Impact of payment model on the behaviour of specialist physicians: A systematic review

Physician payment models are perceived to be an important strategy for improving health, access, quality, and the value of health care. Evidence is predominantly from primary care, and little is known regarding whether specialists respond similarly.We conducted a systematic review to synthesize evidence on the impact of specialist physician payment models across the domains of health care quality; clinical outcomes; utilization, access, and costs; and patient and physician satisfaction. We searched Medline, Embase, and six other databases from their inception through October 2018. Eligible articles addressed specialist physicians, payment models, outcomes of interest, and used an experimental or quasi-experimental design.Of 11,648 studies reviewed for eligibility, 11 articles reporting on seven payment reforms were included. Fee-for-service (FFS) was associated with increased desired utilization and fewer adverse outcomes (in the case of hemodialysis patients) and better access to care (in the case of emergency department services). Replacing FFS with capitation and salary models led to fewer elective surgical procedures (cataracts and tubal ligations) and, with an episode-based model, appeared to increase the use of less costly resources. Four of the seven reforms met their goals but many had unintended consequences.Payment model appears to affect utilization of specialty care, although the association with other outcomes is unclear due to mixed results or lack of evidence. Studies of salary and salary-based reforms point to specialists responding to some incentives differently than theory would predict. Additional research is warranted to improve the evidence driving specialist payment policy.     

Physician-patient communication in the primary care office: a systematic review

BACKGROUND: The physician-patient interview is the key component of all health care, particularly of primary medical care. This review sought to evaluate existing primary-care-based research studies to determine which verbal and nonverbal behaviors on the part of the physician during the medical encounter have been linked in empirical studies with favorable patient outcomes. METHODS: We reviewed the literature from 1975 to 2000 for studies of office interactions between primary care physicians and patients that evaluated these interactions empirically using neutral observers who coded observed encounters, videotapes, or audiotapes. Each study was reviewed for the quality of the methods and to find statistically significant relations between specific physician behaviors and patient outcomes. In examining nonverbal behaviors, because of a paucity of clinical outcome studies, outcomes were expanded to include associations with patient characteristics or subjective ratings of the interaction by observers. RESULTS: We found 14 studies of verbal communication and 8 studies of nonverbal communication that met inclusion criteria. Verbal behaviors positively associated with health outcomes included empathy, reassurance and support, various patient-centered questioning techniques, encounter length, history taking, explanations, both dominant and passive physician styles, positive reinforcement, humor, psychosocial talk, time in health education and information sharing, friendliness, courtesy, orienting the patient during examination, and summarization and clarification. Nonverbal behaviors positively associated with outcomes included head nodding, forward lean, direct body orientation, uncrossed legs and arms, arm symmetry, and less mutual gaze. CONCLUSION: Existing research is limited because of lack of consensus of what to measure, conflicting findings, and relative lack of empirical studies (especially of nonverbal behavior). Nonetheless, medical educators should focus on teaching and reinforcing behaviors known to be facilitative, and to continue to understand further how physician behavior can enhance favorable patient outcomes, such as understanding and adherence to medical regimens and overall satisfaction.     

Multimorbidity and quality of life in primary care: a systematic review

Background  

Many patients with several concurrent medical conditions (multimorbidity) are seen in the primary care setting. A thorough understanding of outcomes associated with multimorbidity would benefit primary care workers of all disciplines. The purpose of this systematic review was to clarify the relationship between the presence of multimorbidity and the quality of life (QOL) or health-related quality of life (HRQOL) of patients seen, or likely to be seen, in the primary care setting.     

