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Hsieh HM, Wang YH, Chen HF. Associations between participation in a diabetes pay-for-performance program and health outcomes and healthcare utilization among people with comorbid schizophrenia and type 2 diabetes in Taiwan. Gen Hosp Psychiatry 2025; 94:99-107. [PMID: 40043624 DOI: 10.1016/j.genhosppsych.2025.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2024] [Revised: 02/27/2025] [Accepted: 02/27/2025] [Indexed: 04/12/2025]
Abstract
OBJECTIVE Few population-based studies with large sample sizes have examined the long-term effects of integrated diabetes care in patients with schizophrenia. This study aimed to examine the association between participation in the nationwide diabetes Pay-for-Performance (DM-P4P) program and both health outcomes and healthcare utilization in individuals with schizophrenia comorbid with type 2 diabetes in Taiwan. STUDY SETTING AND DESIGN This was a longitudinal, real-world, nested case-control follow-up study from 2015 to 2021 in Taiwan. DATA SOURCE AND ANALYTICAL SAMPLE Multiple national population-based databases were used, including Taiwanese population-based longitudinal National Health Insurance (NHI) claims database, registry for NHI enrollment, catastrophic illness registry, board-certificated specialist registry, and registry for health care facilities. A total of 6172 schizophrenia patients with type 2 diabetes and matched controls were compared on a set of process outcome, health utilization, and direct medical cost measures between DM-P4P and non-P4P patients, with a follow-up period of at least three years. Generalized linear regression models were used to investigate the factors influencing participation in the DM-P4P program and to compare health outcomes. PRINCIPLE FINDINGS Schizophrenia patients with more severe diabetes complications and chronic comorbid conditions, or those who had previously participated in a schizophrenia P4P program, were more likely to participate in the program. Those who participated in the DM-P4P program were more likely to receive regular diabetes check-ups, and to have had more DM-related outpatient visits but fewer emergency room visits, hospitalizations, and related expenditures, as well as lower all-cause mortality, than non-DM-P4P patients. CONCLUSIONS The nationwide DM-P4P program positively affected health outcomes and healthcare utilization among people with schizophrenia comorbid with type 2 diabetes. Policymakers should consider establishing incentive mechanisms to encourage integrated care for schizophrenia patients with diabetes.
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Affiliation(s)
- Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Center for Big Data Research, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Yu-Hsin Wang
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan; National Health Insurance Administration, Kao-Ping Division, Ministry of Health and Welfare, Taiwan
| | - Hsueh-Fen Chen
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan; Center for Big Data Research, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Healthcare Administration and Medical Informatics, College of Health Sciences, Kaohsiung Medical University, Kaohsiung, Taiwan.; Division of Medical Statistics and Bioinformatics, Department of Medical Research, Kaohsiung Medical University, Kaohsiung, Taiwan..
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Sung MC, Chung KP, Cheng SH. Impact of a diabetes pay-for-performance program on nonincentivized mental disorders: a panel study based on claims database analysis. COST EFFECTIVENESS AND RESOURCE ALLOCATION 2023; 21:41. [PMID: 37415154 DOI: 10.1186/s12962-023-00450-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
BACKGROUND Diabetes is one of the most prevalent chronic diseases with subsequent complications. The positive effects of diabetes pay-for-performance (P4P) programs on treatment outcomes have been reported. The program provides financial incentives based on physiological care indicators, but common mental disorder complications such as depression are not covered. METHODS This study employed a natural experimental design to examine the spillover effects of diabetes P4P program on patients with nonincentivized depressive symptoms. The intervention group consisted of diabetes patients enrolled in the DM P4P program from 2010 to 2015. Unenrolled patients were selected by propensity score matching to form the comparison group. Difference-in-differences analyses were conducted to evaluate the effects of P4P programs. We employed generalized estimating equation (GEE) models, difference-in-differences analyses and difference-in-difference-in-differences analyses to evaluate the net effect of diabetes P4P programs. Changes in medical expenses (outpatient and total health care costs) over time were analysed for the treatment and comparison groups. RESULTS The results showed that enrolled patients had a higher incidence of depressive symptoms than unenrolled patients. The outpatient and total care expenses of diabetes patients with depressive symptoms were lower in the intervention group than in the comparison group. Diabetes patients with depressive symptoms enrolled in the DM P4P program had lower expenses for depression-related care than those not enrolled in the program. CONCLUSIONS The DM P4P program benefits diabetes patients by screening for depressive symptoms and lowering accompanying health care expenses. These positive spillover effects may be an important aspect of physical and mental health in patients with chronic disease enrolled in disease management programs while contributing to the control of health care expenses for chronic diseases.
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Affiliation(s)
- Ming-Chan Sung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Kuo-Piao Chung
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
| | - Shou-Hsia Cheng
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan.
- Population Health Research Center, National Taiwan University, 17, Xu-Zhou Road, Taipei, 100, Taiwan.
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Campion TSD, Daly JO, Wake M, Ahern S, Said JM. The role of Australian clinical quality registries in pregnancy care: A scoping review. Aust N Z J Obstet Gynaecol 2022; 62:472-482. [PMID: 35538882 PMCID: PMC9545682 DOI: 10.1111/ajo.13540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 04/17/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Pregnancy represents a time of increased morbidity and mortality for women and their infants. Clinical quality registries (CQRs) collect, analyse and report key healthcare quality indicators for patient cohorts to improve patient care. There are limited data regarding existing CQRs in pregnancy. This scoping review aimed to: (1) identify Australian CQRs specific to pregnancy care and describe their general characteristics; and (2) outline their aims and measured outcomes METHODS: The scoping review was undertaken according to Joanna Briggs Institute guidelines. CQRs were identified using a systematic approach from publications (Ovid MEDLINE, PubMed, Google Scholar), peer consultation, the Australian register of clinical registries and web searches. Details surrounding general characteristics, aims and outcomes were collated. RESULTS We identified two primary sources of information about pregnancy care. (1) Six CQRs are specific to pregnancy (Australia and New Zealand twin-twin transfusion syndrome registry, Australian Pregnancy Register for women with epilepsy and those taking anti-epileptic drugs, National Register of Antipsychotic Medication in Pregnancy, Australasian Maternity Outcomes Surveillance System, Neonatal Alloimmune Thrombocytopaenia Registry and the Diabetes in Pregnancy clinical register). (2) Fourteen observational cohort studies were facilitated by non-pregnancy-specific CQRs where a subsection of patients underwent pregnancy. CONCLUSIONS Australian CQRs currently report varied information regarding some selected conditions during pregnancy and offer therapeutic and epidemiological insight into their care. Further research into their effectiveness is warranted. We note the lack of a CQR spanning the common problems of pregnancy in general, where significant health, service and economic gains are possible.
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Affiliation(s)
- Tarun Sai David Campion
- Department of Obstetrics and GynaecologyThe University of MelbourneParkvilleVictoriaAustralia
| | - J. Oliver Daly
- Joan Kirner Women's & Children's at Sunshine HospitalWestern HealthSt AlbansVictoriaAustralia
| | - Melissa Wake
- Population HealthMurdoch Children's Research InstituteParkvilleVictoriaAustralia
- Department of PaediatricsThe University of MelbourneParkvilleVictoriaAustralia
- Liggins InstituteThe University of AucklandAucklandNew Zealand
| | - Susannah Ahern
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Joanne M. Said
- Department of Obstetrics and GynaecologyThe University of MelbourneParkvilleVictoriaAustralia
- Population HealthMurdoch Children's Research InstituteParkvilleVictoriaAustralia
- Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
- Maternal Fetal MedicineJoan Kirner Women's & Children's at Sunshine Hospital, Western HealthSt AlbansVictoriaAustralia
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4
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Forner D, Noel CW, Guttman MP, Haas B, Enepekides D, Rigby MH, Taylor SM, Nathens AB, Eskander A. Volume-outcome relationships in laryngeal trauma processes of care: a retrospective cohort study. Eur J Trauma Emerg Surg 2022; 48:4131-4141. [PMID: 35320370 DOI: 10.1007/s00068-022-01950-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 03/07/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE The extent to which patients with laryngeal trauma undergo investigation and intervention is largely unknown. The objective of this study was to therefore determine the association between hospital volume and processes of care in patients sustaining laryngeal trauma. METHODS This retrospective cohort study used the American College of Surgeons Trauma Quality Improvement Program database. Adult patients (≥ 18) who sustained traumatic laryngeal injuries between 2012 and 2016 were eligible. The exposure of interest was average annual laryngeal trauma volume categorized into quartiles. The primary and secondary outcomes of interest were the performances of diagnostic and therapeutic laryngeal procedures respectively. Multivariable logistic regression under a generalized estimating equations approach was utilized. RESULTS In total, 1164 patients were included. The average number of laryngeal trauma cases per hospital ranged from 0.2 to 7.2 per year. Diagnostic procedures were performed in 31% of patients and therapeutic in 19%. In patients with severe laryngeal injuries, diagnostic procedures were performed on a higher proportion of patients at high volume centers than low volume centers (46% vs 25%). In adjusted analysis, volume was not associated with the performance of diagnostic procedures. Patients treated at centers in the second (OR 1.94 [95% CI 1.29-2.90]) and third (OR 1.67 [95% CI 1.08-2.57]) volume quartiles had higher odds of undergoing a therapeutic procedure compared to the lowest volume quartile. CONCLUSION Hospital volume may be associated with processes of care in laryngeal trauma. Additional research is required to investigate how these findings relate to patient and health system outcomes.
