Shelley Farrar

Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis

Objective To examine whether the introduction of payment by results (a fixed tariff case mix based payment system) was associated with changes in key outcome variables measuring volume, cost, and quality of care between 2003/4 and 2005/6. Setting Acute care hospitals in England. Design Difference-in-differences analysis (using a control group created from trusts in England and providers in Scotland not implementing payment by results in the relevant years); retrospective analysis of patient level secondary data with fixed effects models. Data sources English hospital episode statistics and Scottish morbidity records for 2002/3 to 2005/6. Main outcome measures Changes in length of stay and proportion of day case admissions as a proxy for unit cost; growth in number of spells to measure increases in output; and changes in in-hospital mortality, 30 day post-surgical mortality, and emergency readmission after treatment for hip fracture as measures of impact on quality of care. Results Length of stay fell more quickly and the proportion of day cases increased more quickly where payment by results was implemented, suggesting a reduction in the unit costs of care associated with payment by results. Some evidence of an association between the introduction of payment by results and growth in acute hospital activity was found. Little measurable change occurred in the quality of care indicators used in this study that can be attributed to the introduction of payment by results. Conclusion Reductions in unit costs may have been achieved without detrimental impact on the quality of care, at least in as far as these are measured by the proxy variables used in this study.

Using discrete choice modelling in priority setting: an application to clinical service developments.

Limited resources for health care means that techniques are required to aid the process of priority setting. This paper represents one of the first attempts to use discrete choice modelling (DCM) within the area of priority setting. It is shown how the technique can be used to estimate cost per unit of benefit ratios for competing clinical service developments. Integer programming is proposed as a method to be used, alongside DCM, to help policy makers select the optimal combination of clinical service developments within a given budget. The technique is also shown to be internally valid and internally consistent. It is argued that DCM is a potentially useful technique to be used within the area of priority setting more generally. However, further work is required to address methodological issues around the technique.

Assessing community values in health care: Is the ‘Willingness to pay’ method feasible?

In this paper an economics approach to assessing community values in health care priority setting is examined. The approach is based on the concept of ‘willingness to pay’ (WTP). Eighty two parents were interviewed with regard to three aspects of provision of child health services. For each aspect a choice of two courses of action was presented. Parents were asked which course of action they preferred and what was the maximum amount of money they would be prepared to pay for this rather than their less preferred option. WTP responses are acceptable to the majority of respondents and appear to ‘behave’ in accordance witha priori expectations. A method of assessing the influence of ability to pay on preferences and WTP is outlined. Preferences and WTP do not appear to have been unduly distorted by ability to pay. Use of WTP data does have the potential to provide health care purchasers and providers with information on intensity as well as direction of the preferences of members of the community.

Response-ordering effects: a methodological issue in conjoint analysis

Conjoint analysis is a technique relatively new to the evaluation of health care services in the UK. The technique uses data generated from questionnaires. This paper addresses the issue of response-ordering effects that may result from the ordering of dimensions of benefit within a question. Two questionnaires were given to 216 hospital consultants as part of a priority setting exercise. These were identical other than the ordering of the dimensions within each question. The regression analysis was segmented according to questionnaire type and the coefficients of the segmentation were tested for statistically significant differences. The results show no evidence of ordering effects.

Needs assessment: developing an economic approach

Health authorities and health boards in the UK are required under the provisions of the NHS Act, 1990, to assess the needs of their resident populations for health care and, through contracting, to act as purchasers of services informed by those needs. This paper presents an economic approach to informing the purchaser on priority setting for contracting. For illustrative purposes, the technique is applied to services for elderly people with dementia. The paper demonstrates that an economic approach to needs assessment is both desirable and practicable.

