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

Lessons learned from a pay-for-performance scheme for appropriate prescribing using electronic health records from general practices in the Netherlands

INTRODUCTION

A nationwide pay-for-performance (P4P) scheme was introduced in the Netherlands between 2018 and 2023 to incentivize appropriate prescribing in general practice. Appropriate prescribing was operationalised as adherence to prescription formularies and measured based on electronic health records (EHR) data. We evaluated this P4P scheme from a learning health systems perspective.

METHODS

We conducted semi-structured interviews with 15 participants representing stakeholders of the scheme: general practitioners (GPs), health insurers, pharmacists, EHR suppliers and formulary committees. We used a thematic approach for data analysis.

RESULTS

Using EHR data showed several benefits, but lack of uniformity of EHR systems hindered consistent measurements. Specific indicators were favoured over general indicators as they allow GPs to have more control over their performance. Most participants emphasized the need for GPs to jointly reflect on their performance. Communication to GPs appeared to be challenging. Partly because of these challenges, impact of the scheme on prescribing behaviour was perceived as limited. However, several unexpected positive effects of the scheme were mentioned, such as better EHR recording habits.

CONCLUSIONS

This study identified benefits and challenges useful for future P4P schemes in promoting appropriate care with EHR data. Enhancing uniformity in EHR systems is crucial for more consistent quality measurements. Future P4P schemes should focus on high-quality feedback, peer-to-peer learning and establish a single point of communication for healthcare providers.

Pay-for-performance in Taiwan: A systematic review and meta-analysis of the empirical literature

OBJECTIVES

This study aimed to assess the impact of pay-for-performance (P4P) programmes on healthcare in Taiwan.

STUDY DESIGN

This was a systematic review and meta-analysis.

METHODS

A systematic literature search was performed using the PubMed, Medline, Embase, Cochrane review, Scopus, Web of Science and PsycINFO databases up to July 2023. Meta-analysis of the available outcomes was conducted using a random-effects model.

RESULTS

The search yielded 85 studies, of which 58 investigated the programme for diabetes mellitus (DM), eight looked at the programme for chronic kidney disease (CKD), and the remaining studies examined programmes for breast cancer, tuberculosis, schizophrenia and chronic obstructive pulmonary disease. The DM P4P programme was a cost-effective strategy associated with reduced hospitalisation and subsequent complications. The CKD P4P was associated with a lower risk of dialysis initiation. The P4P programme also improved outcomes in breast cancer, cure rates in tuberculosis, reduced admissions for schizophrenia and reduced acute exacerbation in chronic obstructive pulmonary disease. The meta-analysis revealed that the P4P programme for DM (odds ratio [OR] = 0.59; 95% confidence interval [CI] = 0.48-0.73) and CKD (OR = 0.73; 95% CI = 0.67-0.81) significantly reduced mortality risk. However, participation rate in the DM P4P programme was only 19% in 2014.

CONCLUSIONS

P4P programmes in Taiwan improve quality of care. However, participation was voluntary and the participation rate was very low, raising the concern of selective enrolment of participants (i.e. 'cherry-picking' behaviour) by physicians. Future programme reforms should focus on well-designed features with the aim of reducing healthcare disparities.

An Internationally Derived Process of Healthcare Professionals' Proactive Deprescribing Steps and Constituent Activities

Proactive deprescribing is the process of tapering or stopping a medicine before harm occurs. This study aimed to specify and validate, with an international sample of healthcare professionals, a proactive deprescribing process of steps and constituent activities. We developed a proactive deprescribing process framework of steps which we populated with literature-derived activities required to be undertaken by healthcare professionals. We distributed a survey to healthcare professionals internationally, requesting for each activity the frequency of its occurrence in practice and whether it was important. Extended response questions investigated barriers and enablers to deprescribing. The 263 survey respondents were from 25 countries. A proactive deprescribing process was developed comprising four steps: (1) identify a patient for potential stop of a medicine, (2) evaluate a patient for potential stop of a medicine, (3) stop a medicine(s), and (4) monitor after a medicine has been stopped, and 17 activities. All activities were considered important by ≥70% of respondents. Nine activities required healthcare professionals to undertake in direct partnership with the patient and/or caregiver, of which seven were only sometimes undertaken. Deprescribing interventions should include a focus on addressing the barriers and enablers of healthcare professionals undertaking the activities that require direct partnership with the patient and/or caregiver.

A Randomized Controlled Trial of a Pay-for-Performance Initiative to Reduce Costs of Care for High-Need Psychiatric Patients

OBJECTIVE

Pay-for-performance (P4P) initiatives hold promise for improving health care delivery but are rarely applied to behavioral health or tested in randomized controlled trials (RCTs). This RCT examined the effectiveness of a P4P initiative to reduce total cost of 24-hour care among patients with high needs for psychiatric care in a large county in California.

METHODS

From August 2016 to March 2022, a total of 652 adult residents of Santa Clara County, California, were enrolled in a P4P initiative (mean±SD age=46.7±13.3 years, 61% male, 51% White, and 60% diagnosed as having a bipolar or psychotic disorder). Participants were randomly assigned to usual full-service partnerships from the county (N=327) or a comparable level of care from a contractor who agreed to a schedule of financial penalties and rewards based on whether enrollees (N=325) used more or less care than a historical cohort of similar county patients. The primary outcome was total cost of 24-hour psychiatric services. Secondary outcomes were costs of each of the 24-hour care services.

RESULTS

The proportion of the total sample that used 24-hour psychiatric services decreased over the 36-month study period. Intent-to-treat analyses revealed no differences between the two study conditions in total care costs during the follow-up period. No significant care utilization differences were observed between the two conditions in most of the individual 24-hour services.

CONCLUSIONS

A P4P initiative for high-need patients was no more effective than usual care for reducing costs of 24-hour psychiatric care.

Impact of reimbursement systems on patient care - a systematic review of systematic reviews

BACKGROUND

There is not yet sufficient scientific evidence to answer the question of the extent to which different reimbursement systems influence patient care and treatment quality. Due to the asymmetry of information between physicians, health insurers and patients, market-based mechanisms are necessary to ensure the best possible patient care. The aim of this study is to investigate how reimbursement systems influence multiple areas of patient care in form of structure, process and outcome indicators.

METHODS

For this purpose, a systematic literature review of systematic reviews is conducted in the databases PubMed, Web of Science and the Cochrane Library. The reimbursement systems of salary, bundled payment, fee-for-service and value-based reimbursement are examined. Patient care is divided according to the three dimensions of structure, process, and outcome and evaluated in eight subcategories.

RESULTS

A total of 34 reviews of 971 underlying primary studies are included in this article. International studies identified the greatest effects in categories resource utilization and quality/health outcomes. Pay-for-performance and bundled payments were the most commonly studied models. Among the systems examined, fee-for-service and value-based reimbursement systems have the most positive impact on patient care.

CONCLUSION

Patient care can be influenced by the choice of reimbursement system. The factors for successful implementation need to be further explored in future research.

Ethnic differences in depression and anxiety among adults with atopic eczema: Population-based matched cohort studies within UK primary care

BACKGROUND

Evidence demonstrates that individuals with atopic eczema (eczema) have increased depression and anxiety; however, the role of ethnicity in these associations is poorly understood. We aimed to investigate whether associations between eczema and depression or anxiety differed between adults from white and minority ethnic groups in the UK.

METHODS

We used UK Clinical Practice Research Datalink GOLD to conduct matched cohort studies of adults (≥18 years) with ethnicity recorded in primary care electronic health records (April 2006-January 2020). We matched (age, sex, practice) adults with eczema to up to five adults without. We used stratified Cox regression with an interaction between eczema and ethnicity, to estimate hazard ratios (HRs) for associations between eczema and incident depression and anxiety in individuals from white ethnic groups and a pooled minority ethnic group (adults from Black, South Asian, Mixed and Other groups).

