Quality and Outcomes Framework: what have we learnt?

Opting out of the Quality and Outcomes Framework (QOF) and impact on practices' performance

Background

Financial incentives are being increasingly adopted to help improve standards of care within general practice. However their effects on care quality are unclear. This study aimed to evaluate the impact of practices opting out of the Quality and Outcomes Framework (QOF), a financial incentive scheme in UK general practice.

Study design

A retrospective before and after study of all practices in Tower Hamlets, east London.

Methods

Practices were given an option by local commissioners of opting out of QOF without a financial penalty and instead opting for a locally designed financial incentive scheme that promoted more holistic care. We compared those practices which opted out of QOF to those which continued. We used national, publicly available QOF achievement data from 2016/17 and 2017/18. We undertook a sub-analysis of 16 QOF indicators to better understand the impact of the intervention.

Results

Of the 36 practices in Tower Hamlets, 7 decided to continue with QOF and 29 opted out. The intervention resulted in a small but statistically significant reduction in the total QOF achievement scores of practices which opted out of QOF. The sub-analysis of 16 QOF indicators showed statistically significant reductions in most of achievement scores net of exceptions for the practices that opted out. The differences in performance between the two cohorts of practices became smaller when exceptions were included.

Conclusions

The removal of QOF financial incentives can result in a reduction in achievement of QOF-related indicators but the size of the effect seems to depend on the QOF exception rates. An alternative incentive scheme that promotes a more holistic approach to care seems to be welcomed by general practices.

Primary healthcare professionals' approach to clinical coding: a qualitative interview study in Wales

BACKGROUND

Clinical coding allows for structured and standardised recording of patients' electronic healthcare records. How clinical and non-clinical staff in general practice approach clinical coding is poorly understood.

AIM

To explore primary care staff's experiences and views on clinical coding.

DESIGN AND SETTING

Qualitative, semi-structured interview study among primary care staff across Wales.

METHOD

All general practices within Wales were invited to participate via NHS health boards. Semi-structured questions guided interviews, conducted between February 2023 and June 2023. Audio-recorded data were transcribed and analysed using reflexive thematic analysis.

RESULTS

A total of 19 participants were interviewed and six themes were identified: coding challenges, motivation to code, making coding easier, daily task of coding, what and when to code, and coding through COVID.

CONCLUSION

This study demonstrates the complexity of clinical coding in primary care. Clinical and non-clinical staff spoke of systems that lacked intuitiveness, and the challenges of multimorbidity and time pressures when coding in clinical situations. These challenges are likely to be exacerbated in socioeconomically deprived areas, leading to underreporting of disease in these areas. Challenges of clinical coding may lead to implications for data quality, particularly the validity of research findings generated from studies reliant on clinical coding from primary care. There are also consequences for patient care. Participants cared about coding quality and wanted a better way of using coding. There is a need to explore technological and non-technological solutions, such as artificial intelligence, training, and education to unburden people using clinical coding in primary care.

Beyond empathy training for practitioners: Cultivating empathic healthcare systems and leadership

Empathic care benefits patients and practitioners, and empathy training for practitioners can enhance empathy. However, practitioners do not operate in a vacuum. For empathy to thrive, healthcare consultations must be situated in a nurturing milieu, guided by empathic, compassionate leaders. Empathy will be suppressed, or even reversed if practitioners are burned out and working in an unpleasant, under-resourced environment with increasingly poorly served and dissatisfied patients. Efforts to enhance empathy must therefore go beyond training practitioners to address system-level factors that foster empathy. These include patient education, cultivating empathic leadership, customer service training for reception staff, valuing cleaning and all ancillary staff, creating healing spaces, and using appropriate, efficiency saving technology to reduce the administrative burden on healthcare practitioners. We divide these elements into environmental factors, organisational factors, job factors, and individual characteristics.

Relationships between the Structural Characteristics of General Medical Practices and the Socioeconomic Status of Patients with Diabetes-Related Performance Indicators in Primary Care

The implementation of monitoring for general medical practice (GMP) can contribute to improving the quality of diabetes mellitus (DM) care. Our study aimed to describe the associations of DM care performance indicators with the structural characteristics of GMPs and the socioeconomic status (SES) of patients. Using data from 2018 covering the whole country, GMP-specific indicators standardized by patient age, sex, and eligibility for exemption certificates were computed for adults. Linear regression models were applied to evaluate the relationships between GMP-specific parameters (list size, residence type, geographical location, general practitioner (GP) vacancy and their age) and patient SES (education, employment, proportion of Roma adults, housing density) and DM care indicators. Patients received 58.64% of the required medical interventions. A lower level of education (hemoglobin A1c test: β = -0.108; ophthalmic examination: β = -0.100; serum creatinine test: β = -0.103; and serum lipid status test: β = -0.108) and large GMP size (hemoglobin A1c test: β = -0.068; ophthalmological examination β = -0.031; serum creatinine measurement β = -0.053; influenza immunization β = -0.040; and serum lipid status test β = -0.068) were associated with poor indicators. A GP age older than 65 years was associated with lower indicators (hemoglobin A1c test: β = -0.082; serum creatinine measurement: β = -0.086; serum lipid status test: β = -0.082; and influenza immunization: β = -0.032). Overall, the GMP-level DM care indicators were significantly influenced by GMP characteristics and patient SES. Therefore, proper diabetes care monitoring for the personal achievements of GPs should involve the application of adjusted performance indicators.

Preparing for and Not Waiting for Surgery

Cancer surgery is an essential treatment strategy but can disrupt patients' physical and psychological health. With worldwide demand for surgery expected to increase, this review aims to raise awareness of this global public health concern, present a stepwise framework for preoperative risk evaluation, and propose the adoption of personalised prehabilitation to mitigate risk. Perioperative medicine is a growing speciality that aims to improve clinical outcome by preparing patients for the stress associated with surgery. Preparation should begin at contemplation of surgery, with universal screening for established risk factors, physical fitness, nutritional status, psychological health, and, where applicable, frailty and cognitive function. Patients at risk should undergo a formal assessment with a qualified healthcare professional which informs meaningful shared decision-making discussion and personalised prehabilitation prescription incorporating, where indicated, exercise, nutrition, psychological support, 'surgery schools', and referral to existing local services. The foundational principles of prehabilitation can be adapted to local context, culture, and population. Clinical services should be co-designed with all stakeholders, including patient representatives, and require careful mapping of patient pathways and use of multi-disciplinary professional input. Future research should optimise prehabilitation interventions, adopting standardised outcome measures and robust health economic evaluation.

Recent trends in asthma diagnosis, preschool wheeze diagnosis and asthma exacerbations in English children and adolescents: a SABINA Jr study

BACKGROUND

Asthma-related burden remains poorly characterised in children in the UK. We quantified recent trends in asthma prevalence and burden in a UK population-based cohort (1‒17-year-olds).

METHODS

The Clinical Practice Research Datalink Aurum database (2008‒2018) was used to assess annual asthma incidence and prevalence in 1‒17-year-olds and preschool wheeze in 1‒5-year-olds, stratified by sex and age. During the same period, annual asthma exacerbation rates were assessed in those with either a diagnosis of preschool wheeze or asthma.

RESULTS

Annual asthma incidence rates decreased by 51% from 1403.4 (95% CI 1383.7 to 1423.2) in 2008 to 688.0 (95% CI 676.3 to 699.9) per 105 person-years (PYs) in 2018, with the most pronounced decrease observed in 1‒5-year olds (decreasing by 65%, from 2556.9 (95% CI 2509.8 to 2604.7) to 892.3 (95% CI 866.9 to 918.3) per 105 PYs). The corresponding decreases for the 6‒11- and 12‒17-year-olds were 36% (1139.9 (95% CI 1110.6 to 1169.7) to 739.9 (95% CI 720.5 to 759.8)) and 20% (572.3 (95% CI 550.4 to 594.9) to 459.5 (95% CI 442.9 to 476.4)) per 105 PYs, respectively. The incidence of preschool wheeze decreased over time and was slightly more pronounced in the 1‒3 year-olds than in the 4-year-olds. Prevalence of asthma and preschool wheeze also decreased over time, from 18.0% overall in 2008 to 10.2% in 2018 for asthma. Exacerbation rates increased over time from 1.33 (95% CI 1.31 to 1.35) per 10 PYs in 2008 to 1.81 (95% CI 1.78 to 1.83) per 10 PYs in 2018.

