Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis

Farrar, Shelley; Yi, Deokhee; Sutton, Matt; Chalkley, Martin; Sussex, Jon; Scott, Anthony

doi:10.1136/bmj.b3047

Cited by 149 publications

(175 citation statements)

References 21 publications

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“…Analysis by health economists of the financial implications of implementing a guideline's recommendations and generation of methods that would allow users to manage these appropriately would be another step that could be taken to further overcome guidelines that have poor applicability. The design of financial incentives to increase uptake of guidelines that will improve patient outcomes has been popular in the United Kingdom [10] . Payment by results is a scheme that provides financial incentive for hospitals that adopt practices recommended by some of the National Institutes for Health and Care Excellence (NICE) guidelines [23].…”

Section: Discussionmentioning

confidence: 99%

High Methodologic Quality But Poor Applicability: Assessment of the AAOS Guidelines Using The AGREE II Instrument

Sabharwal

Patel

Gauher

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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Background The American Academy of Orthopaedic Surgeons (AAOS) is a globally recognized leader in musculoskeletal and orthopaedic education. Clinical guidelines are one important focus of the AAOS' educational efforts. Although their recommendations sometimes generate controversy, a critical appraisal of the overall quality of these guidelines has not, to our knowledge, been reported. Questions/purposes We wished to assess the overall quality of the AAOS guidelines using the AGREE II (Advancing Guideline Development, Reporting and Evaluation in Health Care) instrument. Methods All 14 guidelines available on the AAOS website as of August 2, 2013 were evaluated. Appraisal was performed by three reviewers, independently, using the AGREE II instrument. This is an internationally recognized and validated assessment tool for evaluating guideline quality. Interrater reliability was calculated and descriptive statistics were performed. Strong interrater reliability was shown using a Spearman's Rho test (correlation coefficient C 0.95). Results The overall results for AGREE II domains across all 14 guidelines were: scope and purpose (median score, 95%), stakeholder involvement (median score, 83%), rigor of development (median score, 94%), clarity of presentation (median score, 92%), applicability (median score, 48%), and editorial independence (median score, 79%). Conclusions This study showed that the overall quality of the AAOS guidelines is high, however their applicability was found to be poor. The value of guidelines that have a high quality but that are difficult for clinicians to implement is questionable. Numerous suggestions have been proposed to improve applicability including; health economist involvement in guideline production, implementation of pilot studies and audit to monitor uptake of the guidelines and clinician feedback sessions and barrier analysis studies. Future AAOS guidelines should consider and implement steps that can improve their applicability.

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Section: Discussionmentioning

confidence: 99%

High Methodologic Quality But Poor Applicability: Assessment of the AAOS Guidelines Using The AGREE II Instrument

Sabharwal

Patel

Gauher

et al. 2014

Clinical Orthopaedics &Amp; Related Research

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“…As noted above, though, factors other than the introduction of activity-based funding may have affected this outcome. For example, in England, the introduction of activity-based funding was contemporaneous with large funding increases to the NHS and the use of other policy instruments, such as waiting time targets, so isolating its specific impact is virtually impossible (Propper et al, 2007;Audit Commission, 2008b;Farrar et al, 2009; see also Sussex and Farrar, 2009). Not only has hospital activity increased in absolute terms but there has also been a change in its composition.…”

Section: Impactmentioning

confidence: 99%

“…Increased patient throughput may be expected to result in increased aggregate expenditure on hospital services (as in France; Or, 2009), yet the costs per case may be lower (as in England, proxied by changes in length of stay and share of day-case activity; Farrar et al, 2009). Quality of care might be adversely affected if patients are discharged from hospital 'quicker and sicker'; but shorter hospital stays are associated with a lower probability of acquiring hospital infections ceteris paribus Clarke, 1996).…”

Section: Impactmentioning

confidence: 99%

Paying for hospital care: the experience with implementing activity-based funding in five European countries