RESULTS

We identified separate cohorts for depression (215,073 with eczema matched to 646,539 without) and anxiety (242,598 with eczema matched to 774,113 without). After adjusting for matching variables and potential confounders (age, sex, practice, deprivation, calendar period), we found strong evidence (p < 0.01) of ethnic differences in associations between eczema and depression (minority ethnic groups: HR = 1.33, 95% CI = 1.22,1.45; white ethnic groups: HR = 1.15, 95% CI = 1.12,1.17) and anxiety (minority ethnic groups: HR = 1.41, 95% CI = 1.28,1.55; white ethnic groups: HR = 1.17, 95% CI = 1.14,1.19).

CONCLUSIONS

Adults with eczema from minority ethnic groups appear to be at increased depression and anxiety risk compared with their white counterparts. Culturally adapted mental health promotion and prevention strategies should be considered in individuals with eczema from minority ethnic groups.

The relationship between Quality and Outcomes Framework scores and socioeconomic deprivation: a longitudinal study

BACKGROUND

The Quality Outcomes Framework (QOF) is a pay incentive scheme in England designed to improve and standardise general practice. QOF attainment has been used as a proxy for primary care quality in previous research.

AIM

To investigate whether there is a relationship between socioeconomic deprivation and QOF attainment in primary care in England.

DESIGN & SETTING

Retrospective longitudinal study of primary care providers in England.

METHOD

QOF scores were obtained for individual general practices in England from between 2007-2019 and linked to practice-level Indices of Multiple Deprivation (IMD) scores derived from census data. Beta regression analyses were used to analyse the relationship with either percentage of total QOF attainment or of domain-specific attainment with multivariate analyses, adjusting for additional practice-level demographics. QOF attainment in the most affluent quintile was used as the reference group.

RESULTS

General practices in less deprived areas have consistently outperformed those in more deprived areas in terms of QOF achievement. Initially, the gap between least and most deprived practices decreased, however since 2015 there has been relatively little change in comparative performance. The magnitude of inequality was reduced after adjusting for demographic factors. Of the independent variables analysed, the proportion of patients aged >65 years ('over 65s') had the strongest relationship with QOF attainment.

CONCLUSION

There remains an inequality in primary care quality by socioeconomic deprivation in England, even after accounting for demographic differences.

Long-term Effectiveness of the National Diabetes Quality Assessment Program in South Korea

OBJECTIVE

This study examined the long-term effectiveness of the national diabetes quality assessment program (NDQAP) in diabetes.

RESEARCH DESIGN AND METHODS

From the Health Insurance Review and Assessment Service database, 399,984 individuals with diabetes who visited a primary care clinic from 1 July 2012 to 30 June 2013 were included and followed up until 31 May 2021. The NDQAP included five quality assessment indicators: regular outpatient visits, continuity of prescriptions, regular testing of glycated hemoglobin and lipids, and regular fundus examination. Cox proportional hazards models estimated hazard ratios (HRs) and 95% confidence intervals (CIs) for diabetes complications and all-cause mortality by the achievement of quality assessment indicators.

RESULTS

During the mean follow-up duration of 7.6 ± 1.8 years, 20,054 cases (5.0%) of proliferative diabetic retinopathy (PDR), 6,281 end-stage kidney diseases (ESKD; 1.6%), 1,943 amputations (0.5%), 9,706 myocardial infarctions (MIs; 2.4%), 26,975 strokes (6.7%), and 35,799 all-cause mortality (8.9%) occurred. Each achievement of quality assessment indicator was associated with a decreased risk of diabetes complications and all-cause mortality. Individuals who were managed in high-quality institutions had a lower risk of PDR (HR 0.82; 95% CI 0.80-0.85), ESKD (HR 0.77; 95% CI 0.73-0.81), amputation (HR 0.75; 95% CI 0.69-0.83), MI (HR 0.85; 95% CI 0.82-0.89), stroke (HR 0.86; 95% CI 0.84-0.88), and all-cause mortality (HR 0.96; 95% CI 0.94-0.98) than those who were not managed in high-quality institutions.

CONCLUSIONS

In Korea, the achievement of NDQAP indicators was associated with a decreased risk of diabetes complications and all-cause mortality.

Exploring patient perspectives: A qualitative inquiry into healthcare perceptions, experiences and satisfaction in Lebanon

BACKGROUND

Patient perspectives have received increasing importance within health systems over the past four decades. Measures of patient experience and satisfaction are commonly used. However, these measures do not capture all the information that is available through engaging with patients. An improved understanding of the various types of patient perspectives and the distinctions between them is needed. The lack of such knowledge limits the usefulness of including patient perspectives as components within pay-for-performance initiatives. This study aimed to explore patient perspectives on hospital care in Lebanon. It also aimed to contribute insights that may improve the national pay-for-performance initiative and to the knowledge on engaging patients towards person-centered health systems.

METHODS

We conducted a qualitative study using focus group discussions with persons recently discharged after hospitalization under the coverage of the Lebanese Ministry of Public Health. This study was implemented in 2017 and involved 42 participants across eight focus groups. Qualitative content analysis was used to analyze the information provided by participants.

RESULTS

Five overall themes supported by 17 categories were identified, capturing the meaning of the participants' perspectives: health is everything; being turned into second class citizens; money and personal connections make all the difference; wanting to be treated with dignity and respect; and tolerating letdown, for the sake of right treatment. The most frequently prioritized statement in a ranking exercise regarding patient satisfaction was regular contact with the patient's doctor.

CONCLUSIONS

Patient perspectives include more than what is traditionally incorporated in measures of patient satisfaction and experience. Patient valuing of health and their perceptions on each of the health system, and access and quality of care should also be taken into account. Hospital pay-for-performance initiatives can be made more responsive through a broader consideration of these perspectives. More broadly, health systems would benefit from wider engagement of patients. We propose a framework relating patient perspectives to value-based healthcare and health system performance.

Differences in Use of Clinical Decision Support Tools and Implementation of Aspirin, Blood Pressure Control, Cholesterol Management, and Smoking Cessation Quality Metrics in Small Practices by Race and Sex

Importance

Practice-level evidence is needed to clarify the value of population-based clinical decision support (CDS) tools in reducing racial and sex disparities in cardiovascular care.

Objective

To evaluate the association between CDS tools and racial and sex disparities in the aspirin use, blood pressure control, cholesterol management, and smoking cessation (ABCS) care quality metrics among smaller primary care practices.

Design, Setting, and Participants

This cross-sectional study used practice-level data from the Agency for Healthcare Research and Quality-funded EvidenceNOW initiative. The national initiative from May 1, 2015, to April 30, 2021, spanned 12 US states and focused on improving cardiovascular preventive care by providing quality improvement support to smaller primary care practices. A total of 576 primary care practices in EvidenceNOW submitted both survey data and electronic health record (EHR)-derived ABCS data stratified by race and sex.

Main Outcomes and Measures

Practice-level estimates of disparities between Black and White patients and between male and female patients were calculated as the difference in proportions of eligible patients within each practice meeting ABCS care quality metrics. The association between CDS tools (EHR prompts, standing orders, and clinical registries) and disparities was evaluated by multiply imputed multivariable models for each CDS tool, adjusted for practice rurality, ownership, and size.

