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ABSTRACT: BACKGROUND: Process evaluations are recommended to open the 'black box' of complex interventions evaluated in trials, but there is limited guidance to help researchers design process evaluations. Much current literature on process evaluations of complex interventions focuses on qualitative methods, with less attention paid to quantitative methods. This discrepancy led us to develop our own framework for designing process evaluations of cluster-randomised controlled trials. METHODS: We reviewed recent theoretical and methodological literature and selected published process evaluations; these publications identified a need for structure to help design process evaluations. We drew upon this literature to develop a framework through iterative exchanges, and tested this against published evaluations. RESULTS: The developed framework presents a range of candidate approaches to understanding trial delivery, intervention implementation and the responses of targeted participants. We believe this framework will be useful to others designing process evaluations of complex intervention trials. We also propose key information that process evaluations could report to facilitate their identification and enhance their usefulness. CONCLUSION: There is no single best way to design and carry out a process evaluation. Researchers will be faced with choices about what questions to focus on and which methods to use. The most appropriate design depends on the purpose of the process evaluation; the framework aims to help researchers make explicit their choices of research questions and methods.Trial registration: Clinicaltrials.gov NCT01425502.
Trials 01/2013; 14(1):15. · 2.02 Impact Factor
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ABSTRACT: OBJECTIVE: To assess the nature and extent of physical-health comorbidities in people with schizophrenia and related psychoses compared with controls. DESIGN: Cross-sectional study. SETTING: 314 primary care practices in Scotland. PARTICIPANTS: 9677 people with a primary care record of schizophrenia or a related psychosis and 1 414 701 controls. Main outcome measures Primary care records of 32 common chronic physical-health conditions and combinations of one, two and three or more physical-health comorbidities adjusted for age, gender and deprivation status. RESULTS: Compared with controls, people with schizophrenia were significantly more likely to have one physical-health comorbidity (OR 1.21, 95% CI 1.16 to 1.27), two physical-health comorbidities (OR 1.37, 95% CI 1.29 to 1.44) and three or more physical-health comorbidities (OR 1.19, 95% CI 1.12 to 1.27). Rates were highest for viral hepatitis (OR 3.98, 95% CI 2.81 to 5.64), constipation (OR 3.24, 95% CI 3.00 to 4.49) and Parkinson's disease (OR 3.07, 95% CI 2.42 to 3.88) but people with schizophrenia had lower recorded rates of cardiovascular disease, including atrial fibrillation (OR 0.62, 95% CI 0.51 to 0.73), hypertension (OR 0.71, 95% CI 0.67 to 0.76), coronary heart disease (OR 0.75, 95% CI 0.61 to 0.71) and peripheral vascular disease (OR 0.83, 95% CI 0.71 to 0.97). CONCLUSIONS: People with schizophrenia have a wide range of comorbid and multiple physical-health conditions but are less likely than people without schizophrenia to have a primary care record of cardiovascular disease. This suggests a systematic under-recognition and undertreatment of cardiovascular disease in people with schizophrenia, which might contribute to substantial premature mortality observed within this patient group.
BMJ open. 01/2013; 3(4).
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ABSTRACT: here is a symp-tom of the most common kind, a symptom which, when understood, throws a flood of light upon the patient's state, and yet you, who reckon to be able to teach students how to examine patients, have never given it the slightest consideration.'' I quote this incident to show what should be the first step in investigating disease, and the only individual whose opportunity permits him to take it. The neces-sity that the general practitioner should participate in other fields of research is obvious as soon as a real perception of medical research is obtained. I know quite well that these views at present will fail to carry conviction. All I wish you to do is to pause from time to time and ask whether they are true.
