Increasing capitation in mixed remuneration schemes: Effects on service provision and process quality of care.

Many health systems apply mixed remuneration schemes for general practitioners, but little is known about the effects on service provision of changing the relative mix of fee for services and capitation. We apply difference-in-differences analyses to evaluate a reform that effectively reversed the mix between fee for services and capitation from 80/20 to 20/80 for patients with type 2 diabetes. Our results show reductions in provision of both the contact services that became capitated and in other non-capitated (still-billable) services. Reduced provision also occurred for guideline-recommended process quality services. We find that the effects are mainly driven by patients with co-morbidities and by general practitioners with high income, relatively many diabetes patients, and solo practitioners. Thus, increasing capitation in a mixed remuneration schemes appears to reduce service provision for patients with type 2 diabetes monitored in general practice with a risk of unwanted quality effects.

Cost-Effectiveness of Semaglutide vs. Empagliflozin, Canagliflozin, and Sitagliptin for Treatment of Patients with Type 2 Diabetes in Denmark: A Decision-Analytic Modelling Study.

OBJECTIVE: The aim was to evaluate the cost-effectiveness of oral and subcutaneous semaglutide versus other oral glucose-lowering drugs (i.e., empagliflozin, canagliflozin, and sitagliptin) for the management of type 2 diabetes (T2D) in Denmark using clinically relevant treatment intensification rules. METHODS: A Markov-type cohort model for evaluating the cost-effectiveness of treatment pathways for T2D was used to produce cost-effectiveness estimates based on four head-to-head trials. Evidence from PIONEER 2 and 3 trials was used to evaluate the cost-effectiveness of oral semaglutide vs. empagliflozin and sitagliptin. Evidence from SUSTAIN 2 and 8 trials was used to evaluate the cost-effectiveness of subcutaneous semaglutide vs. sitagliptin and canagliflozin. Base case analyses used trial product estimands of treatment efficacy to avoid the confounding effects of rescue medication use during trials. Deterministic scenario analyses and probabilistic sensitivity analyses were conducted to assess robustness of cost-effectiveness estimates. RESULTS: Semaglutide-based treatment regimens were consistently associated with higher lifetime diabetes treatment costs, lower costs of complications, and higher lifetime accumulated QALYs. The PIONEER 2 analysis estimated the cost-effectiveness of oral semaglutide vs. empagliflozin was DKK 150,618/QALY (€20,189). The PIONEER 3 analysis estimated the cost-effectiveness of oral semaglutide vs. sitagliptin was DKK 95,093/QALY (€12,746). The SUSTAIN 2 analysis estimated the cost-effectiveness of subcutaneous semaglutide vs. sitagliptin was DKK 79,982/QALY (€10,721). The SUSTAIN 8 analysis estimated the cost-effectiveness of subcutaneous semaglutide vs. canagliflozin was DKK 167,664/QALY (€22,474). CONCLUSIONS: Daily oral and weekly subcutaneous semaglutide are likely to both increase cost and health benefits, but are likely to do so under commonly considered cost-effectiveness thresholds. TRIAL REGISTRATIONS: Clinicaltrials.gov: NCT02863328 (PIONEER 2; registered August 11, 2016); NCT02607865 (PIONEER 3; registered November 18, 2015); NCT01930188 (SUSTAIN 2; registered August 28, 2013); NCT03136484 (SUSTAIN 8; registered May 2, 2017).

Use of electronic patient data overview with alerts in primary care increases prescribing of lipid-lowering medications in patients with type 2 diabetes.

AIMS/HYPOTHESIS: We aimed to assess whether general practices (GPs) using an electronic disease management program (DMP) with population overviews, including alerts when patients failed to receive guideline-recommended prescription medications, increased prescriptions of lipid-lowering drugs for patients with type 2 diabetes with no history of lipid-lowering treatment. METHODS: This observational study included 165 GPs that reached a high level of use of the DMP in 2012 and a control group of 135 GPs who reached a high level of use in 2013 and, hence, who were less exposed to the DMP throughout 2012. A binary measure for having been prescribed and filled lipid-lowering drugs at any time within a 12-month exposure period was derived for all patients with type 2 diabetes who did not receive a prescription for lipid-lowering drugs in the baseline year prior to the study period (i.e. 2011). Results were derived using ORs from multivariate logistic regression analyses. Subgroup stratification based on age, sex, diabetes duration, deprivation status and Charlson Comorbidity Index (CCI) score was conducted and assessed. Placebo tests were carried out to assess bias from selection to treatment. RESULTS: Patients who did not receive a prescription of lipid-lowering drugs in the year prior to being listed with GPs that used the DMP had statistically significant greater odds of receiving a prescription of lipid-lowering medications when compared with individuals who attended control GPs (OR 1.23 [95% CI 1.09, 1.38]). When the analysis period was shifted back by 2 years, no significant differences in lipid-lowering drug prescription between the two groups were found to occur, which indicates that these results were not driven by selection bias. Subgroup analyses showed that the increase in lipid-lowering drug prescriptions was primarily driven by changes among male participants (OR 1.32 [95% CI 1.12, 1.54]), patients aged 60-70 years (OR 1.40 [95% CI 1.13, 1.74]), patients with a diabetes duration of ≤5 years (OR 1.33 [95% CI 1.13, 1.56]), non-deprived patients (OR 1.25 [95% CI 1.08, 1.45]) and patients without comorbidities (CCI score = 0; OR 1.27 [95% CI 1.11, 1.45]). CONCLUSIONS/INTERPRETATION: Access to population overviews using a DMP with alerts of clinical performance measures with regard to adhering to guideline-recommended prescription of medications can increase GP prescriptions of lipid-lowering drugs.