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Affiliation(s)
- David Forner
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Christopher W Noel
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada
| | - Matthew P Guttman
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Barbara Haas
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Danny Enepekides
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada.,Department of Otolaryngology, Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 047, Toronto, ON, M4N 3M5, Canada
| | - Matthew H Rigby
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - S Mark Taylor
- Division of Otolaryngology, Head & Neck Surgery, Dalhousie University, Halifax, NS, Canada
| | - Avery B Nathens
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada.,Division of General Surgery, Department of Surgery, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Antoine Eskander
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada. .,Department of Otolaryngology, Head & Neck Surgery, University of Toronto, Toronto, ON, Canada. .,Department of Otolaryngology, Head & Neck Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room T2 047, Toronto, ON, M4N 3M5, Canada.
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5
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Bellass S, Canvin K, McLintock K, Wright N, Farragher T, Foy R, Sheard L. Quality indicators and performance measures for prison healthcare: a scoping review. HEALTH & JUSTICE 2022; 10:13. [PMID: 35257254 PMCID: PMC8902782 DOI: 10.1186/s40352-022-00175-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 02/20/2022] [Indexed: 06/10/2023]
Abstract
BACKGROUND Internationally, people in prison should receive a standard of healthcare provision equivalent to people living in the community. Yet efforts to assess the quality of healthcare through the use of quality indicators or performance measures have been much more widely reported in the community than in the prison setting. This review aims to provide an overview of research undertaken to develop quality indicators suitable for prison healthcare. METHODS An international scoping review of articles published in English was conducted between 2004 and 2021. Searches of six electronic databases (MEDLINE, CINAHL, Scopus, Embase, PsycInfo and Criminal Justice Abstracts) were supplemented with journal searches, author searches and forwards and backwards citation tracking. RESULTS Twelve articles were included in the review, all of which were from the United States. Quality indicator selection processes varied in rigour, and there was no evidence of patient involvement in consultation activities. Selected indicators predominantly measured healthcare processes rather than health outcomes or healthcare structure. Difficulties identified in developing performance measures for the prison setting included resource constraints, data system functionality, and the comparability of the prison population to the non-incarcerated population. CONCLUSIONS Selecting performance measures for healthcare that are evidence-based, relevant to the population and feasible requires rigorous and transparent processes. Balanced sets of indicators for prison healthcare need to reflect prison population trends, be operable within data systems and be aligned with equivalence principles. More effort needs to be made to meaningfully engage people with lived experience in stakeholder consultations on prison healthcare quality. Monitoring healthcare structure, processes and outcomes in prison settings will provide evidence to improve care quality with the aim of reducing health inequalities experienced by people living in prison.
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Affiliation(s)
- Sue Bellass
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK.
| | - Krysia Canvin
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Kate McLintock
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
| | - Nat Wright
- Spectrum Community Health CIC, Wakefield, UK
| | - Tracey Farragher
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Robbie Foy
- Leeds Institute for Health Sciences, University of Leeds, Leeds, UK
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Pallua J, Schirmer M. Identification of Five Quality Needs for Rheumatology (Text Analysis and Literature Review). Front Med (Lausanne) 2021; 8:757102. [PMID: 34760902 PMCID: PMC8573257 DOI: 10.3389/fmed.2021.757102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 09/28/2021] [Indexed: 12/14/2022] Open
Abstract
Background: While the use of the term "quality" in industry relates to the basic idea of making processes measurable and standardizing processes, medicine focuses on achieving health goals that go far beyond the mere implementation of diagnostic and therapeutic processes. However, the quality management systems used are often simple, self-created concepts that concentrate on administrative processes without considering the quality of the results, which is essential for the patient. For several rheumatic diseases, both outcome and treatment goals have been defined. This work summarizes current mainstreams of strategies with published quality efforts in rheumatology. Methods: PubMed, Cochrane Library, and Web of Science were used to search for studies, and additional manual searches were carried out. Screening and content evaluation were carried out using the PRISMA-P 2015 checklist. After duplicate search in the Endnote reference management software (version X9.1), the software Rayyan QCRI (https://rayyan.qcri.org) was applied to check for pre-defined inclusion and exclusion criteria. Abstracts and full texts were screened and rated using Voyant Tools (https://voyant-tools.org/). Key issues were identified using the collocate analysis. Results: The number of selected publications was small but specific (14 relevant correlations with coefficients >0.8). Using trend analysis, 15 publications with relative frequency of keywords >0.0125 were used for content analysis, revealing 5 quality needs. The treat to target (T2T) initiative was identified as fundamental paradigm. Outcome parameters required for T2T also allow quality assessments in routine clinical work. Quality care by multidisciplinary teams also focusing on polypharmacy and other quality aspects become essential, A global software platform to assess quality aspects is missing. Such an approach requires reporting of multiple outcome parameters according to evidence-based clinical guidelines and recommendations for the different rheumatic diseases. All health aspects defined by the WHO (physical, mental, and social health) have to be integrated into the management of rheumatic patients. Conclusion: For the future, quality projects need goals defined by T2T based initiatives in routine clinical work, secondary quality goals include multidisciplinary cooperation and reduction of polypharmacy. Quality indicators and standards in different health systems will provide new information to optimize patients' care in different health systems.
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Affiliation(s)
- Johannes Pallua
- University Hospital for Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
- Fachhochschule Gesundheit, Health University of Applied Sciences Tyrol, Innsbruck, Austria
| | - Michael Schirmer
- Department of Internal Medicine, University Clinic II, Innsbruck Medical University, Innsbruck, Austria
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Chen TT, Oldenburg B, Hsueh YS. Chronic care model in the diabetes pay-for-performance program in Taiwan: Benefits, challenges and future directions. World J Diabetes 2021; 12:578-589. [PMID: 33995846 PMCID: PMC8107979 DOI: 10.4239/wjd.v12.i5.578] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Revised: 02/08/2021] [Accepted: 04/05/2021] [Indexed: 02/06/2023] Open
Abstract
In this review, we discuss the chronic care model (CCM) in relation to the diabetes pay-for-performance (P4P) program in Taiwan. We first introduce the 6 components of the CCM and provide a detailed description of each of the activities in the P4P program implemented in Taiwan, mapping them onto the 6 components of the CCM. For each CCM component, the following three topics are described: the definition of the CCM component, the general activities implemented related to this component, and practical and empirical practices based on hospital or local government cases. We then conclude by describing the possible successful features of this P4P program and its challenges and future directions. We conclude that the successful characteristics of this P4P program in Taiwan include its focus on extrinsic and intrinsic incentives (i.e., shared care network), physician-led P4P and the implementation of activities based on the CCM components. However, due to the low rate of P4P program coverage, approximately 50% of patients with diabetes cannot enjoy the benefits of CCM-related activities or receive necessary examinations. In addition, most of these CCM-related activities are not allotted an adequate amount of incentives, and these activities are mainly implemented in hospitals, which compared with primary care providers, are unable to execute these activities flexibly. All of these issues, as well as insufficient implementation of the e-CCM model, could hinder the advanced improvement of diabetes care in Taiwan.
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Affiliation(s)
- Tsung-Tai Chen
- Department of Public Health, College of Medicine, Fu Jen Catholic University, New Taipei 24205, Taiwan
| | - Brian Oldenburg
- Noncommunicable Disease Control Unit, Melbourne School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
| | - Ya-Seng Hsueh
- Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Melbourne 3053, Australia
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Jacobs R, Aylott L, Dare C, Doran T, Gilbody S, Goddard M, Gravelle H, Gutacker N, Kasteridis P, Kendrick T, Mason A, Rice N, Ride J, Siddiqi N, Williams R. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2020. [DOI: 10.3310/hsdr08250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | - Lauren Aylott
- Expert by experience
- Hull York Medical School, York, UK
| | | | | | - Simon Gilbody
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | | | - Tony Kendrick
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Jemimah Ride
- Centre for Health Economics, University of York, York, UK
| | - Najma Siddiqi
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Rachael Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
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Blagden S, Hungerford D, Limmer M. Meningococcal vaccination in primary care amongst adolescents in North West England: an ecological study investigating associations with general practice characteristics. J Public Health (Oxf) 2019; 41:149-157. [PMID: 29385512 DOI: 10.1093/pubmed/fdy010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Revised: 12/01/2017] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND In 2015 the meningococcal ACWY (MenACWY) vaccination was introduced amongst adolescents in England following increased incidence and mortality associated with meningococcal group W. METHODS MenACWY vaccination uptake data for 17-18 years old and students delivered in primary care were obtained for 20 National Health Service clinical commissioning groups (CCGs) via the ImmForm vaccination system. Data on general practice characteristics, encompassing demographics and patient satisfaction variables, were extracted from the National General Practice Profiles resource. Univariable analysis of the associations between practice characteristics and vaccination was performed, followed by multivariable negative binomial regression. RESULTS Data were utilized from 587 general practices, accounting for ~8% of all general practices in England. MenACWY vaccination uptake varied from 20.8% to 46.8% across the CCGs evaluated. Upon multivariable regression, vaccination uptake increased with increasing percentage of patients from ethnic minorities, increasing percentage of patients aged 15-24 years, increasing percentage of patients that would recommend their practice and total Quality and Outcomes Framework achievement for the practice. Conversely, vaccination uptake decreased with increasing deprivation. CONCLUSIONS This study has identified several factors independently associated with MenACWY vaccination in primary care. These findings will enable a targeted approach to improve general practice-level vaccination uptake.
