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Bar-Yishay M, Adler L, Bar El A, Boker Faran L, Mizrahi Reuveni M, Sternberg SA, Schejter E, Radomyslsky Z, Segal Y, Azuri J, Yehoshua I. MACCABI-RED, community emergency care at the press of a button: a descriptive study. Fam Pract 2024:cmae032. [PMID: 38870094 DOI: 10.1093/fampra/cmae032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Maccabi-RED is a new service developed in Israel that allows primary care staff to direct urgent cases to specialists in the community for evaluation in their local clinics on the same day as an alternative to an emergency department (ED) visit. A primary care physician or a nurse can activate the service, and all nearby specialists receive "a call" and can decide if they are willing to accept it, thus allowing the patient to avoid an unnecessary visit to the ED. AIM To quantify and characterize the medical care provided by this service in a large national healthcare system. DESIGN AND SETTING Multicenter, community-based, retrospective cohort study. METHODS All Maccabi-RED visits recorded between September 2021 and August 2022 were included. Patient characteristics were compared to national demographics. Descriptive statistics were used to present data regarding recorded diagnoses, treating physicians, treatments or referrals provided, and subsequent emergency department admissions or hospitalizations. RESULTS 31831 visits were recorded. Most frequent diagnoses were musculoskeletal pain (12.1%), otitis or otalgia (7.8%), contusions (7.6%), fractures (7.1%), foreign body (6.7%), pregnancy-related symptoms (6.3%), and upper-respiratory or unspecified viral infection (6.3%). The most common treatments reported were foreign body removal (5%) and cast application (3.5%). Only 7.8% of visits resulted in emergency department admission within seven days (any cause). The average time from patient request to physician treatment was 91 min. CONCLUSIONS Maccabi-RED is being widely used by patients nationwide. Additional studies are needed to investigate whether Maccabi-RED reduces emergency department visits and costs.
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Affiliation(s)
- Mattan Bar-Yishay
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
- Department of Family Medicine and Siaal Research Center for Family Medicine and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
| | - Limor Adler
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
- Department of Family Medicine, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Alon Bar El
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | - Limor Boker Faran
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | - Miri Mizrahi Reuveni
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | | | - Eduardo Schejter
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | - Zorian Radomyslsky
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
- Faculty of Medicine, Ariel University, Ariel 40700, Israel
| | - Yakov Segal
- Health Division, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
| | - Joseph Azuri
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
- Department of Family Medicine, Faculty of Medical & Health Sciences, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Ilan Yehoshua
- Department of Family Medicine, Maccabi Healthcare Services, Tel Aviv 6812509, Israel
- Department of Family Medicine and Siaal Research Center for Family Medicine and Primary Care, The Haim Doron Division of Community Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva 84105, Israel
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Gavaldà-Espelta E, Lleixà-Fortuño MDM, Aguilar Martín C, Pozo M, Ferré-Ferraté M, Tomàs-Navarro B, Curto-Romeu C, Lucas-Noll J, Baucells-Lluis J, Gonçalves AQ, Ferré-Grau C. Integrated Care Model Salut+Social Assessment by Professionals, Informal Caregivers and Chronic or Social Dependent Patients: A Qualitative Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15467. [PMID: 36497541 PMCID: PMC9739042 DOI: 10.3390/ijerph192315467] [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: 10/07/2022] [Revised: 11/02/2022] [Accepted: 11/19/2022] [Indexed: 06/17/2023]
Abstract
We explored the views of the professionals (from primary care and social services) and users (caregivers and patients) who participated in the clinical trial of the Salut+Social integrated care model to identify the implementation barriers and facilitators, to assess the impact on health and wellbeing and to obtain an assessment of the program. A qualitative descriptive study with a pragmatic, utilitarian approach was performed. Participants were recruited by purposive and convenience sampling. A focus group (FG) and in-depth interviews were conducted with professionals and users, respectively. Thematic content analysis was employed. A total of 11 professionals and 8 users participated in the FG and interviews, respectively. Seven themes were identified: (1) contextualizing the previous scenario; (2) achievements of the program from the professionals' perspective; (3) facilitators and barriers of the integrated care model; (4) proposals for improving the integrated care model; (5) users' assessment of the care received within the program framework; (6) users' perception of the impact on health and wellbeing; (7) users' demands for better care. Professionals reported improved coordination between services and highlighted the need for a protocol for emergencies and to strengthen community orientation. Users proposed more frequent home visits. This study shows the acceptability of the new model by professionals and the users' satisfaction with the care received.
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Affiliation(s)
- Ester Gavaldà-Espelta
- Direcció d’Atenció Primària Terres de l’Ebre, Gerència Territorial Terres de l’Ebre, Institut Català de la Salut, 43500 Tortosa, Spain
- Departament d’Infermeria, Programa de Doctorat Infermeria i Salut, Universitat Rovira i Virgili, 43002 Tarragona, Spain
| | - Maria del Mar Lleixà-Fortuño
- Departament d’Infermeria, Programa de Doctorat Infermeria i Salut, Universitat Rovira i Virgili, 43002 Tarragona, Spain
- Departament d’Igualtat i Feminismes a les Terres de l’Ebre, Direcció de Serveis Territorials a les Terres de l’Ebre, Generalitat de Catalunya, 43500 Tortosa, Spain
| | - Carina Aguilar Martín
- Unitat d’Avaluació, Direcció d’Atenció Primària Terres de l’Ebre, Institut Català de la Salut, 43500 Tortosa, Spain
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 43500 Tortosa, Spain
| | - Macarena Pozo
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 43500 Tortosa, Spain
| | - Maria Ferré-Ferraté
- Gerència Territorial Terres de l’Ebre, Institut Català de la Salut, 43500 Tortosa, Spain
| | - Begoña Tomàs-Navarro
- Equip d’Atenció Primària Amposta, Gerència Territorial Terres de l’Ebre, Institut Català de la Salut, 43870 Amposta, Spain
| | - Claudia Curto-Romeu
- Equip d’Atenció Primària Amposta, Gerència Territorial Terres de l’Ebre, Institut Català de la Salut, 43870 Amposta, Spain
| | - Jorgina Lucas-Noll
- Direcció d’Atenció Primària Terres de l’Ebre, Gerència Territorial Terres de l’Ebre, Institut Català de la Salut, 43500 Tortosa, Spain
- Departament d’Infermeria, Programa de Doctorat Infermeria i Salut, Universitat Rovira i Virgili, 43002 Tarragona, Spain
| | - Jordi Baucells-Lluis
- Direcció de Sistemes d’Informació i Comunicació, Gerència Territorial Terres de l’Ebre, Institut Català de la Salut, 43500 Tortosa, Spain
| | - Alessandra Queiroga Gonçalves
- Unitat de Suport a la Recerca Terres de l’Ebre, Fundació Institut Universitari per a la Recerca a l’Atenció Primària de Salut Jordi Gol i Gurina (IDIAPJGol), 43500 Tortosa, Spain
- Unitat Docent de Medicina de Familia i Comunitària, Tortosa-Terres de l’Ebre, Institut Català de la Salut, 43500 Tortosa, Spain
| | - Carmen Ferré-Grau
- Departament d’Infermeria, Programa de Doctorat Infermeria i Salut, Universitat Rovira i Virgili, 43002 Tarragona, Spain
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Kadel R, Allen J, Darlington O, Masters R, Collins B, Charles JM, Asaria M, Dyakova M, Bellis M, Cookson R. Cost of health inequality to the NHS in Wales. Front Public Health 2022; 10:959283. [PMID: 36187677 PMCID: PMC9523137 DOI: 10.3389/fpubh.2022.959283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 08/22/2022] [Indexed: 01/24/2023] Open
Abstract
Background Forty years from the seminal work of Welsh GP Julian Tudor Hart on the Inverse Care Law, inequalities in health and healthcare remain deeply embedded in Wales. There is a wider gap (over 17 years) in healthy life expectancy between people living in the most and least deprived neighborhoods in Wales. This health inequality is reflected in additional healthcare use. In this study we estimate the cost of inequality associated with this additional healthcare use to the publicly funded National Health Service (NHS) in Wales. Methods We retrieved administrative data on all NHS inpatient admissions, outpatient and accident and emergency attendances in Wales between April 2018 and March 2019 from Digital Health and Care Wales (DHCW). Hospital service use data were translated to costs using Healthcare Resource Group (HRG) and health service specific unit cost data and linked with area level mid-year population and deprivation indices in order to calculate the healthcare costs associated with socioeconomics deprivation. Results Inequality in healthcare use between people from more and less deprived neighborhoods was associated with an additional cost of £322 million per year to the NHS in Wales, accounting for 8.7% of total NHS hospital expenditure in the country. Emergency inpatient admissions made up by far the largest component of this additional cost contributing £247.4 million, 77% of the total. There are also substantial costs of inequality for A&E attendances and outpatient visits, though not maternity services. Elective admissions overall have a negative cost of inequality, since among men aged 50-75 and women aged 60-70, elective utilization is actually negatively associated with deprivation. Conclusion There are wide inequalities in health and healthcare use between people living in more deprived neighborhoods and those living in less deprived neighborhoods in Wales. Tackling health inequality through a combination of health promotion and early intervention policies targeted toward deprived communities could yield substantial improvement in health and wellbeing, as well as savings for the Welsh NHS through reduced use of emergency hospital care.
