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BACKGROUND: Despite longstanding efforts and calls for reform, Canada's incremental approach to healthcare changes has left the country lagging behind other OECD nations. Reform to the Canadian healthcare system is essential to develop a higher performing system. This study sought to gain a deeper understanding of the views of Canadian stakeholders on structural and process deficiencies and strategies to improve the Canadian healthcare system substantially and meaningfully. METHODS: We conducted individual, ~ 45-minute, semi-structured virtual interviews from May 2022 to August 2022. Using existing contacts and snowball sampling, we targeted one man and one woman from five regions in Canada across four stakeholder groups: (1) public citizens; (2) healthcare leaders; (3) academics; and (4) political decision makers. Interviews centered on participants' perceptions of the state of the current healthcare system, including areas where major improvements are required, and strategies to achieve suggested enhancements; Donabedian's Model (i.e., structure, process, outcomes) was the guiding conceptual framework. Interviews were audio-recorded, transcribed verbatim, and de-identified, and inductive thematic analysis was performed independently and in duplicate according to published methods. RESULTS: The data from 31 interviews with 13 (41.9%) public citizens, 10 (32.3%) healthcare leaders, 4 (12.9%) academics, and 4 (12.9%) political decision makers resulted in three themes related to the structure of the healthcare system (1. system reactivity; 2. linkage with the Canadian identity; and 3. political and funding structures), three themes related to healthcare processes (1. staffing shortages; 2. inefficient care; and 3. inconsistent care), and three strategies to improve short- and long-term population health outcomes (1. delineating roles and revising incentives; 2. enhanced health literacy; 3. interdisciplinary and patient-centred care). CONCLUSION: Canadians in our sample identified important structural and process limitations to the Canadian healthcare system. Meaningful reforms are needed and will require addressing the link between the Canadian identity and our healthcare system to facilitate effective development and implementation of strategies to improve population health outcomes.
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AIM: To estimate the real-world effectiveness of sodium-glucose co-transporter-2 inhibitors (SGLT2is) versus dipeptidyl peptidase-4 inhibitors (DPP4is) at reducing loss of kidney function and adverse kidney events in adults with varying levels of albuminuria. MATERIALS AND METHODS: In this retrospective cohort study using administrative data, we matched new SGLT2i users 1:2 to DPP4i users on diabetes therapy, chronic kidney disease (CKD) stage, albuminuria and time-conditional propensity score. Albuminuria was defined by spot urine albumin or equivalent as mild, moderate or severe. Linear regression was used to model the estimated glomerular filtration rate (eGFR), and Poisson regression for a composite kidney outcome (> 40% loss of eGFR, kidney replacement therapy or death from kidney causes) and all-cause mortality. RESULTS: SGLT2i users (n = 19 238, median age 57.9 years, female 40.9%) had mostly nil/mild albuminuria (70.7%). SGLT2is were associated with a 1.36 (95% CI 0.98-1.74) mL/min/1.73m2 (P < .001) acute (≤ 60 days) decline in eGFR, relative to DPP4is. Thereafter, SGLT2is were associated with 1.04 (95% CI 0.93-1.15) mL/min/1.73m2 (P < .001) less annual eGFR loss. SGLT2i users had fewer adverse kidney outcomes (incidence rate ratio [IRR] 0.58 [0.47-0.71]; P < .001), but not all-cause mortality (IRR 0.82 [0.66-1.01]; P = .06). Outcomes were similar considering only those with nil/mild albuminuria. CONCLUSIONS: SGLT2is may prevent eGFR decline and reduce the risk of adverse kidney events in adults with diabetes and nil or non-severe albuminuria.
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Diabetes Mellitus Tipo 2, Diabetes Mellitus, Inibidores da Dipeptidil Peptidase IV, Insuficiência Renal Crônica, Inibidores do Transportador 2 de Sódio-Glicose, Simportadores, Feminino, Humanos, Pessoa de Meia-Idade, Albuminúria/tratamento farmacológico, Albuminúria/complicações, Diabetes Mellitus Tipo 2/complicações, Diabetes Mellitus Tipo 2/tratamento farmacológico, Glucose, Rim, Insuficiência Renal Crônica/complicações, Insuficiência Renal Crônica/tratamento farmacológico, Estudos Retrospectivos, Sódio, Inibidores do Transportador 2 de Sódio-Glicose/efeitos adversosRESUMO
BACKGROUND: The influence of fee-for-service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood. METHODS AND RESULTS: This retrospective, population-based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed-effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67-0.68) imaging tests per consultation. After adjustment, patients seeing fee-for-service physicians had 2.07 (95% CI, 1.68-2.54) and fee-for-service physicians with ability to interpret had 2.87 (95% CI, 2.16-3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site-level variation 40% and physician-level variation 29%. CONCLUSIONS: We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.
