Patients in England are more likely to choose general practices with higher clinical quality as measured by Quality and Outcomes Framework (QOF) points. A 1 standard deviation increase in QOF points is associated with a 20% increase in demand for a practice. While the effect of quality on an individual's choice is small, the large number of potential patients means quality has a large effect on total demand for a practice. Quality is the main driver of choice, more so than distance, practice characteristics, or patient attributes. This provides incentive for practices to improve quality to attract more patients.
Slides from the presentation on extrapolation from progression free survival to overall survival in oncology given at the 2017 HTAi Annual Meeting in Rome
This document summarizes an audit of adult patient characteristics, management, and outcomes related to acute lower gastrointestinal bleeding (LGIB) at hospitals in the UK, including Aintree University Hospital. The audit examined 2,528 patients across 174 UK hospitals and 52 patients at Aintree based on 17 standards of care. Key findings included that 49% of UK patients and 33% of Aintree patients had no inpatient investigations to identify the bleeding source. Performance against the standards was variable both nationally and at Aintree, indicating opportunities for improvement in LGIB management and care.
This document summarizes a study that used multi-criteria decision analysis (MCDA) to understand stakeholders' preferences on decision criteria for the treatment obinutuzumab for indolent non-Hodgkin lymphoma in Italy. Stakeholders including patients, clinicians, and payers participated in an online survey and meetings to provide weights and scores on criteria such as disease severity and cost. The results showed similarity between patients and clinicians prioritizing criteria related to disease impact, while payers distributed weights more evenly. Obinutuzumab scored highly on disease severity and therapeutic benefit but lower on economic criteria. The overall value score can help inform coverage decisions by identifying priority outcomes and consensus views.
Anti-cancer therapy is big business. In Australia alone between 2000 and 2009, cancer-related pharmaceutical expenditure has risen over 200% to over half a billion dollars per annum.
The Value of Targeted Sequencing in Advanced Cancer: DCE to Elicit the Public...Office of Health Economics
This project seeks to elicit the public’s preferences for different features of a genomic test to sequence advanced solid cancer tumours. Understanding the relative preferences for various attributes of targeted testing are useful for determining the value of sequencing approaches, and informing technology adoption decisions. A discrete choice experiment (DCE) survey was designed to assess the preferences of members of the Australian general public for targeted sequencing in advanced cancer. The survey presented respondents with 12 questions in which they had to choose between two unlabelled tests (Test A and Test B). Tests were specified in terms of five attributes: time to receive the test result; cost of the test; likelihood that the test result will lead to a change in treatment; length of time health care professionals spend describing the test; and type of health care team who explains the test result. Respondents were sampled from an online panel and also completed questions related to demographic and socio-economic factors, experiences of cancer and familial history. We found that cost, timeliness, expertise/location and likeliness of changing treatment regimes were identified as attributes of genomic sequencing that are most valuable to a sample of the public. These results will ultimately be compared with the results of an ongoing DCE being conducted with patients with advanced cancer who are undergoing sequencing.
Author(s) and affiliation(s): Paula Lorgelly (OHE), Grace Hampson (OHE), James Buchanan (Oxford), Melissa Martyn (MGHA), Jayesh Desai (PeterMac), Clara Gaff (MGHA), and iPREDICT MGHA Flagship collaborators
Conference/meeting: EuHEA 2018
Location: Maastricht, the Netherlands
Date: 12/07/2018
The document summarizes a comparative analysis of access to orphan medicinal products (OMPs) in the UK, France, Germany, Italy, and Spain. It finds that OMPs have the widest availability in Germany and Italy, where Germany automatically reimburses all authorized OMPs and around 60% are reimbursed in Italy. Germany and France also provide the broadest access overall. The UK mechanisms provide access to less than 50% of authorized OMPs, while Germany provides the quickest access. On average, it takes around 24 months for countries to grant access, but times vary between countries.
Slides from the presentation on extrapolation from progression free survival to overall survival in oncology given at the 2017 HTAi Annual Meeting in Rome
This document summarizes an audit of adult patient characteristics, management, and outcomes related to acute lower gastrointestinal bleeding (LGIB) at hospitals in the UK, including Aintree University Hospital. The audit examined 2,528 patients across 174 UK hospitals and 52 patients at Aintree based on 17 standards of care. Key findings included that 49% of UK patients and 33% of Aintree patients had no inpatient investigations to identify the bleeding source. Performance against the standards was variable both nationally and at Aintree, indicating opportunities for improvement in LGIB management and care.
This document summarizes a study that used multi-criteria decision analysis (MCDA) to understand stakeholders' preferences on decision criteria for the treatment obinutuzumab for indolent non-Hodgkin lymphoma in Italy. Stakeholders including patients, clinicians, and payers participated in an online survey and meetings to provide weights and scores on criteria such as disease severity and cost. The results showed similarity between patients and clinicians prioritizing criteria related to disease impact, while payers distributed weights more evenly. Obinutuzumab scored highly on disease severity and therapeutic benefit but lower on economic criteria. The overall value score can help inform coverage decisions by identifying priority outcomes and consensus views.
Anti-cancer therapy is big business. In Australia alone between 2000 and 2009, cancer-related pharmaceutical expenditure has risen over 200% to over half a billion dollars per annum.
The Value of Targeted Sequencing in Advanced Cancer: DCE to Elicit the Public...Office of Health Economics
This project seeks to elicit the public’s preferences for different features of a genomic test to sequence advanced solid cancer tumours. Understanding the relative preferences for various attributes of targeted testing are useful for determining the value of sequencing approaches, and informing technology adoption decisions. A discrete choice experiment (DCE) survey was designed to assess the preferences of members of the Australian general public for targeted sequencing in advanced cancer. The survey presented respondents with 12 questions in which they had to choose between two unlabelled tests (Test A and Test B). Tests were specified in terms of five attributes: time to receive the test result; cost of the test; likelihood that the test result will lead to a change in treatment; length of time health care professionals spend describing the test; and type of health care team who explains the test result. Respondents were sampled from an online panel and also completed questions related to demographic and socio-economic factors, experiences of cancer and familial history. We found that cost, timeliness, expertise/location and likeliness of changing treatment regimes were identified as attributes of genomic sequencing that are most valuable to a sample of the public. These results will ultimately be compared with the results of an ongoing DCE being conducted with patients with advanced cancer who are undergoing sequencing.
