英国初级卫生保健制度及其信息化建设初探

重点介绍英国在卫生服务提供、卫生筹资、资源调配、制度建设等方面的基本做法和工作特点,以及英国卫生信息化管理建设的机构与投入情况,分析信息化在支撑医疗保健服务绩效管理、全科医生服务质量控制、全科医生均质化培养、信息便民服务等方面发挥的重要作用,为了解、借鉴英国卫生制度提供有益的参考.     

Effect of Payment Incentives on Cancer Screening in Ontario Primary Care

PURPOSE

There is limited evidence for the effectiveness of pay for performance despite its widespread use. We assessed whether the introduction of a pay-for-performance scheme for primary care physicians in Ontario, Canada, was associated with increased cancer screening rates and determined the amounts paid to physicians as part of the program.

METHODS

We performed a longitudinal analysis using administrative data to determine cancer screening rates and incentive costs in each fiscal year from 1999/2000 to 2009/2010. We used a segmented linear regression analysis to assess whether there was a step change or change in screening rate trends after incentives were introduced in 2006/2007. We included all Ontarians eligible for cervical, breast, and colorectal cancer screening.

RESULTS

We found no significant step change in the screening rate for any of the 3 cancers the year after incentives were introduced. Colon cancer screening was increasing at a rate of 3.0% (95% CI, 2.3% to 3.7%) per year before the incentives were introduced and 4.7% (95% CI, 3.7% to 5.7%) per year after. The cervical and breast cancer screening rates did not change significantly from year to year before or after the incentives were introduced. Between 2006/2007 and 2009/2010, $28.3 million, $31.3 million, and $50.0 million were spent on financial incentives for cervical, breast, and colorectal cancer screening, respectively.

CONCLUSIONS

The pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure. Policy makers should consider other strategies for improving rates of cancer screening.     

The Effect of Capitation on Switching Primary Care Physicians

Objective.  To examine the relationship between patient case-mix, utilization, primary care physician (PCP) payment method, and the probability that patients switch their PCPs.
Data Sources/Study Setting.  Administrative enrollment and claims/encounter data for 1994–1995 from four physician organizations.
Study Design.  We developed a conceptual model of patient switching behavior, which we used to guide the specification of multivariate logistic analyses focusing on interactions between patient case-mix, utilization, and PCP reimbursement methods.
Data Collection/Extraction Methods.  Claims data were aggregated to the encounter level; a switch was defined as a change in PCP since the previous encounter. The PCPs were reimbursed on either a capitated or fee-for-service (FFS) basis.
Principal Findings.  Patients with stable chronic conditions (Ambulatory Diagnostic Groups [ADG] 10) and capitated PCPs were 36 percent more likely to switch PCPs than similar patients with FFS PCPs, controlling for patient age and sex and physician fixed effects. When the number of previous encounters was included in the model, this relationship was no longer significant. Instead high utilizers with capitated PCPs were significantly more likely to switch PCPs than were similar patients with FFS PCPs.
Conclusions.  A patient's demographics and utilization are associated with the probability that the patient will switch PCPs. Capitated PCP payment was associated with higher rates of switching among high utilizers of health care resources. These findings raise concerns about the continuity and quality of care experienced by vulnerable patients in an era of changing financial incentives.     

Primary Care Practice Organization Influences Colorectal Cancer Screening Performance

