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1.
N Engl J Med ; 383(14): 1349-1357, 2020 10 01.
Artigo em Inglês | MEDLINE | ID: mdl-32997909

RESUMO

BACKGROUND: The gender gap in physician pay is often attributed in part to women working fewer hours than men, but evidence to date is limited by self-report and a lack of detail regarding clinical revenue and gender differences in practice style. METHODS: Using national all-payer claims and data from electronic health records, we conducted a cross-sectional analysis of 24.4 million primary care office visits in 2017 and performed comparisons between female and male physicians in the same practices. Our primary independent variable was physician gender; outcomes included visit revenue, visit counts, days worked, and observed visit time (interval between the initiation and the termination of a visit). We created multivariable regression models at the year, day, and visit level after adjustment for characteristics of the primary care physicians (PCPs), patients, and types of visit and for practice fixed effects. RESULTS: In 2017, female PCPs generated 10.9% less revenue from office visits than their male counterparts (-$39,143.2; 95% confidence interval [CI], -53,523.0 to -24,763.4) and conducted 10.8% fewer visits (-330.5 visits; 95% CI, -406.6 to -254.3) over 2.6% fewer clinical days (-5.3 days; 95% CI, -7.7 to -3.0), after adjustment for age, academic degree, specialty, and number of sessions worked per week, yet spent 2.6% more observed time in visits that year than their male counterparts (1201.3 minutes; 95% CI, 184.7 to 2218.0). Per visit, after adjustment for PCP, patient, and visit characteristics, female PCPs generated equal revenue but spent 15.7% more time with a patient (2.4 minutes; 95% CI, 2.1 to 2.6). These results were consistent in subgroup analyses according to the gender and health status of the patients and the type and complexity of the visits. CONCLUSIONS: Female PCPs generated less visit revenue than male colleagues in the same practices owing to a lower volume of visits, yet spent more time in direct patient care per visit, per day, and per year. (Funded in part by the Robert Wood Johnson Foundation.).


Assuntos
Médicos de Atenção Primária/economia , Atenção Primária à Saúde/economia , Estudos Transversais , Registros Eletrônicos de Saúde , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Assistência ao Paciente , Atenção Primária à Saúde/organização & administração , Fatores Sexuais , Fatores de Tempo , Estados Unidos , Carga de Trabalho
2.
Rev Bras Enferm ; 73(suppl 2): e20200256, 2020.
Artigo em Inglês, Português | MEDLINE | ID: covidwho-788928

RESUMO

OBJECTIVE: to reflect on the challenges and power of the nursing care process in Primary Health Care in the face of the New Coronavirus, COVID-19, in the Brazilian scenario. METHOD: reflective study, based on the discursive formulation in the context of COVID-19 in Primary Health Care, based on theoretical foundations and practical effects of neoliberal policy, the care process, and Nursing. RESULTS: in Brazil, COVID-19, has caused the need for challenges for strengthening primary care in the face of neoliberal policy, but it presents the potential of dialogue with communities and the (re)creation of the nursing care process through solidary collaborative networks. FINAL CONSIDERATIONS: reflecting on the nursing care process in primary care restores the strength present in the cooperation between health teams and community solidarity networks to change social and health circumstances, despite the challenge imposed by underfunding aggravated by neoliberalism.


Assuntos
Betacoronavirus , Infecções por Coronavirus/enfermagem , Processo de Enfermagem/organização & administração , Pneumonia Viral/enfermagem , Política , Atenção Primária à Saúde/economia , Brasil/epidemiologia , Infecções por Coronavirus/epidemiologia , Saúde Global , Humanos , Processo de Enfermagem/economia , Pandemias , Pneumonia Viral/epidemiologia , Fatores Socioeconômicos
3.
Rev Bras Enferm ; 73(suppl 2): e20200256, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32965400

