Primary Care Costs Research Articles

Job satisfaction of public and private primary care physicians in Malaysia: analysis of findings from QUALICO-PC

BackgroundJob satisfaction of doctors is an important factor determining quality and performance of a health system. The aim of this study was to assess job satisfaction among doctors of the public and private primary care clinics in Malaysia and evaluate factors that could influence the job satisfaction rating.MethodsThis study was part of the Quality and Costs of Primary Care (QUALICOPC) Malaysia, a cross-sectional survey conducted between August 2015 and June 2016 in Malaysia. Data was collected from doctors recruited from public and private primary care clinics using a standardised questionnaire. Comparisons were made between doctors working in public and private clinics, and logistic regression analysis was used to determine factors influencing the likelihood of job satisfaction outcomes.ResultsA total of 221 doctors from the public and 239 doctors from the private sector completed the questionnaire. Compared to private doctors, a higher proportion of public doctors felt they were being overloaded with the administrative task (59.7% vs 36.0%) and part of the work does not make sense (33.9% vs 18.4%). Only 62.9% of public doctors felt that there was a good balance between effort and reward while a significantly higher proportion (85.8%) of private doctors reported the same. Over 80% of doctors in both sectors indicated continued interest in their job and agreed that being a doctor is a well-respected job. Logistic regression analysis showed public-private sector and practice location (urban-rural) to be significantly associated with work satisfaction outcomes.ConclusionA higher proportion of public doctors experienced pressure from administrative tasks and felt that part of their work does not make sense than their colleague in the private sector. At the same time, the majority of private doctors reported positive outcome on effort-and-reward balance compared to only one third of public doctors. The finding suggests that decreasing administrative workload and enhancing work-based supports might be the most effective ways to improve job satisfaction of primary care doctors because these are some of the main aspects of the job that doctors, especially in public clinics, are most unhappy with.

PMH47 THE IMPACT OF A DIGITAL SLEEP-IMPROVEMENT PROGRAM ON HEALTH CARE COSTS

Access to non-pharmacological interventions for insomnia is limited, despite evidence for their effectiveness. This is due in part to a shortage of trained providers. Digital cognitive behavioural therapy for insomnia (dCBT-I), which requires less input per session, is therefore an attractive complement or substitute to face-to-face cognitive behavioural therapy. Sleepio is a self-help programme for sleep improvement, which has been shown to improve sleep quality. However, there is little evidence available regarding its impact on health care use. In this study, we sought to identify whether providing access to Sleepio results in a change in the trend of patients' primary care costs. The study adopted a before and after quasi-experimental design alongside population-wide rollout of Sleepio in a region of England. A segmented regression analysis of the interrupted time series data was used to estimate the change in trend of the average primary care costs per patient per week. Data were collected from two sources: i) primary care providers, and ii) Sleepio user data collected through the app. Interim results are presented, based on data from 12 months pre-intervention (October 2017) to 6 months post-intervention (May 2019). More than 6,000 individuals used the Sleepio service, with around a third converting to dCBT-I and gaining 30 minutes extra sleep per night, on average. Of dCBT-I users within the clinical range on the Sleep Condition Indicator, 42% moved to a non-clinical range. Preliminary results show that people with a diagnosis of insomnia who were referred to Sleepio had a lower rate of hospital referrals and hypnotics prescriptions. Interim findings show that population rollout of Sleepio may be effective in improving sleep for people with clinically significant sleep problems, and that this is associated with changes in health service use that may be cost-saving.

PND60 HEALTH CARE RESOURCE UTILIZATION AND DIRECT MEDICAL COSTS AMONG PATIENTS WITH INCIDENT MIGRAINE INITIATING TREATMENT - A COHORT STUDY USING THE CLINICAL PRACTICE RESEARCH DATALINK

