scholarly journals Improving the effectiveness and efficiency of outpatient services: a scoping review of interventions at the primary–secondary care interface

2016 ◽  
Vol 22 (1) ◽  
pp. 53-64 ◽  
Author(s):  
Eleanor M Winpenny ◽  
Céline Miani ◽  
Emma Pitchforth ◽  
Sarah King ◽  
Martin Roland
Keyword(s):  
Primary Care ◽  
Cost Effectiveness ◽  
Scoping Review ◽  
Secondary Care ◽  
Qualitative Evidence Synthesis ◽  
Outpatient Services ◽  
Referral Behaviour ◽  
Effectiveness And Efficiency ◽  
Primary Care Clinicians ◽  
Primary Care Practitioners

Objectives Variation in patterns of referral from primary care can lead to inappropriate overuse or underuse of specialist resources. Our aim was to review the literature on strategies involving primary care that are designed to improve the effectiveness and efficiency of outpatient services. Methods A scoping review to update a review published in 2006. We conducted a systematic literature search and qualitative evidence synthesis of studies across five intervention domains: transfer of services from hospital to primary care; relocation of hospital services to primary care; joint working between primary care practitioners and specialists; interventions to change the referral behaviour of primary care practitioners and interventions to change patient behaviour. Results The 183 studies published since 2005, taken with the findings of the previous review, suggest that transfer of services from secondary to primary care and strategies aimed at changing referral behaviour of primary care clinicians can be effective in reducing outpatient referrals and in increasing the appropriateness of referrals. Availability of specialist advice to primary care practitioners by email or phone and use of store-and-forward telemedicine also show potential for reducing outpatient referrals and hence reducing costs. There was little evidence of a beneficial effect of relocation of specialists to primary care, or joint primary/secondary care management of patients on outpatient referrals. Across all intervention categories there was little evidence available on cost-effectiveness. Conclusions There are a number of promising interventions which may improve the effectiveness and efficiency of outpatient services, including making it easier for primary care clinicians and specialists to discuss patients by email or phone. There remain substantial gaps in the evidence, particularly on cost-effectiveness, and new interventions should continue to be evaluated as they are implemented more widely. A move for specialists to work in the community is unlikely to be cost-effective without enhancing primary care clinicians’ skills through education or joint consultations with complex patients.

scholarly journals Outpatient services and primary care: scoping review, substudies and international comparisons

2016 ◽  
Vol 4 (15) ◽  
pp. 1-290 ◽  
Author(s):  
Eleanor Winpenny ◽  
Céline Miani ◽  
Emma Pitchforth ◽  
Sarah Ball ◽  
Ellen Nolte ◽  
...  
Keyword(s):  
Primary Care ◽  
Cost Effectiveness ◽  
Scoping Review ◽  
Secondary Care ◽  
Outpatient Services ◽  
Community Based ◽  
Educational Value ◽  
New Models ◽  
Effectiveness And Efficiency

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.

scholarly journals Effectiveness and cost-effectiveness of Improving clinicians’ diagnostic and communication Skills on Antibiotic prescribing Appropriateness in patients with acute Cough in primary care in CATalonia (the ISAAC-CAT study): study protocol for a cluster randomised controlled trial

Trials ◽  
2019 ◽  
Vol 20 (1) ◽  
Author(s):  
Rafa Ruiz ◽  
Ana Moragas ◽  
Marta Trapero-Bertran ◽  
Antoni Sisó ◽  
Anna Berenguera ◽  
...  
Keyword(s):  
Primary Care ◽  
Cost Effectiveness ◽  
Communication Skills ◽  
Controlled Trial ◽  
Sensitivity Analyses ◽  
Antibiotic Prescribing ◽  
Cluster Randomised ◽  
Life Years ◽  
Effectiveness And Efficiency ◽  
Tract Infections

