Ambulatory specialist costs and morbidity of coordinated and uncoordinated patients before and after abolition of copayment: A cohort analysis.

To strengthen the coordinating function of general practitioners (GPs) in the German healthcare system, a copayment of €10 was introduced in 2004. Due to a perceived lack of efficacy and a high administrative burden, it was abolished in 2012. The present cohort study investigates characteristics and differences of GP-coordinated and uncoordinated patients in Bavaria, Germany, concerning morbidity and ambulatory specialist costs and whether these differences have changed after the abolition of the copayment. We performed a retrospective routine data analysis, using claims data of the Bavarian Association of the Statutory Health Insurance Physicians during the period 2011-2012 (with copayment) and 2013-2016 (without copayment), covering 24 quarters. Coordinated care was defined as specialist contact only with referral. Multinomial regression modelling, including inverse probability of treatment weighting, was used for the cohort analysis of 500 000 randomly selected patients. Longitudinal regression models were calculated for cost estimation. Coordination of care decreased substantially after the abolition of the copayment, accompanied by increasing proportions of patients with chronic and mental diseases in the uncoordinated group, and a corresponding decrease in the coordinated group. In the presence of the copayment, uncoordinated patients had €21.78 higher specialist costs than coordinated patients, increasing to €24.94 after its abolition. The results indicate that patients incur higher healthcare costs for specialist ambulatory care when their care is uncoordinated. This effect slightly increased after abolition of the copayment. Beyond that, the abolition of the copayment led to a substantial reduction in primary care coordination, particularly affecting vulnerable patients. Therefore, coordination of care in the ambulatory setting should be strengthened.

General practitioners' income and activity: the impact of multi-professional group practice in France.

France has first experimented, in 2009, and then generalized a practice level add-on payment to promote Multi-Professional Primary Care Groups (MPCGs). Team-based practices are intended to improve both the efficiency of outpatient care supply and the attractiveness of medically underserved areas for healthcare professionals. To evaluate its financial attractiveness and thus the sustainability of MPCGs, we analyzed the evolution of incomes (self-employed income and wages) of General Practitioners (GPs) enrolled in a MPCG, compared with other GPs. We also studied the impacts of working in a MPCG on GPs' activity through both the quantity of medical services provided and the number of patients encountered. Our analyses were based on a quasi-experimental design, with a panel dataset over the period 2008-2014. We accounted for the selection into MPCG by using together coarsened exact matching and difference-in-differences (DID) design with panel-data regression models to account for unobserved heterogeneity. We show that GPs enrolled in MPCGs during the period exhibited an increase in income 2.5% higher than that of other GPs; there was a greater increase in the number of patients seen by the GPs' (88 more) without involving a greater increase in the quantity of medical services provided. A complementary cross-sectional analysis for 2014 showed that these changes were not detrimental to quality in terms of bonuses related to the French pay-for-performance program for the year 2014. Hence, our results suggest that labor and income concerns should not be a barrier to the development of MPCGs, and that MPCGs may improve patient access to primary care services.

Design of the PROstate cancer follow-up care in Secondary and Primary hEalth Care study (PROSPEC): a randomized controlled trial to evaluate the effectiveness of primary care-based follow-up of localized prostate cancer survivors.