RESUMO

OBJECTIVE: to reflect on the challenges and power of the nursing care process in Primary Health Care in the face of the New Coronavirus, COVID-19, in the Brazilian scenario. METHOD: reflective study, based on the discursive formulation in the context of COVID-19 in Primary Health Care, based on theoretical foundations and practical effects of neoliberal policy, the care process, and Nursing. RESULTS: in Brazil, COVID-19, has caused the need for challenges for strengthening primary care in the face of neoliberal policy, but it presents the potential of dialogue with communities and the (re)creation of the nursing care process through solidary collaborative networks. FINAL CONSIDERATIONS: reflecting on the nursing care process in primary care restores the strength present in the cooperation between health teams and community solidarity networks to change social and health circumstances, despite the challenge imposed by underfunding aggravated by neoliberalism.


Assuntos
Betacoronavirus , Infecções por Coronavirus/enfermagem , Processo de Enfermagem/organização & administração , Pneumonia Viral/enfermagem , Política , Atenção Primária à Saúde/economia , Brasil/epidemiologia , Infecções por Coronavirus/epidemiologia , Saúde Global , Humanos , Processo de Enfermagem/economia , Pandemias , Pneumonia Viral/epidemiologia , Fatores Socioeconômicos
4.
J Ment Health Policy Econ ; 23(3): 81-91, 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-32853157

RESUMO

BACKGROUND: Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. AIMS OF THE STUDY: In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks. METHODS: We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models. RESULTS: We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. DISCUSSION: These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. IMPLICATIONS FOR HEALTH POLICIES: Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. IMPLICATIONS FOR FURTHER RESEARCH: Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.


Assuntos
Organizações de Assistência Responsáveis , Capitação/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/economia , Motivação , Atenção Primária à Saúde/economia , Análise Custo-Benefício/estatística & dados numéricos , Planos de Pagamento por Serviço Prestado/estatística & dados numéricos , Gastos em Saúde , Humanos , Modelos Econômicos , Modelos Teóricos , Setor Público
5.
J Ment Health Policy Econ ; 23(3): 101-109, 2020 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-32853159

RESUMO

BACKGROUND: Since June 2017, the Primary Health Care Integrated Geriatric Services Initiative (PHC IGSI) has been implemented in Alberta, Canada to, among other aims, reduce costs of unplanned health service utilization while maximizing the utilization of available community resources to support people living with dementia living in communities. AIM OF THE STUDY: We performed an economic evaluation of this initiative to inform policy regarding sustainability, scale up and spread. METHODS: We used a cohort design together with a difference-in-difference approach and a propensity score matching technique to calculate impacts of the intervention on patient's health service utilization, including inpatient, outpatient and physician services, as well as prescription drugs. We then used a decision tree to compare between benefits and costs of the intervention and reported net benefits (NB) and return on investment ratios (ROI). We used a health system perspective and a time horizon of 1 year. Both deterministic and probabilistic sensitivity analyses were performed for the uncertainty of parameters. We analyzed real-world data extracted from the Alberta Health Administrative Databases. All costs/savings were inflated to 2019 CAD (CAD 1 \sim = USD 0.75) using the Canadian Consumer Price Index. RESULTS: The intervention reduced the use of hospital (inpatient, emergency, and outpatient) services by increasing the use of community services (physician and prescription drug). As hospital services are expensive, the PHC IGSI community intervention resulted in a NB from CAD 554 to 4,046 per patient-year for the health system, and a ROI from 1.3 to 3.1 meaning that every CAD invested in PHC IGSI would bring CAD 1.3 to 3.1 in return. The probability of PHC IGSI to be cost-saving was 56.4% to 69.3%. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: The PHC IGSI is cost-effective in Alberta. IMPLICATIONS FOR HEALTH POLICY: The savings would be larger if the initiative is sustained, scaled up and spread because of not only a reduced cost of intervention in the sustainability phase, but also because of the increased number of patients that would be impacted. IMPLICATIONS FOR FURTHER RESEARCH: Future studies taking a societal perspective to also include costs for families and health and social sectors at the community level, would be desirable. Additionally, future works to determine how wellbeing is impacted by the PHC IGSI as vertical and horizontal integration interventions are implemented at the community level, are essential to undertake. Finally, in addition to people living with dementia, the PHC IGSI also supports people living in the community with frailty and other geriatric syndromes, therefore, the cost-savings estimated in this study are likely underestimated.