Screening accuracy for late-life depression in primary care: a systematic review

OBJECTIVE: To determine the accuracy of depression screening instruments for older adults in primary care. STUDY DESIGN: Systematic review. DATA SOURCES: MEDLINE, PsycINFO (search dates 1966 to January 2002), and the Cochrane database on depression, anxiety and neurosis. We also searched the second Guide to Clinical Preventive Services, the 1993 Agency for Health Care Policy and Research Clinical Practice Guideline on Depression, and recent systematic reviews. Hand-checking of bibliographies and extensive peer review were also used to identify potential articles. OUTCOMES MEASURED: A predefined search strategy targeted only studies of adults aged 65 years or older in primary care or community settings, including long-term care. Articles were included in this review if they reported original data and tested depression screening instruments against a criterion standard, yielding sensitivity and specificity. RESULTS: Eighteen articles met criteria and are included in this review, representing 9 different screening instruments. The most commonly evaluated were the Geriatric Depression Scale (30- and 15-item versions), the Center for Epidemiologic Studies Depression Scale, and the SelfCARE(D). Differences in the performance of these 3 instruments were minimal; sensitivities ranged from 74% to 100% and specificities ranged from 53% to 98%. CONCLUSIONS: Accurate and feasible screening instruments are available for detecting late-life depression in primary care. More research is needed to determine the accuracy of depression screening instruments for demented individuals, and for those with subthreshold depressive disorders.     

Family history tools for primary care: A systematic review

BackgroundMany medical family history (FH) tools are available for various settings. Although FH tools can be a powerful health screening tool in primary care (PC), they are currently underused.ObjectivesThis review explores the FH tools currently available for PC and evaluates their clinical performance.MethodsFive databases were systematically searched until May 2021. Identified tools were evaluated on the following criteria: time-to-complete, integration with electronic health record (EMR) systems, patient administration, risk-assessment ability, evidence-based management recommendations, analytical and clinical validity and clinical utility.ResultsWe identified 26 PC FH tools. Analytical and clinical validity was poorly reported and agreement between FH and gold standard was commonly inadequately reported and assessed. Sensitivity was acceptable; specificity was found in half of the reviewed tools to be poor. Most reviewed tools showed a capacity to successfully identify individuals with increased risk of disease (6.2–84.6% of high and/or moderate or increased risk individuals).ConclusionDespite the potential of FH tools to improve risk stratification of patients in PC, clinical performance of current tools remains limited as well as their integration in EMR systems. Twenty-one FH tools are designed to be self-administered by patients.     

Efficacy of self-help manuals for anxiety disorders in primary care: a systematic review

OBJECTIVE: The purpose of this study was to review effectiveness studies of self-help manuals for anxiety disorders in primary care. METHODS: A systematic review of six identified randomized controlled trials was carried out. In addition to outcome, the articles were coded on quality variables. RESULTS: The studies included differed with respect to the methodological quality, measurements used and size of the study population. Despite these differences, global results suggest that a self-help manual is an effective treatment possibility for primary care patients with anxiety disorders. The more time that was spent on guidance on the use of the self-help manual the greater was its effectiveness. CONCLUSION: Treatment with a self-help manual for anxiety disorders may be effective in primary care. Data are lacking on the feasibility and cost-effectiveness of these manuals.     

Do family physicians need more payment for working better? Financial incentives in primary care

IntroductionFinancial incentives are widely used in health services to improve the quality of care or to reach some specific targets. Pay for performance systems were also introduced in the primary health care systems of many European countries.ObjectiveOur study aims to describe and compare recent existing primary care indicators and related financing in European countries.MethodsLiterature search was performed and questionnaires were sent to primary care experts of different countries within the European General Practice Research Network.ResultsTen countries have published primary care quality indicators (QI) associated with financial incentives. The number of QI varies from 1 to 134 and can modify the finances of physicians with up to 25% of their total income.ConclusionsThe implementations of these schemes should be critically evaluated with continuous monitoring at national or regional level; comparison is required between targets and their achievements, health gains and use of resources as well.     