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Affiliation(s)
- Sarah Blagden
- Lancashire County Council, County Hall, Fishergate, Preston, UK.,Health Education North West, Regatta Place, Brunswick Business Park, Summers Road, Liverpool, UK.,Division of Health Research, Furness Building, Lancaster University, Lancaster, UK
| | - Daniel Hungerford
- The Centre for Global Vaccine Research, Institute of Infection and Global Health, The Ronald Ross Building, University of Liverpool, Liverpool, UK.,Field Epidemiology Service, Public Health England North West, Suite 3b, Cunard Building, Water Street, Liverpool, UK
| | - Mark Limmer
- Division of Health Research, Furness Building, Lancaster University, Lancaster, UK
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10
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Variation in anticoagulation for atrial fibrillation between English clinical commissioning groups: an observational study. Br J Gen Pract 2018; 68:e551-e558. [PMID: 29970397 DOI: 10.3399/bjgp18x697913] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 02/05/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Despite improvement in anticoagulation for atrial fibrillation (AF), substantial variation in anticoagulation persists between clinical commissioning groups (CCGs) and regions in England. AIM To identify reasons for variation between English CCGs in anticoagulation for AF. DESIGN AND SETTING A 4-year observational study from 2012/2013 to 2015/2016, of the national Quality and Outcomes Framework. METHOD Multiple regression and Pearson's correlation coefficients were used to analyse anticoagulation for AF in relation to older age, Index of Multiple Deprivation, prescription of non-vitamin K antagonist oral anticoagulants (NOACs), and exception reporting, as well as stroke hospital admission and mortality. RESULTS The proportion of eligible patients in England prescribed anticoagulants for AF without exceptions for clinical complexity or patient dissent increased from 65.1% in 2012/2013 to 77.9% in 2015/2016. In 2015, 290 920 additional eligible people were anticoagulated in association with use of the CHA2DS2VASc rather than CHADS2 score. From 2012 to 2015, exception reporting almost halved from 20% to 10.2%. Variation in CCG anticoagulation was not associated with deprivation or NOAC use. There was a strong negative association between exception reporting representing patient complexity and anticoagulation performance, accounting for 57% of the variation in anticoagulation without exceptions (multiple regression coefficient = -0.81; 95% confidence intervals = -0.92 to -0.71; P<0.001). CONCLUSION Anticoagulation for AF has improved substantially in England in association with considerable increases in the eligible population as a result of decreased exception reporting and the use of the CHA2DS2VASc score. There is still substantial room for improvement in most CCGs because, even allowing for exceptions, nine out of 10 CCGs failed to achieve 90% anticoagulation.
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Westby MD, Marshall DA, Jones CA. Development of quality indicators for hip and knee arthroplasty rehabilitation. Osteoarthritis Cartilage 2018; 26:370-382. [PMID: 29292095 DOI: 10.1016/j.joca.2017.10.020] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 10/24/2017] [Accepted: 10/25/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To develop quality indicators (QIs) reflecting the minimum acceptable standard of rehabilitation care before and after elective total hip arthroplasty (THA) and total knee arthroplasty (TKA) for osteoarthritis (OA). METHODS Informed by high quality evidence and using a modified RAND-UCLA Delphi approach, an 18-member Canadian panel of clinicians, researchers and patients considered 81 proposed QIs (40 for THA, 42 for TKA) addressing rehabilitation before and after elective THA and TKA. Panelists rated QIs for their importance and validity on a 9-point Likert scale through two rounds of online rating interspersed with a moderated and anonymous online discussion forum. Those QIs with median ratings of ≥7 for importance and validity with no disagreement based on the inter-percentile range adjusted for symmetry were included in the final sets. RESULTS Fifteen panelists from seven provinces and varied practice settings completed the Delphi process. Of the 81 plus one additional QIs (total of 82), 67 (82%) were rated as both important and valid (31 for THA, 36 for TKA). For THA, 14 pre-op, six acute and eight post-acute QIs were accepted. For TKA, 16 pre-op, 10 acute and eight post-acute indicators were accepted. Two of three 'across-continuum' QIs were rated appropriate for both procedures. CONCLUSION This work represents the first QIs with which to measure, report and benchmark quality of care in patients receiving rehabilitation before and after THA/TKA surgery. The QIs will be further tested for reliability and feasibility before being widely disseminated in clinical settings and used to assess care gaps.
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Affiliation(s)
- M D Westby
- Centre for Hip Health and Mobility, Vancouver Coastal Health Research Institute, 2635 Laurel Street, Vancouver, British Columbia, V5Z 1M9, Canada.
| | - D A Marshall
- Department of Community Health Sciences, Arthur JE Child Chair in Rheumatology Research, University of Calgary, Calgary, Alberta, Canada
| | - C A Jones
- Department of Physical Therapy, Faculty of Rehabilitation Medicine, University of Alberta, Edmonton, Alberta, Canada
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12
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Nuckols TK, Conlon C, Robbins M, Dworsky M, Lai J, Roth CP, Levitan B, Seabury S, Seelam R, Benner D, Asch SM. Quality of care and patient-reported outcomes in carpal tunnel syndrome: A prospective observational study. Muscle Nerve 2018; 57:896-904. [PMID: 29272038 DOI: 10.1002/mus.26041] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/10/2017] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Higher quality care for carpal tunnel syndrome (CTS) may be associated with better outcomes. METHODS This prospective observational study recruited adults diagnosed with CTS from 30 occupational health centers, evaluated physicians' adherence to recommended care processes, and assessed results of the Boston Carpal Tunnel Questionnaire (BCTQ) and Short Form Health Survey version 2 (SF-12v2) at recruitment and at 18 months. RESULTS Among 343 individuals, receiving better care (80th vs. 20th percentile for adherence) was associated with greater improvements in BCTQ Symptom Severity scores (-0.18, 95% confidence interval [CI] -0.32 to -0.05), BCTQ Functional Status scores (-0.21, 95% CI -0.34 to -0.08), and SF12-v2 Physical Component scores (1.75, 95% CI 0.33-3.16). Symptoms improved more when physicians assessed and managed activity, patients underwent necessary surgery, and employers adjusted job tasks. DISCUSSION Efforts should be made to ensure that patients with CTS receive essential care processes including necessary surgery and activity assessment and management. Muscle Nerve 57: 896-904, 2018.
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Affiliation(s)
- Teryl K Nuckols
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA.,Division of General Internal Medicine, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Craig Conlon
- Employee Health, The Permanente Medical Group, Oakland, California, USA
| | - Michael Robbins
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Michael Dworsky
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Julie Lai
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Carol P Roth
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Barbara Levitan
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | - Seth Seabury
- University of Southern California, USC Schaeffer Center, Los Angeles, California, USA
| | - Rachana Seelam
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA
| | | | - Steven M Asch
- RAND Corporation, 1776 Main Street Santa Monica, California, 90407, USA.,VA Palo Alto Health Care System, Menlo Park, California, USA.,Division of General Medical Disciplines, Stanford University School of Medicine, Palo Alto, California, USA
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Identifying primary care quality indicators for people with serious mental illness: a systematic review. Br J Gen Pract 2017; 67:e519-e530. [PMID: 28673958 PMCID: PMC5519123 DOI: 10.3399/bjgp17x691721] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2016] [Accepted: 03/08/2017] [Indexed: 01/24/2023] Open
Abstract
Background Serious mental illness (SMI) — which comprises long-term conditions such as schizophrenia, bipolar disorder, and other psychoses — has enormous costs for patients and society. In many countries, people with SMI are treated solely in primary care, and have particular needs for physical care. Aim The objective of this study was to systematically review the literature to create a list of quality indicators relevant to patients with SMI that could be captured using routine data, and which could be used to monitor or incentivise better-quality primary care. Design and setting A systematic literature review, combined with a search of quality indicator databases and guidelines. Method The authors assessed whether indicators could be measured from routine data and the quality of the evidence. Results Out of 1847 papers and quality indicator databases identified, 27 were included, from which 59 quality indicators were identified, covering six domains. Of the 59 indicators, 52 could be assessed using routine data. The evidence base underpinning these indicators was relatively weak, and was primarily based on expert opinion rather than trial evidence. Conclusion With appropriate adaptation for different contexts, and in line with the relative responsibilities of primary and secondary care, use of the quality indicators has the potential to improve care and to improve the physical and mental health of people with SMI. However, before the indicators can be used to monitor or incentivise primary care quality, more robust links need to be established, with improved patient outcomes.
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Sicsic J, Franc C. Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:609-621. [PMID: 27329654 DOI: 10.1007/s10198-016-0813-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/14/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP. OBJECTIVE Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old. METHODS Based on an administrative database of 50,752 women aged 50-74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use). RESULTS Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41-2.35 %)], but the effect was not significantly different following the implementation of the contract. CONCLUSION The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.