Objective. To identify primary care practice characteristics associated with colorectal cancer (CRC) screening performance, controlling for patient-level factors.
Data Sources/Study Setting. Primary care director survey (1999–2000) of 155 VA primary care clinics linked with 38,818 eligible patients' sociodemographics, utilization, and CRC screening experience using centralized administrative and chart-review data (2001).
Study Design. Practices were characterized by degrees of centralization (e.g., authority over operations, staffing, outside-practice influence); resources (e.g., sufficiency of nonphysician staffing, space, clinical support arrangements); and complexity (e.g., facility size, academic status, managed care penetration), adjusting for patient-level covariates and contextual factors.
Data Collection/Extraction Methods. Chart-based evidence of CRC screening through direct colonoscopy, sigmoidoscopy, or consecutive fecal occult blood tests, eliminating cases with documented histories of CRC, polyps, or inflammatory bowel disease.
Principal Findings. After adjusting for sociodemographic characteristics and health care utilization, patients were significantly more likely to be screened for CRC if their primary care practices had greater autonomy over the internal structure of care delivery ( p <.04), more clinical support arrangements ( p <.03), and smaller size ( p <.001).
Conclusions. Deficits in primary care clinical support arrangements and local autonomy over operational management and referral procedures are associated with significantly lower CRC screening performance. Competition with hospital resource demands may impinge on the degree of internal organization of their affiliated primary care practices.     

Effects of Facilitated Team Meetings and Learning Collaboratives on Colorectal Cancer Screening Rates in Primary Care Practices: A Cluster Randomized Trial

PURPOSE

The purpose of this study was to evaluate a primary care practice–based quality improvement (QI) intervention aimed at improving colorectal cancer screening rates.

METHODS

The Supporting Colorectal Cancer Outcomes through Participatory Enhancements (SCOPE) study was a cluster randomized trial of New Jersey primary care practices. On-site facilitation and learning collaboratives were used to engage multiple stakeholders throughout the change process to identify and implement strategies to enhance colorectal cancer screening. Practices were analyzed using quantitative (medical records, surveys) and qualitative data (observations, interviews, and audio recordings) at baseline and a 12-month follow-up.

RESULTS

Comparing intervention and control arms of the 23 participating practices did not yield statistically significant improvements in patients’ colorectal cancer screening rates. Qualitative analyses provide insights into practices’ QI implementation, including associations between how well leaders fostered team development and the extent to which team members felt psychologically safe. Successful QI implementation did not always translate into improved screening rates.

CONCLUSIONS

Although single-target, incremental QI interventions can be effective, practice transformation requires enhanced organizational learning and change capacities. The SCOPE model of QI may not be an optimal strategy if short-term guideline concordant numerical gains are the goal. Advancing the knowledge base of QI interventions requires future reports to address how and why QI interventions work rather than simply measuring whether they work.     

Prevalence of Colorectal Cancer Testing and Screening in a Multiethnic Primary Care Population

Colorectal cancer (CRC) screening is strongly supported by evidence and widely recommended, but remains underutilized. This study reports the prevalence of CRC diagnostic testing and CRC screening in three racial/ethnic groups attending the same primary care clinic. A cross-sectional survey was conducted to elicit past history of CRC testing, including test type, indication and timing. A comparable number of African American, Hispanic and non-Hispanic white patients aged 50–80 were recruited. 560 surveys were completed: mean age was 63.4 years, 64% reported minority race/ethnicity, and 96.8% had insurance. Overall, 62.5% [95% CI: 58.5%, 66.5%] of patients were current with any type of CRC test, when diagnostic and screening procedures were included. However, 48.6% [95% CI: 44.5%, 52.7%] of the sample was current with CRC screening, when only procedures performed for screening in asymptomatic patients were included. Patients least likely to be current with testing were those of minority race/ethnicity (48.2% of Hispanics, 56.7% of African Americans and 67.5% of non Hispanic whites, p < 0.05), younger age, (57.6% of those aged 50–64, and 71.4% of those aged 65–80, p < 0.005), and those with private insurance alone (56.0% private, 67.7% public and 68.1% mixed, p < 0.05). Our findings indicate that racial/ethnic and age related disparities in CRC screening exist even in a patient population that has the same source of health care and no differences in insurance status. These results underline the need for providers to emphasize CRC screening in their practices to minority patients and those younger than 65 years of age.     

Validation of PHQ-2 and PHQ-9 to Screen for Major Depression in the Primary Care Population

PURPOSE Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9.METHODS Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed.RESULTS There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999.CONCLUSIONS We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.     