CONCLUSION

Paediatric asthma incidence decreased in the UK since 2008, particularly in 1-5-year-olds; this was accompanied by a decline in asthma prevalence. Preschool wheeze incidence also decreased in this age group. However, exacerbation rates have been increasing.

Identifying potential biases in code sequences in primary care electronic healthcare records: a retrospective cohort study of the determinants of code frequency

OBJECTIVES

To determine whether the frequency of diagnostic codes for long-term conditions (LTCs) in primary care electronic healthcare records (EHRs) is associated with (1) disease coding incentives, (2) General Practice (GP), (3) patient sociodemographic characteristics and (4) calendar year of diagnosis.

DESIGN

Retrospective cohort study.

SETTING

GPs in England from 2015 to 2022 contributing to the Clinical Practice Research Datalink Aurum dataset.

PARTICIPANTS

All patients registered to a GP with at least one incident LTC diagnosed between 1 January 2015 and 31 December 2019.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number of diagnostic codes for an LTC in (1) the first and (2) the second year following diagnosis, stratified by inclusion in the Quality and Outcomes Framework (QOF) financial incentive programme.

RESULTS

3 113 724 patients were included, with 7 723 365 incident LTCs. Conditions included in QOF had higher rates of annual coding than conditions not included in QOF (1.03 vs 0.32 per year, p<0.0001). There was significant variation in code frequency by GP which was not explained by patient sociodemographics. We found significant associations with patient sociodemographics, with a trend towards higher coding rates in people living in areas of higher deprivation for both QOF and non-QOF conditions. Code frequency was lower for conditions with follow-up time in 2020, associated with the onset of the COVID-19 pandemic.

CONCLUSIONS

The frequency of diagnostic codes for newly diagnosed LTCs is influenced by factors including patient sociodemographics, disease inclusion in QOF, GP practice and the impact of the COVID-19 pandemic. Natural language processing or other methods using temporally ordered code sequences should account for these factors to minimise potential bias.

The quality of prison primary care: cross-sectional cluster-level analyses of prison healthcare data in the North of England

Background

Prisoners have significant health needs, are relatively high users of healthcare, and often die prematurely. Strong primary care systems are associated with better population health outcomes. We investigated the quality of primary care delivered to prisoners.

Methods

We assessed achievement against 30 quality indicators spanning different domains of care in 13 prisons in the North of England. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records over 2017-20. Multi-level mixed effects logistic regression models explored associations between indicator achievement and prison and prisoner characteristics.

Findings

Achievement varied markedly between indicators, prisons and over time. Achieved processes of care ranged from 1% for annual epilepsy reviews to 94% for blood pressure checks in diabetes. Intermediate outcomes of care ranged from only 0.2% of people with epilepsy being seizure-free in the preceding year to 34% with diabetes having sufficient blood pressure control. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, e.g., 1.93-fold for gabapentinoid prescribing without coded neuropathic pain (odds ratio [OR] range 0.67-1.29) and 169-fold for dried blood spot testing (OR range 0.05-8.45). Shorter lengths of stay were frequently associated with lower achievement. Ethnicity was associated with some indicators achievement, although the associations differed (both positive and negative) with indicators.

Interpretation

We found substantial scope for improvement and marked variations in quality, which were largely unaltered after adjustment for prison and prisoner characteristics.

Funding

National Institute for Health and Care Research Health and Social Care and Delivery Research Programme: 17/05/26.

What is the role of randomised trials in implementation science?

BACKGROUND

There is a consistent demand for implementation science to inform global efforts to close the gap between evidence and practice. Key evaluation questions for any given implementation strategy concern the assessment and understanding of effects. Randomised trials are generally accepted as offering the most trustworthy design for establishing effectiveness but may be underused in implementation science.

MAIN BODY

There is a continuing debate about the primacy of the place of randomised trials in evaluating implementation strategies, especially given the evolution of more rigorous quasi-experimental designs. Further critiques of trials for implementation science highlight that they cannot provide 'real world' evidence, address urgent and important questions, explain complex interventions nor understand contextual influences. We respond to these critiques of trials and highlight opportunities to enhance their timeliness and relevance through innovative designs, embedding within large-scale improvement programmes and harnessing routine data. Our suggestions for optimising the conditions for randomised trials of implementation strategies include strengthening partnerships with policy-makers and clinical leaders to realise the long-term value of rigorous evaluation and accelerating ethical approvals and decluttering governance procedures for lower risk studies.

CONCLUSION

Policy-makers and researchers should avoid prematurely discarding trial designs when evaluating implementation strategies and work to enhance the conditions for their conduct.

Persistent high prevalence of modifiable cardiovascular risk factors among patients with osteoarthritis in the UK in 1992-2017

OBJECTIVES

To compare the annual and period prevalence of modifiable cardiovascular risk factors (MCVRFs) between populations with and without osteoarthritis (OA) in the UK over 25 years.

METHODS

215 190 patients aged 35 years and over from the UK Clinical Practice Research Datalink GOLD database who were newly diagnosed OA between 1992 and 2017, as well as 1:1 age-matched, sex-matched, practice-matched and index year-matched non-OA individuals, were incorporated. MCVRFs including smoking, hypertension, type 2 diabetes, obesity and dyslipidaemia were defined by Read codes and clinical measurements. The annual and period prevalence and prevalence rate ratios (PRRs) of individual and clustering (≥1, ≥2 and ≥3) MCVRFs were estimated by Poisson regression with multiple imputations for missing values.

RESULTS

The annual prevalence of MCVRFs increased in the population with OA between 1992 and 2017 and was consistently higher in the population with OA compared with the population without OA between 2004 and 2017. Trends towards increased or stable annual PRRs for individuals and clustering of MCVRFs were observed. A 26-year period prevalence of single and clustering MCVRFs was significantly higher in individuals with OA compared with non-OA individuals. Period PRRs were higher in Southern England, women and increased with age for most MCVRFs except for obesity, which has the higher PRR in the youngest age group.

CONCLUSIONS

A consistently higher long-term prevalence of MCVRFs was observed in individuals with OA compared to those without OA. The higher prevalence of obesity in the youngest age group with OA highlights the need for public health strategies. Further research to understand MCVRF management in OA populations is necessary.

Validation of patient- and GP-reported core sets of quality indicators for older adults with multimorbidity in primary care: results of the cross-sectional observational MULTIqual validation study

BACKGROUND

Older adults with multimorbidity represent a growing segment of the population. Metrics to assess quality, safety and effectiveness of care can support policy makers and healthcare providers in addressing patient needs. However, there is a lack of valid measures of quality of care for this population. In the MULTIqual project, 24 general practitioner (GP)-reported and 14 patient-reported quality indicators for the healthcare of older adults with multimorbidity were developed in Germany in a systematic approach. This study aimed to select, validate and pilot core sets of these indicators.

METHODS

In a cross-sectional observational study, we collected data in general practices (n = 35) and patients aged 65 years and older with three or more chronic conditions (n = 346). One-dimensional core sets for both perspectives were selected by stepwise backward selection based on corrected item-total correlations. We established structural validity, discriminative capacity, feasibility and patient-professional agreement for the selected indicators. Multilevel multivariable linear regression models adjusted for random effects at practice level were calculated to examine construct validity.

