Abstract
Best practices in team-based incentive design remain underexplored. This study examines under group-based pay-for-performance, how managers incentivize physicians for teamwork through internal feedback and payment distribution methods. In collaboration with Taiwan Association of Family Medicine, authors conducted a national survey of physician groups, with a response rate of 48.3%. Multilevel linear regression was applied to 134 groups, collectively consisting of 1,245 physicians in Taiwan. The outcome variables were two manager-rated scores for group performance on achieving (a) comprehensive, coordinated, continuous care, and (b) patient health improvement. The results indicate that providing each physician feedback on peer performance is superior to not providing it; when providing peer information within a group, concealing identities is superior to revealing them. These findings imply that application of the principle of social comparison can be effective; however, caution should be taken when disclosure of identifiable peer performance may intensify peer competition and undermine care coordination in team-based models. Further, groups that distribute payments equally among physicians perform better than groups that distributed payment proportionally to physicians' patient shares. The findings are germane to small teams, where physicians do not have full control over care processes and outcomes, and need to work cooperatively to maximize group-based payment.
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Affiliation(s)
- Li-Lin Liang
- Department of Business Management, National Sun Yat-sen University, No.70 Lien-Hai Rd., Kaohsiung 804, Taiwan; Research Center for Epidemic Prevention, National Yang Ming Chiao Tung University, No.155, Sec. 2, Li‑Nong Street, Taipei 112, Taiwan.
| | - A Dale Tussing
- Department of Economics, Syracuse University, 900 South Crouse Ave. Syracuse, NY 13244, USA
| | - Nicole Huang
- Institute of Hospital and Health Care Administration, National Yang Ming Chiao Tung University, No.155, Sec. 2, Li‑Nong Street, Taipei 112, Taiwan
| | - Shu-Ling Tsai
- National Health Insurance Administration, Ministry of Health and Welfare, No.140, Sec.3, Hsinyi Rd., Taipei 106, Taiwan
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Spycher J, Dusheiko M, Beaupère P, Gravier B, Moschetti K. Healthcare in a pure gatekeeping system: utilization of primary, mental and emergency care in the prison population over time. HEALTH & JUSTICE 2021; 9:11. [PMID: 33987749 PMCID: PMC8120814 DOI: 10.1186/s40352-021-00136-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/13/2021] [Indexed: 06/12/2023]
Abstract
BACKGROUND This study investigates the prisoner and prison-level factors associated with healthcare utilization (HCU) and the dynamic effects of previous HCU and health events. We analyze administrative data collected on annual adult prisoner-stay HCU (n = 10,136) including physical and mental chronic disease diagnoses, acute health events, penal circumstances and prison-level factors between 2013 and 2017 in 4 prisons of Canton of Vaud, Switzerland. Utilization of four types of health services: primary, nursing, mental and emergency care; are assessed using multivariate and multi-level negative binomial regressions with fixed/random effects and dynamic models conditional on prior HCU and lagged health events. RESULTS In a prison setting with health screening on detention, removal of financial barriers to care and a nurse-led gatekeeping system, we find that health status, socio-demographic characteristics, penal history, and the prison environment are associated with HCU overtime. After controlling for chronic and past acute illnesses, female prisoners have higher HCU, younger adults more emergencies, and prisoners from Africa, Eastern Europe, and the Americas lower HCU. New prisoners, pretrial detainees or repeat offenders utilize more all types of care. Overcrowding increases primary care but reduces utilization of mental and emergency services. Higher expenditure on medical staff resources is associated with more primary care visits and less emergency visits. The dynamics of HCU across types of care shows persistence over time related to emergency use, previous somatic acute illnesses, and acting out events. There is also evidence of substitution between psychiatric and primary care. CONCLUSIONS The prison healthcare system provides an opportunity to diagnose and treat unmet health needs for a marginalized population. Access to psychiatric and chronic disease management during incarceration and prevention of emergency or acute events can reduce future demand for care. Prioritization of high-risk patients and continuity of care inside and outside of prisons may reduce public health pressures in the criminal system. The prison environment and prisoners' penal circumstances impacts healthcare utilization, suggesting better coordination between the criminal justice and prison health systems is required.
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Affiliation(s)
- Jacques Spycher
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
| | | | - Pascale Beaupère
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- Service of Correctional Medicine and Psychiatry (SMPP), University hospital of Lausanne (CHUV), Lausanne, Switzerland
| | | | - Karine Moschetti
- Center for Primary Care and Public Health (Unisanté), University of Lausanne, Lausanne, Switzerland
- Technology Assessment Unit (UET), University hospital of Lausanne (CHUV), Lausanne, Switzerland
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17
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Gunn LH, McKay AJ, Molokhia M, Valabhji J, Molina G, Majeed A, Vamos EP. Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study. J R Soc Med 2021; 114:299-312. [PMID: 33821695 DOI: 10.1177/01410768211005109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions. DESIGN Historical cohort study. SETTING A total of 330 English primary care practices, 2010-2017, using UK Clinical Practice Research Datalink. PARTICIPANTS A total of 84,441 adults with type 2 diabetes. MAIN OUTCOME MEASURES The primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission. RESULTS There were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89-0.92; p < 0.001 and 0.87; 95% CI 0.86-0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96-0.99; p = 0.001). Strong associations were found between completing 7-9 (vs. either 4-6 or 0-3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7-9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions. CONCLUSIONS Attaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.
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Affiliation(s)
- Laura H Gunn
- Department of Public Health Sciences, 14727University of North Carolina at Charlotte, Charlotte, NC 28223, USA.,School of Data Science, 14727University of North Carolina at Charlotte, Charlotte, NC 28223, USA.,Department of Primary Care and Public Health, 4615Imperial College London, London W6 8RP, UK
| | - Ailsa J McKay
- Department of Primary Care and Public Health, 4615Imperial College London, London W6 8RP, UK
| | - Mariam Molokhia
- Department of Population Health Sciences, King's College London, London SE1 1UL, UK
| | - Jonathan Valabhji
- NHS England and NHS Improvement, London SE1 6LH, UK.,Department of Diabetes and Endocrinology, St Mary's Hospital, Imperial College Healthcare NHS Trust, London W2 1NY, UK.,Division of Metabolism, Digestion and Reproduction, 4615Imperial College London, London SW7 2AZ, UK
| | - German Molina
- Department of Primary Care and Public Health, 4615Imperial College London, London W6 8RP, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, 4615Imperial College London, London W6 8RP, UK
| | - Eszter P Vamos
- Department of Primary Care and Public Health, 4615Imperial College London, London W6 8RP, UK
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18
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Stokes J, Shah V, Goldzahl L, Kristensen SR, Sutton M. Does prevention-focused integration lead to the triple aim? An evaluation of two new care models in England. J Health Serv Res Policy 2021; 26:125-132. [PMID: 33106038 PMCID: PMC8013794 DOI: 10.1177/1355819620963500] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES To examine the effectiveness of two integrated care models ('vanguards') in Salford and South Somerset in England, United Kingdom, in relation to patient experience, health outcomes and costs of care (the 'triple aim'). METHODS We used difference-in-differences analysis combined with propensity score weighting to compare the two care model sites with control ('usual care') areas in the rest of England. We estimated combined and separate annual effects in the three years following introduction of the new care model, using the national General Practice Patient Survey (GPPS) to measure patient experience (inter-organisational support with chronic condition management) and generic health status (EQ-5D); and hospital episode statistics (HES) data to measure total costs of secondary care. As secondary outcomes we measured proxies for improved prevention: cost per user of secondary care (severity); avoidable emergency admissions; and primary care utilisation. RESULTS Both intervention sites showed an increase in total costs of secondary care (approximately £74 per registered patient per year in Salford, £45 in South Somerset) and cost per user of secondary care (£130-138 per person per year). There were no statistically significant effects on health status or patient experience of care. There was a more apparent short-term negative effect on measured outcomes in South Somerset, in terms of increased costs and avoidable emergency admissions, but these reduced over time. CONCLUSION New care models such as those implemented within the Vanguard programme in England might lead to unintended secondary care cost increases in the short to medium term. Cost increases appeared to be driven by average patient severity increases in hospital. Prevention-focused population health management models of integrated care, like previous more targeted models, do not immediately improve the health system's triple aim.