Results

Across the 576 practices included in the analysis, 219 (38.0%) had patient panels that were more than half White and 327 (56.8%) had panels that were more than half women. The proportion of White compared with Black patients meeting metrics for blood pressure (difference, 5.16% [95% CI, 4.29%-6.02%]; P < .001) and cholesterol management (difference, 1.49% [95% CI, 0.04%-2.93%] P = .04) was higher; the proportion of men meeting metrics for aspirin use (difference, 4.36% [95% CI, 3.34%-5.38%]; P < .001) and cholesterol management (difference, 3.88% [95% CI, 3.14%-4.63%]; P < .001) was higher compared with women. Conversely, the proportion of women meeting practice blood pressure control (difference, -1.80% [95% CI, -2.32% to -1.28%]; P < .001) and smoking cessation counseling (difference, -1.67% [95% CI, -2.38% to -0.95%]; P < .001) metrics was higher compared with men. Use of CDS tools was not associated with differences in race or sex disparities except for the smoking metric. Practices using CDS tools showed a higher proportion of men meeting the smoking counseling metric than women (coefficient, 3.82 [95% CI, 0.95-6.68]; P = .009).

Conclusions and Relevance

The findings of this cross-sectional study suggest that practices using CDS tools had small disparities that were not statistically significant, but CDS tools were not associated with reductions in disparities. More research is needed on effective practice-level interventions to mitigate disparities.

Alternative Reimbursement Models for Health Providers in High-Performance Sport: Stakeholder Experiences and Perceptions

BACKGROUND

Value-based healthcare provider reimbursement models have been proposed as an alternative to traditional fee-for-service arrangements that can align financial reimbursement more closely to the outcomes of value to patients and society. This study aimed to investigate stakeholder perceptions and experiences of different reimbursement systems for healthcare providers in high-performance sport, with a focus on fee-for-service versus salaried provider models.

METHODS

Three in-depth semi-structured focus group discussions and one individual interview were conducted with key stakeholders across the Australian high-performance sport system. Participants included healthcare providers, health managers, sports managers and executive personnel. An interview guide was developed using the Exploration, Preparation, Implementation, Sustainment framework, with key themes deductively mapped to the innovation, inner context and outer context domains. A total of 16 stakeholders participated in a focus group discussion or interview.

RESULTS

Participants identified several key advantages of salaried provider models over fee-for-service arrangements, including: the potential for more proactive and preventive models of care; enhanced inter-disciplinary collaboration; and the ability for providers to have a deeper understanding of context and how their role aligns with a broader set of priorities for an athlete and the organisation. Noted challenges of salaried provider models included the potential for providers to revert to reactive care delivery when not afforded adequate capacity to provide services, and difficulties for providers in demonstrating and quantifying the value of their work.

CONCLUSIONS

Our findings suggest that high-performance sporting organisations seeking to improve primary prevention and multidisciplinary care should consider salaried provider arrangements. Further research to confirm these findings using prospective, experimental study designs remains a priority.

The Cost of Uncontrolled Blood Pressure in Australian General Practice: A Modelling Study Using Electronic Health Records (MedicineInsight)

BACKGROUND

Hypertension is the most common condition seen in Australian general practice. Despite hypertension being amenable to lifestyle modifications and pharmacological treatment, only around half of these patients have controlled blood pressure levels (< 140/90 mmHg), placing them at an increased risk of cardiovascular disease.

OBJECTIVE

We aimed to estimate the health and acute hospitalisation costs of uncontrolled hypertension among patients attending general practice.

METHODS

We used population data and electronic health records from 634,000 patients aged 45-74 years who regularly attended an Australian general practice between 2016 and 2018 (MedicineInsight database). An existing worksheet-based costing model was adapted to calculate the potential cost savings for acute hospitalisation of primary cardiovascular disease events by reducing the risk of a cardiovascular event over the next 5 years through improved systolic blood pressure control. The model estimated the number of expected cardiovascular disease events and associated acute hospital costs under current levels of systolic blood pressure and compared this estimate with the expected number of cardiovascular disease events and costs under different levels of systolic blood pressure control.

RESULTS

The model estimated that across all Australians aged 45-74 years who visit their general practitioner (n = 8.67 million), 261,858 cardiovascular disease events can be expected over the next 5 years at current systolic blood pressure levels (mean 137.8 mmHg, standard deviation = 12.3 mmHg), with a cost of AUD$1813 million (in 2019-20). By reducing the systolic blood pressure of all patients with a systolic blood pressure greater than 139 mmHg to 139 mmHg, 25,845 cardiovascular disease events could be avoided with an associated reduction in acute hospital costs of AUD$179 million. If systolic blood pressure is lowered further to 129 mmHg for all those with systolic blood pressure greater than 129 mmHg, 56,169 cardiovascular disease events could be avoided with potential cost savings of AUD$389 million. Sensitivity analyses indicate that potential cost savings range from AUD$46 million to AUD$1406 million and AUD$117 million to AUD$2009 million for the two scenarios, respectively. Cost savings by practice range from AUD$16,479 for small practices to AUD$82,493 for large practices.

CONCLUSIONS

The aggregate cost effects of poor blood pressure control in primary care are high, but cost implications at the individual practice level are modest. The potential cost savings improve the potential to design cost-effective interventions, but such interventions may be best targeted at a population level rather than at individual practices.

Implementation Challenges of Family Physician Program: A Systematic Review on Global Evidence

Background

The family physician program, as one of the core arms of health care systems, has faced various implementation challenges around the world. Experiences in the implementation of family physician program can be helpful for nations that seek to apply for similar programs. The aim of this study is to systematically review the implementation challenges of family physician program across the world.

Methods

A systematic search was conducted from January 2000 to February 2022 across scientific databases of Embase, MEDLINE, Web of Science, Scopus, CINAHL, EBSCO, and Google Scholar. The Framework approach was used to analyze the selected studies. The quality of the included studies was evaluated using the McMaster Critical Review Form for qualitative studies.

Results

35 studies upon the study inclusion criteria were included. Based on the Six Building Blocks frame, seven themes and 21 subthemes were developed as the implementation challenges of family physician program. 1) Governance: policy guidance, intelligence, coalition, regulation, system design, and accountability; 2) Financing: financing and payment system; 3) Health workforce: education, research, recruitment and motivation opportunities; 4) Service delivery: management of health services, service package, referral system, continuity of care; 5) Health information systems: production and evaluating the health information system; 6) Availability: provision basic health services, maintenance of facilities; and 7) Cultural considerations: behavior and social determinants of health.

Conclusion

Scientific governance, financing, and payment mechanisms, workforce empowerment, designing a strong health information system, and providing access to services with cultural considerations can result in the successful implementation of the family physician program in communities.

Intervention design in cognitively impaired populations-Lessons learned from the OPTIMIZE deprescribing pragmatic trial

BACKGROUND

Polypharmacy is common in older adults with cognitive impairment and multiple chronic conditions, increasing risks of adverse drug events, hospitalization, and death. Deprescribing, the process of reducing or stopping potentially inappropriate medications, may improve outcomes. The OPTIMIZE pragmatic trial examined whether educating and activating patients, family members and clinicians about deprescribing reduces number of chronic medications and potentially inappropriate medications. Acceptability and challenges of intervention delivery in cognitively impaired older adults are not well understood.

METHODS

We explored mechanisms of intervention implementation through post hoc qualitative interviews and surveys with stakeholder groups of 15 patients, 7 caregivers, and 28 clinicians. We assessed the context in which the intervention was delivered, its implementation, and mechanisms of impact.

RESULTS

Acceptance of the intervention was affected by contextual factors including cognition, prior knowledge of deprescribing, communication, and time constraints. All stakeholder groups endorsed the acceptability, importance, and delivery of the intervention. Positive mechanisms of impact included patients scheduling specific appointments to discuss deprescribing and providers being prompted to consider deprescribing. Recollection of intervention materials was inconsistent but most likely shortly after intervention delivery. Short visit times remained the largest provider barrier to deprescribing.

