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Gkiouleka A, Wong G, Sowden S, Kuhn I, Moseley A, Manji S, Harmston RR, Siersbaek R, Bambra C, Ford JA. Reducing health inequalities through general practice: a realist review and action framework. HEALTH AND SOCIAL CARE DELIVERY RESEARCH 2024; 12:1-104. [PMID: 38551093 DOI: 10.3310/ytww7032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/02/2024]
Abstract
Background Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities. Objectives We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice. Design Realist review. Main outcome measures Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria. Review methods Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence. Results Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships. Limitations The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care. Conclusions Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred. Future work Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice. Study registration This trial is registered as PROSPERO CRD42020217871. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Anna Gkiouleka
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences and Radcliffe Observatory Quarter, University of Oxford, Oxford, UK
| | - Sarah Sowden
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Isla Kuhn
- University of Cambridge Medical Library, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Annie Moseley
- Patient and Public Involvement Representative, Norwich, UK
| | - Sukaina Manji
- Department of Educational Research, Lancaster University, Lancaster, UK
| | | | - Rikke Siersbaek
- Health System Foundations for Sláintecare Implementation, Centre for Health Policy and Management, Trinity College Dublin, University of Dublin, Dublin, Ireland
| | - Clare Bambra
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John A Ford
- Wolfson Institute of Population Health, Queen Mary University of London, London, UK
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Liao YS, Tsai WC, Chiu LT, Kung PT. Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program. Health Policy 2023; 138:104917. [PMID: 37776765 DOI: 10.1016/j.healthpol.2023.104917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 09/17/2023] [Accepted: 09/19/2023] [Indexed: 10/02/2023]
Abstract
Most patients are diagnosed as having diabetes only after experiencing diabetes complications. Educational attainment might have a positive relationship with diabetes prognosis. The diabetes pay-for-performance (P4P) program-providing comprehensive, continuous medical care-has improved diabetes prognosis in Taiwan. This retrospective cohort study investigated how educational attainment affects the presence of diabetes complications at diabetes diagnosis and mortality risk in patients with diabetes enrolled in the P4P program. From the National Health Insurance Research Database, we identified patients aged >45 years who had received a new diagnosis of type 2 diabetes during 2002-2015; they were followed up until the end of 2017. We next used logistic regression analysis to explore whether the patients with different educational attainments had varied diabetic complication risks at diabetes diagnosis. The Cox proportional hazard model was employed to examine the association of different educational attainments in people with diabetes with mortality risk after their enrollment in the P4P program. The results indicated that as educational attainment increased, the risk of diabetes complications at type 2 diabetes diagnosis decreased gradually. When type 2 diabetes with different educational attainments joined the P4P program, high school education had the highest effect on reducing mortality risk; however, those with ≤ 6th grade education had the lowest impact.
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Affiliation(s)
- Yi-Shu Liao
- Department of Pathology, Taichung Armed Forces General Hospital, National Defense Medical Center, Taiwan; Department of Public Health, China Medical University, Taiwan
| | - Wen-Chen Tsai
- Department of Health Services Administration, China Medical University, Taiwan
| | - Li-Ting Chiu
- Department of Health Services Administration, China Medical University, Taiwan
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taiwan; Department of Medical Research, China Medical University Hospital, Taiwan.
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Hayanga B, Stafford M, Ashworth M, Hughes J, Bécares L. Ethnic inequities in the patterns of personalized care adjustments for 'informed dissent' and 'patient unsuitable': a retrospective study using Clinical Practice Research Datalink. J Public Health (Oxf) 2023; 45:e692-e701. [PMID: 37434314 PMCID: PMC10687864 DOI: 10.1093/pubmed/fdad104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 06/02/2023] [Indexed: 07/13/2023] Open
Abstract
BACKGROUND In England, general practitioners voluntarily take part in the Quality and Outcomes Framework, which is a program that seeks to improve care by rewarding good practice. They can make personalized care adjustments (PCAs), e.g. if patients choose not to have the treatment/intervention offered ('informed dissent') or because they are considered to be clinically 'unsuitable'. METHODS Using data from the Clinical Practice Research Datalink (Aurum), this study examined patterns of PCA reporting for 'informed dissent' and 'patient unsuitable', how they vary across ethnic groups and whether ethnic inequities were explained by sociodemographic factors or co-morbidities. RESULTS The odds of having a PCA record for 'informed dissent' were lower for 7 of the 10 minoritized ethnic groups studied. Indian patients were less likely than white patients to have a PCA record for 'patient unsuitable'. The higher likelihood of reporting for 'patient unsuitable' among people from Black Caribbean, Black Other, Pakistani and other ethnic groups was explained by co-morbidities and/or area-level deprivation. CONCLUSIONS The findings counter narratives that suggest that people from minoritized ethnic groups often refuse medical intervention/treatment. The findings also illustrate ethnic inequities in PCA reporting for 'patient unsuitable', which are linked to clinical and social complexity and should be tackled to improve health outcomes for all.
