Influence of financial and reputational incentives on primary care performance: a longitudinal study

BackgroundThe Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time.AimTo determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme.Design and settingObservational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013.MethodThe authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards.ResultsBoth the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from −0.121 percentage points per quality point (95% CI = −0.220 to −0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013.ConclusionIn the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.

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Impact of a national primary care pay-for-performance scheme on ambulatory care sensitive hospital admissions: a small-area analysis in England

BMJ Open ◽

10.1136/bmjopen-2019-036046 ◽

2020 ◽

Vol 10 (9) ◽

pp. e036046

Author(s):

Christos Grigoroglou ◽

Luke Munford ◽

Roger Webb ◽

Navneet Kapur ◽

Tim Doran ◽

...

Keyword(s):

Primary Care ◽

Ambulatory Care ◽

Small Area ◽

Negative Binomial ◽

Hospital Admissions ◽

Pay For Performance ◽

Administrative Dataset ◽

Practice Performance ◽

Quality And Outcomes ◽

Ambulatory Care Sensitive

ObjectiveWe aimed to spatially describe hospital admissions for ambulatory care sensitive conditions (ACSC) in England at small-area geographical level and assess whether recorded practice performance under one of the world’s largest primary care pay-for-performance schemes led to reductions in these potentially avoidable hospitalisations for chronic conditions incentivised in the scheme.SettingWe obtained numbers of ACSC hospital admissions from the Hospital Episode Statistics database and information on recorded practice performance from the Quality and Outcomes Framework (QOF) administrative dataset for 2015/2016. We fitted three sets of negative binomial models to examine ecological associations between incentivised ACSC admissions, general practice performance, deprivation, urbanity and other sociodemographic characteristics.ResultsHospital admissions for QOF incentivised ACSCs varied within and between regions, with clusters of high numbers of hospital admissions for incentivised ACSCs identified across England. Our models indicated a very small effect of the QOF on reducing admissions for incentivised ACSCs (0.993, 95% CI 0.990 to 0.995), however, other factors, such as deprivation (1.021, 95% CI 1.020 to 1.021) and urbanicity (0.875, 95% CI 0.862 to 0.887), were far more important in explaining variations in admissions for ACSCs. People in deprived areas had a higher risk of being admitted in hospital for an incentivised ACSC condition.ConclusionSpatial analysis based on routinely collected data can be used to identify areas with high rates of potentially avoidable hospital admissions, providing valuable information for targeting resources and evaluating public health interventions. Our findings suggest that the QOF had a very small effect on reducing avoidable hospitalisation for incentivised conditions. Material deprivation and urbanicity were the strongest predictors of the variation in ACSC rates for all QOF incentivised conditions across England.

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Predictive factors for failure of the levonorgestrel releasing intrauterine system in women with heavy menstrual bleeding

BMC Women s Health ◽

10.1186/s12905-021-01210-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Pleun Beelen ◽

Marian J. van den Brink ◽

Malou C. Herman ◽

Peggy M. Geomini ◽

Ruben G. Duijnhoven ◽

...

Keyword(s):