BACKGROUND: In its 2006 report, From cancer patient to cancer survivor: lost in transition, the U.S. Institute of Medicine raised the need for a more coordinated and comprehensive care model for cancer survivors. Given the ever increasing number of cancer survivors, in general, and prostate cancer survivors, in particular, there is a need for a more sustainable model of follow-up care. Currently, patients who have completed primary treatment for localized prostate cancer are often included in a specialist-based follow-up care program. General practitioners already play a key role in providing continuous and comprehensive health care. Studies in breast and colorectal cancer suggest that general practitioners could also consider to provide survivorship care in prostate cancer. However, empirical data are needed to determine whether follow-up care of localized prostate cancer survivors by the general practitioner is a feasible alternative. METHODS: This multicenter, randomized, non-inferiority study will compare specialist-based (usual care) versus general practitioner-based (intervention) follow-up care of prostate cancer survivors who have completed primary treatment (prostatectomy or radiotherapy) for localized prostate cancer. Patients are being recruited from hospitals in the Netherlands, and randomly (1:1) allocated to specialist-based (N = 195) or general practitioner-based (N = 195) follow-up care. This trial will evaluate the effectiveness of primary care-based follow-up, in comparison to usual care, in terms of adherence to the prostate cancer surveillance guideline for the timing and frequency of prostate-specific antigen assessments, the time from a biochemical recurrence to retreatment decision-making, the management of treatment-related side effects, health-related quality of life, prostate cancer-related anxiety, continuity of care, and cost-effectiveness. The outcome measures will be assessed at randomization (≤6 months after treatment), and 12, 18, and 24 months after treatment. DISCUSSION: This multicenter, prospective, randomized study will provide empirical evidence regarding the (cost-) effectiveness of specialist-based follow-up care compared to general practitioner-based follow-up care for localized prostate cancer survivors. TRIAL REGISTRATION: Netherlands Trial Registry, Trial NL7068 (NTR7266). Prospectively registered on 11 June 2018.

What sets the conditions for success in community-partnered evaluation work? Multiple perspectives on a small-scale research-practice partnership evaluation.

The goals of this study are: (a) to share reflections from multiple stakeholders involved in a foundation-funded community-partnered evaluation project, (b) to share information that might be useful to researchers, practitioners, and funders considering the merits of researcher/practitioner evaluation projects, and (c) to make specific suggestions for funders and researcher/practitioner teams starting an evaluation project. Three stakeholders in a small-scale research-practice partnership (RPP) reflected on the evaluation project by responding to three prompts. A researcher, community organization leader, and funder at a small foundation share specific tips for those considering a small-scale RPP. Engaging in a small-scale RPPs can be a very meaningful experience for individual researchers and smaller organizations and funders. The benefits and challenges align and differ in many ways with those encountered in larger projects.

Antidepressant Prescribing in England: Patterns and Costs.

OBJECTIVE: The number of prescriptions for antidepressants (ADs) in England and Wales has almost doubled in the past decade. The objective of this article is to describe the current prescribing rates of different antidepressants by general practice (GP) practice. METHODS: We collated the prescribing behavior in each GP practice in the year April 1, 2017, to March 31, 2018. The monthly GP practice prescribing data reports for medication prescribing for each British National Formulary code and practice, as well as the prescriptions, quantity, and costs were examined in relation to prescribing practice. RESULTS: The data showed that 2.1 billion doses of antidepressant were prescribed to a total population of 52 million people. That equates to 11% of individuals taking ≥ 1 antidepressants on any day. Selective serotonin reuptake inhibitors (SSRIs) were the most prescribed class of ADs, with sertraline the most prescribed SSRI. The other most prescribed ADs were citalopram, fluoxetine, and mirtazapine. Some older agents, such as trimipramine and doxepin, are prescribed at a very high tariff. CONCLUSIONS: Broadly, the findings are in keeping with National Institute for Health and Care Excellence guidance in that the bulk of prescriptions were for SSRIs. Regular audit of patient treatment at a general practice level will ensure appropriate targeted use of licensed medications as supported by the evidence base.

How does the integration of collaborative care elements in a gatekeeping system affect the costs for mental health care in Germany?