O’Reilly

Busse²,

Häkkinen

et al. 2012

HEPL

105

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: Following the US experience, activity-based funding has become the most common mechanism for reimbursing hospitals in Europe. Focusing on five European countries (England, Finland, France, Germany and Ireland), this paper reviews the motivation for introducing activity-based funding, together with the empirical evidence available to assess the impact of implementation. Despite differences in the prevailing approaches to reimbursement, the five countries shared several common objectives, albeit with different emphasis, in moving to activity-based funding during the 1990s and 2000s. These include increasing efficiency, improving quality of care and enhancing transparency. There is substantial cross-country variation in how activity-based funding has been implemented and developed. In Finland and Ireland, for instance, activity-based funding is principally used to determine hospital budgets, whereas the models adopted in the other three countries are more similar to the US approach. Assessing the impact of activity-based funding is complicated by a shortage of rigorous empirical evaluations. What evidence is currently available, though, suggests that the introduction of activity-based funding has been associated with an increase in activity, a decline in length of stay and/or a reduction in the rate of growth in hospital expenditure in most of the countries under consideration.

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“…12 Such a payment system has been argued to provide incentives to reduce costs, by, for example, reducing length of stay (LOS), and to increase in the levels of activity, therefore reducing waiting times. 13 How strongly these incentives will affect the outcomes of hospitals will depend on how much of their revenue relates directly to their activity levels; in England it accounts for around 60% of hospitals' revenue. 14 In terms of elective activity, there is evidence that PbR has increased activity levels and the proportion of activity performed as day cases and reduced LOS.…”

Section: Introductionmentioning

confidence: 99%

Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth

Chalkley

McCormick

Anderson

et al. 2017

Health Serv Deliv Res

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BackgroundThe English NHS faces financial pressures that may render the growth rates of elective admissions seen between 2001/2 and 2011/12 unsustainable. A better understanding of admissions growth, and the influence of policy, are needed to minimise the impact on health gain for patients.ObjectivesThis project had several objectives: (1) to better understand the determinants of elective activity and policy to moderate growth at minimum health loss for patients; (2) to build a rich data set integrating health, practice and local area data to study general practitioner (GP) referrals and resulting admissions; (3) to predict patients whose treatment is unlikely to be cost-effective using patient-reported outcomes and to examine variation in provider performance; and (4) to study how policies that aim to reduce elective admissions may change demand for emergency care. The main drivers of elective admissions growth have increased either supply of or demand for care, and could include, for example, technical innovations or increased awareness of treatment benefits. Of the factors studied, neither system reform nor population ageing appears to be a key driver. The introduction of the prospective payment tariff ‘Payment by Results’ appears to have led to primary care trusts (PCTs) having increasingly similar lengths of stay. In deprived areas, increasing GP supply appears to moderate elective admissions. Reducing the incidence of single-handed practices tends to reduce referrals and admissions. Policies to reduce referrals are likely to reduce admissions but treatments may be particularly reduced in the lowest referring practices, in which resulting health loss may be greatest. In this model, per full-time equivalent, female and highly experienced GPs identify more patients admitted by specialists.ResultsIt appears from our studies that some patient characteristics are associated with not achieving sufficient patient gain to warrant cost-effective treatment. The introduction of independent sector treatment centres is estimated to have caused an increase in emergency activity rates at local PCTs. The explanations offered for increasing elective admissions indicate that they are manageable by health policy.ConclusionsFurther work is required to understand some of the results identified, such as whether or not high-volume Clinical Commissioning Groups are fulfilling unmet need; why some practices refer at low rates relative to admissions; why the period effect, which results from factors that equally affect all in the study at a point in time, dominates in the age–period–cohort analysis; and exactly how the emergency and elective sections of hospital treatment interact. This project relies on the analysis of secondary data. This type of research does not easily facilitate the important input of clinical experts or service users. It would be beneficial if other methods, including surveys and consultation with key stakeholders, could be incorporated into future research now that we have uncovered important questions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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Has payment by results affected the way that English hospitals provide care? Difference-in-differences analysis

Cited by 149 publications

References 21 publications

High Methodologic Quality But Poor Applicability: Assessment of the AAOS Guidelines Using The AGREE II Instrument

High Methodologic Quality But Poor Applicability: Assessment of the AAOS Guidelines Using The AGREE II Instrument

Paying for hospital care: the experience with implementing activity-based funding in five European countries

Elective hospital admissions: secondary data analysis and modelling with an emphasis on policies to moderate growth

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