TY - JOUR
T1 - The association between primary care quality and healthcare utilisation, costs and outcomes for people with serious mental illness: retrospective observational study
AU - Jacobs, Rowena
AU - Aylott, Lauren
AU - Dare, Ceri
AU - Doran, Timothy
AU - Gilbody, Simon
AU - Goddard, Maria Karen
AU - Gravelle, Hugh Stanley Emrys
AU - Gutacker, Nils
AU - Kasteridis, Panagiotis
AU - Kendrick, Tony
AU - Mason, Anne
AU - Rice, Nigel
AU - Ride, Jemimah Ruth
AU - Siddiqi, Najma
AU - Williams, Rachael
N1 - © Queen’s Printer and Controller of HMSO 2020. Uploaded in accordance with the publisher’s self-archiving policy. Further copying may not be permitted; contact the publisher for details
PY - 2020/6
Y1 - 2020/6
N2 - Background
Serious mental illness (SMI), including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with SMI are treated in primary care by general practitioners (GPs), who are financially incentivised to meet quality targets for patients with chronic conditions, including SMI, under the Quality and Outcomes Framework (QOF). The QOF, however, omits important aspects of quality.
Objective(s)
We examined whether better quality of primary care for people with SMI improved a range of outcomes.
Design and setting
We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, Accident & Emergency (A&E) attendances, Office for National Statistics mortality data, and community mental health records in the Mental Health Minimum Dataset. We used survival analysis to estimate whether selected quality indicators affect the time until patients experience an outcome.
Participants
Four cohorts of people with SMI depending on the outcomes examined and inclusion criteria.
Interventions
Quality of care was measured with: i) QOF indicators: care plans and annual physical reviews ;and ii) non-QOF indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by GPs).
Main outcome measures
Several outcomes were examined: emergency admissions for i) SMI and ii) ambulatory care sensitive conditions (ACSCs); iii) all unplanned admissions; iv) A&E attendances; v) mortality; vi) re-entry into specialist mental health services; vii) costs attributed to primary, secondary and community mental healthcare.
Results
Care plans were associated with lower risk of A&E attendance (Hazard ratio (HR) 0.74, 95%CI 0.69-0.80), SMI admission (HR 0.67, 95%CI 0.59-0.75), ACSC admission (HR 0.73, 95%CI 0.64-0.83), and lower overall healthcare (£53), primary care (£9), hospital (£26), and mental healthcare costs (£12).
Annual reviews were associated with reduced risk of A&E attendance (HR 0.80, 95%CI 0.76-0.85), SMI admission (HR 0.75, 95%CI 0.67-0.84), ACSC admission (HR 0.76, 95%CI 0.67-0.87), and lower overall healthcare (£34), primary care (£9), and mental healthcare costs (£30).
Higher GP continuity was associated with lower risk of A&E presentation (HR 0.89, 95%CI 0.83-0.97), ACSC admission (HR 0.77, 95%CI 0.65-0.92), but not SMI admission. High continuity was associated with lower primary care costs (£3).
Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or A&E presentation.
None of the quality measures were statistically significantly associated with risk of re-entry into specialist mental healthcare.
Limitations
There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.
Conclusions
Better performance on QOF measures and continuity of care are associated with better outcomes and lower resource utilisation and could generate moderate cost savings.
Future work
Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.
AB - Background
Serious mental illness (SMI), including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with SMI are treated in primary care by general practitioners (GPs), who are financially incentivised to meet quality targets for patients with chronic conditions, including SMI, under the Quality and Outcomes Framework (QOF). The QOF, however, omits important aspects of quality.
Objective(s)
We examined whether better quality of primary care for people with SMI improved a range of outcomes.
Design and setting
We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, Accident & Emergency (A&E) attendances, Office for National Statistics mortality data, and community mental health records in the Mental Health Minimum Dataset. We used survival analysis to estimate whether selected quality indicators affect the time until patients experience an outcome.
Participants
Four cohorts of people with SMI depending on the outcomes examined and inclusion criteria.
Interventions
Quality of care was measured with: i) QOF indicators: care plans and annual physical reviews ;and ii) non-QOF indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by GPs).
Main outcome measures
Several outcomes were examined: emergency admissions for i) SMI and ii) ambulatory care sensitive conditions (ACSCs); iii) all unplanned admissions; iv) A&E attendances; v) mortality; vi) re-entry into specialist mental health services; vii) costs attributed to primary, secondary and community mental healthcare.
Results
Care plans were associated with lower risk of A&E attendance (Hazard ratio (HR) 0.74, 95%CI 0.69-0.80), SMI admission (HR 0.67, 95%CI 0.59-0.75), ACSC admission (HR 0.73, 95%CI 0.64-0.83), and lower overall healthcare (£53), primary care (£9), hospital (£26), and mental healthcare costs (£12).
Annual reviews were associated with reduced risk of A&E attendance (HR 0.80, 95%CI 0.76-0.85), SMI admission (HR 0.75, 95%CI 0.67-0.84), ACSC admission (HR 0.76, 95%CI 0.67-0.87), and lower overall healthcare (£34), primary care (£9), and mental healthcare costs (£30).
Higher GP continuity was associated with lower risk of A&E presentation (HR 0.89, 95%CI 0.83-0.97), ACSC admission (HR 0.77, 95%CI 0.65-0.92), but not SMI admission. High continuity was associated with lower primary care costs (£3).
Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or A&E presentation.
None of the quality measures were statistically significantly associated with risk of re-entry into specialist mental healthcare.
Limitations
There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.
Conclusions
Better performance on QOF measures and continuity of care are associated with better outcomes and lower resource utilisation and could generate moderate cost savings.
Future work
Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.
KW - serious mental illness;
KW - quality indicators
KW - general practitioners
KW - primary healthcare;
KW - survival analysis
KW - England
U2 - 10.3310/hsdr08250
DO - 10.3310/hsdr08250
M3 - Article
SN - 2050-4349
VL - 8
JO - Health Services and Delivery Research
JF - Health Services and Delivery Research
IS - 25
M1 - HS&DR 13/54/40
ER -