Changes in patient experiences of primary care during health service reforms in England between 2003 and 2007

The performance of general practice in the English National Health Service (NHS): an analysis using Starfield's framework for primary care

General practice in the English National Health Service (NHS) is in crisis. In response, politicians are proposing fundamental reform to the way general practice is organized. But ideas for reform are contested, and there are conflicting interpretations of the problems to be addressed. We use Barbara Starfield's "4Cs" framework for high-performing primary care to provide an overall assessment of the current role and performance of general practice in England. We first assessed theoretical alignment between Starfield's framework and the role of general practice in England. We then assessed actual performance using publicly available national data and targeted literature searches. We found close theoretical alignment between Starfield's framework and the model of NHS general practice in England. But, in practice, its model of universal comprehensive care risks being undermined by worsening and inequitable access, while continuity of care is declining. Underlying causes of current challenges in general practice in England appear more closely linked to under-resourcing than the fundamental design of the system. General practice in England must evolve, but wholesale re-organization is likely to damage and distract. Instead, policymakers should focus on adequately resourcing general practice while supporting general practice teams to improve the quality and coordination of local services.

Exploring the impact of pharmacist comprehensive annual care plans on perceived quality of chronic illness care by patients in Alberta, Canada

Background:

In 2012, the Government of Alberta introduced a funding program to remunerate pharmacists to develop a comprehensive annual care plan (CACP) for patients with complex needs. The objective of this study is to explore patients’ perceptions of the care they received through the pharmacist CACP program in Alberta.

Methods:

We invited 3442 patients who received a pharmacist-billed CACP within the previous 3 months and 6888 matched controls across Alberta to complete an online questionnaire. The questionnaire consisted of the short version Patient Assessment of Chronic Illness Care (PACIC-11), with 3 additional pharmacy-specific assessment questions added. Additional questions related to health status and demographics were also included.

Results:

Overall, most patients indicated a low level of chronic illness care by pharmacists, with few differences noted between CACP patients and non-CACP controls. Of note, controls reported higher quality of care for 5 domains within the adapted PACIC-like tool compared with CACP patients (p < 0.05 for all). Interestingly, only 79 (44%) of CACP patients reported that they had received a CACP, whereas only 192 (66%) of control patients reported that they did not receive a care plan. In a sensitivity analysis including only these respondents, individuals who received a CACP perceived a significantly higher quality of chronic illness care across all PACIC domains.

Conclusion:

Overall, chronic illness care incentivized by the pharmacist CACP program in Alberta is perceived to be moderate to low. When limited to respondents who explicitly recognized receiving the service or not, the perceptions of quality of care were more positive. This suggests that better implementation of CACP by pharmacists may be associated with improved quality of care and that some redesign is needed to engage patients more. Can Pharm J (Ott) 2021;154:xx-xx.

Is continuity of primary care declining in England? Practice-level longitudinal study from 2012 to 2017

BACKGROUND

Continuity of care is a core principle of primary care related to improved patient outcomes and reduced healthcare costs. Evidence suggests continuity of care in England is declining.

AIM

To confirm reports of declining continuity of care, explore differences in decline according to practice characteristics, and examine associations between practice populations or appointment provision and changes in continuity of care.

DESIGN AND SETTING

Longitudinal design on GP Patient Survey data reported annually in June or July from 2012 to 2017, whereby the unit of analysis was English general practices that existed in 2012.

METHOD

Linear univariable and bivariable multilevel models were used to determine decline in average annual percentage of patients having a preferred GP and seeing this GP 'usually' according to practicelevel continuity of care, rural/urban location, and deprivation. Associations between percentage of patients having a preferred GP or seeing this GP usually and patients' experiences with the appointment system and practice population characteristics were modelled.

RESULTS

In 2012, 56.7% of patients had a preferred GP, which had declined by 9.4 percentage points (pp) (95% CI = -9.6 to -9.2) by 2017. Of patients with a preferred GP, 66.4% saw that GP 'usually' in 2012; this had declined by 9.7 pp (95% CI = -10.0 to -9.4) by 2017. This decline was visible in all types of practices, irrespective of baseline continuity, rural/urban location, or level of deprivation. At practice level, an increase over time in the percentage of patients reporting good overall experience of making appointments was associated with an increase in both the percentage of patients having a preferred GP and those able to see that GP 'usually'.

CONCLUSION

Patients reported a steady decline in continuity of care over time, which should concern clinicians and policymakers. Ability of practices to offer patients a satisfactory appointment system could partly counteract this decline.

Patient and public perception and experience of community pharmacy services post-discharge in the UK: a rapid review and qualitative study

OBJECTIVES

To investigate the perception and experience of patients and the public (PP) about community pharmacy (CP) services and other primary care services after hospital discharge back home.

DESIGN AND SETTING

A rapid review and qualitative study exploring PP perceptions of primary care, focusing on CP services in the UK.

METHODS

A mixed-methods approach was adopted including a rapid review undertaken between 24 April and 8 May 2019 across four databases (MEDLINE, EMBASE, PsycINFO and CINAHL). Semistructured interviews were then conducted investigating for shifts in current PP perception, but also nuanced opinion pertaining to CP services. A convenience sampling technique was used through two online PP groups for recruitment. Thematic framework analysis was applied to interview transcripts.

PARTICIPANTS

Any consenting adults ≥18 years old were invited regardless of their medical condition, and whether they had used post-discharge services or not.

