Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis.

OBJECTIVE: To determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared with England where the scheme continued. DESIGN: Controlled interrupted time series regression analysis. SETTING: General practices in Scotland and England. PARTICIPANTS: 979 practices with 5 599 171 registered patients in Scotland, and 7921 practices with 56 270 628 registered patients in England in 2013-14, decreasing to 864 practices in Scotland and 6873 in England in 2018-19, mainly due to practice mergers. MAIN OUTCOME MEASURES: Changes in quality of care at one year and three years after withdrawal of QOF financial incentives in Scotland at the end of the 2015-16 financial year for 16 indicators (two complex processes, nine intermediate outcomes, and five treatments) measured annually for financial years from 2013-14 to 2018-19. RESULTS: A significant decrease in performance was observed for 12 of the 16 quality of care indicators in Scotland one year after QOF was abolished and for 10 of the 16 indicators three years after QOF was abolished, compared with England. At three years, the absolute percentage point difference between Scotland and England was largest for recording (by tick box) of mental health care planning (-40.2 percentage points, 95% confidence interval -45.5 to -35.0) and diabetic foot screening (-22.8, -33.9 to -11.7). Substantial reductions were, however, also observed for intermediate outcomes, including blood pressure control in patients with peripheral arterial disease (-18.5, -22.1 to -14.9), stroke or transient ischaemic attack (-16.6, -20.6 to -12.7), hypertension (-13.7, -19.4 to -7.9), diabetes (-12.7, -15.0 to -12.4), or coronary heart disease (-12.8, -14.9 to -10.8), and for glycated haemoglobin control in people with HbA1c levels ≤75 mmol/mol (-5.0, -8.4 to -1.5). No significant differences were observed between Scotland and England for influenza immunisation and antiplatelet or anticoagulant treatment for coronary heart disease three years after withdrawal of incentives. CONCLUSION: The abolition of financial incentives in Scotland was associated with reductions in recorded quality of care for most performance indicators. Changes to pay for performance should be carefully designed and implemented to monitor and respond to any reductions in care quality.

Integrated Care in England - what can we Learn from a Decade of National Pilot Programmes?

INTRODUCTION: For more than a decade the English NHS has pursued integrated care through three national pilot programmes. The independent evaluators of these programmes here identify several common themes that inform the development of integrated care. DESCRIPTION: The three pilot programmes shared the aim of better coordination between hospital and community-based health services and between health and social care. Each programme recruited local pilot sites that designed specific interventions to support inter-professional and inter-organisational collaboration.The pilots were highly heterogenous and results varied both within and between the three programmes. While staff were generally positive about their achievements, pilots had mixed success especially in reducing unplanned hospital admissions. Common facilitators to achieving pilots' objectives included effective senior leadership and shared values, simple interventions and additional funding. Barriers included short timescales, poor professional engagement, information and data sharing problems, and conflicts with changing national policy. DISCUSSION: There was little stable or shared understanding of what 'integrated care' meant resulting in different practices and priorities. An increasing focus on reducing unplanned hospital use among national sponsors created a mismatch in expectations between local and national actors. CONCLUSION: Pilots in all three national programmes made some headway against their objectives but were limited in their impact on unplanned hospital admissions.

Economic evaluation of patient direct access to NHS physiotherapy services.