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Planos de Pagamento por Serviço Prestado, Médicos, Adulto, Humanos, Estudos Retrospectivos, Estudos de Coortes, AlbertaRESUMO
We hosted a deliberative dialogue with citizens (n = 3), policy researchers (n = 3), government decision makers (n = 3) and health system leaders (n = 3) to identify evidence-informed policy options to improve the value of Canadian healthcare. The analysis resulted in three themes: (1) the need for a vision to guide reforms, (2) community-based care and (3) community-engaged care. Results suggest the need for a new paradigm: community-focused health systems. Such a paradigm could serve as a North Star guiding healthcare transformation, improving value by aligning citizen and healthcare system goals, prioritizing spending on services that address the social determinants of health and improving quality and equity.
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Atenção à Saúde, Política de Saúde, Humanos, Canadá, Formulação de Políticas, GovernoRESUMO
BACKGROUND: Choosing Wisely Canada (CWC) recommends avoiding noninvasive advanced cardiac testing (e.g., exercise stress testing [EST], echocardiography and myocardial perfusion imaging [MPI]) for preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery. In this study, we assessed the temporal trends in testing, overlapping with the introduction of the CWC recommendations in 2014, and patient and provider factors associated with low-value testing. METHODS: In this population-based retrospective cohort study, we used linked health administrative data in Alberta, Canada, to identify adult patients who underwent elective noncardiac surgery between Apr. 1, 2011, and Mar. 31, 2019, who had preoperative noninvasive advanced cardiac tests (EST, echocardiography or MPI) within 6 months before surgery. We included electrocardiography as an exploratory outcome. We excluded patients at high risk using the Revised Cardiac Risk Index (score ≥ 1 considered to indicate high risk), and modelled patient and temporal factors associated with the number of tests. RESULTS: We identified 1 045 896 elective noncardiac operations performed in 798 599 patients and 25 599 advanced preoperative cardiac tests; 2.1% of operations were preceded by advanced cardiac testing. The incidence of testing increased over the study period, and, by 2018/19, patients were 1.3 times (95% confidence interval 1.2-1.4) more likely to receive a preoperative advanced test compared to 2011/12. Urban patients were more likely to receive a preoperative advanced cardiac test than their rural counterparts. Electrocardiography was the most common preoperative cardiac test, preceding 182 128 procedures (17.4%). INTERPRETATION: Preoperative advanced cardiac testing was infrequent in adult Albertans who underwent low-risk elective noncardiac operations. Despite CWC recommendations, the use of some tests appears to be increasing, and there was substantial variation across geographic areas.
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Procedimentos Cirúrgicos Eletivos, Pesquisa, Adulto, Humanos, Estudos de Coortes, Estudos Retrospectivos, AlbertaRESUMO
OBJECTIVES: Our aim in this study was to describe patterns and patient-level factors associated with use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) among adults with diabetes being treated in Alberta, Canada. METHODS: Using linked administrative data sets from 2014 to 2019, we defined a retrospective cohort of adults with prevalent or incident type 2 diabetes with indications for SGLT2i use and who did not have advanced kidney disease (glomerular filtration rate <30 mL/min per 1.73 m2) or previous amputation. We describe medication dispensation patterns of SGLT2is over time in the overall cohort and among the subgroup with cardiovascular disease (CVD). Multivariable logistic regression was used to determine patients' characteristics associated with SGLT2i use. RESULTS: Of the 341,827 patients with diabetes (mean age, 60.7 years; 45.6% female), 107,244 (31.3%) had CVD. The proportion of patients with an SGLT2i prescription increased in a linear fashion to a maximum of 10.8% (95% confidence interval [CI], 10.7% to 10.9%) of the eligible cohort by the end of the observation period (March 2019). The proportion of filled prescriptions was similar for patients with CVD (10.4%; 95% CI, 10.1% to 10.6%) and for those without CVD (10.9%; 95% CI, 10.8% to 11.0%). Patients' characteristics associated with lower odds of filling an SGLT2i prescription included female sex, older age and lower income. CONCLUSIONS: The use of SGLT2is is increasing among patients with diabetes but remains low even in those with CVD. Policy and practice changes to increase prescribing, especially in older adults, may help to reduce morbidity and mortality related to cardiovascular and renal complications.