Multivariable Analysis ◽

Previous Treatment ◽

Study Data ◽

Heavy Menstrual Bleeding ◽

Menstrual Bleeding ◽

Younger Age ◽

Future Child ◽

Multivariable Regression ◽

General Practices ◽

Multivariable Regression Models

Abstract Background This study was conducted to identify factors that are associated with failure of treatment using the levonorgestrel releasing intrauterine system (LNG-IUS) in women with heavy menstrual bleeding. Methods For this study, data of a cohort of women treated with an LNG-IUS was used. Women who suffered from heavy menstrual bleeding, aged 34 years and older, without intracavitary pathology and without a future child wish, were recruited in hospitals and general practices in the Netherlands. Eight potential prognostic baseline variables (age, body mass index, caesarean section, vaginal delivery, previous treatment, anticoagulant use, dysmenorrhea, and pictorial blood assessment score) were analyzed using univariable and multivariable regression models to estimate the risk of failure. The main outcome measure was discontinuation of the LNG-IUS within 24 months of follow up, defined as removal of the LNG-IUS or receiving an additional intervention. Results A total of 209 women received the LNG-IUS, 201 women were included in the analyses. 93 women (46%) discontinued LNG-IUS treatment within 24 months. Multivariable analysis showed younger age (age below 45) (adjusted RR 1.51, 95% CI 1.10–2.09, p = .012) and severe dysmenorrhea (adjusted RR 1.36, 95% CI 1.01–1.82, p = .041) to be associated with a higher risk of discontinuation. Conclusions High discontinuation rates are found in women who receive an LNG-IUS to treat heavy menstrual bleeding. A younger age and severe dysmenorrhea are found to be risk factors for discontinuation of LNG-IUS treatment. These results are relevant for counselling women with heavy menstrual bleeding.

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Outcomes of a 12-month patient-centred medical home model in improving patient activation and self-management behaviours among primary care patients presenting with chronic diseases in Sydney, Australia: A before-and-after study.

10.21203/rs.2.24539/v4 ◽

2020 ◽

Author(s):

James John ◽

W Kathy Tannous ◽

Amanda Jones

Keyword(s):

Chronic Diseases ◽

Regression Models ◽

Patient Activation ◽

Self Management ◽

Before And After ◽

Multivariable Regression ◽

General Practices ◽

Multivariable Regression Models ◽

Sydney Australia

Abstract Background: Studies report that increased levels of patient activation is associated with increased engagement with the health care system, better adherence to treatment protocols, and improved health outcomes. This study aims to evaluate the outcomes of a 12-month Patient-Centred Medical Home (PCMH) model called ‘WellNet’ on the activation levels of patients with one or more chronic diseases in general practices across Northern Sydney, Australia.Methods: A total of 636 patients aged 40 years and above with one or more chronic conditions consented to participate in the WellNet program which was delivered across six general practices in Northern Sydney, Australia. The WellNet intervention includes team-based care with general physicians and trained chronic disease management care coordinators collaborating with patients in designing a patient-tailored care plan with improved self-management support and care navigation according to the level of risk and health care needs. The level of patient activation was measured using the validated PAM 13-item scale at baseline and follow-up. A before and after case-series design was employed to determine the adjusted mean differences between baseline and 12-months using repeated measures analysis of covariance (ANCOVA). Additionally, the backward stepwise multivariable regression models were employed to identify significant predictors of activation at follow-up.Results: Of the 626 patients, 420 reported their PAM scores at follow-up. The mean (SD) baseline PAM score was 57.9 (13.0). The adjusted model showed significant mean difference in PAM scores by increase of 6.5 (95% CI 5.0-8.1; p-value<0.001) after controlling for baseline covariates. The multivariable regression models showed that older age (B = -0.14; 95% CI -0.28, -0.01) and private insurance (uninsured patients) (B = -3.41; 95% CI -6.50, -0.32) were significantly associated with lower PAM scores at 12 months whereas higher baseline PAM score (B = 0.48; 95% CI 0.37, 0.59) was significantly associated with higher follow-up PAM score.Conclusion: The WellNet study is the first of its kind in Australia to report on changes in the patient activation levels among patients with one or more chronic diseases. PCMH has the potential to improve patient activation and engagement which can lead to long-term health benefits and sustained self-management behaviours.

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The Impact of Weather and Seasons on Falls and Physical Activity among Older Adults with Glaucoma: A Longitudinal Prospective Cohort Study

Sensors ◽

10.3390/s21103415 ◽

2021 ◽

Vol 21 (10) ◽

pp. 3415

Author(s):

Hursuong Vongsachang ◽

Aleksandra Mihailovic ◽

Jian-Yu E ◽

David S. Friedman ◽

Sheila K. West ◽

...