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Affiliation(s)
- Brenda Hayanga
- Department of Global Health and Social Medicine, King’s College London, London WC2B 4BG, UK
| | | | - Mark Ashworth
- Department of Population Health Sciences, King’s College London, London SE1 1UL, UK
| | - Jay Hughes
- The Health Foundation, London EC4Y 8AP, UK
| | - Laia Bécares
- Department of Global Health and Social Medicine, King’s College London, London WC2B 4BG, UK
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Tsai YS, Tsai WC, Chiu LT, Kung PT. Diabetes Pay-for-Performance Program Participation and Dialysis Risk in Relation to Educational Attainment: A Retrospective Cohort Study. Healthcare (Basel) 2023; 11:2913. [PMID: 37998405 PMCID: PMC10671833 DOI: 10.3390/healthcare11222913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/03/2023] [Accepted: 11/05/2023] [Indexed: 11/25/2023] Open
Abstract
Pay-for-performance (P4P) programs for diabetes care enable the provision of comprehensive and continuous health care to diabetic patients. However, patient outcomes may be affected by the patient's educational attainment. The present retrospective cohort study aimed to examine the effects of the educational attainment of diabetic patients on participation in a P4P program in Taiwan and the risk of dialysis. The data were obtained from the National Health Insurance Research Database of Taiwan. Patients newly diagnosed with type 2 diabetes mellitus (T2DM) aged 45 years from 2002 to 2015 were enrolled and observed until the end of 2017. The effects of their educational attainment on their participation in a P4P program were examined using the Cox proportional hazards model, while the impact on their risk for dialysis was investigated using the Cox proportional hazards model. The probability of participation in the P4P program was significantly higher in subjects with a junior high school education or above than in those who were illiterate or had only attained an elementary school education. Subjects with higher educational attainment exhibited a lower risk for dialysis. Different educational levels had similar effects on reducing dialysis risk among diabetic participants in the P4P program.
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Affiliation(s)
- Yi-Shiun Tsai
- Department of Orthopedics, Feng Yuan Hospital, Taichung 420210, Taiwan;
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Li-Ting Chiu
- Department of Health Services Administration, College of Public Health, China Medical University, Taichung 406040, Taiwan; (W.-C.T.); (L.-T.C.)
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung 413305, Taiwan
- Department of Medical Research, China Medical University Hospital, Taichung 404327, Taiwan
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Wilding A, Munford L, Guthrie B, Kontopantelis E, Sutton M. Family doctor responses to changes in target stringency under financial incentives. JOURNAL OF HEALTH ECONOMICS 2022; 85:102651. [PMID: 35858512 DOI: 10.1016/j.jhealeco.2022.102651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
Healthcare providers may game when faced with targets. We examine how family doctors responded to a temporary but substantial increase in the stringency of targets determining payments for controlling blood pressure amongst younger hypertensive patients. We apply difference-in-differences and bunching techniques to data from electronic health records of 107,148 individuals. Doctors did not alter the volume or composition of lists of their hypertension patients. They did increase treatment intensity, including a 1.2 percentage point increase in prescribing antihypertensive medicines. They also undertook more blood pressure measurements. Multiple testing increased by 1.9 percentage points overall and by 8.8 percentage points when first readings failed more stringent target. Exemption of patients from reported performance increased by 0.8 percentage points. Moreover, the proportion of patients recorded as exactly achieving the more stringent target increased by 3.1 percentage points to 16.6%. Family doctors responded as intended and gamed when set more stringent pay-for-performance targets.