CONCLUSIONS

Our work identifies key learnings in intervention delivery that can guide future scaling of deprescribing interventions in this population. We highlight the critical roles of timing and repetition in intervention delivery to cognitively impaired populations and the barrier posed by short consultation times. The acceptability of the intervention to patients and family members highlights the potential to incorporate deprescribing education into routine clinical practice and expand proven interventions to other vulnerable populations.

Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness

A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.

Characteristics associated with influenza vaccination uptake in pregnancy: a retrospective cohort study

BACKGROUND

Pregnant women are at increased risk from influenza, yet maternal influenza vaccination levels remain suboptimal.

AIM

To estimate associations between sociodemographic and health characteristics and seasonal influenza vaccination uptake among pregnant women, and to understand trends over time to inform interventions to improve vaccine coverage.

DESIGN AND SETTING

Retrospective cohort study using linked electronic health records of women in North West London with a pregnancy overlapping an influenza season between September 2010 and February 2020.

METHOD

A multivariable mixed-effects logistic regression model was used to identify associations between characteristics of interest and the primary outcome of influenza vaccination.

RESULTS

In total, 451 954 pregnancies, among 260 744 women, were included. In 85 376 (18.9%) pregnancies women were vaccinated against seasonal influenza. Uptake increased from 8.4% in 2010/11 to 26.4% in 2017/18, dropping again to 21.1% in 2019/20. Uptake was lowest among women aged 15-19 years (11.9%; reference category) or ≥40 years (15.2%; odds ratio [OR] 1.17, 95% confidence interval [CI] = 1.10 to 1.24); of Black (14.1%; OR 0.55, 95% CI = 0.53 to 0.57) or unknown ethnicity (9.9%; OR 0.42, 95% CI = 0.39 to 0.46); who lived in more deprived areas (OR least versus most deprived [reference category] 1.16, 95% CI = 1.11 to 1.21); or with no known risk factors for severe influenza.

CONCLUSION

Seasonal influenza vaccine uptake in pregnant women increased in the decade before the COVID-19 pandemic, but remained suboptimal. Targeted approaches are recommended to reducing inequalities in access to vaccination and should focus on women of Black ethnicity, younger and older women, and women living in deprived areas.

Pfizer and Palbociclib in China: Analyzing an Oncology Pay-for-Performance Plan

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.

The Different Classification of Hospitals Impact on Medical Outcomes of Patients in China

Background

In China, different classification of hospitals (COH) provide treatment for patients with different degrees of illness. COH play an important role in Chinese medical outcomes, but there is a lack of quantitative description of how much impact the results have. The objective of this study is to examine the correlation between COH on medical outcomes with the hope of providing insights into appropriate care and resource allocation.

Methods

From the perspective of the COH framework, using the Urban Employee Basic Medical Insurance (UEBMI) data of Chengdu City from 2011 to 2015, with a sample size of 512,658 hospitalized patients, this study used the nested multinomial logit model (NMNL) to estimate the impact of COH on the medical outcomes.

Results

The patients were mainly elderly, with an average age of 66.28 years old. The average length of stay was 9.61 days. The female and male gender were split evenly. A high level of hospitals is positively and significantly associated with the death and transfer rates (p < 0.001), which may be related to more severe illness among patients in high COH.

Conclusion

The COH made a difference in the medical outcomes significantly. COH should be reasonably selected according to disease types to achieve the optimal medical outcome. So, China should promote the construction of a tiered delivery system.

Incentivizing appropriate prescribing in primary care: Development and first results of an electronic health record-based pay-for-performance scheme

OBJECTIVE

Part of the funding of Dutch General Practitioners (GPs) care is based on pay-for-performance, including an incentive for appropriate prescribing according to guidelines in national formularies. Aim of this paper is to describe the development of an indicator and an infrastructure based on prescription data from GP Electronic Health Records (EHR), to assess the level of adherence to formularies and the effects of the pay-for-performance scheme, thereby assessing the usefulness of the infrastructure and the indicator.

METHODS

Adherence to formularies was calculated as the percentage of first prescriptions by the GP for medications that were included in one of the national formularies used by the GP, based on prescription data from EHRs. Adherence scores were collected quarterly for 2018 and 2019 and subsequently sent to health insurance companies for the pay-for-performance scheme. Adherence scores were used to monitor the effect of the pay-for-performance scheme.

RESULTS

75% (2018) and 83% (2019) of all GP practicesparticipated. Adherence to formularies was around 85% or 95%, depending on the formulary used. Adherence improved significantly, especially for practices that scored lowest in 2018.

DISCUSSION

We found high levels of adherence to national formularies, with small improvements after one year. The infrastructure will be used to further stimulate formulary-based prescribing by implementing more actionable and relevant indicators on adherence scores for GPs.

Treatment and prescribing trends of antihypertensive drugs in 2.7 million UK primary care patients over 31 years: a population-based cohort study

OBJECTIVES

To describe the prescribing trends of antihypertensive drugs in primary care patients and assess the trajectory of antihypertensive drug prescriptions, from first-line to third-line, in patients with hypertension according to changes to the United Kingdom (UK) hypertension management guidelines.

DESIGN

Population-based cohort study.

SETTING AND PARTICIPANTS

We used the UK Clinical Practice Research Datalink, an electronic primary care database representative of the UK population. Between 1988 and 2018, we identified all adult patients with at least one prescription for a thiazide diuretic, angiotensin-converting enzyme (ACE) inhibitor, angiotensin receptor blocker, beta-blocker or calcium channel blocker (CCB).

PRIMARY AND SECONDARY OUTCOME MEASURES

We estimated the period prevalence of patients with antihypertensive drug prescriptions for each calendar year over a 31-year period. Treatment trajectory was assessed by identifying patients with hypertension newly initiating an antihypertensive drug, and treatment changes were defined by a switch or add-on of a new class. This cohort was stratified before and after 2007, the year following important changes to UK hypertension management guidelines.

RESULTS

The cohort included 2 709 241 patients. The prevalence of primary care patients with antihypertensive drug prescriptions increased from 7.8% (1988) to 21.9% (2018) and was observed for all major classes except thiazide diuretics. Patients with hypertension initiated thiazide diuretics (36.8%) and beta-blockers (23.6%) as first-line drugs before 2007, and ACE inhibitors (39.9%) and CCBs (31.8%) after 2007. After 2007, 17.3% were not prescribed guideline-recommended first-line agents. Overall, patients were prescribed a median of 2 classes (IQR 1-2) after first-line treatment.

CONCLUSION

Nearly one-quarter of primary care patients were prescribed antihypertensive drugs by the end of the study period. Most patients with hypertension initiated guideline-recommended first-line agents. Not all patients, particularly females, were prescribed recommended agents however, potentially leading to suboptimal cardiovascular outcomes. Future research should aim to better understand the implication of this finding.

The effect of hormone replacement therapy on the survival of UK women: a retrospective cohort study 1984-2017

OBJECTIVE

To estimate the effect of estrogen-only and combined hormone replacement therapy (HRT) on the hazards of overall and age-specific all-cause mortality in healthy women aged 46-65 at first prescription.

DESIGN

Matched cohort study.

SETTING

Electronic primary care records from The Health Improvement Network (THIN) database, UK (1984-2017).

POPULATION

105 199 HRT users (cases) and 224 643 non-users (controls) matched on age and general practice.

METHODS

Weibull-Double-Cox regression models adjusted for age at first treatment, birth cohort, type 2 diabetes, hypertension and hypertension treatment, coronary heart disease, oophorectomy, hysterectomy, body mass index, smoking and deprivation status.

MAIN OUTCOME MEASURES

All-cause mortality.