OBJECTIVES: Our aim was to undertake an economic evaluation of patient direct access to physiotherapy in the UK NHS by comparing the number of patients treated, waiting time, cost and health gain from a direct access pathway versus traditional GP-referral to NHS physiotherapy. DESIGN: The authors used a discrete event simulation (DES) model to represent a hypothetical GP practice of 10,000 patients. Costs were measured from the perspective of the NHS and society. Outcomes were predicted waiting times, the total number of patients with musculoskeletal conditions who received physiotherapy and quality adjusted life years (QALYs) gained, each estimated over a one year period. Model inputs were based on a pilot cluster randomised controlled trial (RCT) conducted in four general practices in Cheshire, UK, and other sources from the literature. RESULTS: Direct access could increase the number of patients receiving at least one physiotherapy appointment by 63%, but without investment in extra physiotherapist capacity would increase waiting time dramatically. The increase in activity is associated with a cost of £4999 per QALY gained. CONCLUSIONS: Direct access to physiotherapy services would be cost-effective and benefit patients given current cost per QALY thresholds used in England. This is because physiotherapy itself is cost-effective, rather than through savings in GP time. Direct access without an increase in supply of physiotherapists would increase waiting times and would be unlikely to be cost saving for the NHS owing to the likely increase in the use of physiotherapy services.

Developing measures to capture the true value of primary care.

Primary care (PC) is an essential building block for any high quality healthcare system, and has a particularly positive impact on vulnerable patients. It contributes to the overall performance of health systems, and countries that reorient their health system towards PC are better prepared to achieve universal health coverage. Monitoring the actual performance of PC in health systems is essential health policy to support PC. However, current indicators are often too narrowly defined to account for quality of care in the complex populations with which PC deals. This article reviews a number of conceptual frameworks developed to capture PC values in robust measures and indicators that can inform policy and practice performance. Each have benefits and limitations. Further work is needed to develop meaningful primary health care (PHC) and PC measures to inform strategic action by policymakers and governments for improved overall performance of health systems.

When is referral from primary care to specialist services appropriate for survivors of stroke? A modified RAND-appropriateness consensus study.

BACKGROUND: There is guidance in the United Kingdom about what long-term care stroke survivors should receive, but a lack of guidance about who should deliver it and where this care should take place. This is a key issue given the evidence that current needs are not well addressed. The purpose of this study was to explore when a referral from generalist to specialist services is appropriate in the long-term management of stroke survivors. METHODS: A modified RAND-Appropriateness method was used to gain consensus from a range of stroke specialist and generalist clinicians. Ten panelists rated fictional patient scenarios based on long-term post-stroke needs. Round 1 was an online survey in which panelists rated the scenarios for a) need for referral to specialist care and b) if referral was deemed necessary, need for this to be specifically to a stroke specialist. Round 2 was a face-to-face meeting in which panelists were presented with aggregate scores from round 1, and invited to discuss and then re-rate the scenarios. RESULTS: Seventeen scenarios comprising 69 referral decisions were discussed. Consensus on whether the patient needed to be referred to a specialist was achieved for 59 (86%) decisions. Of the 44 deemed needing referral to specialists, 18 were judged to need referral to a stroke-specialist and 14 to a different specialist. However, for 12 decisions there was no consensus about which specialist the patient should be referred to. For some scenarios (spasticity; incontinence; physical disability; communication; cognition), referral was deemed to be indicated regardless of severity, whereas indications for referral for topics such as risk factor management and pain depended on complexity and/or severity. CONCLUSIONS: There was broad agreement about when a stroke survivor requires referral to specialist care, but less agreement about destination of referral. Nevertheless, there was agreement that some of the longer-term issues facing stroke survivors are best addressed by stroke specialists, some by other specialists, and some by primary care. This has implications for models of longer-term stroke care, which need to reflect that optimal care requires access to, and better co-ordination between, both generalist and specialist healthcare.

Development and validation of the Cambridge Multimorbidity Score.