A systematic review of case-mix models for home health care payment: Making sense of variation

BackgroundCase-mix based payment of health care services offers potential to contain expenditure growth and simultaneously support needs-based care provision. However, limited evidence exists on its application in home health care (HHC). Therefore, this study aimed to synthesize available international literature on existing case-mix models for HHC payment.MethodsWe performed a systematic review of scientific literature, supplemented with grey literature. We searched for literature using six scientific databases, reference lists, expert consultation, and targeted websites. Data on study design, case-mix model attributes, and conclusions were extracted narratively.ResultsOf 3303 references found, 22 scientific studies and 27 grey documents met eligibility criteria. Eight case-mix models for HHC were identified, from the US, Canada, New Zealand, Australia, and Germany. Three countries have implemented a case-mix model as part of a HHC payment system. Different combinations of in total 127 unique case-mix predictors are included across models to predict HHC use. Case-mix models also differ in targeted services, operationalization, and outcome measures and predictive power.ConclusionsCase-mix based payment is not yet widely used within HHC. Multiple varieties were found between HHC case-mix models, and no one best form of a model seems to exist. Even though varieties are partly inevitable due to country-specific contexts, developing a shared vision in case-mix model attributes would be key to achieving efficient, needs-based HHC.     

Clinical leadership and integrated primary care: A systematic literature review

Background: Leaders are needed to address healthcare changes essential for implementation of integrated primary care. What kind of leadership this needs, which professionals should fulfil this role and how these leaders can be supported remains unclear.

Objectives: To review the literature on the effectiveness of programmes to support leadership, the relationship between clinical leadership and integrated primary care, and important leadership skills for integrated primary care practice.

Methods: We systematically searched PubMed, CINAHL, Embase, PsycINFO until June 2018 for empirical studies situated in an integrated primarycare setting, regarding clinical leadership, leadership skills, support programmes and integrated-care models. Two researchers independently selected relevant studies and critically appraised studies on methodological quality, summarized data and mapped qualitative data on leadership skills.

Results: Of the 3207 articles identified, 56 were selected based on abstract and title, from which 20 met the inclusion criteria. Selected papers were of mediocre quality. Two non-controlled studies suggested that leadership support programmes helped prepare and guide leaders and positively contributed to implementation of integrated primary care. There was little support that leaders positively influence implementation of integrated care. Leaders’ relational and organizational skills as well as process-management and change-management skills were considered important to improve care integration. Physicians seemed to be the most adequate leaders.

Conclusion: Good quality research on clinical leadership in integrated primary care is scarce. More profound knowledge is needed about leadership skills, required for integrated-care implementation, and leadership support aimed at developing these skills.     

Contract design for primary care physicians: Physician location and practice behaviour in small communities

Most western countries employ a combination of fee-for-service, fixed salary and per capita subsidies to finance the services of general practitioners. Based on Norwegian data, the authors demonstrate that these fianancial schemes have been used in different types of municipalities. The authors argue that the fee-for-service and per capita components should be allowed to vary between primary physicians and municipalities: (a) If the patient population per primary physician is low and patient supply is unstable, the per capita subsidy or work-free income should be differentiated to ensure recruitment of physicians. (b) Physicians in municipalities with low physician coverage should be allotted a low basic grant, whilst per capita subsidy and fee-for-service payments should be used to stimulate service production. The opposite situation exists where there is a potential of supplier inducement due to high physician coverage. (c) The responsibility for designing contracts should be assigned to local rather than national authorities. These suggestions go against important elements in the reform of primary physician services in Norway. This revised version was published online in July 2006 with corrections to the Cover Date.     

The impact of improved access to after-hours primary care on emergency department and primary care utilization: A systematic review

Access to after-hours primary care is problematic in many developed countries, leading patients to instead visit the emergency department for non-urgent conditions. However, emergency department utilization for conditions treatable in primary care settings may contribute to emergency department overcrowding and increased health system costs. This systematic review examines the impact of various initiatives by developed countries to improve access to after-hours primary care on emergency department and primary care utilization. We performed a systematic review on the impact of improved access to after-hours primary and searched CINAHL, EMBASE, MEDLINE, and Scopus. We identified 20 studies that examined the impact of improved access to after-hours primary care on ED utilization and 6 studies that examined the impact on primary care utilization. Improved access to after-hours primary care was associated with increased primary care utilization, but had a mixed effect on emergency department utilization, with limited evidence of a reduction in non-urgent and semi-urgent emergency department visits. Although our review suggests that improved access to after-hours primary care may limit emergency department utilization by shifting patient care from the emergency department back to primary care, rigorous research in a given institutional context is required before introducing any initiative to improve access to after-hours primary care.     

