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To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jhealeco.2006.12.003 Byline: Mark Dusheiko (a), Hugh Gravelle (a), Ning Yu (b), Stephen Campbell (c) Keywords: Budgets; Gatekeepers; Fundholding; Patient satisfaction; Health care Abstract: Between 1991 and 1998 English general practices had the option of holding budgets for prescribing and elective secondary care. Fundholding was reintroduced in 2005. We examine the effect of fundholding on patients' satisfaction with their practice, using a cross section of 4441 patients from 60 practices in the last year of fundholding (1998). We employ instrumental variables to allow for the endogeneity of fundholding. Patients of fundholders were less satisfied with the opening hours of their practice, their GP's knowledge of their medical history, with their GP's ability to arrange tests and willingness to refer to a specialist, and were more likely to agree that their doctor was more concerned about keeping costs down. Fundholder practices performed better on a number of process measures of care, and fundholding patients were more satisfied with additional non-medical services provided by the practice. The probability that patients were overall at least very satisfied with their GP practice was 0.073 (95% CI, 0.009-0.138) smaller in fundholding practices. Author Affiliation: (a) National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York YO10 5DD, England (b) Tayside Centre for General practice, MacKenzie Building, University of Dundee, Dundee DD2 4BF, Scotland (c) National Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL, England Article History: Received 17 December 2004; Revised 13 March 2006; Accepted 18 December 2006

To link to full-text access for this article, visit this link: http://dx.doi.org/10.1016/j.jhealeco.2005.08.001 Byline: Mark Dusheiko (a), Hugh Gravelle (a), Rowena Jacobs (b), Peter Smith (b) Keywords: Budgets; Health care; Gatekeeping; Fundholding; Admission rates Abstract: In many health care systems generalist physicians act as gatekeepers to secondary care. Under the English fundholding scheme from 1991/1992 to 1998/1999 general practices could elect to be given a budget to meet the costs of certain types of elective surgery (chargeable electives) for their patients and could retain any surplus. They did not pay for non-chargeable electives or for emergency admissions. Non-fundholding practices did not bear the cost of any type of hospital admissions. Fundholding is to be reintroduced from April 2005. We estimate the effect of fundholding using a differences in differences methodology on a large 4-year panel of English general practices before and after the abolition of fundholding. The abolition of fundholding increased ex-fundholders' admission rates for chargeable elective admissions by between 3.5 and 5.1%. The effect on the early wave fundholders was greater (around 8%) than on later wave fundholders. We also use differences in differences for two types of admissions (non-chargeable electives, emergencies) not covered by fundholding as additional controls for unobserved temporal factors. These differences in differences in differences estimates suggest that the abolition of fundholding increased ex-fundholders' chargeable elective admissions by 4.9% (using the non-chargeables DID) and by 3.5% (using the emergencies DID). Author Affiliation: (a) National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York, UK (b) Centre for Health Economics, University of York, York, UK Article History: Received 27 December 2004; Revised 19 July 2005; Accepted 3 August 2005

An analysis of the demand by medical practices for elective surgery in the UK National Health Service is offered. Additional information on the model of the determinants of practice admission rates in UK hospitals is included.

Background and Aims Inflammatory bowel disease [IBD] places an economic strain on health systems due to expensive pharmaceutical therapy, risk of hospitalisation and surgery, and long-term monitoring. The evolving treatment guidelines advocate rapid scale-up to biologic agents in order to improve health outcomes and quality of life. This study evaluated changes in health care utilisation and expenditures for IBD in Switzerland over time. Methods We extracted clinical, patient, and resource consumption data from the Swiss IBD Cohort Study between 2006 and 2016. Average unit costs for IBD-related events were derived from Swiss claims data and pharmaceutical price lists. We used multivariate regression, controlling for patient-level characteristics, to estimate trends and determinants of direct and indirect costs and resource utilisation. Results We included 2365 adults diagnosed with Crohn's disease [CD; N = 1353] and ulcerative colitis [UC; N = 1012]. From 2006–16, mean health care expenditures per patient per year were 9504 euros [70% drugs, 23% inpatient, 7% outpatient] for CD and 5704 euros [68% drugs, 22% inpatient, 10% outpatient] for UC. Health care costs increased by 7% [CD] and 10% [UC] per year, largely due to rising pharmaceutical expenditures driven by increased biologic agent use. Inpatient, outpatient, and indirect costs fluctuated and did not offset increased pharmaceutical costs. Disease characteristics were important predictors of costs. Conclusions Increased expenditure for IBD was marked by a shift towards greater pharmaceutical management over the past decade. This study highlights the need to identify cost-effective treatment strategies in the face of increased uptake and expenditures associated with innovative treatments. [ABSTRACT FROM AUTHOR]