International Journal of Epidemiology 12/2012; 41(6):1518-22. · 6.41 Impact Factor
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ABSTRACT: OBJECTIVE: to compare the prescription of psychotropic medications for patients living in care homes with that for patients living at home.Design and setting: retrospective population database study in the Tayside region of Scotland. SUBJECTS: 70,297 patients aged ≥65 and followed until death or the end of the study. METHODS: examining registered addresses for all people aged 65-99 identified those in care. The prescriptions for a 12-week period was examined and psychotropic drug use compared by their place of residence. Comparisons of prescriptions pre- and post-admission were performed for people admitted to a care home from Jan 2005 to Dec 2006. RESULTS: people living in care (4.1%) received 9.80 more prescribed items (P < 0.001) from 1.63 more British National Formulary (BNF) categories (P < 0.001) than people living at home over a 12-week period. They were more likely to receive any psychotropic medication (42 versus 16%, odds ratio (OR) 3.09, 95% CI: 2.79-3.41).Over 70% of 1,715 people admitted to care homes during the study who received psychotropic medication commenced the medication prior to admission. Patients who started anti-psychotics in the 30 days prior to admission were less likely to have stopped them (OR: 0.53, 95% CI: 0.30-0.94). CONCLUSION: prolonged prescription of psychotropic medications is commonplace in care home residents. Almost half of the people prescribed antipsychotic drugs received them for a minimum of 6 months. Systematic medication reviews must be established in all care homes to promote safe and effective prescription to this at-risk population.
Age and Ageing 09/2012; · 3.09 Impact Factor
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ABSTRACT: BACKGROUND: Trials of complex interventions are criticized for being 'black box', so the UK Medical Research Council recommends carrying out a process evaluation to explain the trial findings. We believe it is good practice to pre-specify and publish process evaluation protocols to set standards and minimize bias. Unlike protocols for trials, little guidance or standards exist for the reporting of process evaluations. This paper presents the mixed-method process evaluation protocol of a cluster randomized trial, drawing on a framework designed by the authors.Methods/designThis mixed-method evaluation is based on four research questions and maps data collection to a logic model of how the data-driven quality improvement in primary care (DQIP) intervention is expected to work. Data collection will be predominately by qualitative case studies in eight to ten of the trial practices, focus groups with patients affected by the intervention and quantitative analysis of routine practice data, trial outcome and questionnaire data and data from the DQIP intervention. DISCUSSION: We believe that pre-specifying the intentions of a process evaluation can help to minimize bias arising from potentially misleading post-hoc analysis. We recognize it is also important to retain flexibility to examine the unexpected and the unintended. From that perspective, a mixed-methods evaluation allows the combination of exploratory and flexible qualitative work, and more pre-specified quantitative analysis, with each method contributing to the design, implementation and interpretation of the other.As well as strengthening the study the authors hope to stimulate discussion among their academic colleagues about publishing protocols for evaluations of randomized trials of complex interventions.Data-driven quality improvement in primary care trial registrationClinicalTrials.gov: NCT01425502.
Trials 08/2012; 13(1):154. · 2.02 Impact Factor
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ABSTRACT: Long-term disorders are the main challenge facing health-care systems worldwide, but health systems are largely configured for individual diseases rather than multimorbidity. We examined the distribution of multimorbidity, and of comorbidity of physical and mental health disorders, in relation to age and socioeconomic deprivation.
In a cross-sectional study we extracted data on 40 morbidities from a database of 1,751,841 people registered with 314 medical practices in Scotland as of March, 2007. We analysed the data according to the number of morbidities, disorder type (physical or mental), sex, age, and socioeconomic status. We defined multimorbidity as the presence of two or more disorders.
42·2% (95% CI 42·1-42·3) of all patients had one or more morbidities, and 23·2% (23·08-23·21) were multimorbid. Although the prevalence of multimorbidity increased substantially with age and was present in most people aged 65 years and older, the absolute number of people with multimorbidity was higher in those younger than 65 years (210,500 vs 194,996). Onset of multimorbidity occurred 10-15 years earlier in people living in the most deprived areas compared with the most affluent, with socioeconomic deprivation particularly associated with multimorbidity that included mental health disorders (prevalence of both physical and mental health disorder 11·0%, 95% CI 10·9-11·2% in most deprived area vs 5·9%, 5·8%-6·0% in least deprived). The presence of a mental health disorder increased as the number of physical morbidities increased (adjusted odds ratio 6·74, 95% CI 6·59-6·90 for five or more disorders vs 1·95, 1·93-1·98 for one disorder), and was much greater in more deprived than in less deprived people (2·28, 2·21-2·32 vs 1·08, 1·05-1·11).