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Affiliation(s)
- Jonathan Sicsic
- CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France.
| | - Carine Franc
- CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France
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Johnston KJ, Hockenberry JM. Are Two Heads Better Than One or Do Too Many Cooks Spoil the Broth? The Trade-Off between Physician Division of Labor and Patient Continuity of Care for Older Adults with Complex Chronic Conditions. Health Serv Res 2017; 51:2176-2205. [PMID: 27891605 DOI: 10.1111/1475-6773.12600] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To examine the effects of physician division of labor and patient continuity of care (COC) on the care quality and outcomes of older adults with complex chronic conditions. DATA SOURCES/STUDY SETTING Seven years (2006-2012) of panel data from the Medicare Current Beneficiary Survey (MCBS). STUDY DESIGN Regression models were used to estimate the effect of the specialty-type of physicians involved in annual patient evaluation and management, as well as patient COC, on simultaneous care processes and following year outcomes. DATA COLLECTION/EXTRACTION METHODS Multiyear cohorts of Medicare beneficiaries with diabetes and/or heart failure were retrospectively identified to create a panel of 15,389 person-year observations. PRINCIPAL FINDINGS Involvement of both primary care physicians and disease-relevant specialists is associated with better compliance with process-of-care guidelines, but patients seeing disease-relevant specialists also receive more repeat cardiac imaging (p < .05). Patient COC is associated with less repeat cardiac imaging and compliance with some recommended care processes (p < .05), but the effects are small. Receiving care from a disease-relevant specialist is associated with lower rates of following year functional impairment, institutionalization in long-term care, and ambulatory care sensitive hospitalization (p < .05). CONCLUSIONS Annual involvement of disease-relevant specialists in the care of beneficiaries with complex chronic conditions leads to more resource use but has a beneficial effect on outcomes.
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Affiliation(s)
- Kenton J Johnston
- Department of Health Management and Policy and Center for Outcomes Research, College for Public Health and Social Justice, Saint Louis University, St Louis, MO
| | - Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA
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Hepner KA, Watkins KE, Farmer CM, Rubenstein L, Pedersen ER, Pincus HA. Quality of care measures for the management of unhealthy alcohol use. J Subst Abuse Treat 2017; 76:11-17. [PMID: 28340902 PMCID: PMC5384607 DOI: 10.1016/j.jsat.2016.11.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/14/2016] [Accepted: 11/21/2016] [Indexed: 12/28/2022]
Abstract
There is a paucity of quality measures to assess the care for the range of unhealthy alcohol use, ranging from risky drinking to alcohol use disorders. Using a two-phase expert panel review process, we sought to develop an expanded set of quality of care measures for unhealthy alcohol use, focusing on outpatient care delivered in both primary care and specialty care settings. This process generated 25 candidate measures. Eight measures address screening and assessment, 11 address aspects of treatment, and six address follow-up. These quality measures represent high priority targets for future development, including creating detailed technical specifications and pilot testing them to evaluate their utility in terms of feasibility, reliability, and validity.
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Affiliation(s)
| | | | - Carrie M Farmer
- RAND Corporation, 4570 Fifth Avenue, Pittsburgh, PA 15213, USA.
| | - Lisa Rubenstein
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA; VA Greater Los Angeles at Sepulveda, 16111 Plummer St. (152), North Hills, CA 91343, USA; Department of Medicine and School of Public Health, UCLA, 10833 Le Conte Avenue, Los Angeles, CA 90095, USA.
| | - Eric R Pedersen
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA.
| | - Harold Alan Pincus
- RAND Corporation, 1776 Main Street, Santa Monica, CA 90407, USA; Department of Psychiatry, Columbia University and New York-Presbyterian Hospital, 1051 Riverside Drive, Unit 09, New York, NY 10032, USA.
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Abstract
Research on the effects of pay-for-performance (P4P) in health care indicates largely disappointing results. This central finding, however, may mask important heterogeneity in the effects of P4P. We conducted a literature review to assess whether hospital and physician performance in P4P vary by patient and catchment area factors, organizational and structural capabilities, and P4P program characteristics. Several findings emerged: organizational size, practice type, teaching status, and physician age and gender modify performance in P4P. For physician practices and hospitals, a higher proportion of poor and minority patients is consistently associated with worse performance. Other theoretically influential characteristics-including information technology and staffing levels-yield mixed results. Inconsistent and contradictory effects of bonus likelihood, bonus size, and marginal costs on performance in P4P suggest organizations have not responded strategically to financial incentives. We conclude that extant heterogeneity in the effects of P4P does not fundamentally alter current assessments about its effectiveness.
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18
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Influence of a Pay-for-Performance Program on Glycemic Control in Patients Living with Diabetes by Family Physicians in a Canadian Province. Can J Diabetes 2016; 41:190-196. [PMID: 27908559 DOI: 10.1016/j.jcjd.2016.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/02/2016] [Accepted: 09/21/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We evaluated the influence of the introduction of a pay-for-performance program implemented in 2010 for family physicians on the glycemic control of patients with diabetes. METHODS Administrative data for all 583 eligible family physicians and 83,580 adult patients with diabetes in New Brunswick over 10 years were used. We compared the probability of receiving at least 2 tests for glycated hemoglobin (A1C) levels and achieving glycemic control before (2005-2009) and after (2010-2014) the implementation of the program and between patients divided based on whether a physician claimed the incentive or did not. RESULTS Patients living with diabetes showed greater odds of receiving at least 2 A1C tests per year if the detection of their diabetes occurred after (vs. before) the implementation of the program (OR, 99% CI=1.23, 1.18 to 1.28), if a physician claimed the incentive (vs. not claiming it) for their care (1.92, 1.87 to 1.96) in the given year, and if they were followed by a physician who ever (vs. never) claimed the incentive (1.24, 1.15 to 1.34). In a cohort-based analysis, patients for whom an incentive was claimed (vs. not claimed) had greater odds of receiving at least 2 A1C tests per year before implementation of the incentive, and these odds increased by 56% (1.49 to 1.62) following its implementation. However, there was no difference in A1C values among the various comparison groups. CONCLUSIONS Introduction of the incentive was associated with greater odds of having a minimum of 2 A1C tests per year, which may suggest that it led physicians to provide better follow-up care for patients with diabetes. However, the incentive program has not been associated with differences in glycemic control.
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Chen YC, Lee CTC, Lin BJ, Chang YY, Shi HY. Impact of pay-for-performance on mortality in diabetes patients in Taiwan: A population-based study. Medicine (Baltimore) 2016; 95:e4197. [PMID: 27399144 PMCID: PMC5058873 DOI: 10.1097/md.0000000000004197] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The impact of pay-for-performance (P4P) programs on long-term mortality for chronic illnesses, especially diabetes mellitus, has been rarely reported. Several studies described the favorable impact of P4P for diabetes mellitus on medical utilizations or intermediate outcomes. Therefore, this study aimed to investigate the impact of a P4P program on mortality in patients with type 2 diabetes. METHODS The P4P group in this population-based cohort study was 2090 individuals with a primary diagnosis of type 2 diabetes who had been newly enrolled in the P4P program of Taiwan between January 1, 2004 and December 31, 2004. Matched by 1:1 ratio, patients in the non-P4P group were selected by propensity score matching (PSM) for sex, age, the first year of diagnosis as diabetes, and 32 other potential confounding factors. Mean (SD) age was 60.91 (12.04) years when diabetes was first diagnosed and mean (SD) duration of diabetes was 4.3 (1.9) years at baseline. The time-dependent Cox regression model was used to explore the impact of P4P on all-cause mortality. RESULTS During a mean of 5.13 years (SD = 1.07 years) of follow-up, 206 and 263 subjects died in the P4P group and the non-P4P group, respectively. After adjusting for the potential confounding factors at baseline, survival was significantly longer in the P4P group than in the non-P4P group (hazard ratio, 0.76 [95% confidence interval, 0.64-0.92], P = 0.004, by log-rank test). This decrease in mortality is equivalent to one less death for every 37 patients who were treated in the P4P program for 5.13 years. In this study, the P4P program significantly increased the medical utilization of physician visits and diabetes-related examinations, improved the adherence of oral hypoglycemic drugs during the first 3 years and that of insulin during the second 3 years, and was negatively associated with risk of cancer and chronic kidney disease. In annual health expense, there was no significant difference between P4P and non-P4P groups, P = 0.430. CONCLUSIONS As compared with control, pay-for-performance program significantly improved survival in patients with diabetes without increasing the medical cost. The P4P group had significantly lower risk of cancer and chronic kidney disease.
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Affiliation(s)
- Yu-Ching Chen
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung
| | - Charles Tzu-Chi Lee
- Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei
| | - Boniface J. Lin
- College of Medicine, Fu Jen Catholic University, New Taipei
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yong-Yuan Chang
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung
| | - Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung
- Correspondence: Hon-Yi Shi, Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan, 100-Shih-Chun 1st Road, Kaohsiung 80708, Taiwan (e-mail: )
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Hsieh HM, Lin TH, Lee IC, Huang CJ, Shin SJ, Chiu HC. The association between participation in a pay-for-performance program and macrovascular complications in patients with type 2 diabetes in Taiwan: A nationwide population-based cohort study. Prev Med 2016; 85:53-59. [PMID: 26740347 DOI: 10.1016/j.ypmed.2015.12.013] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 12/16/2015] [Accepted: 12/18/2015] [Indexed: 12/20/2022]
Abstract
OBJECTIVE Diabetes and diabetes-related complications are major causes of morbidity and mortality worldwide and contribute substantially to health care costs. Proper care can prevent or delay vascular complications in people with type 2 diabetes. We sought to examine whether a diabetes pay-for-performance (P4P) program under Taiwan's National Health Insurance program decreased risk of macrovascular complications in type 2 diabetes patients, and associated risk factors. RESEARCH DESIGN AND METHOD We conducted a longitudinal observational case and control cohort study using two nationwide population-based databases in Taiwan, 2007-2012. Type 2 diabetes patients with a primary diabetes diagnosis in year 2007 and 2008 were included. We excluded patients with any diabetes complications within 2years before the index date. A propensity score matching approach was used to determine comparable P4P and non-P4P groups. We followed each P4P and non-P4P patient until December 31, 2012. Complication incidence rates per 1000 person-years for each complication were calculated. RESULTS Overall, our results indicated that P4P patients had lower risk of macrovascular complications than non-P4P patients. Specifically, hazard ratios (95% confidence intervals) were 0.84 (0.80-0.88) for stroke, 0.83 (0.75-0.92) for myocardial infarction, 0.72 (0.60-0.85) for atrial fibrillation, 0.93 (0.87-0.98) for heart failure, 0.61 (0.50-0.73) for gangrene, and 0.83 (0.74-0.93) for ulcer of lower limbs. CONCLUSIONS Compared with patients not enrolled in the P4P program, P4P patients had lower risk of developing serious vascular complications. Our empirical findings provide evidence for the potential long-term benefit of P4P programs in reducing risks of macrovascular complications.