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Affiliation(s)
- Rajendra Kadel
- WHO CC on Investment for Health and Wellbeing, Public Health Wales, Cardiff, United Kingdom,*Correspondence: Rajendra Kadel
| | - James Allen
- WHO CC on Investment for Health and Wellbeing, Public Health Wales, Cardiff, United Kingdom
| | - Oliver Darlington
- WHO CC on Investment for Health and Wellbeing, Public Health Wales, Cardiff, United Kingdom
| | - Rebecca Masters
- WHO CC on Investment for Health and Wellbeing, Public Health Wales, Cardiff, United Kingdom
| | - Brendan Collins
- Health and Social Services Group, Finance Directorate, Welsh Government, Cardiff, United Kingdom
| | - Joanna M. Charles
- Health and Social Services Group, Finance Directorate, Welsh Government, Cardiff, United Kingdom
| | - Miqdad Asaria
- Department of Health Policy, London School of Economics and Political Science, London, United Kingdom
| | - Mariana Dyakova
- WHO CC on Investment for Health and Wellbeing, Public Health Wales, Cardiff, United Kingdom
| | - Mark Bellis
- WHO CC on Investment for Health and Wellbeing, Public Health Wales, Cardiff, United Kingdom
| | - Richard Cookson
- Centre for Health Economics, University of York, York, United Kingdom
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Yi SE, Harish V, Gutierrez J, Ravaut M, Kornas K, Watson T, Poutanen T, Ghassemi M, Volkovs M, Rosella LC. Predicting hospitalisations related to ambulatory care sensitive conditions with machine learning for population health planning: derivation and validation cohort study. BMJ Open 2022; 12:e051403. [PMID: 35365510 PMCID: PMC8977821 DOI: 10.1136/bmjopen-2021-051403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To predict older adults' risk of avoidable hospitalisation related to ambulatory care sensitive conditions (ACSC) using machine learning applied to administrative health data of Ontario, Canada. DESIGN, SETTING AND PARTICIPANTS A retrospective cohort study was conducted on a large cohort of all residents covered under a single-payer system in Ontario, Canada over the period of 10 years (2008-2017). The study included 1.85 million Ontario residents between 65 and 74 years old at any time throughout the study period. DATA SOURCES Administrative health data from Ontario, Canada obtained from the (ICES formely known as the Institute for Clinical Evaluative Sciences Data Repository. MAIN OUTCOME MEASURES Risk of hospitalisations due to ACSCs 1 year after the observation period. RESULTS The study used a total of 1 854 116 patients, split into train, validation and test sets. The ACSC incidence rates among the data points were 1.1% for all sets. The final XGBoost model achieved an area under the receiver operating curve of 80.5% and an area under precision-recall curve of 0.093 on the test set, and the predictions were well calibrated, including in key subgroups. When ranking the model predictions, those at the top 5% of risk as predicted by the model captured 37.4% of those presented with an ACSC-related hospitalisation. A variety of features such as the previous number of ambulatory care visits, presence of ACSC-related hospitalisations during the observation window, age, rural residence and prescription of certain medications were contributors to the prediction. Our model was also able to capture the geospatial heterogeneity of ACSC risk in Ontario, and especially the elevated risk in rural and marginalised regions. CONCLUSIONS This study aimed to predict the 1-year risk of hospitalisation from ambulatory-care sensitive conditions in seniors aged 65-74 years old with a single, large-scale machine learning model. The model shows the potential to inform population health planning and interventions to reduce the burden of ACSC-related hospitalisations.
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Affiliation(s)
- Seung Eun Yi
- Layer6 AI, Toronto, Ontario, Canada
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
| | - Vinyas Harish
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario, Canada
| | | | - Mathieu Ravaut
- School of Computer Science and Engineering, Nanyang Technological University, Singapore
| | - Kathy Kornas
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Tristan Watson
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | | | - Marzyeh Ghassemi
- Department of Computer Science, University of Toronto, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario, Canada
| | | | - Laura C Rosella
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Temerty Centre for Artificial Intelligence Research and Education in Medicine, University of Toronto, Toronto, Ontario, Canada
- Vector Institute, Toronto, Ontario, Canada
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, Ontario, Canada
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The impact of an integrated care intervention on mortality and unplanned hospital admissions in a disadvantaged community in England: A difference-in-differences study. Health Policy 2022; 126:549-557. [DOI: 10.1016/j.healthpol.2022.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 03/14/2022] [Accepted: 03/18/2022] [Indexed: 11/22/2022]
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Multilevel Zero-One Inflated Beta Regression Model for the Analysis of the Relationship between Exogenous Health Variables and Technical Efficiency in the Spanish National Health System Hospitals. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph181910166. [PMID: 34639468 PMCID: PMC8508497 DOI: 10.3390/ijerph181910166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Revised: 09/17/2021] [Accepted: 09/22/2021] [Indexed: 11/23/2022]
Abstract
Background: This article proposes a methodological innovation in health economics for the second stage analysis of technical efficiency in hospitals. It investigates the relationship between the installed capacity in regions and hospitals and their ownership structure. Methods: A multilevel zero-one inflated beta regression model is employed to model pure technical efficiency more adequately than other models frequently used in econometrics. Results: Compared to publicly managed hospitals, the mean efficiency index of hospitals with public-private partnership (PPP) formulas was 4.27-fold. This figure was 1.90-fold for private hospitals. Concerning the efficiency frontier, the odds ratio (OR) of PPP models vs. public hospitals was 42.06. The OR of private hospitals vs. public hospitals was 8.17. A one standard deviation increase in the percentage of beds in intensive care units increases the odds of being situated on the efficiency frontier by 50%. Conclusions: The proportion of hospital beds in intensive care units relates to a higher chance of being on the efficiency frontier. Hospital ownership structure is related to the mean efficiency index of Spanish National Health Service hospitals, as well as the odds of being situated on the efficiency frontier.
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Yokoyama K, Ishiki H. Questions Regarding Patient-Reported Symptom Burden as a Predictor of Emergency Department Use and Unplanned Hospitalization in Head and Neck Cancer. J Clin Oncol 2021; 39:2415-2416. [PMID: 33950742 DOI: 10.1200/jco.21.00456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- Kazuki Yokoyama
- Kazuki Yokoyama, MD, and Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
| | - Hiroto Ishiki
- Kazuki Yokoyama, MD, and Hiroto Ishiki, MD, Department of Palliative Medicine, National Cancer Center Hospital, Tokyo, Japan
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Morciano M, Checkland K, Durand MA, Sutton M, Mays N. Comparison of the impact of two national health and social care integration programmes on emergency hospital admissions. BMC Health Serv Res 2021; 21:687. [PMID: 34247592 PMCID: PMC8274044 DOI: 10.1186/s12913-021-06692-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Accepted: 06/23/2021] [Indexed: 12/26/2022] Open
Abstract
Background Policy-makers expect that integration of health and social care will improve user and carer experience and reduce avoidable hospital use. [We] evaluate the impact on emergency hospital admissions of two large nationally-initiated service integration programmes in England: the Pioneer (November 2013 to March 2018) and Vanguard (January 2015 to March 2018) programmes. The latter had far greater financial and expert support from central agencies. Methods Of the 206 Clinical Commissioning Groups (CCGs) in England, 51(25%) were involved in the Pioneer programme only, 22(11%) were involved in the Vanguard programme only and 13(6%) were involved in both programmes. We used quasi-experimental methods to compare monthly counts of emergency admissions between four groups of CCGs, before and after the introduction of the two programmes. Results CCGs involved in the programmes had higher monthly hospital emergency admission rates than non-participants prior to their introduction [7.9 (95% CI:7.8–8.1) versus 7.5 (CI: 7.4–7.6) per 1000 population]. From 2013 to 2018, there was a 12% (95% CI:9.5–13.6%) increase in emergency admissions in CCGs not involved in either programme while emergency admissions in CCGs in the Pioneer and Vanguard programmes increased by 6.4% (95% CI: 3.8–9.0%) and 8.8% (95% CI:4.5–13.1%), respectively. CCGs involved in both initiatives experienced a smaller increase of 3.5% (95% CI:-0.3–7.2%). The slowdown largely occurred in the final year of both programmes. Conclusions Health and social care integration programmes can mitigate but not prevent rises in emergency admissions over the longer-term. Greater financial and expert support from national agencies and involvement in multiple integration initiatives can have cumulative effects. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06692-x.
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Affiliation(s)
- Marcello Morciano
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, UK.
| | - Katherine Checkland
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, UK
| | - Mary Alison Durand
- Department of Health Services Research and Policy, Policy Innovation and Evaluation Research Unit, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics (HOPE) Research Group, University of Manchester, Manchester, M13 9PL, UK
| | - Nicholas Mays
- Department of Health Services Research and Policy, Policy Innovation and Evaluation Research Unit, London School of Hygiene & Tropical Medicine, London, WC1H 9SH, UK
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Leckcivilize A, McNamee P, Cooper C, Steel R. Impact of an anticipatory care planning intervention on unscheduled acute hospital care using difference-in-difference analysis. BMJ Health Care Inform 2021; 28:bmjhci-2020-100305. [PMID: 34035049 PMCID: PMC8154976 DOI: 10.1136/bmjhci-2020-100305] [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: 12/17/2020] [Revised: 04/10/2021] [Accepted: 05/03/2021] [Indexed: 11/04/2022] Open
Abstract
Unscheduled admissions to hospital place great demands on the use of limited healthcare resources in health systems worldwide. A range of approaches exist to manage demand; however, interventions within hospitals have received less attention, and the evidence base on effectiveness is limited. This study aimed to assess the effectiveness of a novel intervention, implemented in National Health Service Lothian, to reduce the number of unscheduled attendances, and to estimate the impact on hospital admissions, length of hospital stay and overall total acute hospital costs. METHODS Before and after observational study of an anticipatory care planning intervention targeted among people identified by a prediction algorithm (Scottish Patients at Risk of Readmission and Admission) as being at high risk of future unscheduled hospital admissions. The statistical significance of the difference in outcomes observed before and after implementation of the intervention between August 2014 and July 2015 was tested using difference-in-difference analysis. RESULTS The intervention was estimated to reduce the number of unscheduled hospital admissions and emergency department (ED) visits by approximately 0.36 (95% CI -0.905 to 0.191) per patient per year (based on 954 and 450 patients in the intervention and control groups, respectively). There was also non-significant reductions in length of hospital stay for unscheduled admissions and hospital costs for ED visits and inpatient care. The overall predicted effect of the intervention for the average participant was a saving of around £2912 (95% CI -7347.0 to 1523.9) per patient per year. CONCLUSION An anticipatory care planning intervention focused among people judged to be at higher risk of future unscheduled hospital admissions can be effective in reducing the number of unscheduled admissions to hospital and ED visits, and may lead to an overall saving in use of hospital resources.