Our findings challenge the single-disease framework by which most health care, medical research, and medical education is configured. A complementary strategy is needed, supporting generalist clinicians to provide personalised, comprehensive continuity of care, especially in socioeconomically deprived areas.
Scottish Government Chief Scientist Office.
The Lancet 05/2012; 380(9836):37-43. · 38.28 Impact Factor
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ABSTRACT: High-risk prescribing of non-steroidal anti-inflammatory drugs (NSAIDs) and antiplatelet agents accounts for a significant proportion of hospital admissions due to preventable adverse drug events. The recently completed PINCER trial has demonstrated that a one-off pharmacist-led information technology (IT)-based intervention can significantly reduce high-risk prescribing in primary care, but there is evidence that effects decrease over time and employing additional pharmacists to facilitate change may not be sustainable.
We will conduct a cluster randomised controlled with a stepped wedge design in 40 volunteer general practices in two Scottish health boards. Eligible practices are those that are using the INPS Vision clinical IT system, and have agreed to have relevant medication-related data to be automatically extracted from their electronic medical records. All practices (clusters) that agree to take part will receive the data-driven quality improvement in primary care (DQIP) intervention, but will be randomised to one of 10 start dates. The DQIP intervention has three components: a web-based informatics tool that provides weekly updated feedback of targeted prescribing at practice level, prompts the review of individual patients affected, and summarises each patient's relevant risk factors and prescribing; an outreach visit providing education on targeted prescribing and training in the use of the informatics tool; and a fixed payment of 350 GBP (560 USD; 403 EUR) up front and a small payment of 15 GBP (24 USD; 17 EUR) for each patient reviewed in the 12 months of the intervention. We hypothesise that the DQIP intervention will reduce a composite of nine previously validated measures of high-risk prescribing. Due to the nature of the intervention, it is not possible to blind practices, the core research team, or the data analyst. However, outcome assessment is entirely objective and automated. There will additionally be a process and economic evaluation alongside the main trial.
The DQIP intervention is an example of a potentially sustainable safety improvement intervention that builds on the existing National Health Service IT-infrastructure to facilitate systematic management of high-risk prescribing by existing practice staff. Although the focus in this trial is on Non-steroidal anti-inflammatory drugs and antiplatelets, we anticipate that the tested intervention would be generalisable to other types of prescribing if shown to be effective.
ClinicalTrials.gov, dossier number: NCT01425502.
Implementation Science 03/2012; 7:24. · 3.10 Impact Factor
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ABSTRACT: INTRODUCTION: High-risk prescribing in primary care is common and causes considerable harm. Feedback interventions to improve care are attractive because they are relatively cheap to widely implement. There is good evidence that feedback has small to moderate effects, but the most recent Cochrane review called for more high-quality, large trials that explicitly test different forms of feedback. METHODS AND ANALYSIS: The study is a three-arm cluster-randomised trial with general practices being randomised and outcomes measured at patient level. 262 practices in three Scottish Health Board areas have been randomised (94% of all possible practices). The two active arms receive different forms of prescribing safety data feedback, with rates of high-risk prescribing compared with a 'usual care' arm. Sample size estimation used baseline data from participating practices. With 85 practices randomised to each arm, then there is 93% power to detect a 25% difference in the percentage of high-risk prescribing (from 6.1% to 4.5%) between the usual care arm and each intervention arm. The primary outcome is a composite of six high-risk prescribing measures (antipsychotic prescribing to people aged ≥75 years; non-steroidal anti-inflammatory drug (NSAID) prescribing to people aged ≥75 without gastroprotection; NSAID prescribing to people prescribed aspirin/clopidogrel without gastroprotection; NSAID prescribing to people prescribed an ACE inhibitor/angiotensin receptor blocker and a diuretic; NSAID prescription to people prescribed an oral anticoagulant without gastroprotection; aspirin/clopidogrel prescription to people prescribed an oral anticoagulant without gastroprotection). The primary analysis will use multilevel modelling to account for repeated measurement of outcomes in patients clustered within practices. ETHICS AND DISSEMINATION: The study was reviewed and approved by the NHS Tayside Committee on Medical Research Ethics B (11/ES/0001). The study will be disseminated via a final report to the funder with a publicly available research summary, and peer reviewed publications. TRIAL REGISTRATION: ClinicalTrials.gov, dossier number NCT01602705.