RESULTS

A total of 21 751 women died over an average of 13.5 years follow-up per participant, of whom 6329 were users and 15 422 non-users. The adjusted hazard ratio (HR) of overall all-cause mortality in combined HRT users was 0.91 (95% CI 0.88-0.94), and in estrogen-only users was 0.99 (0.93-1.07), compared with non-users. Age-specific adjusted HRs for participants aged 46-50, 51-55, 56-60 and 61-65 years at first treatment were 0.98 (0.92-1.04), 0.87 (0.82-0.92), 0.88 (0.82-0.93) and 0.92 (0.85-0.98) for combined HRT users compared with non-users, and 1.01 (0.84-1.21), 1.03 (0.89-1.18), 0.98 (0.86-1.12) and 0.93 (0.81-1.07) for estrogen-only users, respectively.

CONCLUSIONS

Combined HRT was associated with a 9% lower risk of all-cause mortality and estrogen-only formulation was not associated with any significant changes.

TWEETABLE ABSTRACT

Estrogen-only HRT is not associated with all-cause mortality and combined HRT reduces the risks.

What do we mean, 'necessary'?-Achieving balance and recognizing limits in primary healthcare and universal healthcare

Sturmberg and Martin make a compelling case for primary healthcare (PHC) to be the foundation for universal healthcare (UHC). They state that a system should have necessary resources, but what does that mean? Basic economic theory postulates that all resources are limited and that choices must be made between competing options. For a UHC system to be successful and resilient, it must accept that healthcare is a limited right, there will always be inequalities in healthcare delivery and outcomes, primary care physicians and their teams must accept the added burden of balancing the needs of their personal patients with the greater system, leaders and observers of healthcare systems must accept that moderation and balance will often be the best outcome even though they are difficult to measure, and leaders of healthcare systems must accept that they cannot control the system, but contribute by providing context and limited constraints, information, and resources. A deeper understanding of complex adaptive systems will best guide these necessary changes.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Keeping in balance on the multimorbidity tightrope: A narrative analysis of older patients' experiences of living with and managing multimorbidity

Primary care management of patients with multimorbidity in the UK is underpinned by clinical guidelines, quality standards and measurable targets which govern practices of risk management and disease control. There is concern that standardised approaches may not always be appropriate for older patients living with multimorbidity. Using a narrative approach, we elicited the voices of older people living with multiple conditions in order to rethink chronicity, and consider what their accounts might mean for reconfiguring care practices. Within an ethnographic study of multimorbidity and polypharmacy, we conducted in-depth interviews, based on the Biographical Narrative Interpretive Method, with 24 participants aged 65 to 94. Participants were recruited from three general practices in England. All had two or more chronic conditions and were prescribed ten or more medicines. Our analysis draws on Bakhtinian theory, tracing the multiple ways in which participants voiced living with multimorbidity. In this paper, we focus on 'keeping in balance' which emerged as a key meta-conceptualisation across our dataset. Adopting the metaphor of the 'multimorbidity tightrope' we explore the precarity of patients' experiences and show their struggle to create coherence from within a deeply ambiguous living situation. We consider how and to what extent participants' narrative constructions co-opt or resist normative biomedical framings of multimorbidity. Our analysis foregrounds the complex ways in which patients' voices and values may sometimes be at odds with those promoted within professional guidelines. Narrative approaches may offer significant potential for reorienting healthcare towards enabling patients to live a flourishing life, even when facing significant adversity.

Health professionals’ views of the first national GP payment scheme for structured type 2 diabetes care in Ireland: a qualitative study

Background: Payment schemes are widely used to improve chronic disease management in general practice. Although stakeholder views of such schemes could provide valuable learning regarding aspects that work and those which are more difficult to implement, there is a paucity of such data. We explored health professionals’ views of the implementation of the first national general practice payment scheme for type 2 diabetes (T2DM) care in Ireland, the ‘cycle of care’. Methods: Qualitative data were drawn from a multiple case study evaluating the implementation of a National Clinical Programme for Diabetes, collected from April 2016 to June 2017. Interview and focus group transcripts from participants involved in providing diabetes management in general practice and who referenced the cycle of care were eligible for inclusion in the current analysis. Data were analysed using reflective thematic analysis. Results: We analysed data from 28 participants comprising general practitioners (GPs) (n=8), practice nurses (n=9) and diabetes nurse specialists (DNS) (n=11). Participants perceived the cycle of care as “not adequate, but…a good start” to improve T2DM care in general practice in Ireland. Perceived benefits were greater financial viability for T2DM management in general practice, fostering a more proactive approach to T2DM care, delivery of T2DM care closer to patients’ homes, and increased use of other community diabetes services e.g., DNS and podiatry. Participants identified the limited resource for practice nurse time, inflexibility to provide care based on patient need and issues with data submission as drawbacks of the cycle of care. Conclusions: The cycle of care was viewed as a positive first step to increase and improve T2DM care delivered in general practice in Ireland. The implementation issues identified in this study should be considered in the design of future payment schemes targeting chronic disease management in general practice.

Economic Aspects of Delivering Primary Care Services: An Evidence Synthesis to Inform Policy and Research Priorities

Policy Points The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. While there is a large amount of literature on the economic aspects of delivering primary care services, there is a need for more comprehensive overviews of this evidence. In this article, we offer such an overview. Evidence suggests that there are several strategies involving coverage, financing, service delivery, and governance arrangements which can, if implemented, have positive economic impacts on the delivery of primary care services. These include arrangements such as worker task-shifting and telemedicine. The implementation of any such arrangements, based on positive economic evidence, should carefully account for potential impacts on overall health care access and quality. There are many opportunities for further research, with notable gaps in evidence on the impacts of increasing primary care funding or the overall supply of primary care services.

CONTEXT

The 2018 Declaration of Astana reemphasized the importance of primary health care and its role in achieving universal health coverage. To strengthen primary health care, policymakers need guidance on how to allocate resources in a manner that maximizes its economic benefits.

METHODS

We collated and synthesized published systematic reviews of evidence on the economic aspects of different models of delivering primary care services. Building on previous efforts, we adapted existing taxonomies of primary care components to classify our results according to four categories: coverage, financing, service delivery, and governance.

FINDINGS

We identified and classified 109 reviews that met our inclusion criteria according to our taxonomy of primary care components: coverage, financing, service delivery, and governance arrangements. A significant body of evidence suggests that several specific primary care arrangements, such as health workers' task shifting and telemedicine, can have positive economic impacts (such as lower overall health care costs). Notably absent were reviews on the impact of increasing primary care funding or the overall supply of primary care services.

CONCLUSIONS

There is a great opportunity for further research to systematically examine the broader economic impacts of investing in primary care services. Despite progress over the last decade, significant evidence gaps on the economic implications of different models of primary care services remain, which could help inform the basis of future research efforts.

Promoting physical activity with self-management support for those with multimorbidity: a randomised controlled trial

BACKGROUND

Targeted self-management programmes may improve health and increase physical activity (PA) in people with multimorbidity.

AIM

To investigate the impact of a structured, theoretically driven, self-management group education programme on habitual PA levels in people with multimorbidity.

DESIGN AND SETTING

Individually randomised controlled trial with 12-month follow-up, involving nine primary care practices in Leicestershire, UK.

METHOD

In total, 353 adults with multimorbidity (age 67.8 years [±9 years], 161 male sex) were randomised to intervention (n = 180) or control (n = 173) groups. Intervention participants were invited to attend four group-based self-management sessions, centred primarily on increasing PA, and received motivational text-message support. The primary outcome measure was change in overall volume (time and intensity) of daily PA at 12 months, as measured by the GENEActiv wrist-worn accelerometer device.