Rates of sickness certification in European primary care: A systematic review

Background: General practitioners (GPs) are responsible for assessing a patient's capacity for work and issuing a sickness certificate, enabling a patient to receive statutory sick pay and take time away from the workplace. The management of sickness absence across Europe varies considerably, and there is a need for comparable rates of certification to facilitate appropriate health and economic planning. Objective: To systematically review the literature reporting rates of sickness certification in general practice settings. Methods: Electronic databases were searched from their inception to November 2007. Inclusion criteria were reporting a measure of sickness certification, conducted in European primary care. Results: 298 citations were identified from the literature search, of which 11 met the inclusion criteria. These studies demonstrated that the rates of sickness certification are not routinely recorded. The certified rates were subject to wide variation, ranging from 18 per 100 person years in Norway to 239 per 100 person years in Malta.

Conclusion: There is large variability in sickness certification policy and hence sickness certification rates across Europe. A system that enables comparisons across countries would be beneficial in ensuring health and economic planning. To enable a baseline rate of certification to be established and compared across countries, standardized reporting of sickness certification is needed.     

Frequent attenders in late life in primary care: a systematic review of European studies

Background

High utilization of health care services is a costly phenomenon commonly observed in primary care practices. However, while frequent attendance in primary care has been broadly studied across age groups, aspects of high utilization by elderly patients have not been investigated in detail. The aim of this paper is to provide a systematic review of frequent attendance in primary care among elderly people.

Methods

We searched five databases (PubMed, PsycINFO, Web of Science, PubPsych, and Cochrane Library) for published papers addressing frequent attendance in primary health care among elderly individuals. Quality of studies was assessed using established criteria for evaluating methodological quality.

Results

Ten studies met inclusion criteria and were included for detailed analysis. The average number of patients frequently utilizing primary care services varied across studies from 10% to 33% of the elderly samples and subsamples. The definition of frequent attendance across studies differed substantially. The most consistent associations between frequent attendance and old age were found for presence and severity of physical illness. Results on mental disorders and frequent attendance were heterogeneous. Only a few studies have assessed frequent attendance in association with factors such as drug use, social support or sociodemographic aspects; however results were inconsistent.

Conclusions

Severe ill health and the need for treatment serve as the main drivers of frequent attendance in older adults. As results were scarce and divergent, future studies are needed to provide more information on this topic. Since prior studies have offered only a snapshot of this service use behaviour, a longitudinal approach would be preferable in the future.

     

Blood pressure measurement by primary care physicians: comparison with the standard method

OBJECT: To examine the usual methods of blood pressure (BP) measurement by primary care physicians and to compare them with the standard methods. METHOD: Design: Cross-sectional survey by self-administered questionnaire. Subjects: Primary care physicians who graduated from Jichi Medical School and were working at clinics. Each standard method for 20 items was defined as the one that was most frequently recommended by 6 guidelines (USA 3, UK 1, Canada 1, Japan 1) and a recent comprehensive review about BP measurement. RESULTS: Of 333 physicians, 190 (58%) responded (median age 33, range 26 to 45 years). Standard methods and percentages of physicians who follow them are: [BP measurement, 17 items] supported arm 96%; measurement to 2 mmHg 91%; sitting position 86%; mercury sphygmomanometer 83%; waiting > or = 1 minute between readings 58%; palpation to assess systolic BP before auscultation 57%; check accuracy of home BP monitor 56%; Korotkoff Phase V for diastolic BP 51%; bilateral measurements on initial visit 44%; small cuff available 41%; > or = 2 readings in patients with atrial fibrillation 38%; > or = 2 readings on one visit 20%; cuff deflation rate of 2 mmHg/pulse 14%; large cuff available 13%; check accuracy of monitor used for home visit 8%; waiting time > or = 5 minute 3%; readings from the arm with the higher BP 1%. [Knowledge about BP monitor, 2 items] appropriate size bladder: length 11%; width 11%. [Check of sphygmomanometer for leakage, inflate to 200 mmHg then close valve for 1 minute] leakage < 2 mmHg 6%; median 10 (range 0-200) mmHg. Average percentage of all 20 items was 39%. Number of methods physicians follow as standard: median 8 (range 4 to 15) and this number did not correlate with any background characteristics of the physicians. Furthermore, we also obtained information on methods not compared with the standard. Fifty-four percentage of physicians used more standard methods in deciding the start or change of treatment than in measuring BP of patients with good control. About 80% of physicians use home BP readings in diagnosis or treatment of hypertension, but about half of physicians with ambulatory BP monitors use their measured readings. CONCLUSION: Primary care physicians used various techniques for routine BP measurement and no physician completely followed the standard. Such measurements may affect the diagnosis and treatment of hypertension, but measuring all BPs solely by the standard is not practical. We need to have a practical and efficient method of BP measurement for routine practice in the primary care setting.     