Barriers to Primary Care Physicians Prescribing Buprenorphine

PURPOSE

Despite the efficacy of buprenorphine-naloxone for the treatment of opioid use disorders, few physicians in Washington State use this clinical tool. To address the acute need for this service, a Rural Opioid Addiction Management Project trained 120 Washington physicians in 2010–2011 to use buprenorphine. We conducted this study to determine what proportion of those trained physicians began prescribing this treatment and identify barriers to incorporating this approach into outpatient practice.

METHODS

We interviewed 92 of 120 physicians (77%), obtaining demographic information, current prescribing status, clinic characteristics, and barriers to prescribing buprenorphine. Residents and 7 physicians who were prescribing buprenorphine at the time of the course were excluded from the study. We analyzed the responses of the 78 remaining respondents.

RESULTS

Almost all respondents reported positive attitudes toward buprenorphine, but only 22 (28%) reported prescribing buprenorphine. Most (95%, n = 21) new prescribers were family physicians. Physicians who prescribed buprenorphine were more likely to have partners who had received a waiver to prescribe buprenorphine. A lack of institutional support was associated with not prescribing the medication (P = .04). A lack of mental health and psychosocial support was the most frequently cited barrier by both those who prescribe and who do not prescribe buprenorphine.

CONCLUSION

Interventions before and after training are needed to increase the number of physicians who offer buprenorphine for treatment of addiction. Targeting physicians in clinics that agree in advance to institute services, coupled with technical assistance after they have completed their training, their clinical teams, and their administrations is likely to help more physicians become active providers of this highly effective outpatient treatment.     

Annals Journal Club: Yield of Opportunistic Targeted Screening for Type 2 Diabetes in Primary Care: The Diabscreen Study

PURPOSE In screening for type 2 diabetes, guidelines recommend targeting high-risk individuals. Our objectives were to assess the yield of opportunistic targeted screening for type 2 diabetes in primary care and to assess the diagnostic value of various risk factors.METHODS In 11 family practices (total practice population = 49,229) in The Netherlands, we conducted a stepwise opportunistic screening program among patients aged 45 to 75 years by (1) identifying high-risk individuals (=1 diabetes risk factor) and low-risk individuals using the electronic medical record, (2) obtaining a capillary fasting plasma glucose measurement, repeated on a separate day if the value was greater than 110 mg/dL, and (3) obtaining a venous sample if both capillary fasting plasma glucose values were greater than 110 mg/dL and at least 1 sample was 126 mg/dL or greater. We calculated the yield (percentage of invited patients with undiagnosed diabetes), number needed to screen (NNS), and diagnostic value of the risk factors (odds ratio and area under the receiver operating characteristic curve).RESULTS We invited for a first capillary measurement 3,724 high-risk patients seen during usual care and a random sample of 465 low-risk patients contacted by mail. The response rate was 90% and 86%, respectively. Ultimately, 101 high-risk patients (2.7%; 95% confidence interval [CI], 2.2%–3.3%; NNS = 37) and 2 low-risk patients (0.4%; 95% CI, 0.1%–1.6%; NNS = 233) had undiagnosed diabetes (P <.01). The prevalence of diabetes among patients 45 to 75 years old increased from 6.1% to 6.8% as a result. Among diagnostic models containing various risk factors, a model containing obesity alone was the best predictor of undiagnosed diabetes (odds ratio = 3.2; 95% CI, 2.0–5.2; area under the curve=0.63).CONCLUSIONS The yield of opportunistic targeted screening was fair; obesity alone was the best predictor of undiagnosed diabetes. Opportunistic screening for type 2 diabetes in primary care could target middle-aged and older adults with obesity.     

