Do physicians' attitudes toward prioritization predict poor-health patients' access to care?

Physicians often face tight resource constraints, meaning they have to make trade-offs between which patients they care for and the amount of care received. Studies show that patients requiring many resources disproportionately suffer a loss of care when resources are constrained. This study uncovers whether physicians' attitudes toward prioritization of healthcare predicts poor-health patients' access to care. We combine unique survey data on Danish GPs' preferred prioritization principle with register data on their patients' contacts in general practice. We consider different types of contacts as the required effort could impact the need for prioritization. Our results show variation in GPs' prioritization principles, where a majority prefers a principle that may lead to an unequal distribution of services. We further find that GPs' attitudes toward prioritization predict some poor-health patients' access to general practice. GPs who state they prefer the principle of prioritizing patients in the poorest health state when resources tightened provide more contacts to poor-health patients. The additional contacts are typically high-effort contacts such as annual status meetings and home visits, but also low-effort contacts such as emails. Our findings indicate inequity in poor-health patients' access to care across general practices.

Going the extra mile? General practitioners' upcoding of fees for home visits.

General practitioners' (GPs') income often relies on self-reported activities and performances. They can therefore 'game the system' to maximize their remuneration. We investigate whether Danish GPs game their travel fees for home visits. Combining administrative and geographical data, we measure the difference between GPs' traveled and billed distances. We exploit a rise in the fees for home visits. If there is a link between the rise in fees and upcoding, we interpret this finding as indicative of gaming behavior. We find that upcoding occurs slightly more often than downcoding (16% vs. 13% of visits) for visits that can be both upcoded and downcoded. Using linear probability models with GP fixed effects, we find that the fee rise is associated with a reduction in upcoding of 0.6% of home visits (2.8% for visits where upcoding is feasible) and no change in downcoding. Importantly, we find no statistically significant differences in the reduction in upcoding across distance bands despite large differences in their fee rises. We therefore conclude that there is no causal evidence of GPs gaming their fees.

Age, morbidity, or something else? A residual approach using microdata to measure the impact of technological progress on health care expenditure.

This study measures the increment of health care expenditure (HCE) that can be attributed to technological progress and change in medical practice by using a residual approach and microdata. We examine repeated cross-sections of individuals experiencing an initial health shock at different point in time over a 10-year window and capture the impact of unobservable technology and medical practice to which they are exposed after allowing for differences in health and socioeconomic characteristics. We decompose the residual increment in the part that is due to the effect of delaying time to death, that is, individuals surviving longer after a health shock and thus contributing longer to the demand of care, and the part that is due to increasing intensity of resource use, that is, the basket of services becoming more expensive to allow for the cost of innovation. We use data from the Danish National Health System that offers universal coverage and is free of charge at the point of access. We find that technological progress and change in medical practice can explain about 60% of the increment of HCE, in line with macroeconomic studies that traditionally investigate this subject.

Cost-effectiveness of a transdiagnostic psychotherapy program for youth with common mental health problems.

OBJECTIVES: Our objective was to evaluate the cost-effectiveness of the transdiagnostic psychotherapy program Mind My Mind (MMM) for youth with common mental health problems using a cost-utility analysis (CUA) framework and data from a randomized controlled trial. Furthermore, we analyzed the impact of the choice of informant for both quality-of-life reporting and preference weights on the Incremental Cost-Effectiveness Ratio (ICER). METHODS: A total of 396 school-aged (6-16 years) youth took part in the 6-month trial carried out in Denmark. CUAs were carried out for the trial period and four one-year extrapolation scenarios. Costs were based on a combination of budget and self-reported costs. Youths and parents were asked to report on the youth's quality-of-life three times during the trial using the Child Health Utility 9D (CHU9D). Parental-reported CHU9D was used in the base case together with preference weights of a youth population. Analyses using self-reported CHU9D and preference weights of an adult population were also carried out. RESULTS: The analysis of the trial period resulted in an ICER of €170,465. The analyses of the one-year scenarios resulted in ICERs between €23,653 and €50,480. The ICER increased by 24% and 71% compared to the base case when using self-reported CHU9D and adult preference weights, respectively. CONCLUSION: The MMM intervention has the potential to be cost-effective, but the ICER is dependent on the duration of the treatment effects. Results varied significantly with the choice of informant and the choice of preference weights indicating that both factors should be considered when assessing CUA involving youth.