Assuntos
Prestação Integrada de Cuidados de Saúde/economia , Serviços de Saúde para Idosos/economia , Atenção Primária à Saúde/economia , Idoso , Alberta , Redução de Custos , Análise Custo-Benefício , Serviços de Saúde , Humanos
6.
PLoS One ; 15(8): e0236472, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32760071

RESUMO

BACKGROUND: Previous studies have shown that influenza is associated with a substantial healthcare burden in the United Kingdom (UK), but more studies are needed to evaluate the resource use and direct medical costs of influenza in primary care and secondary care. METHODS: A retrospective observational database study in the UK to describe the primary care and directly-associated secondary care resource use, and direct medical costs of acute respiratory illness (ARI), according to age, and risk status (NCT Number: 01521416). Patients with influenza, ARI or influenza-related respiratory infections during 9 consecutive pre-pandemic influenza peak seasons were identified by READ codes in the linked Clinical Practice Research Datalink (CPRD) and Hospital Episodes Statistics (HES) dataset. The study period was from 21st January 2001 to 31st March 2009. RESULTS: A total of 156,193 patients had ≥1 general practitioner (GP) episode of ARI, and a total of 82,204 patients received ≥1 GP prescription, at a mean of 2.5 (standard deviation [SD]: 3.0) prescriptions per patient. The total cost of GP consultations and prescriptions equated to £462,827 per year per 100,000 patients. The yearly cost of prescribed medication for ARI was £319,732, at an estimated cost of £11,596,350 per year extrapolated to the UK, with 40% attributable to antibiotics. The mean cost of hospital admissions equated to a yearly cost of £981,808 per 100,000 patients. The total mean direct medical cost of ARI over 9 influenza seasons was £21,343,445 (SD: £10,441,364), at £136.65 (SD: £66.85) per case. CONCLUSIONS: Extrapolating to the UK population, for pre-pandemic influenza seasons from 2001 to 2009, the direct medical cost of ARI equated to £86 million each year. More studies are needed to assess the costs of influenza disease to help guide public health decision-making for seasonal influenza in the UK.


Assuntos
Custos e Análise de Custo , Recursos em Saúde/provisão & distribução , Atenção Primária à Saúde/economia , Infecções Respiratórias , Atenção Secundária à Saúde/economia , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Estudos Transversais , Bases de Dados Factuais , Humanos , Pessoa de Meia-Idade , Infecções Respiratórias/economia , Infecções Respiratórias/epidemiologia , Estudos Retrospectivos , Reino Unido , Adulto Jovem
7.
BMJ ; 370: m2588, 2020 07 30.
Artigo em Inglês | MEDLINE | ID: mdl-32732322