RESULTS

At baseline, the total sample achieved 22 min of moderate-vigorous intensity PA per day (mean/participant). At 12 months, in the complete-case analysis, a reduction in daily mean PA volume was seen in the intervention group relative to control (-0.80 milligravity [m g]; 95% confidence interval [CI] = -1.57 to -0.03; P = 0.04). Reductions were also seen in the intervention group in time spent in moderate-vigorous PA (-3.86 min per day; 95% CI= -6.70 to -1.03; P = 0.008) and time spent at an intensity equivalent to a slow walk (-4.66 min per day; 95% CI = -8.82 to -0.51; P = 0.028). However, the per-protocol analysis (excluding participants who did not attend at least one education session) found no between-group differences in overall daily PA at 12 months (-0.65 mg; 95% CI = -1.46 to 0.15; P = 0.11).

CONCLUSION

The self-management programme elicited a slight reduction in PA levels in people with multimorbidity. Future research should identify and target subgroups of those with multimorbidity in greatest need of PA promotion in order to maximise potential capacity for benefit, and also focus on refining the intervention in order to increase efficacy in increasing PA.

Satisfaction of Township Hospitals Health Workers on How They Are Paid in China

BACKGROUND

Township Hospitals (THs) are crucial providers in China's primary health delivery system. Low job satisfaction of THs health workers has been one of biggest challenges to strengthening the health system in China. Even huge amounts of studies confirmed low remuneration level as a key demotivating factor though few studies have explored the feelings of health workers on how they were paid.

OBJECTIVE

To analyze how the key design of Performance-based Salary System (PBS) influences the satisfaction of health workers on the payment system in China's THs.

METHOD

A cross-sectional study was conducted in 47 THs in Shandong China, and a total of 1136 participants were recruited. Expectancy theory was applied to design the measurements on designs of PBS. The associations between PBS design and satisfaction of health workers were analyzed by logistic regression.

RESULTS

Three key components of PBS design were all related to the satisfaction of health workers. Those health workers who were aware of assessment methods were more likely to be satisfied with how they were paid (OR = 2.44, p < 0.001) compared with those being not aware of the methods. The knowledge on personal performance was also associated with being satisfied (OR = 3.34, p < 0.001). The percentage of floating income in total income was negatively associated with the satisfaction, and one percentage point increase in floating income proportion could result in the possibility of being satisfied decreasing by 2.82% (95%CI -4.9 to -0.7, p = 0.01). Subgroup analysis found that only in those with lower value on monetary income, the negative influence of more floating income was significant.

CONCLUSIONS

When policymakers or managers apply performance-related payment to incentivize certain work behavior, they should pay attention to the design details, including keeping transparency in the performance assessment criteria, clear performance feedback, and setting the proportion of the performance-related part based on the preference of health workers in certain cultural settings.

What do end-users want to know about managing the performance of healthcare delivery systems? Co-designing a context-specific and practice-relevant research agenda

Background

Despite increasing interest in joint research priority-setting, few studies engage end-user groups in setting research priorities at the intersection of the healthcare and management disciplines. With health systems increasingly establishing performance management programmes to account for and incentivize performance, it is important to conduct research that is actionable by the end-users involved with or impacted by these programmes. The aim of this study was to co-design a research agenda on healthcare performance management with and for end-users in a specific jurisdictional and policy context.

Methods

We undertook a rapid review of the literature on healthcare performance management (n = 115) and conducted end-user interviews (n = 156) that included a quantitative ranking exercise to prioritize five directions for future research. The quantitative rankings were analysed using four methods: mean, median, frequency ranked first or second, and frequency ranked fifth. The interview transcripts were coded inductively and analysed thematically to identify common patterns across participant responses.

Results

Seventy-three individual and group interviews were conducted with 156 end-users representing diverse end-user groups, including administrators, clinicians and patients, among others. End-user groups prioritized different research directions based on their experiences and information needs. Despite this variation, the research direction on motivating performance improvement had the highest overall mean ranking and was most often ranked first or second and least often ranked fifth. The research direction was modified based on end-user feedback to include an explicit behaviour change lens and stronger consideration for the influence of context.

Conclusions

Joint research priority-setting resulted in a practice-driven research agenda capable of generating results to inform policy and management practice in healthcare as well as contribute to the literature. The results suggest that end-users are keen to open the “black box” of performance management to explore more nuanced questions beyond “does performance management work?” End-users want to know how, when and why performance management contributes to behaviour change (or fails to) among front-line care providers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12961-021-00779-x.

Psychological interventions to improve self-management of type 1 and type 2 diabetes: a systematic review

BACKGROUND

For people with diabetes mellitus to achieve optimal glycaemic control, motivation to perform self-management is important. The research team wanted to determine whether or not psychological interventions are clinically effective and cost-effective in increasing self-management and improving glycaemic control.

OBJECTIVES

The first objective was to determine the clinical effectiveness of psychological interventions for people with type 1 diabetes mellitus and people with type 2 diabetes mellitus so that they have improved (1) glycated haemoglobin levels, (2) diabetes self-management and (3) quality of life, and fewer depressive symptoms. The second objective was to determine the cost-effectiveness of psychological interventions.

DATA SOURCES

The following databases were accessed (searches took place between 2003 and 2016): MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, PsycINFO, EMBASE, Cochrane Controlled Trials Register, Web of Science, and Dissertation Abstracts International. Diabetes conference abstracts, reference lists of included studies and Clinicaltrials.gov trial registry were also searched.

REVIEW METHODS

Systematic review, aggregate meta-analysis, network meta-analysis, individual patient data meta-analysis and cost-effectiveness modelling were all used. Risk of bias of randomised and non-randomised controlled trials was assessed using the Cochrane Handbook (Higgins JP, Altman DG, Gøtzsche PC, Jüni P, Moher D, Oxman AD, et al. The Cochrane Collaboration's tool for assessing risk of bias in randomised trials. BMJ 2011;343:d5928).

DESIGN

Systematic review, meta-analysis, cost-effectiveness analysis and patient and public consultation were all used.

SETTING

Settings in primary or secondary care were included.

PARTICIPANTS

Adolescents and children with type 1 diabetes mellitus and adults with types 1 and 2 diabetes mellitus were included.

INTERVENTIONS

The interventions used were psychological treatments, including and not restricted to cognitive-behavioural therapy, counselling, family therapy and psychotherapy.

MAIN OUTCOME MEASURES

Glycated haemoglobin levels, self-management behaviours, body mass index, blood pressure levels, depressive symptoms and quality of life were all used as outcome measures.

RESULTS

A total of 96 studies were included in the systematic review (n = 18,659 participants). In random-effects meta-analysis, data on glycated haemoglobin levels were available for seven studies conducted in adults with type 1 diabetes mellitus (n = 851 participants) that demonstrated a pooled mean difference of -0.13 (95% confidence interval -0.33 to 0.07), a non-significant decrease in favour of psychological treatment; 18 studies conducted in adolescents/children with type 1 diabetes mellitus (n = 2583 participants) that demonstrated a pooled mean difference of 0.00 (95% confidence interval -0.18 to 0.18), indicating no change; and 49 studies conducted in adults with type 2 diabetes mellitus (n = 12,009 participants) that demonstrated a pooled mean difference of -0.21 (95% confidence interval -0.31 to -0.10), equivalent to reduction in glycated haemoglobin levels of -0.33% or ≈3.5 mmol/mol. For type 2 diabetes mellitus, there was evidence that psychological interventions improved dietary behaviour and quality of life but not blood pressure, body mass index or depressive symptoms. The results of the network meta-analysis, which considers direct and indirect effects of multiple treatment comparisons, suggest that, for adults with type 1 diabetes mellitus (7 studies; 968 participants), attention control and cognitive-behavioural therapy are clinically effective and cognitive-behavioural therapy is cost-effective. For adults with type 2 diabetes mellitus (49 studies; 12,409 participants), cognitive-behavioural therapy and counselling are effective and cognitive-behavioural therapy is potentially cost-effective. The results of the individual patient data meta-analysis for adolescents/children with type 1 diabetes mellitus (9 studies; 1392 participants) suggest that there were main effects for age and diabetes duration. For adults with type 2 diabetes mellitus (19 studies; 3639 participants), baseline glycated haemoglobin levels moderated treatment outcome.