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Affiliation(s)
- Jonathan Stokes
- Research Fellow, Health Organisation, Policy, and Economics,
Centre for Primary Care and Health Services Research, University of Manchester,
UK
- Jonathan Stokes, Health Organisation,
Policy, and Economics, Centre for Primary Care and Health Services Research,
University of Manchester, Manchester M13 9PL, UK.
| | - Vishalie Shah
- Research Associate, Health Organisation, Policy, and Economics,
Centre for Primary Care and Health Services Research, University of Manchester,
UK
| | | | - Søren Rud Kristensen
- Senior Lecturer, Faculty of Medicine, Institute of Global Health
Innovation, Imperial College London, UK
- Associate Professor, Danish Centre for Health Economics
Research, University of Southern Denmark, Denmark
| | - Matt Sutton
- Associate Professor, Danish Centre for Health Economics
Research, University of Southern Denmark, Denmark
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Developing measures to capture the true value of primary care. BJGP Open 2021; 5:BJGPO.2020.0152. [PMID: 33563701 PMCID: PMC8170610 DOI: 10.3399/bjgpo.2020.0152] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 12/06/2020] [Indexed: 11/01/2022] Open
Abstract
Primary care (PC) is an essential building block for any high quality healthcare system, and has a particularly positive impact on vulnerable patients. It contributes to the overall performance of health systems, and countries that reorient their health system towards PC are better prepared to achieve universal health coverage. Monitoring the actual performance of PC in health systems is essential health policy to support PC. However, current indicators are often too narrowly defined to account for quality of care in the complex populations with which PC deals. This article reviews a number of conceptual frameworks developed to capture PC values in robust measures and indicators that can inform policy and practice performance. Each have benefits and limitations. Further work is needed to develop meaningful primary health care (PHC) and PC measures to inform strategic action by policymakers and governments for improved overall performance of health systems.
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Stokes J, Guthrie B, Mercer SW, Rice N, Sutton M. Multimorbidity combinations, costs of hospital care and potentially preventable emergency admissions in England: A cohort study. PLoS Med 2021; 18:e1003514. [PMID: 33439870 PMCID: PMC7815339 DOI: 10.1371/journal.pmed.1003514] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 01/19/2021] [Accepted: 01/05/2021] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND Patients with multimorbidities have the greatest healthcare needs and generate the highest expenditure in the health system. There is an increasing focus on identifying specific disease combinations for addressing poor outcomes. Existing research has identified a small number of prevalent "clusters" in the general population, but the limited number examined might oversimplify the problem and these may not be the ones associated with important outcomes. Combinations with the highest (potentially preventable) secondary care costs may reveal priority targets for intervention or prevention. We aimed to examine the potential of defining multimorbidity clusters for impacting secondary care costs. METHODS AND FINDINGS We used national, Hospital Episode Statistics, data from all hospital admissions in England from 2017/2018 (cohort of over 8 million patients) and defined multimorbidity based on ICD-10 codes for 28 chronic conditions (we backfilled conditions from 2009/2010 to address potential undercoding). We identified the combinations of multimorbidity which contributed to the highest total current and previous 5-year costs of secondary care and costs of potentially preventable emergency hospital admissions in aggregate and per patient. We examined the distribution of costs across unique disease combinations to test the potential of the cluster approach for targeting interventions at high costs. We then estimated the overlap between the unique combinations to test potential of the cluster approach for targeting prevention of accumulated disease. We examined variability in the ranks and distributions across age (over/under 65) and deprivation (area level, deciles) subgroups and sensitivity to considering a smaller number of diseases. There were 8,440,133 unique patients in our sample, over 4 million (53.1%) were female, and over 3 million (37.7%) were aged over 65 years. No clear "high cost" combinations of multimorbidity emerged as possible targets for intervention. Over 2 million (31.6%) patients had 63,124 unique combinations of multimorbidity, each contributing a small fraction (maximum 3.2%) to current-year or 5-year secondary care costs. Highest total cost combinations tended to have fewer conditions (dyads/triads, most including hypertension) affecting a relatively large population. This contrasted with the combinations that generated the highest cost for individual patients, which were complex sets of many (6+) conditions affecting fewer persons. However, all combinations containing chronic kidney disease and hypertension, or diabetes and hypertension, made up a significant proportion of total secondary care costs, and all combinations containing chronic heart failure, chronic kidney disease, and hypertension had the highest proportion of preventable emergency admission costs, which might offer priority targets for prevention of disease accumulation. The results varied little between age and deprivation subgroups and sensitivity analyses. Key limitations include availability of data only from hospitals and reliance on hospital coding of health conditions. CONCLUSIONS Our findings indicate that there are no clear multimorbidity combinations for a cluster-targeted intervention approach to reduce secondary care costs. The role of risk-stratification and focus on individual high-cost patients with interventions is particularly questionable for this aim. However, if aetiology is favourable for preventing further disease, the cluster approach might be useful for targeting disease prevention efforts with potential for cost-savings in secondary care.
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Affiliation(s)
- Jonathan Stokes
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, United Kingdom
| | - Bruce Guthrie
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Stewart W. Mercer
- Usher Institute, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Nigel Rice
- Department of Economics and Related Studies and Centre for Health Economics, University of York, York, United Kingdom
| | - Matt Sutton
- Centre for Primary Care and Health Services Research, University of Manchester, Manchester, United Kingdom
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21
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Thavam T, Devlin RA, Thind A, Zaric GS, Sarma S. The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1279-1293. [PMID: 32676753 DOI: 10.1007/s10198-020-01216-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/25/2020] [Indexed: 06/11/2023]
Abstract
Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.
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Affiliation(s)
- Thaksha Thavam
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, ON, Canada
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
- Ivey School of Business, University of Western Ontario, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada.
- ICES, Toronto, ON, Canada.