RESUMO

OBJECTIVE: To assess whether differences in income between male and female physicians vary according to the sex composition of physician practices. DESIGN: Retrospective observational study. SETTING: US national survey of physician salaries, 2014-18. PARTICIPANTS: 18 802 physicians from 9848 group practices (categorized according to proportion of male physicians ≤50%, >50-75%, >75-90%, and >90%). MAIN OUTCOME MEASURES: Sex differences in physician income in relation to the sex composition of physician practices after multivariable adjustment for physician specialty, years of experience, hours worked, measures of clinical workload, practice type, and geography. RESULTS: Among 11 490 non-surgical specialists, the absolute adjusted sex difference in annual income (men versus women) was $36 604 (£29 663; €32 621) (95% confidence interval $24 903 to $48 306; 11.7% relative difference) for practices with 50% or less of male physicians compared with $91 669 ($56 587 to $126 571; 19.9% relative difference) for practices with at least 90% of male physicians (P=0.03 for difference). Similar findings were observed among surgical specialists (n=3483), with absolute adjusted sex difference in annual income of $46 503 ($42 198 to $135 205; 10.2% relative difference) for practices with 50% or less of male physicians compared with $149 460 ($86 040 to $212 880; 26.9% relative difference) for practices with at least 90% of male physicians (P=0.06 for difference). Among primary care physicians (n=3829), sex differences in income were not related to the proportion of male physicians in a practice. CONCLUSIONS: Among both non-surgical and surgical specialists, sex differences in income were largest in practices with the highest proportion of male physicians, even after detailed adjustment for factors that might explain sex differences in income.


Assuntos
Prática de Grupo/organização & administração , Prática de Grupo/estatística & dados numéricos , Renda/estatística & dados numéricos , Médicos/economia , Médicos/estatística & dados numéricos , Feminino , Humanos , Masculino , Médicas/economia , Médicas/estatística & dados numéricos , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Distribuição por Sexo , Cirurgiões/economia , Cirurgiões/estatística & dados numéricos , Estados Unidos
11.
Value Health ; 23(6): 743-750, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32540232

RESUMO

OBJECTIVES: Markov models characterize disease progression as specific health states based on clinical or biological measures. However, these measures are not always collected outside clinical trials. In this article, an alternative approach is presented that uses real-world data to define the health states and to model transitions between them, specific to a local setting, to estimate the cost-effectiveness of telemonitoring (TM) versus no TM for heart failure. METHODS: The incidence of hospitalization for usual care was estimated from hospital episode statistics (HES) data in the United Kingdom and converted into a monthly transition matrix with 5 health states (4 states are defined based on the number of hospitalizations in the previous year and death) to estimate the cost-effectiveness of TM in a local UK primary care trust (PCT) using probabilistic sensitivity analysis from a healthcare perspective. RESULTS: Geographical variation in hospitalization rates were present, which led to different health state transition matrices in different localities. In the PCT that was evaluated, TM accrued mean additional costs of £3610 and 0.075 additional quality-adjusted life-years (QALYs) compared with usual care per patient, resulting in a mean incremental cost effectiveness ratio of £48 172/QALY. CONCLUSIONS: The use of administrative data to define health states and transition matrices based on health service events is feasible, and TM was not cost-effective in our analysis. Given the increasing emphasis on using real-world evidence, it is likely that these approaches will be used more in the future.


Assuntos
Insuficiência Cardíaca/terapia , Hospitalização/estatística & dados numéricos , Cadeias de Markov , Telemedicina/métodos , Análise Custo-Benefício , Progressão da Doença , Nível de Saúde , Insuficiência Cardíaca/economia , Hospitalização/economia , Humanos , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/métodos , Anos de Vida Ajustados por Qualidade de Vida , Avaliação da Tecnologia Biomédica , Telemedicina/economia , Reino Unido
12.
PLoS One ; 15(6): e0234577, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32555696

RESUMO

The effects of hepatitis C virus (HCV), such as morbidity and mortality associated with cirrhosis and liver cancer, is a major public health issue in Australia. Highly effective treatment has recently been made available to all Australians living with HCV. A decision-analytic model was developed to evaluate the cost-effectiveness of the hepatology partnership, compared to usual care. A Markov model was chosen, as it is state-based and able to include recursive events, which accurately reflects the natural history of the chronic and repetitive nature of HCV. Cost-effectiveness of the new model of care is indicated by the incremental cost-effectiveness ratio (ICER), where the mean change to costs associated with the new model of care is divided by the mean change in quality adjusted life-years (QALYs). Ten thousand iterations of the model were run, with the majority (73%) of ICERs representing cost-savings. In comparison to usual care, the intervention improves health outcomes (22.38 QALYs gained) and reduces costs by $42,122 per patient. When compared to usual care, a partnership approach to management of HCV is cost-effective and good value for money, even when key model parameters are changed in scenario analyses. Reduction in costs is driven by improved efficiency of the new model of care, where more patients are treated in a timely manner, away from the expensive tertiary setting. From an economic perspective, a reduction in hospital-based care is a positive outcome and represents a good investment for decision-makers who wish to maximise health gain per dollar spent.


