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1.
JAMA ; 322(1): 57-68, 2019 07 02.
Artigo em Inglês | MEDLINE | ID: mdl-31265101

RESUMO

Importance: Hawaii Medical Service Association (HMSA), the Blue Cross Blue Shield of Hawaii, introduced Population-based Payments for Primary Care (3PC), a new capitation-based primary care payment system, in 2016. The effect of this system on quality measures has not been evaluated. Objective: To evaluate whether the 3PC system was associated with changes in quality, utilization, or spending in its first year. Design, Setting, and Participants: Observational study using HMSA claims and clinical registry data from January 1, 2012, to December 31, 2016, and a propensity-weighted difference-in-differences method to compare 77 225 HMSA members in Hawaii attributed to 107 primary care physicians (PCPs) and 4 physician organizations participating in the first wave of the 3PC and 222 233 members attributed to 312 PCPs and 14 physician organizations that continued in a fee-for-service model in 2016 but had 3PC start dates thereafter. Exposures: Participation in the 3PC system. Main Outcomes and Measures: The primary outcome was the change in a composite measure score reflecting the probability that a member achieved an eligible measure out of 13 pooled Healthcare Effectiveness Data and Information Set quality measures. Primary care visits and total cost of care were among 15 secondary outcomes. Results: In total, the study included 299 458 HMSA members (mean age, 42.1 years; 51.5% women) and 419 primary care physicians (mean age, 54.9 years; 34.8% women). The risk-standardized composite measure scores for 2012 to 2016 changed from 75.1% to 86.6% (+11.5 percentage points) in the 3PC group and 74.3% to 83.5% (+9.2 percentage points) in the non-3PC group (differential change, 2.3 percentage points [95% CI, 2.1 to 2.6 percentage points]; P < .001). Of 15 prespecified secondary end points for utilization and spending, 11 showed no significant difference. Compared with the non-3PC group, the 3PC system was associated with a significant reduction in the mean number of primary care visits (3.3 to 3.0 visits vs 3.3 to 3.1 visits; adjusted differential change, -3.9 percentage points [95% CI, -4.6 to -3.2 percentage points]; P < .001), but there was no significant difference in mean total cost of care ($3344 to $4087 vs $2977 to $3564; adjusted differential change, 1.0% [95% CI, -1.3% to 3.4%]; P = .39). Conclusions and Relevance: In its first year, the 3PC population-based primary care payment system in Hawaii was associated with small improvements in quality and a reduction in PCP visits but no significant difference in the total cost of care. Additional research is needed to assess longer-term outcomes as the program is more fully implemented and to determine whether results are generalizable to other health care markets.


Assuntos
Planos de Seguro Blue Cross Blue Shield/economia , Atenção Primária à Saúde/economia , Melhoria de Qualidade , Mecanismo de Reembolso , Adulto , Capitação , Redução de Custos , Feminino , Hawaii , Pesquisas sobre Serviços de Saúde , Humanos , Revisão da Utilização de Seguros , Masculino , Pessoa de Meia-Idade , Médicos de Atenção Primária , Indicadores de Qualidade em Assistência à Saúde
6.
Ter Arkh ; 91(1): 19-23, 2019 Mar 10.
Artigo em Inglês | MEDLINE | ID: mdl-31090366

RESUMO

AIM: The aim of this article is to establish a weighted average costs of the workflow of the doctor-the therapist of the district, providing primary health care to the population in the outpatient setting to determine the costs when you visit one patient. MATERIALS AND METHODS: Held fotohronometra working process research 39 physicians in the 17th precinct pilot areas from all Federal districts. Within fotohronometra research conducted 6474 measurement. RESULTS: The average time a physician of the district while visiting a patient in a medical organization made up of 15.30±2.0 min, while visiting at home - 32.5±2.0 min the Largest proportion of the working time of the doctor-the therapist of the district while visiting a patient in the outpatient setting is necessary to work with medical records (47.31%). On core activities while visiting a patient in the practitioner, the district spends to 45.54% of the time. For other activities - 7.15%. CONCLUSION: As a result fotohronometra research workflow of doctors-therapists of district, providing primary health care in outpatient settings, set the average time a physician of the district while visiting one patient (15.30±2.0 min), while visiting at home (32.5±2.0 min).


