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Franklin M, Hinde S, Hunter RM, Richardson G, Whittaker W. Is Economic Evaluation and Care Commissioning Focused on Achieving the Same Outcomes? Resource-Allocation Considerations and Challenges Using England as a Case Study. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2024; 22:435-445. [PMID: 38467989 PMCID: PMC11178631 DOI: 10.1007/s40258-024-00875-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 02/08/2024] [Indexed: 03/13/2024]
Abstract
Commissioning describes the process of contracting appropriate care services to address pre-identified needs through pre-agreed payment structures. Outcomes-based commissioning (i.e., paying services for pre-agreed outcomes) shares a common goal with economic evaluation: achieving value for money for relevant outcomes (e.g., health) achieved from a finite budget. We describe considerations and challenges as to the practical role of relevant outcomes for evaluation and commissioning, seeking to bridge a gap between economic evaluation evidence and care commissioning. We describe conceptual (e.g., what are 'relevant' outcomes) alongside practical considerations (e.g., quantifying and using relevant endpoint or surrogate outcomes) and pertinent issues when linking outcomes to commissioning-based payment mechanisms, using England as a case study. Economic evaluation often focuses on a single endpoint health-focused maximand, e.g., quality-adjusted life-years (QALYs), whereas commissioning often focuses on activity-based surrogate outcomes (e.g., health monitoring), as easier-to-measure key performance indicators that are more acceptable (e.g., by clinicians) and amenable to being linked with payment structures. However, payments linked to endpoint and/or surrogate outcomes can lead to market inefficiencies; for example, when surrogates do not have the intended causal effect on endpoint outcomes or when service activity focuses on only people who can achieve prespecified payment-linked outcomes. Accounting for and explaining direct links from commissioners' payment structures to surrogate and then endpoint economic outcomes is a vital step to bridging a gap between economic evaluation approaches and commissioning. Decision-analytic models could aid this but they must be designed to account for relevant surrogate and endpoint outcomes, the payments assigned to such outcomes, and their interaction with the system commissioners purport to influence.
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Affiliation(s)
- Matthew Franklin
- Sheffield Centre for Health and Related Research (SCHARR), Division of Population Health, School of Medicine and Population Health, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK.
| | - Sebastian Hinde
- Centre for Health Economics (CHE), University of York, Heslington, York, YO10 5DD, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, Royal Free Medical School, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Gerry Richardson
- Centre for Health Economics (CHE), University of York, Heslington, York, YO10 5DD, UK
| | - William Whittaker
- Division of Population Health, Health Services Research & Primary Care, Alliance Manchester Business School, Institute for Health Policy and Organisation, Oxford Road, Manchester, M13 9PL, UK
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Chaves ACC, Scherer MDDA, Conill EM. What contributes to Primary Health Care effectiveness? Integrative literature review, 2010-2020. CIENCIA & SAUDE COLETIVA 2023; 28:2537-2551. [PMID: 37672445 DOI: 10.1590/1413-81232023289.15342022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Accepted: 01/11/2023] [Indexed: 09/08/2023] Open
Abstract
Primary Health Care (PHC) intends to rearrange services to make it more effective. Nevertheless, effectiveness in PHC is quite a challenge. This study reviews several articles regarding the effectiveness improvements in PHC between 2010 and 2020. Ninety out of 8,369 articles found in PubMed and the Virtual Health Library databases search were selected for thematic analysis using the Atlas.ti® 9.0 software. There were four categories identified: strategies for monitoring and evaluating health services, organizational arrangements, models and technologies applied to PHC. Studies concerning the sensitive conditions indicators were predominant. Institutional assessment programs, PHC as a structuring policy, appropriate workforce, measures to increase access and digital technologies showed positive effects. However, payment for performance is still controversial. The expressive number of Brazilian publications reveals the broad diffusion of PHC in the country and the concern on its performance. These findings reassure well-known aspects, but it also points to the need for a logical model to better define what is intended as effectiveness within primary health care as well as clarify the polysemy that surrounds the concept. We also suggest substituting the term "resolvability", commonly used in Brazil, for "effectiveness".
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Lu JFR, Chen YI, Eggleston K, Chen CH, Chen B. Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:717-733. [PMID: 35995886 DOI: 10.1007/s10198-022-01504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 07/26/2022] [Indexed: 05/20/2023]
Abstract
Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.