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Affiliation(s)
- Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Tsung-Hsien Lin
- Department of Internal Medicine, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Cardiology, Department of Internal Medicine, Kaohsiung Medical University Hospital, Taiwan.
| | - I-Chen Lee
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Chun-Jen Huang
- Department of Psychiatry, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Psychiatry, Faculty of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
| | - Shyi-Jang Shin
- Graduate Institute of Medical Genetics, Kaohsiung Medical University, Kaohsiung, Taiwan; Division of Endocrinology and Metabolism, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan.
| | - Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan; Research Education and Epidemiology Center, Changhua, Taiwan.
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Krauth C, Liersch S, Jensen S, Amelung VE. Would German physicians opt for pay-for-performance programs? A willingness-to-accept experiment in a large general practitioners' sample. Health Policy 2016; 120:148-58. [PMID: 26852868 DOI: 10.1016/j.healthpol.2016.01.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Revised: 01/06/2016] [Accepted: 01/07/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Implementing pay-for-performance (P4P) programs is a non-trivial task. As evaluation studies showed, P4P programs often failed to improve performance quality. A crucial element for the successful implementation of P4P is to gain acceptance with health care providers. OBJECTIVES The aim of our study was to determine, if (and at what bonus rate) German general practitioners (GPs) would participate in a P4P program. We further examined differences between respondents who would participate in a P4P program (participants) versus respondents who would not participate (non-participants). METHODS A mail survey was conducted among 2493 general practitioners (GPs) in Lower Saxony (with a response rate of 36.2%). The questionnaire addressed attitudes toward P4P and included a willingness to accept experiment concerning P4P implementation. RESULTS The participation rate increased from 28% (at a bonus of 2.5%) to 50% (at a bonus of 20%). Participants showed better performance in target achievement and expected higher gains from P4P than non-participants. Major attitude differences were found in assessing feasibility of P4P, incentivizing performance and unintended consequences. The crucial factor for (not) accepting P4P might be the sense of (un)fairness of P4P. CONCLUSION To convince GPs to participate in P4P, better evidence for the effectiveness of P4P is required. To address the concerns of GPs, future endeavors should be directed to tailoring P4P programs. Finally, program implementation must be well communicated and thoroughly discussed with health care providers.
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Affiliation(s)
- Christian Krauth
- Hannover Medical School, Center for Health Economics Research Hannover (CHERH), Carl-Neuberg-St. 1, 30625 Hanover, Germany.
| | - Sebastian Liersch
- Hannover Medical School, Center for Health Economics Research Hannover (CHERH), Carl-Neuberg-St. 1, 30625 Hanover, Germany
| | - Sören Jensen
- Hannover Medical School, Center for Health Economics Research Hannover (CHERH), Carl-Neuberg-St. 1, 30625 Hanover, Germany
| | - Volker Eric Amelung
- Hannover Medical School, Center for Health Economics Research Hannover (CHERH), Carl-Neuberg-St. 1, 30625 Hanover, Germany
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Westby MD, Klemm A, Li LC, Jones CA. Emerging Role of Quality Indicators in Physical Therapist Practice and Health Service Delivery. Phys Ther 2016; 96:90-100. [PMID: 26089040 PMCID: PMC4706598 DOI: 10.2522/ptj.20150106] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Accepted: 06/08/2015] [Indexed: 12/27/2022]
Abstract
Quality-based care is a hallmark of physical therapy. Treatment effectiveness must be evident to patients, managers, employers, and funders. Quality indicators (QIs) are tools that specify the minimum acceptable standard of practice. They are used to measure health care processes, organizational structures, and outcomes that relate to aspects of high-quality care of patients. Physical therapists can use QIs to guide clinical decision making, implement guideline recommendations, and evaluate and report treatment effectiveness to key stakeholders, including third-party payers and patients. Rehabilitation managers and senior decision makers can use QIs to assess care gaps and achievement of benchmarks as well as to guide quality improvement initiatives and strategic planning. This article introduces the value and use of QIs to guide clinical practice and health service delivery specific to physical therapy. A framework to develop, select, report, and implement QIs is outlined, with total joint arthroplasty rehabilitation as an example. Current initiatives of Canadian and American physical therapy associations to develop tools to help clinicians report and access point-of-care data on patient progress, treatment effectiveness, and practice strengths for the purpose of demonstrating the value of physical therapy to patients, decision makers, and payers are discussed. Suggestions on how physical therapists can participate in QI initiatives and integrate a quality-of-care approach in clinical practice are made.
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Affiliation(s)
- Marie D Westby
- M.D. Westby, PT, PhD, School of Public Health, University of Alberta, c/o Arthritis Research Canada, 5591 No. 3 Rd, Richmond, British Columbia, Canada V6X 2C7.
| | - Alexandria Klemm
- A. Klemm, BKin, Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
| | - Linda C Li
- L.C. Li, PT, PhD, Department of Physical Therapy, University of British Columbia
| | - C Allyson Jones
- C.A. Jones, PT, PhD, Department of Physical Therapy, University of Alberta, Edmonton, Alberta, Canada
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Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system. J Trauma Acute Care Surg 2015; 78:1168-75. [PMID: 26151519 DOI: 10.1097/ta.0000000000000663] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND According to Donabedian's health care quality model, improvements in the structure of care should lead to improvements in clinical processes that should in turn improve patient outcome. This model has been widely adopted by the trauma community but has not yet been validated in a trauma system. The objective of this study was to assess the performance of an integrated trauma system in terms of structure, process, and outcome and evaluate the correlation between quality domains. METHODS Quality of care was evaluated for patients treated in a Canadian provincial trauma system (2005-2010; 57 centers, n = 63,971) using quality indicators (QIs) developed and validated previously. Structural performance was measured by transposing on-site accreditation visit reports onto an evaluation grid according to American College of Surgeons criteria. The composite process QI was calculated as the average sum of proportions of conformity to 15 process QIs derived from literature review and expert opinion. Outcome performance was measured using risk-adjusted rates of mortality, complications, and readmission as well as hospital length of stay (LOS). Correlation was assessed with Pearson's correlation coefficients. RESULTS Statistically significant correlations were observed between structure and process QIs (r = 0.33), and process and outcome QIs (r = -0.33 for readmission, r = -0.27 for LOS). Significant positive correlations were also observed between outcome QIs (r = 0.37 for mortality-readmission; r = 0.39 for mortality-LOS and readmission-LOS; r = 0.45 for mortality-complications; r = 0.34 for readmission-complications; 0.63 for complications-LOS). CONCLUSION Significant correlations between quality domains observed in this study suggest that Donabedian's structure-process-outcome model is a valid model for evaluating trauma care. Trauma centers that perform well in terms of structure also tend to perform well in terms of clinical processes, which in turn has a favorable influence on patient outcomes. LEVEL OF EVIDENCE Prognostic study, level III.
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Abstract
BACKGROUND Pay for performance was implemented in 2009 in France. The system was optional at first and then became widespread. Since 2012, it has been standard for most GPs. Several studies have attempted to investigate its efficiency and the GP's opinion of the system, but few studies have yet to examine the patient's view. AIM To gain an understanding of the views of French family practice patients about pay for performance. DESIGN AND SETTING Forty patients were interviewed between March and July 2013 in the Île-de-France region, of France. METHOD A qualitative study using semi-structured individual interviews, in primary care. RESULTS Most of the patients did not know what pay for performance was and stated that they had not noticed any change in care since the system began. Some patients noted the possible benefits in the quality of care, such as an improvement in follow-up and prevention, better information provided by the GP, and a decrease in the volume of prescriptions and therefore health costs. Other patients were concerned about potential downsides, such as an overprescription of unnecessary medical treatments, an increase in health costs, patient selection, and standardised consultations that do not necessarily take into account the patient's individual concerns. CONCLUSION Since implementation of pay for performance, patients had not noticed any modification in their medical care. They could understand the need for change in the remuneration policy and expressed their agreement about performance-based remuneration if, and only if, it is not the cause of depersonalised health care.