RESULTS

Twelve GP-reported and seven patient-reported indicators were selected, with item-total correlations ranging from 0.332 to 0.576. Fulfilment rates ranged from 24.6 to 89.0%. Between 0 and 12.7% of the values were missing. Seventeen indicators had agreement rates between patients and professionals of 24.1% to 75.9% and one had 90.7% positive and 5.1% negative agreement. Patients who were born abroad (- 1.04, 95% CI =  - 2.00/ - 0.08, p = 0.033) and had higher health-related quality of life (- 1.37, 95% CI =  - 2.39/ - 0.36, p = 0.008), fewer contacts with their GP (0.14, 95% CI = 0.04/0.23, p = 0.007) and lower willingness to use their GPs as coordinators of their care (0.13, 95% CI = 0.06/0.20, p < 0.001) were more likely to have lower GP-reported healthcare quality scores. Patients who had fewer GP contacts (0.12, 95% CI = 0.04/0.20, p = 0.002) and were less willing to use their GP to coordinate their care (0.16, 95% CI = 0.10/0.21, p < 0.001) were more likely to have lower patient-reported healthcare quality scores.

CONCLUSIONS

The quality indicator core sets are the first brief measurement tools specifically designed to assess quality of care for patients with multimorbidity. The indicators can facilitate implementation of treatment standards and offer viable alternatives to the current practice of combining disease-related metrics with poor applicability to patients with multimorbidity.

Time to focus on chronic liver diseases in the community: A review of primary care hepatology tools, pathways of care and reimbursement mechanisms

Addressing primary care's low confidence in detecting and managing chronic liver disease is becoming increasingly important owing to the escalating prevalence of its common lifestyle-related metabolic risk factors - obesity, physical inactivity, smoking and alcohol consumption. Whilst liver blood testing is frequently carried out in the management of long-term conditions, its interpretation is not typically focused on specific liver disease risk. Educational steps for primary care should outline how liver fibrosis is the flag of pathological concern, encourage use of pragmatic algorithms such as fibrosis-4 index to differentiate between those requiring referral for further fibrosis risk assessment and those who can be managed in the community, and emphasise that isolated minor liver function test abnormalities are unreliable for estimating the risk of fibrosis progression. Measures to increase primary care's interest and engagement should make use of existing frameworks for the management of long-term conditions, so that liver disease is considered alongside other metabolic disorders, including type 2 diabetes, cardiovascular disease, chronic kidney disease etc. Selling points when considering the required investment in developing local fibrosis assessment pathways include reduced repeat testing of minor abnormalities and improved secondary care referrals, plus improvements in the patient's journey through long-term multimorbidity care. A focus on improving chronic liver disease is likely to have wide-ranging benefits across co-existing metabolic disorders, particularly when pathways are aligned with community lifestyle support services. The important message for primary care is to increase the value of existing monitoring rather than to generate more work.

Variation in the reference range limits of thyroid function tests and association with the prevalence of levothyroxine treatment

Many individuals with marginally abnormal thyroid function test (TFT) results may be treated and it is unknown if the limits of the thyrotropin (TSH) and free thyroxine (FT4) reference intervals reported alongside the laboratory results are associated with the prevalence of levothyroxine treatment. We obtained information regarding reported TFT reference intervals from UK National Health Service (NHS) laboratories and evaluated its relationship with the prevalence of levothyroxine treatment for corresponding health areas for 2014. The upper limit of serum TSH was significantly, linearly, independently, and negatively associated with prevalent levothyroxine treatment: -0.54% (95% CI, -0.68% to -0.40%). The lower limit of serum FT4 was significantly and independently associated with the prevalence of levothyroxine treatment in a non-linear (J-shaped) manner with an increase being noted from a FT4 level of ≈9.5 pmol/L onwards. We conclude that minor changes in the reference range limits for serum TSH and FT4 are associated with levothyroxine treatment.

Changes in public satisfaction with GP services in Britain between 1998 and 2019: a repeated cross-sectional analysis of attitudinal data

Background

Between 1998 and 2019, the structure and process of general practitioner services in Britain underwent a series of reforms and experienced distinct funding environments. This paper examines changes in satisfaction with GP services over time against this backdrop.

Methods

Data were extracted from the British Social Attitudes Survey for the period 1998–2019. Logistic regression analyses investigated changes in overall satisfaction and among specific population sub-groups differentiated by socio-demographic characteristics whilst taking account of time trend and interaction effects between sub-group membership and time trend.

Results

Sustained and significant changes in satisfaction coincided closely with changes to the funding environment. Distinct patterns were evident among sub-groups. Satisfaction appeared to fall more sharply during austerity for low income groups, older people and people who had fewer formal qualifications/years in education.

Conclusion

While a series of policy initiatives were adopted over the period examined, public satisfaction seemed to move in a manner consistent with levels of government expenditure rather than exhibiting distinct breaks that coincided with policy initiatives. As services recover from the pandemic it will be necessary to invest in a significant and sustained way to rebuild public satisfaction.

Understanding multimorbidity trajectories in Scotland using sequence analysis

Understanding how multiple conditions develop over time is of growing interest, but there is currently limited methodological development on the topic, especially in understanding how multimorbidity (the co-existence of at least two chronic conditions) develops longitudinally and in which order diseases occur. We aim to describe how a longitudinal method, sequence analysis, can be used to understand the sequencing of common chronic diseases that lead to multimorbidity and the socio-demographic factors and health outcomes associated with typical disease trajectories. We use the Scottish Longitudinal Study (SLS) linking the Scottish census 2001 to disease registries, hospitalisation and mortality records. SLS participants aged 40–74 years at baseline were followed over a 10-year period (2001–2011) for the onset of three commonly occurring diseases: diabetes, cardiovascular disease (CVD), and cancer. We focused on participants who transitioned to at least two of these conditions over the follow-up period (N = 6300). We use sequence analysis with optimal matching and hierarchical cluster analysis to understand the process of disease sequencing and to distinguish typical multimorbidity trajectories. Socio-demographic differences between specific disease trajectories were evaluated using multinomial logistic regression. Poisson and Cox regressions were used to assess differences in hospitalisation and mortality outcomes between typical trajectories. Individuals who transitioned to multimorbidity over 10 years were more likely to be older and living in more deprived areas than the rest of the population. We found seven typical trajectories: later fast transition to multimorbidity, CVD start with slow transition to multimorbidity, cancer start with slow transition to multimorbidity, diabetes start with slow transition to multimorbidity, fast transition to both diabetes and CVD, fast transition to multimorbidity and death, fast transition to both cancer and CVD. Those who quickly transitioned to multimorbidity and death were the most vulnerable, typically older, less educated, and more likely to live in more deprived areas. They also experienced higher number of hospitalisations and overnight stays while still alive. Sequence analysis can strengthen our understanding of typical disease trajectories when considering a few key diseases. This may have implications for more active clinical review of patients beginning quick transition trajectories.

Australian general practitioner perceptions to sharing clinical data for secondary use: a mixed method approach

OBJECTIVE

The potential for data collected in general practice to be linked and used to address health system challenges of maintaining quality care, accessibility and safety, including pandemic support, has led to an increased interest in public acceptability of data sharing, however practitioners have rarely been asked to share their opinions on the topic. This paper attempts to gain an understanding of general practitioner's perceptions on sharing routinely collected data for the purposes of healthcare planning and research. It also compares findings with data sharing perceptions in an international context.  MATERIALS AND METHODS: A mixed methods approach combining an initial online survey followed by face-to-face interviews (before and during COVID-19), designed to identify the barriers and facilitators to sharing data, were conducted on a cross sectional convenience sample of general practitioners across Western Australia (WA).

RESULTS

Eighty online surveys and ten face-to-face interviews with general practitioners were conducted from November 2020 - May 2021. Although respondents overwhelmingly identified the importance of population health research, their willingness to participate in data sharing programs was determined by a perception of trust associated with the organisation collecting and analysing shared data; a clearly defined purpose and process of collected data; including a governance structure providing confidence in the data sharing initiative simultaneously enabling a process of data sovereignty and autonomy.