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Affiliation(s)
- Jui-Fen Rachel Lu
- Graduate Institute of Business and Management and Department of Health Care Management, College of Management, Chang Gung University, Taoyuan City, Taiwan
- Department of Radiation Oncology, Chang Gung Memorial Hospital in Linkou, Taoyuan City, Taiwan
| | - Ying Isabel Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Karen Eggleston
- Shorenstein Asia-Pacific Research Center, Freeman Spogli Institute for International Studies, Stanford University, and NBER, Stanford, CA, USA
| | - Chih-Hung Chen
- Division of Metabolism, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Brian Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
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4
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Ashworth M, L'Esperance V, Gerada C. Primary care: a national asset. Br J Gen Pract 2023; 73:244-245. [PMID: 37230791 PMCID: PMC10229176 DOI: 10.3399/bjgp23x732885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023] Open
Affiliation(s)
- Mark Ashworth
- School of Life Course and Population Sciences, King's College London, London
| | - Veline L'Esperance
- National Institute for Health and Care Research (NIHR) Doctoral Research Fellow, School of Life Course and Population Sciences, King's College London, London
| | - Clare Gerada
- School of Life Course and Population Sciences, King's College London, London
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5
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Checkland K. Quality improvement in primary care. BMJ 2023; 380:582. [PMID: 36948511 DOI: 10.1136/bmj.p582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Affiliation(s)
- Kath Checkland
- School of Health Sciences, University of Manchester, Manchester, UK
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6
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Sanchez MA, Sanchez S, Bouazzi L, Peillard L, Ohl-Hurtaud A, Quantin C. Does the implementation of pay-for-performance indicators improve the quality of healthcare? First results in France. Front Public Health 2023; 11:1063806. [PMID: 36969635 PMCID: PMC10035788 DOI: 10.3389/fpubh.2023.1063806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 02/20/2023] [Indexed: 03/12/2023] Open
Abstract
BackgroundPay-for-performance (P4P) models are intended to promote quality of care in both hospitals and primary care settings. They are considered as a means of changing medical practices, particularly in primary care.ObjectivesThe first objective of this study was to assess how performance indicators changed over time, measured through “Remuneration on Public Health Objectives” (ROSP) scores, between 2017 and 2020 in a large French region (Grand Est region), and to compare this evolution in the rural vs. urban areas of the region. The second objective was to focus on the area with the least improvement in ROSP scores and to investigate whether the scores and the available sociodemographic characteristics of the area were associated.MethodsFirst, we measured the evolution over time of P4P indicators (i.e., ROSP scores) obtained from the regional health insurance system, for GP practices in the Grand Est region between 2017 and 2020. We then compared the scores between the Aube Department and the rest of the region (urban areas). To address the second objective, we focused on the area found to have the least improvement in indicators to investigate whether there was a relationship between ROSP score and sociodemographic characteristics.ResultsMore than 40,000 scores were collected. We observed an overall improvement in scores over the study period. The urban area (Grand Est region minus the Aube) scored better than the rural area (Aube) for chronic disease management [median 0.91 (0.84–0.95) vs. 0.90(0.79–0.94), p < 0.001] and prevention [median 0.36 (0.22–0.45) vs. 0.33 (0.17–0.43), p < 0.001], but not for efficiency, where the rural area (Aube) performed better [median 0.67(0.56–0.74) vs. 0.69 (0.57–0.75 in the rest of the Grand Est region, p = 0.004]. In the rural area, we found no significant association between ROSP scores and sociodemographic characteristics, except for extreme rurality in some sub-areas.ConclusionsAt the regional level, the overall improvement in scores observed between 2017 and 2020 suggests that the implementation of ROSP indicators have improved the quality of care, particularly in urban areas. These results also suggest that efforts should be focused on rural areas, which already had the lowest scores at the start of the P4P program.