Assuntos
Médicos/economia , Atenção Primária à Saúde/economia , Custos e Análise de Custo , Assistência à Saúde/economia , Humanos
7.
BMC Musculoskelet Disord ; 20(1): 186, 2019 May 01.
Artigo em Inglês | MEDLINE | ID: mdl-31043169

RESUMO

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.


Assuntos
Análise Custo-Benefício/estatística & dados numéricos , Doenças Musculoesqueléticas/terapia , Atenção Primária à Saúde/economia , Triagem/economia , Adolescente , Adulto , Idoso , Procedimentos Clínicos/economia , Procedimentos Clínicos/organização & administração , Feminino , Seguimentos , Clínicos Gerais/economia , Clínicos Gerais/estatística & dados numéricos , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/psicologia , Enfermeiras e Enfermeiros/economia , Enfermeiras e Enfermeiros/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Fisioterapeutas/economia , Fisioterapeutas/estatística & dados numéricos , Atenção Primária à Saúde/organização & administração , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de Vida , Suécia , Resultado do Tratamento , Triagem/estatística & dados numéricos , Adulto Jovem
8.
Artigo em Russo | MEDLINE | ID: mdl-30990980

RESUMO

The article analyzes the results of implementing per capita financing mechanism in medical organizations providing primary medical sanitary care. The comprehensive methodology was applied, including analysis and generalization of experience, statistical, analytical, sociological, monographic description, economic, comparative analysis, organizational experiment. The analysis demonstrated that in actual conditions number of subjects of the Russian Federation, being able to include in per capita standard only those volumes of additional medical care that can be directly impacted by primary health care unit decreased significantly.


Assuntos
Atenção Primária à Saúde , Financiamento de Capital , Atenção Primária à Saúde/economia , Federação Russa
9.
Implement Sci ; 14(1): 37, 2019 04 18.
Artigo em Inglês | MEDLINE | ID: mdl-30999936

RESUMO

BACKGROUND: Collaborative care is an evidence-based program for treating depression in primary care. We sought to expand this model by recruiting clinics interested in incorporating community partners (i.e., community-based organizations (CBO) and/or family members) in the care team. Seven sites implemented evidence-based collaborative care programs with community partners while collecting information on costs of implementing and sustaining programs. METHODS: Sites retrospectively collected data on planning and implementation costs with technical assistance from study researchers. Sites also prospectively collected cost of care activities over a 1-month period once the program was implemented to determine resources needed to sustain programs. Personnel salary costs were adjusted, adding 30% for benefits and 30% for administrative overhead. RESULTS: The programs implemented varied considerably in staffing, involvement of care partners, and allocation of costs. Total planning and implementation costs varied from $39,280 to $60,575. The largest implementation cost category involved workflow development and ranged from $16,325 to $31,375 with the highest costs in this category attributed to the most successful implementation among clinic-CBO programs. Following implementation, cost per patient over the 1-month period ranged from $154 to $544. Ongoing strategic decision-making and administrative costs, which were included in cost of care, ranged from $284 to $2328 for the month. CONCLUSIONS: Sites implemented collaborative care through differing partnerships, staffing, and related costs. Costs to implement and sustain programs developed in partnership are often not collected but are crucial to understanding financial aspects of developing sustainable partnerships. Assessing such costs is feasible and can inform future partnership efforts.