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Affiliation(s)
| | - Paul McNamee
- Health Economics Research Unit, University of Aberdeen, Aberdeen, UK
| | | | - Robby Steel
- Division of Psychiatry, Royal Infirmary of Edinburgh, Edinburgh, UK
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Corry DAS, Doherty J, Carter G, Doyle F, Fahey T, O’Halloran P, McGlade K, Wallace E, Brazil K. Acceptability of a nurse-led, person-centred, anticipatory care planning intervention for older people at risk of functional decline: A qualitative study. PLoS One 2021; 16:e0251978. [PMID: 34015046 PMCID: PMC8136649 DOI: 10.1371/journal.pone.0251978] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 05/06/2021] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND As the population of older adults increases, the complexity of care required to support those who choose to remain in the community amplifies. Anticipatory Care Planning (ACP), through earlier identification of healthcare needs, is evidenced to improve quality of life, decrease aggressive interventions, and prolong life. With patient acceptability of growing importance in the design, implementation, and evaluation of healthcare interventions, this study reports on the acceptability of a primary care based ACP intervention on the island of Ireland. METHODS As part of the evaluation of a feasibility cluster randomized controlled trial (cRCT) testing an ACP intervention for older people at risk of functional decline, intervention participants [n = 34] were interviewed in their homes at 10-week follow-up to determine acceptability. The intervention consisted of home visits by specifically trained registered nurses who assessed participants' health, discussed their health goals and plans, and devised an anticipatory care plan in collaboration with participants' GPs and adjunct clinical pharmacist. Thematic analysis was employed to analyze interview data. The feasibility cRCT involved eight general practitioner (GP) practices as cluster sites, stratified by jurisdiction, four in Northern Ireland (NI) (two intervention, two control), and four in the Republic of Ireland (ROI) (two intervention, two control). Participants were assessed for risk of functional decline. A total of 34 patients received the intervention and 31 received usual care. FINDINGS Thematic analysis resulted in five main themes: timing of intervention, understanding of ACP, personality & individual differences, loneliness & social isolation, and views on healthcare provision. These map across the Four Factor Model of Acceptability ('4FMA'), a newly developed conceptual framework comprising four components: intervention factors, personal factors, social support factors, and healthcare provision factors. CONCLUSION Acceptability of this primary care based ACP intervention was high, with nurses' home visits, GP anchorage, multidisciplinary working, personalized approach, and active listening regarded as beneficial. Appropriate timing, and patient health education emerged as vital.
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Affiliation(s)
- Dagmar A. S. Corry
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Julie Doherty
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Gillian Carter
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Frank Doyle
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Tom Fahey
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
| | - Peter O’Halloran
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
| | - Kieran McGlade
- School of Medicine, Dentistry, and Biomedical Sciences, Queen’s University Belfast, Dunluce Health Centre, Belfast, Northern Ireland, United Kingdom
| | - Emma Wallace
- Department of General Practice, RCSI University of Medicine and Health Sciences, Dublin, Republic of Ireland
- Department of Health Psychology, Royal College of Surgeons in Ireland, Dublin, Republic of Ireland
| | - Kevin Brazil
- Centre for Evidence and Social Innovation, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
- School of Nursing and Midwifery, Queen’s University Belfast, Belfast, Northern Ireland, United Kingdom
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Walsh ME, Cronin S, Boland F, Ebell MH, Fahey T, Wallace E. Geographical variation of emergency hospital admissions for ambulatory care sensitive conditions in older adults in Ireland 2012-2016. BMJ Open 2021; 11:e042779. [PMID: 33952537 PMCID: PMC8103372 DOI: 10.1136/bmjopen-2020-042779] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVE Ambulatory care sensitive (ACS) conditions are those for which intensified primary care management could potentially prevent emergency admissions. This study aimed to quantify geographical variation in emergency admissions with ACS conditions in older adults and explore factors influencing variation. DESIGN Repeated cross-sectional study. SETTING 34 public hospitals in the Ireland. PARTICIPANTS Adults aged ≥65 years hospitalised for seven ACS conditions between 2012 and 2016 (chronic obstructive pulmonary disease, congestive heart failure (CHF), diabetes, angina, pyelonephritis/urinary tract infections (UTIs), dehydration and pneumonia). PRIMARY OUTCOME MEASURE Age and sex standardised emergency admission rates (SARs) per 1000 older adults. ANALYSIS Age and sex SARs were calculated for 21 geographical areas. Extremal quotients and systematic components of variance (SCV) quantified variation. Spatial regression analyses was conducted for SARs with unemployment, urban population proportion, hospital turnover, supply of general practitioners (GPs), and supply of hospital-based specialists as explanatory variables. RESULTS Over time, an increase in UTI/pyelonephritis SARs was seen while SARs for angina and CHF decreased. Geographic variation was moderate overall and high for dehydration and angina (SCV=11.7-50.0). For all conditions combined, multivariable analysis showed lower urban population (adjusted coefficient: -2.2 (-3.4 to -0.9, p<0.01)), lower GP supply (adjusted coefficient: -5.5 (-8.2 to -2.9, p<0.01)) and higher geriatrician supply (adjusted coefficient: 3.7 (0.5 to 6.9, p=0.02)) were associated with higher SARs. CONCLUSIONS Future research should evaluate methods of preventing admissions for ACS conditions among older adults, including how resources are allocated at a local level.
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Affiliation(s)
- Mary E Walsh
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Sinead Cronin
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Fiona Boland
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Mark H Ebell
- Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | - Tom Fahey
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Emma Wallace
- HRB Centre for Primary Care Research, Department of General Practice, Royal College of Surgeons in Ireland, Dublin, Ireland
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12
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Meng D, Xu G, Davidson PM. Perceived unmet needs for community-based long-term care services among urban older adults: A cross sectional study. Geriatr Nurs 2021; 42:740-747. [PMID: 33872858 DOI: 10.1016/j.gerinurse.2021.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 03/16/2021] [Accepted: 03/18/2021] [Indexed: 10/21/2022]
Abstract
The purpose of this study was to explore the perceived unmet needs for community-based long-term care services among older urban adults in China. We analyzed the cross-sectional data of 5,201 urban community respondents ≥65 years of age from the seventh wave of the 2018 Chinese Longitudinal Healthy Longevity Survey (CLHLS). The chi-squared automatic interaction detection technique was used to examine the variables associated with older adults' unmet needs for four common types of community-based services: personal care, grocery shopping, home visits, and psychological consulting. We found that the majority of the older adults perceived that they needed the four services, but only 9%-27.4% of the respondents reported that their perceived needs were met. There was a high prevalence of unmet community-based service needs (51.3%-55.5%) among urban older adults in China. Factors associated with unmet needs included depression status, ADL (activities of daily living) limitations, self-rated health, number of surviving children, educational attainment, and marital status. The results suggest that policy makers should develop services targeting specific segments of the older population, increasing the adequacy of services provided.
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Affiliation(s)
- Dijuan Meng
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, 210023, Jiangsu, China
| | - Guihua Xu
- School of Nursing, Nanjing University of Chinese Medicine, Nanjing, 210023, Jiangsu, China
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13
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Fry CH, Heppleston E, Fluck D, Han TS. Derivation of age-adjusted LACE index thresholds in the prediction of mortality and frequent hospital readmissions in adults. Intern Emerg Med 2020; 15:1319-1325. [PMID: 32725518 PMCID: PMC7511461 DOI: 10.1007/s11739-020-02448-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 07/10/2020] [Indexed: 11/30/2022]
Abstract
The LACE index has been shown to predict hospital readmissions and death with variable accuracy. A LACE index ≥ 10 is considered as high risk in the existing literature. We aimed to derive age-specific LACE index thresholds in the prediction of mortality and frequent readmissions. Analysis of prospectively collected data of consecutive alive-discharge episodes between 01/04/2017 and 31/03/2019 to a single hospital was conducted. The derivation of LACE index thresholds for predicting all-cause mortality within 6 months of hospital discharge or frequent readmissions (≥ 2 times within 28 days) was examined by receiver operating characteristics (ROC) in 32270 patients (14878 men, 17392 women) aged 18-107 year (mean = 64.0 years, SD = 20.5). For all patients with a LACE index ≥ 10, the area under the curve (AUC) for predicting mortality was 80.5% (95% CI 79.7-81.3) and for frequent readmissions was 84.0% (83.0-85.1). Two-graph ROC plots showed that the LACE index threshold where sensitivity equates specificity was 9.5 (95% intermediate range = 5.6-13.5) for predicting mortality and 10.3 (95% intermediate range = 6.6-13.6) for frequent readmissions. These thresholds were lowest among youngest individuals and rose progressively with age for mortality prediction: 18-49 years = 5.0, 50-59 years = 6.5, 60-69 years = 8.0, 70-79 years = 9.8 and ≥ 80 years = 11.6, and similarly for frequent readmissions: 18-49 years = 5.1, 50-59 years = 7.5, 60-69 years = 9.1, 70-79 years = 10.6 and ≥ 80 years = 12.0. Positive and negative likelihood ratios (LRs) ranged 1.5-3.3 and 0.4-0.6 for predicting mortality, and 2.5-4.4 and 0.3-0.6 for frequent readmissions, respectively, with stronger evidence in younger than in older individuals (LRs further from unity). In conclusion, the LACE index predicts mortality and frequent readmissions at lower thresholds and stronger in younger than in older individuals. Age should be taken into account when using the LACE index for identifying patients at high risk.
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Affiliation(s)
- Christopher Henry Fry
- School of Physiology, Pharmacology and Neuroscience, University of Bristol, Bristol, BS8 1TD, UK
| | - Erica Heppleston
- Quality Department, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK
| | - David Fluck
- Department of Cardiology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK
| | - Thang Sieu Han
- Department of Endocrinology, Ashford and St Peter's NHS Foundation Trust, Guildford Road, Chertsey, Surrey, KT16 0PZ, UK.