BACKGROUND: Health services have failed to respond to the pressures of multimorbidity. Improved measures of multimorbidity are needed for conducting research, planning services and allocating resources. METHODS: We modelled the association between 37 morbidities and 3 key outcomes (primary care consultations, unplanned hospital admission, death) at 1 and 5 years. We extracted development (n = 300 000) and validation (n = 150 000) samples from the UK Clinical Practice Research Datalink. We constructed a general-outcome multimorbidity score by averaging the standardized weights of the separate outcome scores. We compared performance with the Charlson Comorbidity Index. RESULTS: Models that included all 37 conditions were acceptable predictors of general practitioner consultations (C-index 0.732, 95% confidence interval [CI] 0.731-0.734), unplanned hospital admission (C-index 0.742, 95% CI 0.737-0.747) and death at 1 year (C-index 0.912, 95% CI 0.905-0.918). Models reduced to the 20 conditions with the greatest combined prevalence/weight showed similar predictive ability (C-indices 0.727, 95% CI 0.725-0.728; 0.738, 95% CI 0.732-0.743; and 0.910, 95% CI 0.904-0.917, respectively). They also predicted 5-year outcomes similarly for consultations and death (C-indices 0.735, 95% CI 0.734-0.736, and 0.889, 95% CI 0.885-0.892, respectively) but performed less well for admissions (C-index 0.708, 95% CI 0.705-0.712). The performance of the general-outcome score was similar to that of the outcome-specific models. These models performed significantly better than those based on the Charlson Comorbidity Index for consultations (C-index 0.691, 95% CI 0.690-0.693) and admissions (C-index 0.703, 95% CI 0.697-0.709) and similarly for mortality (C-index 0.907, 95% CI 0.900-0.914). INTERPRETATION: The Cambridge Multimorbidity Score is robust and can be either tailored or not tailored to specific health outcomes. It will be valuable to those planning clinical services, policymakers allocating resources and researchers seeking to account for the effect of multimorbidity.

Opportunities and barriers for providing HIV testing through community health centers in mainland China: a nationwide cross-sectional survey.

BACKGROUND: Primary care may be an avenue to increase coverage of HIV testing but it is unclear what challenges primary healthcare professionals in low- and middle-income countries face. We describe the HIV testing practices in community health centres (CHCs) and explore the staff's attitude towards further development of HIV testing services at the primary care level in China. METHODS: We conducted a national, cross-sectional survey using a stratified random sample of CHCs in 20 cities in 2015. Questionnaires were completed by primary care doctors and nurses in CHCs, and included questions regarding their demographics, clinical experience and their views on the facilitators and barriers to offering HIV testing in their CHC. Multivariate logistic regression was conducted to examine the association between staff who would offer HIV testing and their sociodemographic characteristics. RESULTS: A total of 3580 staff from 158 CHCs participated. Despite the majority (81%) agreeing that HIV testing was an important part of healthcare, only 25% would provide HIV testing when requested by a patient. The majority (71%) were concerned about reimbursement, and half (47%) cited lack of training as a major barrier. Almost half (44%) believed that treating people belonging to high-risk populations would scare other patients away, and 6% openly expressed their dislike of people belonging to high-risk populations. Staff who would offer HIV testing were younger (adjusted odds ratio (aOR) 0.97 per year increase in age, 95% confidence interval (CI):0.97-0.98); trained as a doctor compared to a nurse (aOR 1.79, 95%CI:1.46-2.15); held a bachelor degree or above (aOR 1.34, 95%CI:1.11-1.62); and had previous HIV training (aOR 1.55, 95%CI:1.27-1.89). CONCLUSIONS: Improving HIV training of CHC staff, including addressing stigmatizing attitudes, and improving financial reimbursement may help increase HIV testing coverage in China.

Continuous Digital Monitoring of Walking Speed in Frail Elderly Patients: Noninterventional Validation Study and Longitudinal Clinical Trial.

