Dataset Information

Effects of non-medical health coaching on multimorbid patients in primary care: a difference-in-differences analysis.

ABSTRACT:

Background

Health systems, globally, are attempting to strengthen primary care to promote a population-health management approach to care provision, incentivising prevention and self-management. This paper evaluates the "Enhanced Primary Care" model implemented in a geographical region in England. Enhanced Primary Care introduces a new non-medical role, health coaches, to the traditional primary care team to provide additional support for patients with chronic conditions. We evaluate effects of health coaching on patient outcomes using a quasi-experiment.

Methods

We estimate the programme's effects on health status (EQ-5D-5L, physical functioning, psychological wellbeing, and resilience), health behaviour (smoking habit), experience of care (person-centeredness and continuity of care), and health care (primary care) utilisation using data from 3.5 million respondents to the national GP Patient Surveys between 2013 and 2017. We use a weighted difference-in-differences design to compare changes in outcomes over time between intervention practices and comparable control practices in the rest of England. We conduct our main analysis on multimorbid patients and additional analysis on all patients to assess population-level effects.

Results

For multimorbid patients, we find reductions in psychological wellbeing (short and medium term) of -0.0174 (95% confidence interval?-0.0283 to -0.0065), relative difference?-2% from the pre-intervention mean; and person-centeredness (short term) of -0.0356 (-0.0530 to -0.0183), -4%. We find no significant effects on other outcome measures. For population-level effects, in the short term we find reductions in primary care utilisation of -0.0331 (-0.0448 to -0.0214), -5%. All other outcomes are not consistently statistically significant.

Conclusions

Our results show that there is very little effect of health coaching on patient experience and outcomes in the short-to-medium term (up to 14?months). Introduction of Enhanced Primary Care was associated with slightly lower psychological wellbeing and person-centeredness amongst multimorbid patients (it might be initially difficult for patients to adjust to the model). However, it was also associated with a decline in primary care visits at the population-level (potentially freeing up practitioner time for more complex patients). The results raise important questions regarding primary care workforce changes advocated in the NHS Long Term Plan, and the time horizon of any benefits of prevention strategies.

SUBMITTER: Shah V

PROVIDER: S-EPMC6704561 | biostudies-literature | 2019 Aug

REPOSITORIES: biostudies-literature

ACCESS DATA

Publications

Effects of non-medical health coaching on multimorbid patients in primary care: a difference-in-differences analysis.

Shah Vishalie V Stokes Jonathan J Sutton Matt M

BMC health services research 20190822 1

<h4>Background</h4>Health systems, globally, are attempting to strengthen primary care to promote a population-health management approach to care provision, incentivising prevention and self-management. This paper evaluates the "Enhanced Primary Care" model implemented in a geographical region in England. Enhanced Primary Care introduces a new non-medical role, health coaches, to the traditional primary care team to provide additional support for patients with chronic conditions. We evaluate eff ...[more]

PMID: 31438937

Similar Datasets

Project description:ObjectivesTo assess the risk of mortality in primary care patients, multimorbid (?2 chronic conditions) or not, prescribed hypnotics/anxiolytics.DesignA longitudinal cohort study SETTING: Primary healthcare in the Reykjavik area.Participants114 084 individuals (aged 10-79 years, average 38.5, SD 18.4) contacting general practitioners during 2009-2012 (mortality follow-up to 31 December 2016). Of those, the reference group comprised 58 560 persons who were neither multimorbid nor had redeemed prescriptions for hypnotics/anxiolytics. Participants (16 108) redeeming prescriptions for hypnotics/anxiolytics on a regular basis for 3 consecutive years were considered as consistent, long-term users. They were subdivided into low-dose (1-300 defined daily doses (DDD)/3 years), medium-dose (301-1095 DDDs/3 years) and high-dose users (>1095 DDDs/3 years). All six groups taking these drugs were compared with the reference group.Main outcome measuresAll-cause mortality.ResultsHRs were calculated with the no multimorbidity-no drug group as a reference, using Cox proportional hazards regression model adjusting for age, sex and the number of chronic conditions (n=111 767), patients with cancer excluded. During follow-up, 516 358 person-years in total, 1926 persons died. Mean follow-up was 1685 days (4.6 years), range 1-1826 days (5.0 years). For all multimorbid patients who took no drugs the HR was 1.14 (95% CI 1.00 to 1.30) compared with those without multimorbidity. HRs in the non-multimorbid participants varied from 1.49 to 3.35 (95% CI ranging from 1.03 to 4.11) with increasing doses of hypnotics/anxiolytics, and correspondingly from 1.55 to 3.52 (1.18 to 4.29) in multimorbid patients.ConclusionsMortality increased in a dose-dependent manner among both multimorbid and non-multimorbid patients taking hypnotics/anxiolytics. This increase was clearly associated with prescribing of these drugs. Their use should be limited to the recommended period of 2-4 up to 6 weeks; long-term use may incur increased risk and should be re-examined.