Systematic identification and stratification of help-seeking school-aged youth with mental health problems: a novel approach to stage-based stepped-care.

We investigated whether a novel visitation model for school-aged youth with mental health problems based on a stage-based stepped-care approach facilitated a systematic identification and stratification process without problems with equity in access. The visitation model was developed within the context of evaluating a new transdiagnostic early treatment for youth with anxiety, depressive symptoms, and/or behavioural problems. The model aimed to identify youth with mental health problems requiring an intervention, and to stratify the youth into three groups with increasing severity of problems. This was accomplished using a two-phase stratification process involving a web-based assessment and a semi-structured psychopathological interview of the youth and parents. To assess problems with inequity in access, individual-level socioeconomic data were obtained from national registers with data on both the youth participating in the visitation and the background population. Altogether, 573 youth and their parents took part in the visitation process. Seventy-five (13%) youth had mental health problems below the intervention threshold, 396 (69%) were deemed eligible for the early treatment, and 52 (9%) had symptoms of severe mental health problems. Fifty (9%) youth were excluded for other reasons. Eighty percent of the 396 youth eligible for early treatment fulfilled criteria of a mental disorder. The severity of mental health problems highlights the urgent need for a systematic approach. Potential problems in reaching youth of less resourceful parents, and older youth were identified. These findings can help ensure that actions are taken to avoid equity problems in future mental health care implementations.

Sample restrictions and the elicitation of a constant willingness to pay per quality adjusted life year.

It is well established that the underlying theoretical assumptions needed to obtain a constant proportional trade-off between a quality adjusted life year (QALY) and willingness to pay (WTP) are restrictive and often empirically violated. In this paper, we set out to investigate whether the proportionality conditions (in terms of scope insensitivity and severity independence) can be satisfied when data is restricted to include only respondents who pass certain consistency criteria. We hypothesize that the more we restrict the data, the better the compliance with the requirement of constant proportional trade-off between WTP and QALY. We revisit the Danish data from the European Value of a QALY survey eliciting individual WTP for a QALY (WTP-Q). Using a "chained approach" respondents were first asked to value a specified health state using the standard gamble (SG) or the time-trade-off (TTO) approach and subsequently asked their WTP for QALY gains of 0.05 and 0.1 (tailored according to the respondent's SG/TTO valuation). Analyzing the impact of the different exclusion criteria on the two proportionality conditions, we find strong evidence against a constant WTP-Q. Restricting our data to include only respondents who pass the most stringent consistency criteria does not impact on the performance of the proportionality conditions for WTP-Q.

Post robotic investment: Cost consequences and impact on length of stay for obese women with endometrial cancer.

INTRODUCTION: The aim of the study was to investigate whether robotic-assisted surgery is associated with lower incremental resource use among obese patients relative to non-obese patients after a Danish nationwide adoption of robotic-assisted surgery in women with early-stage endometrial cancer. This is a population-based cohort study based on registers and clinical data. MATERIAL AND METHODS: All women who underwent surgery (robotic, laparoscopic and laparotomy) from 2008 to 2015 were included and divided according to body mass index (<30 and ≥30). Robotic-assisted surgery was gradually introduced in Denmark (2008-2013). We compared resource use post-surgery in obese vs non-obese women who underwent surgery before and after a nationwide adoption of robotic-assisted surgery. The key exposure variable was exposure to robotic-assisted surgery. Clinical and sociodemographic data were linked with national register data to determine costs and bed days 12 months before and after surgery applying difference-in-difference analyses. RESULTS: In total, 3934 women were included. The adoption of robotic-assisted surgery did not demonstrate statistically significant implications for total costs among obese women (€3,417; 95% confidence interval [CI] -€854 to €7,688, p = 0.117). Further, for obese women, a statistically significant reduction in bed days related to the index hospitalization was demonstrated (-1.9 bed days; 95% CI -3.6 to -0.2, p = 0.025). However, for non-obese women, the adoption of robotic-assisted surgery was associated with statistically significant total costs increments of €9,333 (95% CI €3,729-€1,4936, p = 0.001) and no reduction in bed days related to the index hospitalization was observed (+0.9 bed days; 95% CI -0.6 to 2.3, p = 0.242). CONCLUSIONS: The national investment in robotic-assisted surgery for endometrial cancer seems to have more modest cost implications post-surgery for obese women. This may be partly driven by a significant reduction in bed days related to the index hospitalization among obese women, as well as reductions in subsequent hospitalizations.

