Integrated Care (IC) and utilization: some evidence

Is integration of primary, secondary and social care better for patients and is it cost effective? Andrew Street, Professor of Health Economics, discusses a recent paper he published with co-authors Anne Mason and Panagiotis Kasteridis, which evaluated the cost-effectiveness of integrated care (IC) programmes in South Somerset for people with long-term conditions.

Objectives: As part of the Vanguard programme, two integrated care models were introduced in South Somerset for people with complex care needs: the Complex Care Team and Enhanced Primary Care. The authors assessed their impact on a range of utilization measures and mortality. 

• Complex Care Team (CCT), provides senior medical input, care coordination, and a personalized care plan to support self-care.
• Staffed by GPs with expertise in chronic care management, complex care nurses and other keyworkers, the CCTs aim to prevent avoidable hospitalizations or, for those in hospital, to support appropriate inpatient care.

Methods: They used monthly individual-level linked primary and secondary care data from April 2014 to March 2018 to assess outcomes before and after the introduction of the care models. The analysis sample included 564 Complex Care Team and 841 Enhanced Primary Care cases that met specific criteria. 

They employed propensity score methods to identify out-of-area control patients and difference-in-differences analysis to isolate the care models’ impact. 

Results: They found no evidence of significantly reduced utilization in any of the Complex Care Team or Enhanced Primary Care cohorts. The death rate was significantly lower only for those in the first Enhanced Primary Care cohort. 

Conclusions: The integrated care models did not significantly reduce utilization nor consistently reduce mortality. Future research should test longer-term outcomes associated with the new models of care and quantify their contribution in the context of broader initiatives.

Watch Andrew Street explaining the article (5m) 

Article (pdf) Evaluating integrated care for people with complex needs (2021)

Photo Richard Long 2012 A circle in Antartica

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Economic leaders call for gender equality in pandemic recovery, june 2021

"Only if we seize on this opportunity to prioritise gender equality can we build a more prosperous world for all"

LSE Director Minouche Shafik has joined leaders from the International Monetary Fund, European Central Bank, World Trade Organisation, European Commission and United Nations to call on governments around the world to prioritise gender equality as they seek to recover from the economic impact of COVID-19.

The statement, published by LSE and shared by the Bill and Melinda Gates Foundation, has been signed by:

• Kristalina Georgieva, Managing Director of the International Monetary Fund
• Christine Lagarde, President of the European Central Bank
• Ursula von der Leyen, President of the European Commission
• Ngozi Okonjo-Iweala, Director-General of the World Trade Organisation
• Minouche Shafik, Director of The London School of Economics and Political Science;
• Vera Songwe, UN Under-Secretary General and Executive Secretary of the Economic Commission for Africa.

Within the statement, these leading figures highlight how women and girls from all parts of the world – both rich and poor – continue to face significant inequality, and bear the heaviest cost in times of economic hardship:

“From accepting gender pay gaps, to neglecting childcare, governments have not prioritised their needs. The result is a feeble, patchwork economic infrastructure - particularly in fields such as caregiving, retail, and tourism, where women are disproportionately represented - that leaves women struggling...

This inequality, they argue, has made countries weaker when faced with a crisis like a pandemic. But the response to COVID-19 also provides an opportunity to accelerate progress towards gender equality, and build stability and opportunity for everyone.

Three key policy areas
The statement calls for governments to focus on three key areas, “…to ensure that economic recovery prioritises women and girls, underpins an inclusive future, and ensures the world is prepared to withstand the next crisis.”

1. Governments must ensure that money, stimulus efforts, and social protection schemes get directly into the hands of women.
2. Countries must close gender data gaps and strengthen monitoring, evaluation, and data systems to support more effective public policy.
3. Governments must reduce the burden of unpaid care work and support better childcare to strengthen women’s labor force participation.

The statement concludes with a warning, “We have no time to waste … The risks of inaction cannot be overstated. Refusing to economically support women and girls will not just set this recovery back, it will leave our economies more vulnerable to future shocks.

Acces to the Full Statement (pdf) 

photo: Salvem lo Montsià rocblackblock

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Health care technology and COVID-19: what will happen in the long term?

Research published by the Health Foundation in march 2021 explores the challenges of implementing health care technologies and investigates patient and staff experiences of technology during the first phase of the coronavirus (COVID-19) pandemic. It draws on learning from the Health Foundation’s programmes and YouGov surveys of over 4,000 UK adults and over 1,000 NHS staff conducted in October 2020.

During the pandemic, there has been increased NHS use of both established and newer technologies to reduce face-to-face contact and manage demand. Phone consultations dominate, followed by some well-established uses of technology, such as booking appointments by phone or using the NHS website. But some emerging or less established uses of technology, including several explicitly promoted by national bodies, are also apparent. For example, accessing care records electronically, devices for home monitoring, video consultations, and the NHS app.