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Doenças Cardiovasculares, Diabetes Mellitus Tipo 2, Inibidores do Transportador 2 de Sódio-Glicose, Humanos, Feminino, Idoso, Pessoa de Meia-Idade, Masculino, Diabetes Mellitus Tipo 2/tratamento farmacológico, Diabetes Mellitus Tipo 2/epidemiologia, Diabetes Mellitus Tipo 2/complicações, Estudos de Coortes, Estudos Retrospectivos, Inibidores do Transportador 2 de Sódio-Glicose/uso terapêutico, Doenças Cardiovasculares/tratamento farmacológico, Glucose, Sódio/uso terapêutico, Alberta/epidemiologiaRESUMO
In this study on medication adherence among newly diagnosed patients with uncomplicated, incident hypertension, we conducted a retrospective cohort study using available administrative and laboratory data from April 1, 2012 to March 31, 2017 in Alberta, Canada to understand the extent to which baseline laboratory assessment and/or subsequent follow-up was associated with persistence with antihypertensive therapy. We determined the frequency of baseline and follow-up testing and compared the rates of medication persistence by patient-, neighbourhood-, and treatment-related factors. Of 103 232 patients with newly diagnosed, uncomplicated hypertension who filled their first prescription within our study timeframe, 52.5% were non-persistent within 6 months. Persistent patients were more often female and residing in neighbourhoods with higher social status (with exception to rurality). Aside from older age, the strongest predictor of persistence was performance of laboratory testing related to hypertension with an apparent effect in which higher levels of medication persistence were seen with more frequent laboratory testing. We concluded that medication persistence was far from optimal, dropping off considerably after 6 months for more than half of patients. Medication persistence is a substantial barrier to realizing the full societal benefits of antihypertensive treatment. Ongoing follow up with patients, including laboratory testing, may be a critical component of better long term treatment persistence.
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Anti-Hipertensivos, Hipertensão, Humanos, Feminino, Anti-Hipertensivos/uso terapêutico, Hipertensão/diagnóstico, Hipertensão/tratamento farmacológico, Hipertensão/epidemiologia, Estudos Retrospectivos, Análise de Dados, Adesão à MedicaçãoRESUMO
BACKGROUND: Assessment of potential geographic variation in quality indicators of atrial fibrillation care may identify opportunities for improvement in the quality of atrial fibrillation care. The objective of this study was to assess for potential geographic variation in the quality of atrial fibrillation care in Alberta, Canada. METHODS: In a population-based cohort of adults (age ≥ 18 yr) with incident nonvalvular atrial fibrillation (NVAF) diagnosed between Apr. 1, 2008, and Mar. 31, 2016, in Alberta, we investigated the variation in national quality indicators of atrial fibrillation care developed by the Canadian Cardiovascular Society. Specifically, we assessed the geographic and temporal variation in the proportion of patients with initiation of oral anticoagulant therapy, persistence with therapy, ischemic stroke and major bleeding outcomes 1 year after atrial fibrillation diagnosis using linked administrative data sets. We defined stroke risk using the CHADS2 score. We assessed geographic variation using small-area variation statistics and geospatial data analysis. RESULTS: Of the 64 093 patients in the study cohort (35 019 men [54.6%] and 29 074 women [45.4%] with a mean age of 69 [standard deviation 15.9] yr), 36 199 were at high risk for stroke and 14 411 were at moderate risk. Within 1 year of NVAF diagnosis, 20 180 patients (55.7%) in the high-risk group and 6448 patients (44.7%) in the moderate-risk group were prescribed anticoagulation. A total of 2187 patients (3.4%) had an ischemic stroke, and 2996 patients (4.7%) experienced a major bleed. There was substantial regional variation observed in initiation of oral anticoagulant therapy but not in the proportion of patients with ischemic stroke or major bleeding. Among the 64 Health Status Areas in Alberta, therapy initiation rates ranged from 22.6% to 71.2% among patients at high stroke risk and from 22.7% to 55.8% among those at moderate stroke risk, with clustering of lower therapy initiation rates in rural northern regions. INTERPRETATION: The rate of initiation of oral anticoagulant therapy among adults with incident atrial fibrillation was less than 60% in patients in whom oral anticoagulant therapy would be considered guideline-appropriate care. The large geographic variation in oral anticoagulant prescribing warrants additional study into patient, provider and health care system factors that contribute to variation and drive disparities in high-quality, equitable atrial fibrillation care.
