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Lau YS, Malisauskaite G, Brookes N, Hussein S, Sutton M. Complements or substitutes? Associations between volumes of care provided in the community and hospitals. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2021; 22:1167-1181. [PMID: 34138375 PMCID: PMC8526459 DOI: 10.1007/s10198-021-01329-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Accepted: 05/27/2021] [Indexed: 06/12/2023]
Abstract
Policymakers often suggest that expansion of care in community settings may ease increasing pressures on hospital services. Substitution may lower overall health system costs, but complementarity due to previously unidentified needs might raise them. We used new national data on community and primary medical care services in England to undertake system-level analyses of whether activity in the community acts as a complement or a substitute for activity provided in hospitals. We used two-way fixed effects regression to relate monthly counts of community care and primary medical care contacts to emergency department attendances, outpatient visits and admissions for 242 hospitals between November 2017 and September 2019. We then used national unit costs to estimate the effects of increasing community activity on overall system expenditure. The findings show community care contacts to be weak substitutes with all types of hospital activity and primary care contacts are weak substitutes for emergency hospital attendances and admissions. Our estimates ranged from 28 [95% CI 21, 45] to 517 [95% CI 291, 7265] community care contacts and from 34 [95% CI 17, 1283] to 1655 [95% CI - 1995, 70,145] GP appointments to reduce one hospital service visit. Primary care and planned hospital services are complements. Increases in community services and primary care activity are both associated with increased overall system expenditure of £34 [95% CI £156, £54] per visit for community care and £41 [95% CI £78, £74] per appointment in general practice. Expansion of community-based services may not generate reductions in hospital activity and expenditure.
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Affiliation(s)
- Yiu-Shing Lau
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK.
| | | | - Nadia Brookes
- Centre for Health Services Studies, University of Kent, Kent, UK
| | - Shereen Hussein
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK
- Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Melbourne, Australia
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van den Bogaart EHA, Kroese MEAL, Spreeuwenberg MD, Martens H, Steijlen PM, Ruwaard D. Reorganising dermatology care: predictors of the substitution of secondary care with primary care. BMC Health Serv Res 2020; 20:510. [PMID: 32503509 PMCID: PMC7275501 DOI: 10.1186/s12913-020-05368-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Accepted: 05/26/2020] [Indexed: 01/18/2023] Open
Abstract
Background The substitution of healthcare is a way to control rising healthcare costs. The Primary Care Plus (PC+) intervention of the Dutch ‘Blue Care’ pioneer site aims to achieve this feat by facilitating consultations with medical specialists in the primary care setting. One of the specialties involved is dermatology. This study explores referral decisions following dermatology care in PC+ and the influence of predictive patient and consultation characteristics on this decision. Methods This retrospective study used clinical data of patients who received dermatology care in PC+ between January 2015 and March 2017. The referral decision following PC+, (i.e., referral back to the general practitioner (GP) or referral to outpatient hospital care) was the primary outcome. Stepwise logistic regression modelling was used to describe variations in the referral decisions following PC+, with patient age and gender, number of PC+ consultations, patient diagnosis and treatment specialist as the predicting factors. Results A total of 2952 patients visited PC+ for dermatology care. Of those patients with a registered referral, 80.2% (N = 2254) were referred back to the GP, and 19.8% (N = 558) were referred to outpatient hospital care. In the multivariable model, only the treating specialist and patient’s diagnosis independently influenced the referral decisions following PC+. Conclusion The aim of PC+ is to reduce the number of referrals to outpatient hospital care. According to the results, the treating specialist and patient diagnosis influence referral decisions. Therefore, the results of this study can be used to discuss and improve specialist and patient profiles for PC+ to further optimise the effectiveness of the initiative.
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Affiliation(s)
- Esther H A van den Bogaart
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229, GT, The Netherlands.