Assuntos
Análise Custo-Benefício , Hepatite C Crônica/tratamento farmacológico , Administração dos Cuidados ao Paciente/economia , Atenção Primária à Saúde/economia , Anos de Vida Ajustados por Qualidade de Vida , Adulto , Austrália , Gerenciamento Clínico , Feminino , Hepacivirus , Humanos , Masculino , Cadeias de Markov , Pessoa de Meia-Idade , Administração dos Cuidados ao Paciente/métodos , Atenção Primária à Saúde/normas
13.
Health Aff (Millwood) ; 39(9): 1605-1614, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: covidwho-615681

RESUMO

As a result of the coronavirus disease 2019 (COVID-19) pandemic, virtually all in-person outpatient visits were canceled in many parts of the country between March and May 2020. We sought to estimate the potential impact of COVID-19 on the operating expenses and revenues of primary care practices. Using a microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements, including telemedicine visits, we estimated that over the course of calendar year 2020, primary care practices would be expected to lose 67,774 in gross revenue per full-time-equivalent physician (the difference between 2020 gross revenue with COVID-19 and the anticipated gross revenue if COVID-19 had not occurred). We further estimated that the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion. This could more than double if COVID-19 telemedicine payment policies are not sustained.


Assuntos
Infecções por Coronavirus/epidemiologia , Gastos em Saúde , Cobertura do Seguro/economia , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Atenção Primária à Saúde/economia , Infecções por Coronavirus/economia , Infecções por Coronavirus/prevenção & controle , Assistência à Saúde/organização & administração , Feminino , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Modelos Econômicos , Pandemias/economia , Pandemias/prevenção & controle , Pneumonia Viral/economia , Pneumonia Viral/prevenção & controle , Atenção Primária à Saúde/estatística & dados numéricos , Estados Unidos
14.
Health Aff (Millwood) ; 39(9): 1605-1614, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32584605

RESUMO

As a result of the coronavirus disease 2019 (COVID-19) pandemic, virtually all in-person outpatient visits were canceled in many parts of the country between March and May 2020. We sought to estimate the potential impact of COVID-19 on the operating expenses and revenues of primary care practices. Using a microsimulation model incorporating national data on primary care use, staffing, expenditures, and reimbursements, including telemedicine visits, we estimated that over the course of calendar year 2020, primary care practices would be expected to lose 67,774 in gross revenue per full-time-equivalent physician (the difference between 2020 gross revenue with COVID-19 and the anticipated gross revenue if COVID-19 had not occurred). We further estimated that the cost at a national level to neutralize the revenue losses caused by COVID-19 among primary care practices would be $15.1 billion. This could more than double if COVID-19 telemedicine payment policies are not sustained.


Assuntos
Infecções por Coronavirus/epidemiologia , Gastos em Saúde , Cobertura do Seguro/economia , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Atenção Primária à Saúde/economia , Infecções por Coronavirus/economia , Infecções por Coronavirus/prevenção & controle , Assistência à Saúde/organização & administração , Feminino , Humanos , Cobertura do Seguro/estatística & dados numéricos , Masculino , Modelos Econômicos , Pandemias/economia , Pandemias/prevenção & controle , Pneumonia Viral/economia , Pneumonia Viral/prevenção & controle , Atenção Primária à Saúde/estatística & dados numéricos , Estados Unidos
16.
Med Care ; 58(8): 681-688, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32265355

