A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK

Background: The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff. Methods: We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers’ perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis. Results: We included 18 qualitative studies that where on the providers’ perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners’ in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and radition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems. Conclusions: Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an ‘influencer role’ rather than being ‘responsive agents’. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes

Service utilization and suicide among people with schizophrenia spectrum disorders

Objective: To compare individuals with and without schizophrenia spectrum disorders (SSD) (schizophrenia, schizoaffective disorder, or psychotic disorder not otherwise specified) who die by suicide. Method: This is a retrospective case control study which compared all individuals who died by suicide in Ontario, Canada with (cases) and without (controls) SSD between January 1, 2008 and December 31, 2012. Cases (individuals with SSD) were compared to controls on demographics, clinical characteristics, and health service utilization proximal to suicide. A secondary analysis compared the characteristics of those with SSD and those with severe mental illness (defined as those without SSD who have had a psychiatric hospitalization within the five-years before suicide (excluding the 30 days prior to death)). Results: Among 5650 suicides, 663 (11.7%) were by individuals with SSD. Compared to other suicides, SSD suicides were significantly more likely to be between the ages of 25–34. SSD suicide victims were significantly more likely to reside in the lowest income neighbourhoods and to reside in urban areas. SSD victims were also significantly more likely to have comorbid mood and personality disorders and all types of health service utilization, including outpatient mental health service contact in the 30 days prior to death, even when compared only with those who had a history of mental health hospitalization. Conclusions: Individuals with schizophrenia spectrum disorder account for over 1 in 10 suicide deaths, tend to be younger, poorer, urban, more clinically complex, and have higher rates of mental health service contact prior to death. The demographic and service utilization differences persist even when the SSD group is compared with a population with severe mental illness that is not SSD. Suicide prevention strategies for people with schizophrenia spectrum disorder should emphasize the importance of clinical suicide risk assessment during clinical encounters, particularly early in the course of illness

Comparative safety of chronic versus intermittent benzodiazepine prescribing in older adults : a population-based cohort study

BACKGROUND: Benzodiazepine treatment recommendations for older adults differ markedly between guidelines, especially their advice on the acceptability of long-term use. AIMS: Using population-based data we compared risks associated with chronic versus intermittent benzodiazepine usage in older adults. The primary outcome was falls resulting in hospital/emergency department visits. METHODS: We undertook a retrospective population-based cohort study using linked healthcare databases in adults aged ⩾ 66 years in Ontario, Canada, with a first prescription for benzodiazepines. Chronic and intermittent benzodiazepine users, based on the 180 days from index prescription, were matched (1:2 ratio) by sex, age and propensity score, then followed for up to 360 days. Hazard ratios (HRs) for outcomes were calculated from Cox regression models. RESULTS: A total of 57,041 chronic and 113,839 matched intermittent users were included. Hospitalization/emergency department visits for falls occurred during follow up in 4.6% chronic versus 3.2% intermittent users (HR = 1.13, 95% confidence interval (CI): 1.08 to 1.19; p < 0.0001). There were significant excess risks in chronic users for most secondary outcomes: hip fractures, hospitalizations/emergency department visits, long-term care admission and death, but not wrist fractures. Adjustment for benzodiazepine dosage had minimal impact on HRs. CONCLUSION: Our study demonstrates evidence of significant excess risks associated with chronic benzodiazepine use compared to intermittent use. The excess risks may inform decision-making by older adults and clinicians about whether short- or long-term benzodiazepine use is a reasonable option for symptom management

Emergency department visits for self-harm in adolescents after release of the Netflix series ‘13 Reasons Why’

Objective:To determine whether the release of the first season of the Netflix series ‘13 Reasons Why’ was associated with changes in emergency department presentations for self-harm.Methods:Healthcare utilization databases were used to identify emergency department and outpatient presentations according to age and sex for residents of Ontario, Canada. Data from 2007 to 2018 were used in autoregressive integrated moving average models for time series forecasting with a pre-specified hypothesis that rates of emergency department presentations for self-harm would increase in the 3-month period following the release of 13 Reasons Why (1 April 2017 to 30 June 2017). Chi-square and t tests were used to identify demographic and health service use differences between those presenting to emergency department with self-harm during this epoch compared to a control period (1 April 2016 to 30 June 2016).Results:There was a significant estimated excess of 75 self-harm-related emergency department visits (+6.4 in the 3 months after 13 Reasons Why above what was predicted by the autoregressive integrated moving average model (standard error = 32.4; p = 0.02); adolescents aged 10–19 years had 60 excess visits (standard error = 30.7; p = 0.048), whereas adults demonstrated no significant change. Sex-stratified analyses demonstrated that these findings were largely driven by significant increases in females. There were no differences in demographic or health service use characteristics between those who presented to emergency department with self-harm in April to June 2017 vs April to June 2016.Conclusions:This study demonstrated a significant increase in self-harm emergency department visits associated with the release of 13 Reasons Why. It adds to previously published mortality, survey and helpline data collectively demonstrating negative mental health outcomes associated with 13 Reasons Why