Author(s) and affiliation(s): Paula Lorgelly (OHE), Grace Hampson (OHE), James Buchanan (Oxford), Melissa Martyn (MGHA), Jayesh Desai (PeterMac), Clara Gaff (MGHA), and iPREDICT MGHA Flagship collaborators
Conference/meeting: EuHEA 2018
Location: Maastricht, the Netherlands
Date: 12/07/2018
The document summarizes a comparative analysis of access to orphan medicinal products (OMPs) in the UK, France, Germany, Italy, and Spain. It finds that OMPs have the widest availability in Germany and Italy, where Germany automatically reimburses all authorized OMPs and around 60% are reimbursed in Italy. Germany and France also provide the broadest access overall. The UK mechanisms provide access to less than 50% of authorized OMPs, while Germany provides the quickest access. On average, it takes around 24 months for countries to grant access, but times vary between countries.
This document summarizes Professor Adrian Towse's presentation on assessing the value of new antibiotics. It discusses the challenges of developing new antibiotics due to scientific and economic hurdles. Current health technology assessment frameworks may not fully capture antibiotics' value in addressing antimicrobial resistance. Additional elements of value for antibiotics are proposed, including insurance value, diversity value, and enablement value. Evidence requirements for assessing these new elements were discussed. While not unique to antibiotics, these elements provide a more comprehensive evaluation. Further refinement is needed to incorporate these elements into health technology assessments.
Introduction of the NZ Health IT Plan enables better gout management - Reflections of an early adopter. Presented by Peter Gow, Counties Manukau DHB, at HINZ 2014, 12 November 2014, 11.37am, Plenary Room
This document summarizes Adrian Towse's presentation on multi-indication pricing at HTAi Rome in June 2017. It discusses the benefits of multi-indication pricing in allowing prices to better reflect the relative value of different indications. However, implementation faces challenges from stakeholders with differing perspectives. UK and US workshops provided feedback supporting the concept but noting administrative hurdles. Options for achieving multi-indication pricing include blended pricing, differential rebates, or a combination approach, but require ability to track drug use by indication using data systems.
Main Presentation UK Diagnostic Summit 2018Walt Whitman
The document summarizes a conference on maximizing diagnostic technology to tackle antimicrobial resistance (AMR) in the UK. It discusses the UK AMR Diagnostic Collaborative, which provides leadership and alignment across the diagnostic system. Key areas of focus for 2018-2019 include diagnostic stewardship, innovation, and understanding how health policy can support rapid diagnostic adoption. Upcoming milestones are surveys on blood culture and industry engagement to help accelerate diagnostic usage and solutions. Continued focus on diagnostics is crucial as the government refreshes its AMR strategy and action plan.
The document discusses using data and analytics to drive improvements in healthcare. It outlines the components of a data-driven organization, including an enterprise data warehouse, metrics, predictive models, protocols, and governance. It also discusses how analytics can help healthcare providers transition to value-based payments by measuring quality, reducing variation, and eliminating waste. Specific examples are provided on how one healthcare system used data to reduce variation in spine care, lower bleeding complications after PCI procedures, identify drug cost opportunities in knee replacements, and lower supply costs for lumbar fusion procedures.
The document summarizes the NHS RightCare approach, which aims to reduce unwarranted variation and improve health outcomes. It does this by ensuring the right care is provided in the right place at the right time using available resources. NHS RightCare provides data, tools, and support to help local health systems identify priority areas for improvement, understand variation compared to similar populations, and implement sustainable changes through a three phase process.
Defining and assessing a delineation uncertainty margin for modern radiotherapyCancer Institute NSW
The implementation of image-guided technology and progressively conformal techniques in modern radiotherapy for the treatment of cancer, ensure the planned distribution of dose is well matched to the clinician-defined target volume. However, this precision relies on the target volume including all malignant tissue, with delineation uncertainty resulting in potential normal tissue toxicities and insufficient dose to the cancer. Methods need to be implemented to minimise delineation uncertainty, and subsequently improve local control and patient outcomes.
Endometrial polyp in women with postmenopausal bleeding a systematic review a...Ahmed Ghoubara
This document presents a systematic review and meta-analysis that assessed the prevalence of hyperplasia and cancer in endometrial polyps among women with postmenopausal bleeding. The review included 10 studies with a total of 2,637 patients. The pooled prevalence of hyperplasia and cancer among women with postmenopausal bleeding and endometrial polyps was estimated to be 8.9%. Sensitivity analyses found that no single study significantly influenced the pooled estimate. The review concluded that the risk of finding hyperplasia or cancer in endometrial polyps among women with postmenopausal bleeding is high, and expectant management of polyps should be considered cautiously.
The experience of survival following Blood and Marrow Transplant in NSW, Aust...Cancer Institute NSW
Over 50% of patients undergoing allogeneic BMT can now be expected to become long-term survivors. Unfortunately many experience significant late morbidity and mortality.
The Lung Cancer Demonstration Project: Implementation and evaluation of a lun...Cancer Institute NSW
The Royal Prince Alfred Hospital lung MDT was established in 1984. Historically, information about MDT decision making was captured as free text in the electronic medical record, including patient investigation and staging. This information was accessible to clinical staff; however, it was not routinely distributed to GPs involved in the patient's care. We identified a potential gap in the current reporting and communication processes.
ECO 11: Medicines Optimisation in Northern Ireland - Frans van AndelInnovation Agency
Frans introduces the work of the Medicines Optimisation Innovation Centre based in Northern Ireland. He talks about their background; aims and how they achieve them; and current key initiatives. Frans also discusses the ongoing work of MOIC in enabling technology, the pharmaceutical industry, knowledge transfer, training and education, and other key initiatives.
Rationale and Procedure for Oncology Pricing and Reimbursement in England Tow...Office of Health Economics
The Biotherapy Development Association convened a two-day workshop in January 2014 to assess access to innovative cancer medicines in Europe. This presentation by OHE's Adrian Towse covers the situation in England, examining challenges that are peculiar to England as well as the English experience with issues common across countries.
This document provides an agenda and overview from a conference on generating evidence and assessing the value of stratified medicines and diagnostic tests. The summary includes:
1. The conference discussed elements of value for diagnostic tests, including reducing adverse drug effects and uncertainty about treatment value.
2. Institutional arrangements for assessing diagnostic value were examined, including joint drug-diagnostic assessments and diagnostic-specific processes.
3. Generating evidence to link diagnostics to patient value and incentivizing uptake were areas of focus, with examples provided.