Assuntos
Continuidade da Assistência ao Paciente/economia , Comportamento Cooperativo , Depressão/terapia , Planejamento em Saúde/economia , Equipe de Assistência ao Paciente/economia , Atenção Primária à Saúde/economia , Idoso , Idoso de 80 Anos ou mais , Redes Comunitárias , Família , Feminino , Humanos , Ciência da Implementação , Masculino , Pessoa de Meia-Idade , Desenvolvimento de Programas , Avaliação de Programas e Projetos de Saúde , Washington
10.
Aten. prim. (Barc., Ed. impr.) ; 51(4): 218-229, abr. 2019. graf, tab
Artigo em Espanhol | IBECS | ID: ibc-180862

RESUMO

Objetivo: Analizar en el contexto de una Zona Básica de Salud (ZBS) la prevalencia de los factores de riesgo cardiovascular (FRCV) y el impacto que generan en la morbilidad y el consumo de recursos sanitarios en la población estratificada según el sistema Clinical Risk Groups (CRG) en Atención Primaria (AP), con la finalidad de identificar la población con multimorbilidad para aplicar medidas preventivas, así como aquella que genera más carga asistencial y necesidades sociales. Diseño: Estudio observacional, de corte transversal y ámbito poblacional para una ZBS durante el año 2013. Emplazamiento: Departamento de salud de Castellón, Comunidad Valenciana (CV). Incluye asistencia ambulatoria en AP y especializada. Participantes: Todos los ciudadanos dados de alta en el Sistema de Información Poblacional (SIP), N = 32.667. Mediciones: Del sistema informatizado Abucasis obtuvimos las variables demográficas, clínicas y de consumo de recursos sanitarios. Consideramos la prevalencia de los FRCV a partir de la presencia o ausencia de los códigos diagnósticos CIE.9.MC. Se analizó la relación de los FRCV con los 9 estados de salud CRG, y se realizó un análisis predictivo con el modelo de regresión logística para evaluar la capacidad explicativa de cada variable. Además, se obtuvo mediante regresión multivariante un modelo explicativo del gasto farmaceútico ambulatorio. Resultados: La población del estado de salud CRG 4 en adelante tenía multimorbilidad. Los estados de salud CRG 7 y CRG 6 tienen mayor prevalencia de FRCV. Fue predictivo que a mayor morbilidad, mayor consumo de recursos, mediante OR superiores a la media, p < 0,05 e intervalos de confianza del 95%. Se observó que un 59,8% del gasto farmacéutico ambulatorio quedaba explicado por el sistema CRG y todos los FRCV (p < 0,05 y R2 corregido = 0,598). En cuanto al efecto de los FRCV sobre los estados de salud CRG, hubo asociación significativa (p < 0,05) para la alteración de la glucemia, dislipidemia e HTA en todos los estados CRG. Conclusiones: El estudio de los FRCV en una población estratificada mediante el sistema CRG identifica y predice dónde se genera mayor impacto en la morbilidad y consumo de recursos sanitarios. Nos permite conocer los grupos de pacientes en quienes desarrollar estrategias de prevención y cronicidad. A nivel de la práctica clínica se aporta un nuevo concepto de multimorbilidad, definido a partir del estado de salud CRG 4 en adelante


Objective: To analyze the prevalence of Cardiovascular Risk Factors (CVRF) in the context of a Basic Health Area and the impact they generate on morbidity and consumption of healthcare resources in the stratified population according to the Clinical System Risk Groups (CRG) in Primary Care, with the purpose of identifying the population with multimorbidity to apply preventive measures, as well as the one that generates the highest care burden and social needs. Design: Observational, cross-sectional and population-based study for a basic health area during 2013. Location: Department of Health 2 (Castellón), Comunidad Valenciana (CV). Includes outpatient care in Primary Care and specialized. Participants: All citizens registered in the Population Information System, N = 32,667. Measurements: From the computerized system Abucasis we obtained the demographic, clinical and consumption variables of health resources. We consider the prevalence of CVRF based on the presence or absence of the ICD.9.MC diagnostic codes. The relationship of the CVRF with the 9 CRG health states was analyzed and a predictive analysis was performed with the logistic regression model to evaluate the explanatory capacity of each variable. In addition, an explanatory model of ambulatory pharmaceutical expenditure was obtained through multivariate regression. Results: The population of health status CRG4 and above had multimorbidity. The CRG7 and 6 health states have a higher prevalence of CVRF; it was predictive that the higher the morbidity, the greater the consumption of resources through OR above the mean, p < 0.05 and the 95% confidence intervals. It was observed that 59.8% of ambulatory pharmaceutical expenditure was explained by the CRG system and all the CVRF (p < 0.05 and R2 corrected = 0.598). Regarding the effect of the CVRF on the CRG health states, there was a significant association (p < 0.05) for the alteration of blood glucose, dyslipidemia and HBP in all the CRG states. Conclusions: The study of CVRF in a stratified population using the CRG system identifies and predicts where the greatest impact on morbidity and consumption of healthcare resources is generated. It allows us to know the groups of patients where to develop prevention and chronicity strategies. At the level of clinical practice, a new concept of multimorbidity is provided, defined from the state of health CRG 4 and above