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Fibrilação Atrial, AVC Isquêmico, Acidente Vascular Cerebral, Adulto, Idoso, Alberta/epidemiologia, Anticoagulantes/efeitos adversos, Anticoagulantes/uso terapêutico, Fibrilação Atrial/diagnóstico, Fibrilação Atrial/tratamento farmacológico, Fibrilação Atrial/epidemiologia, Feminino, Hemorragia/induzido quimicamente, Hemorragia/epidemiologia, Humanos, Masculino, Indicadores de Qualidade em Assistência à Saúde, Acidente Vascular Cerebral/epidemiologia, Acidente Vascular Cerebral/etiologia, Acidente Vascular Cerebral/prevenção & controle, Resultado do TratamentoRESUMO
AIMS: To use real-world prescription data from Alberta, Canada to: (a) describe the prescribing patterns for initial pharmacotherapy for those with newly diagnosed uncomplicated type 2 diabetes; (b) describe medication-taking behaviours (adherence and persistence) in the first year after initiating pharmacotherapy; and (c) explore healthcare system costs associated with prescribing patterns. METHODS: We employed a retrospective cohort design using linked administrative datasets from 2012 to 2017 to define a cohort of those with uncomplicated incident diabetes. We summarized the initial prescription patterns, adherence and costs (healthcare and pharmaceutical) over the first year after initiation of pharmacotherapy. Using multivariable regression, we determined the association of these outcomes with various sociodemographic characteristics. RESULTS: The majority of individuals for whom metformin was indicated as first-line therapy received a prescription for metformin monotherapy (89%). Older individuals, those with higher baseline A1C and those with no comorbidities, were most likely to be started on non-metformin agents. Adherence with the initially prescribed regimen was suboptimal overall, with nearly half (48%) being non-adherent over the first year. One-third of those who started metformin discontinued it in the first 3 months. Those started on non-metformin agents had roughly twice the healthcare costs, and five to seven times higher medication costs, compared to those started on metformin, in the first year after starting therapy. CONCLUSIONS: With the addition of new classes of medications, healthcare providers who look after those with type 2 diabetes have more pharmaceutical options than ever. Most individuals continue to be prescribed metformin monotherapy. However, adherence is suboptimal, and drops off considerably within the first 3 months.
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Diabetes Mellitus Tipo 2/tratamento farmacológico, Custos de Medicamentos, Custos de Cuidados de Saúde/tendências, Adesão à Medicação, Metformina/uso terapêutico, Prescrições/estatística & dados numéricos, Adolescente, Adulto, Idoso, Alberta/epidemiologia, Diabetes Mellitus Tipo 2/economia, Diabetes Mellitus Tipo 2/epidemiologia, Feminino, Seguimentos, Humanos, Hipoglicemiantes/uso terapêutico, Masculino, Pessoa de Meia-Idade, Morbidade/tendências, Estudos Retrospectivos, Adulto JovemRESUMO
BACKGROUND: A range of first-line similarly effective medications ranging in price are recommended for treating uncomplicated hypertension. Considering drug costs alone, thiazides and thiazide-like diuretics are the most cost-efficient option. We determined incident prescribing of thiazides for newly diagnosed hypertension as first-line treatment in Alberta, factors that predicted receiving thiazides vs more costly medications, and how much could be saved if more patients were prescribed thiazides. METHODS: Using a retrospective cohort design, factors predicting receiving thiazides vs other agents were determined using mixed effects logistic regression. Cost savings were simulated by shifting patients from other antihypertensive medications to thiazides and calculating the difference. RESULTS: Within our cohort of 89,548 adults, only 12% received thiazides as first-line treatment whereas 44% received angiotensin converting enzyme inhibitors, 17% received angiotensin receptor blockers, 16% received calcium channel blockers, and 10% received ß-blockers. Antihypertensive medications were typically prescribed by office-based, general practitioners (88%). Being male and receiving a prescription from a physician with ≥ 20 years of practice and a high clinical workload were associated with increased odds of receiving nonthiazides. In the extreme case that all patients received thiazides as their first prescription, spending would have been reduced by a maximum of 95% (CAD$1.8 million). CONCLUSIONS: Only 12% of Albertan adults with incident, uncomplicated hypertension were prescribed thiazides as first-line treatment. With the opportunity for drug cost savings, future research should evaluate the risk of adverse events and side effects across the drug classes and whether the costs associated with managing those risks could offset the savings achieved through increased thiazide use.