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Affiliation(s)
- Marc-Antoine Sanchez
- Information Systems and Digital Department, French Military Health Service, Saint-Mandé, France
- Centre de recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines, Université Paris-Saclay, Inserm, High-Dimensional Biostatistics for Drug Safety and Genomics, Villejuif, France
| | - Stéphane Sanchez
- University Committee of Resources for Research in Health (CURRS), University of Reims, Champagne-Ardenne, Reims, France
- Pole Territorial Santé Publique et Performance, Hôpitaux Champagne Sud, Troyes, France
| | - Leila Bouazzi
- University Committee of Resources for Research in Health (CURRS), University of Reims, Champagne-Ardenne, Reims, France
| | - Louise Peillard
- Pole Territorial Santé Publique et Performance, Hôpitaux Champagne Sud, Troyes, France
| | - Aline Ohl-Hurtaud
- General Practice Department, University of Reims Champagne-Ardenne, Reims, France
| | - Catherine Quantin
- Clinical Epidemiology and Clinical Trials Unit, Biostatistics and Bioinformatics (DIM), Centre d'Investigation Clinique 1432, Clinical Investigation Center, Dijon University Hospital, Dijon, France
- Inserm, Centre de recherche en Epidémiologie et Santé des Populations, Université Paris-Saclay, Université de Versailles Saint-Quentin-en-Yvelines, Villejuif, France
- *Correspondence: Catherine Quantin
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Moffatt S, Wildman J, Pollard TM, Gibson K, Wildman JM, O’Brien N, Griffith B, Morris SL, Moloney E, Jeffries J, Pearce M, Mohammed W. Impact of a social prescribing intervention in North East England on adults with type 2 diabetes: the SPRING_NE multimethod study. PUBLIC HEALTH RESEARCH 2023; 11:1-185. [DOI: 10.3310/aqxc8219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023] Open
Abstract
Background
Link worker social prescribing enables health-care professionals to address patients’ non-medical needs by linking patients into various services. Evidence for its effectiveness and how it is experienced by link workers and clients is lacking.
Objectives
To evaluate the impact and costs of a link worker social prescribing intervention on health and health-care costs and utilisation and to observe link worker delivery and patient engagement.
Data sources
Quality Outcomes Framework and Secondary Services Use data.
Design
Multimethods comprising (1) quasi-experimental evaluation of effects of social prescribing on health and health-care use, (2) cost-effectiveness analysis, (3) ethnographic methods to explore intervention delivery and receipt, and (4) a supplementary interview study examining intervention impact during the first UK COVID-19 lockdown (April–July 2020).
Study population and setting
Community-dwelling adults aged 40–74 years with type 2 diabetes and link workers in a socioeconomically deprived locality of North East England, UK.
Intervention
Link worker social prescribing to improve health and well-being-related outcomes among people with long-term conditions.
Participants
(1) Health outcomes study, approximately n = 8400 patients; EuroQol-5 Dimensions, five-level version (EQ-5D-5L), study, n = 694 (baseline) and n = 474 (follow-up); (2) ethnography, n = 20 link workers and n = 19 clients; and COVID-19 interviews, n = 14 staff and n = 44 clients.
Main outcome measures
The main outcome measures were glycated haemoglobin level (HbA1c; primary outcome), body mass index, blood pressure, cholesterol level, smoking status, health-care costs and utilisation, and EQ-5D-5L score.
Results
Intention-to-treat analysis of approximately 8400 patients in 13 intervention and 11 control general practices demonstrated a statistically significant, although not clinically significant, difference in HbA1c level (–1.11 mmol/mol) and a non-statistically significant 1.5-percentage-point reduction in the probability of having high blood pressure, but no statistically significant effects on other outcomes. Health-care cost estimates ranged from £18.22 (individuals with one extra comorbidity) to –£50.35 (individuals with no extra comorbidity). A statistically non-significant shift from unplanned (non-elective and accident and emergency admissions) to planned care (elective and outpatient care) was observed. Subgroup analysis showed more benefit for individuals living in more deprived areas, for the ethnically white and those with fewer comorbidities. The mean cost of the intervention itself was £1345 per participant; the incremental mean health gain was 0.004 quality-adjusted life-years (95% confidence interval –0.022 to 0.029 quality-adjusted life-years); and the incremental cost-effectiveness ratio was £327,250 per quality-adjusted life-year gained. Ethnographic data showed that successfully embedded, holistic social prescribing providing supported linking to navigate social determinants of health was challenging to deliver, but could offer opportunities for improving health and well-being. However, the intervention was heterogeneous and was shaped in unanticipated ways by the delivery context. Pressures to generate referrals and meet targets detracted from face-to-face contact and capacity to address setbacks among those with complex health and social problems.
