Mark Dusheiko

Impact of case management (Evercare) on frail elderly patients: controlled before and after analysis of quantitative outcome data

Objectives To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people. Design Practice level before and after analysis of hospital admissions data with control group. Setting Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission. Main outcome measures Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out). Results The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval −5.7% to 38.7%), emergency bed days (increase 19.0%, −5.3% to 43.2%), and mortality (increase 34.4%, −1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged ≥65 effects on the rates of emergency admission (increase 2.5%, −2.1% to 7.0%), emergency bed days (decrease −4.9%, −10.8% to 1.0%), and mortality (increase 5.5%, −3.5% to 14.5%) were also non-significant. Conclusions Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.

Follow up of people aged 65 and over with a history of emergency admissions: analysis of routine admission data

Abstract Objective To determine the subsequent pattern of emergency admissions in older people with a history of frequent emergency admissions. Design Analysis of routine admissions data from NHS hospitals using hospital episode statistics (HES) in England. Subjects Individual patients aged  65,  75, and  85 who had at least two emergency admissions in 1997-8. Main outcome measures Emergency admissions and bed use in this “high risk” cohort of patients were counted for the next five years and compared with the general population of the same age. No account was taken of mortality as the analysis was designed to estimate the future use of beds in this high risk cohort. Results Over four to five years, admission rates and bed use in the high risk cohorts fell to the mean rate for older people. Although patients  65 with two or more such admissions were responsible for 38% of admissions in the index year, they were responsible for fewer than 10% of admissions in the following year and just over 3% five years later. Conclusion Patients with multiple emergency admissions are often identified as a high risk group for subsequent admission and substantial claims are made for interventions designed to avoid emergency admission in such patients. Simply monitoring admission rates cannot assess interventions designed to reduce admission among frail older people as rates fall without any intervention. Comparison with a matched control group is necessary. Wider benefits than reduced admissions should be considered when introducing intensive case management of older people.

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study

Objective To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs). Design Controlled longitudinal study. Setting English National Health Service between 1998/99 and 2010/11. Participants Populations registered with each of 6975 family practices in England. Main outcome measures Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs. Results Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11. Conclusions The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

Does Higher Quality of Diabetes Management in Family Practice Reduce Unplanned Hospital Admissions

OBJECTIVE To investigate the association between indicators of quality of diabetic management in English family practices and emergency hospital admissions for short-term complications of diabetes. STUDY SETTING A total of 8,223 English family practices from 2001/2002 to 2006/2007. STUDY DESIGN Multiple regression analyses of associations between admissions and proportions of practice diabetic patients with good (glycated hemoglobin [HbA1c] ≤7.4 percent) and moderate (7.4 percent <HbA1c ≤10 percent) glycemic control. Covariates included diabetes prevalence, baseline admission rates, socioeconomic, demographic, and geographic characteristics. DATA Practice quality measures extracted from practice records linked with practice-level hospital admissions data and practice-level covariates data. PRINCIPAL FINDINGS Practices with 1 percent more patients with moderate rather than poor glycemic control on average had 1.9 percent (95 percent CI: 1.1-2.6 percent) lower rates of emergency admissions for acute hyperglycemic complications. Having more patients with good rather than moderate control was not associated with lower admissions. There was no association of moderate or good control with hypoglycemic admissions. CONCLUSION Cross-sectionally, family practices with better quality of diabetes care had fewer emergency admissions for short-term complications of diabetes. Over time, after controlling for national trends in admissions, improvements in quality in a family practice were associated with a reduction in its admissions.

A person based formula for allocating commissioning funds to general practices in England: development of a statistical model.

Objectives To develop a formula for allocating resources for commissioning hospital care to all general practices in England based on the health needs of the people registered in each practice Design Multivariate prospective statistical models were developed in which routinely collected electronic information from 2005-6 and 2006-7 on individuals and the areas in which they lived was used to predict their costs of hospital care in the next year, 2007-8. Data on individuals included all diagnoses recorded at any inpatient admission. Models were developed on a random sample of 5 million people and validated on a second random sample of 5 million people and a third sample of 5 million people drawn from a random sample of practices. Setting All general practices in England as of 1 April 2007. All NHS inpatient admissions and outpatient attendances for individuals registered with a general practice on that date. Subjects All individuals registered with a general practice in England at 1 April 2007. Main outcome measures Power of the statistical models to predict the costs of the individual patient or each practice’s registered population for 2007-8 tested with a range of metrics (R2 reported here). Comparisons of predicted costs in 2007-8 with actual costs incurred in the same year were calculated by individual and by practice. Results Models including person level information (age, sex, and ICD-10 codes diagnostic recorded) and a range of area level information (such as socioeconomic deprivation and supply of health facilities) were most predictive of costs. After accounting for person level variables, area level variables added little explanatory power. The best models for resource allocation could predict upwards of 77% of the variation in costs at practice level, and about 12% at the person level. With these models, the predicted costs of about a third of practices would exceed or undershoot the actual costs by 10% or more. Smaller practices were more likely to be in these groups. Conclusions A model was developed that performed well by international standards, and could be used for allocations to practices for commissioning. The best formulas, however, could predict only about 12% of the variation in next year’s costs of most inpatient and outpatient NHS care for each individual. Person-based diagnostic data significantly added to the predictive power of the models.