DISCUSSION

Results indicate strong agreement around the importance of sharing patient's medical data for population and health research and planning. Concerns pertaining to lack of trust, governance and secondary use of data continue to be a setback to data sharing with implications for primary care business models being raised.

CONCLUSION

To further increase general practitioner's confidence in sharing their clinical data, efforts should be directed towards implementing a robust data governance structure with an emphasis on transparency and representative stakeholder inclusion as well as identifying the role of government and government funded organisations, as well as building trust with the entities collecting and analysing the data.

Immortal time bias for life-long conditions in retrospective observational studies using electronic health records

Background

Immortal time bias is common in observational studies but is typically described for pharmacoepidemiology studies where there is a delay between cohort entry and treatment initiation.

Methods

This study used the Clinical Practice Research Datalink (CPRD) and linked national mortality data in England from 2000 to 2019 to investigate immortal time bias for a specific life-long condition, intellectual disability. Life expectancy (Chiang’s abridged life table approach) was compared for 33,867 exposed and 980,586 unexposed individuals aged 10+ years using five methods: (1) treating immortal time as observation time; (2) excluding time before date of first exposure diagnosis; (3) matching cohort entry to first exposure diagnosis; (4) excluding time before proxy date of inputting first exposure diagnosis (by the physician); and (5) treating exposure as a time-dependent measure.

Results

When not considered in the design or analysis (Method 1), immortal time bias led to disproportionately high life expectancy for the exposed population during the first calendar period (additional years expected to live: 2000–2004: 65.6 [95% CI: 63.6,67.6]) compared to the later calendar periods (2005–2009: 59.9 [58.8,60.9]; 2010–2014: 58.0 [57.1,58.9]; 2015–2019: 58.2 [56.8,59.7]). Date of entry of diagnosis (Method 4) was unreliable in this CPRD cohort. The final methods (Method 2, 3 and 5) appeared to solve the main theoretical problem but residual bias may have remained.

Conclusions

We conclude that immortal time bias is a significant issue for studies of life-long conditions that use electronic health record data and requires careful consideration of how clinical diagnoses are entered onto electronic health record systems.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01581-1.

Framework for identification and measurement of spillover effects in policy implementation: intended non-intended targeted non-targeted spillovers (INTENTS)

BACKGROUND

There is increasing awareness among researchers and policymakers of the potential for healthcare interventions to have consequences beyond those initially intended. These unintended consequences or "spillover effects" result from the complex features of healthcare organisation and delivery and can either increase or decrease overall effectiveness. Their potential influence has important consequences for the design and evaluation of implementation strategies and for decision-making. However, consideration of spillovers remains partial and unsystematic. We develop a comprehensive framework for the identification and measurement of spillover effects resulting from changes to the way in which healthcare services are organised and delivered.

METHODS

We conducted a scoping review to map the existing literature on spillover effects in health and healthcare interventions and used the findings of this review to develop a comprehensive framework to identify and measure spillover effects.

RESULTS

The scoping review identified a wide range of different spillover effects, either experienced by agents not intentionally targeted by an intervention or representing unintended effects for targeted agents. Our scoping review revealed that spillover effects tend to be discussed in papers only when they are found to be statistically significant or might account for unexpected findings, rather than as a pre-specified feature of evaluation studies. This hinders the ability to assess all potential implications of a given policy or intervention. We propose a taxonomy of spillover effects, classified based on the outcome and the unit experiencing the effect: within-unit, between-unit, and diagonal spillover effects. We then present the INTENTS framework: Intended Non-intended TargEted Non-Targeted Spillovers. The INTENTS framework considers the units and outcomes which may be affected by an intervention and the mechanisms by which spillover effects are generated.

CONCLUSIONS

The INTENTS framework provides a structured guide for researchers and policymakers when considering the potential effects that implementation strategies may generate, and the steps to take when designing and evaluating such interventions. Application of the INTENTS framework will enable spillover effects to be addressed appropriately in future evaluations and decision-making, ensuring that the full range of costs and benefits of interventions are correctly identified.

Primary care for people with severe mental illness and comorbid obstructive airways disease: a qualitative study of patient perspectives with integrated stakeholder feedback

OBJECTIVES

To explore patient and stakeholder perspectives on primary respiratory care for people with severe mental illness (SMI) and comorbid obstructive airways disease (OAD).

DESIGN

Qualitative, semistructured qualitative interviews were undertaken with a purposive sample of people with a diagnosis of SMI (bipolar illness, schizophrenia, affective disorder with psychosis) and comorbid asthma or chronic obstructive pulmonary disease. Transcribed data were analysed using an interpretive phenomenological approach. Study results were discussed with stakeholders.

SETTING

Eight UK general practices.

PARTICIPANTS

16 people aged 45-75 years, with SMI and comorbid asthma or chronic obstructive pulmonary disease, were interviewed. Twenty-one people, four with lived experience of SMI and seventeen health/social care/third sector practitioners, participated in discussion groups at a stakeholder event.

RESULTS

Participants described disability and isolation arising from the interplay of SMI and OAD symptoms. Social support determined ease of access to primary care. Self-management of respiratory health was not person-centred as practitioners failed to consider individual needs and health literacy. Participants perceived smoking cessation impossible without tailored support. Less than half of the practices facilitated personalised access to timely primary care and continuity. Overall, there was a reliance on urgent care if service adaptations and social support were lacking. The stakeholder group expressed concern about gaps in care, the short-term funding of community organisations and fear of loss of benefits. Potential solutions focused on supported navigation of care pathways, relational continuity, individual and community asset building and the evolving social prescriber role.

CONCLUSION

This study suggests that despite UK guidelines and incentives to optimise physical healthcare, primary care fails to consistently deliver integrated biopsychosocial care for patients with SMI and OAD. Collaborative, personalised care that builds social capital and tailors support for self-management is needed, alongside service-level interventions to enhance access to healthcare for patients with comorbid SMI and OAD.

The Effect of Financial Incentives on Quality Measures in the Treatment of Diabetes Mellitus: a Randomized Controlled Trial

BACKGROUND

Financial incentives are often used to improve quality of care in chronic care patients. However, the evidence concerning the effect of financial incentives is still inconclusive.

OBJECTIVE

To test the effect of financial incentives on quality measures (QMs) in the treatment of patients with diabetes mellitus in primary care. We incentivized a clinical QM and a process QM to test the effect of financial incentives on different types of QMs and to investigate the spill-over effect on non-incentivized QMs.

DESIGN/PARTICIPANTS

Parallel cluster randomized controlled trial based on electronic medical records database involving Swiss general practitioners (GPs). Practices were randomly allocated.

INTERVENTION

All participants received a bimonthly feedback report. The intervention group additionally received potential financial incentives on GP level depending on their performance.

MAIN MEASURES

Between-group differences in proportions of patients fulfilling incentivized QM (process QM of annual HbA1c measurement and clinical QM of blood pressure level below 140/95 mmHg) after 12 months.

KEY RESULTS

Seventy-one GPs (median age 52 years, 72% male) from 43 different practices and subsequently 3838 patients with diabetes mellitus (median age 70 years, 57% male) were included. Proportions of patients with annual HbA1c measurements remained unchanged (intervention group decreased from 79.0 to 78.3%, control group from 81.5 to 81.0%, OR 1.09, 95% CI 0.90-1.32, p = 0.39). Proportions of patients with blood pressure below 140/95 improved from 49.9 to 52.5% in the intervention group and decreased from 51.2 to 49.0% in the control group (OR 1.16, 95% CI 0.99-1.36, p = 0.06). Proportions of non-incentivized process QMs increased significantly in the intervention group.

