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Biomedical subjects

David Reeves

Publications and source records attributed to David Reeves.

9 recordsLinked to original sources
PubMed2006

Pay-for-performance programs in family practices in the United Kingdom.

BACKGROUND: In 2004, after a series of national initiatives associated with marked improvements in the quality of care, the National Health Service of the United Kingdom introduced a pay-for-performance contract for family practitioners. This contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience. METHODS: We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England in the first year of the pay-for-performance program (April 2004 through March 2005), data from the U.K. Census, and data on characteristics of individual family practices. We examined the proportion of patients deemed eligible for a clinical quality indicator for whom the indicator was met (reported achievement) and the proportion of the total number of patients with a medical condition for whom a quality indicator was met (population achievement), and we used multiple regression analysis to determine the extent to which practices achieved high scores by classifying patients as ineligible for quality indicators (exception reporting). RESULTS: The median reported achievement in the first year of the new contract was 83.4 percent (interquartile range, 78.2 to 87.0 percent). Sociodemographic characteristics of the patients (age and socioeconomic features) and practices (size of practice, number of patients per practitioner, age of practitioner, and whether the practitioner was medically educated in the United Kingdom) had moderate but significant effects on performance. Exception reporting by practices was not extensive (median rate, 6 percent), but it was the strongest predictor of achievement: a 1 percent increase in the rate of exception reporting was associated with a 0.31 percent increase in reported achievement. Exception reporting was high in a small number of practices: 1 percent of practices excluded more than 15 percent of patients. CONCLUSIONS: English family practices attained high levels of achievement in the first year of the new pay-for-performance contract. A small number of practices appear to have achieved high scores by excluding large numbers of patients by exception reporting. More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income.

Chronic Disease↗
PubMed2006

Advanced nurse roles in UK primary care.

Nurses increasingly work as substitutes for, or to complement, general practitioners in the care of minor illness and the management of chronic diseases. Available research suggests that nurses can provide as high quality care as GPs in the provision of first contact and ongoing care for unselected patients. Reductions in cost are context dependent and rarely achieved. This is because savings on nurses' salaries are often offset by their lower productivity (due to longer consultations, higher patient recall rates, and increased use of tests and investigations). Gains in efficiency are not achieved when GPs continue to provide the services that have been delegated to nurses, instead of focusing on the services that only doctors can provide. Unintended consequences of extending nursing roles include loss of personal continuity of care for patients and increased difficulties with coordination of care as the multidisciplinary team size increases. Rapid access to care is, however, improved. There is a high capital cost involved in moving to multidisciplinary teams because of the need to train staff in new ways of working; revise legislation governing scope of practice; address concerns about legal liability; and manage professional resistance to change. Despite the unintended consequences and the high costs, extending nursing roles in primary care is a plausible strategy for improving service capacity without compromising quality of care or health outcomes for patients.

Cost-Benefit Analysis↗
PubMed2006

Is self-care a cost-effective use of resources? Evidence from a randomized trial in inflammatory bowel disease.

OBJECTIVES: To determine if a whole-system approach to self-management in inflammatory bowel disease (IBD), using a guidebook developed with patients and physicians trained in patient-centred care, leads to cost-effective use of health system resources. METHODS: Cost-effectiveness analysis over a one-year time horizon comparing the whole systems self-management approach to treatment with usual treatment. Nineteen hospitals in the northwest England were randomized to the intervention or to be controls; 651 patients (285 at intervention sites and 366 at control sites) with established IBD were included. The economic evaluation related differential health service costs, from a UK NHS perspective, to differences in quality-adjusted life years (QALYs) based on patients' responses to the EQ-5D. RESULTS: The intervention was associated with a mean reduction in costs of 148 pounds sterling per patient and a small mean reduction in QALYs of 0.00022 per patient compared with the control group. This resulted in an incremental cost per QALY gained of 676,417 pounds sterling for treatment as usual and a probability of around 63% that the whole-system approach to self-management is cost-effective, assuming a willingness to pay up to 30,000 pounds sterling for an additional QALY. CONCLUSIONS: Although there is uncertainty associated with these estimates, more widespread use of this method in chronic disease management seems likely to reduce health care costs without evidence of adverse effect on patient outcomes.

Cost-Benefit Analysis↗
PubMed2005

Recruitment to a trial of self-care skills training in long-term health conditions: analysis of the impact of patient attitudes and preferences.