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Mason T, Sutton M, Whittaker W, McSweeney T, Millar T, Donmall M, Jones A, Pierce M. The impact of paying treatment providers for outcomes: difference-in-differences analysis of the 'payment by results for drugs recovery' pilot. Addiction 2015; 110:1120-8. [PMID: 26058447 DOI: 10.1111/add.12920] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 07/28/2014] [Accepted: 03/09/2015] [Indexed: 11/26/2022]
Abstract
AIMS To estimate the effect on drug misuse treatment completion of a pilot scheme to pay service providers according to rates of recovery. DESIGN A controlled, quasi-experimental (difference-in-differences) observational study using multi-level random effects logistic regression. SETTING Drug misuse treatment providers in all 149 commissioning areas in England in the financial years 2011-12 and 2012-13. PARTICIPANTS Service users treated in England in 2011-12 and 2012-13. INTERVENTION AND COMPARATORS Linkage of provider payments to performance indicators in eight pilot commissioning areas in England compared with all 141 non-pilot commissioning areas in England. MEASUREMENTS Recovery was measured by successful completion of treatment (free from drugs of dependence) and engagement with services was measured by rates of declining to continue with treatment. FINDINGS Following the introduction of the pilot scheme, service users treated in pilot areas were 1.3 percentage points [odds ratio (OR) = 0.859; 95% confidence interval (CI) = 0.788, 0.937] less likely to complete treatment compared with those treated in comparison areas. Service users treated in pilot areas were 0.9 percentage points (OR = 2.934; 95% CI = 2.094, 4.113) more likely to decline to continue with treatment compared with those treated in comparison areas. CONCLUSIONS In the first year of the pilot 'Payment by Results for Drugs Recovery' scheme in England, linking payments to outcomes reduced the probability of completing drug misuse treatment and increased the proportion service users declining to continue with treatment.
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Affiliation(s)
- Thomas Mason
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Matthew Sutton
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - William Whittaker
- Manchester Centre for Health Economics, University of Manchester, Manchester, UK
| | - Tim McSweeney
- Institute for Criminal Policy Research, Birkbeck, University of London
| | - Tim Millar
- National Drug Evidence Centre, University of Manchester, Manchester, UK
| | - Michael Donmall
- National Drug Evidence Centre, University of Manchester, Manchester, UK
| | - Andrew Jones
- National Drug Evidence Centre, University of Manchester, Manchester, UK
| | - Matthias Pierce
- National Drug Evidence Centre, University of Manchester, Manchester, UK
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Navarro-Compán V, Smolen JS, Huizinga TWJ, Landewé R, Ferraccioli G, da Silva JAP, Moots RJ, Kay J, van der Heijde D. Quality indicators in rheumatoid arthritis: results from the METEOR database. Rheumatology (Oxford) 2015; 54:1630-9. [DOI: 10.1093/rheumatology/kev108] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Indexed: 11/13/2022] Open
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Feng Y, Ma A, Farrar S, Sutton M. The tougher the better: an economic analysis of increased payment thresholds on the performance of general practices. HEALTH ECONOMICS 2015; 24:353-371. [PMID: 24391074 DOI: 10.1002/hec.3022] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 08/14/2013] [Accepted: 11/12/2013] [Indexed: 06/03/2023]
Abstract
We investigate whether and how a change in performance-related payment motivated General Practitioners (GPs) in Scotland. We evaluate the effect of increases in the performance thresholds required for maximum payment under the Quality and Outcomes Framework in April 2006. A difference-in-differences estimator with fixed effects was employed to examine the number of patients treated under clinical indicators whose payment schedules were revised and to compare these with the figures for those indicators whose schedules remained unchanged. The results suggest that the increase in the maximum performance thresholds increased GPs' performance by 1.77% on average. Low-performing GPs improved significantly more (13.22%) than their high-performing counterparts (0.24%). Changes to maximum performance thresholds are differentially effective in incentivising GPs and could be used further to raise GPs' performance across all indicators.
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Affiliation(s)
- Yan Feng
- Office of Health Economics, London, UK
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Feasibility and quality of cardiovascular disease prevention within a community-based health insurance program in rural Nigeria. J Hypertens 2015; 33:366-75. [DOI: 10.1097/hjh.0000000000000401] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Jesus TS, Hoenig H. Postacute rehabilitation quality of care: toward a shared conceptual framework. Arch Phys Med Rehabil 2014; 96:960-9. [PMID: 25542676 DOI: 10.1016/j.apmr.2014.12.007] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2014] [Revised: 11/29/2014] [Accepted: 12/02/2014] [Indexed: 10/24/2022]
Abstract
There is substantial interest in mechanisms for measuring, reporting, and improving the quality of health care, including postacute care (PAC) and rehabilitation. Unfortunately, current activities generally are either too narrow or too poorly specified to reflect PAC rehabilitation quality of care. In part, this is caused by a lack of a shared conceptual understanding of what construes quality of care in PAC rehabilitation. This article presents the PAC-rehab quality framework: an evidence-based conceptual framework articulating elements specifically pertaining to PAC rehabilitation quality of care. The widely recognized Donabedian structure, process, and outcomes (SPO) model furnished the underlying structure for the PAC-rehab quality framework, and the International Classification of Functioning, Disability and Health (ICF) framed the functional outcomes. A comprehensive literature review provided the evidence base to specify elements within the SPO model and ICF-derived framework. A set of macrolevel-outcomes (functional performance, quality of life of patient and caregivers, consumers' experience, place of discharge, health care utilization) were defined for PAC rehabilitation and then related to their (1) immediate and intermediate outcomes, (2) underpinning care processes, (3) supportive team functioning and improvement processes, and (4) underlying care structures. The role of environmental factors and centrality of patients in the framework are explicated as well. Finally, we discuss why outcomes may best measure and reflect the quality of PAC rehabilitation. The PAC-rehab quality framework provides a conceptually sound, evidence-based framework appropriate for quality of care activities across the PAC rehabilitation continuum.
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Affiliation(s)
- Tiago Silva Jesus
- Health Psychology Department, Medical School, University Miguel Hernández, Elche, Spain.
| | - Helen Hoenig
- Physical Medicine and Rehabilitation Service, Durham Veterans Administration Medical Center, Durham, NC; Division of Geriatrics, Department of Medicine, Duke University Medical Center, Durham, NC
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Saint-Lary O, Sicsic J. Impact of a pay for performance programme on French GPs' consultation length. Health Policy 2014; 119:417-26. [PMID: 25458971 DOI: 10.1016/j.healthpol.2014.10.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 09/11/2014] [Accepted: 10/05/2014] [Indexed: 11/15/2022]
Abstract
BACKGROUND In 2009, a voluntary-based pay for performance scheme targeting general practitioners (GPs) was introduced in France through the 'Contract for Improving Individual Practices' (CAPI). OBJECTIVE To study the impact of the CAPI on French GPs' consultation length. METHODS Univariate analysis, and multilevel regression analyses were performed to disentangle the different sources of the consultation length variability (intra and inter physician). The dependant variable was the logarithm of the consultation length. Independent variables included patient's sociodemographics as well as the characteristics of GPs and their medical activity. RESULTS Between November 2011 and April 2012, 128 physicians were recruited throughout France and generated 20,779 consultations timed by residents. The average consultation length in the sample was 16.8 min. After adjusting for patients' characteristics only, the consultation length of CAPI signatories was 14.1% lower than that observed for non signatories (p<0.001). After adjusting for GPs' characteristics and the case mix, the CAPI was no longer a significant predictor of the consultation length. The results did not change significantly from one type of consultation to another. CONCLUSION Although the CAPI was extended to all GPs in 2012, our results provide a cautionary message to regulators about its ability to generate higher quality of care.
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Affiliation(s)
- Olivier Saint-Lary
- Collège National des Généralistes Enseignants (CNGE), University Versailles Saint-Quentin en Yvelines, Department of Family Medicine, 78180 Montigny le Bretonneux, France
| | - Jonathan Sicsic
- CERMES3, UMR8211, INSERM U988, Site CNRS, 7, rue Guy Môquet, 94801 Villejuif Cedex, France.
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Falaschetti E, Mindell J, Knott C, Poulter N. Hypertension management in England: a serial cross-sectional study from 1994 to 2011. Lancet 2014; 383:1912-9. [PMID: 24881995 DOI: 10.1016/s0140-6736(14)60688-7] [Citation(s) in RCA: 185] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hypertension is the leading risk factor contributing to the global burden of disease. We aimed to assess the change in blood pressure management between 1994 and 2011 in England with a series of annual surveys. METHODS We did a serial cross-sectional study of five Health Survey for England surveys based on nationally representative samples of non-institutionalised adults (aged ≥16 years). Mean blood pressure levels and rates of awareness, treatment, and control of hypertension were assessed. Hypertension was defined as systolic blood pressure 140 mm Hg or higher, diastolic blood pressure 90 mm Hg or higher, or receiving treatment for high blood pressure. FINDINGS The mean blood pressure levels of men and women in the general population and among patients with treated hypertension progressively improved between 1994 and 2011. In patients with treated hypertension, blood pressure improved from 150·0 (SE 0·59)/80·2 (0·27) mm Hg to 135·4 (0·58)/73·5 (0·41) mm Hg. Awareness, treatment, and control rates among men and women combined also improved significantly across each stage of this 17-year period, with the prevalence of control among treated patients almost doubling from 33% (SE 1·4) in 1994 to 63% (1·7) in 2011. Nevertheless, of all adults with survey-defined hypertension in 2011, hypertension was controlled in only 37%. INTERPRETATION If the same systematic improvement in all aspects of hypertension management continues until 2022, 80% of patients with treated hypertension will have controlled blood pressure levels with a potential annual saving of about 50,000 major cardiovascular events. FUNDING None.