Assuntos
Humanos , Masculino , Feminino , Pessoa de Meia-Idade , Doenças Cardiovasculares/prevenção & controle , Atenção Primária à Saúde/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Custos de Medicamentos/estatística & dados numéricos , Fatores de Risco , Alocação de Recursos para a Atenção à Saúde/estatística & dados numéricos , Estudos Transversais , Grupos de Risco , Risco Ajustado/organização & administração , Nível de Saúde , Múltiplas Afecções Crônicas/epidemiologia
11.
BMC Public Health ; 19(1): 255, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30823909

RESUMO

BACKGROUND: The StopDia study is based on the convincing scientific evidence that type 2 diabetes (T2D) and its comorbidities can be prevented by a healthy lifestyle. The need for additional research is based on the fact that the attempts to translate scientific evidence into actions in the real-world health care have not led to permanent and cost-effective models to prevent T2D. The specific aims of the StopDia study following the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework are to 1) improve the Reach of individuals at increased risk, 2) evaluate the Effectiveness and cost-effectiveness of the digital lifestyle intervention and the digital and face-to-face group lifestyle intervention in comparison to routine care in a randomized controlled trial (RCT), and 3) evaluate the Adoption and Implementation of the StopDia model by the participants and the health care organizations at society level. Finally, we will address the Maintenance of the lifestyle changes at participant level and that of the program at organisatory level after the RCT. METHODS: The StopDia study is carried out in the primary health care system as part of the routine actions of three provinces in Finland, including Northern Savo, Southern Carelia, and Päijät-Häme. We estimate that one fifth of adults aged 18-70 years living in these areas are at increased risk of T2D. We recruit the participants using the StopDia Digital Screening Tool, including questions from the Finnish Diabetes Risk Score (FINDRISC). About 3000 individuals at increased risk of T2D (FINDRISC ≥12 or a history of gestational diabetes, impaired fasting glucose, or impaired glucose tolerance) participate in the one-year randomized controlled trial. We monitor lifestyle factors using the StopDia Digital Questionnaire and metabolism using laboratory tests performed as part of routine actions in the health care system. DISCUSSION: Sustainable and scalable models are needed to reach and identify individuals at increased risk of T2D and to deliver personalized and effective lifestyle interventions. With the StopDia study we aim to answer these challenges in a scientific project that is fully digitally integrated into the routine health care. TRIAL REGISTRATION: ClinicalTials.gov . Identifier: NCT03156478 . Date of registration 17.5.2017.


Assuntos
Diabetes Mellitus Tipo 2/prevenção & controle , Promoção da Saúde/métodos , Programas de Rastreamento/métodos , Atenção Primária à Saúde/métodos , Medição de Risco/métodos , Adolescente , Adulto , Idoso , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/economia , Diabetes Mellitus Tipo 2/etiologia , Feminino , Finlândia , Promoção da Saúde/economia , Estilo de Vida Saudável , Humanos , Masculino , Programas de Rastreamento/economia , Pessoa de Meia-Idade , Atenção Primária à Saúde/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Medição de Risco/economia , Comportamento de Redução do Risco , Inquéritos e Questionários , Adulto Jovem
12.
Int J Equity Health ; 18(1): 32, 2019 02 12.
Artigo em Inglês | MEDLINE | ID: mdl-30755217