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Santos R, Rice N, Gravelle H. Patterns of emergency admissions for ambulatory care sensitive conditions: a spatial cross-sectional analysis of observational data. BMJ Open 2020; 10:e039910. [PMID: 33148755 PMCID: PMC7643517 DOI: 10.1136/bmjopen-2020-039910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To examine the spatial and temporal patterns of English general practices' emergency admissions for Ambulatory Care Sensitive Conditions (ACSCs). DESIGN Observational study of practice level annual hospital emergency admissions data for ACSCs for all English practices from 2004-2017. PARTICIPANTS All patients with an emergency admission to a National Health Service hospital in England who were registered with an English general practice. MAIN OUTCOME MEASURE Practice level age and gender indirectly standardised ratios (ISARs) for emergency admissions for ACSC. RESULTS In 2017, 41.8% of the total variation in ISARs across practices was between the 207 Clinical Commissioning Groups (CCGs) (the administrative unit for general practices) and 58.2% was across practices within CCGs. ACSC ISARs increased by 4.7% between 2004 and 2017, while those for conditions incentivised by the Quality and Outcomes Framework (QOF) fell by 20%. Practice ISARs are persistent: practices with high rates in 2004 also had high rates in 2017. Standardising by deprivation as well as age and gender reduced the coefficient of variation of practice ISARs in 2017 by 22%. CONCLUSIONS There is persistent spatial pattern of emergency admissions for ACSC across England both within and across CCGs. We illustrate the reduction in ACSCs emergency admissions across the study period for conditions incentivised by the QOF but find that this was not accompanied by a reduction in variation in these admissions across practices. The observed spatial pattern persists when admission rates are standardised by deprivation. The persistence of spatial clusters of high emergency admissions for ACSCs within and across CCG boundaries suggests that policies to reduce potentially unwarranted variation should be targeted at practice level.
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Affiliation(s)
- Rita Santos
- Centre for Health Economics, University of York, York, North Yorkshire, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, North Yorkshire, UK
- Department of Economics and Related Studies, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, North Yorkshire, UK
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Grigoroglou C, Munford L, Webb R, Kapur N, Doran T, Ashcroft D, Kontopantelis E. Impact of a national primary care pay-for-performance scheme on ambulatory care sensitive hospital admissions: a small-area analysis in England. BMJ Open 2020; 10:e036046. [PMID: 32907897 PMCID: PMC7482460 DOI: 10.1136/bmjopen-2019-036046] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE We aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world's largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme. SETTING We obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics. RESULTS Hospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition. CONCLUSION Spatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.
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Affiliation(s)
- Christos Grigoroglou
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
| | - Luke Munford
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Health Organisation, Policy and Economics, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Roger Webb
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- Centre for Mental Health and Safety, Division of Psychology & Mental Health, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Navneet Kapur
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Suicide Prevention, Division of Psychology and Mental Health, University of Manchester, Manchester, UK
- Greater Manchester Mental Health Trust, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Darren Ashcroft
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Manchester Academic Health Sciences Centre (MAHSC), Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
- Faculty of Biology, Medicine & Health, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, Greater Manchester, UK
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Sarmento J, Rocha JVM, Santana R. Defining ambulatory care sensitive conditions for adults in Portugal. BMC Health Serv Res 2020; 20:754. [PMID: 32799880 PMCID: PMC7429814 DOI: 10.1186/s12913-020-05620-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Accepted: 08/03/2020] [Indexed: 11/18/2022] Open
Abstract
Background Ambulatory Care Sensitive Conditions (ACSCs) are health conditions for which adequate management, treatment and interventions delivered in the ambulatory care setting could potentially prevent hospitalization. Which conditions are sensitive to ambulatory care varies according to the scope of health care services and the context in which the indicator is used. The need for a country-specific validated list for Portugal has already been identified, but currently no national list exists. The objective of this study was to develop a list of Ambulatory Care Sensitive Conditions for Portugal. Methods A modified web-based Delphi panel approach was designed, in order to determine which conditions can be considered ACSCs in the Portuguese adult population. The selected experts were general practitioners and internal medicine physicians identified by the most relevant Portuguese scientific societies. Experts were presented with previously identified ACSC and asked to select which could be accepted in the Portuguese context. They were also asked to identify other conditions they considered relevant. We estimated the number and cost of ACSC hospitalizations in 2017 in Portugal according to the identified conditions. Results After three rounds the experts agreed on 34 of the 45 initially proposed items. Fourteen new conditions were proposed and four achieved consensus, namely uterine cervical cancer, colorectal cancer, thromboembolic venous disease and voluntary termination of pregnancy. In 2017 133,427 hospitalizations were for ACSC (15.7% of all hospitalizations). This represents a rate of 1685 per 100,000 adults. The most frequent diagnosis were pneumonia, heart failure, chronic obstructive pulmonary disease/chronic bronchitis, urinary tract infection, colorectal cancer, hypertensive disease atrial fibrillation and complications of diabetes mellitus. Conclusions New ACSC were identified. It is expected that this list could be used henceforward by epidemiologic studies, health services research and for healthcare management purposes. ACSC lists should be updated frequently. Further research is necessary to increase the specificity of ACSC hospitalizations as an indicator of healthcare performance.
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Affiliation(s)
- João Sarmento
- NOVA National School of Public Health, Public Health Research Center, Universidade NOVA de Lisboa, Av. Padre Cruz, 1600-560, Lisbon, Portugal.
| | - João Victor Muniz Rocha
- NOVA National School of Public Health, Public Health Research Center, Universidade NOVA de Lisboa, Av. Padre Cruz, 1600-560, Lisbon, Portugal.,Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Rui Santana
- NOVA National School of Public Health, Public Health Research Center, Universidade NOVA de Lisboa, Av. Padre Cruz, 1600-560, Lisbon, Portugal.,Comprehensive Health Research Center, Universidade NOVA de Lisboa, Lisbon, Portugal
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Khan N, Rudoler D, McDiarmid M, Peckham S. A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK. BMC FAMILY PRACTICE 2020; 21:142. [PMID: 32660427 PMCID: PMC7359468 DOI: 10.1186/s12875-020-01208-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff. METHODS We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis. RESULTS We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems. CONCLUSIONS Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.
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Affiliation(s)
| | - David Rudoler
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Unit UA3000, Oshawa, ON, L1H 7K4, Canada
| | - Mary McDiarmid
- Ontario Shores Centre for Mental Health Sciences, 700 Gordon Street, Whitby, ON, L1N 5S9, Canada
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent, Kent, Canterbury, CT2 7NF, UK
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Jacobs R, Aylott L, Dare C, Doran T, Gilbody S, Goddard M, Gravelle H, Gutacker N, Kasteridis P, Kendrick T, Mason A, Rice N, Ride J, Siddiqi N, Williams R. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.
Objectives
We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.
Design and setting
We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.
Participants
Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.
Interventions
Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).
Main outcome measures
Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.
Results
Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.
Limitations
There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.
Conclusions
Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.