Identifying and Managing Pre-Diabetes: A systematic review of screening and i...UKFacultyPublicHealth
This document summarizes a systematic review of screening and intervention studies for pre-diabetes. It found that HbA1c correctly identified half of high risk individuals, while fasting plasma glucose identified a quarter, and HbA1c identified abnormal levels in twice as many people overall. Lifestyle interventions showed relative risk reductions in progression to diabetes at the end of trials and following up post-intervention. However, only a third of the pre-diabetes population was eligible for RCTs, and just over a quarter completed the trials. Qualitative reviews found disconnects between literature and real-world applicability, suggesting a need for individualized, long-term interventions and exploring the underlying complexity of pre-diabetes.
The document provides an overview of the ABCE (Access, Bottlenecks, Costs, and Equity) project in Ghana which collected primary data from 240 health facilities across the country. Key findings include that while facility personnel and capacity have increased in recent years, availability of diagnostic testing and human resources vary substantially between facility types. The study also found opportunities to improve efficiency and increase service outputs given current resource levels. Results of the ABCE project can help inform health policy in Ghana by identifying areas of strength and those needing further development in the country's health system.
Implementing American Heart Association Practice Standards for Inpatient ECG ...Allina Health
Implementing American Heart Association Practice Standards for Inpatient ECG Monitoring: An Interventional Study at Abbott Northwestern Hospital presented by Kristin Sandau, PhD, RN
The document provides an overview of the Access, Bottlenecks, Costs, and Equity (ABCE) research project in Uganda. The project collected data from 247 health facilities and over 3,900 patient interviews between 2012-2013. Key findings include: gaps between reported and functional service capacity at facilities, especially for non-HIV services; high availability of HIV/AIDS services but lower availability for non-communicable diseases; and efficiency scores varied widely both across and within facility platforms, indicating potential for expanded service provision.
Health care reforms in England during the last decade have been influenced by the idea that encouraging competition between hospitals, with nationally fixed prices, will increase the quality of care for patients. Some research has found a positive connection between competition and outcomes. A principal criticism of such studies has been the measures of quality of care that were used. This analysis uses NHS PROMs data, collected both before and after treatment, indicating the extent to which the surgery produces improvement in patients’ self-reported health status.
Following an approach common in the literature on competition, hospital market concentration is used as an indicator of competition. Data were collected for 2011–12 for all English NHS hospitals and all elective primary hip replacements.
This presentation explains methods and presents results.
This document summarizes NHS England's approach to gathering patient experience and outcome data. It discusses various data collection methods, including national patient surveys, the Friends and Family Test, and Patient Reported Outcome Measures (PROMs). It notes that PROMs data shows patients report significant health improvements after surgeries and there is some variation in outcomes between hospitals. The document also outlines challenges in using this data and opportunities for the future, such as developing new PROMs for additional clinical areas and engaging patients more in collecting and using their own outcome data.
This document summarizes Professor Adrian Towse's presentation on assessing the value of new antibiotics. It discusses the challenges of developing new antibiotics due to scientific and economic hurdles. Current health technology assessment frameworks may not fully capture antibiotics' value in addressing antimicrobial resistance. Additional elements of value for antibiotics are proposed, including insurance value, diversity value, and enablement value. Evidence requirements for assessing these new elements were discussed. While not unique to antibiotics, these elements provide a more comprehensive evaluation. Further refinement is needed to incorporate these elements into health technology assessments.
Introduction of the NZ Health IT Plan enables better gout management - Reflections of an early adopter. Presented by Peter Gow, Counties Manukau DHB, at HINZ 2014, 12 November 2014, 11.37am, Plenary Room
This document summarizes Adrian Towse's presentation on multi-indication pricing at HTAi Rome in June 2017. It discusses the benefits of multi-indication pricing in allowing prices to better reflect the relative value of different indications. However, implementation faces challenges from stakeholders with differing perspectives. UK and US workshops provided feedback supporting the concept but noting administrative hurdles. Options for achieving multi-indication pricing include blended pricing, differential rebates, or a combination approach, but require ability to track drug use by indication using data systems.
Main Presentation UK Diagnostic Summit 2018Walt Whitman
The document summarizes a conference on maximizing diagnostic technology to tackle antimicrobial resistance (AMR) in the UK. It discusses the UK AMR Diagnostic Collaborative, which provides leadership and alignment across the diagnostic system. Key areas of focus for 2018-2019 include diagnostic stewardship, innovation, and understanding how health policy can support rapid diagnostic adoption. Upcoming milestones are surveys on blood culture and industry engagement to help accelerate diagnostic usage and solutions. Continued focus on diagnostics is crucial as the government refreshes its AMR strategy and action plan.
The document discusses using data and analytics to drive improvements in healthcare. It outlines the components of a data-driven organization, including an enterprise data warehouse, metrics, predictive models, protocols, and governance. It also discusses how analytics can help healthcare providers transition to value-based payments by measuring quality, reducing variation, and eliminating waste. Specific examples are provided on how one healthcare system used data to reduce variation in spine care, lower bleeding complications after PCI procedures, identify drug cost opportunities in knee replacements, and lower supply costs for lumbar fusion procedures.
The document summarizes the NHS RightCare approach, which aims to reduce unwarranted variation and improve health outcomes. It does this by ensuring the right care is provided in the right place at the right time using available resources. NHS RightCare provides data, tools, and support to help local health systems identify priority areas for improvement, understand variation compared to similar populations, and implement sustainable changes through a three phase process.
Defining and assessing a delineation uncertainty margin for modern radiotherapyCancer Institute NSW
The implementation of image-guided technology and progressively conformal techniques in modern radiotherapy for the treatment of cancer, ensure the planned distribution of dose is well matched to the clinician-defined target volume. However, this precision relies on the target volume including all malignant tissue, with delineation uncertainty resulting in potential normal tissue toxicities and insufficient dose to the cancer. Methods need to be implemented to minimise delineation uncertainty, and subsequently improve local control and patient outcomes.
Endometrial polyp in women with postmenopausal bleeding a systematic review a...Ahmed Ghoubara
This document presents a systematic review and meta-analysis that assessed the prevalence of hyperplasia and cancer in endometrial polyps among women with postmenopausal bleeding. The review included 10 studies with a total of 2,637 patients. The pooled prevalence of hyperplasia and cancer among women with postmenopausal bleeding and endometrial polyps was estimated to be 8.9%. Sensitivity analyses found that no single study significantly influenced the pooled estimate. The review concluded that the risk of finding hyperplasia or cancer in endometrial polyps among women with postmenopausal bleeding is high, and expectant management of polyps should be considered cautiously.