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Affiliation(s)
- Anna Wilding
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K..
| | - Luke Munford
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K
| | - Bruce Guthrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, U.K
| | - Evangelos Kontopantelis
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K
| | - Matt Sutton
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K.; Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Australia
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Das-Munshi J, Schofield P, Ashworth M, Gaughran F, Hull S, Ismail K, Robson J, Stewart R, Mathur R. Inequalities in glycemic management in people living with type 2 diabetes mellitus and severe mental illnesses: cohort study from the UK over 10 years. BMJ Open Diabetes Res Care 2021; 9:e002118. [PMID: 34497046 PMCID: PMC8438718 DOI: 10.1136/bmjdrc-2021-002118] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/29/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Using data from a a primary care pay-for-performance scheme targeting quality indicators, the objective of this study was to assess if people living with type 2 diabetes mellitus (T2DM) and severe mental illnesses (SMI) experienced poorer glycemic management compared with people living with T2DM alone, and if observed differences varied by race/ethnicity, deprivation, gender, or exclusion from the scheme. RESEARCH DESIGN AND METHODS Primary care data from a cohort of 56 770 people with T2DM, including 2272 people with T2DM and SMI, from London (UK), diagnosed between January 17, 2008 and January 16, 2018, were used. Adjusted mean glycated hemoglobin (HbA1c) and HbA1c differences were assessed using multilevel regression models. RESULTS Compared with people with T2DM only, people with T2DM/SMI were more likely to be of an ethnic minority background, excluded from the pay-for-performance scheme and residing in more deprived areas. Across the sample, mean HbA1c was lower in those with T2DM and SMI (mean HbA1c: 58 mmol/mol; 95% CI 57 to 59), compared with people with T2DM only (mean HbA1c: 59 mmol/mol; 95% CI 59 to 60). However, HbA1c levels were greater in Bangladeshi, Indian, Pakistani, and Chinese people compared with the White British reference in the T2DM/SMI group. People with T2DM/SMI who had been excluded from the pay-for-performance scheme, had HbA1c levels which were +7 mmol/mol (95% CI 2 to 11) greater than those with T2DM/SMI not excluded. Irrespective of SMI status, increasing deprivation and male gender were associated with increased HbA1c levels. CONCLUSIONS Despite a pay-for-performance scheme to improve quality standards, inequalities in glycemic management in people with T2DM and SMI persist in those excluded from the scheme and by gender, ethnicity, and area-level deprivation.
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Affiliation(s)
- Jayati Das-Munshi
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
- ESRC Centre for Society and Mental Health, King's College London, London, UK
| | - Peter Schofield
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Mark Ashworth
- School of Population Health & Environmental Sciences, King's College London, Faculty of Life Sciences & Medicine (FOLSM), London, UK
| | - Fiona Gaughran
- South London and Maudsley (SLaM) NHS Trust, London, UK
- Department of Psychosis Studies, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
| | - Sally Hull
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Khalida Ismail
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - John Robson
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
| | - Robert Stewart
- Department of Psychological Medicine, King's College London, Institute of Psychiatry, Psychology and Neuroscience (IoPPN), London, UK
- South London and Maudsley (SLaM) NHS Trust, London, UK
| | - Rohini Mathur
- Clinical Effectiveness Group, Institute of Population Health Sciences, Queen Mary, University of London, London, UK
- Department of Non-Communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
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7
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Gupta N, Ayles HM. The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage. HUMAN RESOURCES FOR HEALTH 2020; 18:69. [PMID: 32962707 PMCID: PMC7507591 DOI: 10.1186/s12960-020-00512-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Accepted: 09/09/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce. METHODS A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence. FINDINGS Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients' sex with the policy intervention. Few (15%) of the studies controlled for the provider's sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity). CONCLUSIONS There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.