The research finds that while most of those who used technology more during the early phase of the pandemic found the experience positive, half of these users aged 55 and older (50%) and nearly half of those with a carer (46%) – groups that may have higher need for health care – thought these technology-enabled approaches made for worse quality of care.

Furthermore, the report finds that while 49% of the public and 61% of NHS staff surveyed thought the NHS should be looking to use technology-enabled approaches more in future, a significant minority of both public (36%) and NHS staff surveyed (31%) were unconvinced about the long-term use of these approaches.

While technologies were rolled out with impressive speed, some aspects of implementation – such as evaluation, co-design and customisation – will necessarily have been shortcut, and will need revisiting after the emergency phase of the pandemic is over. Furthermore, many technologies were rolled out specifically to serve pandemic response objectives such as social distancing, so will need to be ‘reoriented’ and developed to serve wider quality and productivity objectives in future.

Through a refresh of the NHS long term plan and other national strategies, policymakers will need to support front-line teams to revisit aspects of implementation and 'reorient' technology-based interventions to serve longer term quality and productivity objectives. Central to this will be evaluating their impact on care quality and developing a vision of ‘what good looks like’.

Access to pdf article (2021)

photo: Strawberry Thief, furnishing fabric, designed by William Morris, made by Morris & Co., 1883, © Victoria and Albert Museum, London 
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Physician health management skills and patient outcomes

 

There are large, persistent differences in patient outcomes across physicians and health facilities. The root causes of these differences are not well understood. One reason could be to find if physicians’ health management styles can affect patient health outcomes and health costs.

As quality contracts become increasingly popular across various health care systems, it is important to highlight what facets of individual physicians’ health management styles have meaningful impact on health outcomes and to what extent they vary across physicians. The physician’s ability to correctly diagnose and treat common conditions is one of the central tenets of quality contracts. But the link between these skills and patient outcomes is at best tenuous. Critics have emphasized that unobserved patient-specific characteristics are important and under-researched contributors to the variability of patient health outcomes conditional on physician clinical skill.

Emilia Simeonova et al. published a working paper in 2020 in the NBER where using data on the population of statin users in Denmark between 2004 and 2008 and matching patients to their primary care physicians, they demostrated that

• The physician’s ability to facilitate adherence with prescription medications (as a proxie of physicians's health management skills) has significant positive effects on patient outcomes and health costs even after controlling for observable and unobservable patient characteristics.
• It is important to know that when we talk of physician skills is more than reflecting the clinical quality of the physician. Physician skills are related to their ability to make an adequate diagnosis and prescribe the correct treatment.
• Younger physicians have on average more adherent patients.There didn't find substantial difference in health management skills between male and female physicians after they controlled for physician age and the patient mix. 
• The interventions aiming at improving physicians’ health management skills as they relate to patient adherence with prescribed therapy will have positive impacts on patient health outcome

Access to NBER working paper (pdf)

photo: Homenatge a Ramon Llull (1976) Josep M. Subirachs ______________________________________________________________________

Public engagement for technological innovations: new evidence

 

 

With the promise to improve lives, and the offer of abundant opportunities, technological innovation is regarded as a crucial enabler for the advancement of societies and economies at large.

Technologies and their applications, however, also present an array of social, economic and regulatory challenges. How to harness the benefits of technological innovation while addressing the risks associated with these developments is the subject of much discussion by governments, regulators, industry, academia and the general public.

A key aspect associated with these discussions and debates is public engagement, which is increasingly being recognised by stakeholders as a critical instrument to encourage transparency and openness, increase representativeness, and build trust in decision making and the technologies themselves. Public engagement is a broad term that is used in a variety of sectors (e.g. in research, healthcare and policymaking). In the context of technological innovation, public engagement is used to describe the involvement of a diverse group of people (the general public, but also other key groups such as lobbyists, civil society organisations and social influencers) in discussions and debates about potential applications of new and emerging technologies, their governance, regulation and the wider issues that could arise from the way that they are developed and adopted.

Better Regulation Executive (BRE), a unit from the Department for Business, Energy and Industrial Strategy in Uk commisioned a report to find recent evidence, in the form of a literature review and case studies, on the use of public engagement for technological innovation.