Migraine is estimated to affect 7.6% of men and 18.3% of women in England. We evaluated health care resource use (HCRU) and costs in primary and secondary care among patients with an incident diagnosis of migraine. An observational study of migraine patients ≥18 years of age with primary care data linked to Hospital Episode Statistics data during 01/01/2015 - 31/12/2015. Annual HCRU and associated costs (reported in 2015 GBP (£)) were assessed 12-months post-index diagnosis. Direct HCRU included primary care visits, referrals to secondary care, inpatient, outpatient and emergency visits and migraine prescribing in primary care. Migraine prescribing was categorised as none, acute only, prophylactic only, acute and prophylactic. HCRU was estimated as consultation rates/person-year and 95% confidence intervals and mean costs were calculated. Cost data was obtained from National Health Service tariff data. 2,859 patients were included (mean age 40, females 76.6%). Patients made an average of 13.21 primary care visits, 2.16 outpatient attendances and were hospitalized 0.33 times for any cause. HCRU tended to be higher among females, patients ≥40 years old and those prescribed prophylactic treatment (about 11 prescriptions/year). Average migraine related visits in primary and secondary care was about 1.5 visits/person. Direct annual expenditure was approximately £4.21M of which £650K comprised of GP and nursing costs and £1.18M was due to hospitalizations (over 15% of hospitalisation costs was due to migraine). Migraine prescribing accounted for about £1.35M with the mean annual cost of prophylactic therapy being about £970 per person in contrast to £36.27/person for acute treatment (mean of 3.67 prescriptions/year). Female patients with incident migraine, older age groups, and patients prescribed prophylactic treatment had higher HCRU and economic burden 12 months following diagnosis. Further research is needed to optimise treatment for newly diagnosed migraine patients to improve clinical and economic outcomes.

Fixed Versus Free Combinations Of Antihypertensive Drugs: Analyses Of Real-World Data Of Persistence With Therapy In Italy.

PurposeTo analyse the pattern of use and cost of antihypertensive drugs in new users in an Italian population, and explore the patient/treatment factors associated with the risk of therapy discontinuation.Patients and methodsIn this retrospective study, information was collected from a population-based electronic primary-care database. Persistence with medication use 1 year from therapy initiation was evaluated for each user using the gap method. Each new user was classified according to his/her pattern of use as: “continuer”, “discontinuer” “switching” or “add-on”. A Cox regression model was used to analyse the factors influencing therapy discontinuation. Primary-care costs comprised specialists’ visits, diagnostic procedures and pharmacologic therapies.ResultsAmong 14,999 subjects included in persistence analyses, 55.1% of cases initially started on monotherapy were classified as discontinuers vs 36.5% of cases taking combination therapy (42.3% vs 32.7%, respectively, for free and fixed combinations, P < 0.01). Old age, high cardiovascular risk and being in receipt of fixed-combination therapy were associated with greater persistence. Overall, the primary-care cost/person/year of hypertension management was ~€95.3 (IQR, 144.9). The monotherapy cost was €88 per patient (IQR, 132.9), and that for combination therapy was €151±148.3. The median cost/patient with a fixed combination was lower than that for a free combination (€98.4 (IQR, 155.3) and €154.9 (IQR, 182.6), respectively).ConclusionThe initial type of therapy prescribed influences persistence. Prescribing fixed combinations might be a good choice as initial therapy.

Primary Health Care in the World: Results of the 40-year Implementation of the Almaty Declaration (1978) and Future Development According to the Astana Declaration (2018)

The article presents the results of the development of primary health care from the aprovement of the Almaty Declaration in 1978 to the signing of the Astana Declaration of 2018. It is emphasized that despite the actions taken, the pace of development and strengthening of primary health care is unsatisfactory, which is confirmed by numerous reports. According to reports of World Health Organization 50% of the world’s population still partially or completely do not have access to basic medical services, including treatment and prevention of infectional and non-communicable diseases, reproductive health, protection of women and children’s health. Taken into accaunt the current situation, WHO held the Global Conference on Primary Health Care, where the reports from world leaders and ministries on this issue were represented. The article discribes the generalized results in the development of primary care in the world according to the submitted reports. It is emphasized that in some countries today, the levels, rates of development of PHC and its financing are insufficient. Patients are forced to pay for basic medical services from their own funds. The negative consequences of paying for services from one’s own funds are felt by more people than 15 years ago. About 925 million people spend more than 10% of the income on medical care, and 200 million spend more than 25% of their income on it. At the same time, indicators of impoverishment as a result of payment for medical care increased among all groups of the population, except the extremely poor. WHO sets one of the global health goals for all countries to increase the cost of primary health care by at least 1% of its gross domestic product .The specified goals, principles and objectives of the PHC that WHO sets for the future are detailed. The full text of the Astana Declaration 2018 is given. The role and participation of the World Association of Family Doctors (Wonca) and Ukraine are described. In general, primary health care has been and will be at the forefront of the world’s health systems priorities, its further development and strengthening is a priority task posed by the World Health Organization for all countries of the world, which will lead to the protection and strengthening of the health of all people, the formation of effective affordable health care for all.