RESUMO

OBJECTIVE: The objective of this study was to compare health care utilization and costs among diabetes patients with physician, nurse practitioner (NP), or physician assistant (PA) primary care providers (PCPs). RESEARCH DESIGN AND METHODS: Cohort study using Veterans Affairs (VA) electronic health record data to examine the relationship between PCP type and utilization and costs over 1 year in 368,481 adult, diabetes patients. Relationship between PCP type and utilization and costs in 2013 was examined with extensive adjustment for patient and facility characteristics. Emergency department and outpatient analyses used negative binomial models; hospitalizations used logistic regression. Costs were analyzed using generalized linear models. RESULTS: PCPs were physicians, NPs, and PAs for 74.9% (n=276,009), 18.2% (n=67,120), and 6.9% (n=25,352) of patients respectively. Patients of NPs and PAs have lower odds of inpatient admission [odds ratio for NP vs. physician 0.90, 95% confidence interval (CI)=0.87-0.93; PA vs. physician 0.92, 95% CI=0.87-0.97], and lower emergency department use (0.67 visits on average for physicians, 95% CI=0.65-0.68; 0.60 for NPs, 95% CI=0.58-0.63; 0.59 for PAs, 95% CI=0.56-0.63). This translates into NPs and PAs having ~$500-$700 less health care costs per patient per year (P<0.0001). CONCLUSIONS: Expanded use of NPs and PAs in the PCP role for some patients may be associated with notable cost savings. In our cohort, substituting care patterns and creating similar clinical situations in which they practice, NPs and PAs may have reduced costs of care by up to 150-190 million dollars in 2013.


Assuntos
Diabetes Mellitus/economia , Pessoal de Saúde/economia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Atenção Primária à Saúde/economia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Diabetes Mellitus/psicologia , Feminino , Pessoal de Saúde/normas , Pessoal de Saúde/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Profissionais de Enfermagem/economia , Profissionais de Enfermagem/normas , Profissionais de Enfermagem/estatística & dados numéricos , Assistentes Médicos/economia , Assistentes Médicos/normas , Assistentes Médicos/estatística & dados numéricos , Médicos/economia , Médicos/normas , Médicos/estatística & dados numéricos , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/estatística & dados numéricos , Estados Unidos , United States Department of Veterans Affairs/economia , United States Department of Veterans Affairs/organização & administração , United States Department of Veterans Affairs/estatística & dados numéricos
17.
Pediatrics ; 145(4)2020 04.
Artigo em Inglês | MEDLINE | ID: mdl-32229620

RESUMO

BACKGROUND AND OBJECTIVES: Children with medical complexity (CMC) comprise only 6% of the pediatric population, account for ∼40% of pediatric health care spending, and provide an important opportunity for cost saving. Savings in this group can have an important impact on pediatric health care costs. The objective of this study was to assess the impact of a multicenter care management program on spending and use in CMC. DESIGN AND METHODS: We conducted a prospective cohort analysis of a population of 4530 CMC enrolled in a learning collaborative designed to improve care for CMC ages 0 to 21 years identified using 3M Clinical Risk Group categories 5b through 9. The primary outcome was total per-member per-year standardized spending; secondary outcomes included inpatient and emergency department (ED) spending and use. We used a 1:1 propensity score match to compare enrolled patients to eligible nonenrolled patients and statistical process control methods to analyze spending and usage rates. RESULTS: Comparison with the matched group showed a 4.6% (95% confidence interval [CI]: 1.9%-7.3%) decrease in total per-member per-year spending (P < .001), a 7.7% (95% CI: 1.2%-13.5%) decrease in inpatient spending (P = .04), and an 11.6% (95% CI: 3.9%-18.4%) decrease in ED spending (P = .04). Statistical process control analysis showed a decrease in hospitalization rate and ED visits. CONCLUSIONS: CMC enrolled in a learning collaborative showed significant decreases in total spending and a significant decrease in the number of hospitalizations and ED visits. Additional research is needed to determine more specific causal factors for the results and if these results are sustainable over time and replicable in other settings.