Paying for Primary Care: The Relationship between Payment Change and Primary Care Physician Behaviour

The Ontario government introduced several alternatives to fee-for-service (FFS) payment for primary care physicians (PCPs), including age-sex adjusted capitation (CAP). There is concern that this reform encouraged PCPs to avoid sicker, more complex patients due to incentives inherent in the new payment schemes. This dissertation analyzed the extent to which this occurred. We conducted a series of studies using patient and PCP level administrative data (1999/00 â 2010/11) from the Institute for Clinical Evaluative Sciences to analyze changes in patient cost and case-mix across payment models in Ontario. Our data captured all Ontarians and PCPs in FFS, enhanced- FFS and CAP payment models during the study period. To ensure our findings were robust we analyzed PCP characteristics associated with selection into different payment models, and controlled for this selection effect in our analysis of the impact of the payment incentives. In our studies, we used both non-parametric (relative distribution) and parametric methods (multinomial selection models). Our results demonstrate that there are differences in cost and case-mix across payment models and that these differences were both pre-existing and a result of responses to payment incentives. PCPs who self-selected into CAP models were more likely to have healthier and wealthier patients than PCPs in FFS models. Furthermore, we found that PCPs who treated healthier patients, benefited financially from payment reform. We did find evidence that PCPs altered the composition of their rosters because of payment incentives; however, the effects were small and largely accounted for by PCP self-selection effects. The mixed CAP payment scheme allowed PCPs to treat sicker patients off roster, which may have ameliorated some of the financial incentives to risk select. Our findings demonstrate that PCPs did respond to financial incentives. In particular, PCPs self-selected into payment models, based on pre-existing characteristics that allowed them to maximize their preferences for consumption and leisure. We did not find strong evidence in support of risk-selection, but did find evidence that age-sex adjusted capitation disproportionately benefited PCPs with pre-existing patient rosters that were less complex. Future reforms to PCP payment should take into account how PCPs sort themselves into payment models, and better account for the heterogeneity of PCP and patient populations.Ph.D.2016-11-30 00:00:0

Assessing Ontario's Personal Support Worker Registry

In response to the growing role of personal support workers (PSWs) in the delivery of health care services to Ontarians, the Ontario government has moved forward with the creation of a PSW registry. This registry will be mandatory for all PSWs employed by publicly funded health care employers, and has the stated objectives of better highlighting the work that PSWs do in Ontario, providing a platform for PSWs and employers to more easily access the labour market, and to provide government with information for human resources planning. In this paper we consider the factors that brought the creation of a PSW registry onto the Ontario government’s policy agenda, discuss how the registry is being implemented, and provide an analysis of the strengths and weaknesses of this policy change

Assessing Ontario's Personal Support Worker Registry

In response to the growing role of personal support workers (PSWs) in the delivery of health care services to Ontarians, the Ontario government has moved forward with the creation of a PSW registry. This registry will be mandatory for all PSWs employed by publicly funded health care employers, and has the stated objectives of better highlighting the work that PSWs do in Ontario, providing a platform for PSWs and employers to more easily access the labour market, and to provide government with information for human resources planning. In this paper we consider the factors that brought the creation of a PSW registry onto the Ontario government’s policy agenda, discuss how the registry is being implemented, and provide an analysis of the strengths and weaknesses of this policy change. Prenant acte du rôle de plus en plus important joué par les préposés aux services de soutien à la personne (PSSP) dans les soins fournis aux Ontariens, le gouvernement de l’Ontario a décidé de créer un registre des PSSP. L’inscription dans ce registre sera obligatoire pour tout PSSP travaillant pour des employeurs financés sur fonds publics et les objectifs suivants sont poursuivis : mettre en valeur le travail des PSSP en Ontario, fournir un point d’accès au marché du travail pour les PSSP et leurs employeurs, et fournir au gouvernement l’information nécessaire pour planifier les ressources humaines dans ce domaine. Dans cet article, nous décrivons les facteurs expliquant comment la décision politique de créer un registre des PSSP a été prise, nous discutons la façon dont celui-ci est mis en place, et nous proposons une analyse des forces et limites de cette décision politique.