BACKGROUND: Digital technologies and advanced analytics have drastically improved our ability to capture and interpret health-relevant data from patients. However, only limited data and results have been published that demonstrate accuracy in target indications, real-world feasibility, or the validity and value of these novel approaches. OBJECTIVE: This study aimed to establish accuracy, feasibility, and validity of continuous digital monitoring of walking speed in frail, elderly patients with sarcopenia and to create an open source repository of raw, derived, and reference data as a resource for the community. METHODS: Data described here were collected as a part of 2 clinical studies: an independent, noninterventional validation study and a phase 2b interventional clinical trial in older adults with sarcopenia. In both studies, participants were monitored by using a waist-worn inertial sensor. The cross-sectional, independent validation study collected data at a single site from 26 naturally slow-walking elderly subjects during a parcours course through the clinic, designed to simulate a real-world environment. In the phase 2b interventional clinical trial, 217 patients with sarcopenia were recruited across 32 sites globally, where patients were monitored over 25 weeks, both during and between visits. RESULTS: We have demonstrated that our approach can capture in-clinic gait speed in frail slow-walking adults with a residual standard error of 0.08 m per second in the independent validation study and 0.08, 0.09, and 0.07 m per second for the 4 m walk test (4mWT), 6-min walk test (6MWT), and 400 m walk test (400mWT) standard gait speed assessments, respectively, in the interventional clinical trial. We demonstrated the feasibility of our approach by capturing 9668 patient-days of real-world data from 192 patients and 32 sites, as part of the interventional clinical trial. We derived inferred contextual information describing the length of a given walking bout and uncovered positive associations between the short 4mWT gait speed assessment and gait speed in bouts between 5 and 20 steps (correlation of 0.23) and longer 6MWT and 400mWT assessments with bouts of 80 to 640 steps (correlations of 0.48 and 0.59, respectively). CONCLUSIONS: This study showed, for the first time, accurate capture of real-world gait speed in slow-walking older adults with sarcopenia. We demonstrated the feasibility of long-term digital monitoring of mobility in geriatric populations, establishing that sufficient data can be collected to allow robust monitoring of gait behaviors outside the clinic, even in the absence of feedback or incentives. Using inferred context, we demonstrated the ecological validity of in-clinic gait assessments, describing positive associations between in-clinic performance and real-world walking behavior. We make all data available as an open source resource for the community, providing a basis for further study of the relationship between standardized physical performance assessment and real-world behavior and independence.

The Primary Care Spend Model: a systems approach to measuring investment in primary care.

Increased investment in primary care is associated with lower healthcare costs and improved population health. The allocation of scarce resources should be driven by robust models that adequately describe primary care activities and spending within a health system, and allow comparisons within and across health systems. However, disparate definitions result in wide variations in estimates of spending on primary care. We propose a new model that allows for a dynamic assessment of primary care spending (PC Spend) within the context of a system's total healthcare budget. The model articulates varied definitions of primary care through a tiered structure which includes overall spending on primary care services, spending on services delivered by primary care professionals and spending delivered by providers that can be characterised by the '4Cs' (first contact, continuous, comprehensive and coordinated care). This unifying framework allows a more refined description of services to be included in any estimate of primary care spend and also supports measurement of primary care spending across nations of varying economic development, accommodating data limitations and international health system differences. It provides a goal for best accounting while also offering guidance, comparability and assessments of how primary care expenditures are associated with outcomes. Such a framework facilitates comparison through the creation of standard definitions and terms, and it also has the potential to foster new areas of research that facilitate robust policy analysis at the national and international levels.

GPs' and practice staff's views of a telephone first approach to demand management: a qualitative study in primary care.

BACKGROUND: To better manage patient demand, some general practices have implemented a 'telephone first' approach in which all patients seeking a face-to-face appointment first have to speak to a GP on the telephone. Previous studies have suggested that there is considerable scope for this new approach, but there remain significant concerns. AIM: To understand the views of GPs and practice staff of the telephone first approach, and to identify enablers and barriers to successful adoption of the approach. DESIGN AND SETTING: A qualitative study of the telephone first approach in 12 general practices that have adopted it, and two general practices that have tried the approach but reverted to their previous system. METHOD: A total of 53 qualitative interviews with GPs and practice staff were conducted. Transcriptions of the interviews were systematically analysed. RESULTS: Staff in the majority of practices reported that the approach was an improvement on their previous system, but all practices experienced challenges; for example, where practices did not have the capacity to meet the increase in demand for telephone consultations. Staff were also aware that the new system suited some patients better than others. Adoption of the telephone first approach could be very stressful, with a negative impact on morale, especially reported in interviews with the two practices that had tried but stopped the approach. Interviewees identified enablers and barriers to the successful adoption of a telephone first approach in primary care. Enablers to successful adoption were: understanding demand, practice staff as pivotal, making modifications to the approach, and educating patients. CONCLUSION: Practices considering adopting or clinical commissioning groups considering funding a telephone first approach should consider carefully a practice's capacity and capability before launching.