| | - Mariëlle E A L Kroese
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229, GT, The Netherlands
| | - Marieke D Spreeuwenberg
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229, GT, The Netherlands.,Research Centre for Technology in Care, Zuyd University of Applied Sciences, Heerlen, the Netherlands
| | - Herm Martens
- Department of Dermatology and GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Peter M Steijlen
- Department of Dermatology and GROW School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health Medicine and Life Sciences, Maastricht University, Duboisdomein 30, Maastricht, 6229, GT, The Netherlands
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Assessing the dose-response relationship between number of office-based visits and hospitalizations for patients with type II diabetes using generalized propensity score matching. PLoS One 2018; 13:e0209197. [PMID: 30571732 PMCID: PMC6301623 DOI: 10.1371/journal.pone.0209197] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/01/2018] [Indexed: 12/04/2022] Open
Abstract
Background Whether inpatient services can be successfully substituted by office-based services has been debated for many decades, but the evidence is still inconclusive. This study aims to investigate the effect of office-based care on use and the expenditure for other healthcare services in patients with type II diabetes (T2D). Methods A generalized propensity score matching approach was used on pooled Medical Expenditure Panel Survey (MEPS) data for 2000–2012 to explore a dose-response effect. Patients were matched by using a comprehensive set of variables selected following a standard model on access to care. Findings Office-based care (up to 5 visits/year) acts as a substitute for other healthcare services and is associated with lower use and expenditure for inpatient, outpatient and emergency care. After five visits, office-based care becomes a complement to other services and is associated with increases in expenditure for T2D. Above 20 to 26 visits per year, depending on the healthcare service under consideration, the marginal effect of an additional office-based visit becomes non-statistically significant. Conclusions Office-based visits appear to be an effective instrument to reduce use of inpatient care and other services, including outpatient and emergency-care, in patients with T2D without any increase in total healthcare expenditure.
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Donley T, King DM, Nyathi N, Okafor A, Mbizo J. Socioeconomic Status, Family Functioning and Delayed Care Among Children With Special Needs. SOCIAL WORK IN PUBLIC HEALTH 2018; 33:366-381. [PMID: 30124396 DOI: 10.1080/19371918.2018.1504703] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Parents of children with special healthcare needs (CSHCN) face tremendous stress in caring for their children. Families of CSHCN face increased barriers to health services as evidence also reflects the influence of socioeconomic factors on access. This study investigates the impact of socioeconomic factors and family functioning on delayed care. Descriptive, bivariate, and adjusted multivariate logistic regression were performed using sampling weights. findings suggest that family dynamics are more impactful on delayed care than socioeconomic predictors. Promoting family-centered care that incorporates social support for families to reduce barriers is essential for improved quality of life and health outcomes.
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Affiliation(s)
- Tiffany Donley
- a Department of Public Health, University of West Florida , Pensacola , Florida , USA
| | - Dione Moultrie King
- b Department of Social Work, University of Alabama at Birmingham , Birmingham , Alabama , USA
| | - Nhlanganiso Nyathi
- c Department of Education and Social Care, Anglia Ruskin University , Peterborough
| | - Anthony Okafor
- a Department of Public Health, University of West Florida , Pensacola , Florida , USA
| | - Justice Mbizo
- a Department of Public Health, University of West Florida , Pensacola , Florida , USA
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Chalkley M, McCormick B, Anderson R, Aragon MJ, Nessa N, Nicodemo C, Redding S, Wittenberg R. Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05070] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe English NHS faces financial pressures that may render the growth rates of elective admissions seen between 2001/2 and 2011/12 unsustainable. A better understanding of admissions growth, and the influence of policy, are needed to minimise the impact on health gain for patients.ObjectivesThis project had several objectives: (1) to better understand the determinants of elective activity and policy to moderate growth at minimum health loss for patients; (2) to build a rich data set integrating health, practice and local area data to study general practitioner (GP) referrals and resulting admissions; (3) to predict patients whose treatment is unlikely to be cost-effective using patient-reported outcomes and to examine variation in provider performance; and (4) to study how policies that aim to reduce elective admissions may change demand for emergency care. The main drivers of elective admissions growth have increased either supply of or demand for care, and could include, for example, technical innovations or increased awareness of treatment benefits. Of the factors studied, neither system reform nor population ageing appears to be a key driver. The introduction of the prospective payment tariff ‘Payment by Results’ appears to have led to primary care trusts (PCTs) having increasingly similar lengths of stay. In deprived areas, increasing GP supply appears to moderate elective admissions. Reducing the incidence of single-handed practices tends to reduce referrals and admissions. Policies to reduce referrals are likely to reduce admissions but treatments may be particularly reduced in the lowest referring practices, in which resulting health loss may be greatest. In this model, per full-time equivalent, female and highly experienced GPs identify more patients admitted by specialists.ResultsIt appears from our studies that some patient characteristics are associated with not achieving sufficient patient gain to warrant cost-effective treatment. The introduction of independent sector treatment centres is estimated to have caused an increase