Mental disorders are widespread, debilitating and associated with high costs. In Germany, usual care (UC) for mental disorders is afflicted by poor coordination between providers and long waiting times. Recently, the primary alternative to UC-the gatekeeping-based general practitioners (GP) program-was extended by the collaborative Psychiatry-Neurology-Psychotherapy (PNP) program, which is a selective contract designed to improve mental health care and the allocation of resources. Here, we assess the effects of the GP program and the PNP program on costs for mental health care. We analyzed claims data from 2014 to 2016 of 55,472 adults with a disorder addressed by PNP to compare costs and sick leave days between PNP, the GP program and UC. The individuals were grouped and balanced via entropy balancing to adjust for potentially confounding covariates. We employed a negative binomial model to compare sick leave days and two-part models to compare sick pay, outpatient, inpatient and medication costs over a 12-month period. The PNP program significantly reduced sick pay by 164€, compared to UC, and by 177€, compared to the GP program. Consistently, sick leave days were lower in PNP. We found lower inpatient costs in PNP than in UC (-194€) and in the GP program (-177€), but no reduction in those shares of inpatient costs that accrued in psychiatric or neurological departments. Our results suggest that integrating collaborative care elements in a gatekeeping system can favourably impact costs. In contrast, we found no evidence that the widely implemented GP program reduces costs for mental health care.

Trends in GP incomes in England, 2008-2017: a retrospective analysis of repeated postal surveys.

BACKGROUND: There is widespread concern over the recruitment and retention of GPs in England. Income is a fundamental consideration affecting the attractiveness of working in general practice. AIM: To report on trends in average incomes earned by GPs in England, adjusted for inflation and contracted time commitment. DESIGN AND SETTING: Postal surveys of random samples of GPs working in England in 2008, 2010, 2012, 2015, and 2017. METHOD: Trends in average reported incomes of partner and salaried GPs were directly standardised for the reported number of sessions worked per week and adjusted for inflation. RESULTS: Data were obtained from between 1000 and 1300 responders each year, representing response rates between 25% and 44%. Almost all responders (96%) reported the income they earned from their job as a GP. Mean nominal annual income decreased by 1.1% from £99 437 in 2008 to £98 373 in 2017 for partner GPs and increased by 4.4% from £49 061 to £51 208 for salaried GPs. Mean sessions worked decreased from 7.7 to 7.0 per week for partner GPs and decreased from 5.6 to 5.3 per week for salaried GPs. Mean income adjusted for sessions worked and inflation decreased by 10.0% for partner GPs and by 7.0% for salaried GPs, between 2008 and 2017. CONCLUSION: The decrease in GP income adjusted for sessions worked and inflation over the last decade may have contributed to the current problems with recruitment and retention.

Association between gifts from pharmaceutical companies to French general practitioners and their drug prescribing patterns in 2016: retrospective study using the French Transparency in Healthcare and National Health Data System databases.

OBJECTIVE: To evaluate the association between gifts from pharmaceutical companies to French general practitioners (GPs) and their drug prescribing patterns. DESIGN: Retrospective study using data from two French databases (National Health Data System, managed by the French National Health Insurance system, and Transparency in Healthcare). SETTING: Primary care, France. PARTICIPANTS: 41 257 GPs who in 2016 worked exclusively in the private sector and had at least five registered patients. The GPs were divided into six groups according to the monetary value of the received gifts reported by pharmaceutical, medical device, and other health related companies in the Transparency in Healthcare database. MAIN OUTCOME MEASURES: The main outcome measures were the amount reimbursed by the French National Health Insurance for drug prescriptions per visit (to the practice or at home) and 11 drug prescription efficiency indicators used by the National Health Insurance to calculate the performance related financial incentives of the doctors. Doctor and patient characteristics were used as adjustment variables. The significance threshold was 0.001 for statistical analyses. RESULTS: The amount reimbursed by the National Health Insurance for drug prescriptions per visit was lower in the GP group with no gifts reported in the Transparency in Healthcare database in 2016 and since its launch in 2013 (no gift group) compared with the GP groups with at least one gift in 2016 (-€5.33 (99.9% confidence interval -€6.99 to -€3.66) compared with the GP group with gifts valued at €1000 or more reported in 2016) (P<0.001). The no gift group also more frequently prescribed generic antibiotics (2.17%, 1.47% to 2.88% compared with the ≥€1000 group), antihypertensives (4.24%, 3.72% to 4.77% compared with the ≥€1000 group), and statins (12.14%, 11.03% to 13.26% compared with the ≥€1000 group) than GPs with at least one gift between 2013 and 2016 (P<0.001). The no gift group also prescribed fewer benzodiazepines for more than 12 weeks (-0.68%, -1.13% to -0.23% compared with the €240-€999 group) and vasodilators (-0.15%, -0.28% to -0.03% compared with the ≥€1000 group) than GPs with gifts valued at €240 or more reported in 2016, and more angiotensin converting enzyme (ACE) inhibitors compared with all ACE and sartan prescriptions (1.67%, 0.62% to 2.71%) compared with GPs with gifts valued at €1000 or more reported in 2016 (P<0.001). Differences were not significant for the prescription of aspirin and generic antidepressants and generic proton pump inhibitors. CONCLUSION: The findings suggest that French GPs who do not receive gifts from pharmaceutical companies have better drug prescription efficiency indicators and less costly drug prescriptions than GPs who receive gifts. This observational study is susceptible to residual confounding and therefore no causal relation can be concluded. TRIAL REGISTRATION: OSF register OSF.IO/8M3QR.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review.