- Institute of Cardiovascular Research, Royal Holloway, University of London, Egham, Surrey, TW20 0EX, UK.
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Investigating the link between medical urgency and hospital efficiency - Insights from the German hospital market. Health Care Manag Sci 2020; 23:649-660. [PMID: 32936387 PMCID: PMC7674330 DOI: 10.1007/s10729-020-09520-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Accepted: 08/06/2020] [Indexed: 10/27/2022]
Abstract
With hospital budgets remaining tight and healthcare expenditure rising due to demographic change and advances in technology, hospitals continue to face calls to contain costs and allocate their resources more efficiently. In this context, efficiency has emerged as an increasingly important way for hospitals to withstand competitive pressures in the hospital market. Doing so, however, can be challenging given unpredictable fluctuations in demand, a prime example of which are emergencies, i.e. urgent medical cases. The link between medical urgency and hospitals' efficiency, however, has been neglected in the literature to date. This study therefore aims to investigate the relationship between hospitals' urgency characteristics and their efficiency. Our analyses are based on 4094 observations from 1428 hospitals throughout Germany for the years 2015, 2016, and 2017. We calculate an average urgency score for each hospital based on all cases treated in that hospital per year and also investigate the within-hospital dispersion of medical urgency. To analyze the association of these urgency measures with hospitals' efficiency we use a two-stage double bootstrap data envelopment analysis approach with truncated regression. We find a negative relationship between the urgency score and hospital efficiency. When testing for non-linear effects, the results reveal a u-shaped association, indicating that having either a high or low overall urgency score is beneficial in terms of efficiency. Finally, our results reveal that higher within-hospital urgency dispersion is negatively related to efficiency.
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15
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Chambers D, Cantrell A, Booth A. Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BackgroundIn 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice.ObjectivesTo map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions.MethodsFor the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA).ResultsA total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were delivered. There was also considerable overlap in the content of interventions. The role of specialist nurses was highlighted in several studies. The five programme theories identified were supported to varying degrees by empirical literature, but all provided valuable insights.LimitationsThe research was conducted by a small team; time and resources limited the team’s ability to consult with a full range of stakeholders.ConclusionsOverall, implementation appears to be favoured by support for self-management by patients and their families/carers, support for services that signpost patients to consider alternatives to seeing their general practitioner when appropriate, recognition of possible reasons why patients seek admission, support for health-care professionals to diagnose and refer patients appropriately and support for workforce roles that promote continuity of care and co-ordination between services.Future workResearch should focus on understanding discrepancies between national and international evidence and the transferability of findings between different contexts; the design and evaluation of implementation strategies informed by theories about how the intervention being implemented might work; and qualitative research on decision-making around hospital referrals and admissions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Duncan Chambers
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anna Cantrell
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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16
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Keeble E, Bardsley M, Durand MA, Hoomans T, Mays N. Area level impacts on emergency hospital admissions of the integrated care and support pioneer programme in England: difference-in-differences analysis. BMJ Open 2019; 9:e026509. [PMID: 31427314 PMCID: PMC6701574 DOI: 10.1136/bmjopen-2018-026509] [Citation(s) in RCA: 4] [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: 11/03/2022] Open
Abstract
OBJECTIVE To examine whether any differential change in emergency admissions could be attributed to integrated care by comparing pioneer and non-pioneer populations from a pre-pioneer baseline period (April 2010 to March 2013) over two follow-up periods: to 2014/2015 and to 2015/2016. DESIGN Difference-in-differences analysis of emergency hospital admissions from English Hospital Episode Statistics. SETTING Local authorities in England classified as either pioneer or non-pioneer. PARTICIPANTS Emergency admissions to all NHS hospitals in England with local authority determined by area of residence of the patient. INTERVENTION Wave 1 of the integrated care and support pioneer programme announced in November 2013. PRIMARY OUTCOME MEASURE Change in hospital emergency admissions. RESULTS The increase in the pioneer emergency admission rate from baseline to 2014/2015 was smaller at 1.93% and significantly different from that of the non-pioneers at 4.84% (p=0.0379). The increase in the pioneer emergency admission rate from baseline to 2015/2016 was again smaller than for the non-pioneers but the difference was not statistically significant (p=0.1879). CONCLUSIONS It is ambitious to expect unequivocal changes in a high level and indirect indicator of health and social care integration such as emergency hospital admissions to arise as a result of the changes in local health and social care provision across organisations brought about by the pioneers in their early years. We should treat any sign that the pioneers have had such an impact with caution. Nevertheless, there does seem to be an indication from the current analysis that there were some changes in hospital use associated with the first year of pioneer status that are worthy of further exploration.
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Affiliation(s)
| | | | - Mary Alison Durand
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Ties Hoomans
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Nicholas Mays
- Policy Innovation and Evaluation Research Unit, Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
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17
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Affiliation(s)
- Susan M Smith
- Department of General Practice, HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland, Dublin, Ireland
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18
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Snooks H, Bailey-Jones K, Burge-Jones D, Dale J, Davies J, Evans BA, Farr A, Fitzsimmons D, Heaven M, Howson H, Hutchings H, John G, Kingston M, Lewis L, Phillips C, Porter A, Sewell B, Warm D, Watkins A, Whitman S, Williams V, Russell I. Effects and costs of implementing predictive risk stratification in primary care: a randomised stepped wedge trial. BMJ Qual Saf 2018; 28:697-705. [PMID: 30397078 PMCID: PMC6820297 DOI: 10.1136/bmjqs-2018-007976] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 09/14/2018] [Accepted: 09/20/2018] [Indexed: 11/16/2022]
Abstract
Aim We evaluated the introduction of a predictive risk stratification model (PRISM) into primary care. Contemporaneously National Health Service (NHS) Wales introduced Quality and Outcomes Framework payments to general practices to focus care on those at highest risk of emergency admission to hospital. The aim of this study was to evaluate the costs and effects of introducing PRISM into primary care. Methods Randomised stepped wedge trial with 32 general practices in one Welsh health board. The intervention comprised: PRISM software; practice-based training; clinical support through two ‘general practitioner (GP) champions’ and technical support. The primary outcome was emergency hospital admissions. Results Across 230 099 participants, PRISM implementation increased use of health services: emergency hospital admission rates by 1 % when untransformed (while change in log-transformed rate ΔL=0.011, 95% CI 0.010 to 0.013); emergency department (ED) attendance rates by untransformed 3 % (while ΔL=0.030, 95% CI 0.028 to 0.032); outpatient visit rates by untransformed 5 % (while ΔL=0.055, 95% CI 0.051 to 0.058); the proportion of days with recorded GP activity by untransformed 1 % (while ΔL=0.011, 95% CI 0.007 to 0.014) and time in hospital by untransformed 3 % (while ΔL=0.029, 95% CI 0.026 to 0.031). Thus NHS costs per participant increased by £76 (95% CI £46 to £106). Conclusions Introduction of PRISM resulted in a statistically significant increase in emergency hospital admissions and use of other NHS services without evidence of benefits to patients or the NHS.
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Affiliation(s)
| | | | | | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Angela Farr
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | | | | | | | | | - Leo Lewis
- International Foundation for Integrated Care, Oxford, UK
| | - Ceri Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | - Bernadette Sewell
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Daniel Warm
- Hywel Dda University Health Board, Carmarthen, UK
| | | | | | | | - Ian Russell
- Medical School, Swansea University, Swansea, UK
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19
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Lynch B, Fitzgerald AP, Corcoran P, Buckley C, Healy O, Browne J. Drivers of potentially avoidable emergency admissions in Ireland: an ecological analysis. BMJ Qual Saf 2018; 28:438-448. [PMID: 30314977 DOI: 10.1136/bmjqs-2018-008002] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 09/07/2018] [Accepted: 09/10/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND Many emergency admissions are deemed to be potentially avoidable in a well-performing health system. OBJECTIVE To measure the impact of population and health system factors on county-level variation in potentially avoidable emergency admissions in Ireland over the period 2014-2016. METHODS Admissions data were used to calculate 2014-2016 age-adjusted emergency admission rates for selected conditions by county of residence. Negative binomial regression was used to identify which a priori factors were significantly associated with emergency admissions for these conditions and whether these factors were also associated with total/other emergency admissions. Standardised incidence rate ratios (IRRs) associated with a 1 SD change in risk factors were reported. RESULTS Nationally, potentially avoidable emergency admissions for the period 2014-2016 (266 395) accounted for 22% of all emergency admissions. Of the population factors, a 1 SD change in the county-level unemployment rate was associated with a 24% higher rate of potentially avoidable emergency admissions (IRR: 1.24; 95% CI 1.04 to 1.41). Significant health system factors included emergency admissions with length of stay equal to 1 day (IRR: 1.20; 95% CI 1.11 to 1.30) and private health insurance coverage (IRR: 0.92; 95% CI 0.89 to 0.96). The full model accounted for 50% of unexplained variation in potentially avoidable emergency admissions in each county. Similar results were found across total/other emergency admissions. CONCLUSION The results suggest potentially avoidable emergency admissions and total/other emergency admissions are primarily driven by socioeconomic conditions, hospital admission policy and private health insurance coverage. The distinction between potentially avoidable and all other emergency admissions may not be as useful as previously believed when attempting to identify the causes of regional variation in emergency admission rates.