Future work
Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | - Lauren Aylott
- Expert by experience
- Hull York Medical School, York, UK
| | | | | | - Simon Gilbody
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | | | - Tony Kendrick
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Jemimah Ride
- Centre for Health Economics, University of York, York, UK
| | - Najma Siddiqi
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Rachael Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
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Reducing the Effect of Critical Illness by Continuing to Think beyond the Intensive Care Unit. Ann Am Thorac Soc 2020; 17:33-35. [PMID: 31891304 DOI: 10.1513/annalsats.201910-753ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
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Effect of a national primary care reform on avoidable hospital admissions (2000-2015): A difference-in-difference analysis. Soc Sci Med 2020; 252:112908. [PMID: 32278243 DOI: 10.1016/j.socscimed.2020.112908] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Revised: 03/02/2020] [Accepted: 03/04/2020] [Indexed: 02/08/2023]
Abstract
In 2006 a major primary care reform was initiated in Portugal. The most significant aspect of this reform was the creation of a new organizational model of primary care provision: Family Health Units (FHUs), consisting of small voluntarily constituted multidisciplinary teams that have functional autonomy and are partly financed through capitation and pay-for-performance. The creation of FHUs sought to increase access to care and to chronic disease management by improving the long-term relationship between health professionals and patients. The objectives of this study are to evaluate the impact of the FHUs implementation on population health outcomes, measured by the rate of hospitalizations for ambulatory care sensitive conditions (ACSC), i.e. avoidable hospital inpatient admissions, and to explore the effectiveness of the pay-for-performance in primary care by analysing the subset of disease specific hospitalizations for ACSC related to the financial incentives. Using data from 276 Portuguese municipalities from 2000 to 2015 (n = 4416) and exploiting the gradual introduction of the FHUs over time, we used a difference-in-differences approach contrasting the evolution of the hospitalization rate for ACSC in municipalities that implemented or not the FHUs. We then explored heterogeneous effects by incentivized (diabetes and hypertension) and non-incentivized disease-specific rates of hospitalizations for ACSC. During the period under analysis, 448 FHUs were created in 126 municipalities. No significant impact of the FHUs implementation on the reduction of the hospitalization rate for ACSC was found. This result also held for the incentivized hospitalizations for ACSC. We only found a statistically significant effect of the FHUs implementation in the reduction of one non-incentivized area (the rate of urinary tract infection ACSC). Our results question the capacity of this payment mechanism to achieve better health outcomes, and invites a more careful and evidence-based action toward its wider diffusion.
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Gravelle H, Liu D, Propper C, Santos R. Spatial competition and quality: Evidence from the English family doctor market. JOURNAL OF HEALTH ECONOMICS 2019; 68:102249. [PMID: 31698252 DOI: 10.1016/j.jhealeco.2019.102249] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Revised: 10/09/2019] [Accepted: 10/14/2019] [Indexed: 06/10/2023]
Abstract
We examine whether family doctor firms in England respond to local competition by increasing their quality. We measure quality in terms of clinical performance and patient-reported satisfaction to capture its multi-dimensional nature. We use a panel covering 8 years for over 8000 English general practices. We measure competition as the number of rival doctors within a small distance and control for a large number of potential confounders. We find that increases in local competition are associated with increases in patient satisfaction and to a lesser extent in clinical quality. However, the magnitude of the effect is small.
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Affiliation(s)
- Hugh Gravelle
- Economics of Health and Social Care Research Centre, Centre for Health Economics, University of York, United Kingdom.
| | - Dan Liu
- Economics of Health and Social Care Research Centre, Centre for Health Economics, University of York, United Kingdom
| | - Carol Propper
- Imperial College London, CMPO University of Bristol, CEPR and IFS, United Kingdom
| | - Rita Santos
- Economics of Health and Social Care Research Centre, Centre for Health Economics, University of York, United Kingdom
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Guest JF, Singh H. Cost-effectiveness of using an extensively hydrolyzed casein formula supplemented with Lactobacillus rhamnosus GG in managing IgE-mediated cow's milk protein allergy in the UK. Curr Med Res Opin 2019; 35:1677-1685. [PMID: 31025591 DOI: 10.1080/03007995.2019.1612339] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Objective: To estimate the cost-effectiveness of using an extensively hydrolyzed casein formula (eHCF) plus the probiotic Lactobacillus rhamnosus GG (eHCF plus LGG; Nutramigen* LGG®) compared to an eHCF alone as first-line dietary management for Immunoglobulin E (IgE)-mediated cow's milk protein allergy (CMPA) in the UK. Methods: Decision modelling was undertaken to estimate the probability of IgE-mediated cow's milk allergic infants being symptom free (i.e. not experiencing urticaria, eczema, asthma or rhinoconjunctivitis) and developing tolerance to cow's milk by 5 years. The model also estimated the cost (at 2016/2017 prices) of healthcare resource use funded by the UK's National Health Service (NHS) over 5 years after starting a formula, as well as the relative cost-effectiveness of the two dietary formulae. Results: At 5 years after the start of a formula the probability of being symptom free was estimated to be 0.97 and 0.76 among infants who were originally fed eHCF plus LGG and an eHCF alone, respectively. This encompassed the probability of children being asthma free at 5 years after the start of treatment, which was 0.99 and 0.91 in the eHCF plus LGG and eHCF alone groups, respectively. Additionally, the probability of acquiring tolerance to cow's milk was estimated to be 0.94 and 0.66 among infants who were originally fed eHCF plus LGG and an eHCF alone, respectively. The estimated total healthcare cost over 5 years of initially feeding infants with eHCF plus LGG was less than that of feeding infants with an eHCF alone (£4229 versus £5136 per patient). Conclusions: First-line management of newly diagnosed infants with IgE-mediated CMPA with eHCF plus LGG instead of an eHCF alone improves outcome, releases healthcare resources for alternative use, reduces the NHS cost of patient management and thereby affords a cost-effective dietetic strategy to the NHS.
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Affiliation(s)
- Julian F Guest
- Catalyst Consultants , Rickmansworth , UK
- Faculty of Life Sciences and Medicine, King's College , London , UK
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31
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Workload impact of the Quality and Outcomes Framework for patients with diabetes: an interrupted time series in general practice. Br J Gen Pract 2019; 69:e570-e577. [PMID: 31308001 DOI: 10.3399/bjgp19x704645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 03/13/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND There are substantial concerns about GP workload. The Quality and Outcomes Framework (QOF) has been perceived by both professionals and patients as bureaucratic, but the full impact of the QOF on GP workload is not well known. AIM To assess the impact of the QOF on GP consultation rates for patients with diabetes mellitus. DESIGN AND SETTING This study used interrupted time series of 13 248 745 general practice consultations for 37 065 patients with diabetes mellitus in England. METHOD Clinical Practice Research Datalink general practice data were used from 2000/2001 to 2014/2015, with introduction of the QOF (1 April 2004) as the intervention, and mean annual GP consultation rates as the primary outcome. RESULTS Mean annual GP clinical consultation rates were 8.10 per patient in 2000/2001, 6.91 in 2004/2005, and 7.09 in 2014/2015. Introduction of the QOF was associated with an annual change in the trend of GP clinical consultation rates of 0.46 (95% confidence interval [CI] = 0.23 to 0.69, P = 0.001) consultations per patient, giving a post-QOF trend increasing by 0.018 consultations per year. Introduction of the QOF was associated with an immediate stepped increase of 'other' out-of-hours and non-clinical encounters, and trend change of 0.57 (95% CI = 0.34 to 0.81, P<0.001) per year, resulting in a post-QOF trend increasing by 0.27 other encounters per year. CONCLUSION Introduction of the QOF was associated with a modest increase in clinical GP consultation rates and substantial increase in other encounters for patients with diabetes independent of changes in diabetes prevalence. National prevalence of diabetes increased by 90.7% from 2004/2005 to 2014/2015, which, combined with this study's findings, means GPs would have provided nearly double the number of consultations for patients with diabetes over this timescale.