Abstract Background Despite their marginal benefit, about 60% of acute lower respiratory tract infections (ALRTIs) are currently treated with antibiotics in Catalonia. This study aims to evaluate the effectiveness and efficiency of a continuous disease-focused intervention (C-reactive protein [CRP]) and an illness-focused intervention (enhancement of communication skills to optimise doctor-patient consultations) on antibiotic prescribing in patients with ALRTIs in Catalan primary care centres. Methods/design A cluster randomised, factorial, controlled trial aimed at including 20 primary care centres (N = 2940 patients) with patients older than 18 years of age presenting for a first consultation with an ALRTI will be included in the study. Primary care centres will be identified on the basis of socioeconomic data and antibiotic consumption. Centres will be randomly assigned according to hierarchical clustering to any of four trial arms: usual care, CRP testing, enhanced communication skills backed up with patient leaflets, or combined interventions. A cost-effectiveness and cost-utility analysis will be performed from the societal and national healthcare system perspectives, and the time horizon of the analysis will be 1 year. Two qualitative studies (pre- and post-clinical trial) aimed to identify the expectations and concerns of patients with ALRTIs and the barriers and facilitators of each intervention arm will be run. Family doctors and nurses assigned to the interventions will participate in a 2-h training workshop before the inception of the trial and will receive a monthly intervention-tailored training module during the year of the trial period. Primary outcomes will be antibiotic use within the first 6 weeks, duration of moderate to severe cough, and the quality-adjusted life-years. Secondary outcomes will be duration of illness and severity of cough measured using a symptom diary, healthcare re-consultations, hospital admissions, and complications. Healthcare costs will be considered and expressed in 2021 euros (year foreseen to finalise the study) of the current year of the analysis. Univariate and multivariate sensitivity analyses will be carried out. Discussion The ISAAC-CAT project will contribute to evaluate the effectiveness and efficiency of different strategies for more appropriate antibiotic prescribing that are currently out of the scope of the actual clinical guidelines. Trial registration ClinicalTrials.gov, NCT03931577.

Measuring integrated care at the interface between primary care and secondary care: a scoping review

2021 ◽  
Vol ahead-of-print (ahead-of-print) ◽  
Author(s):  
Aimee O'Farrell ◽  
Geoff McCombe ◽  
John Broughan ◽  
Áine Carroll ◽  
Mary Casey ◽  
...  
Keyword(s):  
Primary Care ◽  
Scoping Review ◽  
Full Text ◽  
Secondary Care ◽  
Research Question ◽  
Grey Literature ◽  
Problem Area ◽  
Cochrane Library ◽  
Comprehensive Overview ◽  
Content Type

PurposeIn many healthcare systems, health policy has committed to delivering an integrated model of care to address the increasing burden of disease. The interface between primary and secondary care has been identified as a problem area. This paper aims to undertake a scoping review to gain a deeper understanding of the markers of integration across the primary–secondary interface.Design/methodology/approachA search was conducted of PubMed, SCOPUS, Cochrane Library and the grey literature for papers published in English using the framework described by Arksey and O'Malley. The search process was guided by the “Preferred Reporting Items for Systematic Reviews and Meta-Analyses” (PRISMA).FindingsThe initial database search identified 112 articles, which were screened by title and abstract. A total of 26 articles were selected for full-text review, after which nine articles were excluded as they were not relevant to the research question or the full text was not available. In total, 17 studies were included in the review. A range of study designs were identified including a systematic review (n = 3), mixed methods study (n = 5), qualitative (n = 6) and quantitative (n = 3). The included studies documented integration across the primary–secondary interface; integration measurement and factors affecting care coordination.Originality/valueMany studies examine individual aspects of integration. However, this study is unique as it provides a comprehensive overview of the many perspectives and methodological approaches involved with evaluating integration within the primary–secondary care interface and primary care itself. Further research is required to establish valid reliable tools for measurement and implementation.

Introducing Dentists with Special Interests (DwSIs)— Past, Present and Future Perspectives

2005 ◽  
Vol os12 (1) ◽  
pp. 20-22 ◽  
Author(s):  
Sharon Drake
Keyword(s):  
Primary Care ◽  
Secondary Care ◽  
National Context ◽  
Future Perspectives ◽  
Specialist Training ◽  
Special Interests ◽  
Prior Learning ◽  
Primary Care Sector ◽  
Primary Care Practitioners ◽  
Training Opportunities

This paper provides the national context for the development of practitioners with special interests (PwSIs) in light of the recent introduction of the concept to dentistry. Given the shortage of specialists and consultants in some dental specialities and the fact that a number of referrals could be managed in the primary care sector, the development of an additional tier to bridge the gap between current capacity and demand for services in secondary care seems to be a practical solution. The introduction of the DwSI and the future training opportunities it affords will pave the way for the development of a cadre of accredited primary care practitioners with enhanced skills who, together with their secondary care colleagues, will help widen the choice available to patients in terms of the nature and locality of NHS dental care provided. In time, DwSIs may wish to train to become full specialists or consultants and have their accredited prior learning and experience recognised towards completion of full specialist training.

scholarly journals Systematic review of integrated models of health care delivered at the primary–secondary interface: how effective is it and what determines effectiveness?