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

Income inequality among general practitioners in Iran: a decomposition approach.

BACKGROUND: General practitioners (GPs) are among the most important resources of healthcare system and public health is considerably influenced by the function of this group. Income inequality among GPs considerably affects the motivation and performance of this group. The present study aims to examine the income inequality among Iranian GPs in order to provide the necessary evidence for health human resource policy. METHODS: In this cross-sectional study, the distribution of income and wage inequality among GPs was investigated using income quintiles. We also used the Dagum's model to analyze the inequality between different groups of GPs through the decomposition of the Gini coefficient. Moreover, a regression model was used to determine the effective factors on GPs' income. RESULTS: The results of this study indicated that income and wages of GPs in the highest quintile were eight times more than those of doctors at the lowest quintile. Regression estimates showed that factors such as gender, practice setting, and activity as the family physician (P < 0.001) were effective on income of GPs; and also male and self-employed GPs had significantly more wage (P < 0.001). Total Gini coefficient of GPs' income and wage were estimated at 0.403 and 0.412, respectively. Highest monthly income was found in GPs with 16-20 years practice experience ($8358) based on Purchasing Power Parity (PPP), male ($8339 PPP), and self-employed GPs ($8134 PPP) subgroup. However, the female ($5389 PPP) and single ($5438 PPP) GPs had the lowest income. Population share; income/wage share; income/wage mean; Gini coefficient; and within, between and overlap decomposed components of Gini coefficient are also reported for each GPs subgroups. CONCLUSIONS: We found significant inequalities in income and wages among Iranian GPs. Adjustment of income based on working hours indicated that one of the most common causes of income inequality among GPs in Iran was different workloads among different groups. Since the motivation and function of physicians can be influenced by income inequality, policymakers in the health system should consider factors increasing such inequalities.

How do general practitioners access guidelines and utilise electronic medical records to make clinical decisions on antibiotic use? Results from an Australian qualitative study.

OBJECTIVE: This study aimed to explore how general practitioners (GPs) access and use both guidelines and electronic medical records (EMRs) to assist in clinical decision-making when prescribing antibiotics in Australia. DESIGN: This is an exploratory qualitative study with thematic analysis interpreted using the Theory of Planned Behaviour (TPB) framework. SETTING: This study was conducted in general practice in Victoria, Australia. PARTICIPANTS: Twenty-six GPs from five general practices were recruited to participate in five focus groups between February and April 2018. RESULTS: GPs expressed that current EMR systems do not provide clinical decision support to assist with antibiotic prescribing. Access and use of guidelines were variable. GPs who had more clinical experience were less likely to access guidelines than younger and less experienced GPs. Guideline use and guideline-concordant prescribing was facilitated if there was a practice culture encouraging evidence-based practice. However, a lack of access to guidelines and perceived patients' expectation and demand for antibiotics were barriers to guideline-concordant prescribing. Furthermore, guidelines that were easy to access and navigate, free, embedded within EMRs and fit into the clinical workflow were seen as likely to enhance guideline use. CONCLUSIONS: Current barriers to the use of antibiotic guidelines include GPs' experience, patient factors, practice culture, and ease of access and cost of guidelines. To reduce inappropriate antibiotic prescribing and to promote more rational use of antibiotic in the community, guidelines should be made available, accessible and easy to use, with minimal cost to practicing GPs. Integration of evidence-based antibiotic guidelines within the EMR in the form of a clinical decision support tool could optimise guideline use and increase guideline-concordant prescribing.