LIMITATIONS

Aggregate meta-analysis was limited to glycaemic control for type 1 diabetes mellitus. It was not possible to model cost-effectiveness for adolescents/children with type 1 diabetes mellitus and modelling for type 2 diabetes mellitus involved substantial uncertainty. The individual patient data meta-analysis included only 40-50% of studies.

CONCLUSIONS

This review suggests that psychological treatments offer minimal clinical benefit in improving glycated haemoglobin levels for adults with type 2 diabetes mellitus. However, there was no evidence of benefit compared with control interventions in improving glycated haemoglobin levels for people with type 1 diabetes mellitus.

FUTURE WORK

Future work should consider the competency of the interventionists delivering a therapy and psychological approaches that are matched to a person and their life course.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016033619.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 28. See the NIHR Journals Library website for further project information.

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

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

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

OBJECTIVES

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

DESIGN

Historical cohort study.

SETTING

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

PARTICIPANTS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

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

AIMS

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The effect of commissioning on Portuguese Primary Health Care units' performance: A four-year national analysis

BACKGROUND

Portugal underwent a paradigmatic Primary Health Care (PHC) reform in 2005. The reform implemented better health information systems, goal-oriented management, pay-for-performance schemes, functional autonomy for the front-line units, and the general adoption of commissioning processes. Since the implementation of the reform, the same set of indicators have been monitored nationally every year. However, from 2014-2016, the five Regional Health Administrations could individually select part of set of indicators to be commissioned. As the same some indicators were used commissioned in some regions, but not in others, a natural experimental setting to observe the impact of commissioning on the results by comparing the performance of commissioned versus non-commissioned indicators emerged and the effects of commissioning on PHC performance could be evaluated.

AIM

Our article aims to clarify the effect of commissioning on the results achieved by PHC units in Portugal following the implementation of the reform.

RESULTS

In general, the indicator values improved with time in the three types of units that existed after the reform. However, Model B Family Health Units ('Unidades de Saúde Familiar' or USFs that use pay-for-performance and are more mature) obtained the highest absolute indicator values, followed by Model A USFs (newer units with a fixed salary) and Personalised Health Care Units ('Unidades de Cuidados de Saúde Personalizados' that were created under the model before the reform and offer a fixed salary), respectively.

CONCLUSION

The results show a general increase in indicators in all PHC units. However, the indicators used in the commissioning processes exhibited a greater increase. There was no evidence that the better results exhibited by the commissioned indicators were achieved at the expense of a detrimental effect on non-commissioned indicators.

What drives general practitioners in the UK to improve the quality of care? A systematic literature review

BACKGROUND

In the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated.

OBJECTIVES

(1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature.

METHODS

This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes.

RESULTS

35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition.

DISCUSSION

The majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care.

CONCLUSION

Current research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.

Payment methods for healthcare providers working in outpatient healthcare settings

BACKGROUND

Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services.

OBJECTIVES

To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes.

MAIN RESULTS

We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies.

AUTHORS' CONCLUSIONS

For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.

Improving the Quality of Dementia Care in General Practice: A Qualitative Study

Background: General Practitioners (GPs) play a central role in caring for people with dementia. There is a growing demand for GP-led community-based dementia care, as advocated in the Irish National Dementia Strategy (INDS). However, there is a paucity of research exploring GPs' views on dementia care since publication of the INDS. The aim of this qualitative study is to develop a deeper understanding of how to improve the quality of dementia care in General Practice, explored from the perspective of Irish GPs.

Methods: Semi-structured interviews were conducted with GPs. GPs who completed the “Dementia in Primary Care” CPD module at University College Cork in Ireland were purposively recruited. Interviews were audio-recorded, transcribed, and analyzed by thematic analysis.

Results: 12 interviews were conducted with 7 female and 5 male participants. Experience in General Practice ranged from 3 to 32 years. Most GPs practiced in mixed urban-rural settings (n = 9) and had nursing home commitments (n = 8). The average interview length was 45 minutes. Six major themes emerged from the data set, including resourcing primary care, addressing disparities in secondary care, community-centered care as patient-centered care, linking a dementia network, universal access to care, and raising public awareness.

Conclusion: GPs find dementia care to be a complex and challenging aspect of primary care. While education and training is advocated by GPs, service delivery must be reconfigured. This will necessitate adequate financial resourcing and the restructuring of community-based dementia care services.

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Analysing synthesis of evidence in a systematic review in health professions education: observations on struggling beyond Kirkpatrick

Background: Systematic reviews in health professions education may well under-report struggles to synthesize disparate evidence that defies standard quantitative approaches. This paper reports further process analysis in a previously reported systematic review about mobile devices on clinical placements.Objective: For a troublesome systematic review: (1) Analyse further the distribution and reliability of classifying the evidence to Maxwell quality dimensions (beyond 'Does it work?') and their overlap with Kirkpatrick K-levels. (2) Analyse how the abstracts represented those dimensions of the evidence-base. (3) Reflect on difficulties in synthesis and merits of Maxwell dimensions.Design: Following integrative synthesis of 45 K2-K4 primary studies (by combined content-thematic analysis in the pragmatism paradigm): (1) Hierarchical cluster analysis explored overlap between Maxwell dimensions and K-levels. Independent and consensus-coding to Maxwell dimensions compared (using: percentages; kappa; McNemar hypothesis-testing) pre- vs post-discussion and (2) article abstract vs main body. (3) Narrative summary captured process difficulties and merits.Results: (1) The largest cluster (five-cluster dendrogram) was acceptability-accessibility-K1-appropriateness-K3, with K1 and K4 widely separated. For article main bodies, independent coding agreed most for appropriateness (good; adjusted kappa = 0.78). Evidence increased significantly pre-post-discussion about acceptability (p = 0.008; 31/45→39/45), accessibility, and equity-ethics-professionalism. (2) Abstracts suggested efficiency significantly less than main bodies evidenced: 31.1% vs 44.4%, p = 0.031. 3) Challenges and merits emerged for before, during, and after the review.Conclusions: There should be more systematic reporting of process analysis about difficulties synthesizing suboptimal evidence-bases. In this example, Maxwell dimensions were a useful framework beyond K-levels for classifying and synthesizing the evidence-base.

Tuberculosis screening and management of latent tuberculosis infection prior to biologic treatment in patients with immune-mediated inflammatory diseases: A longitudinal population-based analysis using claims data

BACKGROUND AND AIM

Screening for tuberculosis before treating with biologic agents is recommended in patients with immune-mediated inflammatory diseases (IMIDs). We conducted this study to identify adherence to the recommended practice in a real-world setting in Japan.

METHODS

We used a community-based insurance claims database in a city in the Greater Tokyo Area in Japan. Between July 2012 and January 2019, we enrolled patients with IMIDs in the age range 15 to 74 years who had initiated biologic therapy. Tuberculosis screening was defined as (a) interferon-γ release assay and/or a tuberculin skin test (IGRA/TST) and (b) IGRA/TST and X-ray and/or CT scan (X-ray/CT) within 2 months before starting biologic agents. We analyzed the proportions of patients who underwent tuberculosis screening and their association with the patient- and treatment-related factors and treatment for latent tuberculosis infection (LTBI).