RESUMO

BACKGROUND: Indigenous Australians diagnosed with cancer have poorer survival compared to non-Indigenous Australians. We aim to: 1) identify differences by Indigenous status in out-of-pocket expenditure for the first three-years post-diagnosis; 2) identify differences in the quantity and cost of healthcare services accessed; and 3) estimate the number of additional services required if access was equal between Indigenous and non-Indigenous people with cancer. METHODS: We used CancerCostMod, a model using linked administrative data. The base population was all persons diagnosed with cancer in Queensland, Australia (01JUL2011 to 30JUN2012) (n = 25,553). Each individual record was then linked to their Admitted Patient Data Collection, Emergency Data Information System, Medicare Benefits Schedule (MBS), and Pharmaceutical Benefits Scheme (PBS) records (01JUL2011 to 30JUN2015). We then weighted the population to be representative of the Australian population (approximately 123,900 Australians, 1.7% Indigenous Australians). The patient co-payment charged for each MBS service and PBS prescription was summed for each month from date of diagnosis to 36-months post-diagnosis. We then limited our model to MBS items to identify the quantity and type of healthcare services accessed during the first three-years. RESULTS: On average Indigenous people with cancer had less than half the out-of-pocket expenditure for each 12-month period (0-12 months: mean $401 Indigenous vs $1074 non-Indigenous; 13-24 months: mean $200 vs $484; and 25-36 months: mean $181 vs $441). A stepwise generalised linear model of out-of-pocket expenditure found that Indigenous status was a significant predictor of out of pocket expenditure. We found that Indigenous people with cancer on average accessed 236 services per person, however, this would increase to 309 services per person if Indigenous people had the same rate of service use as non-Indigenous people. CONCLUSIONS: Indigenous people with cancer had lower out-of-pocket expenditure, but also accessed fewer Medicare services compared to their non-Indigenous counterparts. Indigenous people with cancer were less likely to access specialist attendances, pathology tests, and diagnostic imaging through MBS, and more likely to access primary health care, such as services provided by general practitioners.


Assuntos
Custos de Cuidados de Saúde/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Serviços de Saúde/economia , Serviços de Saúde/estatística & dados numéricos , Neoplasias/economia , Grupos Populacionais/estatística & dados numéricos , Atenção Primária à Saúde/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Feminino , Hospitalização/economia , Humanos , Modelos Lineares , Masculino , Medicare/estatística & dados numéricos , Pessoa de Meia-Idade , Grupo com Ancestrais Oceânicos/estatística & dados numéricos , Queensland , Estados Unidos , Adulto Jovem
14.
Einstein (Sao Paulo) ; 17(1): eAO4333, 2019 Feb 07.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30758398

RESUMO

OBJECTIVE: To assess the quality of the Primary Health Care services provided to children and the feasibility of using the Brazilian version of Primary Care Assessment Tool (PCAT-Brazil) as a routine quality assessment tool. METHODS: A cross-sectional study was carried out in Joanópolis, a small rural town in the State of São Paulo (SP), Brazil. Seven health professionals and 502 caretakers of children using the public health center were interviewed using the PCAT-Brazil, collecting data on the core and related attributes of Primary Health Care provided to children. The score of each attribute was calculated. RESULTS: Caretakers rated as good the following attributes; "degree of affiliation", "first contact care - use of services", "coordinated care", and "comprehensive care - available services". The attributes of "first contact accessibility", "long term person care", "comprehensive care - offered services" and "family- and community-oriented care" were scored as poor. The health professionals only rated the attribute of "first contact accessibility" as satisfactory, and considered that all other Primary Health Care attributes needed improvement. To conduct this study, at least 1,241 working hours were invested, and the estimated budget was R$12.900,00 (or U$3,953.00). CONCLUSION: The use of the PCAT-Brazil as a routine assessment and planning tool seemed to be not feasible in the given setting due to high costs, lack of trained personnel and the huge workload. To overcome the encountered obstacles, advices are given based on field experience.