Keyword(s):

Physical Activity ◽

Older Adults ◽

Fall Prevention ◽

Regression Models ◽

Activity Promotion ◽

Injurious Fall ◽

Multivariable Regression ◽

Multivariable Regression Models ◽

The Impact ◽

The Relationship

Understanding periods of the year associated with higher risk for falling and less physical activity may guide fall prevention and activity promotion for older adults. We examined the relationship between weather and seasons on falls and physical activity in a three-year cohort of older adults with glaucoma. Participants recorded falls information via monthly calendars and participated in four one-week accelerometer trials (baseline and per study year). Across 240 participants, there were 406 falls recorded over 7569 person-months, of which 163 were injurious (40%). In separate multivariable regression models incorporating generalized estimating equations, temperature, precipitation, and seasons were not significantly associated with the odds of falling, average daily steps, or average daily active minutes. However, every 10 °C increase in average daily temperature was associated with 24% higher odds of a fall being injurious, as opposed to non-injurious (p = 0.04). The odds of an injurious fall occurring outdoors, as opposed to indoors, were greater with higher average temperatures (OR per 10 °C = 1.46, p = 0.03) and with the summer season (OR = 2.69 vs. winter, p = 0.03). Falls and physical activity should be understood as year-round issues for older adults, although the likelihood of injury and the location of fall-related injuries may change with warmer season and temperatures.

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Pregnancy outcomes in women with preexisting thyroid diseases: a French cohort study

Journal of Developmental Origins of Health and Disease ◽

10.1017/s2040174420001051 ◽

2020 ◽

pp. 1-10

Author(s):

Marion Lecorguillé ◽

Juliane Léger ◽

Anne Forhan ◽

Marie Cheminat ◽

Marie-Noëlle Dufourg ◽

...

Keyword(s):

Thyroid Hormone ◽

Gestational Diabetes ◽

Head Circumference ◽

Thyroid Diseases ◽

Premature Rupture Of Membranes ◽

Premature Rupture ◽

Fetal Head ◽

History Of ◽

Multivariable Regression ◽

Multivariable Regression Models

Abstract Women with thyroid diseases at the beginning of pregnancy may have suboptimal thyroid hormone levels because of potential difficulties in compensating for the physiological thyroid hormone changes occurring in pregnancy. Our objective was to study the association between preexisting thyroid diseases, pregnancy complications, and neonatal anthropometry. In total, 16,395 women from the ELFE French longitudinal birth cohort were included, and 273 declared pre-pregnancy thyroid diseases. Associations were investigated with multivariable regression models, with adjustment for relevant potential confounders. Body mass index (BMI) was additionally adjusted for in a second stage. As compared with other women, women with pre-pregnancy thyroid diseases were more frequently obese (19.6% vs. 9.8%) and had greater odds of gestational diabetes development (odds ratio [OR] = 1.58 [95% confidence interval [CI] 1.08, 2.30]) or had undergone treatment for infertility (OR = 1.57 [95% CI 1.07, 2.31]). After adjustment for BMI, the association with gestational diabetes was no longer significant (OR = 1.27 [95% CI 0.86, 1.88]). After excluding women with another medical history, those with pre-pregnancy thyroid diseases had increased odds of premature rupture of membranes (OR = 1.51 [95% CI 1.01, 2.25]). Children born from mothers with hypothyroidism before conception due to a disease or as a potential side effect of treatment had a smaller head circumference at birth than other children (β = −0.23 [95% CI −0.44, −0.01] cm). In conclusion, pre-pregnancy thyroid diseases were associated with risk of infertility treatment, gestational diabetes, and premature rupture of membranes. The association between history of hypothyroidism and moderate adverse effects on fetal head circumference growth needs replication.

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Abstract 3572: Clinical Outcomes of the “Stroke100 Club”

Stroke ◽

10.1161/str.43.suppl_1.a3572 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Amy K Guzik ◽

Rema Raman ◽

Kain Ernstrom ◽

Dawn M Meyer ◽

Ajeet Sodhi ◽

...