BMJ open. 01/2012; 2(6).
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ABSTRACT: Addressing the problem of preventable drug related morbidity (PDRM) in primary care is a challenge for health care systems internationally. The increasing implementation of clinical information systems in the UK and internationally provide new opportunities to systematically identify patients at risk of PDRM for targeted medication review. The objectives of this study were (1) to develop a set of explicit medication assessment criteria to identify patients with sub-optimally effective or high-risk medication use from electronic medical records and (2) to identify medication use topics that are perceived by UK primary care clinicians to be priorities for quality and safety improvement initiatives.
For objective (1), a 2-round consensus process based on the RAND/UCLA Appropriateness Method (RAM) was conducted, in which candidate criteria were identified from the literature and scored by a panel of 10 experts for 'appropriateness' and 'necessity'. A set of final criteria was generated from candidates accepted at each level. For objective (2), thematically related final criteria were clustered into 'topics', from which a panel of 26 UK primary care clinicians identified priorities for quality improvement in a 2-round Delphi exercise.
(1) The RAM process yielded a final set of 176 medication assessment criteria organised under the domains 'quality' and 'safety', each classified as targeting 'appropriate/necessary to do' (quality) or 'inappropriate/necessary to avoid' (safety) medication use. Fifty-two final 'quality' assessment criteria target patients with unmet indications, sub-optimal selection or intensity of beneficial drug treatments. A total of 124 'safety' assessment criteria target patients with unmet needs for risk-mitigating agents, high-risk drug selection, excessive dose or duration, inconsistent monitoring or dosing instructions. (2) The UK Delphi panel identified 11 (23%) of 47 scored topics as 'high priority' for quality improvement initiatives in primary care.
The developed criteria set complements existing medication assessment instruments in that it is not limited to the elderly, can be implemented in electronic data sets and focuses on drug groups and conditions implicated in common and/or severe PDRM in primary care. Identified priorities for quality and safety improvement can guide the selection of targets for initiatives to address the PDRM problem in primary care.
BMC Clinical Pharmacology 01/2012; 12:5. · 1.36 Impact Factor
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BMJ (Clinical research ed.). 01/2012; 345:e5559.
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ABSTRACT: Antidepressant prescribing is increasing worldwide, prompting policy interventions and targets to halt the rise.
To examine time trends in GP antidepressant prescribing using patient-level data.
Longitudinal population database of all community pharmacy dispensed prescriptions for all 325,000 residents of the Tayside region of Scotland.
In each of 3 study years (1995/1996, 2000/2001 and 2006/2007), the volume of antidepressants prescribed was calculated, and numbers of patients prescribed antidepressants in each year, mean treatment duration, and mean dose per patient in that year examined using descriptive statistics.
Total drug volume increased threefold between 1995/1996 and 2006/2007, largely driven by increases in selective serotonin reuptake inhibitor (SSRI) prescribing, and laterally also in 'other' antidepressant prescribing. Tricyclic prescribing is static, but low-dose amitriptyline increasingly dominates this drug class. Increased drug volume was initially driven by increasing patient numbers (from 8.0% of the population prescribed at least once in 1995/1996 to 11.9% in 2000/2001) and increased treatment duration (from 170 days in the measurement year to 200). Latterly, drug volume increases are increasingly attributable to longer duration of treatment and higher mean daily dose.