BRE Report (2021) PDF and data

The report describes the evidence including:

• Existing examples of public engagement techniques and ten case studies to illustrate how public engagement has been applied around technological innovation
• The impact of the public engagement techniques on, for example, the design of regulatory frameworks, business models, technology adoption and public trust
• Formal evaluation of the effectiveness of the public engagement techniques around technological innovation

The report offer some cross-cutting lessons:

• The use of multiple techniques over the course of the public engagement process can help to engage different ‘publics’ appropriately.
• Spreading public engagement over time allows for reflection and embedding of concepts.
• Having an impact on trust in technologies and technological innovation requires time and considered debate to increase accountability and more systematic public engagement.
• A multi-stakeholder, collaborative approach to public engagement helps to develop informed and considered judgements.
• Using online and digital-enabled public engagement techniques can potentially increase the speed, scale, inclusivity,and geographical coverage of engagement.
• Using some atypical techniques can potentially render public engagement more tangible and user-friendly and could also increase the diversity of participation.
• Having an impact on outcomes such as regulation, policy and market adoption of technological innovation typically requires buy-in and engagement with the right stakeholders.
• It is important to build evaluation into public engagement processes to track impacts and outcomes over time.

photo:NASA (Jan 29, 2021, the day after its full Moon phase. International Space Station orbited 264 miles above China near the Mongolian border.

How to build effective teams in primary care

 

Teamworking is fundamental to the future of general practice. Practices are coming together at scale in primary care networks and new roles are being introduced, creating multidisciplinary and multi-agency teams. Making these teams function effectively is a complex task. King’s Fund published a guide with insights from research, policy analysis and leadership practice.

What are the fundamentals of effective teams?

• A small number of meaningful objectives
• Clear roles and responsibilities among team members
• Reflect on how the team is working together
• Introduce new roles into the teams
• Create a multidisciplinary team
• Ensure good communication within your teams.
• Effective information-sharing systems
• Re-design the physical space into shaered working spaces
• Clinical supervision
• Gather feedback from colleagues and patients
• Access to learning and development
• Give space for team members to talk about their experiences

Access Publication: Effective teams in General Practice (january 2020)

Merry christmas and happy new year 2021. Stay safe.

photo: Children’s Christmas play, 1958. (Nina Leen / The LIFE Picture Collection) ______________________________________________________________________

false optimism not to be at risk of COVID-19

 

 

 

 

 

Koula Asimakopoulou et al. from King’s College London investigated comparative optimism for infection and recovery from COVID-19, and the implications this may have on the second wave and the possible lockdown. The study found that during the first lockdown period, most respondents believed that compared to others, they were unlikely to be at risk of COVID-19.

Data were collected through an international survey (N = 6485) exploring people’s thoughts and psychosocial behaviours relating to COVID‐19. The paper reports UK data.

They found the belief that negative events surrounding risk and recovery from COVID‐19 are perceived as more likely to happen to others rather than to oneself. Researchers believe that comparative optimism may have brought out the anecdotally observed, lack of compliance with lockdown guidelines in the UK. People who believe COVID‐19 is less likely to happen to them than to others may infer that their actual risk is much smaller than that communicated in the media, and thus the strict adherence to lockdown restrictions is unnecessary in their case.

The results showed how participants overwhelmingly believed that as compared to people of their age and gender, they were somewhat or extremely unlikely to have accidentally infected people with COVID‐19 in the past and to infect others or get infected themselves in the next month. They were also comparatively optimistic, but to a lesser extent, about their likelihood of getting hospitalized due to COVID‐19, finding themselves in an ICU, being ventilated, and making a full recovery.

In contrast, participants showed comparative pessimism about COVID‐19 infections in the more distant future. As compared to the average person of their age and gender they felt likely to get infected by COVID‐19 in the next year and to develop COVID‐19‐related symptoms. The authors argued that this finding supports earlier research that shows that people who have experienced some ill health tend to unduly exaggerate their future risk of experiencing further ill health. One important difference between COVID‐19 and other risks is that controlling the pandemic was very much placed in the hands of individuals restricting their lives in the UK—as seen in the slogan urging people to ‘Stay at home’. It is reasonable that participants would reason that in the long term, staying at home would be less possible, plausible or practical. Feeling that compliance with social distancing rules cannot be maintained indefinitely may thus explain these perceptions, in line with research showing that high prevalence negative events may engender comparative pessimism.

The implication for a second lockdown is that where people's experience so far may be that they have not been ill with COVID, they are likely to be even more comparatively optimistic than they were in March. Thinking that COVID has not happened to you so far so it is unlikely to happen to you now, can be even more dangerous than it was earlier in the spring. Both comparative optimism and comparative pessimism may have important consequences for people’s psychological well‐being and their likelihood of engaging in risk behaviours or responding to further lockdown measures.

Acces article (pdf free) Comparative optimism about infection and recovery from COVID‐19; Implications for adherence with lockdown advice

photo: Càpsules de confinament. Museu Can Framis Fundació Vilacasas. 2020 

Obra 'Sense títol' d'Eulàlia Valldosera, (Vertical)

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