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Affiliation(s)
- Neeru Gupta
- Department of Sociology, University of New Brunswick, PO Box 4400, 9 Macaulay Lane, Fredericton, New Brunswick, E3B 5A3, Canada.
| | - Holly M Ayles
- Faculty of Management, University of New Brunswick, PO Box 4400, 7 Macaulay Lane, Fredericton, New Brunswick, E3B 5A3, Canada
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Lee J, Valle E. The need for health systems education during medical training in the UK. BMJ LEADER 2020. [DOI: 10.1136/leader-2019-000178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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Lee JA, Meacock R, Kontopantelis E, Matheson J, Gittins M. Deprivation and primary care funding in Greater Manchester after devolution: a cross-sectional analysis. Br J Gen Pract 2019; 69:e794-e800. [PMID: 31501163 PMCID: PMC6733588 DOI: 10.3399/bjgp19x705545] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 05/10/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND In April 2016 Greater Manchester gained control of its health and social care budget, a devolution that aimed to reduce health inequities both within Greater Manchester and between Greater Manchester and the rest of the country. AIM To describe the relationship between practice location deprivation and primary care funding and care quality measurements in the first year of Greater Manchester devolution (2016/2017). DESIGN AND SETTING Cross-sectional analysis of 472 general practices in Greater Manchester in England. METHOD Financial data for each general practice were linked to the area deprivation of the practice location, as measured by the 2015 Index of Multiple Deprivation. Practices were categorised into five quintiles relative to national deprivation. NHS Payments data and indicators of care quality were compared across social deprivation quintiles. RESULTS Practices in areas of greater deprivation did not receive additional funding per registered patient. Practices in less deprived quintiles received higher National Enhanced Services payments from NHS England than practices in the most deprived quintile. A trend was observed towards funding to more deprived practices being supported by Local Enhanced Service payments from clinical commissioning groups, but these represent a small proportion of overall practice income. Practices in less deprived areas had better care quality measurements according to Quality and Outcomes Framework achievement and Care Quality Commission ratings. CONCLUSION Following devolution, primary care practices in Greater Manchester are still reliant on funding from national funding schemes, which poorly reflect its deprivation. The devolved administration's ability to address health inequities at the primary care level seems uncertain.
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Affiliation(s)
| | | | | | - James Matheson
- Hill Top Surgery, Hope Citadel Healthcare, Shared Health Foundation, Oldham
| | - Matthew Gittins
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester
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Dawson J, Rigby-Brown A, Adams L, Baker R, Fernando J, Forrest A, Kirkwood A, Murray R, West M, Wike P, Wilde M. Developing and evaluating a tool to measure general practice productivity: a multimethod study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Systems for measuring the performance of general practices are extremely limited.
Objectives
The aim was to develop, pilot test and evaluate a measure of productivity that can be applied across all typical general practices in England, and that may result in improvements in practice, thereby leading to better patient outcomes.
Methods
Stage 1 – the approach used was based on the Productivity Measurement and Enhancement System (ProMES). Through 16 workshops with 80 general practice staff and 72 patient representatives, the objectives of general practices were identified, as were indicators that could measure these objectives and systems to convert the indicators into an effectiveness score and a productivity index. This was followed by a consensus exercise involving a face-to-face meeting with 16 stakeholders and an online survey with 27 respondents. An online version of the tool [termed the General Practice Effectiveness Tool (GPET)] and detailed guidance were created. Stage 2 – 51 practices were trained to use the GPET for up to 6 months, entering data on each indicator monthly and getting automated feedback on changes in effectiveness over time. The feasibility and acceptability of the GPET were examined via 38 telephone interviews with practice representatives, an online survey of practice managers and two focus groups with patient representatives.
Results
The workshops resulted in 11 objectives across four performance areas: (1) clinical care, (2) practice management, (3) patient focus and (4) external focus. These were measured by 52 indicators, gathered from clinical information systems, practice records, checklists, a short patient questionnaire and a short staff questionnaire. The consensus exercise suggested that this model was appropriate, but that the tool would be of more benefit in tracking productivity within practices than in performance management. Thirty-eight out of 51 practices provided monthly data, but only 28 practices did so for the full period. Limited time and personnel changes made participation difficult for some. Over the pilot period, practice effectiveness increased significantly. Perceptions of the GPET were varied. Usefulness was given an average rating of 4.5 out of 10.0. Ease of use was more positive, scoring 5.6 out of 10.0. Five indicators were highlighted as problematic to gather, and 27% of practices had difficulties entering data. Feedback from interviews suggested difficulties using the online system and finding time to make use of feedback. Most practices could not provide sufficient monthly financial data to calculate a conventional productivity index.