Promoting access to family medicine in Québec, Canada: Analysis of bill 20, enacted in November 2015.

Primary care can potentially make an important contribution to improving health system performance. However, Canada does not fare as well as other developed countries in terms of timely access to primary health care services. In November 2015, Bill 20 was introduced in the province of Québec. The goal of Bill 20 was to optimize the utilisation of medical and financial resources to improve access to primary care. Bill 20 states the obligations of general practitioners to register a minimum number of patients, ensure the continuity of care of that population, and practice a minimum number of hours in hospitals. Many actors agreed that access to primary care had to be improved in Québec, but disagreed with Bill 20. In particular, family physicians strongly opposed the financial penalties that were introduced for physicians failing to meet the specified targets. In January 2018, 3 years after Bill 20, indicators for patient registration and continuity of care have considerably improved. However, the attractiveness of general practice seems to have decreased among medical graduates, which creates uncertainty regarding the sustainability of the achievements brought on by Bill 20.

A needs assessment for a minor eye condition service within Leeds, Bradford and Airedale, UK.

BACKGROUND: There are a number of limitations to the present primary eye care system in the UK. Patients with minor eye conditions typically either have to present to their local hospital or GP, or face a charge when visiting eye care professionals (optometrists). Some areas of the UK have commissioned enhanced community services to alleviate this problem; however, many areas have not. The present study is a needs assessment of three areas (Leeds, Airedale and Bradford) without a Minor Eye Conditions Service (MECS), with the aim of determining whether such a service is clinically or economically viable. METHOD: A pro forma was developed for optometrists and practice staff to complete when a patient presented whose reason for attending was due to symptoms indicative of a problem that could not be optically corrected. This form captured the reason for visit, whether the patient was seen, the consultation funding, the outcome and where the patient would have presented to if the optometrists could not have seen them. Optometrists were invited to participate via Local Optical Committees. Results were submitted via a Google form or a Microsoft Excel document and were analysed in Microsoft Excel. RESULTS: Seventy-five percent of patients were managed in optometric practice. Nine and 16% of patients required subsequent referral to their General Practitioner or hospital ophthalmology department, respectively. Should they not have been seen, 34% of patients would have presented to accident and emergency departments and 59% to their general practitioner. 53% of patients paid privately for the optometrist appointment, 28% of patients received a free examination either through use of General Ophthalmic Service sight tests (9%) or optometrist good will (19%) and 19% of patients did not receive a consultation and were redirected to other providers (e.g. pharmacy, accident and emergency or General Practitioner). 88% of patients were satisfied with the level of service. Cost-analyses revealed a theoretical cost saving of £3198 to the NHS across our sample for the study period, indicating cost effectiveness. CONCLUSIONS: This assessment demonstrates that a minor eye condition service in the local areas would be economically and clinically viable and well received by patients.

Details matter: Physician responses to multiple payments for the same activity.

The UK Quality and Outcomes Framework rewards general practices for achieving quality indicators for chronic disease management. Some indicators are multi-rewarded. For example, there are indicators for controlling blood pressure for patients with diabetes and for patients with chronic heart disease. Thus if a patient has diabetes and heart disease the practice is rewarded twice for controlling her blood pressure. Other indicators are singly rewarded: the incentivised activity is only for patients with single specific condition. We compare general practice performance on single and multi-reward indicators. We use a 2005/6-2012/13 panel of over 800 Scottish general practices, control for practice characteristics, practice fixed effects, indicator characteristics (whether the indicator was for measurement, treatment, or intermediate outcome, maximum payment, upper thresholds), condition, and year and cluster on indicators. We find that the proportion of patients with a given condition for whom a quality indicator was achieved was higher, and the proportion who were exception reported was lower, for multi-reward indicators than for single reward indicators. We also exploit the replacement of multi-reward smoking indicators by single reward indicators in 2006/7. Compared to indicators which were always single or always multi-reward, the proportion of the relevant patients for whom the smoking indicators were achieved fell when the smoking indicators were no longer multi-reward. Fine details of pay for performance schemes matter: they affect physician behaviour and patient outcomes.

