Family doctors and change in practice strategy since 1986.

OBJECTIVES--To investigate the changes in practice strategy that have taken place since 1986. DESIGN--Comparison of practices in 1986 and 1992. SETTING--93% of group practices (26 practices) in a single family health services authority. MAIN OUTCOME MEASURES--Changes in staffing, premises, equipment, clinic services, and incomes between 1986 and 1992. RESULTS--In 1986, 28% of practices employed a nurse; in 1992, 92% did so. Between 1986 and 1992, 14 cost-rent schemes costing more than 10,000 pounds had been started. Certain practices, designated innovators, were more likely to possess specified items of equipment than other practices. Computer ownership was widespread: 77% of practices had a computer, compared with 36% in 1986. In 1992, 16 practices had a manager, compared with 10 in 1986. Clinic services provided by more than half of practices were well established services (antenatal, for example), new services for which a payment had been introduced (such as diabetes, asthma, minor surgery), or the more readily provided "new" clinic services (diet, smoking cessation). Gross income increased, but so did practice costs, especially for innovators. Practices in the more affluent area of the family health services authority were still more likely to invest in their premises and staff, and to provide more services than those in the declining area. In the more affluent area, practices had higher costs but also higher incomes. CONCLUSION--Between 1986 and 1992, practices in this area invested heavily in equipment and services, but differences remain, depending on the location of the practice. Investment has increased, particularly in the more deprived part of the area, so that the inconsistency in standards has been much reduced. Practice incomes have risen, but so also have workload and costs.     

Costs and cost effectiveness of cardiovascular screening and intervention: the British family heart study.

OBJECTIVE--To measure costs and cost effectiveness of the British family heart study cardiovascular screening and intervention programme. DESIGN--Cost effectiveness analysis of randomised controlled trial. Clinical and resource use data taken from trial and unit cost data from external estimates. SETTING--13 general practices across Britain. SUBJECTS--4185 men aged 40-59 and their 2827 partners. INTERVENTION--Nurse led programme using a family centered approach, with follow up according to degree of risk. MAIN OUTCOME MEASURES--Cost of the programme it self; overall short term cost to NHS; cost per 1% reduction in coronary risk at one year. RESULTS--Estimated cost of putting the programme into practice for one year was 63 pounds per person (95% confidence interval 60 pounds to 65 pounds). The overall short term cost to the health service was 77 pounds per man (29 pounds to 124 pounds) but only 13 pounds per woman (-48 pounds to 74 pounds), owing to differences in utilisation of other health service resources. The cost per 1% reduction in risk was 5.08 pounds per man (5.92 pounds including broader health service costs) and 5.78 pounds per woman (1.28 pounds taking into account wider health service savings). CONCLUSIONS--The direct cost of the programme to a four partner practice of 7500 patients would be approximately 58,000 pounds. Annually, 8300 pounds would currently be paid to a practice of this size working to the maximum target on the health promotion bands, plus any additional reimbursement of practice staff salaries for which the practice qualified. The broader short term costs to the NHS may augment these costs for men but offset them considerably for women.     

Family doctors and innovation in general practice

Family doctors have been presented with changes in government policies and incentives in a recent white paper on primary care. Little work has been done, however, to find out how general practitioners respond to such measures. The response of general practitioners to professional and economic incentives was examined in relation to the location of the practice and the characteristics of the practitioners in seven different areas of England. The areas represented urban, rural, affluent, and deprived communities. The overall response rate was 74%, but the response varied among the areas, being poorest (64%) in an inner city area. Practices were subdivided as innovative, traditional, or intermediate, according to whether they employed a nurse and participated in the cost rent scheme and the vocational training scheme. Innovative practices were defined as fulfilling two of these criteria and traditional practices as fulfilling none; the remainder were classed as intermediate. The results showed that these three types of practice had distinct strategies that were related to financial constraints and the local population. Innovative practices had more partners and were often located in rural or affluent suburban areas; traditional practices had fewer partners and were more common in urban and working class areas. Innovative practices seemed to be in the best position to increase their services, and hence their incomes, in response to the recent proposals in the white paper. Practices in areas of developmental difficulty (predominantly urban but not necessarily inner city areas) had been less able to respond to existing incentives and had a smaller margin available for developing their services.In view of the effect of local constraints of economics and population on the strategy of practices, concentrating resources for primary care in local budgets for working class and urban areas may be preferable to extending the system of charging fees for services provided by family doctors.     