Impact of the Southwark and Lambeth Integrated Care Older People's Programme on hospital utilisation and costs: controlled time series and cost-consequence analysis.

OBJECTIVES: To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN: Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING: 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES: Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS: By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS: The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.

Associations between general practice characteristics with use of urgent referrals for suspected cancer and endoscopies: a cross-sectional ecological study.

BACKGROUND: Large variation in measures of diagnostic activity has been described previously between English general practices, but related predictors remain understudied. OBJECTIVE: To examine associations between general practice population and characteristics, with the use of urgent referrals for suspected cancer, and use of endoscopy. METHODS: Cross-sectional observational study of English general practices. We examined practice-level use (/1000 patients/year) of urgent referrals for suspected cancer, gastroscopy, flexible sigmoidoscopy and colonoscopy. We used mixed-effects Poisson regression to examine associations with the sociodemographic profile of practice populations and other practice attributes, including the average age, sex and country of qualification of practice doctors. RESULTS: The sociodemographic characteristics of registered patients explained much of the between-practice variance in use of urgent referrals (32%) and endoscopic investigations (18-25%), all being higher in practices with older and more socioeconomically deprived patients. Practice-level attributes explained a substantial amount of between-practice variance in urgent referral (19%) but little of the variance in endoscopy (3%-4%). Adjusted urgent referral rates were higher in training practices and those with younger GPs. Practices with mean doctor ages of 41 and 57 years (at the 10th/90th centiles of the national distribution) would have urgent referral rates of 24.1 and 19.1/1000 registered patients, P < 0.001. CONCLUSION: Most between-practice variation in use of urgent referrals and endoscopies seems to reflect health need. Some practice characteristics, such as the mean age of GPs, are associated with appreciable variation in use of urgent referrals, though these associations do not seem strong enough to justify targeted interventions.

Quality of Care in the United Kingdom after Removal of Financial Incentives.

BACKGROUND: The benefits of pay-for-performance schemes in improving the quality of care remain uncertain. There is little information on the effect of removing incentives from existing pay-for-performance schemes. METHODS: We conducted interrupted time-series analyses of electronic medical record (EMR) data from 2010 to 2017 for 12 quality-of-care indicators in the United Kingdom's Quality and Outcomes Framework for which financial incentives were removed in 2014 and 6 indicators for which incentives were maintained. We estimated the effects of removing incentives on changes in performance on quality-of-care measures. RESULTS: Complete longitudinal data were available for 2819 English primary care practices with more than 20 million registered patients. There were immediate reductions in documented quality of care for all 12 indicators in the first year after the removal of financial incentives. Reductions were greatest for indicators related to health advice, with a reduction of 62.3 percentage points (95% confidence interval [CI], -65.6 to -59.0) in EMR documentation of lifestyle counseling for patients with hypertension. Changes were smaller for indicators involving clinical actions that automatically update the EMR, such as laboratory testing, with a reduction of 10.7 percentage points (95% CI, -13.6 to -7.8) in control of cholesterol in patients with coronary heart disease and 12.1 percentage points (95% CI, -13.6 to -10.6) for thyroid-function testing in patients with hypothyroidism. There was little change in performance on the 6 quality measures for which incentives were maintained. CONCLUSIONS: Removal of financial incentives was associated with an immediate decline in performance on quality measures. In part, the decline probably reflected changes in EMR documentation, but declines on measures involving laboratory testing suggest that incentive removal also changed the care delivered.