in emergency activity rates at local PCTs. The explanations offered for increasing elective admissions indicate that they are manageable by health policy.ConclusionsFurther work is required to understand some of the results identified, such as whether or not high-volume Clinical Commissioning Groups are fulfilling unmet need; why some practices refer at low rates relative to admissions; why the period effect, which results from factors that equally affect all in the study at a point in time, dominates in the age–period–cohort analysis; and exactly how the emergency and elective sections of hospital treatment interact. This project relies on the analysis of secondary data. This type of research does not easily facilitate the important input of clinical experts or service users. It would be beneficial if other methods, including surveys and consultation with key stakeholders, could be incorporated into future research now that we have uncovered important questions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
| | - Barry McCormick
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Robert Anderson
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | | | - Nazma Nessa
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
- Department for Business, Innovation and Skills, London, UK
| | - Catia Nicodemo
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Stuart Redding
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
| | - Raphael Wittenberg
- Centre for Health Service Economics and Organisation, Nuffield Department of Primary Care, University of Oxford, Oxford, UK
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Thorsen O, Hartveit M, Johannessen JO, Fosse L, Eide GE, Schulz J, Bærheim A. Typologies in GPs' referral practice. BMC FAMILY PRACTICE 2016; 17:76. [PMID: 27430983 PMCID: PMC4949760 DOI: 10.1186/s12875-016-0495-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 07/13/2016] [Indexed: 12/04/2022]
Abstract
Background GPs’ individual decisions to refer and the various ways of working when they refer are important determinants of secondary care use. The objective of this study was to explore and describe potential characteristics of GPs’ referral practice by investigating their opinions about referring and their self-reported experiences of what they do when they refer. Methods Observational cross-sectional study using data from 128 Norwegian GPs who filled in a questionnaire with statements on how they regarded the referral process, and who were invited to collect data when they actually referred to hospital during one month. Only elective referrals were recorded. The 57 participants (44,5 %) recorded data from 691 referrals. The variables were included in a principal component analysis. A multiple linear regression analysis was conducted to identify typologies with GP’s age, gender, specialty in family medicine and location as independent variables. Results Eight principal components describe the different ways GPs think and work when they refer. Two typologies summarize these components: confidence characterizing specialists in family medicine, mainly female, who reported a more patient-centred practice making priority decisions when they refer, who confer easily with hospital consultants and who complete the referrals during the consultation; uncertainty characterizing young, mainly male non-specialists in family medicine, experiencing patients’ pressure to be referred, heavy workload, having reluctance to cooperate with the patient and reporting sparse contact with hospital colleagues. Conclusions Training specialists in family medicine in patient-centred method, easy conference with hospital consultant and cooperation with patients while making the referral may foster both self-reflections on own competences and increased levels of confidence. Electronic supplementary material The online version of this article (doi:10.1186/s12875-016-0495-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Olav Thorsen
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway. .,Department of Research, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.
| | - Miriam Hartveit
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway.,Section for Research and Innovation, Helse Fonna HF, Box 2170, Haugesund, N-5504, Norway
| | - Jan Olav Johannessen
- Centre for Clinical Psychosis Research, Division of Psychiatry, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.,Faculty of Social Sciences, University of Stavanger, Box 8100, Stavanger, N-4068, Norway
| | - Lars Fosse
- Department of Orthopaedics, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway
| | - Geir Egil Eide
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway.,Centre for Clinical Research, Haukeland University Hospital, Box 1400, Bergen, N-5021, Norway
| | - Jörn Schulz
- Department of Research, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway.,Section of Biostatistics, Stavanger University Hospital, Box 8100, Stavanger, N-4068, Norway
| | - Anders Bærheim
- Department of Global Public Health and Primary Care, University of Bergen, Box 7800, Bergen, N-5020, Norway
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Winpenny E, Miani C, Pitchforth E, Ball S, Nolte E, King S, Greenhalgh J, Roland M. Outpatient services and primary care: scoping review, substudies and international comparisons. HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04150] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
