Keep it Simple? Predicting Primary Health Care Costs with Measures of Morbidity and Multimorbidity

In this paper we investigate the relationship between patients’ primary care costs (consultations, tests, drugs) and their age, gender, deprivation and alternative measures of their morbidity and multimorbidity. Such information is required in order to set capitation fees or budgets for general practices to cover their expenditure on providing primary care services. It is also useful to examine whether practices’ expenditure decisions vary equitably with patient characteristics. Electronic practice record keeping systems mean that there is very rich information on patient diagnoses. But the diagnostic information (with over 9000 possible diagnoses) is too detailed to be practicable for setting capitation fees or practice budgets. Some method of summarizing such information into more manageable measures of morbidity is required. We therefore compared the ability of eight measures of patient morbidity and multimorbidity to predict future primary care costs using data on 86,100 individuals in 174 English practices. The measures were derived from four morbidity descriptive systems (17 chronic diseases in the Quality and Outcomes Framework (QOF), 17 chronic diseases in the Charlson scheme, 114 Expanded Diagnosis Clusters (EDCs), and 68 Adjusted Clinical Groups (ACGs)). We found that, in general, for a given disease description system, counts of diseases and sets of disease dummy variables had similar explanatory power and that measures with more categories did better than those with fewer. The EDC measures performed best, followed by the QOF and ACG measures. The Charlson measures had the worst performance but still improved markedly on models containing only age, gender, deprivation and practice effects. Allowing for individual patient morbidity greatly reduced the association of age and cost. There was a pro-deprived bias in expenditure: after allowing for morbidity, patients in areas in the highest deprivation decile had costs which were 22% higher than those in the lowest deprivation decile. The predictive ability of the best performing morbidity and multimorbidity measures was very good for this type of individual level cross section data, with R2 ranging from 0.31 to 0.46. The statistical method of estimating the relationship between patient characteristics and costs was less important than the type of morbidity measure. Rankings of the morbidity and multimorbidity measures were broadly similar for generalised linear models with log link and Poisson errors and for OLS estimation. It would be currently feasible to combine the results from our study with the data on the number of patients with each QOF disease, which is available on all practices in England, to calculate budgets for general practices to cover their primary care costs.multimorbidity; primary care; utilisation; costs; deprivation; budgets

A Novel Approach for a Low-Cost Deployable Antenna

The Naval Research Laboratory (NRL) has designed, built, and fully qualified a low cost, low Passive Intermodulation (PIM) 12-foot (3.66-m) diameter deployable ultra high frequency (UHF) antenna for the Tacsat-4 program. The design utilized novel approaches in reflector material and capacitive coupling techniques. This paper discusses major design trades, unique design characteristics, and lessons learned from the development of the Tacsat 4 deployable antenna. This antenna development was sponsored by the Office of Naval Research

Keep it simple? Predicting primary health care costs with clinical morbidity measures

AbstractModels of the determinants of individuals’ primary care costs can be used to set capitation payments to providers and to test for horizontal equity. We compare the ability of eight measures of patient morbidity and multimorbidity to predict future primary care costs and examine capitation payments based on them. The measures were derived from four morbidity descriptive systems: 17 chronic diseases in the Quality and Outcomes Framework (QOF); 17 chronic diseases in the Charlson scheme; 114 Expanded Diagnosis Clusters (EDCs); and 68 Adjusted Clinical Groups (ACGs). These were applied to patient records of 86,100 individuals in 174 English practices. For a given disease description system, counts of diseases and sets of disease dummy variables had similar explanatory power. The EDC measures performed best followed by the QOF and ACG measures. The Charlson measures had the worst performance but still improved markedly on models containing only age, gender, deprivation and practice effects. Comparisons of predictive power for different morbidity measures were similar for linear and exponential models, but the relative predictive power of the models varied with the morbidity measure. Capitation payments for an individual patient vary considerably with the different morbidity measures included in the cost model. Even for the best fitting model large differences between expected cost and capitation for some types of patient suggest incentives for patient selection. Models with any of the morbidity measures show higher cost for more deprived patients but the positive effect of deprivation on cost was smaller in better fitting models

Which features of primary care affect unscheduled secondary care use?:A systematic review

OBJECTIVES: To conduct a systematic review to identify studies that describe factors and interventions at primary care practice level that impact on levels of utilisation of unscheduled secondary care. SETTING: Observational studies at primary care practice level. PARTICIPANTS: Studies included people of any age of either sex living in Organisation for Economic Co-operation and Development (OECD) countries with any health condition. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome measure was unscheduled secondary care as measured by emergency department attendance and emergency hospital admissions. RESULTS: 48 papers were identified describing potential influencing features on emergency department visits (n=24 studies) and emergency admissions (n=22 studies). Patient factors associated with both outcomes were increased age, reduced socioeconomic status, lower educational attainment, chronic disease and multimorbidity. Features of primary care affecting unscheduled secondary care were more complex. Being able to see the same healthcare professional reduced unscheduled secondary care. Generally, better access was associated with reduced unscheduled care in the USA. Proximity to healthcare provision influenced patterns of use. Evidence relating to quality of care was limited and mixed. CONCLUSIONS: The majority of research was from different healthcare systems and limited in the extent to which it can inform policy. However, there is evidence that continuity of care is associated with reduced emergency department attendance and emergency hospital admissions