RESULTS

Of 421 patients presumed to have initiated biologic therapy, 202 (48%) underwent IGRA/TST and 169 (40%) underwent IGRA/TST and X-ray/CT. Patients aged 65 to 74 years were more likely to undergo tuberculosis screening than those aged 45 to 64 years. Compared to infliximab, IGRA/TST was less frequently performed in patients treated with etanercept, adalimumab, golimumab, abatacept, and tocilizumab. Treatment for LTBI was provided to 67 (16%) patients. Proportions of patients receiving LTBI treatment did not significantly differ according to the screening status.

CONCLUSION

There was low adherence to the recommendations for tuberculosis screening and prophylactic treatment before biologic therapy. It is necessary to continue alerting clinical practitioners to the importance of screening for tuberculosis and treatment for LTBI.

Concordance in the recording of stroke across UK primary and secondary care datasets: a population-based cohort study

Background

Previous work has demonstrated that the recording of acute health outcomes, such as myocardial infarction (MI), may be suboptimal in primary healthcare databases.

Aim

To assess the completeness and accuracy of the recording of stroke in UK primary care.

Design & setting

A population-based longitudinal cohort study.

Method

Cases of stroke were identified separately in Clinical Practice Research Datalink (CPRD) primary care records and linked Hospital Episode Statistics (HES). The recording of events in the same patient across the two datasets was compared. The reliability of strategies to identify fatal strokes in primary care and hospital records was also assessed.

Results

Of the 75 674 stroke events that were identified in either CPRD or HES data during the period of the study, 54 929 (72.6%) were recorded in CPRD and 51 013 (67.4%) were recorded in HES. Two-fifths (n = 30 268) of all recorded strokes were found in both datasets (allowing for a time window of 120 days). Among these 'matched' strokes the subtype was recorded accurately in approximately 75% of CPRD records (compared with coding in HES); however, 43.5% of ischaemic strokes in HES were coded as 'non-specific' strokes in CPRD data. Furthermore, 48.2% had same-day recordings, and 56.2% were date-matched within ±1 day.

Conclusion

The completeness and accuracy of stroke recording is improved by the use of linked hospital and primary care records. For studies that have a time-sensitive research question, the use of linked, as opposed to stand-alone, CPRD data is strongly recommended.

Performance-based pharmacy payment models: the case for change

In response to rising healthcare costs, healthcare payers across the globe have been experimenting with performance-based payment models that link payments to providers with the quality of care that they provide. Community pharmacy in Australia has yet to be significantly affected by these changes. Initial steps have been taken to fund quality-linked interventions by pharmacists, such as the provision of medicines in dose administration aids, but funding for dispensing prescriptions remains solely based on a fee-for-service model. At the foundation of any performance-based payment model are measures that, in aggregate, reflect the quality of care that is provided. Patient adherence to prescription regimens can be correlated with the counselling provided by pharmacists and, as such, can serve as the measure on which a performance-based payment model for dispensing can be constructed. Experience in the US suggests per-prescription payments to a pharmacy can be increased or decreased by a small, yet meaningful, amount based on a measure of the level of adherence of patients of the pharmacy. The current dispensing payment model in the Australian Pharmaceutical Benefits Scheme may be able to be modified in a similar manner to support provision by pharmacists of improved quality of care.

Spending and quality after three years of Medicare's bundled payments for medical conditions: quasi-experimental difference-in-differences study

OBJECTIVE

To evaluate whether longer term participation in the bundled payments for care initiative (BPCI) for medical conditions in the United States, which held hospitals financially accountable for all spending during an episode of care from hospital admission to 90 days after discharge, was associated with changes in spending, mortality, or health service use.

DESIGN

Quasi-experimental difference-in-differences analysis.

SETTING

US hospitals participating in bundled payments for acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease (COPD), or pneumonia, and propensity score matched to non-participating hospitals.

PARTICIPANTS

238 hospitals participating in the Bundled Payments for Care Improvement initiative (BPCI) and 1415 non-BPCI hospitals. 226 BPCI hospitals were matched to 700 non-BPCI hospitals.

MAIN OUTCOME MEASURES

Primary outcomes were total spending on episodes and death 90 days after discharge. Secondary outcomes included spending and use by type of post-acute care. BPCI and non-BPCI hospitals were compared by patient, hospital, and hospital market characteristics. Market characteristics included population size, competitiveness, and post-acute bed supply.

RESULTS

In the 226 BPCI hospitals, episodes of care totaled 261 163 in the baseline period and 93 562 in the treatment period compared with 211 208 and 78 643 in the 700 matched non-BPCI hospitals, respectively, with small differences in hospital and market characteristics after matching. Differing trends were seen for some patient characteristics (eg, mean age change -0.3 years at BPCI hospitals v non- BPCI hospitals, P<0.001). In the adjusted analysis, participation in BPCI was associated with a decrease in total episode spending (-1.2%, 95% confidence interval -2.3% to -0.2%). Spending on care at skilled nursing facilities decreased (-6.3%, -10.0% to -2.5%) owing to a reduced number of facility days (-6.2%, -9.8% to -2.6%), and home health spending increased (4.4%, 1.4% to 7.5%). Mortality at 90 days did not change (-0.1 percentage points, 95% confidence interval -0.5 to 0.2 percentage points).

CONCLUSIONS

In this longer term evaluation of a large national programme on medical bundled payments in the US, participation in bundles for four common medical conditions was associated with savings at three years. The savings were generated by practice changes that decreased use of high intensity care after hospital discharge without affecting quality, which also suggests that bundles for medical conditions could require multiple years before changes in savings and practice emerge.

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

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

The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study

Background

Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.

Objectives

We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.

Design and setting

We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.

Participants

Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.

Interventions

Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).

Main outcome measures

Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.

Results

Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.

Limitations

There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.

Conclusions

Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.

Future work

Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Awareness of, attitude toward, and willingness to participate in pay for performance programs among family physicians: a cross-sectional study

Background

The National Health Insurance Administration of Taiwan has introduced several pay-for-performance programs to improve the quality of healthcare. This study aimed to provide government with evidence-based research findings to help primary care physicians to actively engage in pay-for-performance programs.

Methods

We conducted a questionnaire survey among family physicians with age-stratified sampling from September 2016 to December 2017. The structured questionnaire consisted of items including the basic demographics of the surveyee and their awareness of and attitudes toward the strengths and/or weaknesses of the pay-for-performance programs, as well as their subjective norms, and the willingness to participate in the pay-for-performance programs. Univariate analysis and multivariate logistic regression analysis were performed to compare the differences between family physicians who participate in the pay-for-performance programs versus those who did not.

Results

A total of 543 family physicians completed the questionnaire. Among family physicians who participated in the pay-for-performance programs, more had joined the Family Practice Integrated Care Project [Odds ratio (OR): 2.70; 95% Confidence interval (CI): 1.78 ~ 4.09], had a greater awareness of pay-for-performance programs (OR: 2.37; 95% CI: 1.50 ~ 3.83), and a less negative attitude to pay-for-performance programs (OR: 0.50; 95% CI: 0.31 ~ 0.80) after adjusting for age and gender. The major reasons for family physicians who decided to join the pay-for-performance programs included believing the programs help enhance the quality of healthcare (80.8%) and recognizing the benefit of saving health expenditure (63.4%). The causes of unwillingness to join in a pay-for-performance program among non-participants were increased load of administrative works (79.6%) and inadequate understanding of the contents of the pay-for-performance programs (62.9%).

Conclusions

To better motivate family physicians into P4P participation, hosting effective training programs, developing a more transparent formula for assessing financial risk, providing sufficient budget for healthcare quality improvement, and designing a reasonable profit-sharing plan to promote collaboration between different levels of medical institutions are all imperative.