ORCID Profile
0000-0002-3266-1474
Current Organisations
University of Manchester
,
University of Glasgow
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Publisher: SAGE Publications
Date: 27-10-2020
Abstract: To examine the effectiveness of two integrated care models (‘vanguards’) in Salford and South Somerset in England, United Kingdom, in relation to patient experience, health outcomes and costs of care (the ‘triple aim’). We used difference-in-differences analysis combined with propensity score weighting to compare the two care model sites with control (‘usual care’) areas in the rest of England. We estimated combined and separate annual effects in the three years following introduction of the new care model, using the national General Practice Patient Survey (GPPS) to measure patient experience (inter-organisational support with chronic condition management) and generic health status (EQ-5D) and hospital episode statistics (HES) data to measure total costs of secondary care. As secondary outcomes we measured proxies for improved prevention: cost per user of secondary care (severity) avoidable emergency admissions and primary care utilisation. Both intervention sites showed an increase in total costs of secondary care (approximately £74 per registered patient per year in Salford, £45 in South Somerset) and cost per user of secondary care (£130–138 per person per year). There were no statistically significant effects on health status or patient experience of care. There was a more apparent short-term negative effect on measured outcomes in South Somerset, in terms of increased costs and avoidable emergency admissions, but these reduced over time. New care models such as those implemented within the Vanguard programme in England might lead to unintended secondary care cost increases in the short to medium term. Cost increases appeared to be driven by average patient severity increases in hospital. Prevention-focused population health management models of integrated care, like previous more targeted models, do not immediately improve the health system’s triple aim.
Publisher: Elsevier BV
Date: 08-2022
Publisher: Royal College of General Practitioners
Date: 05-01-2021
Abstract: After decades of steady progress, life expectancy at birth has stalled in England. Inequalities are also rising, and life expectancy has fallen for females living in the most deprived areas. However, less attention has been given to trends in other measures of population health, particularly health-related quality of life (HRQoL). To examine trends and inequalities in HRQoL in England between 2012 and 2017. The authors used nationally representative survey data on 3.9 million adults to examine HRQoL (measured by EQ-5D-5L overall score, plus each of the five health domains — mobility, selfcare, usual activity, pain/discomfort, and anxiety/depression). The study explored trends across time, and inequalities by sex, age, and deprivation. Although HRQoL seemed steady overall between 2012 and 2017, there is evidence of increasing inequality across population subgroups. There was a rise in sex disparity over time, the female–male gap in EQ-5D-5L increased from −0.009 in 2012 to −0.016 in 2017. Trends for the youngest females and those living in the most deprived areas were of the greatest concern. Females in the most deprived regions suffered a 1.3% decrease in HRQoL between 2012 and 2017, compared with a 0.5% decrease for males. The key contribution to the decline in HRQoL, particularly in females, was a 1.5% increase in reported levels of anxiety/depression between 2012 and 2017. Developing interventions to address these worrying trends should be a policy priority. A particular focus should be on mental health in younger populations, especially for females and in deprived areas.