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32
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Olsen KR, Laudicella M. Health care inequality in free access health systems: The impact of non-pecuniary incentives on diabetic patients in Danish general practices. Soc Sci Med 2019; 230:174-183. [DOI: 10.1016/j.socscimed.2019.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 11/09/2018] [Accepted: 03/05/2019] [Indexed: 12/11/2022]
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Begg A. Life after QOF. PRACTICAL DIABETES 2019. [DOI: 10.1002/pdi.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Alan Begg
- TownheadLinks Health Centre Montrose UK
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34
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Vlaanderen FP, Tanke MA, Bloem BR, Faber MJ, Eijkenaar F, Schut FT, Jeurissen PPT. Design and effects of outcome-based payment models in healthcare: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:217-232. [PMID: 29974285 PMCID: PMC6438941 DOI: 10.1007/s10198-018-0989-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 06/22/2018] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. METHODS We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. RESULTS We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. DISCUSSION Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.
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Affiliation(s)
- F P Vlaanderen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands.
| | - M A Tanke
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
| | - B R Bloem
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands
| | - M J Faber
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboudumc, Nijmegen, The Netherlands
| | - F Eijkenaar
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - F T Schut
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - P P T Jeurissen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
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Hodgson K, Deeny SR, Steventon A. Ambulatory care-sensitive conditions: their potential uses and limitations. BMJ Qual Saf 2019; 28:429-433. [PMID: 30819838 DOI: 10.1136/bmjqs-2018-008820] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/08/2019] [Indexed: 11/04/2022]
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Pearce C, McLeod A, Rinehart N, Patrick J, Fragkoudi A, Ferrigi J, Deveny E, Whyte R, Shearer M. POLAR Diversion: Using General Practice Data to Calculate Risk of Emergency Department Presentation at the Time of Consultation. Appl Clin Inform 2019; 10:151-157. [PMID: 30812041 DOI: 10.1055/s-0039-1678608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVE This project examined and produced a general practice (GP) based decision support tool (DST), namely POLAR Diversion, to predict a patient's risk of emergency department (ED) presentation. The tool was built using both GP/family practice and ED data, but is designed to operate on GP data alone. METHODS GP data from 50 practices during a defined time frame were linked with three local EDs. Linked data and data mapping were used to develop a machine learning DST to determine a range of variables that, in combination, led to predictive patient ED presentation risk scores. Thirteen percent of the GP data was kept as a control group and used to validate the tool. RESULTS The algorithm performed best in predicting the risk of attending ED within the 30-day time category, and also in the no ED attendance tests, suggesting few false positives. At 0 to 30 days the positive predictive value (PPV) was 74%, with a sensitivity/recall of 68%. Non-ED attendance had a PPV of 82% and sensitivity/recall of 96%. CONCLUSION Findings indicate that the POLAR Diversion algorithm performed better than previously developed tools, particularly in the 0 to 30 day time category. Its utility increases because of it being based on the data within the GP system alone, with the ability to create real-time "in consultation" warnings. The tool will be deployed across GPs in Australia, allowing us to assess the clinical utility, and data quality needs in further iterations.
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Affiliation(s)
| | - Adam McLeod
- Outcome Health, East Burwood, Victoria, Australia
| | | | - Jon Patrick
- Health Language Analytics, Eveleigh, New South Wales, Australia
| | | | | | - Elizabeth Deveny
- South East Melbourne Primary Health Network, Melbourne, Australia
| | - Robin Whyte
- Eastern Melbourne Primary Health Network, Box Hill, Victoria, Australia
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Hand BN, Boan AD, Bradley CC, Charles JM, Carpenter LA. Ambulatory Care Sensitive Admissions in Individuals With Autism Spectrum Disorder, Intellectual Disability, and Population Controls. Autism Res 2018; 12:295-302. [DOI: 10.1002/aur.2050] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Revised: 08/28/2018] [Accepted: 10/30/2018] [Indexed: 11/07/2022]
Affiliation(s)
- Brittany N. Hand
- Department of Pediatrics The Ohio State University Charleston SC USA
| | - Andrea D. Boan
- Department of Pediatrics Medical University of South Carolina Charleston SC USA
| | | | - Jane M. Charles
- Department of Pediatrics Medical University of South Carolina Charleston SC USA
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Ride J, Kasteridis P, Gutacker N, Kronenberg C, Doran T, Mason A, Rice N, Gravelle H, Goddard M, Kendrick T, Siddiqi N, Gilbody S, Dare CRJ, Aylott L, Williams R, Jacobs R. Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England. BMJ Open 2018; 8:e023135. [PMID: 30498040 PMCID: PMC6278786 DOI: 10.1136/bmjopen-2018-023135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI). DESIGN, SETTING, PARTICIPANTS Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database. OUTCOMES AND ANALYSIS Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC). RESULTS Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews. CONCLUSIONS Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.
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Affiliation(s)
- Jemimah Ride
- Centre for Health Economics, University of York, York, UK
| | | | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Christoph Kronenberg
- CINCH, University Duisburg-Essen, Essen, Germany
- Leibniz Science Campus Ruhr, Essen, Germany
- RWI – Leibniz-Institute for Economic Research, Essen, Germany
| | - Tim Doran
- Department of Health Sciences, The University of York, York, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Najma Siddiqi
- Department of Health Sciences, The University of York, York, UK
| | - Simon Gilbody
- Department of Health Sciences, The University of York, York, UK
| | | | | | | | - Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
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Grigoroglou C, Munford L, Webb RT, Kapur N, Doran T, Ashcroft DM, Kontopantelis E. Association between a national primary care pay-for-performance scheme and suicide rates in England: spatial cohort study. Br J Psychiatry 2018; 213:600-608. [PMID: 30058517 DOI: 10.1192/bjp.2018.143] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Pay-for-performance policies aim to improve population health by incentivising improvements in quality of care.AimsTo assess the relationship between general practice performance on severe mental illness (SMI) and depression indicators under a national incentivisation scheme and suicide risk in England for the period 2006-2014. METHOD Longitudinal spatial analysis for 32 844 small-area geographical units (lower super output areas, LSOAs), using population-structure adjusted numbers of suicide as the outcome variable. Negative binomial models were fitted to investigate the relationship between spatially estimated recorded quality of care and suicide risk at the LSOA level. Incidence rate ratios (IRRs) were adjusted for deprivation, social fragmentation, prevalence of depression and SMI as well as other 2011 Census variables. RESULTS No association was found between practice performance on the mental health indicators and suicide incidence in practice localities (IRR=1.000, 95% CI 0.998-1.002). IRRs indicated elevated suicide risks linked with area-level social fragmentation (1.030; 95% CI 1.027-1.034), deprivation (1.013, 95% CI 1.012-1.014) and rurality (1.059, 95% CI 1.027-1.092). CONCLUSIONS Primary care has an important role to play in suicide prevention, but we did not observe a link between practices' higher reported quality of care on incentivised mental health activities and lower suicide rates in the local population. It is likely that effective suicide prevention needs a more concerted, multiagency approach. Better training in suicide prevention for general practitioners is also essential. These findings pertain to the UK but have relevance to other countries considering similar programmes.Declaration of interestNone.