Long term resource consequences of a nationwide introduction of robotic surgery for women with early stage endometrial cancer.

OBJECTIVE: The majority of cost-studies related to robotic surgery has a short follow-up and primarily report the costs from the index surgery. The aim of this study was to evaluate the long-term resource consequences of introducing robotic surgery for early stage endometrial cancer in Denmark. METHODS: The study included all women with early stage endometrial cancer who underwent robotic, laparoscopic and open access surgery from January 2008 to June 2015. Data was linked from national databases to determine resource consumption and costs from hospital treatments, outpatient contacts, primary health care sector visits, labor market affiliation and prescription of medication. Each patient was observed in a period of 12 months before- and after surgery. The key exposure variable was women who were exposed to robotic surgery compared to those who were not. RESULTS: A total of 4133 women underwent surgery for early stage endometrial cancer. The study found additional costs of $7309 (95% confidence interval [CI] 2100-11,620, P = 0.001) per patient in the group exposed to robotic surgery including long-term costs post-surgery compared to the non-exposed group (non-robotic group). When controlling for time trends, the introduction of robotic surgery did not reduce the number of bed days (mean diff -0.42, 95% CI -3.03-2.19, P = 0.752). CONCLUSIONS: The introduction of robotic surgery for early stage endometrial cancer did not generate any long-term cost savings. The additional costs of robotic surgery were primarily driven by the index surgery. Any reduction in bed days could be explained by time trends.

Testing the myth of fee-for-service and overprovision in health care.

Paying on the basis of fee-for-service (FFS) is often associated with a risk of overprovision. Policymakers are therefore increasingly looking to other payment schemes to ensure a more efficient delivery of health care. This study tests whether context plays a role for overprovision under FFS. Using a laboratory experiment involving medical students, we test the extent of overprovision under FFS when the subjects face different fee sizes, patient types, and market conditions. We observe that decreasing the fee size has an effect on overprovision under both market conditions. We also observe that patients who are harmed by excess treatment are at little risk of overprovision. Finally, when subjects face resource constraints but still have an incentive to overprovide high-profit services, they hesitate to do so, implying that the presence of opportunity costs in terms of reduced benefits to other patients protects against overprovision. Thus, this study provides evidence that the risk of overprovision under FFS depends on fee sizes, patients' health profiles, and market conditions.

Is there additional value attached to health gains at the end of life? A revisit.

Researchers have in recent years sought to establish whether the general public value treatment at the end of life (EOL) more highly than other treatments. Results are mixed, with social preferences most often exhibiting lack of preferences for EOL treatments. This null result may be driven by the often applied study design, where respondents are to choose between treatments targeting patients with varying fixed life expectancies. When remaining life is certain and salient, a rule-of-rescue sentiment may drive preferences across all scenarios. This study presents a different design, where the comparator is a preventive intervention. We study preferences from both an individual and social perspective and find no preference for an EOL premium.

A Stated Preference Approach to Assess whether Health Status Impacts on Marginal Utility of Consumption.

A sample of Danish citizens (n = 2000) was asked to participate in a hypothetical experiment in which they could self-insure against a certain loss in income across two periods of time (one in which the person is in good health and one in which the person is in poorer health). Our results suggest that reduced health impacts on the marginal utility of consumption, but not in a linear fashion. Amongst a majority of respondents inferior, health increases the marginal utility of consumption for intermediate health states, whereas this is not the case for less and more severe health states. Copyright © 2016 John Wiley & Sons, Ltd.

How does HPV vaccination status relate to risk perceptions and intention to participate in cervical screening? a survey study.