Limitations
It was not possible to create a measure that provides comparability between all practices, and most practices could not provide sufficient financial data to create a productivity index, leaving an effectiveness measure instead. Having a relatively small number of practices, with no control group, limited this study, and there was a limited timescale for the testing and evaluation.
Implications
The GPET has demonstrated some viability as a tool to aid practice improvement. The model devised could serve as a basis for measuring effectiveness in general practice more widely.
Future work
Some additional research is needed to refine the GPET. Enhanced testing with a control sample would evaluate whether or not it is the use of the GPET that leads to improved performance.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Jeremy Dawson
- Sheffield University Management School, The University of Sheffield, Sheffield, UK
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Anna Rigby-Brown
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Lee Adams
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | | | - Amanda Forrest
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK
| | - Anna Kirkwood
- The Medical School, The University of Sheffield, Sheffield, UK
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Gupta N, Lavallée R, Ayles J. Effects of Pay-for-Performance for Primary Care Physicians on Preventable Diabetes-Related Hospitalization Costs Among Adults in New Brunswick, Canada: A Quasiexperimental Evaluation. Can J Diabetes 2018; 43:354-360.e1. [PMID: 30679059 DOI: 10.1016/j.jcjd.2018.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs. METHODS We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive. RESULTS Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes. CONCLUSIONS The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, Department of Sociology, Fredericton, New Brunswick, Canada.
| | - René Lavallée
- Government of New Brunswick, Department of Health, Fredericton, New Brunswick, Canada
| | - James Ayles
- Government of New Brunswick, Department of Health, Fredericton, New Brunswick, Canada
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Hunt V, Anderson D, Lowrie R, Montgomery Sardar C, Ballantyne S, Bryson G, Kyle J, Hanlon P. A non-randomised controlled pilot study of clinical pharmacist collaborative intervention for community dwelling patients with COPD. NPJ Prim Care Respir Med 2018; 28:38. [PMID: 30305634 PMCID: PMC6180130 DOI: 10.1038/s41533-018-0105-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/13/2018] [Accepted: 08/07/2018] [Indexed: 01/12/2023] Open
Abstract
UK, home-based patients with COPD receive specialist care from respiratory physicians, nurses, and general practitioners (GPs), but increasing complexity of therapeutic options and a GP/Nurse workforce crisis suggests merit in testing the role of home visits by a clinical pharmacist. We conducted a non-randomised intervention study with a contemporaneous comparator group, in Glasgow (Scotland). A clinical pharmacist (working closely with a consultant respiratory physician) visited patients with COPD living at home, assessing respiratory and other co-morbid conditions, and medicines then, with patient approval, agreed treatment modifications with a consultant physician. Comparator group-patients were drawn from another hospital out-patient clinic. Main outcomes were exacerbations during 4-months of follow-up and respiratory hospitalisations (number and duration) after 1 year. In the intervention group, 86 patients received a median of three home visits; 87 received usual care (UC). At baseline, patients in the intervention group were similar to those in UC in terms of respiratory hospitalisations although slightly younger, more likely to receive specific maintenance antibiotics/Prednisolone and to have had exacerbations. Sixty-two (72.1%) of the intervention group received dose changes; 45 (52.3%) had medicines stopped/started and 21 (24.4%) received an expedited review at the specialist respiratory consultant clinic; 46 (53.5%) were referred to other healthcare services. Over one-third were referred for bone scans and 11% received additional investigations. At follow-up, 54 (63.5%) of intervention group participants had an exacerbation compared with 75 (86.2%) in the UC group (p = 0.001); fewer had respiratory hospitalisations (39 (45.3%) vs. 66 (76.7%); p < 0.001). Hospitalisations were shorter in the intervention group. Pharmacist-consultant care for community dwelling patients with COPD, changed clinical management and improved outcomes. A randomised controlled trial would establish causality. Clinical pharmacists, working in collaboration with respiratory specialists, can help people who live at home with chronic obstructive pulmonary disease (COPD) better manage their medications and symptoms. In a non-randomised pilot study, Richard Lowrie from the NHS Greater Glasgow and Clyde,
UK, and colleagues found that patients with COPD who receive standard at-home care—which includes visits to GP surgeries and hospital-based respiratory out-patient clinics, and visits from respiratory specialist nurses—were more likely to experience exacerbations and need lengthy hospital stays than those who additionally received home visits from a clinical pharmacist. The pharmacist, in consultation with the patient’s respiratory physician, often proposed medication changes and suggested additional testing or referrals that presumably explain the improved health outcomes. The authors conclude that a large, randomised trial is warranted to further evaluate the merits of this collaborative intervention for community dwelling patients with COPD.