Assuntos
Acesso aos Serviços de Saúde , Atenção Primária à Saúde/normas , Adulto , Brasil , Cuidadores , Criança , Pré-Escolar , Estudos Transversais , Estudos de Viabilidade , Pessoal de Saúde , Acesso aos Serviços de Saúde/economia , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Humanos , Lactente , Recém-Nascido , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , População Rural , Inquéritos e Questionários
15.
Fam Med ; 51(2): 185-192, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30736045

RESUMO

BACKGROUND AND OBJECTIVES: Fee for service (FFS), the dominant payment model for primary care in the United States, compensates physicians based on volume. There are many initiatives exploring alternative payment models that prioritize value over volume. The Family Medicine for America's Health (FMAHealth) Payment Team has developed a comprehensive primary care payment (CPCP) model to support the move from activity- and volume-based payment to performance-based payment for value. METHODS: In 2016-2017, the FMAHealth Payment Team performed a comprehensive study of the current state of primary care payment models in the United States. This study explored the features, motivations, successes, and failures of a wide variety of payment arrangements. RESULTS: The results of this work have informed a definition of comprehensive primary care payment (CPCP) as well as a CPCP calculator. This quantitative methodology calculates a base rate and includes modifiers that recognize the importance of infrastructure and resources that have been found to be successful in innovative models. The modifiers also incorporate adjustments for chronic disease burden, social determinants of health, quality, and utilization. CONCLUSIONS: The calculator and CPCP methodology offer a potential roadmap for transitioning from volume to value and details how to calculate such an adjustable comprehensive payment. This has impact and interest for all levels of the health care system and is intended for use by practices of all types as well as health systems, employers, and payers.


Assuntos
Assistência Integral à Saúde/economia , Medicina de Família e Comunidade/organização & administração , Modelos Econômicos , Atenção Primária à Saúde/economia , Assistência à Saúde , Planos de Pagamento por Serviço Prestado/economia , Humanos , Estados Unidos
16.
Rev Epidemiol Sante Publique ; 67 Suppl 1: S33-S40, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30639052

RESUMO

BACKGROUND: The state of populations' health is linked to their access to quality healthcare. Best achieving this primary condition - a health, social and humanitarian condition - is an ongoing public policy objective. Although significant effort goes into this, do public policies sufficiently take into account the state of health of the most vulnerable populations? In France, reducing the non-take-up (NTU) of healthcare is a priority in current national health insurance policy. Under the local plans to tackle non-take-up, lack of understanding and exit from the system (PLANIR), national health insurance is currently rolling out a regional and partnership-based intervention framework in order to prevent NTU of healthcare by welfare clients. This social investment is unprecedented, yet the impact of the framework on the most vulnerable populations still seems to be limited. METHOD: The study of this example is based on monitoring of the framework's general implementation. This task was entrusted to the research team co-founded by the author, ODENORE (Observatory for the Non-take-up of Social Rights and Public Services). It is organized in four parts: quantitative monitoring of the detection and addressing of non-take-up situations (n=160,000 questionnaires); analysis of the results through qualitative interviews with beneficiaries and individuals who rejected the framework (n=365 interviews); analysis of the framework's implementation, using qualitative interviews and participant observations at the services in charge of the framework's implementation (n=18 collective interviews across three sites), and an analysis of the partnership through collective interviews with all the actors in the areas involved in the framework (three sites). RESULTS: The analysis shows that the integration of the most vulnerable populations' state of health into a common-law framework for intervention is hindered by three limitations: the framework's neutrality regarding public decisions and non-decisions that exacerbate social and regional health inequalities; its organizational design, which does not take into account the need for long-term medical-psycho-social care; and the absence of regulation capable of bringing together and coordinating the actors working towards healthcare access locally but with different populations. CONCLUSION: The difficulties of integrating the most vulnerable populations into a common-law framework such as the one proposed by the national health insurance do not seem insurmountable-provided, that is, that the regulatory authority (the regional health agencies) are willing and able to make it a strategic organizational objective at local level.