A "U-shaped" Curve: Appreciating How Primary Care Residency Intention Relates to the Cost of Board Preparation and Examination.

Introduction: The shortage of primary care physicians in the United States has warranted an investigation into how medical education debt and other factors influence medical students’ interests in primary care (PC) residencies. However, sparse research has studied how the cost of board preparation and examination relates to career choice. The objective of this study was to determine if there is an association between the cost of preparing and sitting for board examinations and the intention to enter a PC residency for osteopathic medical students.Methods: We postulated that students who incurred higher financial costs from preparing and sitting for board examinations would be more likely to be interested in non-primary care (NPC) residencies. Using a non-experimental survey design, this study asked respondents to evaluate the following: “I plan to enter a Primary Care Residency (Family Medicine OR General Internal Medicine OR Pediatrics)” using a Likert scale. Respondents were also asked to select which board examination(s) and pertinent resource(s) they had purchased. Total costs were calculated per student.Results: A total of 25,852 osteopathic medical students received the survey, of which 1,280 students responded to and completed it, yielding a 4.95% response rate. The distribution of respondents’ intentions to pursue a primary care residency and costs spent yielded a “U” shaped curve. Respondents who Strongly Agreed and Strongly Disagreed to the statement “I plan to enter a Primary Care Residency” spent $5,744 and $5,070 on board-preparation and examination, respectively. No statistically significant differences were found between the cost of preparing and sitting for board examinations and the intention to enter primary care residencies when individuals were grouped by year in school and gender.Conclusions: Because competitive NPC specialties have relatively higher salaries, we suspected that students who intended to pursue these specialties would have had higher financial costs from board examination and preparation compared to students who intended to pursue PC residencies such as family medicine. Our findings further illustrate these specific educational costs do not correlate with students’ stated intentions to enter primary care residencies. As efforts continue to determine a solution for the primary care physician shortage, it becomes clearer that the focus must also encompass non-financial influences that shape career choice.

Case Identification and Characterization of Autistic Young Adults in 2010 Medicare Fee-for-Service Claims.

Medicare is a public insurer for whom many autistic adults are eligible in the United States, but little is known about autistic beneficiaries who are covered. A challenge in using claim data is identification of autism spectrum disorder (ASD) cases to ensure accurate characterization. Some work suggests that relying on one claim could identify probable ASD, although other works indicate that two claims are necessary for case identification. The purpose of the current study was to describe the sample of Medicare young adult beneficiaries, and determine whether using a 1+ versus 2+ claim case identification resulted in similar interpretation of sample demographic characteristics and primary care utilization patterns in Medicare professional service claims. We used Medicare Limited Data Sets (2008-2010) claims. After ASD case identification using ICD-9-CM (299.xx), 527 unique beneficiaries in the last claim year of 2010 professional service file were identified as having at least one claim of ASD. Of these, 69% (n = 364) had two or more claims. Proportions and zero-inflated negative binomial regression were used to examine differences in demographic characteristics and primary care utilization and costs for the 1+ and 2+ samples. Medicare claims contain a sample of autistic adults with expected demographics identified in historic prevalence cohorts. No differences in age, gender, race/ethnicity, Hispanic status, or dual-eligibility months or Adjusted Clinical Groups (ACG)® concurrent risk scores were identified between the 1+ and 2+ samples. No difference was found in the overall estimation of primary care use or costs between the 1+ and 2+ samples based on Zellner's seemingly unrelated regression methods. This study is the first to describe a national sample of Medicare-insured autistic adults. We found that using a 1+ case identification results in a sample that is demographically similar to a 2+ claim sample, and produces similar estimates of utilization as a 2+ claim sample.

Robotic-assisted surgery compared with laparoscopic resection surgery for rectal cancer: the ROLARR RCT