CONTEXTE: De nombreux médicaments tous aussi efficaces les uns que les autres, mais de prix variable, sont recommandés pour le traitement de première intention de l'hypertension non compliquée. Si l'on tient compte du coût du médicament seulement, les thiazides et les diurétiques apparentés aux thiazides sont les options les plus économiques. Nous avons évalué le taux de prescription d'un thiazide pour le traitement de première intention de l'hypertension nouvellement diagnostiquée en Alberta, les facteurs de prédiction de la prescription d'un thiazide plutôt que d'un autre médicament plus coûteux, ainsi que les économies qui pourraient être réalisées si on prescrivait un thiazide à un plus grand nombre de patients. MÉTHODOLOGIE: Dans le cadre de notre étude de cohorte rétrospective, nous avons déterminé les facteurs de prédiction de la prescription d'un thiazide plutôt que d'un autre agent à l'aide d'une régression logistique à effets mixtes. Nous avons simulé les économies qui pourraient être réalisées en faisant passer à un thiazide les patients à qui un autre médicament antihypertenseur a été prescrit et en calculant la différence. RÉSULTATS: Dans notre cohorte de 89 548 adultes, seulement 12 % des patients ont reçu un thiazide en première intention; 44 % ont reçu un inhibiteur de l'enzyme de conversion de l'angiotensine; 17 %, un antagoniste des récepteurs de l'angiotensine; 16 %, un inhibiteur calcique; et 10 %, des bêtabloquants. Les agents antihypertenseurs sont généralement prescrits par des omnipraticiens en cabinet (88 %). Le fait d'être un homme et le fait d'obtenir une prescription auprès d'un médecin exerçant depuis au moins 20 ans et ayant une lourde charge de travail clinique étaient associés à une probabilité supérieure de recevoir un agent autre qu'un thiazide. Dans le cas extrême où tous les patients se verraient prescrire un thiazide en première intention, la réduction des dépenses pourrait atteindre 95 % (soit 1,8 million de dollars canadiens). CONCLUSIONS: En Alberta, un thiazide a été prescrit en première intention à seulement 12 % des adultes venant de recevoir un diagnostic d'hypertension non compliquée. Compte tenu des économies qui pourraient être réalisées si un thiazide était prescrit dans ce contexte, il conviendrait d'effectuer des recherches plus poussées pour évaluer le risque de manifestations indésirables et d'effets secondaires associé aux différentes classes de médicaments, et pour déterminer si les coûts liés à la prise en charge de ce risque annuleraient les économies réalisées en augmentant le recours aux thiazides.
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Increasing private healthcare financing has been suggested as a solution toward improving healthcare quality and access within the Canadian healthcare system. However, Lee et al. (2021) find no evidence that increasing private financing would address the challenges faced by Canadian healthcare. We suggest turning our focus away from reforms that solely increase private healthcare financing and toward evidence-based delivery-system reforms to address both quality and sustainability. We present examples and supporting evidence of the effectiveness of patient-, physician-, organization- and system-level strategies. Changes should engage physicians and be implemented across Canada to facilitate a cultural shift toward experimentation and high-value care delivery.
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Reforma dos Serviços de Saúde, Médicos, Canadá, Atenção à Saúde, Humanos, Qualidade da Assistência à SaúdeRESUMO
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.
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Planos de Pagamento por Serviço Prestado, Médicos, Humanos, Atenção Primária à Saúde, Qualidade da Assistência à Saúde, Salários e BenefíciosRESUMO
BACKGROUND: Health care payers are interested in policy-level interventions to increase peritoneal dialysis use in end-stage renal disease. We examined whether increases in physician remuneration for peritoneal dialysis were associated with greater peritoneal dialysis use. METHODS: We studied a cohort of patients in Alberta who started long-term dialysis with at least 90 days of preceding nephrologist care between Jan. 1, 2001, and Dec. 31, 2014. We compared peritoneal dialysis use 90 days after dialysis initiation in patients cared for by fee-for-service nephrologists and those cared for by salaried nephrologists before and after weekly peritoneal dialysis remuneration increased from $0 to $32 (fee change 1, Apr. 1, 2002), $49 to $71 (fee change 2, Apr. 1, 2007), and $71 to $135 (fee change 3, Apr. 1, 2009). Remuneration for peritoneal dialysis remained less than hemodialysis until fee change 3. We performed a patient-level differences-in-differences logistic regression, adjusted for demographic characteristics and comorbidities, as well as an unadjusted interrupted time-series analysis of monthly outcome data. RESULTS: Our cohort included 4262 patients. There was no statistical evidence of a difference in the adjusted differences-indifferences estimator following fee change 1 (0.89, 95% confidence interval [CI] 0.44-1.81), 2 (1.15, 95% CI 0.73-1.83), or 3 (1.52, 95% CI 0.96-2.40). There was no significant difference in the immediate change or the trend over time in peritoneal dialysis use between fee-for-service and salaried groups following any of the fee changes in the interrupted time-series analysis. INTERPRETATION: We identified no statistical evidence of an increase in peritoneal dialysis use following increased fee-for-service remuneration for peritoneal dialysis. It remains unclear what role, if any, physician payment plays in selection of dialysis modality.