Assuntos
Serviço Hospitalar de Emergência/economia , Custos de Cuidados de Saúde/estatística & dados numéricos , Hospitalização/economia , Programas de Assistência Gerenciada/economia , Atenção Primária à Saúde/economia , Adolescente , Criança , Pré-Escolar , Redução de Custos , Feminino , Seguimentos , Gastos em Saúde , Humanos , Lactente , Recém-Nascido , Masculino , Estudos Prospectivos , Adulto Jovem
18.
PLoS Med ; 17(3): e1003046, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32142507

RESUMO

BACKGROUND: The majority of people do not achieve recommended levels of physical activity. There is a need for effective, scalable interventions to promote activity. Self-monitoring by pedometer is a potentially suitable strategy. We assessed the effectiveness and cost-effectiveness of a very brief (5-minute) pedometer-based intervention ('Step It Up') delivered as part of National Health Service (NHS) Health Checks in primary care. METHODS AND FINDINGS: The Very Brief Intervention (VBI) Trial was a two parallel-group, randomised controlled trial (RCT) with 3-month follow-up, conducted in 23 primary care practices in the East of England. Participants were 1,007 healthy adults aged 40 to 74 years eligible for an NHS Health Check. They were randomly allocated (1:1) using a web-based tool between October 1, 2014, and December 31, 2015, to either intervention (505) or control group (502), stratified by primary care practice. Participants were aware of study group allocation. Control participants received the NHS Health Check only. Intervention participants additionally received Step It Up: a 5-minute face-to-face discussion, written materials, pedometer, and step chart. The primary outcome was accelerometer-based physical activity volume at 3-month follow-up adjusted for sex, 5-year age group, and general practice. Secondary outcomes included time spent in different intensities of physical activity, self-reported physical activity, and economic measures. We conducted an in-depth fidelity assessment on a subsample of Health Check consultations. Participants' mean age was 56 years, two-thirds were female, they were predominantly white, and two-thirds were in paid employment. The primary outcome was available in 859 (85.3%) participants. There was no significant between-group difference in activity volume at 3 months (adjusted intervention effect 8.8 counts per minute [cpm]; 95% CI -18.7 to 36.3; p = 0.53). We found no significant between-group differences in the secondary outcomes of step counts per day, time spent in moderate or vigorous activity, time spent in vigorous activity, and time spent in moderate-intensity activity (accelerometer-derived variables); as well as in total physical activity, home-based activity, work-based activity, leisure-based activity, commuting physical activity, and screen or TV time (self-reported physical activity variables). Of the 505 intervention participants, 491 (97%) received the Step it Up intervention. Analysis of 37 intervention consultations showed that 60% of Step it Up components were delivered faithfully. The intervention cost £18.04 per participant. Incremental cost to the NHS per 1,000-step increase per day was £96 and to society was £239. Adverse events were reported by 5 intervention participants (of which 2 were serious) and 5 control participants (of which 2 were serious). The study's limitations include a participation rate of 16% and low return of audiotapes by practices for fidelity assessment. CONCLUSIONS: In this large well-conducted trial, we found no evidence of effect of a plausible very brief pedometer intervention embedded in NHS Health Checks on objectively measured activity at 3-month follow-up. TRIAL REGISTRATION: Current Controlled Trials (ISRCTN72691150).