CONCLUSION

GP level financial incentives did not result in more frequent HbA1c measurements or in improved blood pressure control. Interestingly, we could confirm a spill-over effect on non-incentivized process QMs. Yet, the mechanism of spill-over effects of financial incentives is largely unclear.

TRIAL REGISTRATION

ISRCTN13305645.

Factors associated with variation in emergency diagnoses of cancer at general practice level in England

BACKGROUND

Cancer patients diagnosed following an emergency presentation have poorer outcomes. We explore whether practice characteristics are associated with differences in the proportion of emergency presentations.

METHODS

Univariable and multivariable logistic regression models were fitted to investigate the relationships between 2017-18 emergency cancer presentations at practice level in England and access and continuity in primary care, trust in healthcare professionals, 2-week-wait (2WW) referrals, quality and outcomes framework (QOF) achievements and socio-demographic factors (age, gender and deprivation).

RESULTS

Our analysis using comprehensive nationwide data found that the following practice level factors have significant associations with a lower proportion of emergency diagnosis of cancer: increased trust and confidence in the practice healthcare professionals; higher 2WW referral and conversion rate; higher total practice QOF score and higher satisfaction with appointment times or higher proportion able to see preferred GP. Our results also show that practices in more deprived areas are significantly associated with a higher proportion of emergency diagnoses of cancer.

CONCLUSIONS

Regional cancer networks should focus their efforts in increasing both the quantity and appropriateness of 2WW referrals from primary care. In addition, primary care clinicians should be supported to undertake high quality consultations, thus building trust with patients and ensuring continuity of care.

Clinical usefulness of brief screening tool for activating weight management discussions in primary cARE (AWARE): A nationwide mixed methods pilot study

Objective

The Edmonton Obesity Staging System (EOSS) is based on weight related health complications among individuals with overweight and obesity requiring clinical intervention. We aimed to assess the clinical usefulness of a new screening tool based on the EOSS for activating weight management discussions in general practice.

Methods

We enrolled five General Practitioners (GPs) and 25 of their patients located nationwide in metropolitan areas of Australia to test the feasibility, acceptability, and accuracy of the new ‘EOSS-2 Risk Tool’, using cross-sectional and qualitative study designs. Diagnostic accuracy of the tool for the presence of EOSS ≥2 criteria was based on clinical information collected prospectively. To assess feasibility and applicability, we explored the views of GP and patient participants by thematic analysis of transcribed verbatim and de-identified data collected by semi-structured telephone interviews.

Results

Nineteen (76%) patients were aged ≥45 years, five (20%) were male, and 20 (80%) were classified with obesity. All 25 patients screened positive for EOSS ≥2 criteria by the tool. Interviews with patients continued until data saturation was reached resulting in a total of 23 interviews. Our thematic analysis revealed five themes: GP recognition of obesity as a health priority (GPs expressed strong interest in and understanding of its importance as a health priority); obesity stigma (GPs reported the tool helped them initiate health based and non-judgmental conversations with their patients); patient health literacy (GPs and patients reported increased awareness and understanding of weight related health risks), patient motivation for self-management (GPs and patients reported the tool helped focus on self-management of weight related complications), and applicability and scalability (GPs stated it was easy to use, relevant to a range of their patient groups, and scalable if integrated into existing patient management systems).

Conclusion

The EOSS-2 Risk Tool is potentially clinically useful for activating weight management discussions in general practice. Further research is required to assess feasibility and applicability.

The GP-OH (General Practice - Organizational Health) Survey: Development and Validation of a Novel Instrument to Measure Organizational Health in General Practice

Primary care healthcare organizations are complex and multidimensional, and there has been much discussion about the potential dangers of focusing on outcomes as quality indicators in isolation without understanding the processes and system characteristics that drive them. Organizational health, as a concept, shifts the focus of measurement upstream and considers the elements needed for sustainable long-term success. This study has both designed and tested the first survey seeking to measure organizational health specifically within the context of primary care. A stepwise approach was taken to ensure that the validity and reliability of the survey was examined at multiple stages.Supplemental data for this article is available online at https://doi.org/10.1080/00185868.2021.1947164.

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

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

Why Is the Electronic Health Record So Challenging for Research and Clinical Care?

BACKGROUND

 The electronic health record (EHR) has become increasingly ubiquitous. At the same time, health professionals have been turning to this resource for access to data that is needed for the delivery of health care and for clinical research. There is little doubt that the EHR has made both of these functions easier than earlier days when we relied on paper-based clinical records. Coupled with modern database and data warehouse systems, high-speed networks, and the ability to share clinical data with others are large number of challenges that arguably limit the optimal use of the EHR OBJECTIVES:  Our goal was to provide an exhaustive reference for those who use the EHR in clinical and research contexts, but also for health information systems professionals as they design, implement, and maintain EHR systems.

METHODS

 This study includes a panel of 24 biomedical informatics researchers, information technology professionals, and clinicians, all of whom have extensive experience in design, implementation, and maintenance of EHR systems, or in using the EHR as clinicians or researchers. All members of the panel are affiliated with Penn Medicine at the University of Pennsylvania and have experience with a variety of different EHR platforms and systems and how they have evolved over time.

RESULTS

 Each of the authors has shared their knowledge and experience in using the EHR in a suite of 20 short essays, each representing a specific challenge and classified according to a functional hierarchy of interlocking facets such as usability and usefulness, data quality, standards, governance, data integration, clinical care, and clinical research.

CONCLUSION

 We provide here a set of perspectives on the challenges posed by the EHR to clinical and research users.

Associations between attainment of incentivised primary care indicators and emergency hospital admissions among type 2 diabetes patients: a population-based historical cohort study

OBJECTIVES

England has invested considerably in diabetes care over recent years through programmes such as the Quality and Outcomes Framework and National Diabetes Audit. However, associations between specific programme indicators and key clinical endpoints, such as emergency hospital admissions, remain unclear. We aimed to examine whether attainment of Quality and Outcomes Framework and National Diabetes Audit primary care diabetes indicators is associated with diabetes-related, cardiovascular, and all-cause emergency hospital admissions.

DESIGN

Historical cohort study.

SETTING

A total of 330 English primary care practices, 2010-2017, using UK Clinical Practice Research Datalink.

PARTICIPANTS

A total of 84,441 adults with type 2 diabetes.

MAIN OUTCOME MEASURES

The primary outcome was emergency hospital admission for any cause. Secondary outcomes were (1) diabetes-related and (2) cardiovascular-related emergency admission.

RESULTS

There were 130,709 all-cause emergency admissions, 115,425 diabetes-related admissions and 105,191 cardiovascular admissions, corresponding to unplanned admission rates of 402, 355 and 323 per 1000 patient-years, respectively. All-cause hospital admission rates were lower among those who met HbA1c and cholesterol indicators (incidence rate ratio = 0.91; 95% CI 0.89-0.92; p < 0.001 and 0.87; 95% CI 0.86-0.89; p < 0.001), respectively), with similar findings for diabetes and cardiovascular admissions. Patients who achieved the Quality and Outcomes Framework blood pressure target had lower cardiovascular admission rates (incidence rate ratio = 0.98; 95% CI 0.96-0.99; p = 0.001). Strong associations were found between completing 7-9 (vs. either 4-6 or 0-3) National Diabetes Audit processes and lower rates of all admission outcomes (p-values < 0.001), and meeting all nine National Diabetes Audit processes had significant associations with reductions in all types of emergency admissions by 22% to 26%. Meeting the HbA1c or cholesterol Quality and Outcomes Framework indicators, or completing 7-9 National Diabetes Audit processes, was also associated with longer time-to-unplanned all-cause, diabetes and cardiovascular admissions.

CONCLUSIONS

Attaining Quality and Outcomes Framework-defined diabetes intermediate outcome thresholds, and comprehensive completion of care processes, may translate into considerable reductions in emergency hospital admissions. Out-of-hospital diabetes care optimisation is needed to improve implementation of core interventions and reduce unplanned admissions.