Assuntos
Implementação de Plano de Saúde , Política de Saúde , Acesso aos Serviços de Saúde , Disparidades em Assistência à Saúde , Populações Vulneráveis , Tomada de Decisões , Emergências , França/epidemiologia , Implementação de Plano de Saúde/legislação & jurisprudência , Implementação de Plano de Saúde/organização & administração , Implementação de Plano de Saúde/normas , Política de Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/legislação & jurisprudência , Acesso aos Serviços de Saúde/organização & administração , Acesso aos Serviços de Saúde/estatística & dados numéricos , Disparidades em Assistência à Saúde/legislação & jurisprudência , Disparidades em Assistência à Saúde/organização & administração , Disparidades em Assistência à Saúde/normas , Humanos , Programas Nacionais de Saúde/legislação & jurisprudência , Programas Nacionais de Saúde/organização & administração , Programas Nacionais de Saúde/tendências , Direitos do Paciente/legislação & jurisprudência , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/legislação & jurisprudência , Atenção Primária à Saúde/organização & administração , Fatores Socioeconômicos , Populações Vulneráveis/estatística & dados numéricos
17.
Lakartidningen ; 1162019 01 04.
Artigo em Sueco | MEDLINE | ID: mdl-30620380

RESUMO

In a recent study of more than 500 000 hospitalisations, doctors with personal knowledge of their patients used less resources, more often discharged them to their own home and their patients had lower mortality. Furthermore, other studies have shown that personal continuity increases patient satisfaction as well as compliance and reduces costs for medical services and visits to emergency services. In a Swedish context we discuss how a combination of organizational factors and personal listing on physicians and continuity of care favour personal knowledge between physician and patient and contribute to a primary care that works well for both the frail elderly and the healthy young.


Assuntos
Continuidade da Assistência ao Paciente , Assistência à Saúde/organização & administração , Assistência à Saúde/economia , Assistência à Saúde/normas , Humanos , Relações Médico-Paciente , Médicos , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/organização & administração , Atenção Primária à Saúde/normas , Qualidade da Assistência à Saúde , Suécia , Estados Unidos
18.
Eur Psychiatry ; 57: 10-18, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30658275

RESUMO

BACKGROUND: Late-life depression is a highly prevalent disorder that causes a large economic burden. A stepped collaborative care program was set up in order to improve care for patients with late-life depression in primary care in Germany: GermanIMPACT is the adaption of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program that has already been established in primary care in the USA. The aim of this study was to determine the cost-effectiveness of GermanIMPACT compared with treatment as usual from a societal perspective. METHODS: This study is part of a 12-month bi-centric cluster-randomized controlled trial aiming to assess the effectiveness of GermanIMPACT compared with treatment as usual among patients with late-life depression. A cost-effectiveness analysis using depression-free days (DFDs) was performed. Net-monetary benefit (NMB) regressions adjusted for baseline differences for different willingness-to-pay (WTP) thresholds were conducted and cost-effectiveness acceptability curves were constructed. RESULTS: In total, n = 246 patients (intervention group: n = 139; control group: n = 107) with a mean age of 71 from 71 primary care practices were included in the analysis. After 12 months, adjusted mean differences in costs and DFDs between intervention group and control group were +€354 and +21.4, respectively. Only the difference in DFDs was significant (p = 0.022). According to the unadjusted incremental cost-effectiveness ratio, GermanIMPACT was dominant compared with treatment as usual. The probability of GermanIMPACT being cost-effective was 80%, 90% or 95% if societal WTP per DFD was ≥€70, ≥€110 or ≥€180, respectively. CONCLUSION: Evidence for cost-effectiveness of GermanIMPACT relative to treatment as usual is not clear. Only if societal WTP was ≥€180 for an additional DFD, GermanIMPACT could be considered cost-effective with certainty.