Background Robotic rectal cancer surgery is gaining popularity, but there are limited data about its safety and efficacy. Objective To undertake an evaluation of robotic compared with laparoscopic rectal cancer surgery to determine its safety, efficacy and cost-effectiveness. Design This was a multicentre, randomised trial comparing robotic with laparoscopic rectal resection in patients with rectal adenocarcinoma. Setting The study was conducted at 26 sites across 10 countries and involved 40 surgeons. Participants The study involved 471 patients with rectal adenocarcinoma. Recruitment took place from 7 January 2011 to 30 September 2014 with final follow-up on 16 June 2015. Interventions Robotic and laparoscopic rectal cancer resections were performed by high anterior resection, low anterior resection or abdominoperineal resection. There were 237 patients randomised to robotic and 234 to laparoscopic surgery. Follow-up was at 30 days, at 6 months and annually until 3 years after surgery. Main outcome measures The primary outcome was conversion to laparotomy. Secondary end points included intra- and postoperative complications, pathological outcomes, quality of life (QoL) [measured using the Short Form questionnaire-36 items version 2 (SF-36v2) and the Multidimensional Fatigue Inventory-20 (MFI-20)], bladder and sexual dysfunction [measured using the International Prostatic Symptom Score (I-PSS), the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI)], and oncological outcomes. An economic evaluation considered the costs of robotic and laparoscopic surgery, including primary and secondary care costs up to 6 months post operation. Results Among 471 randomised patients [mean age 64.9 years, standard deviation (SD) 11.0 years; 320 (67.9%) men], 466 (98.9%) patients completed the study. Data were analysed on an intention-to-treat basis. The overall rate of conversion to laparotomy was 10.1% and occurred in 19 (8.1%) patients in the robotic-assisted group and in 28 (12.2%) patients in the conventional laparoscopic group {unadjusted risk difference 4.12% [95% confidence interval (CI) –1.35% to 9.59%], adjusted odds ratio 0.61 [95% CI 0.31 to –1.21]; p = 0.16}. Of the nine prespecified secondary end points, including circumferential resection margin positivity, intraoperative complications, postoperative complications, plane of surgery, 30-day mortality and bladder and sexual dysfunction, none showed a statistically significant difference between the groups. No difference between the treatment groups was observed for longer-term outcomes, disease-free and overall survival (OS). Males were at a greater risk of local recurrence than females and had worse OS rates. The costs of robotic and laparoscopic surgery, excluding capital costs, were £11,853 (SD £2940) and £10,874 (SD £2676) respectively. Conclusions There is insufficient evidence to conclude that robotic rectal surgery compared with laparoscopic rectal surgery reduces the risk of conversion to laparotomy. There were no statistically significant differences in resection margin positivity, complication rates or QoL at 6 months between the treatment groups. Robotic rectal cancer surgery was on average £980 more expensive than laparoscopic surgery, even when the acquisition and maintenance costs for the robot were excluded. Future work The lower rate of conversion to laparotomy in males undergoing robotic rectal cancer surgery deserves further investigation. The introduction of new robotic systems into the market may alter the cost-effectiveness of robotic rectal cancer surgery. Trial registration Current Controlled Trials ISRCTN80500123. Funding This project was funded by the Efficacy and Mechanism Evaluation (EME) programme, a Medical Research Council and National Institute for Health Research (NIHR) partnership, with contributions from the Chief Scientist Office, Scottish Government Health and Social Care Directorate, the Health and Care Research Wales and the Health and Social Care Research and Development Division, Public Health Agency in Northern Ireland. The funders of the study had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; and preparation, review or approval of the manuscript or the decision to submit for publication. The project will be published in full in Efficacy and Mechanism Evaluation; Vol. 6, No. 10. See the NIHR Journals Library website for further project information. Philip Quirke and Nicholas West were supported by Yorkshire Cancer Research Campaign and the MRC Bioinformatics initiative. David Jayne was supported by a NIHR Research Professorship.

The Annual Direct and Indirect Health Care Costs for Patients with Chronic Pruritus and their Determining Factors

The Annual Direct and Indirect Health Care Costs for Patients with Chronic Pruritus and their Determining Factors

Abstract SY29-01: The Cancer Tsunami: What is it and what does it mean for survivors, clinicians, and researchers