Comparison of Cardiovascular Risk Screening Methods and Mortality Data among Hungarian Primary Care Population: Preliminary Results of the First Government-Financed Managed Care Program

Introduction

Besides participation in the primary prevention, screening as secondary prevention is an important requirement for primary care services. The effect of this work is influenced by the characteristics of individual primary care practices and doctors’ screening habits, as well as by the regulation of screening processes and available financial resources. Between 1999 and 2009, a managed care program was introduced and carried out in Hungary, financed by the government. This financial support and motivation gave the opportunity to increase the number of screenings.

Method

4,462 patients of 40 primary care practices were screened on the basis of SCORE risk assessment. The results of the screening were compared on the basis of two groups of patients, namely: those who had been pre-screened (pre-screening method) for known risk factors in their medical history (smoking, BMI, age, family cardiovascular history), and those randomly screened. The authors also compared the mortality data of participating primary care practices with the regional and national data.

Results

The average score was significantly higher in the pre-screened group of patients, regardless of whether the risk factors were considered one by one or in combination. Mortality was significantly lower in the participating primary practices than had been expected on the basis of the national mortality data.

Conclusion

This government-financed program was a big step forward to establish a proper screening method within Hungarian primary care. Performing cardiovascular screening of a selected target group is presumably more appropriate than screening within a randomly selected population. Both methods resulted in a visible improvement in regional mortality data, though it is very likely that with pre-screening a more cost-effective selection for screening may be obtained.     

Adoption of Liquid-Based Cervical Cancer Screening Tests by Family Physicians and Gynecologists

Objective. To examine reasons for the adoption of liquid-based cervical cancer screening tests.
Data Sources/Study Setting. A mailed survey of 250 family physicians and 250 gynecologists in Maryland in 2000. Additional data were obtained from the AMA Master File of Physicians.
Study Design. Key outcome variables in this cross-sectional survey were early adoption of a liquid-based test by the end of 1997 and overall adoption by the time of the survey. Adoption was viewed in terms of a supply and demand theoretical framework with marketing influencing physician and patient demand as well as supply by insurance companies and laboratories.
Data Collection. Random samples of family physicians and gynecologists were selected from the AMA Master File of Physicians. The overall response rate was 61.9 percent.
Principal Findings. By 2000, 96 percent of gynecologists and 75 percent of family physicians in Maryland were using liquid-based cervical cancer screening tests, most commonly the ThinPrep® Pap Test™. Gynecologists were more likely than family physicians to have been early adopters (34 percent versus 5 percent, p <.01). Part of this variation in adoption was due to aggressive marketing to gynecologists, who were more likely than family physicians to receive information in the mail from the test manufacturer (89 percent versus 56 percent, p <.01) and to have been informed by the manufacturer that a patient had inquired about physicians' use of the test (22 percent versus 8 percent, p <.01).
Conclusions. The rapid diffusion of liquid-based cervical cancer screening tests occurred despite general agreement that the Pap smear has been one of the most successful cancer prevention interventions ever. Commercial marketing campaigns appear to contribute to the more rapid rate of diffusion of technology among specialists compared with generalists.     

Increasing Cancer Screening: A Meta-Analysis

Background.Primary care physicians believe preventive services are important, but perform these activities infrequently. Numerous studies have attempted to increase cancer screening, employing a variety of interventions with varying results.Methods.We conducted a meta-analysis of published studies to identify effective office-based interventions for increasing cancer screening. Selected studies: (a) evaluated an intervention in a primary care setting, (b) addressed screening for breast, cervical, or colorectal cancer, and (c) reported results allowing calculation of an effect size. Study qualities and results were coded, entered, and analyzed using DSTAT.Results.Interventions targeting either physican or patient were equally successful (d= +0.1894 andd= +0.1756, respectively). However, studies targeting both physician and patient demonstrated a smaller effect size (d= +0.0514). Greater success was found for interventions targeting the physician both during and outside the patient visit (d= +0.1222 during visit,d= +0.1849 outside visit,d= +0.3375 both). Similarly, screening behavior improved when the physicians were the target of more than one, but not more than three, interventions (d= +0.1360,d= +0.2495,d= +0.6829,d= −0.0058).Conclusions.Cancer screening activities increase with interventions that target either the physician or the patient and, when physicians are targeted, multiple interventions to serve as behavior cues and increase awareness appear optimal.     