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Affiliation(s)
- Vicki Hunt
- East Renfrewshire Health and Social Care Partnership Eastwood Health and Care Centre, Drumby Crescent, Glasgow, Scotland, United Kingdom
| | | | - Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, G3 8SJ, United Kingdom.
| | - Colette Montgomery Sardar
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, G3 8SJ, United Kingdom
| | - Susan Ballantyne
- Prescribing Support Pharmacy Team, North East Glasgow HSCP, Glasgow, United Kingdom
| | - Graeme Bryson
- Glasgow City Health and Social Care Partnership, Glasgow, United Kingdom
| | - John Kyle
- General Practice and Primary Care Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Peter Hanlon
- General Practice and Primary Care Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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Variation in anticoagulation for atrial fibrillation between English clinical commissioning groups: an observational study. Br J Gen Pract 2018; 68:e551-e558. [PMID: 29970397 DOI: 10.3399/bjgp18x697913] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/05/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Despite improvement in anticoagulation for atrial fibrillation (AF), substantial variation in anticoagulation persists between clinical commissioning groups (CCGs) and regions in England. AIM To identify reasons for variation between English CCGs in anticoagulation for AF. DESIGN AND SETTING A 4-year observational study from 2012/2013 to 2015/2016, of the national Quality and Outcomes Framework. METHOD Multiple regression and Pearson's correlation coefficients were used to analyse anticoagulation for AF in relation to older age, Index of Multiple Deprivation, prescription of non-vitamin K antagonist oral anticoagulants (NOACs), and exception reporting, as well as stroke hospital admission and mortality. RESULTS The proportion of eligible patients in England prescribed anticoagulants for AF without exceptions for clinical complexity or patient dissent increased from 65.1% in 2012/2013 to 77.9% in 2015/2016. In 2015, 290 920 additional eligible people were anticoagulated in association with use of the CHA2DS2VASc rather than CHADS2 score. From 2012 to 2015, exception reporting almost halved from 20% to 10.2%. Variation in CCG anticoagulation was not associated with deprivation or NOAC use. There was a strong negative association between exception reporting representing patient complexity and anticoagulation performance, accounting for 57% of the variation in anticoagulation without exceptions (multiple regression coefficient = -0.81; 95% confidence intervals = -0.92 to -0.71; P<0.001). CONCLUSION Anticoagulation for AF has improved substantially in England in association with considerable increases in the eligible population as a result of decreased exception reporting and the use of the CHA2DS2VASc score. There is still substantial room for improvement in most CCGs because, even allowing for exceptions, nine out of 10 CCGs failed to achieve 90% anticoagulation.
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Lowrie R, McConnachie A, Williamson AE, Kontopantelis E, Forrest M, Lannigan N, Mercer SW, Mair FS. Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data. BMC Med 2017; 15:77. [PMID: 28395660 PMCID: PMC5387284 DOI: 10.1186/s12916-017-0833-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 03/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. METHODS We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. RESULTS Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices. CONCLUSIONS Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled.
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Affiliation(s)
- Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Andrea E. Williamson
- General Practice and Primary Care, School of Medicine, MVLS, University of Glasgow, Glasgow, Scotland UK
| | - Evangelos Kontopantelis
- The Farr Institute of Health Informatics Research, University of Manchester, Manchester, England UK
| | - Marie Forrest
- East Glasgow Health and Social Care Partnership, Paradise Health Centre, Glasgow, Scotland UK
| | - Norman Lannigan
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Stewart W. Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Frances S. Mair
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
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Abstract
The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value-Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success.
