Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data

The role of pay-for-performance in reducing healthcare disparities: A narrative literature review

As American healthcare shifts to value-based payment, Pay-for-Performance (P4P) has become an important and controversial topic. One of the main controversies pertains to its potential to narrow or widen existing healthcare disparities depending on how the program is designed and implemented. It is thus imperative to understand which design features are most likely to reduce disparities. We conducted a systematic literature review from 2004 to 2021 of P4P's impact on disparities. Given the interdisciplinary nature of P4P research, multiple search strategies were combined, and many study designs were eligible for analysis. The literature was then qualitatively analyzed, with themes and major findings developed using Grounded Theory. Six major design features emerged as most promising in leveraging P4P to reduce disparities: 1) Risk/Case-Mix Adjustment; 2) Stratified Performance Measures/Stratification; 3) Disparity Reduction Metrics; 4) Exception Reporting; 5) Pay-for-Improvement; and 6) Population-Specific Metrics. Each design feature has its own mechanism, strengths, and weaknesses. We identify and define these features' direct and indirect effects on healthcare disparities. The interaction of each design feature with one another, with P4P as a whole, and within the larger reimbursement system can have considerable effects on disparities. Promising strategies exist to leverage P4P to narrow disparities for clinically and socially complex patients. The six design features discussed in this review help P4P programs address structural disadvantages faced by such patients and their providers. In regard to health equity, these design features can transform P4P from being part of the problem to being part of the solution.

Identification and management of frailty in English primary care: a qualitative study of national policy

Background

Policymakers are directing attention to addressing the needs of an ageing population. Since 2017, general practices in England have been contractually required to identify and code ‘frailty’ as a new clinical concept and, in doing so, support targeted management for this population with the aim of improving outcomes. However, embedding frailty policies into routine practice is not without challenges and little is currently known about the success of the programme.

Aim

To explore the implementation of a national policy on frailty identification and management in English primary care.

Design & setting

Qualitative study entailing interviews with primary care professionals in the North of England.

Method

Semi-structured interviews were conducted with GPs (n = 10), nurses (n = 6), practice managers (n = 3), and health advisors (n = 3). Normalisation process theory (NPT) and ‘system thinking’ provided sensitising frameworks to support data collection and analysis.

Results

Primary care professionals were starting to use the concept of frailty to structure care within practices and across organisations; however, there was widespread concern about the challenge of providing expanded care for the identified needs with existing resources. Concerns were also expressed around how best to identify the frail subpopulation and the limitations of current tools for this, and there was a professional reticence to use the term ‘frailty’ with patients.

Conclusion

Findings suggests that additional, focused resources and the development of a stronger evidence base are essential to facilitate professional engagement in policies to improve the targeted coding and management of frailty in primary care.

Disparities in glycaemic control, monitoring, and treatment of type 2 diabetes in England: A retrospective cohort analysis

BACKGROUND

Disparities in type 2 diabetes (T2D) care provision and clinical outcomes have been reported in the last 2 decades in the UK. Since then, a number of initiatives have attempted to address this imbalance. The aim was to evaluate contemporary data as to whether disparities exist in glycaemic control, monitoring, and prescribing in people with T2D.

METHODS AND FINDINGS

A T2D cohort was identified from the Royal College of General Practitioners Research and Surveillance Centre dataset: a nationally representative sample of 164 primary care practices (general practices) across England. Diabetes healthcare provision and glucose-lowering medication use between 1 January 2012 and 31 December 2016 were studied. Healthcare provision included annual HbA1c, renal function (estimated glomerular filtration rate [eGFR]), blood pressure (BP), retinopathy, and neuropathy testing. Variables potentially associated with disparity outcomes were assessed using mixed effects logistic and linear regression, adjusted for age, sex, ethnicity, and socioeconomic status (SES) using the Index of Multiple Deprivation (IMD), and nested using random effects within general practices. Ethnicity was defined using the Office for National Statistics ethnicity categories: White, Mixed, Asian, Black, and Other (including Arab people and other groups not classified elsewhere). From the primary care adult population (n = 1,238,909), we identified a cohort of 84,452 (5.29%) adults with T2D. The mean age of people with T2D in the included cohort at 31 December 2016 was 68.7 ± 12.6 years; 21,656 (43.9%) were female. The mean body mass index was 30.7 ± SD 6.4 kg/m2. The most deprived groups (IMD quintiles 1 and 2) showed poorer HbA1c than the least deprived (IMD quintile 5). People of Black ethnicity had worse HbA1c than those of White ethnicity. Asian individuals were less likely than White individuals to be prescribed insulin (odds ratio [OR] 0.86, 95% CI 0.79-0.95; p < 0.01), sodium-glucose cotransporter-2 (SGLT2) inhibitors (OR 0.68, 95% CI 0.58-0.79; p < 0.001), and glucagon-like peptide-1 (GLP-1) agonists (OR 0.37, 95% CI 0.31-0.44; p < 0.001). Black individuals were less likely than White individuals to be prescribed SGLT2 inhibitors (OR 0.50, 95% CI 0.39-0.65; p < 0.001) and GLP-1 agonists (OR 0.45, 95% CI 0.35-0.57; p < 0.001). Individuals in IMD quintile 5 were more likely than those in the other IMD quintiles to have annual testing for HbA1c, BP, eGFR, retinopathy, and neuropathy. Black individuals were less likely than White individuals to have annual testing for HbA1c (OR 0.89, 95% CI 0.79-0.99; p = 0.04) and retinopathy (OR 0.82, 95% CI 0.70-0.96; p = 0.011). Asian individuals were more likely than White individuals to have monitoring for HbA1c (OR 1.10, 95% CI 1.01-1.20; p = 0.023) and eGFR (OR 1.09, 95% CI 1.00-1.19; p = 0.048), but less likely for retinopathy (OR 0.88, 95% CI 0.79-0.97; p = 0.01) and neuropathy (OR 0.88, 95% CI 0.80-0.97; p = 0.01). The study is limited by the nature of being observational and defined using retrospectively collected data. Disparities in diabetes care may show regional variation, which was not part of this evaluation.

CONCLUSIONS

Our findings suggest that disparity in glycaemic control, diabetes-related monitoring, and prescription of newer therapies remains a challenge in diabetes care. Both SES and ethnicity were important determinants of inequality. Disparities in glycaemic control and other areas of care may lead to higher rates of complications and adverse outcomes for some groups.

A non-randomised controlled pilot study of clinical pharmacist collaborative intervention for community dwelling patients with COPD

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.

Cultural primer for cardiometabolic health: health disparities, structural factors, community, pathways to improvement, and clinical applications

The quest to optimize cardiometabolic health has created great interest in nonmedical health variables in the population, community-based research and coordination, and addressing social, ethnic, and cultural barriers. All of these may be of equal or even greater importance than classical health care delivery in achieving individual well-being. One dominant issue is health disparity - causes, methods of reduction, and community versus other levels of solutions. This communication summarizes some major views regarding social structures, followed by amplification and synthesis of central ideas in the literature. The role of community involvement, tools, and partnerships is also presented in this Primer. Recent views of how these approaches could be incorporated into cardiometabolic initiatives and strategies follow, with implications for research. Two examples comparing selected aspects of community leverage and interventions in relation to individual approaches to health care equity are examined in depth: overall performance in reducing cardiovascular risk and mortality, and the recent National Diabetes Prevention Program, both touching upon healthy diets and adherence. Finally, the potential that precision medicine offers, and possible effects on disparities are also discussed.