Limitations
The limitations of the study include (1) a reduced sample size because of non-participation of seven general practices; (2) incompleteness and unreliability of some of the Quality and Outcomes Framework data; (3) unavailability of accurate data on intervention intensity and patient comorbidity; (4) reliance on an exploratory analysis with significant sensitivity analysis; and (5) limited perspectives from voluntary, community and social enterprise.
Conclusions
This social prescribing model resulted in a small improvement in glycaemic control. Outcome effects varied across different groups and the experience of social prescribing differed depending on client circumstances.
Future work
To examine how the NHS Primary Care Network social prescribing is being operationalised; its impact on health outcomes, service use and costs; and its tailoring to different contexts.
Trial registration
This trial is registered as ISRCTN13880272.
Funding
This project was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme, Community Groups and Health Promotion (grant no. 16/122/33) and will be published in full in Public Health Research; Vol. 11, No. 2. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Suzanne Moffatt
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - John Wildman
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Kate Gibson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Josephine M Wildman
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola O’Brien
- Department of Psychology, Northumbria University, Newcastle upon Tyne, UK
| | - Bethan Griffith
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Eoin Moloney
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jayne Jeffries
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Pearce
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Wael Mohammed
- Public Health Economics and Decision Science (DTC), Sheffield University, Sheffield, UK
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8
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Strohbehn GW, Cooperrider JH, Yang D, Fendrick AM, Ratain MJ, Zaric GS. Pfizer and Palbociclib in China: Analyzing an Oncology Pay-for-Performance Plan. Value Health Reg Issues 2022; 31:34-38. [PMID: 35395499 DOI: 10.1016/j.vhri.2022.01.007] [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: 07/02/2021] [Revised: 12/21/2021] [Accepted: 01/23/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVES China is poised to become the world's second-largest oncology drug market. Its ability to continue broadening health coverage is in question. Institutional innovations such as performance-based risk-sharing agreements (PBRSAs) have been developed to promote access to novel therapeutics beyond that provided by public health insurance and central procurement systems. We examine in depth the financial implications of a PBRSA developed in China for the breast cancer drug palbociclib. METHODS We generated a 2-state Markov model from PBRSA information made publicly available. Model inputs included breast cancer outcomes data from the published literature. The primary analysis estimates the percentage reduction in overall drug expenditures due to the PBRSA. Sensitivity analyses explored the financial impact of varied computed tomography scan utilization, rebate rate, and rebate duration. RESULTS Estimated palbociclib expenditures for the PBRSA cohort totaled $36 278 000. Based on the publicly available information for the PBRSA, an effective discount of 1.3% was estimated. The effective discount was insensitive to changes in computed tomography scan utilization. CONCLUSIONS The palbociclib PBRSA likely had negligible impact on patient access to therapy and limited downstream financial impact to patients and payers. The short duration of the rebate window, small rebate, and disease indolence contributed to the low expected rebate percentage.
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Affiliation(s)
- Garth W Strohbehn
- Ann Arbor Veterans Affairs Center for Clinical Management and Research, University of Michigan, Ann Arbor, MI, USA; Rogel Comprehensive Cancer Center, University of Michigan, Ann Arbor, MI, USA.