The experience of survival following Blood and Marrow Transplant in NSW, Aust...Cancer Institute NSW
Over 50% of patients undergoing allogeneic BMT can now be expected to become long-term survivors. Unfortunately many experience significant late morbidity and mortality.
The Lung Cancer Demonstration Project: Implementation and evaluation of a lun...Cancer Institute NSW
The Royal Prince Alfred Hospital lung MDT was established in 1984. Historically, information about MDT decision making was captured as free text in the electronic medical record, including patient investigation and staging. This information was accessible to clinical staff; however, it was not routinely distributed to GPs involved in the patient's care. We identified a potential gap in the current reporting and communication processes.
ECO 11: Medicines Optimisation in Northern Ireland - Frans van AndelInnovation Agency
Frans introduces the work of the Medicines Optimisation Innovation Centre based in Northern Ireland. He talks about their background; aims and how they achieve them; and current key initiatives. Frans also discusses the ongoing work of MOIC in enabling technology, the pharmaceutical industry, knowledge transfer, training and education, and other key initiatives.
Rationale and Procedure for Oncology Pricing and Reimbursement in England Tow...Office of Health Economics
The Biotherapy Development Association convened a two-day workshop in January 2014 to assess access to innovative cancer medicines in Europe. This presentation by OHE's Adrian Towse covers the situation in England, examining challenges that are peculiar to England as well as the English experience with issues common across countries.
This document provides an agenda and overview from a conference on generating evidence and assessing the value of stratified medicines and diagnostic tests. The summary includes:
1. The conference discussed elements of value for diagnostic tests, including reducing adverse drug effects and uncertainty about treatment value.
2. Institutional arrangements for assessing diagnostic value were examined, including joint drug-diagnostic assessments and diagnostic-specific processes.
3. Generating evidence to link diagnostics to patient value and incentivizing uptake were areas of focus, with examples provided.
Identifying and Managing Pre-Diabetes: A systematic review of screening and i...UKFacultyPublicHealth
This document summarizes a systematic review of screening and intervention studies for pre-diabetes. It found that HbA1c correctly identified half of high risk individuals, while fasting plasma glucose identified a quarter, and HbA1c identified abnormal levels in twice as many people overall. Lifestyle interventions showed relative risk reductions in progression to diabetes at the end of trials and following up post-intervention. However, only a third of the pre-diabetes population was eligible for RCTs, and just over a quarter completed the trials. Qualitative reviews found disconnects between literature and real-world applicability, suggesting a need for individualized, long-term interventions and exploring the underlying complexity of pre-diabetes.
The document provides an overview of the ABCE (Access, Bottlenecks, Costs, and Equity) project in Ghana which collected primary data from 240 health facilities across the country. Key findings include that while facility personnel and capacity have increased in recent years, availability of diagnostic testing and human resources vary substantially between facility types. The study also found opportunities to improve efficiency and increase service outputs given current resource levels. Results of the ABCE project can help inform health policy in Ghana by identifying areas of strength and those needing further development in the country's health system.
Implementing American Heart Association Practice Standards for Inpatient ECG ...Allina Health
Implementing American Heart Association Practice Standards for Inpatient ECG Monitoring: An Interventional Study at Abbott Northwestern Hospital presented by Kristin Sandau, PhD, RN
The document provides an overview of the Access, Bottlenecks, Costs, and Equity (ABCE) research project in Uganda. The project collected data from 247 health facilities and over 3,900 patient interviews between 2012-2013. Key findings include: gaps between reported and functional service capacity at facilities, especially for non-HIV services; high availability of HIV/AIDS services but lower availability for non-communicable diseases; and efficiency scores varied widely both across and within facility platforms, indicating potential for expanded service provision.
Health care reforms in England during the last decade have been influenced by the idea that encouraging competition between hospitals, with nationally fixed prices, will increase the quality of care for patients. Some research has found a positive connection between competition and outcomes. A principal criticism of such studies has been the measures of quality of care that were used. This analysis uses NHS PROMs data, collected both before and after treatment, indicating the extent to which the surgery produces improvement in patients’ self-reported health status.
Following an approach common in the literature on competition, hospital market concentration is used as an indicator of competition. Data were collected for 2011–12 for all English NHS hospitals and all elective primary hip replacements.
This presentation explains methods and presents results.
This document summarizes NHS England's approach to gathering patient experience and outcome data. It discusses various data collection methods, including national patient surveys, the Friends and Family Test, and Patient Reported Outcome Measures (PROMs). It notes that PROMs data shows patients report significant health improvements after surgeries and there is some variation in outcomes between hospitals. The document also outlines challenges in using this data and opportunities for the future, such as developing new PROMs for additional clinical areas and engaging patients more in collecting and using their own outcome data.
Outcome Measures in Cancer: Do disease specific instruments offer greater sen...Office of Health Economics
Paula's slides for her presentation on Outcomes Measures in Cancer given at the C2E2 Rounds Conference at the University of British Columbia on July 5th, 2017.
The document discusses barriers and solutions to adopting diagnostic technologies in healthcare. It provides examples of diagnostic technologies that have been successfully adopted in the UK, such as Coaguchek for INR testing and faecal calprotectin testing. Both faced initial barriers but were able to demonstrate benefits like improved patient outcomes and efficiency. The document outlines tips for implementing diagnostics, such as collecting baseline data, gaining stakeholder support, and clearly defining the patient pathway and expected impact. Overall it advocates that diagnostic technologies can help address gaps in healthcare if barriers are overcome and benefits are demonstrated.
This document discusses technology assessment, outcomes research, and economic analyses in healthcare. It provides background on rising healthcare costs in the US without clear improvements in health outcomes compared to other countries. The rationale for assessing new technologies and their impact is described. Key aspects of technology assessment are outlined, including technical efficacy, diagnostic accuracy, diagnostic impact, therapeutic impact, patient outcomes, and societal outcomes. Challenges with randomized controlled trials in assessing technologies are reviewed. The National Lung Screening Trial is presented as an example. Finally, computed tomography for appendicitis is analyzed as a hypothetical example of how modeling could be used to assess a technology when a randomized trial may not be feasible.