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Affiliation(s)
- Brenda Lynch
- School of Public Health, University College Cork, Cork, Ireland
| | | | - Paul Corcoran
- School of Public Health, University College Cork, Cork, Ireland
| | - Claire Buckley
- School of Public Health, University College Cork, Cork, Ireland
| | - Orla Healy
- Public Health, Health Service Executive South, Cork, Ireland
| | - John Browne
- School of Public Health, University College Cork, Cork, Ireland
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20
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Reducing emergency hospital admissions: a population health complex intervention of an enhanced model of primary care and compassionate communities. Br J Gen Pract 2018; 68:e803-e810. [PMID: 30297434 DOI: 10.3399/bjgp18x699437] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 08/09/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Reducing emergency admissions to hospital has been a cornerstone of healthcare policy. Little evidence exists to show that systematic interventions across a population have achieved this aim. The authors report the impact of a complex intervention over a 44-month period in Frome, Somerset, on unplanned admissions to hospital. AIM To evaluate a population health complex intervention of an enhanced model of primary care and compassionate communities on population health improvement and reduction of emergency admissions to hospital. DESIGN AND SETTING A cohort retrospective study of a complex intervention on all emergency admissions in Frome Medical Practice, Somerset, compared with the remainder of Somerset, from April 2013 to December 2017. METHOD Patients were identified using broad criteria, including anyone giving cause for concern. Patient-centred goal setting and care planning combined with a compassionate community social approach was implemented broadly across the population of Frome. RESULTS There was a progressive reduction, by 7.9 cases per quarter (95% confidence interval [CI] = 2.8 to 13.1, P = 0.006), in unplanned hospital admissions across the whole population of Frome during the study period from April 2013 to December 2017, a decrease of 14.0%. At the same time, there was a 28.5% increase in admissions per quarter within Somerset, with a rise in the number of unplanned admissions of 236 per quarter (95% CI = 152 to 320, P<0.001). CONCLUSION The complex intervention in Frome was associated with highly significant reductions in unplanned admissions to hospital, with a decrease in healthcare costs across the whole population of Frome.
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21
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Wallace E, Johansen ME. Clinical Prediction Rules: Challenges, Barriers, and Promise. Ann Fam Med 2018; 16:390-392. [PMID: 30201634 PMCID: PMC6130996 DOI: 10.1370/afm.2303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/14/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
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22
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Stokes J, Riste L, Cheraghi-Sohi S. Targeting the 'right' patients for integrated care: stakeholder perspectives from a qualitative study. J Health Serv Res Policy 2018; 23:243-251. [PMID: 29984592 DOI: 10.1177/1355819618788100] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective To explore the perceptions of relevant stakeholders in terms of targeting the 'right' patients for integrated care. Methods Secondary analysis of qualitative interviews with relevant stakeholders (including programme managers, programme initiators, a representative of the payers, medical and social care professionals and allied health services staff) from two integrated care sites in England. A thematic analysis was conducted of cross-cutting themes. Results Both sites focused on individualized management of 'high-risk' patients through multidisciplinary team case management. The data-driven approach to targeting patients, recommended in the policy literature, did not align with stakeholders' experience of selecting patients in practice. The 'right' patients were at lower risk than those recommended by policy, and their complexities were identified as comprising mostly social rather than medical issues. Conclusions These findings raise timely questions about the individualized management approach. They potentially explain why management of high-risk patients has not been found to be effective using quantitative measures, undermining the assumption that this approach will lead to cost savings. There is a need to expand beyond an individually targeted approach to incorporate prevention and to address social issues.
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Affiliation(s)
- Jonathan Stokes
- 1 Research Fellow, Manchester Centre for Health Economics, University of Manchester, UK
| | - Lisa Riste
- 2 Research Fellow, Centre for Primary Care, University of Manchester, UK
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Round T, Ashworth M, Crilly T, Ferlie E, Wolfe C. An integrated care programme in London: qualitative evaluation. JOURNAL OF INTEGRATED CARE 2018; 26:296-308. [PMID: 30464724 PMCID: PMC6195169 DOI: 10.1108/jica-02-2018-0020] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE A well-funded, four-year integrated care programme was implemented in south London. The programme attempted to integrate care across primary, acute, community, mental health and social care. The purpose of this paper is to reduce hospital admissions and nursing home placements. Programme evaluation aimed to identify what worked well and what did not; lessons learnt; the value of integrated care investment. DESIGN/METHODOLOGY/APPROACH Qualitative data were obtained from documentary analysis, stakeholder interviews, focus groups and observational data from programme meetings. Framework analysis was applied to stakeholder interview and focus group data in order to generate themes. FINDINGS The integrated care project had not delivered expected radical reductions in hospital or nursing home utilisation. In response, the scheme was reformulated to focus on feasible service integration. Other benefits emerged, particularly system transformation. Nine themes emerged: shared vision/case for change; interventions; leadership; relationships; organisational structures and governance; citizens and patients; evaluation and monitoring; macro level. Each theme was interpreted in terms of "successes", "challenges" and "lessons learnt". RESEARCH LIMITATIONS/IMPLICATIONS Evaluation was hampered by lack of a clear evaluation strategy from programme inception to conclusion, and of the evidence required to corroborate claims of benefit. PRACTICAL IMPLICATIONS Key lessons learnt included: importance of strong clinical leadership, shared ownership and inbuilt evaluation. ORIGINALITY/VALUE Primary care was a key player in the integrated care programme. Initial resistance delayed implementation and related to concerns about vertical integration and scepticism about unrealistic goals. A focus on clinical care and shared ownership contributed to eventual system transformation.
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Affiliation(s)
- Thomas Round
- School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | - Mark Ashworth
- School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
| | | | - Ewan Ferlie
- King's Business School, King's College London, London, UK
| | - Charles Wolfe
- School of Population Health & Environmental Sciences, Faculty of Life Sciences & Medicine, King's College London, London, UK
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Snooks H, Bailey-Jones K, Burge-Jones D, Dale J, Davies J, Evans B, Farr A, Fitzsimmons D, Harrison J, Heaven M, Howson H, Hutchings H, John G, Kingston M, Lewis L, Phillips C, Porter A, Sewell B, Warm D, Watkins A, Whitman S, Williams V, Russell IT. Predictive risk stratification model: a randomised stepped-wedge trial in primary care (PRISMATIC). HEALTH SERVICES AND DELIVERY RESEARCH 2018. [DOI: 10.3310/hsdr06010] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWith a higher proportion of older people in the UK population, new approaches are needed to reduce emergency hospital admissions, thereby shifting care delivery out of hospital when possible and safe.Study aimTo evaluate the introduction of predictive risk stratification in primary care.ObjectivesTo (1) measure the effects on service usage, particularly emergency admissions to hospital; (2) assess the effects of the Predictive RIsk Stratification Model (PRISM) on quality of life and satisfaction; (3) assess the technical performance of PRISM; (4) estimate the costs of PRISM implementation and its effects; and (5) describe the processes of change associated with PRISM.DesignRandomised stepped-wedge trial with economic and qualitative components.SettingAbertawe Bro Morgannwg University Health Board, south Wales.ParticipantsPatients registered with 32 participating general practices.InterventionPRISM software, which stratifies patients into four (emergency admission) risk groups; practice-based training; and clinical support.Main outcome measuresPrimary outcome – emergency hospital admissions. Secondary outcomes – emergency department (ED) and outpatient attendances, general practitioner (GP) activity, time in hospital, quality of life, satisfaction and costs.Data sourcesRoutine anonymised linked health service use data, self-completed questionnaires and staff focus groups and interviews.ResultsAcross 230,099 participants, PRISM implementation led to increased emergency admissions to hospital [ΔL = 0.011, 95% confidence interval (CI) 0.010 to 0.013], ED attendances (ΔL = 0.030, 95% CI 0.028 to 0.032), GP event-days (ΔL = 0.011, 95% CI 0.007 to 0.014), outpatient visits (ΔL = 0.055, 95% CI 0.051 to 0.058) and time spent in hospital (ΔL = 0.029, 95% CI 0.026 to 0.031). Quality-of-life scores related to mental health were similar between phases (Δ = –0.720, 95% CI –1.469 to 0.030); physical health scores improved in the intervention phase (Δ = 1.465, 95% CI 0.774 to 2.157); and satisfaction levels were lower (Δ = –0.074, 95% CI – 0.133 to –0.015). PRISM implementation cost £0.12 per patient per year and costs of health-care use per patient were higher in the intervention phase (Δ = £76, 95% CI £46 to £106). There was no evidence of any significant difference in deaths between phases (9.58 per 1000 patients per year in the control phase and 9.25 per 1000 patients per year in the intervention phase). PRISM showed good general technical performance, comparable with existing risk prediction tools (c-statistic of 0.749). Qualitative data showed low use by GPs and practice staff, although they all reported using PRISM to generate lists of patients to target for prioritised care to meet Quality and Outcomes Framework (QOF) targets.LimitationsIn Wales during the study period, QOF targets were introduced into general practice to encourage targeting care to those at highest risk of emergency admission to hospital. Within this dynamic context, we therefore evaluated the combined effects of PRISM and this contemporaneous policy initiative.ConclusionsIntroduction of PRISM increased emergency episodes, hospitalisation and costs across, and within, risk levels without clear evidence of benefits to patients.Future research(1) Evaluation of targeting of different services to different levels of risk; (2) investigation of effects on vulnerable populations and health inequalities; (3) secondary analysis of the Predictive Risk Stratification: A Trial in Chronic Conditions Management data set by health condition type; and (4) acceptability of predictive risk stratification to patients and practitioners.Trial and study registrationCurrent Controlled Trials ISRCTN55538212 and PROSPERO CRD42015016874.FundingThe National Institute for Health Research Health Services Delivery and Research programme.
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Affiliation(s)
| | | | | | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | | | - Angela Farr
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | | | - Martin Heaven
- The FARR Institute, Swansea University Medical School, Swansea, UK
| | - Helen Howson
- Bevan Commission, School of Management, Swansea University, Swansea, UK
| | | | | | | | - Leo Lewis
- International Foundation for Integrated Care, Oxford, UK
| | - Ceri Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | | | - Bernadette Sewell
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Daniel Warm
- Hywel Dda University Health Board, Hafan Derwen, Carmarthen, UK
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Krämer J, Schreyögg J, Busse R. Classification of hospital admissions into emergency and elective care: a machine learning approach. Health Care Manag Sci 2017; 22:85-105. [PMID: 29177993 DOI: 10.1007/s10729-017-9423-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Accepted: 11/07/2017] [Indexed: 10/18/2022]
Abstract
Rising admissions from emergency departments (EDs) to hospitals are a primary concern for many healthcare systems. The issue of how to differentiate urgent admissions from non-urgent or even elective admissions is crucial. We aim to develop a model for classifying inpatient admissions based on a patient's primary diagnosis as either emergency care or elective care and predicting urgency as a numerical value. We use supervised machine learning techniques and train the model with physician-expert judgments. Our model is accurate (96%) and has a high area under the ROC curve (>.99). We provide the first comprehensive classification and urgency categorization for inpatient emergency and elective care. This model assigns urgency values to every relevant diagnosis in the ICD catalog, and these values are easily applicable to existing hospital data. Our findings may provide a basis for policy makers to create incentives for hospitals to reduce the number of inappropriate ED admissions.