Who had access to doctors before and after new universal capitated subsidies in New Zealand?

In 2002, the New Zealand government introduced universal capitated subsidies for general practitioner consultations amid a broader programme of reform intended to reduce inequities in access and encourage more preventive healthcare visits. While consultation numbers increased in the short run, the issue of cost barriers to access has once more garnered significant policy attention, with many commentators concerned that the funding necessary to maintain low fees has not kept up with cost pressures. A longer-term assessment is useful in understanding the relationship between evolving policy conditions and service use. This article explores how the distribution of access to GPs changed in the short and long run using New Zealand Health Survey data from 2002/03 to 2015/16. I find that the capitation subsidies were associated with improved access for indigenous Maori and more preventive visits as intended by 2006/07. However, from 2006/07 onward patients with the greatest health need began reporting fewer and less frequent doctors' visits per annum. I discuss potential explanations, focussing on the role of capitation subsidies and the successor price-capping scheme. This research contributes evidence to international scholarship on the long-term factors necessary for universal capitated subsidisation to sustainably reduce access inequities, with attention to local nuance.

Gender differences in the incomes of self-employed French physicians: The role of family structure.

In most developed countries, the average income of female physicians remains much lower than that of their male counterparts. This paper analyses how much of the gender earnings gap among French self-employed physicians can be attributed to women's family responsibilities, choice of medical specialty, and opportunity to charge extra billings. The question is of growing concern for regulators because it may influence patients' future access to care. We used an exhaustive administrative database that merges information on the medical activity, earnings, and family structure of self-employed doctors in 2005, 2008, and 2011. Using the 2011 database, results suggest that when demographic and professional characteristics are controlled, female physicians still exhibit an annual earnings gap that varies according to family structure: having young children worsens the situation of female physicians, particularly GPs. Using our panel datasets from 2005, we show that there is a 'carer effect' of having children for female doctors that exacerbates the gender income gap, particularly for GPs. We do not highlight any real strategic behaviour of female specialists authorised to charge extra fees to increase their extra billings after a birth to maintain their previous income.

The role of financial factors in the mobility and location choices of General Practitioners in Australia.

BACKGROUND: The geographic distribution of health workers is a pervasive policy concern. Many governments are responding by introducing financial incentives to attract health care workers to locate in areas that are underserved. However, clear evidence of the effectiveness of such financial incentives is lacking. METHODS: This paper examines General Practitioners' (GPs) relocation choices in Australia and proposes a dynamic location choice model accounting for both source and destination factors associated with a choice to relocate, thereby accounting for push and pull factors associated with job separation. The model is used to simulate financial incentive policies and assess potential for such policies to redistribute GPs. This paper examines the role of financial factors in relocating established GPs into neighbourhoods with relatively low socioeconomic status. The paper uses a discrete choice model and panel data on GPs' actual changes in location from one year to the next. RESULTS: This paper finds that established GPs are not very mobile, even when a financial incentive is offered. Policy simulation predicts that 93.2% of GPs would remain at their current practice and that an additional 0.8% would be retained or would relocate in a low-socioeconomic status (SES) neighbourhood in response to a hypothetical financial incentive of a 10% increase in the earnings of all metropolitan GPs practising in low-SES neighbourhoods. CONCLUSION: With current evidence on the effectiveness of redistribution programmes limited to newly entering GPs, the policy simulations in this paper provide an insight into the potential effectiveness of financial incentives as a redistribution policy targeting the entire GP population. Overall, the results suggest that financial considerations are part of many factors influencing the location choice of GPs. For instance, GP practice ownership played almost as important a role in mobility as earnings.