Keyword(s):

Regression Models ◽

Young Patients ◽

Older Age ◽

Advanced Age ◽

Stroke Severity ◽

Old Patients ◽

Multivariable Regression ◽

Independent Variable ◽

Poor Outcomes ◽

Multivariable Regression Models

Background: Patients with advanced age or high NIHSS have poorer tPA outcomes. When combined, old age (≥80yo) and elevated NIHSS (≥20) may have an even worse outcome. Patients who are also in this “Stroke100 Club” (any combination of age and NIHSS ≥100) by other means, have not been fully assessed. We evaluated discharge destination, 90-day mRS, sICH and death in treated and untreated Stroke100 Club patients. We further compared patients with age ≥ 80 and NIHSS ≥ 20 (“80/20s”), those who reached 100 without both characteristics (“non80/20s”) and ‘controls’. Methods: The UCSD SPOTRIAS prospectively collected database was analyzed for AIS patients (with and without tPA). Multivariable regression models including the Stroke100 group as an independent variable was used. Outcomes were adjusted for baseline mRS. For comparing categorical outcomes between controls, “80/20s” and “non80/20s” subgroups, a Fisher’s exact was used. Results: The IV tPA subset included 257 patients (mean age 71, 52% male, 85% white, mean NIHSS 12). 53 were in the “Stroke100 Club” (28 80/20, 25 non80/20), with more women (68% p= 0.002), higher NIHSS (22.5 p<0.0001), older age (mean age 86.4 p<0.0001), higher pre stroke mRS (34.6% mRS 3-6 vs 7.84%, p<0.0001), more HTN (p=0.045) and more afib (p= 0.008). There were 284 non tPA patients (mean age 69.52, 54% male, 85% white, mean NIHSS 5.92). 21 were in the “Stroke100 Club” (14 80/20, 7 non80/20), with higher NIHSS (23 p<0.0001), older age (mean 86.2 p<0.0001), higher pre stroke mRS (45.5% 3-6 vs 9.5%, p= 0.0001), and more afib (p= 0.0002). Stroke100 Club 90day mRS(3-6) outcomes were worse in both tPA treated patients (OR=6.77, p= 0.0001) and nontreated patients (OR 31.57, p= 0.001). sICH rates (in tPA subjects) were not different (3.8% vs 3.4%, p> 0.99). Conclusions: There is a question of treatment outcome in patients with various permutations of stroke severity and advanced age. Our data corroborates the concern of poor outcomes for Stroke100 Club patients, but notes no increased sICH with tPA. Though outcome may be poor, withholding tPA should be discouraged as worse outcomes were not due to sICH. Young patients with severe strokes or old patients with mild strokes may have outcomes similar to the standard “80/20” Stroke100 patients, however further adjusted analysis is ongoing. In addition, further analyses are being done to compare tPA to non tPA patients.

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Abstract 51: Access to Primary Stroke Centers for Older Adults and Implications for Travel Times, and Mortality

Stroke ◽

10.1161/str.46.suppl_1.51 ◽

2015 ◽

Vol 46 (suppl_1) ◽

Author(s):

Kimon Bekelis ◽

Kendrew Wong ◽

Nancy Marth ◽

Weiping Zhou ◽

Jonathan Skinner

Keyword(s):