Associations between attainment of incentivised primary care diabetes indicators and mortality in an English cohort

AIMS

To describe associations between incentivised primary care clinical and process indicators and mortality, among patients with type 2 diabetes in England.

METHODS

A historical 2010-2017 cohort (n = 84,441 adults) was derived from the UK CPRD. Exposures included English Quality and Outcomes Framework glycated haemoglobin (HbA1c; 7.5%, 59 mmol/mol), blood pressure (140/80 mmHg), and cholesterol (5 mmol/L) indicator attainment; and number of National Diabetes Audit care processes completed, in 2010-11. The primary outcome was all-cause mortality.

RESULTS

Over median 3.9 (SD 2.0) years follow-up, 10,711 deaths occurred. Adjusted hazard ratios (aHR) indicated 12% (95% CI 8-16%; p < 0.0001) and 16% (11-20%; p < 0.0001) lower mortality rates among those who attained the HbA1c and cholesterol indicators, respectively. Rates were also lower among those who completed 7-9 vs. 0-3 or 4-6 care processes (aHRs 0.76 (0.71-0.82), p < 0.0001 and 0.61 (0.53-0.71), p < 0.0001, respectively), but did not obviously vary by blood pressure indicator attainment (aHR 1.04, 1.00-1.08; p = 0.0811).

CONCLUSIONS

Cholesterol, HbA1c and comprehensive process indicator attainment, was associated with enhanced survival. Review of community-based care provision could help reduce the gap between indicator standards and current outcomes, and in turn enhance life expectancy.

Exploring frontliners' knowledge, participation and evaluation in the implementation of a pay-for-performance program (PMAQ) in primary health care in Brazil

Purpose

This paper employs implementation theory and the political literature on performance measurement to understand how frontline health workers know, participate and evaluate the Brazilian National Program for Improving Access and Quality of Primary Care (PMAQ, 2nd round).

Design/methodology/approach

This paper develops an implementation theory-driven qualitative analysis. The research is developed in the city of Goiania (Brazil): a challenging organizational context in primary care (PHC). Interviews were carried out with 25 frontliners – managers, doctors, nurses and community health workers. Data were thematically and hierarchically analysed according to theoretical concepts such as policy knowledge, policy adherence, forms of accountability, alternative logics, organizational capacity and policy feedback.

Findings

Results show the need to foster organizational capacity, knowledge, participation and policy feedback at the frontline. Successful implementation would require those adaptations to counteract policy challenges/failures or the emergence of alternative logics.

Research limitations/implications

The study was conducted in only one setting, however, our sample includes different types of professionals working in units with different levels of organization capacity, located in distinct HDs, expressing well the implementation of PMAQ/P4P. Qualitative researches need to be developed for further exploring the same/other factors.

Social implications

Findings can be used to improve discussions/planning and design of P4P programs in the city and State of Goias.

Originality/value

The majority of analysis of PMAQ are of a quantitative or results-based nature. This article focuses on politically significant and unanswered questions regarding the implementation of PMAQ.

Working lives of GPs in Scotland and England: cross-sectional analysis of national surveys

OBJECTIVES

The UK faces major problems in retaining general practitioners (GPs). Scotland introduced a new GP contract in April 2018, intended to better support GPs. This study compares the career intentions and working lives of GPs in Scotland with GPs in England, shortly after the new Scotland contract was introduced.

DESIGN AND SETTING

Comparison of cross-sectional analysis of survey responses of GPs in England and Scotland in 2017 and 2018, respectively, using linear regression to adjust the differences for gender, age, ethnicity, urbanicity and deprivation.

PARTICIPANTS

2048 GPs in Scotland and 879 GPs in England.

MAIN OUTCOME MEASURES

Four intentions to reduce work participation (5-point scales: 1='none', 5='high'): reducing working hours; leaving medical work entirely; leaving direct patient care; or continuing medical work but outside the UK. Four domains of working life: job satisfaction (7-point scale: 1='extremely dissatisfied', 7='extremely satisfied'); job stressors (5-point-scale: 1='no pressure', 5='high pressure); positive and negative job attributes (5-point scales: 1='strongly disagree', 5='strongly agree').

RESULTS

Compared with England, GPs in Scotland had lower intention to reduce work participation, including a lower likelihood of reducing work hours (2.78 vs 3.54; adjusted difference=-0.52; 95% CI -0.64 to -0.41), a lower likelihood of leaving medical work entirely (2.11 vs 2.76; adjusted difference=-0.32; 95% CI -0.42 to -0.22), a lower likelihood of leaving direct patient care (2.23 vs 2.93; adjusted difference=-0.37; 95% CI -0.47 to -0.27), and a lower likelihood of continuing medical work but outside of the UK (1.41 vs 1.61; adjusted difference=-0.2; 95% CI -0.28 to -0.12). GPs in Scotland reported higher job satisfaction, lower job stressors, similar positive job attributes and lower negative job attributes.

CONCLUSION

Following the introduction of the new contract in Scotland, GPs in Scotland reported significantly better working lives and lower intention to reduce work participation than England.

A comparison, for older people with diabetes, of health and health care utilisation in two different health systems on the island of Ireland

Background

There are social and economic differences between Northern Ireland (NI) and the Republic of Ireland (ROI). There are also differences in the health care systems in the two jurisdictions. The aims of this study are to compare health (prevalence of diabetes and related complications) and health care utilisation (general practitioner, outpatient or accident and emergency utilisation) among older people with diabetes in the NI and ROI.

Methods

Large scale comparable surveys of people over 50 years of age in Northern Ireland (NICOLA, wave 1) and the Republic of Ireland (TILDA, wave 1) are used to compare people with diabetes (type I and type II) in the two jurisdictions. The combined data set comprises 1536 people with diabetes. A coarsened exact matching approach is used to compare health care utilisation among people with diabetes in NI and ROI with equivalent demographic, lifestyle and illness characteristics (age, gender, education, smoking status and self-related health, number of other chronic diseases and number of diabetic complications).

Results

The overall prevalence of diabetes in the 50 to 84 years old age group is 3.4 percentage points higher in NI (11.1% in NI, 7.7% ROI, p-value < 0.01). The diabetic population in NI appear sicker – with more diabetic complications and more chronic illnesses. Comparing people with diabetes in the two jurisdictions with similar levels of illness we find that there are no statistically significant differences in GP, outpatient or A&E utilisation.

Conclusion

Despite the proximity of NI and ROI there are substantial differences in the prevalence of diabetes and its related complications. Despite differences in the health services in the two jurisdictions the differences in health care utilisation for an equivalent cohort are small.

Stakeholder views of podiatry services in the UK for people living with arthritis: a qualitative study

BACKGROUND

The aim of this study was to explore the views of stakeholders in podiatry services, patients, commissioners and general practitioners (GP), to further understand experiences of referral, access and provision of treatment in the National Health Service (NHS) for foot problems for patients living with arthritis.

METHOD

To explore in-depth individual views and experiences of stakeholders in podiatry services, 19 patients who had arthritis (osteoarthritis and/or rheumatoid arthritis) participated in one of four focus groups. In addition, seven commissioners and/or GPs took part in semi structured interviews. A purposive sampling strategy was adopted for all focus groups and semi structured interviews. To account for geographical variations, the focus groups and semi structured interviews were conducted across two predetermined regions of the United Kingdom (UK), Yorkshire and Hampshire. Data was rendered anonymous and transcribed verbatim. Thematic analysis was employed to identify key meanings and report patterns within the data.

RESULTS

Five key themes derived from the focus groups and interviews suggest a variety of factors influencing referral, access and provision of treatment for foot problems within the UK. 1. Systems working together (navigation of different care pathways, access and referral opportunities for people with OA or RA, education around foot health services for people with OA or RA); 2.Finance (financial variations, different care systems, wasting resources); 3. Understanding what podiatry services have to offer (podiatrists are leaders in foot health services, service requirements in relation to training standards and health needs); 4. Person factors of foot pain (arthritis is invisible, affects quality of life, physical and mental wellbeing); 5. Facilitators of foot care (NICE guidelines, stakeholder events, supporting self-management strategies).