Innovations conference 2014 building a quality cancer system concurrent sessi...Cancer Institute NSW
The document summarizes findings from a survey of GPs in NSW, Australia that was part of an international cancer benchmarking study. Key findings included:
- GPs expressed strong support for timely cancer diagnosis but less so for lung cancer. Nearly half saw gatekeeping as important.
- There were differences in access to diagnostic tests and specialists between urban and rural GPs, and between public and private systems.
- Waiting times heavily influenced referral pathways.
- The findings can help improve coordination between primary and specialist cancer care and provide a baseline for monitoring changes over time.
Technology Assessment, Outcomes Research and Economic Analysesevadew1
This document discusses technology assessment, outcomes research, and economic analyses in healthcare. It provides background on rising healthcare costs in the US and outlines a hierarchy for assessing new medical technologies from technical efficacy to patient and societal outcomes. Randomized controlled trials are described as the gold standard but limitations are noted. Alternative study designs like modeling and assessing intermediate outcomes are proposed when RCTs are not feasible. The document uses CT for appendicitis as an example to work through initial steps in outcomes research. It also discusses limitations and alternative outcomes like assessing the therapeutic value of diagnostic tests.
This document discusses defining value in regional anesthesia and who gets to define important outcomes. It notes that patients define outcomes related to their experience, providers focus on quality and efficiency, and governments increasingly influence outcomes through incentive programs. It reviews programs in the US, UK, and Ontario that link hospital funding to performance on metrics related to patient experience, quality, and cost. The document argues that regional anesthesia can improve value by reducing pain and complications, increasing efficiency through models like block rooms, and potentially improving population health outcomes like mortality.
Jacquie White, Deputy Director of NHS England Long Term Conditions, Older People & End of Life Care and Dr Eileen Pepler, Academic, Researcher and Consultant in the Canadian Healthcare will discuss how NHS England work in chronic disease is being translated into a Canadian context.
This document discusses structures and processes for quality improvement and waste reduction in Alberta Health Services. It outlines several key points:
1) Strategic Clinical Networks and Operational Clinical Networks are being implemented to drive clinically-led change, use best evidence to standardize practices, and improve outcomes across Alberta.
2) Clinical variance measurement is important to understand differences in care and outcomes across regions. Managing unjustified variance can improve patient care and reduce costs.
3) Health technology reassessment evaluates existing technologies to determine optimal use compared to alternatives, which could lead to reduced scope, decommissioning, or disinvestment. Several reassessment projects are proposed.
This document discusses a project in Oldham, England that aimed to reduce antibiotic prescribing through the use of C-reactive protein (CRP) point-of-care testing. The project provided CRP testing machines to 8 high-prescribing general practices over 6 months. A total of 359 CRP tests were completed, with 78% showing results under 20mg/L where antibiotics are not routinely needed. Based on the results, antibiotics were prescribed in line with NICE guidelines 88% of the time. Patient and staff feedback on the testing was positive, finding it aided diagnosis and reduced unnecessary antibiotic use. Further funding and adoption of CRP testing could help Oldham and other areas improve antibiotic stewardship.
Care by design magill retrospective mixed methods analysis sep 21 2011Paul Grundy
This document summarizes a mixed methods analysis of practice transformation at the University of Utah Community Clinics from 2003-2009. Key elements of the transformation included implementing care teams with expanded medical assistant roles, standardized schedules, and pre-visit planning. Both qualitative and quantitative data were collected through surveys, interviews, observations and clinical/operational data. Preliminary results found improved quality measures, patient satisfaction, and access associated with higher levels of transformation implementation. Future analysis will link data on implementation, clinical outcomes, operations and costs to assess total impact on care delivery and costs. Challenges included coordinating multi-method research and navigating approvals for clinical and claims data.
The document analyzes the relationship between clinical computing systems used by family practices in the UK and their performance under the Quality and Outcomes Framework (QOF) pay-for-performance scheme between 2007-2011. Statistical models found that practices' choice of clinical computing system was a significant predictor of their QOF achievement scores, with some systems associated with better performance than others. Practices using the Vision 3 or Synergy systems tended to score highest overall, while those using the PCS system tended to score the lowest. Performance varied by the type of clinical activities as well.
Public Reporting as a Catalyst for Better Consumer DecisionsATLAS Conference
Greater efficiency in the process of matching patients to appropriate providers is vital to achieving the Triple Aim. As patients research and choose among appropriate providers, sound decision-making will depend on the accessibility of high-quality data that enables them to make meaningful, actionable comparisons. Online public-reporting tools, such as those published by U.S. News, CMS and others, serve as venues for consumer decision-making. Driven by current trends in data transparency, rapid advances in public reporting can be anticipated. This presentation will outline several recent and expected future developments in the evolution of key public-reporting tools, and discuss their role in facilitating patient engagement and access to appropriate care.
Mr James Downie, CEO, presented on the topic 'Moving towards value based funding' at the 2017 Activity-Based Funding Conference, hosted by the Health Service Executive, Ireland on 11 May 2017.
Multispecialty Physician Networks: Improved Quality and Accountability - The ...EvidenceNetwork.ca
Multispecialty Physician Networks: Improved Quality and Accountability - The “Health Care Neighbourhood”
by Thérèse A. Stukel, Rick Glazier, Sue Schultz, Jun Guan Institute for Clinical Evaluative Sciences Toronto
Funded by: CIHR Emerging Team Grant in Applied Health Services and Policy Research
Similar to Hugh Gravelle: The impact of care quality on patient choice (20)
This document discusses the potential impacts of automation on healthcare employment and discusses alternative views beyond job loss. It notes that automation may lead to reconfiguring of healthcare work rather than outright job loss. Examples of existing technologies that have automated tasks in healthcare like pharmacy automation and emerging technologies like decision support systems and personal health tracking are provided. The document advocates that automation could lead to a virtuous cycle in healthcare if it allows workers to focus on tasks that require human skills and judgment.
Evaluation of the Integrated Care and Support Pioneers ProgrammeNuffield Trust
This document summarizes the findings of evaluations of the Integrated Care and Support Pioneers Programme in the UK. The evaluations found that while Pioneers aspired to comprehensive system change, their activities focused more narrowly on initiatives like risk stratification and care coordination teams. Progress was difficult to measure against indicators and Pioneers faced challenges from financial pressures and competing priorities. The evaluations concluded that further integration will be challenging under increasing demands on the health system.
The document discusses lessons learned from the Southwark and Lambeth Integrated Care (SLIC) program in London. Key points:
- SLIC aimed to reduce hospital admissions and care home placements for older adults through risk stratification, holistic assessments, and care management.