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Falência Renal Crônica/epidemiologia, Diálise Peritoneal/economia, Remuneração, Adulto, Idoso, Alberta/epidemiologia, Duração da Terapia, Planos de Pagamento por Serviço Prestado, Feminino, Humanos, Masculino, Pessoa de Meia-Idade, Médicos, Vigilância da PopulaçãoRESUMO
Importance: Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases. Objective: To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists. Design, Setting, and Participants: A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109â¯839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics. Exposures: Specialist physician payment model (salary-based or FFS). Main Outcomes and Measures: Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs. Results: A total of 90â¯605 patients received care from FFS physicians and 19â¯234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31â¯898 patients (15â¯949 FFS, 15â¯949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care-sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13). Conclusions and Relevance: Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases.
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Doença Crônica/economia, Custos de Cuidados de Saúde/estatística & dados numéricos, Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos, Qualidade da Assistência à Saúde/normas, Especialização/estatística & dados numéricos, Adulto, Doença Crônica/epidemiologia, Doença Crônica/terapia, Estudos de Coortes, Feminino, Humanos, Masculino, Pessoa de Meia-Idade, Médicos/classificação, Médicos/estatística & dados numéricos, Indicadores de Qualidade em Assistência à Saúde, Qualidade da Assistência à Saúde/economia, Qualidade da Assistência à Saúde/estatística & dados numéricos, Estudos RetrospectivosRESUMO
BACKGROUND: As the adverse clinical outcomes common in patients with chronic kidney disease (CKD) can be prevented or delayed, information on the cost of care across the spectrum of CKD can inform investments in CKD care. OBJECTIVES: To determine the cost of caring for patients with CKD who are not on dialysis or transplant at baseline. DESIGN: Population-based cohort study using administrative health data. SETTING: Alberta, Canada. PATIENTS: Cohort of 219 641 adults with CKD categorized by estimated glomerular filtration rate (eGFR) between April 1, 2012, and March 31, 2014, into Kidney Disease: Improving Global Outcomes (KDIGO) CKD categories, excluding patients on dialysis or transplant at baseline. MEASUREMENTS: The primary outcome was 1-year cumulative unadjusted health care costs, including the cost of drugs, physician visits, emergency department visits, outpatient procedures (including dialysis and other day medicine and surgery procedures), and hospitalizations for the year following each patient's index date. METHODS: Mean 1-year direct medical costs were estimated for the cohort as a whole and for patients in the different KDIGO CKD categories as defined at baseline. Costs were further categorized according to baseline demographic and clinical characteristics, and by type of care (ie, kidney care and cardiovascular care). RESULTS: In 219 641 adults with CKD, the mean unadjusted cumulative 1-year cost of care was Can$14 634 per patient (median = Can$3672; Q1 = Can$1496, Q3 = Can$10 221). Costs were higher for those with more comorbidity, those with lower eGFR, and those with more severe albuminuria. The cost of kidney and cardiovascular care was Can$230 (1.6% of total costs) and Can$720 (4.9% of total costs), respectively, for the cohort overall. These costs increased substantially for patients with lower eGFR, averaging Can$14 169 (32.3% of total costs) and Can$2395 (5.5% of total costs) for kidney and cardiovascular care, respectively, for people with eGFR<15 mL/min/1.73 m2 at baseline. LIMITATIONS: We only have estimates of the cost of health care for people with CKD, and not the costs borne by patients or their families. As we have not included costs for people without CKD in this analysis, we are unable to assess the incremental costs associated with CKD. CONCLUSIONS: We identified that patients with CKD, even when not on dialysis at baseline, had high health care costs (more than twice the cost per person in Canada in 2015), with a graded association between severity of CKD and costs. Our findings can inform current and future cost estimates across the spectrum of CKD, including an estimate of potential savings that might result from interventions that slow or prevent kidney disease.