2015 ◽  
Vol 21 (4) ◽  
pp. 391 ◽  
Author(s):  
Geoffrey K. Mitchell ◽  
Letitia Burridge ◽  
Jianzhen Zhang ◽  
Maria Donald ◽  
Ian A. Scott ◽  
...  
Keyword(s):  
Systematic Review ◽  
Primary Care ◽  
Service Delivery ◽  
Disease Control ◽  
Usual Care ◽  
Clinical Outcomes ◽  
Secondary Care ◽  
Design Elements ◽  
Primary Care Practitioners ◽  
The Impact

Integrated multidisciplinary care is difficult to achieve between specialist clinical services and primary care practitioners, but should improve outcomes for patients with chronic and/or complex chronic physical diseases. This systematic review identifies outcomes of different models that integrate specialist and primary care practitioners, and characteristics of models that delivered favourable clinical outcomes. For quality appraisal, the Cochrane Risk of Bias tool was used. Data are presented as a narrative synthesis due to marked heterogeneity in study outcomes. Ten studies were included. Publication bias cannot be ruled out. Despite few improvements in clinical outcomes, significant improvements were reported in process outcomes regarding disease control and service delivery. No study reported negative effects compared with usual care. Economic outcomes showed modest increases in costs of integrated primary–secondary care. Six elements were identified that were common to these models of integrated primary–secondary care: (1) interdisciplinary teamwork; (2) communication/information exchange; (3) shared care guidelines or pathways; (4) training and education; (5) access and acceptability for patients; and (6) a viable funding model. Compared with usual care, integrated primary–secondary care can improve elements of disease control and service delivery at a modestly increased cost, although the impact on clinical outcomes is limited. Future trials of integrated care should incorporate design elements likely to maximise effectiveness.

Peptic Ulcer Disease

2009 ◽  
Vol 2 (8) ◽  
pp. 486-492 ◽  
Author(s):  
P. J. Woodland ◽  
Ben Stubbs
Keyword(s):  
Primary Care ◽  
Peptic Ulcer ◽  
Peptic Ulcer Disease ◽  
Secondary Care ◽  
Current Treatment ◽  
Lifetime Risk ◽  
Significant Problem ◽  
Peptic Ulcers ◽  
Ulcer Disease ◽  
Primary Care Practitioners

People in Western populations have a 1 in 10 lifetime risk of developing peptic ulcer disease. Although recent decades have seen major advances in our knowledge and treatment of peptic ulcers, symptoms and complications from peptic ulcers remain a significant problem for primary and secondary care practitioners. Primary care practitioners have a central role in the prevention, recognition and treatment of peptic ulcers. This article summarizes the causes, presentations, investigation and current treatment of peptic ulcer disease.

VP132 Cost Effectiveness Of A Predictive Risk Model In Primary Care

2017 ◽  
Vol 33 (S1) ◽  
pp. 209-210
Author(s):  
Helen Snooks ◽  
Alison Porter ◽  
Mark Kingston ◽  
Bridie Evans ◽  
Deborah Burge-Jones ◽  
...  
Keyword(s):  
Primary Care ◽  
Cost Effectiveness ◽  
High Risk ◽  
Health Services ◽  
Risk Stratification ◽  
Financial Burden ◽  
Risk Level ◽  
Emergency Admissions ◽  
Predictive Risk ◽  
Primary Care Practitioners

INTRODUCTION:Emergency admissions to hospital are a major financial burden on health services. In one area of the United Kingdom (UK), we evaluated a predictive risk stratification tool (PRISM) designed to support primary care practitioners to identify and manage patients at high risk of admission. We assessed the costs of implementing PRISM and its impact on health services costs. At the same time as the study, but independent of it, an incentive payment (‘QOF’) was introduced to encourage primary care practitioners to identify high risk patients and manage their care.METHODS:We conducted a randomized stepped wedge trial in thirty-two practices, with cluster-defined control and intervention phases, and participant-level anonymized linked outcomes. We analysed routine linked data on patient outcomes for 18 months (February 2013 – September 2014). We assigned standard unit costs in pound sterling to the resources utilized by each patient. Cost differences between the two study phases were used in conjunction with differences in the primary outcome (emergency admissions) to undertake a cost-effectiveness analysis.RESULTS:We included outcomes for 230,099 registered patients. We estimated a PRISM implementation cost of GBP0.12 per patient per year.Costs of emergency department attendances, outpatient visits, emergency and elective admissions to hospital, and general practice activity were higher per patient per year in the intervention phase than control phase (adjusted δ = GBP76, 95 percent Confidence Interval, CI GBP46, GBP106), an effect that was consistent and generally increased with risk level.CONCLUSIONS:Despite low reported use of PRISM, it was associated with increased healthcare expenditure. This effect was unexpected and in the opposite direction to that intended. We cannot disentangle the effects of introducing the PRISM tool from those of imposing the QOF targets; however, since across the UK predictive risk stratification tools for emergency admissions have been introduced alongside incentives to focus on patients at risk, we believe that our findings are generalizable.

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