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Affiliation(s)
- Tim Doran
- Department of Health Sciences, University of York, Heslington, York YO10 5DD, United Kingdom;
| | - Kristin A Maurer
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109; ,
| | - Andrew M Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109; ,
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Thorne T. How could the quality and outcomes framework (QOF) do more to tackle health inequalities? LONDON JOURNAL OF PRIMARY CARE 2016; 8:80-84. [PMID: 28250839 PMCID: PMC5330348 DOI: 10.1080/17571472.2016.1215370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
This paper outlines how the quality and outcomes framework (QOF) has done little to close the health inequality gap, and proposes possible ways in which future iterations of QOF could do more to address this crucial public health problem.
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Affiliation(s)
- Tim Thorne
- Health Care Management iBSc, King’s College London, London, UK
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Foskett-Tharby R, Nick H, Gill P. Pay for performance and the management of hypertension. J Transl Int Med 2016; 4:14-19. [PMID: 28191512 DOI: 10.1515/jtim-2016-0004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Affiliation(s)
- Rachel Foskett-Tharby
- Primary Care Clinical Sciences, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kindom
| | - Hex Nick
- York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York, YO10 5NQ, United Kingdom
| | - Paramjit Gill
- Primary Care Clinical Sciences, Institute of Applied Health Research, University of Birmingham, Edgbaston, Birmingham, B15 2TT, United Kindom
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Roland M. Should doctors be able to exclude patients from pay-for-performance schemes? BMJ Qual Saf 2015; 25:653-6. [PMID: 26717988 DOI: 10.1136/bmjqs-2015-005003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2015] [Indexed: 12/25/2022]
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Reilly S, Olier I, Planner C, Doran T, Reeves D, Ashcroft DM, Gask L, Kontopantelis E. Inequalities in physical comorbidity: a longitudinal comparative cohort study of people with severe mental illness in the UK. BMJ Open 2015; 5:e009010. [PMID: 26671955 PMCID: PMC4679912 DOI: 10.1136/bmjopen-2015-009010] [Citation(s) in RCA: 77] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Little is known about the prevalence of comorbidity rates in people with severe mental illness (SMI) in UK primary care. We calculated the prevalence of SMI by UK country, English region and deprivation quintile, antipsychotic and antidepressant medication prescription rates for people with SMI, and prevalence rates of common comorbidities in people with SMI compared with people without SMI. DESIGN Retrospective cohort study from 2000 to 2012. SETTING 627 general practices contributing to the Clinical Practice Research Datalink, a UK primary care database. PARTICIPANTS Each identified case (346,551) was matched for age, sex and general practice with 5 randomly selected control cases (1,732,755) with no diagnosis of SMI in each yearly time point. OUTCOME MEASURES Prevalence rates were calculated for 16 conditions. RESULTS SMI rates were highest in Scotland and in more deprived areas. Rates increased in England, Wales and Northern Ireland over time, with the largest increase in Northern Ireland (0.48% in 2000/2001 to 0.69% in 2011/2012). Annual prevalence rates of all conditions were higher in people with SMI compared with those without SMI. The discrepancy between the prevalence of those with and without SMI increased over time for most conditions. A greater increase in the mean number of additional conditions was observed in the SMI population over the study period (0.6 in 2000/2001 to 1.0 in 2011/2012) compared with those without SMI (0.5 in 2000/2001 to 0.6 in 2011/2012). For both groups, most conditions were more prevalent in more deprived areas, whereas for the SMI group conditions such as hypothyroidism, chronic kidney disease and cancer were more prevalent in more affluent areas. CONCLUSIONS Our findings highlight the health inequalities faced by people with SMI. The provision of appropriate timely health prevention, promotion and monitoring activities to reduce these health inequalities are needed, especially in deprived areas.
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Affiliation(s)
- Siobhan Reilly
- Division of Health Research, Faculty of Health and Medicine, Lancaster University, Lancaster, UK
| | - Ivan Olier
- Manchester Institute of Biotechnology, University of Manchester, Manchester, UK
| | - Claire Planner
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - David Reeves
- Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, UK
| | - Linda Gask
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK
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