Tackling Alcohol Misuse Purchasing Patterns Affected by Minimum Pricing for Alcohol

BackgroundAlcohol consumption is associated with a range of health and social harms that increase with the level of consumption. Policy makers are interested in effective and cost-effective interventions to reduce alcohol consumption and associated harms. Economic theory and research evidence demonstrate that increasing price is effective at the population level. Price interventions that target heavier consumers of alcohol may be more effective at reducing alcohol-related harms with less impact on moderate consumers. Minimum pricing per unit of alcohol has been proposed on this basis but concerns have been expressed that ‘moderate drinkers of modest means’ will be unfairly penalized. If those on low incomes are disproportionately affected by a policy that removes very cheap alcohol from the market, the policy could be regressive. The effect on households’ budgets will depend on who currently purchases cheaper products and the extent to which the resulting changes in prices will impact on their demand for alcohol. This paper focuses on the first of these points.ObjectiveThis paper aims to identify patterns of purchasing of cheap off-trade alcohol products, focusing on income and the level of all alcohol purchased.MethodThree years (2006–08) of UK household survey data were used. The Expenditure and Food Survey provides comprehensive 2-week data on household expenditure. Regression analyses were used to investigate the relationships between the purchase of cheap off-trade alcohol, household income levels and whether the household level of alcohol purchasing is categorized as moderate, hazardous or harmful, while controlling for other household and non-household characteristics. Predicted probabilities and quantities for cheap alcohol purchasing patterns were generated for all households.ResultsThe descriptive statistics and regression analyses indicate that low-income households are not the predominant purchasers of any alcohol or even of cheap alcohol. Of those who do purchase off-trade alcohol, the lowest income households are the most likely to purchase cheap alcohol. However, when combined with the fact that the lowest income households are the least likely to purchase any off-trade alcohol, they have the lowest probability of purchasing cheap off-trade alcohol at the population level. Moderate purchasing households in all income quintiles are the group predicted as least likely to purchase cheap alcohol. The predicted average quantity of low-cost off-trade alcohol reveals similar patterns.ConclusionThe results suggest that heavier household purchasers of alcohol are most likely to be affected by the introduction of a ‘minimum price per unit of alcohol’ policy. When we focus only on those households that purchase off-trade alcohol, lower income households are the most likely to be affected. However, minimum pricing in the UK is unlikely to be significantly regressive when the effects are considered for the whole population, including those households that do not purchase any off-trade alcohol. Minimum pricing will affect the minority of low-income households that purchase off-trade alcohol and, within this group, those most likely to be affected are households purchasing at a harmful level.

Activity-based funding for National Health Service hospitals in England: managers’ experience and expectations

Activity-based funding of hospital services has been introduced progressively since 2003 in the National Health Service (NHS) in England, under the name ‘Payment by Results’ (PbR). It represents a major change from previous funding arrangements based on annual “block” payments for large bundles of services. We interviewed senior local NHS managers about their experience and expectations of the impact of PbR. A high degree of ‘NHS solidarity’ was apparent, and competition between NHS hospitals was muted. PbR has been introduced against a background of numerous other efficiency incentives, and managers did not detect a further PbR-specific boost to efficiency. No impact on care quality, either positive or negative, is yet evident.

The push me, pull you of financial incentives and health inequalities: a mixed methods study investigating smoking cessation in pregnancy and breastfeeding

Abstract Background Financial incentives are increasingly considered to address socially patterned behaviours like smoking in pregnancy and breastfeeding. We investigated their mechanisms of action in relation to health inequalities to inform incentive intervention design. Methods The evidence syntheses we undertook were incentive effectiveness, delivery processes, barriers and facilitators to smoking cessation in pregnancy and also breastfeeding; and incentives for lifestyle behaviours. We searched Medline, Embase, CINAHL, PsycINFO, Web of Science, the Cochrane Library (all sections), MIDIRS, ASSIA, and the Trials Register of Promoting Health Interventions for studies published in English between Jan 1, 1990, and March 31, 2012, using a range of natural language, MeSH, and other index terms. Surveys were done with 1144 respondents from the general public and with 497 maternity and early-years health professionals. Qualitative interviews and focus groups were conducted with pregnant women, recent mothers, and partners in three UK settings (n=88); and with 53 service providers, 24 experts and decision makers, and 63 conference attendees. A discrete choice experiment (DCE) was conducted with 320 female current or ex-smokers. Findings Systematic reviews raised concerns about the reach of incentives, particularly to marginalised groups. Baseline characteristics for people who were eligible, approached, and recruited to studies were under-reported. Sample sizes were mostly small. Surveys revealed mixed acceptability. Less educated, white British, and women general public respondents disagreed (odds ratios [OR] 0·5≤OR Interpretation Financial incentives can help some women, but whether they will address inequalities is unclear because of concerns about reach and resistance to being pushed and pulled. Funding The project was funded by the Health Technology Assessment programme (10/31/02) and will be published in full in Health Technology Assessment . The Chief Scientist Office of the Scottish Government Health and Social Care Directorates funds the Nursing Midwifery and Allied Health Professional Research Unit, University of Stirling; and the Health Services Research Unit and the Health Economics Research Unit, University of Aberdeen.