Assuntos
Depressão/economia , Depressão/terapia , Educação de Pacientes como Assunto/economia , Atenção Primária à Saúde/economia , Idoso , Análise Custo-Benefício , Transtorno Depressivo/economia , Transtorno Depressivo/terapia , Feminino , Alemanha , Custos de Cuidados de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/organização & administração , Resultado do Tratamento
19.
Eval Program Plann ; 72: 170-178, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30368104

RESUMO

While primary health care programmes based on community participation are widely implemented in low- and middle- income settings, empirical evidence on whether and to what extent local people have the capacity to participate, support and drive such programmes scale up is scant in these countries. This paper assessed the level of community capacity to participate in one such programme - the Community-Based Health Planning and Service (CHPS) in Ghana. The capacity assessments were drawn from Chaskin's (2001) theorised indicators of community capacity with modifications to include: sense of community; community members commitment; community leadership commitment; problem solving mechanisms; and access to resources. These capacity measures guided the design of an interview guide used to collect data from community informants, frontline health providers (FLP) and district health managers. Key qualitative themes were built into a questionnaire administered to households selected through systematic sampling approach. Findings showed that growing individualism, low trust in neighbours and apathetic behaviours undermined the capacity of mutual support for CHPS. The capacity to support CHPS was high for local leadership and community social mobilisation groups who often dedicated time to working with FLP to promote maternal and reproductive health service use, and in advocating broader support for CHPS. Within the wider community, commitment to voluntarism was low as members perceived CHPS to be owned by, and run on government funds and resources. Poor voluntarism was compounded by poverty that crippled the capacity to provide needed resource support for CHPS. Findings have great implications for building strong capable communities for participation in community oriented health programmes.


Assuntos
Planejamento em Saúde Comunitária/organização & administração , Participação da Comunidade/métodos , Atenção Primária à Saúde/organização & administração , Avaliação de Programas e Projetos de Saúde , Fortalecimento Institucional/organização & administração , Planejamento em Saúde Comunitária/economia , Gana , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Liderança , Pobreza/estatística & dados numéricos , Atenção Primária à Saúde/economia , Serviços de Saúde Rural , Mobilidade Social , Apoio Social , Confiança , Voluntários/psicologia
20.
Diabetes Obes Metab ; 21(1): 73-83, 2019 01.
Artigo em Inglês | MEDLINE | ID: mdl-30058268

RESUMO

AIM: To evaluate the long-term cost-effectiveness of a Patient Empowerment Programme (PEP) for type 2 diabetes mellitus (DM) in primary care. MATERIALS AND METHODS: PEP participants were subjects with type 2 DM who enrolled into PEP in addition to enrolment in the Risk Assessment and Management Programme for DM (RAMP-DM) at primary care level. The comparison group was subjects who only enrolled into RAMP-DM without participating in PEP (non-PEP). A cost-effectiveness analysis was conducted using a patient-level simulation model (with fixed-time increments) from a societal perspective. We incorporated the empirical data from a matched cohort of PEP and non-PEP groups to simulate lifetime costs and outcomes for subjects with DM with or without PEP. Incremental cost-effectiveness ratios (ICER) in terms of cost per quality adjusted life year (QALY) gained were calculated. Probabilistic sensitivity analysis was conducted with results presented as a cost-effectiveness acceptability curve. RESULTS: With an assumption that the PEP effect would last for 5 years as shown by the empirical data, the incremental cost per subject was US $197 and the incremental QALYs gained were 0.06 per subject, which resulted in an ICER of US $3290 per QALY gained compared with no PEP across the lifetime. Probabilistic sensitivity analysis showed 66% likelihood that PEP is cost-effective compared with non-PEP when willingness-to-pay for a QALY is ≥US $46 153 (based on per capita GDP 2017). CONCLUSIONS: Based on this carefully measured cost of PEP and its potentially large benefits, PEP could be highly cost-effective from a societal perspective as an adjunct intervention for patients with DM.


Assuntos
Diabetes Mellitus Tipo 2 , Participação do Paciente , Atenção Primária à Saúde , Estudos de Casos e Controles , Análise Custo-Benefício , Diabetes Mellitus Tipo 2/epidemiologia , Diabetes Mellitus Tipo 2/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Educação de Pacientes como Assunto , Participação do Paciente/economia , Participação do Paciente/estatística & dados numéricos , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos
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