Background and Aims: We evaluated the cost-effectiveness of early [≤2 years after diagnosis] compared with late or no biologic initiation [starting biologics >2 years after diagnosis or no biologic use] for adults with Crohn's disease in Switzerland., Methods: We developed a Markov cohort model over the patient's lifetime, from the health system and societal perspectives. Transition probabilities, quality of life, and costs were estimated using real-world data. Propensity score matching was used to ensure comparability between patients in the early [intervention] and late/no [comparator] biologic initiation strategies. The incremental cost-effectiveness ratio [ICER] per quality-adjusted life year [QALY] gained is reported in Swiss francs [CHF]. Sensitivity and scenario analyses were performed., Results: Total costs and QALYs were higher for the intervention [CHF384 607; 16.84 QALYs] compared with the comparator [CHF340 800; 16.75 QALYs] strategy, resulting in high ICERs [health system: CHF887 450 per QALY; societal: CHF449 130 per QALY]. In probabilistic sensitivity analysis, assuming a threshold of CHF100 000 per QALY, the probability that the intervention strategy was cost-effective was 0.1 and 0.25 from the health system and societal perspectives, respectively. In addition, ICERs improved when we assumed a 30% reduction in biologic prices [health system: CHF134 502 per QALY; societal: intervention dominant]., Conclusions: Early biologic use was not cost-effective, considering a threshold of CHF100 000 per QALY compared with late/no biologic use. However, early identification of patients likely to need biologics and future drug price reductions through increased availability of biosimilars may improve the cost-effectiveness of an early treatment approach., (Copyright © 2019 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Background and Aims: Inflammatory bowel disease [IBD] places an economic strain on health systems due to expensive pharmaceutical therapy, risk of hospitalisation and surgery, and long-term monitoring. The evolving treatment guidelines advocate rapid scale-up to biologic agents in order to improve health outcomes and quality of life. This study evaluated changes in health care utilisation and expenditures for IBD in Switzerland over time., Methods: We extracted clinical, patient, and resource consumption data from the Swiss IBD Cohort Study between 2006 and 2016. Average unit costs for IBD-related events were derived from Swiss claims data and pharmaceutical price lists. We used multivariate regression, controlling for patient-level characteristics, to estimate trends and determinants of direct and indirect costs and resource utilisation., Results: We included 2365 adults diagnosed with Crohn's disease [CD; N = 1353] and ulcerative colitis [UC; N = 1012]. From 2006-16, mean health care expenditures per patient per year were 9504 euros [70% drugs, 23% inpatient, 7% outpatient] for CD and 5704 euros [68% drugs, 22% inpatient, 10% outpatient] for UC. Health care costs increased by 7% [CD] and 10% [UC] per year, largely due to rising pharmaceutical expenditures driven by increased biologic agent use. Inpatient, outpatient, and indirect costs fluctuated and did not offset increased pharmaceutical costs. Disease characteristics were important predictors of costs., Conclusions: Increased expenditure for IBD was marked by a shift towards greater pharmaceutical management over the past decade. This study highlights the need to identify cost-effective treatment strategies in the face of increased uptake and expenditures associated with innovative treatments., (Copyright © 2019 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Patient non-attendance can lead to worse health outcomes and longer waiting times. In the English National Health Service, around 7% of patients who are referred by their general practice for a hospital outpatient appointment fail to attend. An electronic booking system (Choose and Book-C&B) for general practices making hospital outpatient appointments was introduced in England in 2005 and by 2009 accounted for 50% of appointments. It was intended, inter alia, to reduce the rate of non-attendance. Using a 2004-2009 panel with 7,900 English general practices, allowing for the relaxation of constraints on patient of hospital, and for the potential endogeneity of use of C&B, we estimate that the introduction of C&B reduced non-attendance by referred patients in 2009 by 72,160 (8.7%)., (Copyright © 2017 John Wiley & Sons, Ltd.)

Objective: To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs)., Design: Controlled longitudinal study., Setting: English National Health Service between 1998/99 and 2010/11., Participants: Populations registered with each of 6975 family practices in England., Main Outcome Measures: Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs., Results: Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11., Conclusions: The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities., (© Harrison et al 2014.)