| | | | - Dali Yang
- Department of Political Science, University of Chicago, Chicago, IL, USA
| | - A Mark Fendrick
- Center for Value-Based Insurance Design, University of Michigan, Ann Arbor, MI, USA
| | - Mark J Ratain
- Comprehensive Cancer Center, University of Chicago, Chicago, IL, USA
| | - Gregory S Zaric
- Ivey Business School, Western University, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
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9
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Peel JK, Neves Miranda R, Naimark D, Woodward G, Mamas MA, Madan M, Wijeysundera HC. Financial Incentives for Transcatheter Aortic Valve Implantation in Ontario, Canada: A Cost-Utility Analysis. J Am Heart Assoc 2022; 11:e025085. [PMID: 35411786 PMCID: PMC9238449 DOI: 10.1161/jaha.121.025085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Transcatheter aortic valve implantation (TAVI) is a minimally invasive therapy for patients with severe aortic stenosis, which has become standard of care. The objective of this study was to determine the maximum cost‐effective investment in TAVI care that should be made at a health system level to meet quality indicator goals. Methods and Results We performed a cost‐utility analysis using probabilistic patient‐level simulation of TAVI care from the Ontario, Canada, Ministry of Health perspective. Costs and health utilities were accrued over a 2‐year time horizon. We created 4 hypothetical strategies that represented TAVI care meeting ≥1 quality indicator targets, (1) reduced wait times, (2) reduced hospital length of stay, (3) reduced pacemaker use, and (4) combined strategy, and compared these with current TAVI care. Per‐person costs, quality‐adjusted life years, and clinical outcomes were estimated by the model. Using these, incremental net monetary benefits were calculated for each strategy at different cost‐effectiveness thresholds between $0 and $100 000 per quality‐adjusted life year. Clinical improvements over the current practice were estimated with all comparator strategies. In Ontario, achieving quality indicator benchmarks could avoid ≈26 wait‐list deaths and 200 wait‐list hospitalizations annually. Compared with current TAVI care, the incremental net monetary benefit for this strategy varied from $10 765 (±$8721) and $17 221 (±$8977). This would translate to an annual investment of between ≈$14 to ≈$22 million by the Ontario Ministry of Health to incentivize these performance measures being cost‐effective. Conclusions This study has quantified the modest annual investment required and substantial clinical benefit of meeting improvement goals in TAVI care.
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Affiliation(s)
- John K Peel
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Department of Anesthesiology and Pain Medicine University of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada
| | - Rafael Neves Miranda
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada
| | - David Naimark
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada.,Sunnybrook Research InstituteSunnybrook Health Sciences Centre Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada
| | | | - Mamas A Mamas
- Keele Cardiovascular Research Group Keele University Keele United Kingdom
| | - Mina Madan
- Sunnybrook Research InstituteSunnybrook Health Sciences Centre Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada
| | - Harindra C Wijeysundera
- Institute of Health Policy, Management, and EvaluationUniversity of Toronto Ontario Canada.,Toronto Health Economics and Technology Assessment Collaborative Toronto Ontario Canada.,Sunnybrook Research InstituteSunnybrook Health Sciences Centre Toronto Ontario Canada.,Department of Medicine University of Toronto Ontario Canada
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10
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Giancotti M, Mauro M, Rania F. Exploring the effectiveness of a P4P scheme from the perspective of Italian general practitioners: A replication study. Int J Health Plann Manage 2022; 37:1526-1544. [DOI: 10.1002/hpm.3417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/08/2021] [Accepted: 01/03/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Monica Giancotti
- Department of Clinical and Experimental Medicine Magna Graecia University of Catanzaro Catanzaro Italy
| | - Marianna Mauro
- Department of Clinical and Experimental Medicine Magna Graecia University of Catanzaro Catanzaro Italy
| | - Francesco Rania
- Department of Law, Economics and Sociology Magna Graecia University of Catanzaro Catanzaro Italy
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11
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Khedmati Morasae E, Rose TC, Gabbay M, Buckels L, Morris C, Poll S, Goodall M, Barnett R, Barr B. Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study. Med Care Res Rev 2021; 79:394-403. [PMID: 34323143 PMCID: PMC9052704 DOI: 10.1177/10775587211035280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
National financial incentive schemes for improving the quality of primary care
have come under criticism in the United Kingdom, leading to calls for localized
alternatives. This study investigated whether a local general practice
incentive-based quality improvement scheme launched in 2011 in a city in the
North West of England was associated with a reduction in all-cause emergency
hospital admissions. Difference-in-differences analysis was used to compare the
change in emergency admission rates in the intervention city, to the change in a
matched comparison population. Emergency admissions rates fell by 19 per 1,000
people in the years following the intervention (95% confidence interval [17,
21]) in the intervention city, relative to the comparison population. This
effect was greater among more disadvantaged populations, narrowing socioeconomic
inequalities in emergency admissions. The findings suggest that similar
approaches could be an effective component of strategies to reduce unplanned
hospital admissions elsewhere.