AimThis study updates a previous scoping review published by the National Institute for Health Research (NIHR) in 2006 (Roland M, McDonald R, Sibbald B.Outpatient Services and Primary Care: A Scoping Review of Research Into Strategies For Improving Outpatient Effectiveness and Efficiency. Southampton: NIHR Trials and Studies Coordinating Centre; 2006) and focuses on strategies to improve the effectiveness and efficiency of outpatient services.Findings from the scoping reviewEvidence from the scoping review suggests that, with appropriate safeguards, training and support, substantial parts of care given in outpatient clinics can be transferred to primary care. This includes additional evidence since our 2006 review which supports general practitioner (GP) follow-up as an alternative to outpatient follow-up appointments, primary medical care of chronic conditions and minor surgery in primary care. Relocating specialists to primary care settings is popular with patients, and increased joint working between specialists and GPs, as suggested in the NHS Five Year Forward View, can be of substantial educational value. However, for these approaches there is very limited information on cost-effectiveness; we do not know whether they increase or reduce overall demand and whether the new models cost more or less than traditional approaches. One promising development is the increasing use of e-mail between GPs and specialists, with some studies suggesting that better communication (including the transmission of results and images) could substantially reduce the need for some referrals.Findings from the substudiesBecause of the limited literature on some areas, we conducted a number of substudies in England. The first was of referral management centres, which have been established to triage and, potentially, divert referrals away from hospitals. These centres encounter practical and administrative challenges and have difficulty getting buy-in from local clinicians. Their effectiveness is uncertain, as is the effect of schemes which provide systematic review of referrals within GP practices. However, the latter appear to have more positive educational value, as shown in our second substudy. We also studied consultants who held contracts with community-based organisations rather than with hospital trusts. Although these posts offer opportunities in terms of breaking down artificial and unhelpful primary–secondary care barriers, they may be constrained by their idiosyncratic nature, a lack of clarity around roles, challenges to professional identity and a lack of opportunities for professional development. Finally, we examined the work done by other countries to reform activity at the primary–secondary care interface. Common approaches included the use of financial mechanisms and incentives, the transfer of work to primary care, the relocation of specialists and the use of guidelines and protocols. With the possible exception of financial incentives, the lack of robust evidence on the effect of these approaches and the contexts in which they were introduced limits the lessons that can be drawn for the English NHS.ConclusionsFor many conditions, high-quality care in the community can be provided and is popular with patients. There is little conclusive evidence on the cost-effectiveness of the provision of more care in the community. In developing new models of care for the NHS, it should not be assumed that community-based care will be cheaper than conventional hospital-based care. Possible reasons care in the community may be more expensive include supply-induced demand and addressing unmet need through new forms of care and through loss of efficiency gained from concentrating services in hospitals. Evidence from this study suggests that further shifts of care into the community can be justified only if (a) high value is given to patient convenience in relation to NHS costs or (b) community care can be provided in a way that reduces overall health-care costs. However, reconfigurations of services are often introduced without adequate evaluation and it is important that new NHS initiatives should collect data to show whether or not they have added value, and improved quality and patient and staff experience.FundingThe NIHR Health Services and Delivery Research programme.
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Affiliation(s)
| | | | | | | | - Ellen Nolte
- RAND Europe, Cambridge, UK
- European Observatory on Health Systems and Policies, London School of Economics and Political Science and London School of Hygiene and Tropical Medicine, London, UK
| | | | - Joanne Greenhalgh
- Faculty of Education, Social Sciences and Law, University of Leeds, Leeds, UK
| | - Martin Roland
- Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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van Dijk CE, de Jong JD, Verheij RA, Jansen T, Korevaar JC, de Bakker DH. Compliance with referrals to medical specialist care: patient and general practice determinants: a cross-sectional study. BMC FAMILY PRACTICE 2016; 17:11. [PMID: 26831125 PMCID: PMC4736608 DOI: 10.1186/s12875-016-0401-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Accepted: 01/13/2016] [Indexed: 12/05/2022]
Abstract
Background In a gatekeeper system, primary care physicians and patients jointly decide whether or not medical specialist care is needed. However, it is the patient who decides to actually use the referral. Referral non-compliance could delay diagnosis and treatment. The objective of this study was to assess patient compliance with a referral to medical specialist care and identify patient and practice characteristics that are associated with it. Methods Observational study using data on 48,784 referrals to medical specialist care derived from electronic medical records of 58 general practices for the period 2008–2010. Referral compliance was based on claims data of medical specialist care. Logistic multilevel regression analyses were conducted to determine associations between patient and general practice characteristics and referral compliance. Results In 86.6 % of the referrals, patients complied. Patient and not practice characteristics were significantly associated with compliance. Patients from deprived urban areas and patients aged 18–44 years were less likely to comply, whereas patients aged 65 years and older were more likely to comply. Conclusion About 1 in 8 patients do not use their referral. These patients may not receive adequate care. Demographic and socio-economic factors appear to affect compliance. The results of this study may be used to make general practitioners more aware that some patients are more likely to be noncompliant with referrals.
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Affiliation(s)
- Christel E van Dijk
- NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands.
| | - Judith D de Jong
- NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands.
| | - Robert A Verheij
- NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands.
| | - Tessa Jansen
- NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands.
| | - Joke C Korevaar
- NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands.
| | - Dinny H de Bakker
- NIVEL, Netherlands Institute for Health Services Research, P.O.Box 1568, , 3500 BN,, Utrecht, The Netherlands.
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