CONTEXTE: Les événements cliniques indésirables qui surviennent fréquemment chez les patients atteints d'insuffisance rénale chronique (IRC) peuvent être prévenus ou retardés. Connaître le coût des soins liés à l'ensemble du spectre de la maladie pourrait éclairer les investissements en santé rénale. OBJECTIFS: Établir le coût des soins prodigués aux patients atteints d'IRC non dialysés ou transplantés au moment de l'inclusion. TYPE D'ÉTUDE: Une étude de cohorte représentative de la population réalisée à partir des données administratives en santé. CADRE: Alberta, Canada. SUJETS: Une cohorte de 219 641 adultes atteints d'IRC qui ont été classés entre le 1er avril 2012 et le 31 mars 2014 dans les catégories du KDIGO selon leur DFGe. Les patients dialysés ou transplantés ont été exclus. MESURES: Le résultat principal était le coût cumulatif non ajusté des soins de santé sur un an. Pour l'année suivant la date indice de chaque patient, le total incluait les coûts des médicaments, des consultations médicales, des visites aux urgences, des procédures ambulatoires (dialyse et différentes procédures de chirurgie et de médecine d'un jour) et des hospitalisations. MÉTHODOLOGIE: La moyenne des coûts médicaux directs sur un an a été estimée à l'inclusion pour l'ensemble de la cohorte et pour chaque catégorie d'IRC du KDIGO. Les coûts ont également été classés selon les caractéristiques démographiques et cliniques des patients à l'inclusion, et par types de soins (soins en néphrologie et en cardiologie). RÉSULTATS: Dans la cohorte étudiée, la moyenne des coûts cumulatifs non ajustés sur un an s'établissait à 14 634 $ CA par patient (médiane: 3 672 $; Q1: 1 496 $ et Q3: 10 221 $), et davantage pour les patients présentant des comorbidités, un faible DFGe ou une grave albuminurie. Les coûts des soins en santé rénale et cardiovasculaire pour l'ensemble de la cohorte s'élevaient respectivement à 230 $ (1,6 % du montant total) et 720 $ (4,9 % du montant total) par personne. Ces coûts augmentaient considérablement pour les patients présentant un faible DFGe (<15 ml/min/1,73 m2) à l'inclusion, soit en moyenne 14 169 $ (32,3 % du montant total) en santé rénale et 2 395 $ (5,5 % du montant total) en santé cardiovasculaire. LIMITES: L'estimation ne tient compte que du coût des soins prodigués aux patients, et non des coûts assumés par les patients ou leurs proches. L'analyse n'incluant pas les montants pour les patients non atteints d'IRC, nous n'avons pas été en mesure d'évaluer les coûts différentiels associés à la maladie. CONCLUSION: Nous avons constaté que les patients atteints d'IRC, même s'ils n'étaient pas dialysés à l'inclusion, engendraient des coûts de santé plus élevés (plus de deux fois le coût par personne au Canada en 2015) avec une association graduelle de ceux-ci à la gravité de l'IRC. Nos résultats peuvent orienter les évaluations de coût actuelles et futures pour l'ensemble du spectre de l'IRC, notamment l'estimation des économies potentielles qui pourraient résulter d'interventions visant la prévention de l'insuffisance rénale ou le ralentissement de son évolution.
RESUMO
BACKGROUND: As the number of people with chronic diseases increases, understanding the impact of payment model on the types of patients seen by specialists has implications for improving the quality and value of care. We sought to determine if there is an association between specialist physician payment model and the types of patients seen. METHODS: In this descriptive study, we used administrative data to compare demographic characteristics, illness severity and visit indication of patients with diabetes seen by fee-for-service and salary-based internal medicine and diabetes specialists in Calgary and Edmonton between April 2011 and September 2014. The study cohort included all newly referred adults with diabetes (no appointment with a specialist in prior 4 yr). Diabetes was identified using a validated algorithm that excludes gestational diabetes. RESULTS: Patients managed by salary-based physicians (n = 2736) were sicker than those managed by fee-for-service physicians (n = 21 218). Patients managed by salary-based specialists were more likely to have 5 or more comorbidities (23.0% [n = 628] v. 18.1% [n = 3843]) and to have been admitted to hospital or seen in an emergency department for an ambulatory care sensitive condition in the year before their index visit, probably reflecting poorer disease control or barriers to optimal outpatient care. A higher proportion of visits to salary-based physicians were for appropriate indications (65.2% [n = 744] v. 55.6% [n = 5553]; risk ratio 1.17, 95% confidence interval 1.09-1.27). INTERPRETATION: Salary-based specialists were more likely to see patients with a clear indication for a specialist visit, while fee-for-service specialists were more likely to see healthier patients. Future research is needed to determine if the differences in types of patients are attributable to payment model or other provider- or system-level factors.