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Affiliation(s)
- Jonas Krämer
- Hamburg Center for Health Economics, Universität Hamburg, Esplanade 36, 20354, Hamburg, Germany
| | - Jonas Schreyögg
- Hamburg Center for Health Economics, Universität Hamburg, Esplanade 36, 20354, Hamburg, Germany.
| | - Reinhard Busse
- Department of Healthcare Management, Technische Universität Berlin, 10623, Berlin, Germany
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Stokes J, Man MS, Guthrie B, Mercer SW, Salisbury C, Bower P. The Foundations Framework for Developing and Reporting New Models of Care for Multimorbidity. Ann Fam Med 2017; 15:570-577. [PMID: 29133498 PMCID: PMC5683871 DOI: 10.1370/afm.2150] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Revised: 05/09/2017] [Accepted: 06/15/2017] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Multimorbidity challenges health systems globally. New models of care are urgently needed to better manage patients with multimorbidity; however, there is no agreed framework for designing and reporting models of care for multimorbidity and their evaluation. METHODS Based on findings from a literature search to identify models of care for multimorbidity, we developed a framework to describe these models. We illustrate the application of the framework by identifying the focus and gaps in current models of care, and by describing the evolution of models over time. RESULTS Our framework describes each model in terms of its theoretical basis and target population (the foundations of the model) and of the elements of care implemented to deliver the model. We categorized elements of care into 3 types: (1) clinical focus, (2) organization of care, (3) support for model delivery. Application of the framework identified a limited use of theory in model design and a strong focus on some patient groups (elderly, high users) more than others (younger patients, deprived populations). We found changes in elements with time, with a decrease in models implementing home care and an increase in models offering extended appointments. CONCLUSIONS By encouragin greater clarity about the underpinning theory and target population, and by categorizing the wide range of potentially important elements of an intervention to improve care for patients with multimorbidity, the framework may be useful in designing and reporting models of care and help advance the currently limited evidence base.
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Affiliation(s)
- Jonathan Stokes
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom .,Centre for Health Economics, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Mei-See Man
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Bruce Guthrie
- Quality, Safety and Informatics Research Group, University of Dundee, Dundee, United Kingdom
| | - Stewart W Mercer
- General Practice and Primary Care, Institute for Health and Wellbeing, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Manchester Academic Health Science Centre, School of Health Sciences, University of Manchester, Manchester, United Kingdom
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The role of the Quality and Outcomes Framework in the care of long-term conditions: a systematic review. Br J Gen Pract 2017; 67:e775-e784. [PMID: 28947621 PMCID: PMC5647921 DOI: 10.3399/bjgp17x693077] [Citation(s) in RCA: 115] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/12/2017] [Indexed: 11/24/2022] Open
Abstract
Background Improving care for people with long-term conditions is central to NHS policy. It has been suggested that the Quality and Outcomes Framework (QOF), a primary care pay-for-performance scheme that rewards practices for delivering effective interventions in long-term conditions, does not encourage high-quality care for this group of patients. Aim To examine the evidence that the QOF has improved quality of care for patients with long-term conditions. Design and setting This was a systematic review of research on the effectiveness of the QOF in the UK. Method The authors searched electronic databases for peer-reviewed empirical quantitative research studying the effect of the QOF on a broad range of processes and outcomes of care, including coordination and integration of care, holistic and personalised care, self-care, patient experience, physiological and biochemical outcomes, health service utilisation, and mortality. Because the studies were heterogeneous, a narrative synthesis was carried out. Results The authors identified three systematic reviews and five primary research studies that met the inclusion criteria. The QOF was associated with a modest slowing of both the increase in emergency admissions and the increase in consultations in severe mental illness (SMI), and modest improvements in diabetes care. The nature of the evidence means that the authors cannot be sure that any of these associations is causal. No clear effect on mortality was found. The authors found no evidence that the QOF influences integration or coordination of care, holistic care, self-care, or patient experience. Conclusion The NHS should consider more broadly what constitutes high-quality primary care for people with long-term conditions, and consider other ways of motivating primary care to deliver it.
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Carey IM, Hosking FJ, Harris T, DeWilde S, Beighton C, Cook DG. An evaluation of the effectiveness of annual health checks and quality of health care for adults with intellectual disability: an observational study using a primary care database. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05250] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
People with intellectual disability (ID) have poorer health than the general population; however, there is a lack of comprehensive national data describing their health-care needs and utilisation. Annual health checks for adults with ID have been incentivised through primary care since 2009, but only half of those eligible for such a health check receive one. It is unclear what impact health checks have had on important health outcomes, such as emergency hospitalisation.
Objectives
To evaluate whether or not annual health checks for adults with ID have reduced emergency hospitalisation, and to describe health, health care and mortality for adults with ID.
Design
A retrospective matched cohort study using primary care data linked to national hospital admissions and mortality data sets.
Setting
A total of 451 English general practices contributing data to Clinical Practice Research Datalink (CPRD).
Participants
A total of 21,859 adults with ID compared with 152,846 age-, gender- and practice-matched controls without ID registered during 2009–13.
Interventions
None.
Main outcome measures
Emergency hospital admissions. Other outcomes – preventable admissions for ambulatory care sensitive conditions, and mortality.
Data sources
CPRD, Hospital Episodes Statistics and Office for National Statistics.
Results
Compared with the general population, adults with ID had higher levels of recorded comorbidity and were more likely to consult in primary care. However, they were less likely to have long doctor consultations, and had lower continuity of care. They had higher mortality rates [hazard ratio (HR) 3.6, 95% confidence interval (CI) 3.3 to 3.9], with 37.0% of deaths classified as being amenable to health-care intervention (HR 5.9, 95% CI 5.1 to 6.8). They were more likely to have emergency hospital admissions [incidence rate ratio (IRR) 2.82, 95% CI 2.66 to 2.98], with 33.7% deemed preventable compared with 17.3% in controls (IRR 5.62, 95% CI 5.14 to 6.13). Health checks for adults with ID had no effect on overall emergency admissions compared with controls (IRR 0.96, 95% CI 0.87 to 1.07), although there was a relative reduction in emergency admissions for ambulatory care-sensitive conditions (IRR 0.82, 95% CI 0.69 to 0.99). Practices with high health check participation also showed a relative fall in preventable emergency admissions for their patients with ID, compared with practices with minimal participation (IRR 0.73, 95% CI 0.57 to 0.95). There were large variations in the health check-related content that was recorded on electronic records.
Limitations
Patients with milder ID not known to health services were not identified. We could not comment on the quality of health checks.
Conclusions
Compared with the general population, adults with ID have more chronic diseases and greater primary and secondary care utilisation. With more than one-third of deaths potentially amenable to health-care interventions, improvements in access to, and quality of, health care are required. In primary care, better continuity of care and longer appointment times are important examples that we identified. Although annual health checks can also improve access, not every eligible adult with ID receives one, and health check content varies by practice. Health checks had no impact on overall emergency admissions, but they appeared influential in reducing preventable emergency admissions.
Future work
No formal cost-effectiveness analysis of annual health checks was performed, but this could be attempted in relation to our estimates of a reduction in preventable emergency admissions.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Iain M Carey
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Fay J Hosking
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Tess Harris
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Stephen DeWilde
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Carole Beighton
- Population Health Research Institute, St George’s, University of London, London, UK
| | - Derek G Cook
- Population Health Research Institute, St George’s, University of London, London, UK
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Ashworth M, Gulliford M. Financiamento para medicina de família na próxima década: vida após o QOF. REVISTA BRASILEIRA DE MEDICINA DE FAMÍLIA E COMUNIDADE 2017. [DOI: 10.5712/rbmfc12(39)1575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Round T. Primary care and cancer: Facing the challenge of early diagnosis and survivorship. Eur J Cancer Care (Engl) 2017; 26. [PMID: 28513052 DOI: 10.1111/ecc.12703] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2017] [Indexed: 11/29/2022]
Abstract
With ageing populations and an increasing lifetime risk of cancer, primary care will continue to play an increasingly important role in early diagnosis and cancer survivorship, especially with the lowering of risk thresholds for referral and diagnostic investigations. However, primary care in many countries is in crisis with increasing workloads for primary care physicians. Potential solutions to these challenges will be outlined including development of multidisciplinary teams, diagnostic decision support, increasing access to diagnostics and cost-effective referral pathways.