Project description:BACKGROUND:It is not known whether equity-oriented primary care investment that seeks to scale up the delivery of effective care in disadvantaged communities can reduce health inequality within high-income settings that have pre-existing universal primary care systems. We provide some non-randomised controlled evidence by comparing health inequality trends between two similar jurisdictions-one of which implemented equity-oriented primary care investment in the mid-to-late 2000s as part of a cross-government strategy for reducing health inequality (England), and one which invested in primary care without any explicit equity objective (Ontario, Canada). METHODS:We analysed whole-population data on 32,482 neighbourhoods (with mean population size of approximately 1,500 people) in England, and 18,961 neighbourhoods (with mean population size of approximately 700 people) in Ontario. We examined trends in mortality amenable to healthcare by decile groups of neighbourhood deprivation within each jurisdiction. We used linear models to estimate absolute and relative gaps in amenable mortality between most and least deprived groups, considering the gradient between these extremes, and evaluated difference-in-difference comparisons between the two jurisdictions. RESULTS:Inequality trends were comparable in both jurisdictions from 2004-6 but diverged from 2007-11. Compared with Ontario, the absolute gap in amenable mortality in England fell between 2004-6 and 2007-11 by 19.8 per 100,000 population (95% CI: 4.8 to 34.9); and the relative gap in amenable mortality fell by 10 percentage points (95% CI: 1 to 19). The biggest divergence occurred in the most deprived decile group of neighbourhoods. DISCUSSION:In comparison to Ontario, England succeeded in reducing absolute socioeconomic gaps in mortality amenable to healthcare from 2007 to 2011, and preventing them from growing in relative terms. Equity-oriented primary care reform in England in the mid-to-late 2000s may have helped to reduce socioeconomic inequality in health, though other explanations for this divergence are possible and further research is needed on the specific causal mechanisms.

Project description:BackgroundPay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered.Methods and findingsFor this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care.ConclusionsPerformance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.

Project description:The burden of chronic disease and multimorbidity is rapidly increasing. Self-management support interventions are effective in reduce cost, especially when targeted at a single disease group; however, economical evidence of such complex interventions remains scarce. The objective of this study was to evaluate a cost-effectiveness analysis of a tele-based health-coaching intervention among patients with type 2 diabetes (T2D), coronary artery disease (CAD) and congestive heart failure (CHF).A total of 1570 patients were blindly randomized to intervention (n?=?970) and control (n?=?470) groups. The intervention group received monthly individual health coaching by telephone from a specially trained nurse for 12-months in addition to routine social and healthcare. Patients in the control group received routine social and health care. Quality of life was assessed at the beginning of the intervention and follow-up measurements were made after 12 months health coaching. The cost included all direct health-care costs supplemented with home care and nursing home-care costs in social care. Utility was based on a Health Related Quality of Life (HRQoL) measurement (15D instrument), and cost effectiveness was assessed using incremental cost-effectiveness ratios (ICERs).The cost-effectiveness of health coaching was highest in the T2D group (ICER €20,000 per Quality-Adjusted Life Years [QALY]). The ICER for the CAD group was more modest (€40,278 per QALY), and in the CHF group, costs increased with no marked effect on QoL. Probabilistic sensitivity analysis indicated that at the societal willingness to pay threshold of €50,000 per QALY, the probability of health coaching being cost effective was 55% in the whole study group.The cost effectiveness of health coaching may vary substantially across patient groups, and thus interventions should be targeted at selected subgroups of chronically ill. Based on the results of this study, health coaching improved the QoL of T2D and CAD patients with moderate costs. However, the results are grounded on a short follow-up period, and more evidence is needed to evaluate the long-term outcomes of health-coaching programs.NCT00552903 [Prospectively registered, registration date 1st November 2007, last updated 3rd February 2009].

Dataset Information

Effects of non-medical health coaching on multimorbid patients in primary care: a difference-in-differences analysis.

Background

Methods

Results

Conclusions

Publications

Effects of non-medical health coaching on multimorbid patients in primary care: a difference-in-differences analysis.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure