Patient experience of general practice and use of emergency hospital services in England: regression analysis of national cross-sectional time series data.

BACKGROUND: The UK Government has introduced several national policies to improve access to primary care. We examined associations between patient experience of general practice and rates of visits to accident and emergency (A&E) departments and emergency hospital admissions in England. METHODS: The study included 8124 general practices between 2011-2012 and 2013-2014. Outcome measures were annual rates of A&E visits and emergency admissions by general practice population, according to administrative hospital records. Explanatory variables included three patient experience measures from the General Practice Patient Survey: practice-level means of experience of making an appointment, satisfaction with opening hours and overall experience (on 0-100 scales). The main analysis used random-effects Poisson regression for cross-sectional time series. Five sensitivity analyses examined changes in model specification. RESULTS: Mean practice-level rates of A&E visits and emergency admissions increased from 2011-2012 to 2013-2014 (310.3-324.4 and 98.8-102.9 per 1000 patients). Each patient experience measure decreased; for example, mean satisfaction with opening hours was 79.4 in 2011-2012 and 76.6 in 2013-2014. In the adjusted regression analysis, an SD increase in experience of making appointments (equal to 9 points) predicted decreases of 1.8% (95% CI -2.4% to -1.2%) in A&E visit rates and 1.4% (95% CI -1.9% to -0.9%) in admission rates. This equalled 301 174 fewer A&E visits and 74 610 fewer admissions nationally per year. Satisfaction with opening hours and overall experience were not consistently associated with either outcome measure across the main and sensitivity analyses. CONCLUSIONS: Associations between patient experience of general practice and use of emergency hospital services were small or inconsistent. In England, realistic short-term improvements in patient experience of general practice may only have modest effects on A&E visits and emergency admissions

Integrating a nationally scaled workforce of community health workers in primary care: a modelling study.

Objective To model cost and benefit of a national community health worker workforce. Design Modelling exercise based on all general practices in England. Setting United Kingdom National Health Service Primary Care. Participants Not applicable. Data sources Publicly available data on general practice demographics, population density, household size, salary scales and screening and immunisation uptake. Main outcome measures We estimated numbers of community health workers needed, anticipated workload and likely benefits to patients. Results Conservative modelling suggests that 110,585 community health workers would be needed to cover the general practice registered population in England, costing £2.22bn annually. Assuming community health workerss could engage with and successfully refer 20% of eligible unscreened or unimmunised individuals, an additional 753,592 cervical cancer screenings, 365,166 breast cancer screenings and 482,924 bowel cancer screenings could be expected within respective review periods. A total of 16,398 additional children annually could receive their MMR1 at 12 months and 24,716 their MMR2 at five years of age. Community health workerss would also provide home-based health promotion and lifestyle support to patients with chronic disease. Conclusion A scaled community health worker workforce integrated into primary care may be a valuable policy alternative. Pilot studies are required to establish feasibility and impact in NHS primary care

Importance of accessibility and opening hours to overall patient experience of general practice: analysis of repeated cross-sectional data from a national patient survey.

BACKGROUND: The UK government aims to improve the accessibility of general practices in England, particularly by extending opening hours in the evenings and at weekends. It is unclear how important these factors are to patients' overall experiences of general practice. AIM: To examine associations between overall experience of general practice and patient experience of making appointments and satisfaction with opening hours. DESIGN AND SETTING: Analysis of repeated cross-sectional data from the General Practice Patient Surveys conducted from 2011-2012 until 2013-2014. These covered 8289 general practice surgeries in England. METHOD: Data from a national survey conducted three times over consecutive years were analysed. The outcome measure was overall experience, rated on a five-level interval scale. Associations were estimated as standardised regression coefficients, adjusted for responder characteristics and clustering within practices using multilevel linear regression. RESULTS: In total, there were 2 912 535 responders from all practices in England (n = 8289). Experience of making appointments (β 0.24, 95% confidence interval [CI] = 0.24 to 0.25) and satisfaction with opening hours (β 0.15, 95% CI = 0.15 to 0.16) were modestly associated with overall experience. Overall experience was most strongly associated with GP interpersonal quality of care (β 0.34, 95% CI = 0.34 to 0.35) and receptionist helpfulness was positively associated with overall experience (β 0.16, 95% CI = 0.16 to 0.17). Other patient experience measures had minimal associations (β≤0.06). Models explained ≥90% of variation in overall experience between practices. CONCLUSION: Patient experience of making appointments and satisfaction with opening hours were only modestly associated with overall experience. Policymakers in England should not assume that recent policies to improve access will result in large improvements in patients' overall experience of general practice

A novel approach selected small sets of diagnosis codes with high prediction performance in large healthcare datasets.