Who gets access to an interprofessional team-based primary care programme for patients with complex health and social needs? A cross-sectional analysis

Objectives To determine whether a voluntary referral-based interprofessional team-based primary care programme reached its target population and to assess the representativeness of referring primary care physicians.Design Cross-sectional analysis of administrative health data.Setting Ontario, Canada.Intervention TeamCare provides access to Community Health Centre services for patients of non-team physicians with complex health and social needs.Participants All adult patients who participated in TeamCare between 1 April 2015 and 31 March 2017 (n=1148), and as comparators, all non-referred adult patients of the primary care providers who shared patients in TeamCare (n=546 989), and a 1% random sample of the adult Ontario population (n=117 753).Results TeamCare patients were more likely to live in lower income neighbourhoods with a higher degree of marginalisation relative to comparison groups. TeamCare patients had a higher mean number of diagnoses, higher prevalence of all chronic conditions and had more frequent encounters with the healthcare system in the year prior to participation.Conclusions TeamCare reached a target population and fills an important gap in the Ontario primary care landscape, serving a population of patients with complex needs that did not previously have access to interprofessional team-based care.Strengths and limitations This study used population-level administrative health data. Data constraints limited the ability to identify patients referred to the programme but did not receive services, and data could not capture all relevant patient characteristics

Predicting CBT modality, treatment participation, and reliable improvements for individuals with anxiety and depression in a specialized mental health centre: a retrospective population-based cohort study

Abstract Background Cognitive Behaviour Therapy (CBT) is one of the most successful therapeutic approaches for treating anxiety and depression. Clinical trials show that for some clients, internet-based CBT (eCBT) is as effective as other CBT delivery modes. However, the fidelity of these effects may be weakened in real-world settings where clients and providers have the freedom to choose a CBT delivery mode and switch treatments at any time. The purpose of this study is to measure the CBT attendance rate and identify client-level characteristics associated with delivery mode selection and having reliable and clinically significant improvement (RCSI) of treatment in each delivery mode in a real-world CBT outpatient program. Methods This is a retrospective cohort analysis of electronic medical records collected between May 1, 2019, and March 31, 2022, at Ontario Shores Centre for Mental Health Sciences. Regression models were used to investigate the impact of individual client characteristics on participation and achieving RCSI of different CBT delivery modes. Results Our data show a high attendance rate for two and more CBT sessions across all modalities (98% of electronic, 94% of group, 100% of individual, and 99% of mixed CBT). Individuals were more likely to enter mixed and group CBT modality if they were younger, reported being employed, and reported higher depression severity at the baseline. Among the four modalities of CBT delivery, group CBT clients were least likely to have RCSI. Of those who started sessions, clients were significantly more likely to experience RCSI on the Patient Health Questionnaire (PHQ)-9 and the Generalized Anxiety Disorder (GAD)-7 if they were employed, reported more severe symptoms at baseline, and were living in the most deprived neighborhoods. Conclusions This study will contribute to the body of knowledge about the implementation and treatment planning of different CBT delivery modes in real-world settings. With the changing clinical environment, it is possible to advocate for the adoption of the eCBT intervention to improve therapy practices and achieve better treatment success. The findings can help guide future CBT program planning based on client socio-demographic characteristics, allowing the optimal therapy type to be targeted to the right client at the right time

The relationship between relational continuity and family physician follow-up after an antidepressant prescription in older adults: a retrospective cohort study

Abstract Background Side effects can occur within hours to days of starting antidepressant medications, whereas full therapeutic benefit for mood typically takes up to four weeks. This mismatch between time to harm and lag to benefit often leads to premature discontinuation of antidepressants, a phenomenon that can be partially reversed through early doctor-patient communication and follow-up. We investigated the relationship between relational continuity of care – the number of years family physicians have cared for older adult patients – and early follow-up care for patients prescribed antidepressants. Methods A retrospective cohort study was conducted on residents of Ontario, Canada aged 66 years or older who were dispensed their first antidepressant prescription through the provincial drug insurance program between April 1, 2016, and March 31, 2019. The study utilized multivariable regression to estimate the relationship between relational continuity and 30-day follow-up with the prescribing family physician. Separate estimates were generated for older adults living in urban, non-major urban, and rural communities. Results The study found a small positive relationship between relational continuity of care and follow-up care by the prescribing family physician for patients dispensed a first antidepressant prescription (RRR = 1.005; 95% CI = 1.004, 1.006). The relationship was moderated by the patients’ location of dwelling, where the effect was stronger for older adults residing in non-major urban (RRR = 1.009; 95% CI = 1.007, 1.012) and rural communities (RRR = 1.006; 95% CI = 1.002, 1.011). Conclusions Our findings do not provide strong evidence of a relationship between relational continuity of care and higher quality management of antidepressant prescriptions. However, the relationship is slightly more pronounced in rural communities where access to continuous primary care and specialized mental health services is more limited. This may support the ongoing need for the recruitment and retention of primary care providers in rural communities