The large rise in antidepressant volumes is caused by a complex mixture of more patients being prescribed SSRI and 'other' antidepressants, the use of higher doses, and longer durations of treatment, with the balance changing overtime. Tricyclic prescribing is now largely low dose, and probably for conditions other than depression. Interventions to improve the quality of antidepressant prescribing need to be more subtle than blanket targets to reduce the total volume of antidepressants prescribed.
British Journal of General Practice 09/2011; 61(590):e565-72. · 1.83 Impact Factor
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ABSTRACT: Influenza immunisation is recommended for all people aged ≥65 years and younger people with particular chronic diseases. The Quality and Outcomes Framework (QOF) has provided new financial incentives for influenza immunisation since 2004.
To determine the impact of the 2004 UK General Medical Services contract on the overall uptake of, and socioeconomic inequalities associated with, influenza immunisation.
Retrospective general-practice population database analysis in 15 general practices in Scotland, UK.
Changes in influenza-immunisation uptake for those in at-risk groups between 2003-2004 and 2006-2007 were measured, and variation in uptake examined using multilevel modelling.
Uptake rose from 67.9% in 2003-2004 to 71.4% in 2006-2007. The largest increases were seen in those aged <65 years with chronic disease, with uptake rising from 49.6% to 58.4%, but rates remained considerably lower than in those aged ≥65 years. Differences between practices narrowed (median odds ratio [OR] for two patients randomly selected from different practices: 2.13 (95% confidence interval [CI] = 2.00 to 2.26) in 2003-2004 versus 1.44 (95% CI = 1.40 to 1.49) in 2006-2007. However, inequalities in uptake by patient socioeconomic status did not change: adjusted OR for most deprived versus most affluent was 0.75 (95% CI = 0.70 to 0.80) in 2003-2004 versus 0.72 (95% CI = 0.68 to 0.76) in 2006-2007.
Overall uptake rose significantly and differences between practices narrowed considerably. However, socioeconomic and age inequalities in influenza immunisation persisted in the first 3 years of the QOF. This contrasts with other ecological analyses, which have concluded that the QOF has reduced inequalities. The impact of financial incentives on inequalities is likely to vary, and some kinds of care may require more targeted improvement activity and support.
British Journal of General Practice 07/2011; 61(588):e379-85. · 1.83 Impact Factor
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Catherine A O 'donnell,
Adele Ring,
Gary Mclean,
Suzanne Grant, Bruce Guthrie,
Mark Gabbay,
Frances S Mair,
Caroline Carlisle,
David Heaney,
Matthew Sutton,
Graham C M Watt
04/2011;
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ABSTRACT: To examine the prevalence and patterns of high risk prescribing, defined as potentially inappropriate prescribing of drugs to primary care patients particularly vulnerable to adverse drug events.
Cross sectional population database analysis.
General practices in Scotland.
315 Scottish general practices with 1.76 million registered patients, 139 404 (7.9%) of whom were defined as particularly vulnerable to adverse drug events because of age, comorbidity, or co-prescription.
How reliably each of 15 indicators-four each for non-steroidal anti-inflammatory drugs, co-prescription with warfarin, and prescribing in heart failure, two for dose instructions for methotrexate, and one for antipsychotic prescribing in dementia-and a composite of all 15 could distinguish practices in terms of their rates of high risk prescribing; and characteristics of patients and practices associated with high risk prescribing in a multilevel model.
19 308 of 139 404 (13.9%, 95% confidence interval 13.7% to 14.0%) patients had received at least one high risk prescription in the past year. This composite indicator was a reasonably reliable measure of practice rates of high risk prescribing (reliability >0.7 for 95.6% of practices, >0.8 for 88.2%). The patient characteristic most strongly associated with high risk prescribing was the number of drugs prescribed (>11 long term prescribed drugs v 0; odds ratio 7.90, 95% confidence interval 7.19 to 8.68). After adjustment for patient characteristics, rates of high risk prescribing varied by fourfold between practices, which was not explained by structural characteristics of the practices.