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Affiliation(s)
- Christos Grigoroglou
- NIHR School for Primary Care Research,Centre for Primary Care,Division of Population Health, Health Services Research and Primary Care,University of Manchester, Manchester Academic Health Sciences Centre (MAHSC),UK
| | - Luke Munford
- Research Fellow in Health Economics,Centre for Health Economics,Division of Population Health, Health Services Research and Primary Care,University of Manchester, Manchester Academic Health Sciences Centre (MAHSC),UK
| | - Roger T Webb
- Professor in Mental Health Epidemiology,Centre for Mental Health and Safety,University of Manchester, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre (MAHSC),UK
| | - Nav Kapur
- Professor of Psychiatry and Population Health,Centre for Suicide Prevention,University of Manchester, Greater Manchester Mental Health Trust and NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre (MAHSC),UK
| | - Tim Doran
- Professor of Health Policy,Department of Health Sciences,University of York,UK
| | - Darren M Ashcroft
- Professor of Pharmacoepidemiology,Centre for Pharmacoepidemiology and Drug Safety,School of Health Sciences,Faculty of Biology, Medicine and Health,University of Manchester, NIHR Greater Manchester Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre (MAHSC),UK
| | - Evangelos Kontopantelis
- Professor of Data Science and Health Services Research,Faculty of Biology, Medicine and Health,University of Manchester, Manchester Academic Health Sciences Centre (MAHSC),UK
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Cecil E, Bottle A, Ma R, Hargreaves DS, Wolfe I, Mainous AG, Saxena S. Impact of preventive primary care on children's unplanned hospital admissions: a population-based birth cohort study of UK children 2000-2013. BMC Med 2018; 16:151. [PMID: 30220255 PMCID: PMC6139908 DOI: 10.1186/s12916-018-1142-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Accepted: 07/31/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Universal health coverage (UHC) aims to improve child health through preventive primary care and vaccine coverage. Yet, in many developed countries with UHC, unplanned and ambulatory care sensitive (ACS) hospital admissions in childhood continue to rise. We investigated the relation between preventive primary care and risk of unplanned and ACS admission in children in a high-income country with UHC. METHODS We followed 319,780 children registered from birth with 363 English practices in Clinical Practice Research Datalink linked to Hospital Episodes Statistics, born between January 2000 and March 2013. We used Cox regression estimating adjusted hazard ratios (HR) to examine subsequent risk of unplanned and ACS hospital admissions in children who received preventive primary care (development checks and vaccinations), compared with those who did not. RESULTS Overall, 98% of children had complete vaccinations and 87% had development checks. Unplanned admission rates were 259, 105 and 42 per 1000 child-years in infants (aged < 1 year), preschool (1-4 years) and primary school (5-9 years) children, respectively. Lack of preventive care was associated with more unplanned admissions. Infants with incomplete vaccination had increased risk for all unplanned admissions (HR 1.89, 1.79-2.00) and vaccine-preventable admissions (HR 4.41, 2.59-7.49). Infants lacking development checks had higher risk for unplanned admission (HR 4.63, 4.55-4.71). These associations persisted across childhood. Children who had higher consulting rates with primary care providers also had higher risk of unplanned admission (preschool children: HR 1.17, 1.17-1.17). One third of all unplanned admissions (62,154/183,530) were for ACS infectious illness. Children with chronic ACS conditions, asthma, diabetes or epilepsy had increased risk of unplanned admission (HR 1.90, 1.77-2.04, HR 11.43, 8.48-15.39, and HR 4.82, 3.93-5.91, respectively). These associations were modified in children who consulted more in primary care. CONCLUSIONS A high uptake of preventive primary care from birth is associated with fewer unplanned and ACS admissions in children. However, the clustering of poor health, a lack of preventive care uptake, and social deprivation puts some children with comorbid conditions at very high risk of admission. Strengthening immunisation coverage and preventive primary care in countries with poor UHC could potentially significantly reduce the health burden from hospital admission in children.
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Affiliation(s)
- Elizabeth Cecil
- Department of Primary Care and Public Health, Imperial College London Charing Cross Campus, London, W6 8RP, UK.
| | - Alex Bottle
- Department of Primary Care and Public Health, Imperial College London Charing Cross Campus, London, W6 8RP, UK
| | - Richard Ma
- Department of Primary Care and Public Health, Imperial College London Charing Cross Campus, London, W6 8RP, UK
| | | | - Ingrid Wolfe
- Department of Primary Care and Public Health Sciences, King's College London, London, England
| | - Arch G Mainous
- Department of Health Services Research, Management and Policy, University of Florida, Gainesville, FL, USA
| | - Sonia Saxena
- Department of Primary Care and Public Health, Imperial College London Charing Cross Campus, London, W6 8RP, UK
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Awe OA, Okpalauwaekwe U, Lawal AK, Ilesanmi MM, Feng C, Farag M. Association between patient attachment to a regular doctor and self‐perceived unmet health care needs in Canada: A population‐based analysis of the 2013 to 2014 Canadian community health surveys. Int J Health Plann Manage 2018; 34:309-323. [DOI: 10.1002/hpm.2632] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 07/25/2018] [Indexed: 11/05/2022] Open
Affiliation(s)
- Oluwakemi A. Awe
- School of Public HealthUniversity of Saskatchewan Saskatoon Canada
| | - Udoka Okpalauwaekwe
- Department of Academic Family Medicine, College of MedicineUniversity of Saskatchewan Saskatoon Canada
| | - Adegboyega K. Lawal
- College of Pharmacy and NutritionUniversity of Saskatchewan Saskatoon Canada
| | - Marcus M. Ilesanmi
- Department of Community Health and Epidemiology, College of MedicineUniversity of Saskatchewan Saskatoon Canada
| | - Cindy Feng
- School of Public HealthUniversity of Saskatchewan Saskatoon Canada
| | - Marwa Farag
- School of Public HealthUniversity of Saskatchewan Saskatoon Canada
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Unroe KT, Hickman SE, Carnahan JL, Hass Z, Sachs G, Arling G. Investigating the Avoidability of Hospitalizations of Long Stay Nursing Home Residents: Opportunities for Improvement. Innov Aging 2018; 2:igy017. [PMID: 30480137 PMCID: PMC6234922 DOI: 10.1093/geroni/igy017] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Indexed: 11/18/2022] Open
Abstract
Background and Objectives To examine the relationship between hospital diagnoses associated with hospital transfers of long stay nursing home residents, ratings of avoidability of transfer, and RN-identified quality improvement opportunities. Research Design and Methods Prospective clinical demonstration project, named OPTIMISTIC, with trained RNs embedded in nursing homes that performed root cause analyses for 1,931 transfers to the hospital between November 2014 and July 2016. OPTIMISTIC RNs also rated whether transfers were avoidable, identified quality improvement opportunities, and recorded hospital diagnoses. Resident characteristics were obtained from Minimum Data Set assessments. Relationships between six hospital diagnoses commonly considered “potentially avoidable” and OPTIMISTIC RN root cause analysis findings were examined. Facilities were participating in the OPTIMISTIC demonstration project designed to reduce hospital transfers during the study period. Results Twenty-five percent of acute transfers associated with six common diagnoses were considered definitely or probably avoidable by project RNs versus 22% of transfers associated with other diagnoses. The most common quality improvement opportunity identified for transfers rated as avoidable was that the condition could have been managed safely if appropriate resources were available, a factor cited in 45% of transfers associated with any of the six diagnoses. Problems with communication among stakeholders were the most commonly noted area for improvement (48%) for transfers associated with other diagnoses. Many other areas for quality improvement were noted, including earlier detection of change in status and the need for understanding patient preferences or a palliative care plan. Discussion and Implications Although some nursing home transfers may later be deemed potentially avoidable based on post-transfer hospital diagnosis from Medicare claims data, OPTIMISTIC nurses caring for these residents at time of transfer categorized the majority of these transfers as unavoidable irrespective of the hospital diagnosis. Multiple quality improvement opportunities were identified associated with these hospital transfers, whether the transfer was considered potentially avoidable or unavoidable.