RESULTS

Twenty-five studies met the inclusion criteria. Patients were generally supportive and satisfied with primary care services. However, some barriers to the use of these services included: resource limitations; poor communication between healthcare providers or between patient and healthcare providers; and patients' lack of awareness of available services. From the 11 interviewees, there was a lack of awareness of CP post-discharge services. Nevertheless, there was general appreciation of the benefit of CP services to patients, professionals and wider healthcare system. Potential barriers to uptake and use included: accessibility, resource availability, lack of awareness, and privacy and confidentiality issues related to information-sharing. Several participants felt the uptake of such services should be improved.

CONCLUSION

There was alignment between the review and qualitative study about high patient acceptance, appreciation and satisfaction with primary care services post-discharge. Barriers to the use of CP post-discharge services identified from interviews resonated with the existing literature; this is despite developments in pharmacy practice in recent times towards clinical and public health services.

The association between general practitioner regularity of care and 'high use' hospitalisation

Background

In Australia, as in many high income countries, there has been a movement to improve out-of-hospital care. If primary care improvements can yield appropriately lower hospital use, this would improve productive efficiency. This is especially important among ‘high cost users’, a small group of patients accounting for disproportionately high hospitalisation costs. This study aimed to assess the association between regularity of general practitioner (GP) care and ‘high use’ hospitalisation.

Methods

This retrospective, cohort study used linked administrative and survey data from the 45 and Up Study, conducted in New South Wales, Australia. The exposure was regularity of GP care between 1 July 2005 and 30 June 2009, categorised by quintile (lowest to highest). Outcomes were ‘high use’ of hospitalisation (defined as ≥3 and ≥ 5 admissions within 12 months), extended length of stay (LOS, ≥30 days), a combined metric (≥3 hospitalisations in a 12 month period where ≥1 hospitalisation was ≥30 days) and 30-day readmission between 1 July 2009 and 31 December 2017. Associations were assessed using multivariable logistic regression. Potential for outcome prevention in a hypothetical scenario where all individuals attain the highest GP regularity was estimated via the population attributable fraction (PAF).

Results

Of 253,500 eligible participants, 15% had ≥3 and 7% had ≥5 hospitalisations in a 12-month period. Five percent of the cohort had a hospitalisation lasting ≥30 days and 25% had a readmission within 30 days. Compared with lowest regularity, highest regularity was associated with between 6% (p < 0.001) and 11% (p = 0.027) lower odds of ‘high use’. There was a 7–8% reduction in odds for all regularity levels above ‘low’ regularity for LOS ≥30 days. Otherwise, there was no clear sequential reduction in ‘high use’ with increasing regularity. The PAF associated with a move to highest regularity ranged from 0.05 to 0.13. The number of individuals who could have had an outcome prevented was estimated to be between 269 and 2784, depending on outcome.

Conclusions

High GP regularity is associated with a decreased likelihood of ‘high use’ hospitalisation, though for most outcomes there was not an apparent linear association with regularity.

Does accreditation of general practice promote patient-reported quality of care? A natural cluster randomised experiment

OBJECTIVE

To investigate whether accreditation of general practice in Denmark promotes patient-reported quality of care and patient satisfaction.

DESIGN

A national cluster randomised case control study based on an online version of the Danish Patients Evaluate Practice questionnaire. Mixed effects ordered logit regression models taking account of clustering of patients in different municipalities were used in the analyses.

SETTING

General practice in Denmark.

PARTICIPANTS

A representative sample of the Danish population.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure was patient-reported quality of care, and patient satisfaction with general practice and patient satisfaction with the general practitioner served as secondary outcome measures.

RESULTS

In total, 3609 respondents answered the survey. We found no statistically significant relationships between patient-reported quality of care and practice accreditation (2016: OR=0.89, 95% CI 0.73 to 1.07 and 2017: OR=0.85, 95% CI 0.71 to 1.02) and between patient satisfaction with the general practitioner and accreditation (2016: OR=0.93, 95% CI 0.76 to 1.13 and 2017: OR=0.86, 95% CI 0.70 to 1.04). However, there was a statistically significant negative relationship between patient satisfaction with the general practice and recent practice accreditation compared with satisfaction with practices not yet accredited (OR=0.81, 95% CI 0.67 to 0.97) but no significant relationship between patient satisfaction with the general practice and previous accreditation (OR=0.91, 95% CI 0.76 to 1.09).

CONCLUSION

Accreditation does not promote patient-reported quality of care or patient satisfaction. On the contrary, patient satisfaction with the general practice decreases when general practice is recently accredited.

Longitudinal evaluation of a countywide alternative to the Quality and Outcomes Framework in UK General Practice aimed at improving Person Centred Coordinated Care

OBJECTIVES

To evaluate a county-wide deincentivisation of the Quality and Outcomes Framework (QOF) payment scheme for UK General Practice (GP).

SETTING

In 2014, National Health Service England signalled a move towards devolution of QOF to Clinical Commissioning Groups. Fifty-five GPs in Somerset established the Somerset Practice Quality Scheme (SPQS)-a deincentivisation of QOF-with the goal of redirecting resources towards Person Centred Coordinated Care (P3C), especially for those with long-term conditions (LTCs). We evaluated the impact on processes and outcomes of care from April 2016 to March 2017.

PARTICIPANTS AND DESIGN

The evaluation used data from 55 SPQS practices and 17 regional control practices for three survey instruments. We collected patient experiences ('P3C-EQ'; 2363 returns from patients with 1+LTC; 36% response rate), staff experiences ('P3C-practitioner'; 127 professionals) and organisational data ('P3C-OCT'; 36 of 55 practices at two time points, 65% response rate; 17 control practices). Hospital Episode Statistics emergency admission data were analysed for 2014-2017 for ambulatory-sensitive conditions across Somerset using interrupted time series.