Almost 14% of patients defined as particularly vulnerable to adverse drug events were prescribed one or more high risk drugs. The composite indicator of high risk prescribing used could identify practices as having above average or below average high risk prescribing rates with reasonable confidence. After adjustment, only the number of drugs prescribed long term to patients was strongly associated with high risk prescribing, and considerable unexplained variation existed between practices. High risk prescribing will often be appropriate, but the large variation between practices suggests opportunities for improvement.
BMJ (Clinical research ed.). 01/2011; 342:d3514.
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ABSTRACT: To understand general practitioners' (GPs) and practice nurses' (PNs) experiences of managing multimorbidity in deprived areas and elicit views on what might help.
Qualitative interviews with 19 GPs and PNs in four practices with a high percentage of patients living in the top 15% most deprived areas of Scotland. Data were analysed using constant comparison.
Professionals' discussions of how they managed multimorbidity captured: (1) definitions of multimorbidity that included multiple social, psychological, and health problems associated with deprivation; (2) descriptions of the 'endless struggle' of patients trying to manage illnesses in the midst of chaotic lives with limited personal, social, and material resources; (3) accounts of the ongoing struggle of professionals trying to manage, with personal consequences for some; and (4) ideas on what might help, including 'whole person' approaches.
Professionals' discussions of the difficulties that they face personally and attempt to help those most in need reflect both the continuing existence of the 'inverse care law' and the need for whole system changes to enhance the effectiveness of primary care for patients with multimorbidity in deprived areas.
Chronic Illness 10/2010; 7(1):45-59.
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ABSTRACT: to compare psychotropic prescribing in older people with dementia and the general elderly population.
retrospective population database study in 315 General Practices.
there were 271,365 patients aged > or = 65, of which 10,058 (3.7%) recorded as having dementia.
epidemiology of psychotropic prescribing in older people with and without dementia; multilevel modelling of patient and practice characteristics associated with antipsychotic prescribing.
people with dementia were currently prescribed an antipsychotic drug (17.7%), an antidepressant (28.7%) and a hypnotic/anxiolytic (16.7%). Compared to the general elderly population, antipsychotic prescribing was 17.4 [95% confidence interval (CI) 16.4-18.4], antidepressant prescribing 2.7 (95% CI 2.6-1.8) and hypnotic/anxiolytics 2.2 (95% 2.1-2.3) times more likely in people with dementia. Most antipsychotic prescribing in people with dementia was prolonged (> 16 weeks). Patients living in more deprived areas and registered with larger and more remote practices were more likely to be prescribed prolonged antipsychotics.
over one in six patients are currently prescribed antipsychotic drugs known to be of little benefit and causing significant harm, with other psychotropics equally commonly used. Changing this will require investment in services to support alternative management strategies for people with behavioural and psychological disturbance associated with dementia.
Age and Ageing 09/2010; 39(5):637-42. · 3.09 Impact Factor
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ABSTRACT: Financial incentives may increase performance on targeted activities and have unintended consequences for untargeted activities. An innovative pay-for-performance scheme was introduced for UK general practices in 2004. It incentivised particular quality indicators for targeted groups of patients. We estimate the intended and unintended consequences of this Quality and Outcomes Framework (QOF) using dynamic panel probit models estimated on individual patient records from 315 general practices over the period 2000/1-2005/6. We focus on annual rates of recording of blood pressure, smoking status, cholesterol, body mass index and alcohol consumption. The recording of each risk factor is designated as incentivised or unincentivised for each individual based on whether they have one of the diseases targeted by the QOF. The effect on incentivised factors was substantially larger on the targeted patient groups (+19.9 percentage points) than on the untargeted groups (+5.3 percentage points). There was no obvious evidence of effort diversion but there was evidence of substantial positive spillovers (+10.9 percentage points) onto unincentivised factors for the targeted groups. Moreover, provider responses were larger on those indicators for which more stringent standards were set and greater rewards offered. We conclude that the incentives induced providers to improve targeted quality and make investments in quality that extended beyond the scheme. We estimate that the average provider was paid pound20 500 for recording 410 additional items of information on the risk factors targeted by the financial incentives. Allowance for the positive spillovers reduces the estimated average reward from pound50 to pound25 per additional record.