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Affiliation(s)
| | | | | | - Laura Buckels
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Sharon Poll
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Rob Barnett
- Liverpool Local Medical Committee, Liverpool, UK
| | - Ben Barr
- University of Liverpool, Liverpool, UK
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12
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Love-Koh J, Mirelman A, Suhrcke M. Equity and economic evaluation of system-level health interventions: A case study of Brazil's Family Health Program. Health Policy Plan 2021; 36:229-238. [PMID: 33386400 DOI: 10.1093/heapol/czaa181] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/24/2020] [Indexed: 11/14/2022] Open
Abstract
Distributional economic evaluation estimates the value for money of health interventions in terms of population health and health equity impacts. When applied to interventions delivered at the population and health system-level interventions (PSIs) instead of clinical interventions, additional practical and methodological challenges arise. Using the example of the Programme Saúde da Familia (PSF) in Brazil, a community-level primary care system intervention, we seek to illustrate these challenges and provide potential solutions. We use a distributional cost-effectiveness analysis (DCEA) approach to evaluate the impact of the PSF on population health and between-state health inequalities in Brazil. Data on baseline health status, disease prevalence and PSF effectiveness are extracted from the literature and incorporated into a Markov model to estimate the long-term impacts in terms of disability-adjusted life years. The inequality and average health impacts are analysed simultaneously using health-related social welfare functions. Uncertainty is computed using Monte Carlo simulation. The DCEA encountered several challenges in the context of PSIs. Non-randomized, quasi-experimental methods may not be powered to identify treatment effect heterogeneity estimates to inform a decision model. PSIs are more likely to be funded from multiple public sector budgets, complicating the calculation of health opportunity costs. We estimate a cost-per-disability-adjusted life years of funding the PSF of $2640. Net benefits were positive across the likely range of intervention cost. Social welfare analysis indicates that, compared to gains in average health, changes in health inequalities accounted for a small proportion of the total welfare improvement, even at high levels of social inequality aversion. Evidence on the population health and health equity impacts of PSIs can be incorporated into economic evaluation methods, although with additional complexity and assumptions. The case study results indicate that the PSF is likely to be cost-effective but that the inequality impacts are small and highly uncertain.
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Affiliation(s)
- James Love-Koh
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York YO10 5DD, UK
| | - Andrew Mirelman
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York YO10 5DD, UK.,Health Systems Governance and Financing, Universal Health Coverage and Life Course, WHO, Geneva, Switzerland
| | - Marc Suhrcke
- Centre for Health Economics, University of York, Alcuin A Block, Heslington, York YO10 5DD, UK.,Luxembourg Institute of Socio-Economic Research 11, Porte des Sciences L-4366 Esch-sur-Alzette Luxemburg
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13
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Walker S, Fox A, Altunkaya J, Colbourn T, Drummond M, Griffin S, Gutacker N, Revill P, Sculpher M. Program Evaluation of Population- and System-Level Policies: Evidence for Decision Making. Med Decis Making 2021; 42:17-27. [PMID: 34041992 DOI: 10.1177/0272989x211016427] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Policy evaluations often focus on ex post estimation of causal effects on short-term surrogate outcomes. The value of such information is limited for decision making, as the failure to reflect policy-relevant outcomes and disregard for opportunity costs prohibits the assessment of value for money. Further, these evaluations do not always consider all relevant evidence, other courses of action, or decision uncertainty. METHODS In this article, we explore how policy evaluation could better meet the needs of decision making. We begin by defining the evidence required to inform decision making. We then conduct a literature review of challenges in evaluating policies. Finally, we highlight potential methods available to help address these challenges. RESULTS The evidence required to inform decision making includes the impacts on the policy-relevant outcomes, the costs and associated opportunity costs, and the consequences of uncertainty. Challenges in evaluating health policies are described using 8 categories: 1) valuation space; 2) comparators; 3) time of evaluation; 4) mechanisms of action; 5) effects; 6) resources, constraints, and opportunity costs; 7) fidelity, adaptation, and level of implementation; and 8) generalizability and external validity. Methods from a broad set of disciplines are available to improve policy evaluation, relating to causal inference, decision-analytic modeling, theory of change, realist evaluation, and structured expert elicitation. LIMITATIONS The targeted review may not identify all possible challenges, and the methods covered are not exhaustive. CONCLUSIONS Evaluations should provide appropriate evidence to inform decision making. There are challenges in evaluating policies, but methods from multiple disciplines are available to address these challenges. IMPLICATIONS Evaluators need to carefully consider the decision being informed, the necessary evidence to inform it, and the appropriate methods.[Box: see text].