Publisher: Elsevier BV
Date: 11-2010
Publisher: Public Library of Science (PLoS)
Date: 13-01-2021
DOI: 10.1371/JOURNAL.PMED.1003514
Abstract: Patients with multimorbidities have the greatest healthcare needs and generate the highest expenditure in the health system. There is an increasing focus on identifying specific disease combinations for addressing poor outcomes. Existing research has identified a small number of prevalent “clusters” in the general population, but the limited number examined might oversimplify the problem and these may not be the ones associated with important outcomes. Combinations with the highest (potentially preventable) secondary care costs may reveal priority targets for intervention or prevention. We aimed to examine the potential of defining multimorbidity clusters for impacting secondary care costs. We used national, Hospital Episode Statistics, data from all hospital admissions in England from 2017/2018 (cohort of over 8 million patients) and defined multimorbidity based on ICD-10 codes for 28 chronic conditions (we backfilled conditions from 2009/2010 to address potential undercoding). We identified the combinations of multimorbidity which contributed to the highest total current and previous 5-year costs of secondary care and costs of potentially preventable emergency hospital admissions in aggregate and per patient. We examined the distribution of costs across unique disease combinations to test the potential of the cluster approach for targeting interventions at high costs. We then estimated the overlap between the unique combinations to test potential of the cluster approach for targeting prevention of accumulated disease. We examined variability in the ranks and distributions across age (over/under 65) and deprivation (area level, deciles) subgroups and sensitivity to considering a smaller number of diseases. There were 8,440,133 unique patients in our s le, over 4 million (53.1%) were female, and over 3 million (37.7%) were aged over 65 years. No clear “high cost” combinations of multimorbidity emerged as possible targets for intervention. Over 2 million (31.6%) patients had 63,124 unique combinations of multimorbidity, each contributing a small fraction (maximum 3.2%) to current-year or 5-year secondary care costs. Highest total cost combinations tended to have fewer conditions (dyads/triads, most including hypertension) affecting a relatively large population. This contrasted with the combinations that generated the highest cost for in idual patients, which were complex sets of many (6+) conditions affecting fewer persons. However, all combinations containing chronic kidney disease and hypertension, or diabetes and hypertension, made up a significant proportion of total secondary care costs, and all combinations containing chronic heart failure, chronic kidney disease, and hypertension had the highest proportion of preventable emergency admission costs, which might offer priority targets for prevention of disease accumulation. The results varied little between age and deprivation subgroups and sensitivity analyses. Key limitations include availability of data only from hospitals and reliance on hospital coding of health conditions. Our findings indicate that there are no clear multimorbidity combinations for a cluster-targeted intervention approach to reduce secondary care costs. The role of risk-stratification and focus on in idual high-cost patients with interventions is particularly questionable for this aim. However, if aetiology is favourable for preventing further disease, the cluster approach might be useful for targeting disease prevention efforts with potential for cost-savings in secondary care.
Publisher: Emerald
Date: 07-01-2021
DOI: 10.1108/JHOM-05-2020-0208
Abstract: Three types of payment methods have been introduced across European countries in attempts to encourage better, more integrated care of persons with multimorbidity: pay-for-performance pay-for-coordination and an all-inclusive payment method. We examine whether there are differences in the way these payment methods affect health and healthcare use in persons with multimorbidity. Using in idual-level survey data from twenty European countries, we examine unadjusted differences in average outcomes for the years 2011–2015 by whether countries adopted new payment methods for integrated care. We then test for a differential effect for multimorbid persons using linear, in idual random effects regressions, including country and time fixed effects and clustering standard errors at the country level. We find little effect of varying payment methods on key outcomes for multimorbid in iduals despite the theoretical predictions and the rhetoric in many policy documents. Policymakers should bear in mind that the success of the payment method relies on the specific design of the incentives and their implementation. New effective models of care and how to incentivise these for multimorbid patients is an ongoing research priority. This paper is the first to study the effects of payments for integration on the dimensions and populations these schemes intend to affect health and healthcare use at the in idual level for multimorbid in iduals.
Publisher: Wiley
Date: 06-08-2022
DOI: 10.1002/HEC.4561
Abstract: Better integration is a priority for most international health systems. However, multiple interventions are often implemented simultaneously, making evaluation difficult and providing limited evidence for policy makers about specific interventions. We evaluate a common integrated care intervention, multi‐disciplinary group (MDG) meetings for discussion of high‐risk patients, introduced in one socio‐economically deprived area in the UK in spring 2015. Using data from multiple waves of the national GP Patient Survey and Hospital Episode Statistics, we estimate its effects on primary and secondary care utilization and costs, health status and patient experience. We use triple differences, exploiting the targeting at people aged 65 years and over, parsing effects from other population‐level interventions implemented simultaneously. The intervention reduced the probability of visiting a primary care nurse by three percentage points and decreased length of stay by 1 day following emergency care admission. However, since planned care use increased, overall costs were unaffected. MDG meetings are presumably fulfilling public health objectives by decreasing length of stay and detecting previously unmet needs. However, the effect of MDGs on health system cost is uncertain and health remains unchanged. Evaluations of specific integrated care interventions may be more useful to public decision makers facing budget constraints.