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Affiliation(s)
- Thomas Round
- Primary Care and Public Health Sciences, King's College London, London, UK
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Harries TH, Thornton H, Crichton S, Schofield P, Gilkes A, White PT. Hospital readmissions for COPD: a retrospective longitudinal study. NPJ Prim Care Respir Med 2017; 27:31. [PMID: 28450741 PMCID: PMC5435097 DOI: 10.1038/s41533-017-0028-8] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Revised: 03/03/2017] [Accepted: 03/21/2017] [Indexed: 02/05/2023] Open
Abstract
Prevention of chronic obstructive pulmonary disease hospital readmissions is an international priority aimed to slow disease progression and limit costs. Evidence of the risk of readmission and of interventions that might prevent it is lacking. We aimed to determine readmission risk for chronic obstructive pulmonary disease, factors influencing that risk, and variation in readmission risk between hospitals across 7.5 million people in London. This retrospective longitudinal observational study included all chronic obstructive pulmonary disease admissions to any hospital in the United Kingdom among patients registered at London general practices who had emergency National Health Service chronic obstructive pulmonary disease hospital admissions between April 2006 and March 2010. Influence of patient characteristics, geographical deprivation score, length of stay, day of week of admission or of discharge, and admitting hospital, were assessed using multiple logistic regression. 38,894 chronic obstructive pulmonary disease admissions of 20,932 patients aged ≥ 45 years registered with London general practices were recorded. 6295 patients (32.2%) had at least one chronic obstructive pulmonary disease readmission within 1 year. 1993 patients (10.2%) were readmitted within 30 days and 3471 patients (17.8%) were readmitted within 90 days. Age and patient geographical deprivation score were very weak predictors of readmission. Rates of chronic obstructive pulmonary disease readmissions within 30 days and within 90 days did not vary among the majority of hospitals. The finding of lower chronic obstructive pulmonary disease readmission rates than was previously estimated and the limited variation in these rates between hospitals suggests that the opportunity to reduce chronic obstructive pulmonary disease readmission risk is small. A managed reduction of hospital readmissions for London-based chronic lung disease patients may not be needed. Preventing hospital readmissions for patients with chronic obstructive pulmonary disease (COPD) is a key priority to improve patient care and limit costs. However, few data are available to determine and ultimately reduce the risk of readmission. Timothy Harries at King’s College, London, and co-workers conducted a longitudinal study incorporating all COPD admissions into UK hospitals for 20,932 patients registered at London general practitioners between 2006 and 2010. They found that 32% of patients were readmitted within a year, 17.8% within 90 days and 10% within 30 days. Neither age nor geographical deprivation were useful predictors of readmission. These represent lower than estimated levels of readmission, suggesting there may be fewer opportunities to reduce the risk of readmission further.
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Affiliation(s)
- Timothy H Harries
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK.
| | - Hannah Thornton
- Centre for Academic Primary Care, NIHR School for Primary Care Research, School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Siobhan Crichton
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
| | - Peter Schofield
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
| | - Alexander Gilkes
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
| | - Patrick T White
- King's College London, King's Health Partners, Division of Health and Social Care Research, London, SE1 3QD, UK
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Wallace E, McDowell R, Bennett K, Fahey T, Smith SM. External validation of the Vulnerable Elder's Survey for predicting mortality and emergency admission in older community-dwelling people: a prospective cohort study. BMC Geriatr 2017; 17:69. [PMID: 28320329 PMCID: PMC5359866 DOI: 10.1186/s12877-017-0460-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2016] [Accepted: 03/08/2017] [Indexed: 11/10/2022] Open
Abstract
Background Prospective external validation of the Vulnerable Elder’s Survey (VES-13) in primary care remains limited. The aim of this study is to externally validate the VES-13 in predicting mortality and emergency admission in older community-dwelling adults. Methods Design: Prospective cohort study with 2 years follow-up (2010–2012). Setting: 15 General Practices (GPs) in the Republic of Ireland. Participants: n = 862, aged ≥70 years, community-dwellers Exposure: VES-13 calculated at baseline, where a score of ≥3 denoted high risk. Outcomes: i) Mortality; ii) ≥1 Emergency admission and ≥1 ambulatory care sensitive (ACS) admission over 2 years. Statistical analysis: Descriptive statistics, model discrimination (c-statistic) and sensitivity/specificity. Results Of 862 study participants, a total of 246 (38%) were classified as vulnerable at baseline. Fifty-three (6%) died during follow-up and 246 (29%) had an emergency admission. At the VES-13 cut-point of ≥3 denoting high-risk model discrimination was poor for mortality (c-statistic: 0.61 (95% CI 0.54, 0.67), ≥1 emergency admission (c-statistic: 0.59 (95% CI 0.56, 0.63) and ≥1 ACS emergency admission (c-statistic: 0.63 (95% CI 0.60, 0.67). Conclusions In this study the VES-13 demonstrated relatively limited predictive accuracy in predicting mortality and emergency admission. External validation studies examining the tool in different health settings and healthier populations are needed and represent an interesting area for future research. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0460-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 Stephen's green, Dublin 2, Ireland.
| | - Ronald McDowell
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 Stephen's green, Dublin 2, Ireland
| | - Kathleen Bennett
- Population Health Sciences Division, Royal College of Surgeons of Ireland (RCSI), Dublin 2, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 Stephen's green, Dublin 2, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), 123 Stephen's green, Dublin 2, Ireland
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El Morr C, Ginsburg L, Nam S, Woollard S. Assessing the Performance of a Modified LACE Index (LACE-rt) to Predict Unplanned Readmission After Discharge in a Community Teaching Hospital. Interact J Med Res 2017; 6:e2. [PMID: 28274908 PMCID: PMC5362694 DOI: 10.2196/ijmr.7183] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 01/31/2017] [Accepted: 02/14/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The LACE index was designed to predict early death or unplanned readmission after discharge from hospital to the community. However, implementing the LACE tool in real time in a teaching hospital required practical unavoidable modifications. OBJECTIVE The purpose of this study was to validate the implementation of a modified LACE index (LACE-rt) and test its ability to predict readmission risk using data in a hospital setting. METHODS Data from the Canadian Institute for Health Information's Discharge Abstract Database (DAD), the National Ambulatory Care Reporting System (NACRS), and the hospital electronic medical record for one large community hospital in Toronto, Canada, were used in this study. A total of 3855 admissions from September 2013 to July 2014 were analyzed (N=3855) using descriptive statistics, regression analysis, and receiver operating characteristic analysis. Prospectively collected data from DAD and NACRS were linked to inpatient data. RESULTS The LACE-rt index was a fair test to predict readmission risk (C statistic=.632). A LACE-rt score of 10 is a good threshold to differentiate between patients with low and high readmission risk; the high-risk patients are 2.648 times more likely to be readmitted than those at low risk. The introduction of LACE-rt had no significant impact on readmission reduction. CONCLUSIONS The LACE-rt is a fair tool for identifying those at risk of readmission. A collaborative cross-sectoral effort that includes those in charge of providing community-based care is needed to reduce readmission rates. An eHealth solution could play a major role in streamlining this collaboration.
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Affiliation(s)
- Christo El Morr
- Faculty of Health, School of Health Policy and Management, York University, Toronto, ON, Canada
| | - Liane Ginsburg
- Faculty of Health, School of Health Policy and Management, York University, Toronto, ON, Canada
| | - Seungree Nam
- Faculty of Health, School of Health Policy and Management, York University, Toronto, ON, Canada
| | - Susan Woollard
- North York General Hospital, Medicine, North York General Hospital, Toronto, ON, Canada
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Vuik SI, Mayer E, Darzi A. Enhancing risk stratification for use in integrated care: a cluster analysis of high-risk patients in a retrospective cohort study. BMJ Open 2016; 6:e012903. [PMID: 27993905 PMCID: PMC5168666 DOI: 10.1136/bmjopen-2016-012903] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To show how segmentation can enhance risk stratification tools for integrated care, by providing insight into different care usage patterns within the high-risk population. DESIGN A retrospective cohort study. A risk score was calculated for each person using a logistic regression, which was then used to select the top 5% high-risk individuals. This population was segmented based on the usage of different care settings using a k-means cluster analysis. Data from 2008 to 2011 were used to create the risk score and segments, while 2012 data were used to understand the predictive abilities of the models. SETTING AND PARTICIPANTS Data were collected from administrative data sets covering primary and secondary care for a random sample of 300 000 English patients. MAIN MEASURES The high-risk population was segmented based on their usage of 4 different care settings: emergency acute care, elective acute care, outpatient care and GP care. RESULTS While the risk strata predicted care usage at a high level, within the high-risk population, usage varied significantly. 4 different groups of high-risk patients could be identified. These 4 segments had distinct usage patterns across care settings, reflecting different levels and types of care needs. The 2008-2011 usage patterns of the 4 segments were consistent with the 2012 patterns. DISCUSSION Cluster analyses revealed that the high-risk population is not homogeneous, as there exist 4 groups of patients with different needs across the care continuum. Since the patterns were predictive of future care use, they can be used to develop integrated care programmes tailored to these different groups. CONCLUSIONS Usage-based segmentation augments risk stratification by identifying patient groups with different care needs, around which integrated care programmes can be designed.
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Affiliation(s)
- Sabine I Vuik
- Institute of Global Health Innovation, Imperial College, St Mary's Hospital, London, UK
| | - Erik Mayer
- Department of Surgery, Imperial College, St Mary's Hospital, London, UK
| | - Ara Darzi
- Institute of Global Health Innovation, Imperial College, St Mary's Hospital, London, UK
- Department of Surgery, Imperial College, St Mary's Hospital, London, UK
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Wallace E, McDowell R, Bennett K, Fahey T, Smith SM. External validation of the Probability of repeated admission (Pra) risk prediction tool in older community-dwelling people attending general practice: a prospective cohort study. BMJ Open 2016; 6:e012336. [PMID: 28186935 PMCID: PMC5128991 DOI: 10.1136/bmjopen-2016-012336] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Emergency admission is associated with the potential for adverse events in older people and risk prediction models are available to identify those at highest risk of admission. The aim of this study was to externally validate and compare the performance of the Probability of repeated admission (Pra) risk model and a modified version (incorporating a multimorbidity measure) in predicting emergency admission in older community-dwelling people. SETTING 15 general practices (GPs) in the Republic of Ireland. PARTICIPANTS n=862, ≥70 years, community-dwelling people prospectively followed up for 2 years (2010-2012). EXPOSURE Pra risk model (original and modified) calculated for baseline year where ≥0.5 denoted high risk (patient questionnaire, GP medical record review) of future emergency admission. PRIMARY OUTCOME Emergency admission over 1 year (GP medical record review). STATISTICAL ANALYSIS descriptive statistics, model discrimination (c-statistic) and calibration (Hosmer-Lemeshow statistic). RESULTS Of 862 patients, a total of 154 (18%) had ≥1 emergency admission(s) in the follow-up year. 63 patients (7%) were classified as high risk by the original Pra and of these 26 (41%) were admitted. The modified Pra classified 391 (45%) patients as high risk and 103 (26%) were subsequently admitted. Both models demonstrated only poor discrimination (original Pra: c-statistic 0.65 (95% CI 0.61 to 0.70); modified Pra: c-statistic 0.67 (95% CI 0.62 to 0.72)). When categorised according to risk-category model, specificity was highest for the original Pra at cut-point of ≥0.5 denoting high risk (95%), and for the modified Pra at cut-point of ≥0.7 (95%). Both models overestimated the number of admissions across all risk strata. CONCLUSIONS While the original Pra model demonstrated poor discrimination, model specificity was high and a small number of patients identified as high risk. Future validation studies should examine higher cut-points denoting high risk for the modified Pra, which has practical advantages in terms of application in GP. The original Pra tool may have a role in identifying higher-risk community-dwelling older people for inclusion in future trials aiming to reduce emergency admissions.