Cost and quality impacts of treatment setting for type 2 diabetes patients with moderate disease severity: Hospital- vs. GP-based monitoring.

OBJECTIVES: This study investigates cost and quality implications of moving regular monitoring of patients with moderate severity type 2 diabetes (T2D) away from specialized hospital clinics into general practice (GP). METHODS: A 2016 cross-section of patients with moderate disease severity T2D were algorithmically identified using Danish administrative databases. 152,632 GP- and 21,359 hospital-monitored patients with T2D were identified. Total annual healthcare cost is decomposed into GP, medication, nonhospital-specialist, hospital outpatient and inpatient costs. Hospitalizations are used to proxy for quality of care. Cost and quality impacts of treatment setting are assessed using an instrumental variable (IV) analysis. A wide range of patient confounders are used to reduce selection bias, with the difference in patients' travel-time between nearest specialist outpatient clinic and GP used as an instrument to control for remaining endogeneity of treatment setting. Two-part models are used for zero-inflated outcomes. RESULTS: Average total annual healthcare cost were 14,056 DKK greater amongst hospital-monitored patients. IV analysis accounting for endogeneity of treatment setting indicates hospital-based monitoring is causally linked to higher total annual healthcare costs. The estimated local average treatment effect of hospital-based monitoring on total annual healthcare costs was higher (117.2%, 95% CI: 23.3%, 211.1%) than GP-based monitoring. No difference of treatment settings' quality based on evidence of hospitalizations was found. CONCLUSION: For patients with moderate disease severity T2D, IV analysis accounting for treatment setting endogeneity bias identifies an expected efficiency improvement (average cost reduction without reduction of quality) of moving regular disease management from hospital-based setting to the GP setting.

Evaluation of an Electronic Health Record System With a Disease Management Program and Health Care Treatment Costs for Danish Patients With Type 2 Diabetes.

Importance: Electronic health record (EHR) systems and disease management programs (DMP) are often promoted, but associated health care cost changes are not well understood. Objective: To evaluate the association between annual health care costs of patients with type 2 diabetes and the use of an electronic health record system with a disease management program (EHR/DMP) in general practice. Design, Setting, and Participants: This retrospective cohort study examined patients with type 2 diabetes in Denmark between January 1, 2008, and December 31, 2014, who attended practices that either used an EHR/DMP at a high level or never used the disease management system. An EHR/DMP system was rolled out across general practices in Denmark beginning in 2011 and was discontinued in 2014. Data were analyzed between March 2019 and March 2020. Main Outcomes and Measures: The main outcome was total health care costs, and the secondary outcomes were primary care, medication, nonhospital specialist, and hospital (total, outpatient, inpatient, and emergency) costs. Regression models were used to estimate EHR/DMP-associated percentage differences in patients' annual health care treatment costs across health care treatment categories. All models included general practice-level fixed effects and patient-level controls. Two-part models examined robustness of estimated associations for hospital cost categories. Results: Of 33 970 patients included in the analysis, 15 953 (8016 [50.2%] male; mean [SD] age, 59.9 [13.3] years) attended 244 general practices that used the system at a high level, and 18 017 (9291 [51.6%] male; mean [SD] age, 60.0 [12.9] years) attended 344 general practices that had never used the system. Use of the EHR/DMP was associated with 3.2% higher (95% CI, 0.9%-5.6%) annual general practice treatment costs and with 6.4% lower (95% CI, -11.6% to -1.2%) annual hospital emergency visit costs. The associations between EHR/DMP use and annual total hospital (percentage difference, -0.8%; 95% CI, -7.5% to 5.7%) and total health care (percentage difference, -0.1%; 95% CI, -2.1% to 1.9%) cost changes were not statistically significant. Conclusions and Relevance: Among patients with type 2 diabetes, attendance at general practices that used an EHR/DMP was associated with a moderate increase in primary care costs and a reduction in emergency hospital visit costs but no significant change in total health care costs. Large health care cost savings associated with improved use of EHR-based disease management systems should not be expected to be realized in the short term.