RESULTS

Patient and practitioner experiences were similar in SPQS versus control practices. However, discretion from QOF incentives resulted in time savings in the majority of practices, and SPQS practice data showed a significant increase in P3C oriented organisational processes, with a moderate effect size (Wilcoxon signed rank test; p=0.01; r=0.42). Analysis of transformation plans and organisational data suggested stronger federation-level agreements and informal networks, increased multidisciplinary working, reallocation of resources for other healthcare professionals and changes to the structure and timings of GP appointments. No disbenefits were detected in admission data.

CONCLUSION

The SPQS scheme leveraged time savings and reduced administrative burden via discretionary removal of QOF incentives, enabling practices to engage actively in a number of schemes aimed at improving care for people with LTCs. We found no differences in the experiences of patients or healthcare professionals between SPQS and control practices.

Association between continuity of provider-adjusted regularity of general practitioner contact and unplanned diabetes-related hospitalisation: a data linkage study in New South Wales, Australia, using the 45 and Up Study cohort

OBJECTIVE

To assess the association between continuity of provider-adjusted regularity of general practitioner (GP) contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation.

DESIGN

Cross-sectional study.

SETTING

Individual-level linked self-report and administrative health service data from New South Wales, Australia.

PARTICIPANTS

27 409 survey respondents aged ≥45 years with a prior history of diabetes and at least three GP contacts between 1 July 2009 and 30 June 2015.

MAIN OUTCOME MEASURES

Unplanned diabetes-related hospitalisations or ED presentations, associated costs and bed days.

RESULTS

Twenty-one per cent of respondents had an unplanned diabetes-related hospitalisation or ED presentation. Increasing regularity of GP contact was associated with a lower probability of hospitalisation or ED presentation (19.9% for highest quintile, 23.5% for the lowest quintile). Conditional on having an event, there was a small decrease in the number of hospitalisations or ED presentations for the low (-6%) and moderate regularity quintiles (-8%), a reduction in bed days (ranging from -30 to -44%) and a reduction in average cost of between -23% and -41%, all relative to the lowest quintile. When probability of diabetes-related hospitalisation or ED presentation was included, only the inverse association with cost remained significant (mean of $A3798 to $A6350 less per individual, compared with the lowest regularity quintile). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome.

CONCLUSIONS

Higher regularity of GP contact-that is more evenly dispersed, not necessarily more frequent care-has the potential to reduce secondary healthcare costs and, conditional on having an event, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care.

Evaluation of Brazilian Primary Health Care From the Perspective of the Users: Accessible, Continuous, and Acceptable?

The objective of this study was to examine the experience of primary care center (PCC) users in Brazil, classified according to the quality of its structure, in relation to the aspects of accessibility, continuity, and acceptability. The source of information was the National Program to Improve Access and Quality of Primary Care in 2013-2014. A total of 109 919 interviewees in 24 055 PCCs comprised the sample. Results show that the structure of a PCC was associated with better indicators of accessibility (oral health and medicines) and continuity of care (patient navigation in the health system). No association was found between indicators of accessibility and the PCC structure.

Exploring the impact and use of patients' feedback about their care experiences in general practice settings-a realist synthesis

Background

Policy encourages health care providers to listen and respond to feedback from patients, expecting that it will enhance care experiences. Enhancement of patients' experiences may not yet be a reality, particularly in primary health care settings.

Objective

To identify the issues that influence the use and impact of feedback in this context.

Design and Setting

A realist synthesis of studies of the use of patient feedback within primary health care settings.

Methods

Structured review of published studies between 1971 and January 2015.

Results

Eighteen studies were reported in 20 papers. Eleven studies reported patient survey scores as a primary outcome. There is little evidence that formal patient feedback led to enhanced experiences. The likelihood of patient feedback to health care staff stimulating improvements in future patients' experiences appears to be influenced predominantly by staff perceptions of the purpose of such feedback; the validity and type of data that is collected; and where, when and how it is presented to primary health care teams or practitioners and teams' capacity to change.

Conclusions

There is limited research into how patient feedback has been used in primary health care practices or its usefulness as a stimulant to improve health care experience. Using a realist synthesis approach, we have identified a number of contextual and intervention-related factors that appear to influence the likelihood that practitioners will listen to, act on and achieve improvements in patient experience. Consideration of these may support research and improvement work in this area.

Reports of unintended consequences of financial incentives to improve management of hypertension

Background

Given the increase in financial-incentive programs nationwide, many physicians and physician groups are concerned about potential unintended consequences of providing financial incentives to improve quality of care. However, few studies examine whether actual unintended consequences result from providing financial incentives to physicians. We sought to document the extent to which the unintended consequences discussed in the literature were observable in a randomized clinical trial (RCT) of financial incentives.

Methods

We conducted a qualitative observational study nested within a larger RCT of financial incentives to improve hypertension care. We conducted 30-minute telephone interviews with primary care personnel at facilities participating in the RCT housed at12 geographically dispersed Veterans Affairs Medical Centers nationwide. Participants answered questions about unintended effects, clinic team dynamics, organizational impact on care delivery, study participation. We employed a blend of inductive and deductive qualitative techniques for analysis.

Participants

Sixty-five participants were recruited from RCT enrollees and personnel not enrolled in the larger RCT, plus one primary care leader per site.