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Affiliation(s)
- Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Ronald McDowell
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Kathleen Bennett
- Population and Health Sciences Division, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
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Wallace E, McDowell R, Bennett K, Fahey T, Smith SM. Comparison of count-based multimorbidity measures in predicting emergency admission and functional decline in older community-dwelling adults: a prospective cohort study. BMJ Open 2016; 6:e013089. [PMID: 27650770 PMCID: PMC5051451 DOI: 10.1136/bmjopen-2016-013089] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES Multimorbidity, defined as the presence of 2 or more chronic medical conditions in an individual, is associated with poorer health outcomes. Several multimorbidity measures exist, and the challenge is to decide which to use preferentially in predicting health outcomes. The study objective was to compare the performance of 5 count-based multimorbidity measures in predicting emergency hospital admission and functional decline in older community-dwelling adults attending primary care. SETTING 15 general practices (GPs) in Ireland. PARTICIPANTS n=862, ≥70 years, community-dwellers followed-up for 2 years (2010-2012). Exposure at baseline: Five multimorbidity measures (disease counts, selected conditions counts, Charlson comorbidity index, RxRisk-V, medication counts) calculated using GP medical record and linked national pharmacy claims data. PRIMARY OUTCOMES (1) Emergency admission and ambulatory care sensitive (ACS) admission (GP medical record) and (2) functional decline (postal questionnaire). STATISTICAL ANALYSIS Descriptive statistics and measure discrimination (c-statistic, 95% CIs), adjusted for confounders. RESULTS Median age was 77 years and 53% were women. Prevalent rates ranged from 37% to 91% depending on which measure was used to define multimorbidity. All measures demonstrated poor discrimination for the outcome of emergency admission (c-statistic range: 0.62, 0.65), ACS admission (c-statistic range: 0.63, 0.68) and functional decline (c-statistic range: 0.55, 0.61). Medication-based measures were equivalent to diagnosis-based measures. CONCLUSIONS The choice of measure may have a significant impact on prevalent rates. Five multimorbidity measures demonstrated poor discrimination in predicting emergency admission and functional decline, with medication-based measures equivalent to diagnosis-based measures. Consideration of multimorbidity in isolation is insufficient for predicting these outcomes in community settings.
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Affiliation(s)
- Emma Wallace
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Ronald McDowell
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Kathleen Bennett
- Population Health Sciences Division, Royal College of Surgeons of Ireland (RCSI), Dublin, Ireland
| | - Tom Fahey
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
| | - Susan M Smith
- HRB Centre for Primary Care Research, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
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Conroy SP, Turpin S. New horizons: urgent care for older people with frailty. Age Ageing 2016; 45:577-84. [PMID: 27496917 DOI: 10.1093/ageing/afw135] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Accepted: 05/13/2016] [Indexed: 11/13/2022] Open
Abstract
Urgent care for older people is a major public health issue and attracts much policy attention. Despite many efforts to curb demand, many older people with frailty and urgent care needs to access acute hospital services. The predominant model of care delivered in acute hospitals tends to be medically focussed, yet the evidence-based approaches that appear to be effective invoke a holistic model of care, delivered by interdisciplinary teams embedding geriatric competencies into their service. This article reviews the role for holistic care-termed Comprehensive Geriatric Assessment in the research literature-and how it can be used as an organising framework to guide future iterations of acute services to be better able to meet the multifaceted needs of older people.
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Affiliation(s)
- Simon P Conroy
- University of Leicester School of Medicine, Department of Health Sciences, Room 3.37, Centre for Medicine, University of Leicester, Lancaster Road, Leicester LE1 7HA, UK
| | - Sarah Turpin
- Fellow in Geriatric Emergency Medicine, Leicester Royal Infirmary , Leicester, UK
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Abstract
'Integrated care' is pitched as the solution to current health system challenges. In the literature, what integrated care actually involves is complex and contested. Multi-disciplinary team case management is frequently the primary focus of integrated care when implemented internationally. We examine the practical application of integrated care in the NHS in England to exemplify the prevalence of the case management focus. We look at the evidence for effectiveness of multi-disciplinary team case management, for the focus on high-risk groups and for integrated care more generally. We suggest realistic expectations of what integration of care alone can achieve and additional research questions.
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Affiliation(s)
- Jonathan Stokes
- Research Associate, NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Kath Checkland
- Professor, Centre for Primary Care, NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, UK
| | - Søren Rud Kristensen
- Research Fellow, Manchester Centre for Health Economics, University of Manchester, UK
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Bayliss EA, Powers JD, Ellis JL, Barrow JC, Strobel M, Beck A. Applying Sequential Analytic Methods to Self-Reported Information to Anticipate Care Needs. EGEMS 2016; 4:1258. [PMID: 27563684 PMCID: PMC4975568 DOI: 10.13063/2327-9214.1258] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Purpose: Identifying care needs for newly enrolled or newly insured individuals is important under the Affordable Care Act. Systematically collected patient-reported information can potentially identify subgroups with specific care needs prior to service use. Methods: We conducted a retrospective cohort investigation of 6,047 individuals who completed a 10-question needs assessment upon initial enrollment in Kaiser Permanente Colorado (KPCO), a not-for-profit integrated delivery system, through the Colorado State Individual Exchange. We used responses from the Brief Health Questionnaire (BHQ), to develop a predictive model for cost for receiving care in the top 25 percent, then applied cluster analytic techniques to identify different high-cost subpopulations. Per-member, per-month cost was measured from 6 to 12 months following BHQ response. Results: BHQ responses significantly predictive of high-cost care included self-reported health status, functional limitations, medication use, presence of 0–4 chronic conditions, self-reported emergency department (ED) use during the prior year, and lack of prior insurance. Age, gender, and deductible-based insurance product were also predictive. The largest possible range of predicted probabilities of being in the top 25 percent of cost was 3.5 percent to 96.4 percent. Within the top cost quartile, examples of potentially actionable clusters of patients included those with high morbidity, prior utilization, depression risk and financial constraints; those with high morbidity, previously uninsured individuals with few financial constraints; and relatively healthy, previously insured individuals with medication needs. Conclusions: Applying sequential predictive modeling and cluster analytic techniques to patient-reported information can identify subgroups of individuals within heterogeneous populations who may benefit from specific interventions to optimize initial care delivery.
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Affiliation(s)
- Elizabeth A Bayliss
- Kaiser Permanente Colorado Institute for Health Research; Department of Family Medicine, University of Colorado School of Medicine
| | - J David Powers
- Kaiser Permanente Colorado Institute for Health Research
| | | | | | - MaryJo Strobel
- Kaiser Permanente Colorado, Department of Complete Health Solutions
| | - Arne Beck
- Kaiser Permanente Colorado Institute for Health Research
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Carey IM, Hosking FJ, Harris T, DeWilde S, Beighton C, Shah SM, Cook DG. Do health checks for adults with intellectual disability reduce emergency hospital admissions? Evaluation of a natural experiment. J Epidemiol Community Health 2016; 71:52-58. [PMID: 27312249 PMCID: PMC5256310 DOI: 10.1136/jech-2016-207557] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/20/2016] [Accepted: 05/25/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Annual health checks for adults with intellectual disability (ID) have been incentivised by National Health Service (NHS) England since 2009, but it is unclear what impact they have had on important health outcomes such as emergency hospitalisation. METHODS An evaluation of a 'natural experiment', incorporating practice and individual-level designs, to assess the effectiveness of health checks for adults with ID in reducing emergency hospital admissions using a large English primary care database. For practices, changes in admission rates for adults with ID between 2009-2010 and 2011-2012 were compared in 126 fully participating versus 68 non-participating practices. For individuals, changes in admission rates before and after the first health check for 7487 adults with ID were compared with 46 408 age-sex-practice matched controls. Incident rate ratios (IRRs) comparing changes in admission rates are presented for: all emergency, preventable emergency (for ambulatory care sensitive conditions (ACSCs)) and elective emergency. RESULTS Practices with high health check participation showed no change in emergency admission rate among patients with ID over time compared with non-participating practices (IRR=0.97, 95% CI 0.78 to 1.19), but emergency admissions for ACSCs did fall (IRR=0.74, 0.58 to 0.95). Among individuals with ID, health checks had no effect on overall emergency admissions compared with controls (IRR=0.96, 0.87 to 1.07), although there was a relative reduction in emergency admissions for ACSCs (IRR=0.82, 0.69 to 0.99). Elective admissions showed no change with health checks in either analysis. CONCLUSIONS Annual health checks in primary care for adults with ID did not alter overall emergency admissions, but they appeared influential in reducing preventable emergency admissions.
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Affiliation(s)
- Iain M Carey
- Population Health Research Institute, St George's University of London, London, UK
| | - Fay J Hosking
- Population Health Research Institute, St George's University of London, London, UK
| | - Tess Harris
- Population Health Research Institute, St George's University of London, London, UK
| | - Stephen DeWilde
- Population Health Research Institute, St George's University of London, London, UK
| | - Carole Beighton
- Population Health Research Institute, St George's University of London, London, UK
| | - Sunil M Shah
- Population Health Research Institute, St George's University of London, London, UK
| | - Derek G Cook
- Population Health Research Institute, St George's University of London, London, UK
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