BACKGROUND: Women in several countries will soon be covered by two preventive programmes targeting cervical cancer: HPV vaccination and cervical screening. The HPV vaccines are expected to prevent approximately 70 % of cervical cancers. It has been speculated, that HPV vaccinated women will not attend screening because they falsely think that the vaccine has eliminated their cervical cancer risk. The aim of this study was to investigate the association between HPV vaccination status and perceptions of cervical cancer risk; perceptions of vaccine effect; and intention to participate in cervical screening. Furthermore, to investigate associations between perceptions of cervical cancer risk and intention to participate in cervical screening. METHODS: A random sample of Danish women from the birth cohorts 1993-1995 was invited to complete a web-based questionnaire concerning risk perceptions and intentions to participate in cervical screening. Main outcomes were: perceived lifetime-risk of cervical cancer; perceived HPV vaccine effect; and intention to participate in cervical screening. RESULTS: HPV vaccinated women more often than unvaccinated women intended to participate in screening: adjusted odds ratio (OR) for being HPV vaccinated when intending to participate in screening of 3.89 (95 % CI: 2.50-6.06). HPV vaccinated women perceived cervical cancer risk to be higher than unvaccinated women did: adjusted OR of 0.11 (95 % CI: 0.03-0.39) and 0.51 (95 % CI: 0.33-0.78) for being HPV vaccinated while having the lowest perception of risk (in two different pre-specified dichotomisations). HPV vaccinated women perceived the vaccine effect to be larger than unvaccinated women did: adjusted OR of 0.31 (95 % CI: 0.18-0.51) and 0.37 (95 % CI: 0.25-0.53) for being HPV vaccinated while having the lowest perception of vaccine effect (in two different pre-specified dichotomisations). There were no associations between perceived cervical cancer risk and intention to participate in screening. CONCLUSIONS: HPV vaccinated women more often than unvaccinated women intended to participate in screening and they perceived cervical cancer risk to be higher and the vaccine effect to be larger than unvaccinated women did. However, in our analyses, risk perceptions could not explain screening intentions neither among vaccinated nor among unvaccinated women.

Socio-economic position and time trends in invasive management and case fatality after acute myocardial infarction in Denmark.

BACKGROUND: Lower case fatality and increased use of evidence-based invasive management incl. coronary angiography (CAG) have been reported for patients admitted with acute myocardial infarction (AMI) in the last 25 years. This article seeks to investigate whether these advances have benefitted patients in all socio-economic groups and how this has impacted on inequality in case fatality. METHODS: Forty three thousand eight hundred and forty three patients admitted with AMI in the period from 2001 to 2009 were included. Socio-economic position was measured using individual information on education. Age-standardized cumulative incidence of CAG within 1, 3 and 30 days along with age-standardized case fatality within 30 and 365 days were estimated. Cox regression models were used to model the relative inequality over time. RESULTS: Use of CAG within 1, 3 and 30 days increased for all educational groups over time and the inequality in CAG within 1 and 3 days seen in the beginning of the time frame was eliminated. Case fatality decreased in all educational groups and the relative inequality in 30 days case fatality decreased for women but not 365 days case fatality. No change was seen for inequality in case fatality for men. CONCLUSION: Increased use of CAG within the evidence based time frame was observed along with a decrease in inequality. However, a reduction in inequality was only observed for short term case fatality, and only for women. These results suggest that inequality in case fatality is not primarily driven by inequality in invasive management of AMI.

Effects of numerical information on intention to participate in cervical screening among women offered HPV vaccination: a randomised study.

OBJECTIVES: To investigate the effects of different types of information about benefits and harms of cervical screening on intention to participate in screening among women in the first cohorts offered human papilloma virus (HPV) vaccination. DESIGN: Randomised survey study. SETTING: Denmark. SUBJECTS: A random sample of women from the birth cohorts 1993, 1994 and 1995 drawn from the general population. INTERVENTIONS: A web-based questionnaire and information intervention. We randomised potential respondents to one of the following four different information modules about benefits and harms of cervical screening: no information; non-numerical information; and two numerical information modules. Moreover, we provided HPV-vaccinated women in one of the arms with numerical information about benefits and harms in two steps: firstly, information without consideration of HPV vaccination and subsequently information conditional on HPV vaccination. MAIN OUTCOME MEASURE: Self-reported intention to participate in cervical screening. RESULTS: A significantly lower proportion intended to participate in screening in the two groups of women receiving numerical information compared to controls with absolute differences of 10.5 (95% CI: 3.3-17.6) and 7.7 (95% CI: 0.4-14.9) percentage points, respectively. Among HPV-vaccinated women, we found a significantly lower intention to participate in screening after numerical information specific to vaccinated women (OR of 0.38). CONCLUSIONS: Women are sensitive to numerical information about the benefits and harms of cervical screening. Specifically, our results suggest that HPV-vaccinated women are sensitive to information about the expected changes in benefits and harms of cervical screening after implementation of HPV vaccination. KEY POINTS Women were less likely to participate in cervical screening when they received numerical information about benefits and harms compared to non-numerical or no information. Specifically, numerical information about the potential impact of the reduced risk of cervical cancer among HPV-vaccinated women reduced the intention to participate among vaccinated women.