Development and Validation of a Family History Screening Questionnaire in Australian Primary Care

PURPOSE

We aimed to validate a family history screening questionnaire in an Australian primary care population designed to identify people at increased risk for breast, ovarian, colorectal, and prostate cancer; melanoma; ischemic heart disease; and type 2 diabetes.

METHODS

We prospectively validated the questionnaire in 6 general practices in Perth, Western Australia among 526 patients aged 20 to 50 years who responded to a single invitation from their general practice. They completed the 15-item questionnaire before a reference standard 3-generation pedigree was obtained by a genetic counselor blinded to the questionnaire responses. We calculated diagnostic performance statistics for the questionnaire using the pedigree as the reference standard.

RESULTS

A combination of 9 questions had the following diagnostic performance, expressed as value (95% CI), to identify increased risk of any of the 7 conditions: area under the receiver operating characteristic curve 84.6% (81.2%–88.1%), 95% sensitivity (92%–98%), and 54% specificity (48%–60%). The combination of questions to detect increased risk had sensitivity of 92% (84%–99%) and 96% (93%–99%) for the 5 and 6 conditions applicable only to men and women, respectively. The specificity was 63% (28%–52%) for men and 49% (42%–56%) for women. The positive predictive values were 67% (56%–78%) and 68% (63%–73%), and the false-positive rates were 9% (0.5%–17%) and 9% (3%–15%) for men and women, respectively.

CONCLUSIONS

This simple family history screening questionnaire shows good performance for identifying primary care patients at increased disease risk because of their family history. It could be used in primary care as part of a systematic approach to tailored disease prevention.     

Encouraging Underscreened Women to Have Cervical Cancer Screening: The Effectiveness of a Computer Strategy

Background.Computers that collect data from patients and provide both patients and practitioners with printed feedback on a range of health risks are a tool for assisting general practitioners with preventive care. This study assessed the impact of computer-generated printed feedback on cervical screening among women who were underscreened for cervical cancer.Method.Female attenders at two Australian general practices were randomly allocated to Experimental or Control groups. Women in both groups completed a health risk survey on a touch screen computer prior to their consultation. Those in the Experimental group received printed pages summarizing their results, including their eligibility for cervical screening and last Pap test, for themselves and their doctor. The number and proportion of underscreened women who had a Pap test in the 6 months after completing the computer survey, as determined by pathology records, were examined.Results.Of the 679 participants, 139 were classified as underscreened on the basis of self-report (74 Experimental, 65 Control) and 272 on the basis of their pathology records (148 Experimental, 124 Control). Overall about one-third of women had a test in the 6-month period, and the differences between the groups were not significant for women overall (18–70 years) or for women 18–49 years. Among women 50–70 who were underscreened based on self-report, those receiving the printout were more likely to have a Pap test in the next 6 months (P< 0.05). This pattern was also evident, but did not reach statistical significance, for older women who were underscreened based on pathology records.Conclusions.We are unable to draw conclusions regarding the effectiveness of the computer system due to the modest proportions of women screened, the small numbers, and the fact that the computer survey may have created an intervention effect in the Control group. As the study suggests the computer system is acceptable to women and may be effective for encouraging screening among older women, further exploration of the system is desirable.     

Care From Family Physicians Reported by Pregnant Women in the United States

PURPOSE

We describe the proportion of family physicians providing care of any sort to pregnant women in the United States from 2000 to 2009.

METHODS

We used a repeat, cross-sectional design with data from the nationally representative Integrated Health Interview Series (2000–2009) for respondents who reported being pregnant at the time of the survey (N = 3,204). Using multivariate logistic regression, we modeled changes over time in pregnant women’s reports of care from family physicians. We used interaction terms to test for regional differences in trends.