CONCLUSION

The findings indicate that patients, commissioners and GPs have very similar experiences of referral, access and provision of treatment for foot problems, for patients living with arthritis. Essentially, commissioners and GPs interviewed called for a transformational approach in current systems to include newer models of care that meet the footcare needs of individual patient circumstances. Patients interviewed called for better signposting and information about the different services available to help them manage their foot health needs. To address this, we have formulated a signposting pack for all stakeholders to help them facilitate access to appropriate clinicians 'at the right time, in the right place' to manage foot health problems.

Impact of a national primary care pay-for-performance scheme on ambulatory care sensitive hospital admissions: a small-area analysis in England

OBJECTIVE

We aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world's largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme.

SETTING

We obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics.

RESULTS

Hospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition.

CONCLUSION

Spatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.

Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research

Pay-for-performance (P4P) is the provision of financial incentives to healthcare providers based on pre-specified performance targets. P4P has been used as a policy tool to improve healthcare provision globally. However, researchers tend to cluster into those working on high or low- and middle-income countries (LMICs), with still limited knowledge exchange, potentially constraining opportunities for learning from across income settings. We reflect here on some commonalities and differences in the design of P4P schemes, research questions, methods and data across income settings. We highlight how a global perspective on knowledge synthesis could lead to innovations and further knowledge advancement.

Impact of a pay-for-performance scheme for long-acting reversible contraceptive (LARC) advice on contraceptive uptake and abortion in British primary care: An interrupted time series study

BACKGROUND

Long-acting reversible contraception (LARC) is among the most effective contraceptive methods, but uptake remains low even in high-income settings. In 2009/2010, a target-based pay-for-performance (P4P) scheme in Britain was introduced for primary care physicians (PCPs) to offer advice about LARC methods to a specified proportion of women attending for contraceptive care to improve contraceptive choice. We examined the impact and equity of this scheme on LARC uptake and abortions.

METHODS AND FINDINGS

We examined records of 3,281,667 women aged 13 to 54 years registered with a primary care clinic in Britain (England, Wales, and Scotland) using Clinical Practice Research Datalink (CPRD) from 2004/2005 to 2013/2014. We used interrupted time series (ITS) analysis to examine trends in annual LARC and non-LARC hormonal contraception (NLHC) uptake and abortion rates, stratified by age and deprivation groups, before and after the P4P was introduced in 2009/2010. Between 2004/2005 and 2013/2014, crude LARC uptake rates increased by 32.0% from 29.6 per 1,000 women to 39.0 per 1,000 women, compared with 18.0% decrease in NLHC uptake. LARC uptake among women of all ages increased immediately after the P4P with step change of 5.36 per 1,000 women (all values are per 1,000 women unless stated, 95% CI 5.26-5.45, p < 0.001). Women aged 20 to 24 years had the largest step change (8.40, 8.34-8.47, p < 0.001) and sustained trend increase (3.14, 3.08-3.19, p < 0.001) compared with other age groups. NLHC uptake fell in all women with a step change of -22.8 (-24.5 to -21.2, p < 0.001), largely due to fall in combined hormonal contraception (CHC; -15.0, -15.5 to -14.5, p < 0.001). Abortion rates in all women fell immediately after the P4P with a step change of -2.28 (-2.98 to -1.57, p = 0.002) and sustained decrease in trend of -0.88 (-1.12 to -0.63, p < 0.001). The largest falls occurred in women aged 13 to 19 years (step change -5.04, -7.56 to -2.51, p = 0.011), women aged 20 to 24 years (step change -4.52, -7.48 to -1.57, p = 0.030), and women from the most deprived group (step change -4.40, -6.89 to -1.91, p = 0.018). We estimate that by 2013/2014, the P4P scheme resulted in an additional 4.53 LARC prescriptions per 1,000 women (relative increase of 13.4%) more than would have been expected without the scheme. There was a concurrent absolute reduction of -5.31 abortions per 1,000 women, or -38.3% relative reduction. Despite universal coverage of healthcare, some women might have obtained contraception elsewhere or had abortion procedure that was not recorded on CPRD. Other policies aiming to increase LARC use or reduce unplanned pregnancies around the same time could also explain the findings.

CONCLUSIONS

In this study, we found that LARC uptake increased and abortions fell in the period after the P4P scheme in British primary care, with additional impact for young women aged 20-24 years and those from deprived backgrounds.

Socio-economic differences in cardiovascular disease risk factor prevalence in people with type 2 diabetes in Scotland: a cross-sectional study

AIM

To describe the association between socio-economic status and prevalence of key cardiovascular risk factors in people with type 2 diabetes in Scotland.

METHODS

A cross-sectional study of 264 011 people with type 2 diabetes in Scotland in 2016 identified from the population-based diabetes register. Socio-economic status was defined using quintiles of the area-based Scottish Index of Multiple Deprivation (SIMD) with quintile (Q)1 and Q5 used to identify the most- and least-deprived fifths of the population, respectively. Logistic regression models adjusted for age, sex, health board, history of cardiovascular disease and duration of diabetes were used to estimate odds ratios (ORs) for Q1 compared with Q5 for each risk factor.

RESULTS

The mean (sd) age of the study population was 66.7 (12.8) years, 56% were men, 24% were in Q1 and 15% were in Q5. Crude prevalence in Q1/Q5 was 24%/8.8% for smoking, 62%/49% for BMI ≥ 30 kg/m² , 44%/40% for HbA_1c ≥ 58 mmol/mol (7.5%), 31%/31% for systolic blood pressure (SBP) ≥ 140 mmHg, and 24%/25% for total cholesterol ≥ 5 mmol/l, respectively. ORs [95% confidence intervals (CI)] were 3.08 (2.95-3.21) for current smoking, 1.48 (1.44-1.52) for BMI ≥ 30 kg/m² , 1.11 (1.08-1.15) for HbA_1c ≥ 58 mmol/mol (7.5%), 1.03 (1.00-1.06) for SBP ≥ 140 mmHg and 0.87 (0.84-0.90) for total cholesterol ≥ 5 mmol/l.

CONCLUSIONS

Socio-economic deprivation is associated with higher prevalence of smoking, BMI ≥ 30 kg/m² and HbA_1c ≥ 58 mmol/mol (7.5%), and lower prevalence of total cholesterol ≥ 5 mmol/l among people with type 2 diabetes in Scotland. Effective approaches to reducing inequalities are required as well as reducing risk factor prevalence across the whole population.

A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK

BACKGROUND

The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff.

METHODS

We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis.

RESULTS

We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems.

CONCLUSIONS

Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.

The effect of 'paying for performance' on the management of type 2 diabetes mellitus: a cross-sectional observational study

Background

The ‘cycle of care’ (COC) pay for performance (PFP) programme, introduced in 2015, has resourced Irish GPs to provide structured care to PCRS eligible patients with type 2 diabetes mellitus (T2DM).

Aim

To investigate the effect of COC on management processes.

Design &setting

Cross-sectional observational study undertaken with two points of comparison (2014 and 2017) in participating practices (Republic of Ireland general practices), with comparator data from the United Kingdom National Diabetes Audit (UKNDA) 2015–2016.

Method

Invitations to participate were sent to practices using a discussion forum for Health One clinical software. Participating practices provided data on the processes of care in the management of patients with T2DM. Data on PCRS eligible patients was extracted from the electronic medical record system of participating practices using secure customised software. Descriptive analysis, using IBM SPSS Statistics for Windows (version 25), was performed.