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Affiliation(s)
- Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Aimee Fox
- Adelphi Values, Bollington, Cheshire, UK
| | - James Altunkaya
- Nuffield Department of Population Health, University of Oxford, Oxford, Oxfordshire, UK
| | - Tim Colbourn
- Institute for Global Health, University College London, London, UK
| | - Mike Drummond
- Centre for Health Economics, University of York, York, UK
| | - Susan Griffin
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Paul Revill
- Centre for Health Economics, University of York, York, UK
| | - Mark Sculpher
- Centre for Health Economics, University of York, York, UK
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Gené-Badia J. [Let's take advantage of the COVID-19 pandemic to overcome the inefficient pay for performance scheme]. Aten Primaria 2020; 53:101958. [PMID: 33494032 PMCID: PMC7836365 DOI: 10.1016/j.aprim.2020.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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15
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Anselmi L, Borghi J, Brown GW, Fichera E, Hanson K, Kadungure A, Kovacs R, Kristensen SR, Singh NS, Sutton M. Pay for Performance: A Reflection on How a Global Perspective Could Enhance Policy and Research. Int J Health Policy Manag 2020; 9:365-369. [PMID: 32610713 PMCID: PMC7557422 DOI: 10.34172/ijhpm.2020.23] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2019] [Accepted: 02/15/2020] [Indexed: 12/27/2022] Open
Abstract
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.
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Affiliation(s)
- Laura Anselmi
- Health, Organisation, Policy and Economics (HOPE), Centre for Primary Care and Health Service Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Josephine Borghi
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Garrett Wallace Brown
- School of Politics and International Studies (POLIS), University of Leeds, Leeds, UK
| | | | - Kara Hanson
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | | | - Roxanne Kovacs
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Søren Rud Kristensen
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK
| | - Neha S Singh
- Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Matt Sutton
- Health, Organisation, Policy and Economics (HOPE), Centre for Primary Care and Health Service Research, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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16
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The effect of 'paying for performance' on the management of type 2 diabetes mellitus: a cross-sectional observational study. BJGP Open 2020; 4:bjgpopen20X101021. [PMID: 32238389 PMCID: PMC7330226 DOI: 10.3399/bjgpopen20x101021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/29/2019] [Indexed: 12/20/2022] Open
Abstract
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.
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Gupta N, Lavallée R, Ayles J. Gendered effects of pay for performance among family physicians for chronic disease care: an economic evaluation in a context of universal health coverage. HUMAN RESOURCES FOR HEALTH 2019; 17:40. [PMID: 31151400 PMCID: PMC6544935 DOI: 10.1186/s12960-019-0378-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/13/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Despite increasing popularity among health organizations of pay for performance (P4P) for the provision of comprehensive care for chronic non-communicable diseases, evidence of its effectiveness in improving health system outcomes is weak. An important void in the evidence base is whether there are gendered differences in P4P uptake and in related outcomes amenable to healthcare improvement. This study assesses the gender-specific effects of P4P among family physicians on diabetes healthcare costs in a context of universal health coverage. METHODS We use population-based linked longitudinal administrative datasets on chronic disease cases, physician billings, hospital discharge abstracts, and physician and resident registries in the province of New Brunswick, Canada. We estimate the effects of introduction of a P4P scheme on excess public healthcare costs among cohorts of adult diabetes patients using propensity score-adjusted difference-in-differences regressions stratified by physician's gender. RESULTS We observed greater male physician uptake of incentive payments, seemingly exacerbating gender gaps in professional remuneration. Regression results indicated P4P did not lead to improved outcomes in terms of preventing hospitalization costs among patients, only measurable increases in compensation for both the male and female physician workforce. CONCLUSIONS While P4P was not attributed in this study to reduced hospital burden and enhanced sustainability of healthcare financing, incentive payments were found to be related to earning gaps by physician's gender. Decision-makers should consider that benefits of P4P be monitored not only for patient metrics but also for provider metrics in terms of gender equality especially given feminization of primary care medical workforces.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, 3 Bailey Drive, Fredericton, New Brunswick Canada
| | - René Lavallée
- New Brunswick Department of Health, 520 King Street, Fredericton, New Brunswick Canada
| | - James Ayles
- New Brunswick Department of Health, 520 King Street, Fredericton, New Brunswick Canada
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Begg A. Life after QOF. PRACTICAL DIABETES 2019. [DOI: 10.1002/pdi.2219] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- Alan Begg
- TownheadLinks Health Centre Montrose UK
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