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Affiliation(s)
- Kathleen T Unroe
- Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis.,Regenstrief Institute, IU Center for Aging Research, Indianapolis, Indiana
| | | | - Jennifer L Carnahan
- Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis.,Regenstrief Institute, IU Center for Aging Research, Indianapolis, Indiana
| | - Zach Hass
- Purdue University, West Lafayette, Indiana
| | - Greg Sachs
- Indiana University School of Medicine, Division of General Internal Medicine and Geriatrics, Indianapolis.,Regenstrief Institute, IU Center for Aging Research, Indianapolis, Indiana
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Variation in anticoagulation for atrial fibrillation between English clinical commissioning groups: an observational study. Br J Gen Pract 2018; 68:e551-e558. [PMID: 29970397 DOI: 10.3399/bjgp18x697913] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/05/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Despite improvement in anticoagulation for atrial fibrillation (AF), substantial variation in anticoagulation persists between clinical commissioning groups (CCGs) and regions in England. AIM To identify reasons for variation between English CCGs in anticoagulation for AF. DESIGN AND SETTING A 4-year observational study from 2012/2013 to 2015/2016, of the national Quality and Outcomes Framework. METHOD Multiple regression and Pearson's correlation coefficients were used to analyse anticoagulation for AF in relation to older age, Index of Multiple Deprivation, prescription of non-vitamin K antagonist oral anticoagulants (NOACs), and exception reporting, as well as stroke hospital admission and mortality. RESULTS The proportion of eligible patients in England prescribed anticoagulants for AF without exceptions for clinical complexity or patient dissent increased from 65.1% in 2012/2013 to 77.9% in 2015/2016. In 2015, 290 920 additional eligible people were anticoagulated in association with use of the CHA2DS2VASc rather than CHADS2 score. From 2012 to 2015, exception reporting almost halved from 20% to 10.2%. Variation in CCG anticoagulation was not associated with deprivation or NOAC use. There was a strong negative association between exception reporting representing patient complexity and anticoagulation performance, accounting for 57% of the variation in anticoagulation without exceptions (multiple regression coefficient = -0.81; 95% confidence intervals = -0.92 to -0.71; P<0.001). CONCLUSION Anticoagulation for AF has improved substantially in England in association with considerable increases in the eligible population as a result of decreased exception reporting and the use of the CHA2DS2VASc score. There is still substantial room for improvement in most CCGs because, even allowing for exceptions, nine out of 10 CCGs failed to achieve 90% anticoagulation.
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Bou-Antoun S, Costelloe C, Honeyford K, Mazidi M, Hayhoe BWJ, Holmes A, Johnson AP, Aylin P. Age-related decline in antibiotic prescribing for uncomplicated respiratory tract infections in primary care in England following the introduction of a national financial incentive (the Quality Premium) for health commissioners to reduce use of antibiotics in the community: an interrupted time series analysis. J Antimicrob Chemother 2018; 73:2883-2892. [DOI: 10.1093/jac/dky237] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 05/22/2018] [Indexed: 11/13/2022] Open
Affiliation(s)
- Sabine Bou-Antoun
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Ceire Costelloe
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Kate Honeyford
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Mahsa Mazidi
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Benedict W J Hayhoe
- Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Alison Holmes
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
| | - Alan P Johnson
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Healthcare-Associated Infections and Antimicrobial Resistance, National Infection Service, Public Health England, London, UK
| | - Paul Aylin
- NIHR Health Protection Research Unit, Healthcare Associated Infections and Antimicrobial Resistance, Imperial College London, London, UK
- Department of Primary Care and Public Health, Imperial College London, London, UK
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Chen TT, Hsueh YSA, Ko CH, Shih LN, Yang SS. The effect of a hepatitis pay-for-performance program on outcomes of patients undergoing antiviral therapy. Eur J Public Health 2018; 27:955-960. [PMID: 29020377 DOI: 10.1093/eurpub/ckx114] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Background To examine the effect of a participatory pay-for-performance (P4P) program in Taiwan on health outcomes for patients with severe hepatitis B or C. Methods This study adopted 4-year panel data from the databases of the National Health Insurance Administration (NHIA) in Taiwan. Using the caliper matching method to match patients in the P4P (experimental) group with those in the potential comparison group on a one-to-one basis for the year 2010, we tracked patients up to the year 2013 and employed Cox proportional-hazards regression models to evaluate the effect on patient outcomes. Results The P4P group did not have a lower risk (HR = 0.44, P = 0.05) of hospital admission for severe hepatitis patients (i.e. need antiviral therapy). The risk of developing liver cirrhosis was also lower, but the reduction was not statistically significant (HR = 0.92, P = 0.77). Conclusions This study found that participatory-type P4P has not resulted in reduced hospital admission of hepatitis B or C patients who need antiviral therapy. The means by which the participatory P4P program could strengthen patient-centered care to achieve better patient health outcomes is discussed in detail.
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Affiliation(s)
- Tsung-Tai Chen
- Department of Public Health, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Ya-Seng Arthur Hsueh
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Chun-Hsiung Ko
- Department of Public Health, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
| | - Ling-Na Shih
- Department of Hepatogastroenterology, Taipei Hospital, Ministry of Health and Welfare, New Taipei City, Taiwan
| | - Sien-Sing Yang
- Liver Unit, Cathay General Hospital Medical Center, Taipei, Taiwan.,School of Medicine, College of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan
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Andrade LF, Rapp T, Sevilla-Dedieu C. Quality of diabetes follow-up care and hospital admissions. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2018; 18:153-167. [PMID: 29098481 DOI: 10.1007/s10754-017-9230-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
Diabetes may lead to severe complications. For this reason, disease prevention and improvement of medical follow-up represent major public health issues. The aim of this study was to measure the impact of adherence to French follow-up guidelines on hospitalization of people with diabetes. We used insurance claims data from the years 2010 to 2013 collected for 52,027 people aged over 18, affiliated to a French social security provider and treated for diabetes. We estimated panel data models to explore the association between adherence to guidelines and different measures of hospitalization, controlling for socioeconomic characteristics, diabetes treatment and density of medical supply. The results show that adherence to four guidelines was associated with a significant decrease in hospital admissions, up to approximatively 30% for patients monitored for a complete lipid profile or microalbuminuria during the year. In addition, our analyses confirmed the strong protective effect of income and a significant positive correlation with good supply of hospital care. In conclusion, good adherence to French diabetes guidelines seems to be in line with the prevention of health events, notably complications, that could necessitate hospitalization.