RESULTS

Approximately one-third of pregnant women reported having seen or talked to a family physician for medical care during the prior year, a percentage that remained stable for the period of 2000 to 2009 (adjusted odds ratio for annual change = 1.006). Most pregnant women reported care from multiple types of clinicians, including family physicians, obstetrician-gynecologists, midwives, nurse practitioners, and physician assistants. There were regional differences in trends in family physician care; pregnant women in the North Central United States increasingly reported care from family physicians, whereas women in the South reported a decline (6.7% annual increase vs 4.7% annual decrease, P ≥.001).

CONCLUSIONS

Trends in family medicine care for pregnant women have remained steady for the nation as a whole, but they differ by region of the United States. Most pregnant women reported care from multiple clinicians, highlighting the importance of care coordination for this patient population.     

Cancer Risk Assessment Tools in Primary Care: A Systematic Review of Randomized Controlled Trials

PURPOSE

We conducted this review to identify published randomized controlled trials (RCTs) of cancer risk assessment tools used in primary care and to determine their impact on clinical utility (clinicians), screening uptake (patients), and psychosocial outcomes (patients).

METHODS

We searched EMBASE, PubMed and the Cochrane databases for RCTs of cancer risk assessment tools in primary care up to May 2014. Only studies set in primary care, with patients eligible for screening, and English-language articles were included.

RESULTS

The review included 11 trials of 7 risk tools. The trials were heterogeneous with respect to type of tool that was used, type(s) of cancer assessed, and outcomes measured. Evidence suggested risk tools improved patient risk perception, knowledge, and screening intentions, but not necessarily screening behavior. Overall, uptake of a tool was greater if initiated by patients, if used by a dedicated clinician, and when combined with decision support. There was no increase in cancer worry. Health promotion messages within the tool had positive effects on behavior change. Trials were limited by low-recruitment uptake, and the heterogeneity of the findings necessitated a narrative review rather than a meta-analysis.

CONCLUSIONS

Risk tools may increase intentions to have cancer screening, but additional interventions at the clinician or health system levels may be needed to increase risk-appropriate cancer screening behavior.     

More Comprehensive Care Among Family Physicians is Associated with Lower Costs and Fewer Hospitalizations

PURPOSEComprehensiveness is lauded as 1 of the 5 core virtues of primary care, but its relationship with outcomes is unclear. We measured associations between variations in comprehensiveness of practice among family physicians and healthcare utilization and costs for their Medicare beneficiaries.METHODSWe merged data from 2011 Medicare Part A and B claims files for a complex random sample of family physicians engaged in direct patient care, including 100% of their claimed care of Medicare beneficiaries, with data reported by the same physicians during their participation in Maintenance of Certification for Family Physicians (MC-FP) between the years 2007 and 2011. We created a measure of comprehensiveness from mandatory self-reported survey items as part of MC-FP examination registration. We compared this measure to another derived from Medicare’s Berenson-Eggers Type of Service (BETOS) codes. We then examined the association between the 2 measures of comprehensiveness and hospitalizations, Part B payments, and combined Part A and B payments.RESULTSOur full family physician sample consists of 3,652 physicians providing the plurality of care to 555,165 Medicare beneficiaries. Of these, 1,133 recertified between 2007 and 2011 and cared for 185,044 beneficiaries. There was a modest correlation (0.30) between the BETOS and self-reported comprehensiveness measures. After adjusting for beneficiary and physician characteristics, increasing comprehensiveness was associated with lower total Medicare Part A and B costs and Part B costs alone, but not with hospitalizations; the association with spending was stronger for the BETOS measure than for the self-reported measure; higher BETOS scores significantly reduced the likelihood of a hospitalization.CONCLUSIONSIncreasing family physician comprehensiveness of care, especially as measured by claims measures, is associated with decreasing Medicare costs and hospitalizations. Payment and practice policies that enhance primary care comprehensiveness may help “bend the cost curve.”