Законодательные барьеры для многоцелевого лесопользования

© 2017 Article author(s) (or their employer(s) unless otherwise stated in the text of the article). Background/objectives There are some older patients who are at the decision margin' of admission. This systematic review sought to explore this issue with the following objective: What admission alternatives are there for older patients and are they safe, effective and cost-effective? A secondary objective was to identify the characteristics of those older patients for whom the decision to admit to hospital may be unclear. Design Systematic review of controlled studies (April 2005-December 2016) with searches in Medline, Embase, Cinahl and CENTRAL databases. The protocol is registered at PROSPERO (CRD42015020371). Studies were assessed using Cochrane risk of bias criteria, and relevant reviews were assessed with the AMSTAR tool. The results are presented narratively and discussed. Setting Primary and secondary healthcare interface. Participants People aged over 65 years at risk of an unplanned admission. Interventions Any community-based intervention offered as an alternative to admission to an acute hospital. Primary and secondary outcomes measures Reduction in secondary care use, patient-related outcomes, safety and costs. Results Nineteen studies and seven systematic reviews were identified. These recruited patients with both specific conditions and mixed chronic and acute conditions. The interventions involved paramedic/emergency care practitioners (n=3), emergency department-based interventions (n=3), community hospitals (n=2) and hospital-at-home services (n=11). Data suggest that alternatives to admission appear safe with potential to reduce secondary care use and length of time receiving care. There is a lack of patient-related outcomes and cost data. The important features of older patients for whom the decision to admit is uncertain are: Age over 75 years, comorbidities/multi-morbidities, dementia, home situation, social support and individual coping abilities. Conclusions This systematic review describes and assesses evidence on alternatives to acute care for older patients and shows that many of the options available are safe and appear to reduce resource use. However, cost analyses and patient preference data are lacking

NASA IceCube: CubeSat Demonstration of a Commercial 883-GHz Cloud Radiometer

On April 18 2017, NASA Goddard Space Flight Center’s IceCube 3U CubeSat was launched by an ATLAS V rocket from Cape Canaveral Air Force Station on board a Cygnus resupply spacecraft, as part of NASA’s CubeSat Launch Initiative. Onboard IceCube was an 883 GHz radiometer tuned to detecting ice content in clouds, marking the first time such frequency was used from low-Earth orbit. IceCube successfully demonstrated retrieval of ice water path, generating the first ever global cloud ice map at 883 GHz. Its success provides valuable lessons on how to approach a severely resource-limited space mission and provides great insight into how this experience can be applied to future high-risk, “non-class” missions for NASA and others. IceCube marks the first official NASA Earth Science CubeSat technology demonstration mission. The spacecraft was completed in about 2.5 years starting April 2014 through launch provider delivery in December of 2016. The mission was jointly funded by NASA’s Earth Science Technology Office, after competitive selection, and by NASA’s Earth Science Directorate. IceCube began its technology demonstration mission in June 2017, providing a pathway to advancing the understanding of ice clouds and their role in climate models; quite a tall order for a tiny spacecraft

Model-based cost-effectiveness analysis of B-type natriuretic peptide-guided care in patients with heart failure

OBJECTIVE: Monitoring B-type natriuretic peptide (BNP) to guide pharmacotherapy might improve survival in patients with heart failure with reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF). However, the cost-effectiveness of BNP-guided care is uncertain and guidelines do not uniformly recommend it. We assessed the cost-effectiveness of BNP-guided care in patient subgroups defined by age and ejection fraction. METHODS: We used a Markov model with a 3-month cycle length to estimate the lifetime health service costs, quality-adjusted life years (QALYs) and incremental net monetary benefits (iNMBs) of BNP-guided versus clinically guided care in 3 patient subgroups: (1) HFrEF patients <75 years; (2) HFpEF patients <75 years; and (3) HFrEF patients ≥75 years. There is no evidence of benefit in patients with HFpEF aged ≥75 years. We used individual patient data meta-analyses and linked primary care, hospital and mortality data to inform the key model parameters. We performed probabilistic analysis to assess the uncertainty in model results. RESULTS: In younger patients (<75 years) with HFrEF, the mean QALYs (5.57 vs 5.02) and costs (£63 527 vs £58 139) were higher with BNP-guided care. At the willingness-to-pay threshold of £20 000 per QALY, the positive iNMB (£5424 (95% CI £987 to £9469)) indicates that BNP-guided care is cost-effective in this subgroup. The evidence of cost-effectiveness of BNP-guided care is less strong for younger patients with HFpEF (£3155 (−£10 307 to £11 613)) and older patients (≥75 years) with HFrEF (£2267 (−£1524 to £6074)). BNP-guided care remained cost-effective in the sensitivity analyses, albeit the results were sensitive to assumptions on its sustained effect. CONCLUSIONS: We found strong evidence that BNP-guided care is a cost-effective alternative to clinically guided care in younger patients with HFrEF. It is potentially cost-effective in younger patients with HFpEF and older patients with HFrEF, but more evidence is required, particularly with respect to the frequency, duration and BNP target for monitoring. Cost-effectiveness results from trials in specialist settings cannot be generalised to primary care

Percussion Recital

Program listing performers and works performed