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Affiliation(s)
- L F Andrade
- MGEN Foundation for Public Health, 3 square Max Hymans, 75747, Paris Cedex 15, France
- LIRAES (EA 4470), University of Paris Descartes, 45 rue des Saints-Pères, 75270, Paris Cedex 06, France
| | - T Rapp
- LIRAES (EA 4470), University of Paris Descartes, 45 rue des Saints-Pères, 75270, Paris Cedex 06, France
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Kresge 431 - 677 Huntington Avenue, Boston, MA, 02115, USA
| | - C Sevilla-Dedieu
- MGEN Foundation for Public Health, 3 square Max Hymans, 75747, Paris Cedex 15, France.
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McAlister FA, Bakal JA, Green L, Bahler B, Lewanczuk R. The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions. CMAJ 2018; 190:E276-E284. [PMID: 29530868 PMCID: PMC5849446 DOI: 10.1503/cmaj.170385] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. METHODS We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. RESULTS Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96-0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93-0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03-1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07-1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. INTERPRETATION Care within a primary care network was associated with fewer emergency department visits and fewer hospital days.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta.
| | - Jeffrey A Bakal
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
| | - Lee Green
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
| | - Brad Bahler
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
| | - Richard Lewanczuk
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
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Improving the Recording of Diagnoses in Primary Care with Team Incentives: A Controlled Longitudinal Follow-Up Study. BIOMED RESEARCH INTERNATIONAL 2018; 2018:4606710. [PMID: 29675425 PMCID: PMC5838484 DOI: 10.1155/2018/4606710] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/23/2017] [Accepted: 01/09/2018] [Indexed: 12/24/2022]
Abstract
Introduction We studied whether primary care teams respond to financial group bonuses by improving the recording of diagnoses, whether this intervention leads to diagnoses reflecting the anticipated distribution of diseases, and how the recording of a significant chronic disease, diabetes, alters after the application of these bonuses. Methods We performed an observational register-based retrospective quasi-experimental follow-up study with before-and-after setting and two control groups in primary healthcare of a Finnish town. We studied the rate of recorded diagnoses in visits to general practitioners with interrupted time series analysis. The distribution of these diagnoses was also recorded. Results After group bonuses, the rate of recording diagnoses increased by 17.9% (95% CI: 13.6–22.3) but not in either of the controls (−2.0 to −0.3%). The increase in the rate of recorded diagnoses in the care teams varied between 14.9% (4.7–25.2) and 33.7% (26.6–41.3). The distribution of recorded diagnoses resembled the respective distribution of diagnoses in the former studies of diagnoses made in primary care. The rate of recorded diagnoses of diabetes did not increase just after the intervention. Conclusions In primary care, the completeness of diagnosis recording can be, to varying degrees, influenced by group bonuses without guarantee that recording of clinically significant chronic diseases is improved.
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Pinto Junior EP, Aquino R, Medina MG, Silva MGCD. [Effect of the Family Health Strategy on hospitalizations for primary care sensitive conditions in infants in Bahia State, Brazil]. CAD SAUDE PUBLICA 2018; 34:e00133816. [PMID: 29489948 DOI: 10.1590/0102-311x00133816] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 07/05/2017] [Indexed: 11/21/2022] Open
Abstract
This study aimed to assess the effect of the expansion of the Family Health Strategy (FHS) on hospitalizations for primary care sensitive conditions (PCSCs) in children under one year of age. This was a longitudinal ecological study with the use of panel data, for which the analytical units were the 417 municipalities (counties) in Bahia State, Brazil, from 2000 to 2012. Data were obtained from the official health information systems. The hospitalization rate for PCSCs was the outcome and FHS coverage was the principal exposure. The co-variables referred to demographic and socioeconomic characteristics and the local availability of pediatric beds. Bivariate and multivariate panel data analyses were performed, with negative binomial response and fixed effects models, using crude and adjusted relative risk (RR) as the measure of association, with the respective confidence intervals. To control for trend effect, the models were adjusted for time. From 2000 to 2012, 248,944 hospitalizations for PCSCs were recorded in children under one year, and the median municipal rate of hospitalizations for PCSCs decreased by 52.5% during the period, ranging from 96.9 to 46.0 avoidable hospitalizations per 1,000 live births. After adjusting the model, the reduction in avoidable hospitalizations was maintained at the different FHS coverage levels. This study demonstrated the effects of the consolidation of the FHS on hospitalizations for PCSCs in infants, which indicates the importance of strengthening primary care measures in order to offer case-resolving care during the first contact with the health system and avoid unnecessary hospitalizations.
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Affiliation(s)
| | - Rosana Aquino
- Instituto de Saúde Coletiva, Universidade Federal da Bahia, Salvador, Brasil
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Unroe KT, Carnahan JL, Hickman SE, Sachs GA, Hass Z, Arling G. The Complexity of Determining Whether a Nursing Home Transfer Is Avoidable at Time of Transfer. J Am Geriatr Soc 2018; 66:895-901. [PMID: 29437221 DOI: 10.1111/jgs.15286] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/29/2017] [Accepted: 12/20/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To describe the relationship between nursing facility resident risk conditions and signs and symptoms at time of acute transfer and diagnosis of conditions associated with potentially avoidable acute transfers (pneumonia, urinary tract infection, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD) or asthma, dehydration, pressure sores). DESIGN As part of a demonstration project to reduce potentially avoidable hospital transfers, Optimizing Patient Transfers, Impacting Medical Quality, Improving Symptoms: Transforming Institutional Care (OPTIMISTIC) project clinical staff collected data on residents who transferred to the emergency department (ED) or hospital. Cross-tabulations were used to identify associations between risk conditions or symptoms and hospital diagnoses or death. Mixed-effects logistic regression models were used to describe the significance of risk conditions, signs, or symptoms as predictors of potentially avoidable hospital diagnoses or death. SETTING Indiana nursing facilities (N=19). PARTICIPANTS Long-stay nursing facility residents (N=1,174), who experienced 1,931 acute transfers from November 2014 to July 2016. MEASUREMENTS Participant symptoms, transfers, risk factors, and hospital diagnoses. RESULTS We found that 44% of acute transfers were associated with 1 of 6 potentially avoidable diagnoses. Symptoms before transfer did not discriminate well among hospital diagnoses. Symptoms mapped into multiple diagnoses and most hospital diagnoses had multiple associated symptoms. For example, more than two-thirds of acute transfers of residents with a history of CHF and COPD were for reasons other than exacerbations of those two conditions. CONCLUSION Although it is widely recognized that many transfers of nursing facility residents are potentially avoidable, determining "avoidability" at time of transfer is complex. Symptoms and risk conditions were only weakly predictive of hospital diagnoses.
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Affiliation(s)
- Kathleen T Unroe
- School of Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Indiana University, Indianapolis, Indiana
| | - Jennifer L Carnahan
- School of Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Indiana University, Indianapolis, Indiana
| | - Susan E Hickman
- School of Nursing, Indiana University, Indianapolis, Indiana
| | - Greg A Sachs
- School of Medicine, Department of Medicine, Indiana University, Indianapolis, Indiana.,Regenstrief Institute, Indiana University, Indianapolis, Indiana
| | - Zachary Hass
- School of Nursing, Purdue University, West Lafayette, Indiana
| | - Greg Arling
- School of Nursing, Purdue University, West Lafayette, Indiana
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