Results

Of 250 practices invited, 41 practices participated (16.4%), yielding data from 3146 patients. There were substantial improvements in the rates of recording of glycosylated haemoglobin ([HbA1c] 53.1%–98.3%), total cholesterol ([TC] 59.2%–98.8%), urinary albumin:creatinine ratio ([ACR] 9.9%–42.3%), blood pressure ([BP] 61.4%–98.2%), and body-mass index ([BMI] 39.8%–97.4%) from 2014 to 2017. For the first time, rates of retinopathy screening (76.3%), foot review (64.9%), and influenza immunisation (69.9%) were recorded. Comparison of 2017 data with UKNDA 2015–2016 was broadly similar.

Conclusion

The COC demonstrated much improved rates of recording of clinical and biochemical parameters, and improved achievement of targets in TC and BP, but not HbA1c. Results demonstrate substantial improvements in the processes and quality of care in the management of patients with T2DM.

Improving primary care management of asthma: do we know what really works?

Asthma imposes a substantial burden on individuals and societies. Patients with asthma need high-quality primary care management; however, evidence suggests the quality of this care can be highly variable. Here we identify and report factors contributing to high-quality management. Twelve primary care global asthma experts, representing nine countries, identified key factors. A literature review (past 10 years) was performed to validate or refute the expert viewpoint. Key driving factors identified were: policy, clinical guidelines, rewards for performance, practice organisation and workforce. Further analysis established the relevant factor components. Review evidence supported the validity of each driver; however, impact on patient outcomes was uncertain. Single interventions (e.g. healthcare practitioner education) showed little effect; interventions driven by national policy (e.g. incentive schemes and teamworking) were more effective. The panel's opinion, supported by literature review, concluded that multiple primary care interventions offer greater benefit than any single intervention in asthma management.

Using general practice clinical information system data for research: the case in Australia

General practice is often a patient’s first point of contact with the health system and the gateway to specialist services. In Australia, different aspects of the health system are managed by the Commonwealth Government and individual state / territory governments. Although there is a long history of research using administrative data in Australia, this split in the management and funding of services has hindered whole-system research. Additionally, the administrative data typically available for research are often collected for reimbursement purposes and lack clinical information.

General practices collect a range of patient information including diagnoses, medications prescribed, results of pathology tests ordered and so on. Practices are increasingly using clinical information systems and data extraction tools to make use of this information. This paper describes approaches used on several research projects to access clinical, as opposed to administrative, general practice data which to date has seen little use as a resource for research.

This information was accessed in three ways. The first was by working directly with practices to access clinical and management data to support research. The second involved accessing general practice data through collaboration with Primary Health Networks, recently established in Australia to increase the efficiency and effectiveness of health services for patients. The third was via NPS MedicineWise’s MedicineInsight program, which collects data from consenting practices across Australia and makes these data available to researchers.

We describe each approach including data access requirements and the advantages and challenges of each method. All approaches provide the opportunity to better understand data previously unavailable for research in Australia. The challenge of linking general practice data to other sources, currently being explored for general practice data, is discussed.

Finally, we describe some general practice data collections used for research internationally and how these compare to collections available in Australia.

Impact of specialist and primary care stop smoking support on socio-economic inequalities in cessation in the United Kingdom: a systematic review and national equity initial review completed 22 January 2019; final version accepted 19 July 2019 analysis

AIM

To assess the impact of UK specialist and primary care-based stop smoking support on socio-economic inequalities in cessation.

METHODS

Systematic review and narrative synthesis, with a national equity analysis of stop smoking services (SSS). Ten bibliographic databases were searched for studies of any design, published since 2012, which evaluated specialist or primary care-based stop smoking support by socio-economic status (SES) or within a disadvantaged group. Studies could report on any cessation-related outcome. National Statistics were combined to estimate population-level SSS reach and impact among all smokers by SES. Overall, we included 27 published studies and three collated, national SSS reports for England, Scotland and Northern Ireland (equivalent data for Wales were unavailable).

RESULTS

Primary care providers and SSS in the United Kingdom were particularly effective at engaging and supporting disadvantaged smokers. Low SES groups were more likely to have their smoking status assessed, to receive general practitioner brief cessation advice/SSS referral and to attempt a quit with SSS support. Although disadvantaged SSS clients were less successful in quitting, increased service reach offset these lower quit rates, resulting in higher service impact among smokers from low SES groups. Interventions that offer tailored and targeted support have the potential to improve quit outcomes among disadvantaged smokers.

CONCLUSIONS

Equity-orientated stop smoking support can compensate for lower quit rates among disadvantaged smokers through the use of equity-based performance targets, provision of targeted services and the development of tailored interventions.

Natural language processing for disease phenotyping in UK primary care records for research: a pilot study in myocardial infarction and death

BACKGROUND

Free text in electronic health records (EHR) may contain additional phenotypic information beyond structured (coded) information. For major health events - heart attack and death - there is a lack of studies evaluating the extent to which free text in the primary care record might add information. Our objectives were to describe the contribution of free text in primary care to the recording of information about myocardial infarction (MI), including subtype, left ventricular function, laboratory results and symptoms; and recording of cause of death. We used the CALIBER EHR research platform which contains primary care data from the Clinical Practice Research Datalink (CPRD) linked to hospital admission data, the MINAP registry of acute coronary syndromes and the death registry. In CALIBER we randomly selected 2000 patients with MI and 1800 deaths. We implemented a rule-based natural language engine, the Freetext Matching Algorithm, on site at CPRD to analyse free text in the primary care record without raw data being released to researchers. We analysed text recorded within 90 days before or 90 days after the MI, and on or after the date of death.

RESULTS

We extracted 10,927 diagnoses, 3658 test results, 3313 statements of negation, and 850 suspected diagnoses from the myocardial infarction patients. Inclusion of free text increased the recorded proportion of patients with chest pain in the week prior to MI from 19 to 27%, and differentiated between MI subtypes in a quarter more patients than structured data alone. Cause of death was incompletely recorded in primary care; in 36% the cause was in coded data and in 21% it was in free text. Only 47% of patients had exactly the same cause of death in primary care and the death registry, but this did not differ between coded and free text causes of death.

CONCLUSIONS

Among patients who suffer MI or die, unstructured free text in primary care records contains much information that is potentially useful for research such as symptoms, investigation results and specific diagnoses. Access to large scale unstructured data in electronic health records (millions of patients) might yield important insights.

GP incentives to design hypertension and atrial fibrillation local quality-improvement schemes: a controlled before-after study in UK primary care

BACKGROUND

Financial incentives in the UK such as the Quality and Outcomes Framework (QOF) reward GP surgeries for achievement of nationally defined targets. These have shown mixed results, with weak evidence for some measures, but also possible unintended negative effects.

AIM

To look at the effects of a local intervention for atrial fibrillation (AF) and hypertension, with surgeries rewarded financially for work, including appointing designated practice leads, attendance at peer review workshops, and producing their own protocols.

DESIGN AND SETTING

A controlled before-after study comparing surgery performance measures in UK primary care.

METHOD

This study used published QOF data to analyse changes from baseline in mean scores per surgery relating to AF and hypertension prevalence and management at T1 (12 months) and T2 (24 months) for the intervention group, which consisted of all 58 surgeries in East Lancashire Clinical Commissioning Group (CCG), compared to the control group, which consisted of all other surgeries in north-west England.

RESULTS

There was a small acceleration between T0 (baseline) and T2 in recorded prevalence of hypertension in the intervention group compared to the controls, difference 0.29% (95% confidence interval [CI] = 0.05 to 0.53), P = 0.017, but AF prevalence did not increase more in the intervention group. Improvement in quality of management of AF was significantly better in the intervention group, difference 3.24% (95% CI = 1.37 to 5.12), P = 0.001.

CONCLUSION

This intervention improved diagnosis rates of hypertension but not AF, though it did improve quality of AF management. It indicates that funded time to develop quality-improvement measures targeted at a local population and involving peer support can engage staff and have the potential to improve quality.