The cost-effectiveness of quality improvement projects: a conceptual framework, checklist and online tool for considering the costs and consequences of implementation-based quality improvement.

In resource constrained systems, decision makers should be concerned with the efficiency of implementing improvement techniques and technologies. Accordingly, they should consider both the costs and effectiveness of implementation as well as the cost-effectiveness of the innovation to be implemented. An approach to doing this effectively is encapsulated in the 'policy cost-effectiveness' approach. This paper outlines some of the theoretical and practical challenges to assessing policy cost-effectiveness (the cost-effectiveness of implementation projects). A checklist and associated (freely available) online application are also presented to help services develop more cost-effective implementation strategies.

Decision curve analysis for assessing the usefulness of tests for making decisions to treat: an application to tests for prodromal psychosis.

For a test to be considered useful for making treatment decisions, it is necessary that making treatment decisions based on the results of the test be a preferable strategy to making treatment decisions without the test. Decision curve analysis is a framework for assessing when a test would be expected to be useful, which integrates evidence of a test's performance characteristics (sensitivity and specificity), condition prevalence among at-risk patients, and patient preferences for treatment. We describe decision curve analysis generally and illustrate its potential through an application to tests for prodromal psychosis. Clinical psychosis is often preceded by a prodromal phase, but not all those with prodromal symptoms proceed to develop full psychosis. Patients identified as at risk for developing psychosis may be considered for proactive treatment to mitigate development of clinically defined psychosis. Tests exist to help identify those at-risk patients most likely to develop psychosis, but it is uncertain when these tests would be considered useful for making proactive treatment decisions. We apply decision curve analysis to results from a systematic review of studies investigating clinical tests for predicting the development of psychosis in at-risk populations, and present resulting decision curves that illustrate when the tests may be expected to be useful for making proactive treatment decisions.

Canadian neonatologist practices regarding opioid use in ventilated and spontaneously breathing infants undergoing medical procedures.

OBJECTIVES: Opioids are indicated for the management of procedural pain in neonates. There are limited data describing factors influencing patterns of use. PATIENTS AND METHODS: We conducted an online English survey of Canadian neonatologists using Survey Monkey, whereby they answered questions about the frequency and pattern of use of opioids, and specifically, of morphine and fentanyl, for ventilated and spontaneously breathing infants undergoing selected painful medical procedures. RESULTS: Hundred and twenty nine of 225 (57%) eligible neonatologists participated. They reported that opioids were part of their practice for managing procedural pain in 100% of ventilated infants and 93% of spontaneously breathing infants. Frequency of opioid use was associated with infant ventilation status: spontaneously breathing infants were 28% less likely to receive them (P=0.013). For morphine, the most commonly used dose was 100 microg/kg in ventilated infants and 50 microg/kg in spontaneously breathing infants. For fentanyl, 1 microg/kg was the most frequently used dose in both infant populations. Use of morphine and fentanyl were significantly associated with 2-way interactions (P<0.0001) between infant ventilation status, gestational age, and opioid dose. Eighty-two percent of respondents cited respiratory depression as a concern for spontaneously breathing infants compared with 31% for ventilated infants (P<0.0001). CONCLUSIONS: Neonatologists frequently report using opioids to manage procedural pain, however, spontaneously breathing infants are less likely to receive them, and their use varies according to infant and procedure characteristics. These data point to the need to further investigate, in a more controlled design, the pharmacologic effects of opioids in this population to better guide clinicians about their optimal use.

An examination of the psychometric properties of the Chinese version of the Barratt Impulsiveness Scale, 11th version in a sample of Chinese adolescents.

The current study examined the psychometric properties of the Chinese translation of the Barratt Impulsiveness Scale 11th version in a sample of adolescents from Hunan province, mainland China. During an initial assessment, 396 secondary school students (Grades 10-12) completed the scale and self-report measures assessing problem behaviors and alcohol use. The scale was re-administered 1 mo. later. Analysis gave Cronbach alpha of .80 and test-retest reliability of .70. Confirmatory factor analysis indicated a model containing six first-order factors and two second-order factors best fit the data. Girls reported higher Total scores than boys as well as higher scores on the motor impulsiveness, self-control, and cognitive instability sub-scales. Scores were associated in the predicted direction with a wide variety of self-reported problem behaviors including alcohol use, gambling, and academic misconduct. Current findings indicate that the translated scale is a promising tool with some further development for assessing impulsiveness with Chinese adolescents.