More cost-effective management of patients with musculoskeletal disorders in primary care after direct triaging to physiotherapists for initial assessment compared to initial general practitioner assessment.

BACKGROUND: A model for triaging patients in primary care to provide immediate contact with the most appropriate profession to treat the condition in question has been developed and implemented in parts of Sweden. Direct triaging of patients with musculoskeletal disorders (MSD) to physiotherapists at primary healthcare centres has been proposed as an alternative to initial assessment by general practitioners (GPs) and has been shown to have many positive effects. The aim of this study was to evaluate the cost-effectiveness from the societal perspective of this new care-pathway through primary care regarding triaging patients with MSD to initial assessment by physiotherapists compared to standard practice with initial GP assessment. METHODS: Nurse-assessed patients with MSD (N = 55) were randomised to initial assessment and treatment with either physiotherapists or GPs and were followed for 1 year regarding health-related quality of life, utilization of healthcare resources and absence from work for MSD. Quality-adjusted life-years (QALYs) were calculated based on EQ5D measured at 5 time-points. Costs for healthcare resources and production loss were compiled. Incremental cost-effectiveness ratios (ICERS) were calculated. Multiple imputation was used to compensate for missing values and bootstrapping to handle uncertainty. A cost-effectiveness plane and a cost-effectiveness acceptability curve were construed to describe the results. RESULTS: The group who were allocated to initial assessment by physiotherapists had slightly larger gains in QALYs at lower total costs. At a willingness-to-pay threshold of 20,000 €, the likelihood that the intervention was cost-effective from a societal perspective including production loss due to MSD was 85% increasing to 93% at higher thresholds. When only healthcare costs were considered, triaging to physiotherapists was still less costly in relation to health improvements than standard praxis. CONCLUSION: From the societal perspective, this small study indicated that triaging directly to physiotherapists in primary care has a high likelihood of being cost-effective. However, further larger randomised trials will be necessary to corroborate these findings. TRIAL REGISTRATION: ClinicalTrials.gov NCT02218749 . Registered August 18, 2014.

Cost-Effectiveness of Reclassifying Triptans in Australia: Application of an Economic Evaluation Approach to Regulatory Decisions.

BACKGROUND: Migraine is a common, chronic, disabling headache disorder. Triptans, used as an acute treatment for migraine, are available via prescription in Australia. An Australian Therapeutic Goods Administration (TGA) committee rejected reclassifying sumatriptan and zolmitriptan from prescription medicine to pharmacist-only between 2005 and 2009, largely on the basis of concerns about patient risk. Nevertheless, pharmacist-only triptans may reduce migraine duration and free up healthcare resources. OBJECTIVES: To estimate the cost-effectiveness of reclassifying triptans from prescription-only to pharmacist-only in Australia. METHODS: The study design included decision-analytic modeling combining data from various sources. Behavior before and after reclassification was estimated using medical practitioner and patient surveys and also administrative data. Health outcomes included migraine frequency and duration as well as adverse events (AEs) discussed by the TGA committee. Efficacy and AEs were estimated using randomized controlled trials and observational studies. RESULTS: Reclassifying triptans will reduce migraine duration but increase AEs. This will result in 337 quality-adjusted life-years gained at an increased cost of A$5.9 million over 10 years for all Australian adults older than 15 years (19.6 million). The incremental cost-effectiveness ratio was estimated to be A$17 412/quality-adjusted life-year gained. CONCLUSIONS: The incremental cost-effectiveness ratio is likely to be considered cost-effective by Australian decision makers. Serotonin syndrome, a key concern of the TGA committee, had little impact on the results. Further research is needed regarding pharmacist-only triptan use by migraineurs currently using over-the-counter medicines and by nonmigraineurs, the efficacy of triptans, and the risk of cardiovascular and cerebrovascular AEs and chronic headaches with triptans.