Objectives: To develop a formula for allocating resources for commissioning hospital care to all general practices in England based on the health needs of the people registered in each practice, Design: Multivariate prospective statistical models were developed in which routinely collected electronic information from 2005-6 and 2006-7 on individuals and the areas in which they lived was used to predict their costs of hospital care in the next year, 2007-8. Data on individuals included all diagnoses recorded at any inpatient admission. Models were developed on a random sample of 5 million people and validated on a second random sample of 5 million people and a third sample of 5 million people drawn from a random sample of practices., Setting: All general practices in England as of 1 April 2007. All NHS inpatient admissions and outpatient attendances for individuals registered with a general practice on that date., Subjects: All individuals registered with a general practice in England at 1 April 2007., Main Outcome Measures: Power of the statistical models to predict the costs of the individual patient or each practice's registered population for 2007-8 tested with a range of metrics (R(2) reported here). Comparisons of predicted costs in 2007-8 with actual costs incurred in the same year were calculated by individual and by practice., Results: Models including person level information (age, sex, and ICD-10 codes diagnostic recorded) and a range of area level information (such as socioeconomic deprivation and supply of health facilities) were most predictive of costs. After accounting for person level variables, area level variables added little explanatory power. The best models for resource allocation could predict upwards of 77% of the variation in costs at practice level, and about 12% at the person level. With these models, the predicted costs of about a third of practices would exceed or undershoot the actual costs by 10% or more. Smaller practices were more likely to be in these groups., Conclusions: A model was developed that performed well by international standards, and could be used for allocations to practices for commissioning. The best formulas, however, could predict only about 12% of the variation in next year's costs of most inpatient and outpatient NHS care for each individual. Person-based diagnostic data significantly added to the predictive power of the models.

Objectives: To determine the impact on outcomes in patients of the Evercare approach to case management of elderly people., Design: Practice level before and after analysis of hospital admissions data with control group., Setting: Nine primary care trusts in England that, in 2003-5, piloted case management of elderly people selected as being at high risk of emergency admission., Main Outcome Measures: Rates of emergency admission, emergency bed days, and mortality from April 2001 to March 2005 in 62 Evercare practices and 6960-7695 control practices in England (depending on the analysis being carried out)., Results: The intervention had no significant effect on rates of emergency admission (increase 16.5%, (95% confidence interval -5.7% to 38.7%), emergency bed days (increase 19.0%, -5.3% to 43.2%), and mortality (increase 34.4%, -1.7% to 70.3%) for a high risk population aged >65 with a history of two or more emergency admissions in the preceding 13 months. For the general population aged > or =65 effects on the rates of emergency admission (increase 2.5%, -2.1% to 7.0%), emergency bed days (decrease -4.9%, -10.8% to 1.0%), and mortality (increase 5.5%, -3.5% to 14.5%) were also non-significant., Conclusions: Case management of frail elderly people introduced an additional range of services into primary care without an associated reduction in hospital admissions. This may have been because of identification of additional cases. Employment of community matrons is now a key feature of case management policy in the NHS in England. Without more radical system redesign this policy is unlikely to reduce hospital admissions.

Objective: To determine the subsequent pattern of emergency admissions in older people with a history of frequent emergency admissions., Design: Analysis of routine admissions data from NHS hospitals using hospital episode statistics (HES) in England., Subjects: Individual patients aged > or = 65, > or = 75, and > or = 85 who had at least two emergency admissions in 1997-8., Main Outcome Measures: Emergency admissions and bed use in this "high risk" cohort of patients were counted for the next five years and compared with the general population of the same age. No account was taken of mortality as the analysis was designed to estimate the future use of beds in this high risk cohort., Results: Over four to five years, admission rates and bed use in the high risk cohorts fell to the mean rate for older people. Although patients > or = 65 with two or more such admissions were responsible for 38% of admissions in the index year, they were responsible for fewer than 10% of admissions in the following year and just over 3% five years later., Conclusion: Patients with multiple emergency admissions are often identified as a high risk group for subsequent admission and substantial claims are made for interventions designed to avoid emergency admission in such patients. Simply monitoring admission rates cannot assess interventions designed to reduce admission among frail older people as rates fall without any intervention. Comparison with a matched control group is necessary. Wider benefits than reduced admissions should be considered when introducing intensive case management of older people.