Family doctors: their choice of practice strategy.

The economic decisions taken by family doctors in one family practitioner area in the north of England were examined. There was evidence of a differential response to professional and economic incentives by a group of "high investing" practices. On five indicators of improvement in practice 32% of the practices accounted for 71% of the positive scores. Nearly all the high investing practices were in affluent areas; they were on average larger and had younger partners than the other practices. The high investing practices also faced more financial problems. There was evidence that older doctors with long lists of patients had a different strategy of income maximization. Innovation in primary care is not determined by attitude alone but also by objective factors such as age, location, and size of the practice.     

Estimating the household costs of human–wildlife conflict in China’s giant panda national park

Human–wildlife conflict is a major cause of losses resulting from the establishment of protected areas, most of which are borne by the communities within these areas. It is therefore important to establish a compensation system for such losses. This study measures the total costs of human-wildlife conflict by surveying communities within and surrounding China's Giant Panda National Park. The results show that the primary visible costs from human–wildlife conflict, which include crop loss, livestock depredation, property damage, and human fatalities and injury, were 2185.6 Yuan ($316.9) per household. Approximately 64.9% of households were affected by this conflict in 2020. For each affected household, the average visible costs per capita was 952.6 Yuan ($138.1) or 7.2% of per capita net income. When converting well-being losses caused by human-wildlife conflict into economic costs, we consider visible costs and hidden costs (e.g., transaction, opportunity, and health costs). This study shows that human–wildlife conflict reduced per capita net income by 15.3% and significantly affected household well-being. The average cost of the well-being loss caused by human-wildlife conflict was 38.5 % of per capita net income.     

Cost effectiveness of antenatal screening for cystic fibrosis.

OBJECTIVE--To estimate the cost effectiveness of different antenatal screening programmes for cystic fibrosis. SETTING--Antenatal clinics and general practices in the United Kingdom. DESIGN--Four components of the screening process were identified: information giving, DNA testing, genetic counselling, and prenatal diagnosis. The component costs were derived from the literature and from a pilot screening study in Yorkshire. The cost of a given screening programme was then obtained by summing the components according to the specific screening strategy adopted (sequential and couple), the proportion of carriers detected by the DNA test, and the uptake of screening. Baseline assumptions were made about the proportion with missing information on carrier status from previous pregnancies (20%), the proportion changing partners between pregnancies (20%), and the uptake of prenatal diagnosis (100%). Sensitivity analysis was performed by varying these assumptions. MAIN OUTCOME MEASURE--Cost per affected pregnancy detected. RESULTS--Under the baseline assumptions sequential screening costs between pounds 40,000 and pounds 90,000 per affected pregnancy detected, depending on the carrier detection rate and uptake. Couple screening was more expensive, ranging from pounds 46,000 to pounds 104,000. From the sensitivity analysis a 10% change in the assumed proportion with missing information from a previous pregnancy alters the cost by pounds 4000; a 10% change in the proportion with new partners has a similar effect but only for couple screening; and cost will change directly in proportion to the uptake of prenatal diagnosis. CONCLUSIONS--While economic analysis cannot determine screening policy, the paper provides the NHS with the information on cost effectiveness needed to inform decisions on the introduction of a screening service for cystic fibrosis.     

Survey of equipment in general practice.

Partners in general practice have to buy any equipment they want themselves. As a result partners in high investing practices have lower net incomes. Of the 297 practices in Devon and Cornwall, 265 responded to a questionnaire listing 115 possible items of practice equipment. Overall, practices seemed to be fairly well equipped. Key findings were that 193 of those who responded had an electrocardiograph, 206 had a kit for minor operations, 119 owned a computer, and less than one third owned a microscope. Most of these practices were high investors. There seems to be a shift away from some traditional instruments towards expensive information technology. Government policies are encouraging the use of computers and such equipment, though funds are not necessarily being made available for this purpose.     

Influences of practice characteristics on prescribing in fundholding and non-fundholding general practices: an observational study.

OBJECTIVE: To investigate the variation in prescribing among general practices by examining the contribution to this variation of fundholding, training status, partnership status, and the level of deprivation in the practice population and to investigate the extent to which fundholding has been responsible for any changes in prescribing. DESIGN: Analysis of prescribing data (PACT) for the years 1990-1 (before fundholding) and 1993-4 (after fundholding), Use of multiple linear regressions to investigate the variation among practices in total prescribing costs (net ingredient cost per prescribing units), and mean cost per item in each of the two years and also the change in these variables between years. SETTING: Former Mersey region. SUBJECTS: 384 practices. RESULTS: The models developed explained the variation in cost per item (43% of variation explained for 1990-1, 38% for 1993-4) and prescribing volume (34% for 1990-1, 38% for 1993-4) better than the variation in total prescribing costs (3% for 1990-1, 7% for 1993-4). The models developed to explain the change in these variables between years did not explain more than 10% of the variation. Most of the explained variation in the change in total prescribing costs was accounted for by fundholding. Of the pounds 3.71 saved by first wave fundholders compared with non-fundholders pounds 3.57 was attributable to fundholding alone. CONCLUSION: In neither year did fundholding make a major contribution to the variation in prescribing behaviour among practices, which was better explained by deprivation, training status, and partnership status, but it did seem largely responsible for differences in the rise of total prescribing costs between fundholders and non fundholders.     

High income men have high value as long-term mates in the U.S.: personal income and the probability of marriage,divorce, and childbearing in the U.S.

Using data from the first Census data set that includes complete measures of male biological fertility for a large-scale probability sample of the U.S. population (the 2014 wave of the Study of Income and Program Participation-N = 55,281), this study shows that high income men are more likely to marry, are less likely to divorce, if divorced are more likely to remarry, and are less likely to be childless than low income men. Men who remarry marry relatively younger women than other men, on average, although this does not vary by personal income. For men who divorce who have children, high income is not associated with an increased probability of having children with new partners. Income is not associated with the probability of marriage for women and is positively associated with the probability of divorce. High income women are less likely to remarry after divorce and more likely to be childless than low income women. For women who divorce who have children, high income is associated with a lower chance of having children with new partners, although the relationship is curvilinear. These results are behavioral evidence that women are more likely than men to prioritize earning capabilities in a long-term mate and suggest that high income men have high value as long-term mates in the U.S.     

Hospital admissions for asthma in east London: associations with characteristics of local general practices,prescribing, and population.

OBJECTIVE: To determine the relative importance of appropriate prescribing for asthma in explaining high rates of hospital admission for asthma among east London general practices. DESIGN: Poisson regression analysis describing relation of each general practice''s admission rates for asthma with prescribing for asthma and characteristics of general practitioners, practices, and practice populations. SETTING: East London, a deprived inner city area with high admission rates for asthma. SUBJECTS: All 163 general practices in East London and the City Health Authority (complete data available for 124 practices). MAIN OUTCOME MEASURES: Admission rates for asthma, excluding readmissions, for ages 5-64 years; ratio of asthma prophylaxis to bronchodilator prescribing; selected characteristics of general practitioners, practices, and practice populations. RESULTS: Median admission rate for asthma was 0.9 (range 0-3.6) per 1000 patients per year. Higher admission rates were most strongly associated with small size of practice partnership: admission rates of singlehanded and two partner practices were higher than those of practices with three or more principals by 1.7 times (95% confidence interval 1.4 to 2.0, P < 0.001) and 1.3 times (1.1 to 1.6, P = 0.001) respectively. Practices with higher rates of night visits also had significantly higher admission rates: an increase in night visiting rate by 10 visits per 1000 patients over two years was associated with an increase in admission rates for asthma by 4% (1% to 7%). These associations were independent of asthma prescribing ratios, measures of practice resources, and characteristics of practice populations. CONCLUSIONS: Higher asthma admission rates in east London practices were most strongly associated with smaller partnership size and higher rates of night visiting. Evaluating ways of helping smaller partnerships develop structured proactive care for asthma patients at high risk of admission is a priority.     

Cost effectiveness of treating primary care patients in accident and emergency: a comparison between general practitioners,senior house officers,and registrars.

OBJECTIVES--To compare outcome and costs of general practitioners, senior house officers, and registrars treating patients who attended accident and emergency department with problems assessed at triage as being of primary care type. DESIGN--Prospective intervention study which was later costed. SETTING--Inner city accident and emergency department in south east London. SUBJECTS--4641 patients presenting with primary care problems: 1702 were seen by general practitioners, 2382 by senior house officers, and 557 by registrars. MAIN OUTCOME MEASURES--Satisfaction and outcome assessed in subsample of 565 patients 7-10 days after hospital attendance and aggregate costs of hospital care provided. RESULTS--Most patients expressed high levels of satisfaction with clinical assessment (430/562 (77%)), treatment (418/557 (75%)), and consulting doctor''s manner (434/492 (88%)). Patients'' reported outcome and use of general practice in 7-10 days after attendance were similar: 206/241 (85%), 224/263 (85%), and 52/59 (88%) of those seen by general practitioners, senior house officers, and registrars respectively were fully recovered or improving (chi2 = 0.35, P = 0.840), while 48/240 (20%), 48/268 (18%), and 12/57 (21%) respectively consulted a general practitioner or practice nurse (chi2 = 0.51, P = 0.774). Excluding costs of admissions, the average costs per case were 19.30 pounds, 17.97 pounds, and 11.70 pounds for senior house officers, registrars, and general practitioners respectively. With cost of admissions included, these costs were 58.25 pounds, 44.68 pounds, and 32.30 pounds respectively. CONCLUSION--Management of patients with primary care needs in accident and emergency department by general practitioners reduced costs with no apparent detrimental effect on outcome. These results support new role for general practitioners.     

The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme.

OBJECTIVES--To observe changes in prescribing practice that occurred after the introduction of fundholding in first wave practices and to contrast these with changes occurring in similar non-fundholding practices. DESIGN--Prospective observational study. SETTING--Oxford region fundholding study. SUBJECTS--Eight first wave fundholding practices and five practices that were not interested in fundholding in 1990-1, which were similar in terms of practice size, training status, locality, and urban rural mix. Three of the fundholding and none of the non-fundholding practices were dispensing practices. MAIN OUTCOME MEASURES--Changes in prescribing practice as measured by net cost per prescribing unit, cost per item, number of items prescribed, and substitution rates for generic drugs three years after the introduction of fundholding. Data for fundholding practices were analysed separately according to whether they were dispensing or non-dispensing practices. RESULTS--Prescribing costs rose by a third or more in all types of practice. The patterns of change observed in this cohort after one year of fundholding were reversed. No evidence existed that fundholding had controlled prescribing costs among non-dispensing fundholders; costs among dispensing fundholders rose least, but the differences were small compared with the overall increase in costs. CONCLUSIONS--Early reports of the effectiveness of fundholding in curbing prescribing costs have not been confirmed in this longer term study.     

Economics of microsurgical cases and routine cases in a medical center

This report describes the economic impact of microsurgical cases and routine plastic surgery cases in our medical center. The study is based on a financial analysis of the practices of two surgeons. Financial data of patient encounters (admission to the hospital or a surgical unit) identified with each surgeon were categorized into microsurgical and related cases and routine cases (including cosmetic procedures and general hand cases). Revenues, costs, and profits were tabulated. Data were analyzed for 2 fiscal years (1994-95 and 1995-96). Analysis of the first fiscal year showed that microsurgery encounters (n = 188) generated $4.4 million in revenue with a profit margin after direct costs of $2.5 million (57 percent) and a net profit, after indirect costs, of $1 million (23 percent). Routine encounters (n = 262) generated $1.7 million with a net loss of -$145,000 after direct and indirect costs. In the second fiscal year, microsurgery encounters (n = 230) had income of $4.7 million, a profit over direct costs of $2.5 million (53 percent), and a net profit after indirect costs of $0.9 million (19 percent). Routine cases (n = 202) in the same period earned $1.3 million with a net loss of -$107,000. This analysis formulates a comprehensive definition of microsurgical practice and shows that cases within this definition generated dramatically higher hospital incomes and profits compared with routine plastic surgical practice. In the circumstances of our medical center, development of this subspecialty is fiscally justifiable.     

Costs and cost effectiveness of health checks conducted by nurses in primary care: the Oxcheck study.

OBJECTIVE--To measure the costs and cost effectiveness of the Oxcheck cardiovascular risk factor screening and intervention programme. DESIGN--Cost effectiveness analysis of a randomised controlled trial using clinical and economic data taken from the trial. SETTING--Five general practices in Luton and Dunstable, England. SUBJECTS--2205 patients who attended a health check in 1989-90 and were scheduled for re-examination in 1992-3 (intervention group); 1916 patients who attended their initial health check in 1992-3 (control group). Participants were men and women aged 35-64 years. INTERVENTION--Health check conducted by nurse, with health education and follow up according to degree of risk. MAIN OUTCOME MEASURES--Cost of health check programme; cost per 1% reduction in coronary risk. RESULTS--Health check and follow up cost 29.27 pounds per patient. Estimated programme cost per 1% reduction in coronary risk per participant was between 1.46 pounds and 2.25 pounds; it was nearly twice as much for men as women. CONCLUSIONS--The cost to the practice of implementing Oxcheck-style health checks in an average sized practice of 7500 patients would be 47,000 pounds, a proportion of which could be paid for through staff pay reimbursements and Band Three health promotion target payments. This study highlights the considerable difficulties faced when calculating the costs and benefits of a health promotion programme. Economic evaluations should be integrated into the protocols of randomised controlled trials to enable judgments to be made on the relative cost effectiveness of different prevention strategies.     

What can be concluded from the Oxcheck and British family heart studies: commentary on cost effectiveness analyses.

OBJECTIVES--To provide a commentary on the economic evaluations of the Oxcheck and British family heart studies: direct comparison of their relative effectiveness and cost effectiveness; comparisons with other interventions; and consideration of problems encountered. DESIGN--Modelling from cost and effectiveness data to estimate of cost per life year gained. SUBJECTS--Middle aged men and women. INTERVENTIONS--Screening for cardiovascular risk factors followed by appropriate lifestyle advice and drug intervention in general practice, and other primary coronary risk management strategies. MAIN OUTCOME MEASURES--Life years gained; cost per life year gained. RESULTS--Depending on the assumed duration of risk reduction, the programme cost per discounted life year gained ranged from 34,800 pounds for a 1 year duration to 1500 pounds for 20 years for the British family heart study and from 29,300 pounds to 900 pounds for Oxcheck. These figures exclude broader net clinical and cost effects and longer term clinical and cost effects other than coronary mortality. CONCLUSIONS--Despite differences in underlying methods, the estimates in the two economic analyses of the studies can be directly compared. Neither study was large enough to provide precise estimates of the overall net cost. Modelling to cost per life year gained provides more readily interpretable measures. These estimates emphasise the importance of the relatively weak evidence on duration effect. Only if the effect lasts at least five years is the Oxcheck programme likely to be cost effective. The effect must last for about 10 years to justify the extra cost associated with the British family heart study.     

Do clinical guidelines improve general practice management and referral of infertile couples?

OBJECTIVE--To evaluate guidelines for general practice management and referral of infertile couples. Guidelines were implemented with a disease specific reminder at the time of consultation (the guidelines were embedded within a structured infertility management sheet for each couple). DESIGN--Pragmatic randomised controlled trial. Participating practices were randomised to a group that received the guidelines and a control group. SETTING--82 general practices in Grampian region. SUBJECTS--100 couples referred by general practitioners receiving the guideline and 100 couples referred by control general practitioners. MAIN OUTCOME MEASURES--Whether the general practitioner had taken a full sexual history and examined and investigated both partners appropriately. RESULTS--Characteristics of patients referred by study and control general practitioners did not differ significantly at baseline. Compliance with the guidelines increased for all targeted activities. General practitioners in the study group were more likely to take a sexual history (for example, couples'' use of fertile period, 85% v 69%, p < 0.01); examine both partners (female partner, 68% v 52%, p < 0.05; male partner 39% v 13%, p < 0.01); and investigate both partners (day 21 progesterone, 72% v 41%, p < 0.001; semen analysis, 51% v 41%, p > 0.05). Improvements were greater when general practitioners used the disease specific reminder. CONCLUSION--Receiving guidelines led to improvements in the process of care of infertile couples within general practice. This effect was enhanced when the guidelines were embedded in a structured infertility management sheet for each couple.