RESUMO
OBJECTIVE: The 2008 Mental Health Parity and Addiction Equity Act (MHPAEA) sought to improve access to behavioral health care by regulating health plans' coverage and management of services. Health plans have some discretion in how to achieve compliance with MHPAEA, leaving questions about its likely effects on health plan policies. In this study, the authors' objective was to determine how private health plans' coverage and management of behavioral health treatment changed after the federal parity law's full implementation. METHODS: A nationally representative survey of commercial health plans was conducted in 60 market areas across the continental United States, achieving response rates of 89% in 2010 (weighted N=8,431) and 80% in 2014 (weighted N=6,974). Senior executives at responding plans were interviewed regarding behavioral health services in each year and (in 2014) regarding changes. Student's t tests were used to examine changes in services covered, cost-sharing, and prior authorization requirements for both behavioral health and general medical care. RESULTS: In 2014, 68% of insurance products reported having expanded behavioral health coverage since 2010. Exclusion of eating disorder coverage was eliminated between 2010 (23%) and 2014 (0%). However, more products reported excluding autism treatment in 2014 (24%) than 2010 (8%). Most plans reported no change to prior-authorization requirements between 2010 and 2014. CONCLUSIONS: Implementation of federal parity legislation appears to have been accompanied by continuing improvement in behavioral health coverage. The authors did not find evidence of widespread noncompliance or of unintended effects, such as dropping coverage of behavioral health care altogether.
Assuntos
Acessibilidade aos Serviços de Saúde, Seguro Saúde, Programas de Assistência Gerenciada, Serviços de Saúde Mental, Transtornos Relacionados ao Uso de Substâncias, Acessibilidade aos Serviços de Saúde/economia, Acessibilidade aos Serviços de Saúde/legislação & jurisprudência, Acessibilidade aos Serviços de Saúde/estatística & dados numéricos, Humanos, Seguro Saúde/economia, Seguro Saúde/legislação & jurisprudência, Seguro Saúde/estatística & dados numéricos, Programas de Assistência Gerenciada/economia, Programas de Assistência Gerenciada/legislação & jurisprudência, Programas de Assistência Gerenciada/estatística & dados numéricos, Serviços de Saúde Mental/economia, Serviços de Saúde Mental/legislação & jurisprudência, Serviços de Saúde Mental/estatística & dados numéricos, Transtornos Relacionados ao Uso de Substâncias/economia, Transtornos Relacionados ao Uso de Substâncias/terapia, Estados UnidosRESUMO
INTRODUCTION: Recent payment reforms promote movement from fee-for-service to alternative payment models that shift financial risk from payers to providers, incentivizing providers to manage patients' utilization. Bundled payment, an episode-based fixed payment that includes the prices of a group of services that would typically treat an episode of care, is expanding in the United States. Bundled payment has been recommended as a way to pay for comprehensive SUD treatment and has the potential to improve treatment engagement after detox, which could reduce detox readmissions, improve health outcomes, and reduce medical care costs. However, if moving to bundled payment creates large losses for some providers, it may not be sustainable. The objective of this study was to design the first bundled payment for detox and follow-up care and to estimate its impact on provider revenues. METHODS: Massachusetts Medicaid beneficiaries' behavioral health, medical, and pharmacy claims from July 2010-April 2013 were used to build and test a detox bundled payment for continuously enrolled adults (N=5521). A risk adjustment model was developed using general linear modeling to predict beneficiaries' episode costs. The projected payments to each provider from the risk adjustment analysis were compared to the observed baseline costs to determine the potential impact of a detox bundled payment reform on organizational revenues. This was modeled in two ways: first assuming no change in behavior and then assuming a supply-side cost sharing behavioral response of a 10% reduction in detox readmissions and an increase of one individual counseling and one group counseling session. RESULTS: The mean total 90-day detox episode cost was $3743. Nearly 70% of the total mean cost consists of the index detox, psychiatric inpatient care, and short-term residential care. Risk mitigation, including risk adjustment, substantially reduced the variation of the mean episode cost. There are opportunities for organizations to gain revenue under this bundled payment design, but many providers will lose money under a bundled payment designed using historic payment and costs. CONCLUSIONS: Designing a bundled payment for detox and follow-up care is feasible, but low case volume and the adequacy of the payment are concerns. Thus, a detox episode-based payment will likely be more challenging for smaller, independent SUD treatment providers. These providers are experiencing many changes as financing shifts away from block grant funding toward Medicaid funding. A detox bundled payment in practice would need to consider different risk mitigation strategies, provider pooling, and costs based on episodes of care meeting quality standards, but could incentivize care coordination, which is important to reducing detox readmissions and engaging patients in care.