Regional Variation ◽

Fee For Service ◽

Travel Times ◽

Stroke Patients ◽

Multivariable Regression ◽

Potential Impact ◽

One Year ◽

Multivariable Regression Models ◽

Regionalization Of Care

Background: Regionalization of care to primary stroke centers (PSC) may improve outcomes for stroke patients. We evaluated the current access of Medicare stroke patients to PSC, and its potential impact on mortality. Methods: We performed a retrospective cohort study of a 100% sample of Medicare fee-for-service claims data for patients admitted with stroke in 2008-2009, with one-year follow-up through 2010. Population weighted centroids were created, helicopter pad locations were identified, and driving distances were calculated based on real road network data. Driving and flying speeds, dispatch, scene, and pre-hospital times were estimated using validated models, adjusted for population density. The association of 30-day mortality with travel times, and treatment at a PSC was investigated using multivariable regression models. Results: During the study period, 510,822 patients (mean age 79.6 years, 59.7% females) had a stroke. There was significant regional variation in our cohort, (Figure) with 8.6% of stroke patients having ground access to a PSC within 30 minutes, 14.9% from 30 to 45 minutes, 11.1% from 45 to 60 minutes, 43.9% from 1 to 4.5 hours, and 21.5% over 4.5 hours. The latter group could be limited to 0.1% of stroke patients, if existing helicopter services were used optimally. 164,485 (32.2%) patients received treatment in a PSC, and had modestly decreased mortality (OR, 0.97; 95% CI, 0.95-0.99). For this group, actual travel time to the PSC was not associated with mortality for patients within one hour of the PSC. On the contrary, travel times from 1 to 4.5 hours (OR, 1.15; 95% CI, 1.08-1.22), and over 4.5 hours (OR, 1.41; 95% CI, 1.29-1.54) were associated with increased mortality. Conclusions: There is significant regional variation in access to PSC for elderly stroke patients, with a potential impact on outcomes. Optimal use of helicopter services may address these disparities. Funding: NIH (P01-AG19783, and U01-AG046830-01).

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Autonomy in the Operating Room: A Multicenter Study of Gender Disparities During Surgical Training

Journal of Graduate Medical Education ◽

10.4300/jgme-d-21-00217.1 ◽

2021 ◽

Vol 13 (5) ◽

pp. 666-672

Author(s):

Jenny X. Chen ◽

Edward H. Chang ◽

Francis Deng ◽

Shari Meyerson ◽

Brian George ◽

...

Keyword(s):

Surgical Training ◽

Gender Disparities ◽

Training Level ◽

Surgical Performance ◽

Surgical Trainees ◽

Significant Difference ◽

Multivariable Regression ◽

Operative Performance ◽

And Performance ◽

Multivariable Regression Models

ABSTRACT Background Gender disparities are prevalent in medicine, but their impact on surgical training is not well studied. Objective To quantify gender disparities in trainee intraoperative experiences and explore the variables associated with ratings of surgical autonomy and performance. Methods From September 2015 to May 2019, attending surgeons and trainees from 71 programs assessed trainee autonomy on a 4-level Zwisch scale and performance on a 5-level modified Dreyfus scale after surgical procedures. Multivariable regression models were used to examine the association of trainee gender with autonomy and performance evaluations. Results A total of 3255 trainees and attending surgeons completed 94 619 evaluations. Attendings gave lower ratings of operative autonomy to female trainees than male trainees when controlling for training level, attending, and surgical procedure (effect size B = −0.0199, P = .008). There was no difference in ratings of autonomy at the beginning of training (P = .32); the gap emerged as trainees advanced in years (B = −0.0163, P = .020). The gender difference in autonomy was largest for the most complex cases (B = −0.0502, P = .002). However, there was no difference in attending ratings of surgical performance for female trainees compared to male trainees (B = −0.0124, P = .066). Female trainees rated themselves as having less autonomy and worse performance than males when controlling for training level, attending, procedure, case complexity, and attending ratings (autonomy B = −0.0669, P < .001; performance B = −0.0704, P < .001). Conclusions While there was no significant difference in ratings of operative performance, a small difference between ratings of operative autonomy for female and male surgical trainees was identified.

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1300Associations between self-reported or measured anthropometric variables and cardiometabolic biomarkers in a Danish cohort

International Journal of Epidemiology ◽

10.1093/ije/dyab168.748 ◽

2021 ◽

Vol 50 (Supplement_1) ◽

Author(s):

Jie Zhang ◽

Anja Olsen ◽

Jytte Halkjær ◽

Kristina Elin Nielsen Petersen ◽

Anne Tjønneland ◽

...