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Affiliation(s)
- Emanuela Falaschetti
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, UK.
| | - Jennifer Mindell
- Department of Epidemiology & Public Health, University College London, London, UK
| | - Craig Knott
- Department of Epidemiology & Public Health, University College London, London, UK
| | - Neil Poulter
- International Center for Circulatory Health, National Heart & Lung Institute, Imperial College London, London, UK
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Yazdany J, Trupin L, Schmajuk G, Katz PP, Yelin EH. Quality of care in systemic lupus erythematosus: the association between process and outcome measures in the Lupus Outcomes Study. BMJ Qual Saf 2014; 23:659-66. [PMID: 24614054 DOI: 10.1136/bmjqs-2013-002494] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVES Although process measures to assess quality of care in systemic lupus erythematosus (SLE) are available, their relationship to long-term outcomes has not been studied. Using a prospective, longitudinal cohort study, we examined the associations between high-quality care and two important SLE outcomes, disease activity and damage. METHODS Data were derived from the University of California, San Francisco Lupus Outcomes Study. Participants were followed from 2009 through 2013, responding to yearly surveys. Primary outcomes in this study were clinically meaningful increases in disease activity and damage, assessed by the Systemic Lupus Activity Questionnaire (SLAQ) and the Brief Index of Lupus Damage (BILD), respectively. Using multivariable regression, we examined the relationship between high performance on 13 validated quality measures (receipt of ≥85% of quality measures), and disease outcomes, adjusting for disease status, sociodemographic characteristics, healthcare services and follow-up time. RESULTS The 737 participants were eligible for a mean of five quality measures (SD 2, range 2-12). There were 155 and 162 participants who had clinically meaningful increases in SLAQ and BILD, respectively. In our models, we found no statistically significant relationship between performance on quality measures and changes in SLAQ. However, receiving higher-quality SLE care was significantly protective against increased disease damage (adjusted OR 0.4, 95% CI 0.4 to 0.7), even after adjusting for covariates. DISCUSSION In this community-based cohort, we illustrate for the first time a strong link between processes of care, defined by SLE quality measures, and the subsequent accumulation of disease damage, an important outcome.
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Affiliation(s)
- Jinoos Yazdany
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA
| | - Laura Trupin
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA
| | - Gabriela Schmajuk
- Department of Medicine, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California, USA
| | - Patricia P Katz
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA Institute for Health Policy Studies, University of California, San Francisco, California, USA
| | - Edward H Yelin
- Department of Medicine, Division of Rheumatology, University of California, San Francisco, California, USA Institute for Health Policy Studies, University of California, San Francisco, California, USA
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Powell AA, White KM, Partin MR, Halek K, Hysong SJ, Zarling E, Kirsh SR, Bloomfield HE. More than a score: a qualitative study of ancillary benefits of performance measurement. BMJ Qual Saf 2014; 23:651-8. [PMID: 24522176 DOI: 10.1136/bmjqs-2013-002149] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Prior research has examined clinical effects of performance measurement systems. To the extent that non-clinical effects have been researched, the focus has been on negative unintended consequences. Yet, these same systems may also have ancillary benefits for patients and providers--that is, benefits that extend beyond improvements on clinical measures. The purpose of this study is to identify and describe potential ancillary benefits of performance measures as perceived by primary care staff and facility leaders in a large US healthcare system. METHODS In-person individual semistructured interviews were conducted with 59 primary care staff and facility leaders at four Veterans Health Administration facilities. Transcribed interviews were coded and organised into thematic categories. RESULTS Interviewed staff observed that local performance measurement implementation practices can result in increased patient knowledge and motivation. These effects on patients can lead to improved performance scores and additional ancillary benefits. Performance measurement implementation can also directly result in ancillary benefits for the patients and providers. Patients may experience greater satisfaction with care and psychosocial benefits associated with increased provider-patient communication. Ancillary benefits of performance measurement for providers include increased pride in individual or organisational performance and greater confidence that one's practice is grounded in evidence-based medicine. CONCLUSIONS A comprehensive understanding of the effects of performance measurement systems needs to incorporate ancillary benefits as well as effects on clinical performance scores and negative unintended consequences. Although clinical performance has been the focus of most evaluations of performance measurement to date, both patient care and provider satisfaction may improve more rapidly if all three categories of effects are considered when designing and evaluating performance measurement systems.
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Affiliation(s)
- Adam A Powell
- Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota, USA Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Katie M White
- School of Public Health Center for Care Organization Research and Development (CCORD), University of Minnesota, Minneapolis, Minnesota, USA
| | - Melissa R Partin
- Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota, USA Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Krysten Halek
- Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Sylvia J Hysong
- Houston Center for Quality of Care and Utilization Studies, Michael E DeBakey VA Medical Center, Houston, Texas, USA Baylor College of Medicine, Houston, Texas, USA
| | - Edwin Zarling
- Rosalind Franklin School of Medicine, North Chicago, Illinois, USA
| | - Susan R Kirsh
- Louis Stokes Cleveland Veterans Affairs Medical Center, Cleveland, Ohio, USA Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Hanna E Bloomfield
- Center for Chronic Disease Outcomes Research (CCDOR), Minneapolis VA Health Care System, Minneapolis, Minnesota, USA Department of Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Sicsic J, Le Vaillant M, Franc C. Building a composite score of general practitioners' intrinsic motivation: a comparison of methods. Int J Qual Health Care 2014; 26:167-73. [DOI: 10.1093/intqhc/mzu007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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de Vries ST, Voorham J, Haaijer-Ruskamp FM, Denig P. Potential overtreatment and undertreatment of diabetes in different patient age groups in primary care after the introduction of performance measures. Diabetes Care 2014; 37:1312-20. [PMID: 24595634 DOI: 10.2337/dc13-1861] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To assess whether after the introduction of diabetes performance measures decreases in undertreatment correspond with increases in overtreatment for blood pressure (BP) and glycemic control in different patient age groups. RESEARCH DESIGN AND METHODS We conducted a cohort study using data from the Groningen Initiative to Analyse Type 2 Diabetes Treatment (GIANTT) database. General practices were included when data were available from 1 year before to at least 1 year after the introduction of diabetes performance measures. Included patients had a confirmed diagnosis of type 2 diabetes. Potential overtreatment was defined as prescribing maximum treatment or a treatment intensification to patients with a sustained low-risk factor level. Potential undertreatment was defined as a lack of treatment intensification in patients with a sustained high-risk factor level. Percentages of over- and undertreated patients at baseline were compared with those in subsequent years, and stratified analyses were performed for different patient age groups. RESULTS For BP, undertreatment significantly decreased from 61 to 57% in the first year after the introduction of performance measures. In patients >75 years of age, undertreatment decreased from 65 to ∼61%. Overtreatment was relatively stable (∼16%). For glycemic control, undertreatment significantly increased from 49 to 53%, and overtreatment remained relatively stable (∼7%). CONCLUSIONS The improvement of BP undertreatment after introduction of the performance measures did not correspond with an increase in overtreatment. The performance measures appeared to have little impact on improving glucose-regulating treatment. The trends did not differ among patient age groups.
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Ji R, Wang D, Liu G, Shen H, Wang Y, Li H, Schwamm LH, Wang Y. Impact of macroeconomic status on prehospital management, in-hospital care and functional outcome of acute stroke in China. ACTA ACUST UNITED AC 2013. [DOI: 10.2217/cpr.13.68] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Weizman AV, Nguyen GC. Interventions and targets aimed at improving quality in inflammatory bowel disease ambulatory care. World J Gastroenterol 2013; 19:6375-6382. [PMID: 24151356 PMCID: PMC3801308 DOI: 10.3748/wjg.v19.i38.6375] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Revised: 08/15/2013] [Accepted: 08/20/2013] [Indexed: 02/06/2023] Open
Abstract
Over the past decade, there has been increasing focus on improving the quality of healthcare delivered to patients with chronic diseases, including inflammatory bowel disease. Inflammatory bowel disease is a complex, chronic condition with associated morbidity, health care costs, and reductions in quality of life. The condition is managed primarily in the outpatient setting. The delivery of high quality of care is suboptimal in several ambulatory inflammatory bowel disease domains including objective assessments of disease activity, the use of steroid-sparing agents, screening prior to anti-tumor necrosis factor therapy, and monitoring thiopurine therapy. This review outlines these gaps in performance and provides potential initiatives aimed at improvement including reimbursement programs, quality improvement frameworks, collaborative efforts in quality improvement, and the use of healthcare information technology.
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Weizman AV, Nguyen GC. Quality of care delivered to hospitalized inflammatory bowel disease patients. World J Gastroenterol 2013; 19:6360-6366. [PMID: 24151354 PMCID: PMC3801306 DOI: 10.3748/wjg.v19.i38.6360] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2013] [Revised: 07/24/2013] [Accepted: 08/06/2013] [Indexed: 02/06/2023] Open
Abstract
Hospitalized patients with inflammatory bowel disease (IBD) are at high risk for morbidity, mortality, and health care utilization costs. While the literature on trends in hospitalization rates for this disease is conflicting, there does appear to be significant variation in the delivery of care to this complex group, which may be a marker of suboptimal quality of care. There is a need for improvement in identifying patients at risk for hospitalization in an effort to reduce admissions. Moreover, appropriate screening for a number of hospital acquired complications such as venous thromboembolism and Clostridium difficile infection is suboptimal. This review discusses areas of inpatient care for IBD patients that are in need of improvement and outlines a number of potential quality improvement initiatives such as pay-for-performance models, quality improvement frameworks, and healthcare information technology.