The rise of evidence-based practice has highlighted the importance of effective recruitment to randomised controlled trials if studies are to be adequately powered and valid. However, there are also increasing concerns about patient preferences and choice within trials. The current authors are involved in a trial of a programme to provide self-care skills training for people with long-term health conditions (the 'Expert Patients Programme'), and during the design stage there were significant concerns about the impact of patient preferences on the feasibility and validity of the study, because recruitment required that patients risk randomisation to a waiting list control group. This paper first details the issues raised in this trial, and the methods used to attempt to overcome them. Data on recruitment rates, loss to follow up and patient decision making about participation are presented, which suggested that initial assumptions about the impact of patient preferences were incorrect. Key lessons concerning preferences in this patient population and related issues in trial administration are then discussed.

Attitude↗
PubMed2005

Improvements in quality of clinical care in English general practice 1998-2003: longitudinal observational study.

OBJECTIVE: To measure changes in quality of care for three major chronic diseases (coronary heart disease, asthma, and type 2 diabetes) between 1998 and 2003. DESIGN: Longitudinal cohort study. SETTING: 42 general practices in six geographical areas of England (Avon, Bury/Rochdale, Enfield, Oldham, Somerset, South Essex). PARTICIPANTS: Medical record data for 2300 patients with diabetes, asthma, or coronary heart disease in 1998, and 1495 patients in 2003. MAIN OUTCOME MEASURE: Quality of care assessed against predefined evidence based review criteria. RESULTS: Between 1998 and 2003, quality of care improved markedly in terms of maximum possible scores on the review criteria, from 60.5% to 78.1% for coronary heart disease (change = 17.6, 95% confidence interval 13.9 to 21.4; P < 0.001), 60.1% to 70.3% for asthma (10.2, 4.6 to 15.8; P = 0.001), and 70.4% to 77.7% for diabetes (7.3, 3.5 to 11.1; P = 0.001). Important changes occurred to several indicators potentially related to improved health outcomes. These included improved control of serum cholesterol (to < or = 5 mmol/l) from 17.6% to 61.4% in coronary heart disease and from 21.5% to 52% in diabetes and control of blood pressure to < or = 150/90 in coronary heart disease from 47.3% to 72.2% and to < or = 145/85 in diabetes from 21.8% to 35.8%. A small, non-significant improvement in glycaemic control occurred among diabetic patients (37.9% to 39.7% with HbA1c < 7.4%). Significant improvements also occurred in the recording of exercise capacity and diet and weight advice for patients with coronary heart disease; of smoking advice, peak flow, and symptoms for patients with asthma; and of creatinine, weight, and HbA(1c) for patients with diabetes. Over the five years, more improvement in coronary heart disease care occurred in large practices and practices in affluent areas. CONCLUSIONS: Substantial improvements were seen in quality of care for the three conditions studied between 1998 and 2003, a time of systematic quality improvement initiatives in the NHS. The changes were most marked for coronary heart disease. English general practices could be expected to achieve high clinical quality scores in the initial year of a new contact, which provides financial incentives for high quality care from 2004.

Asthma↗
PubMed2005

Systematic reviews and meta-analyses in the Journal of Antimicrobial Chemotherapy.

Systematic reviews and meta-analyses are powerful tools deployed in the pursuit of evidence-based practice. The Journal of Antimicrobial Chemotherapy (JAC) welcomes the submission of these types of article; however, it is crucial that these studies are conducted properly. In this article we outline the advantages and limitations inherent in these approaches, and the features that we look for when this type of article is submitted to JAC.

Editorial Policies↗
PubMed2004

Investigating relationships between health need, primary care and social care using routine statistics.

Closer integration of primary and social care is central to the agenda of Primary Care Groups and Trusts (PCG/Ts) in England. Relationships between the need for care and primary and social care provision at local levels are investigated using routinely available statistics. Primary care provision is negatively associated with need resulting from material deprivation, but positively associated with older age-related need. Conversely, provision of social care is positively related to need resulting from deprivation but is unrelated to the size of local elderly populations. The 'inverse care law' does not capture the complexity of the relationships between need and provision. A lack of boundary coterminosity represents a serious impediment to the goal of establishing integrated health and social care systems for local populations.

Aged↗
PubMedDate not supplied

Progress and outcomes for children with autism receiving parent-managed intensive interventions.

Parent-managed behavioral interventions for young children with autism are under-researched. We analysed data from 66 children served by 25 different early intervention consultants. After a mean of 31.6 months of intervention, IQ scores had not changed (N = 22). Vineland adaptive behavior scores had increased significantly by 8.9 points (N = 21). No children aged >72 months attained normal functioning, i.e., IQ > 85 and unassisted mainstream school placement (N = 42). Progress for 60 children across 12 months was found for mental age (5.4 months), adaptive behavior (9.7 months), and language (5.1 months). The interventions did not reproduce results from clinic-based professionally directed programs. The effectiveness of the parent-managed intervention model as it has developed and the adequacy of professional services in that model are discussed.

Adaptation, Psychological↗