Results

Emergent themes included possible patient harm, emphasis on documentation over improving care, reduced professional morale, and positive spillover. All discussions of unintended consequences involving patient harm were only concerns, not actual events. Several unintended consequences concerned ancillary initiatives for quality improvement (e.g., practice guidelines and performance measurement systems) rather than financial incentives.

Conclusions

Many unintended consequences of financial incentives noted were either only concerns or attributable to ancillary quality-improvement initiatives. Actual unintended consequences included improved documentation of care without necessarily improving actual care, and positive unintended consequences.

Trial registration

Clinicaltrials.gov Identifier: NCT00302718

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice

OBJECTIVES

To describe how processes of primary care access influence decisions to seek help at the emergency department (ED).

DESIGN

Ethnographic case study combining non-participant observation, informal and formal interviewing.

SETTING

Six general practitioner (GP) practices located in three commissioning organisations in England.

PARTICIPANTS AND METHODS

Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29).

RESULTS

Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like 'urgent' and 'emergency' was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use.

CONCLUSIONS

This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around 'inappropriate' patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

The Use of Enhanced Appointment Access Strategies by Medical Practices

BACKGROUND

Strategies to enhance appointment access are being adopted by medical practices as part of patient-centered medical home (PCMH) implementation, but little is known about the use of these strategies nationally.

OBJECTIVES

We examine practice use of open access scheduling and after-hours care.

RESEARCH DESIGN

Data were analyzed from the Third National Study of Physician Organizations (NSPO3) to examine which enhanced appointment access strategies are more likely to be used by practices with more robust PCMH capabilities and with greater external incentives. Logistic regression estimated the effect of PCMH capabilities and external incentives on practice use of open access scheduling and after-hours care.

SUBJECTS

Physician organizations with >20% primary care physicians (n=1106).

MEASURES

PCMH capabilities included team-based care, health information technology capabilities, quality improvement orientation, and patient experience orientation. External incentives included public reporting, pay-for-performance (P4P), and accountable care organization participation.

RESULTS

A low percentage of practices (19.8%) used same-day open access scheduling, while after-hours care (56.1%) was more common. In adjusted analyses, system-owned practices and practices with greater use of team-based care, health information technology capabilities, and public reporting were more likely to use open access scheduling. Accountable care organization-affiliated practices and practices with greater use of public reporting and P4P were more likely to provide after-hours care.

CONCLUSIONS

Open access scheduling may be most effectively implemented by practices with robust PCMH capabilities. External incentives appear to influence practice adoption of after-hours care. Expanding open access scheduling and after-hours care will require distinct policies and supports.

Patient experiences with family medicine: a longitudinal study after the Dutch health care reforms in 2006

Background

In 2006 The Dutch Health Care system changed to a market oriented system. The GP remuneration changed from ± 2/3 capitation patients and 1/3 private patients before 2006 to a mixed payment scheme. From 2006 onward every patient was insured and the GP received partly capitation, partly fees for consultations and for specific services. This change coincided with many other organisational changes in General Practice care. Our research question was if during the years after 2006 patient experiences of Dutch family practice had changed. We also wanted to explore the influence of patient and practice characteristics on patient experiences. Data on patient experiences were available from 2007 to 2012.

Method

In a series of annual cross sectional patient surveys the performance of GPs and practices was measured. Patient sampling took place as a part of the Dutch accreditation program in 1657 practices involving 2966 GPs. Patients’ experiences, gender, age, health status, and number of annual consultations were documented as well as the type and location of practices. Linear regression analysis was used to examine time trends in patient experiences and the impact of patient and practice characteristics.

Results

78,985 patients assessed the performance of 2966 GPs, and 45,773 patients assessed the organisation of 1657 practices. The number of patients with positive experiences increased significantly between 2007 and 2012; respectively 4.8 % for GPs (beta 0.20 and p < 0.0001) and 6.6 % for practices (beta 0.10, p < 0.004). Higher age, having no chronic illness, more frequent consultations and attending single-handed practices, predicted better patient experiences.

Conclusions

In our evaluation of patient experiences with general practice care from 2007 to 2012 we found an increase of 4.8 % for GPs and 6.6 % for practices respectively. This improvement is significant. While no direct causation can be made, possible explanations may be found in the various reforms in Dutch family practice since 2006. More insight is needed into key determinants of this improvement before policymakers and care providers can attribute the improvement to these reforms.

Using Patient-Reported Information to Improve Clinical Practice

OBJECTIVE

To assess what is known about the relationship between patient experience measures and incentives designed to improve care, and to identify how public policy and medical practices can promote patient-valued outcomes in health systems with strong financial incentives.

DATA SOURCES/STUDY SETTING

Existing literature (gray and peer-reviewed) on measuring patient experience and patient-reported outcomes, identified from Medline and Cochrane databases; evaluations of pay-for-performance programs in the United States, Europe, and the Commonwealth countries.

STUDY DESIGN/DATA COLLECTION

We analyzed (1) studies of pay-for-performance, to identify those including metrics for patient experience, and (2) studies of patient experience and of patient-reported outcomes to identify evidence of influence on clinical practice, whether through public reporting or private reporting to clinicians.