Abstract We are facing a tsunami of cancer survivors; the majority of whom will be older and longer-term survivors most of whom will also have comorbid illnesses. Care of survivors include surveillance for recurrences and new cancers, management of the sequelae of treatment, and health promotion all requiring care coordination. This session will describe the changes in the number and type of survivors, discuss late and long-term effects of cancer and its treatment on this growing population and focus on the impact in vulnerable populations. Needed research and interventions to address the issues survivors face will be examined. Practice, research and policy issues to address survivors care will be discussed. A Research Roadmap for Equitably Improving Outcomes for Cancer Survivors Cancer care delivery is being shaped by growing numbers of cancer survivors coupled with provider shortages, rising costs of primary treatment and follow-up care, significant survivorship health disparities, increased reliance on informal caregivers, and the transition to value-based care. These factors create a compelling need to provide coordinated, comprehensive, personalized care for cancer survivors in ways that meet survivors’ and caregivers’ unique needs while minimizing the impact of provider shortages and controlling costs for healthcare systems, survivors, and families. These changes involve reforming care delivery, education, and policy to equitably improve survivor outcomes and support caregivers. In Dr. Alfano’s talk, she will focus on three critical research priorities to accelerate these changes including: (1) implementing routine assessment of survivors’ needs and functioning and caregivers’ needs; (2) facilitating personalized, tailored, information and referrals from diagnosis onward for both survivors and caregivers, shifting services from point-of-care to point-of-need wherever possible; and (3) disseminating and supporting the implementation of new care methods and interventions. Opportunities and challenges to address these priorities will be discussed. Survivorship Interventions in Vulnerable Populations: Improving Patient Reported Outcomes Via Technology Based Delivery and Addressing the Sociocultural Context Over the past several decades, advances in early detection and treatment efficacy in oncology patients has led to a growing and unprecedented number of cancer survivors. The cancer survivorship experience can be highly variable based on multiple factors including pre-morbid psychosocial functioning, disease severity, financial and social resources, and treatment-related impairment. Benefits of survivorship can be offset by chronic and debilitating treatment-related side effects, ongoing disease monitoring, financial burden and interpersonal disruption. These challenges are often exacerbated in vulnerable populations (e.g., racial/ethnic minorities, rural communities) due to social and contextual barriers, limited access to care, culturally-driven illness beliefs, and competing demands (e.g., family obligations, financial burden) which collectively can further compromise health-related quality of life and overall psychosocial adjustment. Technological advances have ushered in a new era of technology-driven monitoring and care that can provide feasible, precise, ecologically valid and responsive methods to address the needs of cancer survivors. In this presentation, Dr. Penedo will discuss several studies that are capitalizing on e-Health and m-Health technologies to monitor and reduce symptom burden and improve quality of life and other patient reported outcomes in ethnically/racially diverse prostate cancer survivors and Latina breast cancer survivors. Opportunities and challenges will be discussed. Citation Format: Deborah K. Mayer, Catherine Alfano, Frank Panedo. The Cancer Tsunami: What is it and what does it mean for survivors, clinicians, and researchers [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2019; 2019 Mar 29-Apr 3; Atlanta, GA. Philadelphia (PA): AACR; Cancer Res 2019;79(13 Suppl):Abstract nr SY29-01.

Intelligent liver function testing in UK primary care cost effective

Intelligent liver function testing in UK primary care cost effective

An evidence-based model to consolidate medication adherence cost estimation: the medication adherence cost estimation framework.

Aim: To develop a standardized framework determining the economic impact of medication nonadherence. Materials& methods: Secondary analysis of existing literature reported cost data, aggregating cost outcome indicators. Weighted-average cost analysis performed, determining the proportional contribution to total cost. Results: Direct costs were reported in 92% of studies and indirect costs in 4% of studies. Three most utilized cost categories were hospital (68%), primary care (18%) and pharmacy costs (72%). Average unadjusted direct costs ranged from $625 to $154,203 contributing to 88% of the total cost; adjusted medical costs ranged from $565 to $56,313 representing 96% of the total cost. Conclusion: The medication adherence cost estimation framework enables the comparison of costing studies, facilitating informed health policy decision-making based on consistent evidence and terminology.

Bad Medicine: Advanced practitioners versus doctors.

We don’t have enough doctors. This is odd because we have plenty of applicants, good universities, and the money spent on training is a fraction of the cost incurred by a limited supply. For example, locum costs in primary care are £500 a day and, incredibly, some consultants are being paid £375 000 a year.1 Scarcity is highly profitable. Is this scarcity by intent? An attempt over generations by doctors to maintain high pay and the status of the profession with no care for the negative impact on patients? Consider also if the NHS had more doctors and shorter …

The health service capacity of primary health care in West China: different perspectives of physicians and their patients

BackgroundMany countries, including China, have identified the primary health care system as a reform priority. The purpose of this study is to compare the perceived service capacity of primary care from the perspectives of physicians and their patients in Sichuan province of China.MethodsA cross-sectional survey was conducted through Quality and Costs of Primary Care (QUALICOPC) questionnaires. A representative sample of 319 primary care physicians and 641 patients in 48 primary healthcare settings were recruited to take part in the study.ResultsPhysicians perceived equity of care the best, while quality of care was rated the highest from the perspective of patients. They both regarded coordination as the weakest dimension of primary care service capacity.ConclusionsAlthough primary health care reform may have been effective in helping patients acquire better primary care services, our results suggest that coordination is still perceived to be problematic for both physicians and patients. Improving the coordination of care has to be one of the main goals in the future primary care reforms in China.