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Langdown C, Peckham S. The use of financial incentives to help improve health outcomes: is the quality and outcomes framework fit for purpose? A systematic review. J Public Health (Oxf) 2013; 36:251-8. [PMID: 23929885 DOI: 10.1093/pubmed/fdt077] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The quality and outcomes framework (QOF) is one of the world's largest pay-for-performance schemes, rewarding general practitioners for the quality of care they provide. This review examines the evidence on the efficacy of the scheme for improving health outcomes, its impact on non-incentivized activities and the robustness of the clinical targets adopted in the scheme. METHODS The review was conducted using six electronic databases, six sources of grey literature and bibliography searches from relevant publications. Studies were identified using a comprehensive search strategy based on MeSH terms and keyword searches. A total of 21,543 references were identified of which 32 met the eligibility criteria with 11 studies selected for the review. RESULTS Findings provide strong evidence that the QOF initially improved health outcomes for a limited number of conditions but subsequently fell to the pre-existing trend. There was limited impact on non-incentivized activities with adverse effects for some sub-population groups. CONCLUSION The QOF has limited impact on improving health outcomes due to its focus on process-based indicators and the indicators' ceiling thresholds. Further research is required to strengthen the quality of evidence available on the QOF's impact on population health to ensure that the incentive scheme is both clinically and cost-effective.
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Affiliation(s)
- Carwyn Langdown
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent, George Allen Wing, Canterbury, Kent CT2 7NF, UK Policy Research Unit in Commissioning and the Healthcare System, University of Manchester and CHSS, UK
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Litinski V. Games for Health. INTERNATIONAL JOURNAL OF GAMING AND COMPUTER-MEDIATED SIMULATIONS 2013. [DOI: 10.4018/jgcms.2013070108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
How to reduce cost, improve quality, and improve customer engagement are top of mind for healthcare leaders. Healthcare organizations are developing and testing comprehensive engagement strategies to support consumers across the care continuum. In this environment some form of priority setting must occur, and it requires establishing connections between proposed innovation to a process of care and the outcomes. Digital tools offer a promise of meaningful measures that are affordable, embedded in the care delivery system and truly reflect patients’ experiences through the patient journey. This paper proposes a pragmatic path for building a business case for innovative digital health tools in community care settings. It overlays value model for healthcare IT investments with patient activation measures and innovation management techniques. It proposes that the intersection of system-generated measures and psychometric methods for data collection and analysis may lead to development of feasible patient engagement measures for healthcare.
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Hawkins RB, Levy SM, Senter CE, Zhao JY, Doody K, Kao LS, Lally KP, Tsao K. Beyond surgical care improvement program compliance: antibiotic prophylaxis implementation gaps. Am J Surg 2013; 206:451-6. [PMID: 23809676 DOI: 10.1016/j.amjsurg.2013.02.009] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 01/09/2013] [Accepted: 02/28/2013] [Indexed: 11/15/2022]
Abstract
BACKGROUND Despite increased compliance with Surgical Care Improvement Project infection measures, surgical-site infections are not decreasing. The aim of this study was to test the hypothesis that documented compliance with antibiotic prophylaxis guidelines on a pediatric surgery service does not reflect implementation fidelity or adherence to guidelines as intended. METHODS A 7-week observational study of elective pediatric surgical cases was conducted. Adherence was evaluated for appropriate administration, type, timing, weight-based dosing, and redosing of antibiotics. RESULTS Prophylactic antibiotics were administered appropriately in 141 of 143 cases (99%). Of 100 cases (70%) in which antibiotic prophylaxis was indicated, compliance was documented in 100% cases in the electronic medical record, but only 48% of cases adhered to all 5 guidelines. Lack of adherence was due primarily to dosing or timing errors. CONCLUSIONS Lack of implementation fidelity in antibiotic prophylaxis guidelines may partly explain the lack of expected reduction in surgical-site infections. Future studies of Surgical Care Improvement Project effectiveness should measure adherence and implementation fidelity rather than just documented compliance.
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Affiliation(s)
- Russell B Hawkins
- Department of Pediatric Surgery, University of Texas Medical School at Houston, Houston, TX, USA; The Children's Memorial Hermann Hospital, Houston, TX, USA
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Turner JR. Patient and Physician Adherence in Hypertension Management. J Clin Hypertens (Greenwich) 2013; 15:447-52. [DOI: 10.1111/jch.12105] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 03/01/2013] [Accepted: 03/06/2013] [Indexed: 12/16/2022]
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Abstract
Pay-for-performance schemes explicitly link provider remuneration to the quality of care provided, with the aims of modifying provider behavior and improving patient outcomes. If successful, pay-for-performance schemes could drive improvements in quality and efficiency of care. However, financial incentives could also erode providers' intrinsic motivation, narrow their focus, promote unethical behavior, and ultimately increase health care inequalities. Evidence from schemes implemented to date suggests that carefully designed pay-for-performance schemes that align sufficient rewards with clinical priorities can produce modest but significant improvements in processes of diabetic care and intermediate outcomes. There is limited evidence, however, on whether improvements in processes of care result in improved outcomes, in terms of patient satisfaction, reduced complications, and greater longevity. The lack of adequate control groups has limited research findings to date, and more robust studies are needed to explore both the potential long-term benefits of pay-for-performance schemes and their unintended consequences.
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Affiliation(s)
- Tim Doran
- Institute of Population Health, University of Manchester, Williamson Building Oxford Road, Manchester, M13 9PL, UK.
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Kirschner K, Braspenning J, Akkermans RP, Jacobs JEA, Grol R. Assessment of a pay-for-performance program in primary care designed by target users. Fam Pract 2013; 30:161-71. [PMID: 22997223 DOI: 10.1093/fampra/cms055] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects. OBJECTIVE To assess changes in performance after introducing a participatory P4P program. DESIGN An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark. MAIN OUTCOME MEASURES Quality indicators for clinical care (process and outcome) and patient experience. RESULTS We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement. CONCLUSIONS A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.
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Affiliation(s)
- Kirsten Kirschner
- Scientific Institute for Quality of Healthcare, Radboud University Nijmegen Medical Centre, PO Box 9101, Nijmegen 6500 HB, The Netherlands.
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Colais P, Agabiti N, Fusco D, Pinnarelli L, Sorge C, Perucci CA, Davoli M. Inequality in 30-day mortality and the wait for surgery after hip fracture: the impact of the regional health care evaluation program in Lazio (Italy). Int J Qual Health Care 2013; 25:239-47. [PMID: 23335054 DOI: 10.1093/intqhc/mzs082] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
OBJECTIVE INTERVENTIONS that address inequalities in health care are a priority for public health research. We evaluated the impact of the Regional Health Care Evaluation Program in the Lazio region, which systematically calculates and publicly releases hospital performance data, on socioeconomic differences in the quality of healthcare for hip fracture. DESIGN Retrospective cohort study. SETTING and participants We identified, in the hospital information system, elderly patients hospitalized for hip fracture between 01 January 2006 and 31 December 2007 (period 1) and between 01 January 2009 and 30 November 2010 (period 2). MAIN OUTCOME MEASURES We used multivariate regression models to test the association between socioeconomic position index (SEP, level I well-off to level III disadvantaged) and outcomes: mortality within 30 days of hospital arrival, median waiting time for surgery and proportion of interventions within 48 h. RESULTS We studied 11 581 admissions. Lower SEP was associated with a higher risk of 30-day mortality in period 1 (relative risk (RR) = 1.42, P = 0.027), but not in period 2. Disadvantaged people were less likely to undergo intervention within 48 h than well-off persons in period 1 (level II: RR = 0.72, P < 0.001; level III: RR = 0.46, P < 0.001) and period 2 (level II: RR = 0.88, P = 0.037; level III: RR = 0.63, P < 0.001). We observed a higher probability of undergoing intervention within 48 h in period 2 compared with the period 1 for each socioeconomic level. CONCLUSION This study suggests that a systematic evaluation of health outcome approach, including public disclosure of results, could reduce socioeconomic differences in healthcare through a general improvement in the quality of care.
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Affiliation(s)
- P Colais
- Department of Epidemiology, Regional Health Service, Lazio Region Via Santa Costanza 53, 00198 Rome, Italy.
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Goodridge DMG, Shorvon SD. The contribution of British general practice to our knowledge of epilepsy and its effects on people. Br Med Bull 2013; 108:115-30. [PMID: 24133115 DOI: 10.1093/bmb/ldt030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
INTRODUCTION British general practice is a good base for epidemiological research which is evidenced by the study of epilepsy. SOURCES OF DATA A comprehensive search of PubMed using various keywords for articles on epilepsy research performed in British general practice. AREAS OF AGREEMENT Studies in the setting of general practice have contributed significantly to knowledge in the field of epilepsy, especially in relation to epidemiology, studies of prognosis and treatment patterns and psychosocial aspects. AREAS OF CONTROVERSY The extent to which epilepsy can be managed in general practice. GROWING POINTS The importance of primary care research and the importance of collaborative studies between general practice, hospital and university departments. AREAS TIMELY FOR DEVELOPING RESEARCH The effects of interventions at general practice level on seizure control, morbidity and mortality.
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