OBJECTIVES: The objective of the study was to examine an approach for selecting small sets of diagnosis codes with high prediction performance in large datasets of electronic medical records. STUDY DESIGN AND SETTING: This was a modeling study using national hospital and mortality records for patients with myocardial infarction (n = 200,119), hip fracture (n = 169,646), or colorectal cancer surgery (n = 56,515) in England in 2015-2017. One-year mortality was predicted from ICD-10 codes recorded for at least 0.5% of patients using logistic regression ('full' models). An approximation method was used to select fewer codes that explained at least 95% of variation in full model predictions ('reduced' models). RESULTS: One-year mortality was 17.2% (34,520) after myocardial infarction, 27.2% (46,115) after hip fracture, and 9.3% (5,273) after colorectal surgery. Full models included 202, 257, and 209 ICD-10 codes in these populations. C-statistics for these models were 0.884 (95% confidence interval (CI) 0.882, 0.886), 0.798 (0.795, 0.800), and 0.810 (0.804, 0.817). Reduced models included 18, 33, and 41 codes and had c-statistics of 0.874 (95% CI 0.872, 0.876), 0.791 (0.788, 0.793), and 0.807 (0.801, 0.813). Performance was also similar when measured using Brier scores. All models were well calibrated. CONCLUSION: Our approach selected small sets of diagnosis codes that predicted patient outcomes comparably to large, comprehensive sets of codes

Physical multimorbidity, health service use and catastrophic health expenditure by socio-economic groups in China::a population-based panel data analysis

Background Multimorbidity, the presence of two or more mental or physical chronic non-communicable diseases (NCDs), is a major challenge for the health system in China, which faces unprecedented ageing of its population. This study examined: (1) the distribution of physical multimorbidity in relation to socio-economic status, (2) the relationships between physical multimorbidity, healthcare service use, and catastrophic health expenditures, and (3) whether these relationships varied by socio-economic groups and social health insurance schemes. Methods Panel data study design utilized three waves of the nationally-representative China Health and Retirement Longitudinal Study (CHARLS 2011, 2013, 2015), which included 11 718 participants aged ≥50 years, and 11 physical NCDs. Findings Overall, 62% of participants had physical multimorbidity in China in 2015. Multimorbidity increased with age, female gender, higher per capita household expenditure, and higher educational level. However, multimorbidity was more common in poorer regions compared with the most affluent regions. An additional chronic NCD was associated with an increase in the number of outpatient visits of 28.8% (IRR=1.29, 95% CI: 1.27 to 1.31), and days of hospitalisation (IRR=1.38, 95% CI: 1.35 to 1.41). There were similar effects in different socio-economic groups and among those covered by different social health insurance programmes. Overall, multimorbidity was associated with a substantially greater odds of experiencing CHE (AOR=1·29 for the overall population, 95% CI=1·26, 1·32). The effect of multimorbidity on catastrophic health expenditures persisted even among the higher socio-economic groups and those with more generous health insurance coverage. Interpretation Multimorbidity was associated with higher levels of health service use and greater financial burden. Concerted efforts are needed to reduce health inequalities that arise due to multimorbidity, and its adverse economic impact in population groups in China. Social health insurance reforms must place emphasis on reducing out-of-pocket spending for patients with multimorbidity to provide greater financial risk protection

Rural and urban differences in health system performance among older Chinese adults : Cross-sectional analysis of a national sample

Background: Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China. Method: We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain. Findings: Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64). Conclusion: Our findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities

Access to general practice and visits to accident and emergency departments in England: cross-sectional analysis of a national patient survey.

BACKGROUND: The annual number of unplanned attendances at accident and emergency (A&E) departments in England increased by 11% (2.2 million attendances) between 2008-2009 and 2012-2013. A national review of urgent and emergency care has emphasised the role of access to primary care services in preventing A&E attendances. AIM: To estimate the number of A&E attendances in England in 2012-2013 that were preceded by the attending patient being unable to obtain an appointment or a convenient appointment at their general practice. DESIGN AND SETTING: Cross-sectional analysis of a national survey of adults registered with a GP in England. METHOD: The number of general practice consultations in England in 2012-2013 was estimated by extrapolating the linear trend of published data for 2000-2001 to 2008-2009. This parameter was multiplied by the ratio of attempts to obtain a general practice appointment that resulted in an A&E attendance to attempts that resulted in a general practice consultation estimated using the GP Patient Survey 2012-2013. A sensitivity analysis varied the number of consultations by ±12% and the ratio by ±25%. RESULTS: An estimated 5.77 million (99.9% confidence interval = 5.49 to 6.05 million) A&E attendances were preceded by the attending patient being unable to obtain a general practice appointment or a convenient appointment, comprising 26.5% of unplanned A&E attendances in England in 2012-2013. The sensitivity analysis produced values between 17.5% and 37.2% of unplanned A&E attendances. CONCLUSION: A large number of A&E attendances are likely to be preceded by unsuccessful attempts to obtain convenient general practice appointments in England each year