Incentive interventions for smoking cessation in pregnancy: a mixed methods evidence synthesis

Abstract Background Incentives for smoking cessation in pregnancy are attractive to policy makers because evidence of effectiveness for other interventions is scarce. Our aims were to establish the effectiveness of incentive interventions delivered within or outside the NHS to individuals, families, or organisations that are designed to increase and sustain smoking cessation in pregnancy; investigate how incentive delivery processes work, their acceptability, and how they fit with existing barriers, facilitators, and intrinsic and extrinsic motivators to behaviour change; and work in partnership with mother-and-baby groups to inform the design of incentive trials. Methods This study combines a mixed methods evidence synthesis with primary qualitative and survey research to investigate the perspectives of service users, care providers, the general public, experts, and policy makers. Uniquely, two mother-and-baby groups in areas serving disadvantaged populations in Aberdeen and Blackpool, UK, are study coapplicants, and are providing broad, dynamic, and longitudinal service-user contributions. Researchers attend mother-and-baby groups every 4–6 weeks to feedback findings from evidence synthesis, and record and transcribe discussions of included studies that will iteratively inform future qualitative data collection and analysis, guided by a grounded theory approach. Evidence synthesis follows Cochrane guidance. Detailed searches were done in Medline, Medline-in-Process, Embase, CINAHL, PsycINFO, Web of Science, CENTRAL, Cochrane Database of Systematic Reviews, DARE, HTA, MIDIRS, Applied Social Sciences Index and Abstracts, and the Trials Register of Promoting Health Interventions. 1469 abstracts were identified and 215 full-text reports were screened by two researchers. 21 studies—20 incentivising individuals, one incentivising an organisation—were included in quantitative data analysis and quality assessed with instruments such as Cochrane Risk of Bias and guidance from the Centre for Reviews and Dissemination (dependent on whether the population was randomised). All studies and one survey of attitudes to incentives were included in the delivery processes evidence synthesis, with quality assessment with a Mixed Methods Appraisal Tool. Therefore, one mixed methods coding and data extraction form (MMF) was designed iteratively through piloting with four information-rich studies with form modification after discussion between quantitative and qualitative team members. Quantitative data were extracted from full texts and crosschecked by a second reviewer. Two qualitative researchers independently identified themes that were coded by one with the MMF, with a sample crosschecked by the second. Interpretive themes emerged through discussion and a final thematic framework incorporating continuing service user perspectives is under construction, assisted by NVivo 9 data management software. Findings Incentive interventions identified were multifaceted. 14 (70%) of the 20 patient-level studies verified smoking cessation biochemically rather than relying on self-report. Incentives ranged from four packets of gum to larger incentives—eg, US

Intervention vignettes as a qualitative tool to refine complex intervention design

50 per month of abstinence. Incentives were often combined with additional smoking cessation components, with varying intensity: 13 (65%) included counselling or behavioural support, 13 (65%) included self-help guides or educational materials, six (30%) included advice to quit, and six (30%) involved social support (eg, including partners or peers) through education materials or encouragement. Few studies were directly comparable, with only four suitable for inclusion in a formal meta-analysis. The relative risk of cessation was 2·77 (95% CI 1·69–4·24), indicating that incentives were effective. Several key themes emerge for delivery processes and acceptability: individual or relational focus; certain or lottery incentives; hedonic or utilitarian incentives; programme bureaucracy meeting chaotic lifestyles; health professional or independent providers; continuity of care; and targeted interventions. Interpretation Incentives show promise for smoking cessation in pregnancy and contextual factors probably moderate effectiveness. Funding Project funded by the HTA programme (10/31/02) and will be published in full in Health Technology Assessment .