Increasing participation in cervical cancer screening: offering a HPV self-test to long-term non-attendees as part of RACOMIP, a Swedish randomized controlled trial.

RACOMIP is a population-based, randomized trial of the effectiveness and cost-effectiveness of different interventions aimed at increasing participation in a well-run cervical cancer screening program in western Sweden. In this article, we report results from one intervention, offering non-attendees a high-risk human papillomavirus (HPV) self-test. Comparison was made with standard screening invitation routine or standard routine plus a telephone call. Women (8,800), aged 30-62, were randomly selected among women without a registered Pap smear in the two latest screening rounds. These women were randomized 1:5:5 to one of three arms: 800 were offered a high-risk HPV self-test, 4,000 were randomized to a telephone call (reported previously) and 4,000 constituted a control group (standard screening invitation routine). Results were based on intention to treat analysis and cost-effectiveness was calculated as marginal cost per cancer case prevented. The endpoint was the frequency of testing. The total response rate in the self-testing arm was 24.5%, significantly higher than in the telephone arm (18%, RR 1.36, 95% CI 1.19-1.57) and the control group (10.6%, RR 2.33, 95% CI 2.00-2.71). All nine women who tested positive for high-risk HPV attended for a cervical smear and colposcopy. From the health-care sector perspective, the intervention will most likely lead to no additional cost. Offering a self-test for HPV as an alternative to Pap smears increases participation among long-term non-attendees. Offering various screening options can be a successful method for increasing participation in this group.

Framing the willingness-to-pay question: impact on response patterns and mean willingness to pay.

In this study, respondents were randomly allocated to three variants of the payment card format and an open-ended format in order to test for convergent validity. The aim was to test whether preferences (as measured by willingness to pay additional tax) would be affected by framing the willingness-to-pay question differently. Results demonstrated that valuations were highly sensitive to whether respondents were asked to express their maximum willingness to pay per month or per year. Another important finding is that the introduction of a binary response filter prior to the payment card follow-up tends to eliminate the positive aspects of introducing a payment card and produces response patterns that are much in line with those of the open-ended contingent valuation format. However, although a filter will impact on the distribution of willingness-to-pay bids and on the rate of zero and protest bids, the overall impact on the welfare estimate is minor. The outcomes of this study indicate that valuations in the stated preference literature may be, at least in part, a function of the instrument designed to obtain the valuations.

Does the primary screening test influence women's anxiety and intention to screen for cervical cancer? A randomized survey of Norwegian women.

BACKGROUND: Countries must decide whether or not to replace primary cytology-based screening with primary human papillomavirus (HPV)-based screening. We aimed to assess how primary screening for an HPV infection, a sexually transmitted infection (STI), and the type of information included in the invitation letter, will affect screening intention. METHODS: We randomized a representative sample of Norwegian women to one of three invitation letters: 1) Pap smear, 2) HPV testing or 3) HPV testing with additional information about the nature of the infection. Intention to participate, anxiety level and whether women intend to follow-up abnormal results were measured between groups using chi-squared and nonparametric Kruskal-Wallis tests. Determinants of intention were explored using logistic regression. RESULTS: Responses from 3540 women were representative of the Norwegian population with respect to age, civil status and geographic location. No significant difference across invitation letters was found in women's stated intention to participate (range: 91.8-92.3%), anxiety (39-42% were either quite or very worried) or to follow-up after an abnormal result (range: 97.1-97.6%). Strength of intention to participate was only marginally lower for HPV-based invitation letters, albeit significant (p-value = 0.008), when measured on a scale. Only 36-40% of respondents given the HPV invitations correctly understood that they likely had an STI. CONCLUSIONS: We found that switching to primary HPV screening, independent of additional information about HPV infections, is not likely to reduce screening participation rates or increase anxiety; however, women lacked the ability to interpret the meaning of an HPV-test result.