Cost of implementing a community-based primary health care strengthening program: The case of the Ghana Essential Health Interventions Program in northern Ghana.

BackgroundThe absence of implementation cost data constrains deliberations on consigning resources to community-based health programs. This paper analyses the cost of implementing strategies for accelerating the expansion of a community-based primary health care program in northern Ghana. Known as the Ghana Essential Health Intervention Program (GEHIP), the project was an embedded implementation science program implemented to provide practical guidance for accelerating the expansion of community-based primary health care and introducing improvements in the range of services community workers can provide.MethodsCost data were systematically collected from intervention and non-intervention districts throughout the implementation period (2012–2014) from a provider perspective. The step-down allocation approach to costing was used while WHO health system blocks were adopted as cost centers. We computed cost without annualizing capital cost to represent financial cost and cost with annualizing capital cost to represent economic cost.ResultsThe per capita financial cost and economic cost of implementing GEHIP over a three-year period was $1.79, and $1.07 respectively. GEHIP comprised only 3.1% of total primary health care cost. Health service delivery comprised the largest component of cost (37.6%), human resources was 28.6%, medicines was 13.6%, leadership/governance was 12.8%, while health information comprised 7.5% of the economic cost of implementing GEHIP.ConclusionThe per capita cost of implementing the GEHIP program was low. GEHIP project investments had a catalytic effect that improved community-based health planning and services (CHPS) coverage and enhanced the efficient use of routine health system resources rather than expanding overall primary health care costs.

Communication, continuity and coordination of care are the most important patients' values for family medicine in a fee-for-services health system

BackgroundRepresenting 60% of medical consultations in Switzerland, primary care holds an important place in our medical system. Patients’ values in family medicine (FM) are nowadays recognized as important factors to take into account in order to provide good quality of care. The aim of this study is to describe patients’ most important values regarding FM and to assess their associations with socio-demographics factors in a fee-for-services health system.MethodsWe analyzed the Swiss 2012 study on Quality and Costs of Primary Care (QUALICOPC). Two-hundred patients, randomly drawn, answered a questionnaire about their values regarding FM just after their consultation. Explored values were related to communication and patient-centeredness care, continuity and coordination, care access, and patients’ activation. We described values reaching more than 50% of “very important”. Then, multivariate analyses were performed for the most important value of each dimension.ResultsItems related to “communication and patient-centeredness care” and “coordination and continuity of care” are the most recurrently mentioned as “very important”. Items related to access and patients’ activation are generally declared as “very important” by less than 50% of patients. Whatever the domain and the item, women systematically grant items more often as “very important” than men. Variations are observed according to the age, and the presence or not of a chronic disease.ConclusionSuch dimensions should be subject to a special attention by general practitioners and public health authorities as it might enhance the quality of care and the patients’ satisfaction.

Cost of Primary Care during Episodes of Child Diarrhoea in Uttar Pradesh

Cost of Primary Care during Episodes of Child Diarrhoea in Uttar Pradesh

Healthcare utilization and cost trajectories post-stroke: role of caregiver and stroke factors

BackgroundIt is essential to study post-stroke healthcare utilization trajectories from a stroke patient caregiver dyadic perspective to improve healthcare delivery, practices and eventually improve long-term outcomes for stroke patients. However, literature addressing this area is currently limited. Addressing this gap, our study described the trajectory of healthcare service utilization by stroke patients and associated costs over 1-year post-stroke and examined the association with caregiver identity and clinical stroke factors.MethodsPatient and caregiver variables were obtained from a prospective cohort, while healthcare data was obtained from the national claims database. Generalized estimating equation approach was used to get the population average estimates of healthcare utilization and cost trend across 4 quarters post-stroke.ResultsFive hundred ninety-two stroke patient and caregiver dyads were available for current analysis. The highest utilization occurred in the first quarter post-stroke across all service types and decreased with time. The incidence rate ratio (IRR) of hospitalization decreased by 51, 40, 11 and 1% for patients having spouse, sibling, child and others as caregivers respectively when compared with not having a caregiver (p = 0.017). Disability level modified the specialist outpatient clinic usage trajectory with increasing difference between mildly and severely disabled sub-groups across quarters. Stroke type and severity modified the primary care cost trajectory with expected cost estimates differing across second to fourth quarters for moderately-severe ischemic (IRR: 1.67, 1.74, 1.64; p = 0.003), moderately-severe non-ischemic (IRR: 1.61, 3.15, 2.44; p = 0.001) and severe non-ischemic (IRR: 2.18, 4.92, 4.77; p = 0.032) subgroups respectively, compared to first quarter.ConclusionHighlighting the quarterly variations, we reported distinct utilization trajectories across subgroups based on clinical characteristics. Caregiver availability reducing hospitalization supports revisiting caregiver’s role as potential hidden workforce, incentivizing their efforts by designing socially inclusive bundled payment models for post-acute stroke care and adopting family-centered clinical care practices.