Assuntos
Actigrafia/instrumentação , Exercício Físico , Monitores de Aptidão Física , Estilo de Vida Saudável , Atenção Primária à Saúde , Medicina Estatal , Actigrafia/economia , Adulto , Idoso , Análise Custo-Benefício , Inglaterra , Feminino , Monitores de Aptidão Física/economia , Custos de Cuidados de Saúde , Voluntários Saudáveis , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/economia , Medicina Estatal/economia , Fatores de Tempo
19.
Clin Drug Investig ; 40(4): 335-341, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32144652

RESUMO

BACKGROUND: Spinal muscular atrophy (SMA) is a rare disorder, estimated to affect 1 per 10,000 live births. Patients affected with SMA often require intensive, chronic healthcare, which represents great social and economic costs. OBJECTIVE: This study aimed to evaluate the direct medical costs of SMA, from the National Health System perspective in Catalonia, and provide regional data for the development of optimal disease management protocols and resource allocation decisions at the regional level. METHODS: A retrospective, population-based study was designed based on admission records from primary care centres, hospitals and specialised care settings (inpatient and outpatient care), emergency services and extended care facilities obtained from a regional governmental claims database. RESULTS: A total of 396 patients met the inclusion criteria. Annual direct medical costs summed €58,606 per patient, taking into account the use of healthcare resources at all levels of care and excluding the cost of prescription medication. Specialised care represented 81% of the expenses that were mostly associated with respiratory manifestations of SMA. In the year 2016, 71.26% of patients with SMA had four or more systems affected by a chronic condition, versus 23.50% in the general population, which had an impact on healthcare use. CONCLUSIONS: Inpatient extended care and the increased presence of multimorbid chronic conditions in patients with SMA must be taken into account in order to develop multidisciplinary treatment protocols that reflect the complexity of SMA. Forthcoming resource allocation decisions should reflect the intensive use of specialised care registered in patients with SMA.


Assuntos
Custos de Cuidados de Saúde , Hospitalização/economia , Atrofia Muscular Espinal/terapia , Adulto , Assistência Ambulatorial/economia , Bases de Dados Factuais , Assistência à Saúde/economia , Feminino , Humanos , Masculino , Atrofia Muscular Espinal/economia , Atenção Primária à Saúde/economia , Estudos Retrospectivos , Espanha
20.
Aust N Z J Public Health ; 44(2): 121-128, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-32190950

RESUMO

OBJECTIVE: We aimed to quantify the extent to which socioeconomic differences in body mass index (BMI) drive avoidable deaths, incident disease cases and healthcare costs. METHODS: We used population attributable fractions to quantify the annual burden of disease attributable to socioeconomic differences in BMI for Australian adults aged 20 to <85 years in 2016, stratified by quintiles of an area-level indicator of socioeconomic disadvantage (SocioEconomic Index For Areas Indicator of Relative Socioeconomic Disadvantage; SEIFA) and BMI (normal weight, overweight, obese). We estimated direct healthcare costs using annual estimates per person per BMI category. RESULTS: We attributed $AU1.06 billion in direct healthcare costs to socioeconomic differences in BMI in 2016. The greatest number (proportion) of cases and deaths attributable to socioeconomic differences in BMI was observed for type 2 diabetes among women (8,602 total cases [16%], with 3,471 cases [22%] in the most disadvantaged quintile [SEIFA 1]) and all-cause mortality among men (2027 total deaths [4%], with 815 deaths [6%] in SEIFA 1). CONCLUSIONS: Socioeconomic differences in BMI substantially contribute to avoidable deaths, disease cases and direct healthcare costs in Australia. Implications for public health: Population-level policies to reduce socioeconomic differences in overweight and obesity must be identified and implemented.


Assuntos
Efeitos Psicossociais da Doença , Diabetes Mellitus Tipo 2/mortalidade , Custos de Cuidados de Saúde/estatística & dados numéricos , Obesidade/epidemiologia , Sobrepeso/economia , Atenção Primária à Saúde/estatística & dados numéricos , Características de Residência/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Austrália/epidemiologia , Índice de Massa Corporal , Custos e Análise de Custo , Diabetes Mellitus Tipo 2/complicações , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/economia , Sobrepeso/epidemiologia , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/métodos , Fatores Socioeconômicos
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