Keyword(s):

Smoking Status ◽

Cost Effective ◽

Epidemiological Studies ◽

Self Report ◽

Anthropometric Indices ◽

Multivariable Regression ◽

Highly Correlated ◽

Study Participants ◽

Multivariable Regression Models ◽

Metabolic Biomarkers

Abstract Background It is easy and cost-effective to ask study participants to self-report height and weight and self-reported anthropometry is therefore widely used in epidemiological studies. However, it is questioned to what degree self-reported adiposity indices are a solid proxy of measured indices in terms of estimates of health outcomes. The current study aimed to quantify the agreement between self-reported and measured anthropometrics, including height, weight, body mass index (BMI), weight circumference (WC), and weight-to-height ratio (WHtR) in a contemporary cohort of adults, and to assess whether anthropometric indices misreporting yielded inaccurate estimates of associations with cardiometabolic biomarkers. Methods Self-reported and measured anthropometric variables were obtained from the Diet, Cancer, and Health-Next Generation Cohort (n = 39,514). Pearson correlations and Lin’s concordance correlations evaluated the correlation between self-report and measured anthropometrics. Misreporting in relation to age, sex and smoking status was investigated. Multivariable regression models and ROC analyses were used to assess the associations of cardiometabolic biomarkers with self-reported and measured general obesity and abdominal obesity. Results Self-reported height was overreported by 1.07 cm, weight was underreported by 0.32 kg on average, which led to self-reported BMI 0.42 kg/m2 lower than measured. Self-reported and measured height, weight, BMI, WC and WHtR were highly correlated (r = 0.98, 0.99, 0.98, 0.88, 0.86, respectively). Associations between self-reported indices and cardiometabolic biomarkers were comparable to associations assessed with measured anthropometrics. Conclusions The self-reported anthropometric indices were reliable when estimating associations with metabolic biomarkers. Key messages This study found overall agreement between self-reported and measured anthropometric variables.

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Characteristics of patients with type 1 diabetes and additional autoimmune disease in the DPV registry

The Journal of Clinical Endocrinology & Metabolism ◽

10.1210/clinem/dgab376 ◽

2021 ◽

Author(s):

Nicole Prinz ◽

Sascha R Tittel ◽

Rainer Bachran ◽

Robert Birnbacher ◽

Joachim Brückel ◽

...

Keyword(s):

Type 1 Diabetes ◽

Autoimmune Diseases ◽

Diabetes Duration ◽

Insulin Dosage ◽

Insulin Regimen ◽

Autoimmune Thyroid ◽

Population Type ◽

Multivariable Regression ◽

Multivariable Regression Models

Abstract Context Autoimmune diseases affect ~8% of the population. Type 1 diabetes mellitus (T1DM) is linked to other autoimmune diseases (AID) like autoimmune thyroid disease, or Addison’s disease (AD) that may impact diabetes therapy and outcome. Objective To analyze demographic and clinical characteristics of other AID in T1DM from a large standardized registry, the prospective diabetes follow-up (DPV). Methods We searched the registry for T1DM with the additional diagnosis of Hashimoto’s thyroiditis (HT), Graves’ disease (GD), and/or AD. T1DM with other AID (n=6,166, 5.4%) were compared to isolated T1DM (n=107,457). For group comparisons, we used multivariable regression models with age, sex, diabetes duration, migration background, and type of insulin regimen as basic adjustments (microvascular endpoints: additionally adjusted for HbA1c). Results Patients with additional AID were more often female (54.7 vs. 32.0%, p<0.001) and had a longer diabetes duration (7.9 [4.2-12.5] vs. 6.7 [2.7-12.9] years, p<0.001). After adjustment, daily insulin dosage was higher in AD and HT compared to isolated T1DM (0.858±0.032 and 0.813±0.005 vs. 0.793±0.001 IU/kg*d). Retinopathy was less common in HT (1.5%), whereas it was more frequent in GD (3.1%) if compared to isolated T1DM (1.8%). In both GD and HT, microalbuminuria occurred less often (10.6% and 14.3% vs. 15.5%) and neuropathy (2.1% and 1.8% vs. 0.8%) was more common compared to isolated T1DM. Conclusions T1DM with additional AID show heterogeneous differences compared to isolated T1DM. T1DM plus AD or HT requires more insulin. Further, the rate of neuropathy is higher in HD or GD, whereas the rate of microalbuminuria is lower.

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