Is there a link between health care utilisation and subjective well-being? An exploratory study among older Danes.

While extensive research has explored the influence of traditional factors such as socioeconomic position on health care utilisation, the independent role of an individual's well-being in their health care seeking behaviour remains largely uncharted territory. In this study, we delve into the role of subjective well-being (SWB) in health care utilisation. We use a unique link between survey data from a representative group of Danish citizens aged 50-80 and administrative register data containing information on health care utilisation and sociodemographics. We explore whether SWB is a predictor of health care utilisation (general practice services) over and above health (as measured by health-related quality of life (HRQoL)). We find that the association between SWB and number of services provided in general practice differs across levels of HRQoL. Among those with lower HRQoL, we find a positive association between health care utilisation and SWB. Results hold true even when controlling for previous health care utilisation, suggesting that the mechanism is not driven by reverse causality. Our findings suggest that, in particular for vulnerable individuals in poor health and with poor SWB, the propensity to seek care is inappropriately low, and there is a need for more proactive supply-driven health care.

The link between physician motivation and care.

Studies report an unexplained variation in physicians' care. This variation may to some extent be explained by differences in their work motivation. However, empirical evidence on the link between physician motivation and care is scarce. We estimate the associations between different types of work motivation and care. Motivation is measured using validated questions from a nation-wide survey of Danish general practices and linked to high-quality register data on their care in 2019. Using a series of regression models, we find that more financially motivated practices generate more fee-for-services per patient, whereas practices characterised by greater altruistic motivation towards the patient serve a larger share of high-need patients and issue more prescriptions for antibiotics per patient. Practices with higher altruism towards society generate lower medication costs per patient and prescribe a higher rate of narrow-spectrum penicillin, thereby reducing the risk of antimicrobial resistance in the population. Together, our results suggest that practices' motivation is associated with several dimensions of healthcare, and that both their financial motivation and altruism towards patients and society play a role. Policymakers should, therefore, consider targeting all provider motivations when introducing organisational changes and incentive schemes; for example, by paying physicians to adhere to clinical guidelines, while at the same time clearly communicating the guidelines' value from both a patient and societal perspective.

Increasing participation in cervical cancer screening: telephone contact with long-term non-attendees in Sweden. Results from RACOMIP, a randomized controlled trial.

Non-participation is the foremost screening-related risk factor for cervical cancer. We studied the effectiveness and cost-effectiveness of an intervention to increase participation in the context of a well-run screening program. Telephone contact with non-attendees, offering an appointment to take a smear, was compared with a control group in a population-based randomized trial in western Sweden. Of 8,800 randomly selected women aged 30-62, without a registered Pap smear in the two latest screening rounds, 4,000 were randomized to a telephone arm, another 800 were offered a high-risk human papillomavirus (HPV) self-test by mail (not reported in this article) and 4,000 constituted a control group. Endpoints were frequency of testing, frequency of abnormal smears and further assessment of abnormal tests. Participation during the following 12 months was significantly higher in the telephone arm than in the control group, 718 (18.0%) versus 422 (10.6%) [RR: 1.70, 95% confidence interval (CI): 1.52-1.90]. The number of detected abnormal smears was 39 and 19, respectively (RR: 2.05, 95% CI: 1.19-3.55). The respective numbers of further assessed abnormalities were 34 and 18 (RR: 1.89, 95% CI: 1.07-3.34). Twice as many high-grade intraepithelial neoplasia (CIN2+) were detected and treated in the telephone arm: 14 and 7, respectively. Telephone contact with women who have abstained from cervical cancer screening for long time increases participation and leads to a significant increase in detection of atypical smears. Cost calculations indicate that this intervention is unlikely to be cost-generating and this strategy is feasible in the context of a screening program.