- Success required agreement on the problem, dedicated teams, funding shifts to support community care, and leadership development.
- Future programs need a strong business case, co-design with citizens, and a dedicated "engine room" team to drive local transformation.
Effectiveness of the current dominant approach to integrated care in the NHSNuffield Trust
Jonathan Stokes of the Greater Manchester Primary Care Patient Safety Translational Research Centre presents a systematic review of case management in integrated care.
Providing actionable healthcare analytics at scale: Understanding improvement...Nuffield Trust
This document discusses measurement for quality improvement. It explains that measurement in improvement aims to provide a basis for action to improve processes and outcomes, rather than just estimating parameters. Improvement measures should be simple, specific, and available in real-time. Statistical process control methods are important to separate normal variation from changes resulting from interventions. Examples are provided of run charts measuring improvements in recording BMI for mental health patients and compliance with care bundles. The document advocates making the theories behind improvement efforts more explicit.
Ramani Moonesinghe, Associate National Clinical Director for Elective Care at NHS England, discusses the use of data for monitoring care quality at various levels within the system.
This document discusses using statistical process control (CUSUM) charts to monitor mortality rates at the level of individual general practitioners and health authorities. It describes how CUSUM charts could potentially have detected Harold Shipman, a GP who murdered over 200 patients, by spotting outliers in the routine mortality data. The document also discusses challenges in risk adjusting outcomes to account for differences in patient characteristics and casemix between providers. Accurately adjusting for factors like age, comorbidities, and emergency status is important for fair comparisons but difficult using only administrative data.
Martin Utley, Director of the Clinical Operational Research Unit at University College London, reflects upon his involvement in the launch of specific tools to monitor care quality for paediatric cardiac surgery.
Evaluating new models of care: Improvement Analytics UnitNuffield Trust
Martin Caunt, Improvement Analytics Unit Project Director and NHS England and Adam Steventon, Director of Data Analytics at The Health Foundation share insights into how they have approached evaluating new models of care.
Lisa Annaly, Head of Provider Analytics at the Care Quality Commission, discusses lessons learned from the CQC as they have worked to monitor care quality over time.
- Real-time monitoring of healthcare services requires defining both a reporting window and data window to accurately capture demand, activity, and wait times.
- Using only a reporting window (e.g. a single month) to request data can result in invalid or misleading performance metrics, as it does not account for patients with long wait times.
- Defining a larger data window that includes all patients requested before the end of the reporting window and reported after the start avoids this problem, but requires a counterintuitive data request.
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Hugh Gravelle: The impact of care quality on patient choice
1. Does quality affect patients’ choice
of doctor? Evidence from the UK
Rita Santos* Hugh Gravelle*
Carol Propper**
*Centre for Health Economics, University of York
**Imperial College, London; CMPO, University of Bristol
Competition and market mechanisms in health care.workshop. Nuffield Trust, 13 September 2013
2. Motivation
• Governments increasingly adopting policies to create/enhance
choice in health care (and other public services)
• Improve match of patients and providers
• Encourage providers to compete on quality in fixed price regime
• Competition will improve quality only if demand is responsive to
quality
– But
• Noisy quality measures
• Consumers may not value quality
• Does quality affect patients’ choice of provider?
2
3. Our Research Question
• Do English patients respond to differences in quality when
choosing a general practice?
• England is a good “test bed”
– Patients register with a single general practice
– GPs are gatekeepers for elective hospital care
– Care is tax funded and free at point of use, so choice should be driven
only by clinical quality, distance and other practice attributes
– Government actively promotes provision of information to patients eg
NHS Choices website
– Rich set of quality measures for general practice
3
4. What we do
• Data on the choices of 3.4M patients in 2874 small areas (LSOAs)
from amongst nearly 1000 general practices
• Focus on quality, distance, and practice attributes
• Consider appropriate measure of quality, patient heterogeneity,
endogeneity of quality
• We find
– Patients more likely to choose practices which have higher clinical quality
as measured by published data on performance (QOF points)
– Robust across age and gender, socio-economic status
– Quality has small effect on probability patient chooses particular practice
– But large number of potential patients for a practice mean that quality has
large effect on total demand
• 1 SD increase in QOF points would increase demand for a practice by 20%
4
5. Literature on health care quality, demand, and
competition
• Quality and demand
• Hospital sector – quality affects choice of hospital
– Extensive US literature
– Recent UK studies: Sivey 2011; Beckert et al 2012, Gaynor et al 2012
• General practice: few studies of impact of quality on choice because
of lack of good measures of quality
– UK: Dixon et al, 1997
– Norway: Biorn & Godager, 2010); Iversen and Luras 2011
• Competition and quality
• Hospital sector: competition improves quality in fixed price systems
• UK hospital sector: Cooper et al (2011); Gaynor et al (2013)
• UK general practice: Pike (2010) - practices with more rivals within
500m have higher patient satisfaction, smaller ACSC admission rate
5
6. Outline of talk
• Institutional setting
• Data
• Model
• Results
• Conclusions
6
7. Institutional setting: English NHS
• No charges to patients for hospital or primary care
• List system (patient registration) for general practices
• GPs as gatekeepers for elective hospital care
• 8300 practices with 4.2 GPs and 6600 patients
• Practice contracts with NHS
– GMS – mix of capitation, lump sum, quality related payments
– PMS - paid as if GMS plus uplift to reflect additional services
negotiated with local PCT
– Quality and Outcomes Framework – payment for achievement
of quality indicators
– Both contracts link total revenue closely to number of patients
7
8. Institutional background: policy
• Abolition of national body controlling entry (2002)
• Devolution of entry control to local health authorities
• Removal on restrictions on ownership of practices
• Encourage new entry (Darzi health centres)
• NHS Choices website with data on practices
• Patients to be given right to register with any practice
8
9. 9
ONS Neighbourhood Statistics
Socio economic data at LSOA
level
General Medical Services Statistics
Practice and GP characteristics
General Practice Patient Survey
Patient satisfaction by practice
Quality and Outcomes Framework
Clinical quality indicators by
practice
Hospital Episode Statistics
ACSC emergency admission rates
by practice
Attribution Data Set
Patient registered with each
general practice
LSOA by age by gender by
practice cells
Data sets
10. Sample
• Unit of analysis: LSOA
• Population: mean 1500, min 1000
• Attribution Data Set
• Number of patients in each of 8300 practices resident
in each of 32,482 LSOAs in 36 age/gender bands
• At 1 April 2010
• East Midlands Strategic Health Authority
• Mix of urban, rural areas; high proportion of non-UK
qualified GPs; relatively high proportion of pop of Asian
origin
• Not adjacent to Wales or Scotland
• 2875 LSOAs, 3.372M individuals aged ≥25
• 994 practices with 1235 surgeries 10
12. Data: practice QOF quality
• Quality and Outcomes Framework
– National P4P scheme introduced 2004
– Points awarded (max 1000) for achievements of indicators
• Clinical domain
• Organisational domain
• Patient experience domain
• Additional services
• Holistic care
– £125 per point
– Data extracted from practice electronic patient records
• Main quality measure: (lagged) total QOF points in 2006/7
• Also use
– total QOF points 2009/10
– average QOF points 2006/7-2009/10
– domain points
– other measures derived from clinical indicators
12
13. Data: non-QOF quality measures
• Emergency hospital admissions for Ambulatory
Care Sensitive Conditions
• Patient satisfaction
• General Practice Patient Survey 2009: 5% sample of
all patients on lists
• “In general, how satisfied are you with the care you get
at your GP surgery or health centre?”