Publisher: Springer Science and Business Media LLC
Date: 22-08-2019
Publisher: Elsevier BV
Date: 09-2018
DOI: 10.1016/J.HEALTHPOL.2018.07.003
Abstract: Traditional provider payment mechanisms may not create appropriate incentives for integrating care. Alternative payment mechanisms, such as bundled payments, have been introduced without uniform definitions, and existing payment typologies are not suitable for describing them. We use a systematic review combined with ex le integrated care programmes identified from practice in the Horizon2020 SELFIE project to inform a new typology of payment mechanisms for integrated care. The typology describes payments in terms of the scope of payment (Target population, Time, Sectors), the participation of providers (Provider coverage, Financial pooling/sharing), and the single provider atient involvement (Income, Multiple disease/needs focus, and Quality measurement). There is a gap between rhetoric on the need for new payment mechanisms and those implemented in practice. Current payments for integrated care are mostly sector- and disease-specific, with questionable impact on those with the most need for integrated care. The typology provides a basis to improve financial incentives supporting more effective and efficient integrated care systems.
Publisher: Springer Science and Business Media LLC
Date: 12-2019
DOI: 10.1186/S12913-019-4809-3
Abstract: Type 2 diabetes mellitus is preventable through lifestyle intervention. Diabetes prevention programmes (DPPs) aim to deliver prevention-based behaviour change interventions to reduce incidence. Such programmes vary from usual primary care in terms of where, how, and by whom they are delivered. Implementation is therefore likely to face new commissioning, incentive and delivery challenges. We report on the implementation of a national DPP in NHS England, and identify lessons learned in addressing the implementation challenges. In 2017/18, we conducted 20 semi-structured telephone interviews covering 16 s led case sites with the designated lead(s) responsible for local implementation of the programme. Interviews explored the process of implementation, including organisation of the programme, expectations and attitudes to the programme, funding, target populations and referral and clinical pathways. We drew on constant comparative methods to analyse the data and generate over-arching themes. We complemented our qualitative data with a survey focused on variation in the financial incentives used across sites to ensure usual primary care services recruited patients to new providers. We identified five over-arching areas of learning for implementing this large-scale programme: 1) managing new providers 2) promoting awareness of services 3) recruiting patients 4) incentive payments and 5) mechanisms for sharing learning. In general, tensions appeared to be caused by a lack of clear roles/responsibilities between hierarchical actors, and lack of communication. Both local sites and the national NHS coordination team gained experience through learning by doing. Initial tensions with roles and expectations have been worked out during implementation. Implementing a national disease prevention programme is a major task, and one that will be increasingly faced by health systems globally as they aim to adjust to demand pressures. We provide practical learning opportunities for the wider uptake and sustainability of prevention programmes. Future implementers might wish to define clear responsibilities for each actor prior to implementation, ensure early engagement with new providers, offer mechanisms/forums for sharing learning, generate evidence and provide advice on incentive payments, and prioritise public and professional awareness of the programme.
Publisher: Elsevier BV
Date: 08-2020
Publisher: Elsevier BV
Date: 07-2019
DOI: 10.1016/J.SOCSCIMED.2019.05.038
Abstract: An increasing burden of chronic disease and multimorbidity has prompted experimentation with new models of care delivery that aim to improve integration across sectors and reduce overall costs through decreased use of secondary care. One approach to stimulate this change is to pool health and social care budgets to incentivise care delivery in the most efficient location. The Better Care Fund is a large pooled funding initiative gradually taken up by local areas in England between 2014 and 2015. We exploit this variation in timing of uptake to examine the short- (1 year) and intermediate-term (up to 2 years) effects of the Better Care Fund on seven measures of hospital use and costs from a cohort of 14.4 million patients constructed using national Hospital Episode Statistics. We test for differential effects on people with multimorbidity. We find no effects of budget pooling on secondary care use for the whole population. For multimorbid patients the use of bed days increased in the short-term by 0.164 (4.9%) per patient per year. In the short-to intermediate-term, pooling health and social care budgets does not reduce hospital use nor costs. However, pooling funds does appear to stimulate additional integration activity.
Publisher: Springer Science and Business Media LLC
Date: 03-10-2023
Location: United Kingdom of Great Britain and Northern Ireland
Location: United Kingdom of Great Britain and Northern Ireland
No related grants have been discovered for Jonathan Stokes.