Health Economics 03/2009; 19(1):1-13. · 2.12 Impact Factor
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ABSTRACT: The 2004 new General Medical Services (nGMS) contract exemplifies trends across the public services towards increased definition, measurement and regulation of professional work, with general practice income now largely dependent on the quality of care provided across a range of clinical and organisational indicators known collectively as the 'Quality and Outcomes Framework' (QOF). This paper reports an ethnographically based study of the impact of the new contract and the financial incentives contained within it on professional boundaries in UK general practice. The distribution of clinical and administrative work has changed significantly and there has been a new concentration of authority, with QOF decision making and monitoring being led by an internal QOF team of clinical and managerial staff who make the major practice-level decisions about QOF, monitor progress against targets, and intervene to resolve areas or indicators at risk of missing targets. General practitioners and nurses, however, appear to have accommodated these changes by re-creating long established narratives on professional boundaries and clinical hierarchies. This paper is concerned with the impact of these new arrangements on existing clinical hierarchies.
Sociology of Health & Illness 11/2008; 31(2):229-45. · 1.88 Impact Factor
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ABSTRACT: An innovative and expensive performance-related pay scheme was introduced for general practices across the UK in 2004. It was not piloted and baseline performance data were not collected prior to its introduction. We estimate the impact of this Quality and Outcomes Framework (QOF) by analysing annual rates of recording of blood pressure, smoking status, cholesterol, body mass index and alcohol consumption based on individual patient records from 315 general practices over the period 2000/1 to 2005/6. The recording of each risk factor is designated as incentivised or unincentivised for each individual based on whether they have one of the diagnoses targeted by the QOF. The estimated impact is sensitive to the dynamic specification of the recording process and was substantially larger on the targeted patient groups (+19.9 percentage points) than the untargeted groups (+5.3). We also find positive spillovers of (+10.9) for the targeted groups onto unincentivised factors. We propose that the intended rewards per additional record were under-estimated, because account was not taken of substantial multiple-payment for co-morbid patients, levels of pre-QOF recording and the additional rewards available for risk factor control that would be achieved by measurement alone. Based on naïve assumptions, we estimate the intended financial reward per additional risk factor record to be £4.40. Allowing for co-morbidity, pre-QOF performance and the additional ‘control’ rewards, increases this average reward eleven-fold, to £48.90. Taking account of the positive spillovers reduces this figure to £25.10, but it remains substantially larger than what appears to have been intended.
09/2008;
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ABSTRACT: The Shipman Inquiry recommended mortality rate monitoring if it could be 'shown to be workable' in detecting a future mass murderer in general practice.
To examine the effectiveness of cumulative sum (CUSUM) charts, cross-sectional Shewhart charts, and exponentially-weighted, moving-average control charts in mortality monitoring at practice level.
Analysis of Scottish routine general practice data combined with estimation of control chart effectiveness in detecting a 'murderer' in a simulated dataset.
Practice stability was calculated from routine data to determine feasible lengths of monitoring. A simulated dataset of 405,000 'patients' was created, registered with 75 'practices' whose underlying mortality rates varied with the same distribution as case-mix-adjusted mortality in all Scottish practices. The sensitivity of each chart to detect five and 10 excess deaths was examined in repeated simulations. The sensitivity of control charts to excess deaths in simulated data, and the number of alarm signals when control charts were applied to routine data were estimated.
Practice instability limited the length of monitoring and modelling was consequently restricted to a 3-year period. Monitoring mortality over 3 years, CUSUM charts were most sensitive but only reliably achieved >50% successful detection for 10 excess deaths per year and generated multiple false alarms (>15%).
At best, mortality monitoring can act as a backstop to detect a particularly prolific serial killer when other means of detection have failed. Policy should focus on changes likely to improve detection of individual murders, such as reform of death certification and the coroner system.
British Journal of General Practice 05/2008; 58(550):311-7. · 1.83 Impact Factor