Resource use and cost of annual health checks in primary care for people with intellectual disabilities.

The annual health check (AHC) programme, as part of a Directed Enhanced Service, offers an incentive to general practitioners in England to conduct health checks for people with intellectual disabilities (IDs). The aim of this analysis was to estimate the impact on health care costs of AHCs in primary care to the National Health Service in England by comparing adults with ID who did or did not have AHCs using data obtained from The Health Improvement Network. Two hundred eight records of people with ID from The Health Improvement Network database were analysed. Baseline health care resource use was captured at the time the first AHC was recorded (i.e. index date), or the earliest date after 1 April 2008 for those without an AHC. We examined the volume of resource use and associated costs that occurred at the time AHCs were performed, as well as before and after the index date. We then estimated the impact of AHCs on health care costs. The average cost of AHC was estimated at £142.57 (95%CI £135.41 to £149.74). Primary, community and secondary health care costs increased significantly after the index date in the no AHC group owing to higher increase in resource utilisation. Regression analysis showed that the expected health care cost for those who have an AHC is 56% higher than for those who did not have an AHC. Age and gender were also associated with increase in expected health care cost. The level of resource utilisation increased in both (AHC and no AHC) groups after the index date. Although the level of resource use before index date was lower in the no AHC group, it increased after the index date up to almost reaching the level of resource utilisation in the AHC group. Further research is needed to explore if the AHCs are effective in reducing health inequalities.

Patients' and GPs' expectations regarding healthcare-seeking behaviour: a Norwegian comparative study.

BackgroundGPs are Norwegian patients' first contact point with the healthcare system for most medical problems. However, little is known regarding GPs' expectations towards their patients' healthcare-seeking behaviour, or whether doctors and patients have coinciding expectations of what GPs can do for their patients.AimTo investigate patients' and GPs’ expectations regarding patients’ healthcare-seeking behaviour in primary care, and to make comparisons between the two.Design & settingNorwegian data from the Quality and Costs of Primary Care in Europe (QUALICOPC) questionnaire study, with information from GPs and their patients.MethodBinary logistic regression was used to investigate associations between expectations, sex and age of GPs and patients, list size, and geographical location of practice. Results are presented as odds ratios (ORs) with 95% confidence intervals (CIs). Expectation differences between GPs and patients were analysed using generalised estimating equations (GEEs). Due to multiple testing, Bonferroni correction was used to define significance level at P≤0.002.ResultsIn total, 198 GPs (39.1% female) and 1529 patients (61.9% female) responded. No associations with sex or age were found for the GPs' expectations regarding patients' healthcare-seeking behaviour. Among patients, fewer males than females expected that most people would see their GP for sprained ankle (OR 0.7, 95% CI = 0.5 to 0.9), finger cut (OR 0.6, 95% CI = 0.4 to 0.7), smoking cessation (OR 0.6, 95% CI = 0.5 to 0.8), or anxiety (OR 0.4, 95% CI = 0.3 to 0.6). Older patients (aged >65 years) found it more important than younger patients to see a doctor in the presence of medical symptoms. GPs had higher expectations than their patients that people in general would see them for deteriorated vision (OR 4.2, 95% CI = 2.5 to 6.9), sexual problems (OR 1.8, 95% CI =1.3 to 2.6), and anxiety (OR 3.0, 95% CI =1.5 to 6.0).ConclusionFor several common health problems, males are less likely than females to believe that people will see their GP. GPs may overestimate to what degree their patients will see them for a number of common medical problems.