• “How satisfied are you with the hours that your GP
surgery or health centre is open ?”
• “Would you recommend your GP practice or health
centre to someone who has just moved to your local
area?”
13
14. Data: LSOA - practice distances
• Practice locations
• Main surgery – GMS statistics
• Branch surgeries – NHS Choices
• LSOA population weighted centroids
• Linear distance from each LSOA centroid to nearest
branch of each practice within 50km
• Dummy variable = 1/0 as practice located in
different/same PCT as LSOA
14
15. Data: LSOA choice sets
• Practices with branch within 10km of LSOA
centroid
– 99.3% patients choose practice within 10km
• If more than 30 such practices restrict choice
set to 30 practices with largest number patients
from LSOA
15
16. 16
Characteristics of patients in LSOAs
Mean SD Min Max
Proportion female 0.507 0.022 0.276 0.618
Proportion in fair or good self-rated health 0.907 0.032 0.760 0.983
Proportion adults without qualification 0.231 0.071 0.035 0.430
Proportion non white 0.065 0.130 0.000 0.948
Income deprivation score 0.143 0.110 0.013 0.830
Urban 0.731 0.444
Proportion of LSOA registered at nearest
practice
0.399 0.263 0.001 0.998
17. Practice characteristics
17
Mean SD Min Max
Average GP age 47.9 6.7 31.5 72.5
Proportion female GPs 0.362 0.248 0 1
Proportion GPs trained outside Europe 0.267 0.354 0 1
Opted out of out of hours care 0.613 0.487
PMS contract 0.479 0.500
Dispensing practice 0.204 0.403
Patients aged ≥ 25 registered with
practice
4886 3063 653 24988
18. Practice quality measures
18
Mean SD Min Max
QOF 2006/7 total points 956.1 63.6 426.5 1000
QOF 2006/7 clinical points 632.8 36.4 330.5 655
QOF 2006/7 organisational points 166.5 21.0 13.2 181
QOF 2006/7 patient experience points 103.3 16.1 0 108
QOF 2006/7 additional services points 35.3 2.8 6 36
QOF 2006/7 holistic care points 18.3 3.1 0 20
QOF 2009/10 total points 940.5 46.9 545.5 1000
Average QOF total points 2006/7-2009/10 954.6 44.8 545.5 1000
ACSCs 2006/7 per 10,000 259 76 28 679
Overall patient satisfaction 2009 0.89 0.06 0.57 0.99
Satisfaction with opening hours 2009 0.80 0.06 0.45 0.97
Prop patients would recommend practice
2009
0.82 0.10 0.38 0.99
19. Distances
19
Mean SD Min Max
Distance to practices in choice set (km) 4.83 1.65 0.35 9.89
Distance to chosen practice (km) 1.89 1.34 0.13 9.87
Distance to nearest practice (km) 1.20 1.16 0.02 9.81
Proportion practices in different PCT 0.27 0.45 0 1
Prop practices chosen in different PCT 0.19 0.39 0 1
Prop nearest practices in different PCT 0.05 0.22 0 1
Prop LSOA pop registered at nearest
practice
0.40 0.26 0.00 1
21. Model: conditional logit
21
All patients in an LSOA have same choice set
All patients derive same utility from observed practice characteristics
unobserved utility iid type 1 extreme value distribution
P
a
iaj aj iaj
aj
iaj
a C
u
x β
x
1
1
1
robability patient in LSOA choose practice
exp( ) exp( )
Log likelihood ( patients in LSOA choose practice )
ln ln exp( ) exp( )
a
A
a a
iaj aj ajj C
aj
n
aj aj aja j C j C
i a j
P
n a j
L n
x β x β
x β x β
23. Model: interpretation of results
• Report average of marginal effects
• AMEs small
• Potential incentive for practice to increase quality
depends on change in demand for practice
– Depends on change in probability patients will want to
join practice and number of patients in whose choice
set practice falls
• 75,000 individuals 25 yrs within 5 km of av practice
• 25,000 individuals 25 yrs within 2km of av practice
– Small changes in individual probabilities can
translate into large demand increases
23
ˆˆ ˆ ˆ/ (1 )aj kaj k aj ajP x P P
24. Results: preferred model
Average Marginal
Effect
z
QOF 2006/7 Total points 0.00013 6.87
Distance (cubic) -0.06778 -14.18
Practice in different PCT -0.04751 -10.12
GP age -0.00144 -13.31
Prop female GPs 0.01508 6.12
Prop GPs non Europe trained -0.03029 -10.36
Opted Out 0.00543 2.49
PMS contract 0.00564 2.95
BIC 11714907
McFadden R2 0.3955
N LSOA 2,870
N GP practices 987
N patients 3,364,263
Increase 10 QOF pts increase pr(choice) by 0.0013
Mean QOF points = 957, sd = 64. 24
25. Results: other quality measures
• 2006/7 total QOF points performs at least as well as
– domains of QOF
– 2009/10 QOF total points
– av 2006/7-2009/10 total QOF points
• QOF clinical measures adjusted for exceptions and thresholds have no
explanatory power given covariates
• Patient satisfaction
– Overall patient satisfaction insignificant when practice characteristics
and QOF 2006/7 total points included
– Patient satisfaction summarises effect of practice characteristics
(Robertson et al, 2008)
• ACSC admission rates
– Negatively correlated with QOF quality but no additional explanatory
power
25
26. Results: distance
• Cubic preferred to other polynomial
specifications and to log distance
• Distance effects similar (except linear)
26
27. Plot of the average marginal effects of distance for linear (km),
quadratic (km2), cubic (km3), quartic (km4), and quintic (km5)
specifications for baseline model specification.
Average marginal effects of distance
27
Linear specification
28. Model estimation: patient heterogeneity
• Baseline models assume patients homogenous
• Test for observed and unobserved patient preference
heterogeneity
– estimating models for each age and gender group
– stratify LSOAs (separately) by characteristics of the
proportion of pop who are non-white, deprived etc.
– estimate random coefficient model (mixed logit model)
28
29. Results: patient heterogeneity
Separate estimates for 10 age and gender groups
• Young men (25-35) less sensitive to quality
Separate estimates for LSOAs stratified by patient characteristics
(rurality, income deprivation, education deprivation, self
assessed health, ethnicity; top vs other quintiles)
• Rural areas: less sensitive to distance and quality, ratio similar
• More deprived LSOAs more affected by distance and less by
quality (marginal rate of substitution halves)
Unobserved heterogeneity (mixed logit model)
• Similar means, only significant variance in distance and quality
29
30. Mixed logit Conditional logit
Mean of
coefficients
z Coefficient z
QOF 200607 Total points 0.0029 11.55 0.00224 14.58
Practice in different PCT -0.891 -10.55 -0.826 -19.00
Distance -1.556 -38.51 -1.563 -40.06
Distance squared 0.109 9.06 0.121 10.55
Distance cubed -0.00417 -4.58 -0.00432 -4.88
GP age -0.0254 -15.52 -0.025 -15.68
Proportion female GPs 0.262 7.77 0.262 7.85
Proportion GPs non Europe trained -0.522 -18.95 -0.527 -19.33
Opted out 0.0998 2.73 0.0943 2.61
PMS 0.104 3.28 0.098 3.13
Standard deviation of coefficients
QOF 200607 Total points 0.00317 7.02
LSOAs from different PCTs -0.478 -1.76
Distance 0.214 8.28
Distance squared km -0.00439 -1.56
Distance cubic km 0.000341 1.98
GP age 0.00633 1.23
Female GPs 0.0071 0.20
GPs trained outside Europe -0.048 -0.85
Opted out 0.308 2.09
PMS 0.0759 0.34
30
31. Catchment areas and closed lists
• Do data reflect patient or practice choices?
• GPs have obligation to make home visits if medically
required. Higher costs to practices if patient lives
further away.
• Practices can refuse to enrol patient only if
– patient lives outside catchment area agreed with PCT
• If our LSOA choice set radius greater than radii of catchment areas
then zero patients registered with a practice may reflect
catchment area not patient demand
– practice has notified PCT that its list is closed: it will not
accept any more patients
• List turnover averages 8% pa so no practice can have permanently
closed list
• Our data is patients on list at 1 April 2010: stock not flow 31
32. Results: choice set radius
32
Choice set
radius
QOF 2006/7
total points
Distance
(cubic)
10km
AME 0.00013 -0.06778
z 6.87 -14.18
8km
AME 0.00014 -0.07751
z 6.94 -14.2
6km
AME 0.00019 -0.09964
z 7.07 -14.72
4km
AME 0.00029 -0.15248
z 7.76 -16.76
2km
AME 0.00044 -0.26363
z 7.98 -23.16
Quality effects increase as choice set shrinks
33. Results: choice sets only with practices
with LSOA patients
33
Minimum patients from
LSOA in practice
QOF 2006/7
total points
Distance
(cubic)
0 patients
AME 0.00013 -0.06778
z 6.87 -14.18
1 patient
AME 0.00019 -0.0969
z 7.18 -15.6
5 patients
AME 0.00026 -0.1268
z 7.47 -18.01
10 patients
AME 0.00029 -0.14037
z 7.82 20.94
20 patients
AME 0.00032 -0.14739
z 7.99 -24.43
50 patients
AME 0.00031 -0.13713
z 7.07 -25.88
34. Endogeneity?
• Better educated patients care more about quality?
• Quality indicators easier to achieve with better educated
patients?
• Implies quality AME biased upward
• Sicker patients care more about quality?
• Quality indicators harder to achieve with sicker patients?
• Implies quality AME biased downward
• Easier to achieve quality in larger practices (econ of scale)?
• Implies quality AME biased upward
34
35. Endogeneity: two stage residual inclusion
• First stage
– Linear practice quality model
– IV: average quality of two nearest practices
– F statistic for IV: 18.5
• Second stage choice model
– Add residual from stage 1 quality model
– SEs : SD of second stage AMEs from 100 bootstrap
samples LSOAs
35
36. Results: 2SRI model
36
Baseline model 2SRI model
AME z AME
z
bootstrap
QOF 2006/7 points 0.00013 6.87 0.00074 4.35
QOF 2006/7 residuals -0.00044 -3.02
Different PCT -0.06778 -14.18 -0.10942 -9.85
Distance (cubic) -0.04751 -10.12 -0.11108 -18.82
GP age -0.00144 -13.31 -0.00281 -11.50
Female GPs 0.01508 6.12 0.03084 6.52
GPs non Europe trained -0.03029 -10.36 -0.06328 -10.26
Opted out 0.00543 2.49 0.00803 1.78
PMS 0.00564 2.95 0.01021 2.36
Quality AME larger when instrumented
37. Effects on demand
37
AME Extra
metres
Patients
gained
Elasticity
2006/7 QOF points
(1/10th SD increase: 6.4 points )
0.00082 12.4 103.6 1.44
SE 0.00012 0.9 9.4 0.06
Av age GPs
(1/10th SD increase: 0.7 yrs)
-0.00096 -14.6 -120.6 0.003
SE 0.00007 0.9 5.3 0.00
Prop female GPs
(1/10th SD increase: 0.025)
0.00374 56.7 468.1 0.07
SE 0.00061 7.2 47.3 0.01
Prop non-European trained GPs
(1/10th SD increase: 0.035)
-0.01072 -162.7 -1342.4 -0.08
SE 0.00103 -8.7 93.6 0.00
38. Conclusions
• Issue of whether choice will increase quality
current and important
• A pre-requisite for increased competition to
increase quality is that demanders are
responsive to quality
• Find that this does appear to be the case for
choice of GP
38