PRINCIPAL FINDINGS

First, we identify four forms of "patient-reported information" (PRI), each with distinctive roles shaping clinical practice: (1) patient-reported outcomes measuring self-assessed physical and mental well-being, (2) surveys of patient experience with clinicians and staff, (3) narrative accounts describing encounters with clinicians in patients' own words, and (4) complaints/grievances signaling patients' distress when treatment or outcomes fall short of expectations. Because these forms vary in crucial ways, each must be distinctively measured, deployed, and linked with financial incentives. Second, although the literature linking incentives to patients experience is limited, implementing pay-for-performance systems appears to threaten certain patient-valued aspects of health care. But incentives can be made compatible with the outcomes patients value if: (a) a sufficient portion of incentives is tied to patient-reported outcomes and experiences, (b) incentivized forms of PRI are complemented by other forms of patient feedback, and (c) health care organizations assist clinicians to interpret and respond to PRI. Finally, we identify roles for the public and private sectors in financing PRI and orchestrating an appropriate balance among its four forms.

CONCLUSIONS

Unless public policies are attentive to patients' perspectives, stronger financial incentives for clinicians can threaten aspects of care that patients most value. Certain policy parameters are already clear, but additional research is required to clarify how best to collect patient narratives in varied settings, how to report narratives to consumers in conjunction with quantified metrics, and how to promote a "culture of learning" at the practice level that incorporates patient feedback.

Patient-doctor continuity and diagnosis of cancer: electronic medical records study in general practice

Background

Continuity of care may affect the diagnostic process in cancer but there is little research.

Aim

To estimate associations between patient–doctor continuity and time to diagnosis and referral of three common cancers.

Design and setting

Retrospective cohort study in general practices in England.

Method

This study used data from the General Practice Research Database for patients aged ≥40 years with a diagnosis of breast, colorectal, or lung cancer. Relevant cancer symptoms or signs were identified up to 12 months before diagnosis. Patient–doctor continuity (fraction-of-care index adjusted for number of consultations) was calculated up to 24 months before diagnosis. Time ratios (TRs) were estimated using accelerated failure time regression models.

Results

Patient–doctor continuity in the 24 months before diagnosis was associated with a slightly later diagnosis of colorectal (time ratio [TR] 1.01, 95% confidence interval [CI] =1.01 to 1.02) but not breast (TR = 1.00, 0.99 to 1.01) or lung cancer (TR = 1.00, 0.99 to 1.00). Secondary analyses suggested that for colorectal and lung cancer, continuity of doctor before the index consultation was associated with a later diagnosis but continuity after the index consultation was associated with an earlier diagnosis, with no such effects for breast cancer. For all three cancers, most of the delay to diagnosis occurred after referral.

Conclusion

Any effect for patient–doctor continuity appears to be small. Future studies should compare investigations, referrals, and diagnoses in patients with and without cancer who present with possible cancer symptoms or signs; and focus on ‘difficult to diagnose’ types of cancer.

Challenges of managing people with multimorbidity in today's healthcare systems

Multimorbidity is a growing issue and poses a major challenge to health care systems around the world. Multimorbidity is related to ageing but many studies have now shown that it is also socially patterned, being more common and occurring at an earlier age in areas of high socioeconomic deprivation. There is lack of research on patients with multimorbidity, and thus guidelines are based on single-conditions. Polypharmacy is common in multimorbidity, increasing drug-disease and drug-drug interactions. Multimorbid patients need holistic care, but secondary care services are highly specialised and thus are often duplicative and fragmented and thus increase treatment burden in multimorbid patients. The cost of care is high in multimorbidity, due to high rates of primary and secondary care consultations and unplanned hospital admissions. The combination of mental and physical conditions increases complexity of care, and costs. Mental-physical multimorbidity is especially common in deprived areas.General practitioners and primary care teams have a key role in managing patients with multimorbidity, using a patient-centred generalist approach. Consultation length and continuity of care may need to be substantially enhanced in order to enable such patients. This will require a radical change in how health care systems are organised and funded in order to effectively meet the challenges of multimorbidity.

Impact of UK Primary Care Policy Reforms on Short-Stay Unplanned Hospital Admissions for Children With Primary Care-Sensitive Conditions

PURPOSE

We aimed to assess the impact of UK primary care policy reforms implemented in April 2004 on potentially avoidable unplanned short-stay hospital admissions for children with primary care-sensitive conditions.

METHODS

We conducted an interrupted time series analysis of hospital admissions for all children aged younger than 15 years in England between April 2000 and March 2012 using data from National Health Service public hospitals in England. The main outcomes were annual short-stay (<2-day) unplanned hospital admission rates for primary care-sensitive infectious and chronic conditions.

RESULTS

There were 7.8 million unplanned admissions over the study period. More than one-half (4,144,729 of 7,831,633) were short-stay admissions for potentially avoidable infectious and chronic conditions. The primary care policy reforms of April 2004 were associated with an 8% increase in short-stay admission rates for chronic conditions, equivalent to 8,500 additional admissions, above the 3% annual increasing trend. Policy reforms were not associated with an increase in short-stay admission rates for infectious illness, which were increasing by 5% annually before April 2004. The proportion of primary care-referred admissions was falling before the reforms, and there were further sharp reductions in 2004.

CONCLUSIONS

The introduction of primary care policy reforms coincided with an increase in short-stay admission rates for children with primary care-sensitive chronic conditions, and with more children being admitted through emergency departments. Short-stay admission rates for primary care-sensitive infectious illness increased more steadily and could be related to lowered thresholds for hospital admission.

Healthcare reimbursement models and orthopaedic trauma: will there be change in patient management? A survey of orthopaedic surgeons

OBJECTIVES

Healthcare reimbursement models are changing. Fee-for-service may be replaced by pay-for-performance or capitated care. The purpose of this study was to examine the potential changes in orthopaedic trauma surgery patient management based on potential shifts in policy surrounding readmission and reimbursement.

METHODS

An e-mail survey consisting of 3 case-based scenarios was delivered to 375 orthopaedic surgeons. Five options for management of each case were provided. Each of the 3 cases was presented in 3 different healthcare settings: scenario A, our current healthcare setting; scenario B, in which 90-day reoperation or readmission would not be reimbursed; and scenario C, in which a capitated healthcare structure paid a fixed amount per patient.

RESULTS

The response rate was 40.3% with 151 surgeons completing the survey. A 71.1% of the respondents were in private practice settings, whereas 28.3% were in academic centers. In each case, there was significant increase in the respondents' choice to transfer patients to tertiary care centers under both the capitated and penalization systems as compared with the current fee-for-service model.

CONCLUSIONS

This survey is the first of its kind to demonstrate through case-based scenarios that a healthcare system with readmission penalties and capitated reimbursement models may lead to a significant increase in transfer of complex orthopaedic trauma patients to tertiary care centers. Physicians should be encouraged to continue evidence-based medicine instead of making decisions due to finances, and other avenues of healthcare savings should be explored to decrease patient transfer rates with healthcare changes.

'Falling through gaps': primary care patients' accounts of breakdowns in experienced continuity of care

BACKGROUND

Experienced continuity is important for good quality primary care but may be challenging to achieve. Little is known about how discontinuities or gaps in care may arise, how they impact on patients' experiences and how best to understand them so that they can be avoided or managed.

OBJECTIVES

Using the theoretical framework of candidacy, we aim to explore patients' experiences of discontinuities in care and to gain insight into how gaps come to be bridged and why they might remain unresolved.

METHODS

A secondary analysis was undertaken of interview data from a large study into continuity in primary care, involving a diverse sample of 50 patients, recruited from 15 general practices, one walk-in centre and community settings in Leicestershire, UK. Analysis was conducted using a constant comparative approach.

RESULTS

Experiences of gaps in care were common, arising from failures in communication and coordination of care. Although some gaps were easily bridged, many patients described 'falling through gaps' because of difficulties establishing their candidacy for ongoing care when gaps occurred. These patients commonly had complex, chronic conditions and multi-morbidity. Bridging gaps required resources; relationship continuity was a valuable resource for preventing and repairing gaps in care. When gaps were not bridged, distress and dysfunctional use of health services followed.

CONCLUSION

This study demonstrates that some patients with complex chronic conditions and multi-morbidity may be unable to get the continuity they need and highlights the potential for relationship continuity to help prevent vulnerable patients falling through gaps in care.

Performance-based financial incentives for diabetes care: an effective strategy?

The use of financial incentives provided to primary care physicians who achieve target management or clinical outcomes has been advocated to support the fulfillment of care recommendations for patients with diabetes. This article explores the characteristics of incentive models implemented in the context of universal healthcare systems in the United Kingdom, Australia, Taiwan and Canada; the extent to which these interventions have been successful in improving diabetes outcomes; and the key challenges and concerns around implementing incentive models. Research in the effect of incentives in the United Kingdom demonstrates some improvements in process outcomes and achievement of cholesterol, blood pressure and glycated hemoglobin (A1C) targets. Evidence of the efficacy of programs implemented outside of the United Kingdom is very limited but suggests that physicians participating in these enhanced billing incentive programs were already completing the guideline-recommended care prior to the introduction of the incentive. A shift to pay-for-performance programs may have important implications for professionalism and patient-centred care. In the absence of definitive evidence that financial incentives drive the quality of diabetes management at the level of primary care, policy makers should proceed with caution. It is important to look beyond simply modifying physicians' behaviours and address the factors and systemic barriers that make it challenging for patients and physicians to manage diabetes in partnership.

Patient-reported access to primary care in Ontario: effect of organizational characteristics

OBJECTIVE

To describe patient-reported access to primary health care across 4 organizational models of primary care in Ontario, and to explore how access is associated with patient, provider, and practice characteristics.

DESIGN

Cross-sectional survey.

SETTING

One hundred thirty-seven randomly selected primary care practices in Ontario using 1 of 4 delivery models (fee for service, established capitation, reformed capitation, and community health centres).

PARTICIPANTS

Patients included were at least 18 years of age, were not severely ill or cognitively impaired, were not known to the survey administrator, had consenting providers at 1 of the participating primary care practices, and were able to communicate in English or French either directly or through a translator.

MAIN OUTCOME MEASURES

Patient-reported access was measured by a 4-item scale derived from the previously validated adult version of the Primary Care Assessment Tool. Questions were asked about physician availability during and outside of regular office hours and access to health information via telephone. Responses to the scale were normalized, with higher scores reflecting greater patient-reported access. Linear regressions were used to identify characteristics independently associated with access to care.

RESULTS

Established capitation model practices had the highest patient-reported access, although the difference in scores between models was small. Our multilevel regression model identified several patient factors that were significantly (P = .05) associated with higher patient-reported access, including older age, female sex, good-to-excellent self-reported health, less mental health disability, and not working. Provider experience (measured as years since graduation) was the only provider or practice characteristic independently associated with improved patient-reported access.

CONCLUSION

This study adds to what is known about access to primary care. The study found that established capitation models outperformed all the other organizational models, including reformed capitation models, independent of provider and practice variables save provider experience. This suggests that the capitation models might provide better access to care and that it might take time to realize the benefits of organizational reforms.

Comparison of health confidence in rural, suburban and urban areas in the UK and the USA: a secondary analysis

OBJECTIVE

Confidence in healthcare may influence the patients' utilisation of healthcare resources and perceptions of healthcare quality. We sought to determine whether self-reported confidence in healthcare differed between the UK and the USA, as well as by rurality or urbanicity.

DESIGN

A secondary analysis of a subset of survey questions regarding self-reported confidence in healthcare from the 2010 Commonwealth Fund International Health Policy Survey.

SETTING

Telephone survey of participants from the UK and the USA.

PARTICIPANTS

Our final analysis included 1511 UK residents (688 rural, 446 suburban, 372 urban, 5 uncategorised) and 2501 US residents (536 rural, 1294 suburban, 671 urban).

OUTCOME MEASURES

Questions assessed respondents' confidence in the effectiveness and affordability of the treatment. We compared survey outcomes from these questions between, and within, the two regions and among, and within, residence types (rural, suburban and urban).

RESULTS

Significant differences were found in self-reported confidence in healthcare between the UK and US, among residence types, and between the two regions within residence types. Reported levels were higher in the UK. Within regions, significant differences by residence type were found for the US, but not the UK. Within the US, suburban respondents had the highest self-reported confidence in healthcare.

CONCLUSIONS

Significant differences exist between the UK and US in confidence in healthcare. In the US, but not in the UK, self-reported confidence is related to residence type. Within countries, significant differences by residence type were found for the US, but not the UK. Our findings warrant the examination of causes for relative confidence levels in healthcare between regions and among US residence types.

Assessment of a pay-for-performance program in primary care designed by target users

BACKGROUND

Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects.

OBJECTIVE

To assess changes in performance after introducing a participatory P4P program.

DESIGN

An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark.

MAIN OUTCOME MEASURES

Quality indicators for clinical care (process and outcome) and patient experience.

RESULTS

We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement.

CONCLUSIONS

A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

Do English patients want continuity of care, and do they receive it?

BACKGROUND

Interpersonal continuity of care is valued by patients, but there is concern that it has declined in recent years.

AIM

To determine how often patients express preference for seeing a particular GP and the extent to which that preference is met.

DESIGN OF STUDY

Analysis of data from the 2009/2010 English GP Patient Survey.

SETTING

A stratified random sample of adult patients registered with 8362 general practices in England (response rate 39%, yielding 2,169,718 responses).

METHOD

Weighted estimates were calculated of preference for and success in seeing a particular GP. Multilevel logistic regression was used to identify characteristics associated with these two outcomes.

RESULTS

Excluding practices with one GP, 62% of patients expressed a preference for seeing a particular GP. Of these patients, 72% were successful in seeing their preferred GP most of the time. Certain patient groups were associated with more preference for and success in seeing a particular GP. These were older patients (preference odds ratio [OR] = 1.7, success OR = 1.8), those with chronic medical conditions (preference OR = 1.9, success OR = 1.3), those with chronic psychological conditions (preference OR = 1.6, success OR = 1.3), and those recently requesting only non-urgent versus urgent appointments (preference OR = 1.4, success OR = 1.6). Patient groups that had more frequent preference but less success in seeing a preferred GP were females (preference OR = 1.5, success OR = 0.9), patients in larger practices (preference OR = 1.3, success OR = 0.5), and those belonging to non-white ethnic groups.

CONCLUSION

The majority of patients value interpersonal continuity, yet a large minority of patients and specific patient groups are not regularly able to see the GP they prefer.

General practitioners' views on quality markers for children in UK primary care: a qualitative study

BACKGROUND

Children make up about 20% of the UK population and caring for them is an important part of a general practitioner's (GP's) workload. However, the UK Quality Outcomes Framework (pay-for-performance system) largely ignores children - less than 3% of the quality markers relate to them. As no previous research has investigated whether GPs would support or oppose the introduction of child-specific quality markers, we sought their views on this important question.

METHODS

Qualitative interview study with 20 GPs from four primary care trusts in Thames Valley, England. Semi-structured interviews explored GPs' viewpoints on quality markers and childhood conditions that could be developed into markers in general practice. Interviews were audiotaped and transcribed verbatim. Analysis was thematic and used constant comparative method to look for anticipated and emergent themes as the analysis progressed.

RESULTS

All the GPs interviewed supported the development of 'benchmarks' or 'standards' to measure and improve quality of care for children. However no consensus was expressed about the clinical conditions for which quality markers should be developed. Many participants reflected on their concerns about unmet health care needs and felt there may be opportunities to improve proactive care in 'at risk' groups. Some expressed feelings of powerlessness that important child-relevant outcomes such as emergency department visits and emergency admissions were out of their control and more directly related to public health, school and parents/carers. The importance of access was a recurrent theme; access to urgent general practice appointments for children and GP access to specialists when needed.

CONCLUSION

The GPs expressed support for the development of quality markers for the care of children in UK general practice. However, they flagged up a number of important challenges which need to be addressed if markers are to be developed that are measureable, targeted and within the direct control of primary care. Easy access to primary and secondary care appointments may be an important benchmark for commissioners of care.

Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review

PURPOSE

Primary care practices in the United Kingdom have received substantial financial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This article reviews the growing evidence for the impact of the framework on the quality of primary medical care.

METHODS

Five hundred seventy-five articles were identified by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modified Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review.

RESULTS

Quality of care for incentivized conditions during the first year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients' satisfaction with continuity declined, with little change in other domains of patient experience.

CONCLUSIONS

Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefits of similar schemes.

The impact of primary care: a focused review

Primary care serves as the cornerstone in a strong healthcare system. However, it has long been overlooked in the United States (USA), and an imbalance between specialty and primary care exists. The objective of this focused review paper is to identify research evidence on the value of primary care both in the USA and internationally, focusing on the importance of effective primary care services in delivering quality healthcare, improving health outcomes, and reducing disparities. Literature searches were performed in PubMed as well as "snowballing" based on the bibliographies of the retrieved articles. The areas reviewed included primary care definitions, primary care measurement, primary care practice, primary care and health, primary care and quality, primary care and cost, primary care and equity, primary care and health centers, and primary care and healthcare reform. In both developed and developing countries, primary care has been demonstrated to be associated with enhanced access to healthcare services, better health outcomes, and a decrease in hospitalization and use of emergency department visits. Primary care can also help counteract the negative impact of poor economic conditions on health.

Factors associated with variability in the assessment of UK doctors' professionalism: analysis of survey results

OBJECTIVES

To investigate potential sources of systematic bias arising in the assessment of doctors' professionalism.

DESIGN

Linear regression modelling of cross sectional questionnaire survey data.

SETTING

11 clinical practices in England and Wales.

PARTICIPANTS

1065 non-training grade doctors from various clinical specialties and settings, 17,031 of their colleagues, and 30,333 of their patients.

MAIN OUTCOME MEASURES

Two measures of a doctor's professional performance using patient and colleague questionnaires from the United Kingdom's General Medical Council (GMC). We selected potential predictor variables from the characteristics of the doctors and of their patient and colleague assessors.

RESULTS

After we adjusted for characteristics of the doctor as well as characteristics of the patient sample, less favourable scores from patient feedback were independently predicted by doctors having obtained their primary medical degree from any non-European country; doctors practising as a psychiatrist; lower proportions of white patients providing feedback; lower proportions of patients rating their consultation as being very important; and lower proportions of patients reporting that they were seeing their usual doctor. Lower scores from colleague feedback were independently predicted by doctors having obtained their primary medical degree from countries outside the UK and South Asia; currently employed in a locum capacity; working as a general practitioner or psychiatrist; being employed in a staff grade, associate specialist, or other equivalent role; and with a lower proportion of colleagues reporting they had daily or weekly professional contact with the doctor. In fully adjusted models, the doctor's age, sex, and ethnic group were not independent predictors of patient or colleague feedback. Neither the age or sex profiles of the patient or colleague samples were independent predictors of doctors' feedback scores, and nor was the ethnic group of colleague samples.

CONCLUSIONS

Caution is necessary when considering patient and colleague feedback regarding doctors' professionalism. Multisource feedback undertaken for revalidation using the GMC patient and colleague questionnaires should, at least initially, be principally formative in nature.

The effect of financial incentives on the quality of health care provided by primary care physicians

BACKGROUND

The use of blended payment schemes in primary care, including the use of financial incentives to directly reward 'performance' and 'quality' is increasing in a number of countries. There are many examples in the US, and the Quality and Outcomes Framework (QoF) for general practitioners (GPs) in the UK is an example of a major system-wide reform. Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care.

OBJECTIVES

The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians (PCPs) and to identify:i) the different types of financial incentives that have improved quality;ii) the characteristics of patient populations for whom quality of care has been improved by financial incentives; andiii) the characteristics of PCPs who have responded to financial incentives.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), MEDLINE, HealthSTAR, EMBASE, CINAHL, PsychLIT, and ECONLIT. Searches of Internet-based economics and health economics working paper collections were also conducted. Finally, studies were identified through the reference lists of retrieved articles, websites of key organisations, and from direct contact with key authors in the field. Articles were included if they were published from 2000 to August 2009.

SELECTION CRITERIA

Randomised controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series analyses (ITS) evaluating the impact of different financial interventions on the quality of care delivered by primary healthcare physicians (PCPs). Quality of care was defined as patient reported outcome measures, clinical behaviours, and intermediate clinical and physiological measures.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality, in consultation with two other review authors where there was disagreement. For each included study, we reported the estimated effect sizes and confidence intervals.

MAIN RESULTS

Seven studies were included in this review. Three of the studies evaluated single-threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups' performance (tournament-based pay), one study examined a mix of tournament-based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment. Three cluster RCTs examined smoking cessation; one CBA examined patients' assessment of the quality of care; one CBA examined cervical screening, mammography screening, and HbA1c; one ITS focused on four outcomes in diabetes; and one controlled ITS (a difference-in-difference design) examined cervical screening, mammography screening, HbA1c, childhood immunisation, chlamydia screening, and appropriate asthma medication. Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. One study found no effect on quality of care. Poor study design led to substantial risk of bias in most studies. In particular, none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme or health plan.

AUTHORS' CONCLUSIONS

The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. In addition to basing incentive design more on theory, there is a large literature discussing experiences with these schemes that can be used to draw out a number of lessons that can be learned and that could be used to influence or modify the design of incentive schemes. More rigorous study designs need to be used to account for the selection of physicians into incentive schemes. The use of instrumental variable techniques should be considered to assist with the identification of treatment effects in the presence of selection bias and other sources of unobserved heterogeneity. In randomised trials, care must be taken in using the correct unit of analysis and more attention should be paid to blinding. Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. Studies should more consistently describe i) the type of payment scheme at baseline or in the control group, ii) how payments to medical groups were used and distributed within the groups, and iii) the size of the new payments as a percentage of total revenue. Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.