Impact of organisational change on mental health: a systematic review

Although limited evidence is available, organisational change is often cited as the cause of mental health problems. This paper provides an overview of the current literature regarding the impact of organisational change on mental health. A systematic search in PUBMED, PsychInfo and Web of Knowledge combining MeSH search terms for exposure and outcome. The criterion for inclusion was original data on exposure to organisational change with mental health problems as outcome. Both cross-sectional and longitudinal studies were included. We found in 11 out of 17 studies, an association between organisational change and elevated risk of mental health problems was observed, with a less provident association in the longitudinal studies. Based on the current research, this review cannot provide sufficient evidence of an association between organisational change and elevated risk of mental health problems. More studies of long-term effects are required including relevant analyses of confounders.     

Screening questionnaires to identify problem drinking in the primary care setting: a systematic review

Aim

Guidance on screening instruments is lacking. Early recognition of harmful drinking patterns is of socio-economic importance for health policies. Aim of this systematic review was to investigate the validity and reliability of alcohol screening questionnaires to identify problem drinking as a secondary prevention measure.

Subject and methods

About eight million people live in Austria and approximately 360,000 are diagnosed with chronic alcoholism. In 2011, the direct medical cost for alcohol-related diseases was 374 million Euros. The hazardous effects of excessive drinking and the problems caused by alcohol are frequently documented. A systematic search of the literature was conducted in online databases between September and December 2014. Inclusion criteria included the use of alcohol-screening instrument compared to a gold standard, primary care setting, and adults over 18 years.

Results

Eight diagnostic accuracy studies and three systematic reviews were included in this review. The reviewed scientific literature demonstrates the validation of five alcohol-screening instruments plus their abbreviated versions that are currently available in German-speaking countries. Those instruments are suitable for primary care depending on the validated setting.

Conclusion

Primary healthcare workers do not routinely screen for harmful drinking in their usual practice in German-speaking countries. Brief interventions are initiated based on results of screening tests; hence, the opportunity for brief interventions is missed. However, guidance and training on validated alcohol-screening instruments and information on the content of brief interventions is currently missing in German-speaking countries.

     

Preliminary state of development of prediction models for primary care physical therapy: a systematic review

ObjectiveTo summarize the methodological quality and developmental stage of prediction models for musculoskeletal complaints that are relevant for physical therapists in primary care.Study Design and SettingA systematic literature search was carried out in the databases of Medline, Embase, and Cinahl. Studies on prediction models for musculoskeletal complaints that can be used by primary care physical therapists were included. Methodological quality of the studies was assessed and relevant study characteristics were extracted.ResultsThe search retrieved 4,702 references of which 29 studies were included in this review. The study quality of the included studies showed substantial variation. The studied populations consisted mostly of back (n = 10) and neck pain (n = 6) patients, and patients with knee complaints (n = 4). Most studies (n = 22) used “perceived recovery” as primary outcome. Most prediction models (n = 18) were at the derivation level of development.ConclusionsMany prediction models are available for a wide range of patient populations. The developmental stage of most models is preliminary and the study quality is often moderate. We do not recommend physiotherapist to use these models yet. All models reviewed here are in the developmental stage and need validation and impact evaluation before using them in daily practice.