The demand for elective surgery in a public system: time and money prices in the UK National Health Service

We construct a model of the admission process for patients from general practices for elective surgery in the UK National Health Service. Public patients face a positive waiting time, but a zero money price. Fundholding practices faced a positive money price for each patient admitted. The model is tested with data on general practice admission rates for cataract procedures in an English Health Authority. Admission rates are negatively related to waiting times and distance to hospital. Practices respond to financial incentives as predicted by the model: fundholding practices have lower admission rates than non-fundholders and respond differently to changes in waiting times and patient characteristics.

Does better disease management in primary care reduce hospital costs? Evidence from English primary care.

We apply cross-sectional and panel data methods to a database of 5 million patients in 8000 English general practices to examine whether better primary care management of 10 chronic diseases is associated with reduced hospital costs. We find that only primary care performance in stroke care is associated with lower hospital costs. Our results suggest that the 10% improvement in the general practice quality of stroke care between 2004/5 and 2007/8 reduced 2007/8 hospital expenditure by about £130 million in England. The cost savings are due mainly to reductions in emergency admissions and outpatient visits, rather than to lower costs for patients treated in hospital or to reductions in elective admissions.

Socioeconomic inequality in small area use of elective total hip replacement in the English National Health Service in 1991 and 2001

Objectives To compare socioeconomic inequality in small area use of elective total hip replacement in the English National Health Service (NHS) in 1991 and 2001. Methods Hospital Episode Statistics and Census data were aggregated to a common geography of ‘frozen’ 1991 English electoral wards. The Townsend deprivation score was used as the primary indicator of socioeconomic status for each ward, and the sensitivity analysis used other Census indicators. Two main measures of inequality were examined: the indirectly age-sex standardized utilization rate ratio between most and least deprived quintile groups, and the concentration index of deprivation-related inequality in age-sex standardized utilization ratios between small areas. Each standardized utilization ratio is the observed use divided by the expected use, if each age and sex group in the study population had the same use rate as the national population. Results In both years, observed use was below expected use for the bottom third of areas by socioeconomic status. The standardized utilization rate ratio between top and bottom Townsend quintiles fell from 1.41 (95% confidence interval [CI] 1.36-1.47) in 1991 to 1.27 (95% CI 1.23-1.32) in 2001. The proportionate increase in use required to bring the bottom quintile to the level of top thus fell significantly from 41% to 27%. The Town-send-based concentration index also fell from 0.069 (95% CI 0.059-0.079) in 1991 to 0.060 (95% CI 0.050-0.071) in 2001, although this fall was not statistically significant (P=0.085). Other socioeconomic indicators yielded a similar pattern. Conclusions Socioeconomic small area inequality in use of total hip replacement appears to have fallen between 1991 and 2001. One possible explanation is that increased hip replacement rates in the 1990s may have lowered barriers to access, thus allowing this health technology to diffuse further among lower socio-economic groups.

Effects of the Blair/Brown NHS Reforms on Socioeconomic Equity in Health Care

The central objectives of the ‘Blair/Brown’ reforms of the English NHS in the 2000s were to reduce hospital waiting times and improve the quality of care. However, critics raised concerns that the choice and competition elements of reform might undermine socioeconomic equity in health care. By contrast, the architects of reform predicted that accelerated growth in NHS spending combined with increased patient choice of hospital would enhance equity for poorer patients. This paper draws together and discusses the findings of three large-scale national studies designed to shed empirical light on this issue. Study one developed methods for monitoring change in neighbourhood level socioeconomic equity in the utilization of health care, and found no substantial change in equity between 2001-02 and 2008-09 for non-emergency hospital admissions, outpatient admissions (from 2004-05) and a basket of specific hospital procedures (hip replacement, senile cataract, gastroscopy and coronary revascularization). Study two found that increased competition between 2003-04 and 2008-09 had no substantial effect on socioeconomic equity in health care. Study three found that potential incentives for public hospitals to select against socioeconomically-disadvantaged hip replacement patients were small, compared with incentives to select against elderly and co-morbid patients. Taken together, these findings suggest that the Blair/Brown reforms had little effect on socioeconomic equity in health care. This may be because the ‘dose’ of competition was small and most hospital services continued to be provided by public hospitals which did not face strong incentives to select against socioeconomically-disadvantaged patients.

Quality of Disease Management and Risk of Mortality in English Primary Care Practices

OBJECTIVE To investigate whether better management of chronic conditions by family practices reduces mortality risk. DATA Two random samples of 5 million patients registered with over 8,000 English family practices followed up for 4 years (2004/5-2007/8). Measures of the quality of disease management for 10 conditions were constructed for each family practice for each year. The outcome measure was an indicator taking the value 1 if the patient died during a specified year, 0 otherwise. STUDY DESIGN Cross-section and multilevel panel data multiple logistic regressions were estimated. Covariates included age, gender, morbidity, hospitalizations, attributed socio-economic characteristics, and local health care supply measures. PRINCIPAL FINDINGS Although a composite measure of the quality of disease management for all 10 conditions was significantly associated with lower mortality, only the quality of stroke care was significant when all 10 quality measures were entered in the regression. CONCLUSIONS The panel data results suggest that a 1 percent improvement in the quality of stroke care could reduce the annual number of deaths in England by 782 [95 percent CI: 423, 1140]. A longer study period may be necessary to detect any mortality impact of better management of other conditions.