Payment by Results a rational approach to outcomes Duncan Raistrick Leeds Addiction Unit Society for the Study of Addiction Conference 8-9th November 2012 NIHR Nine CLAHRCs approx 10million each CLAHRC for Leeds/York/Bradford Addiction Research in Acute Settings (ARiAS) 1 of 5 themes ARiAS outcome measurement 1 of 6 strands CLAHRC research group: Duncan Raistrick, Gillian Tober, Christine Godfrey, Charlie Lloyd, Steve Parrot, Jude Watson, Veronica Dale Co-opted Expert Group convened March 2011: Owen Bowden-Jones, Alex Copello, Ed Day, Eilish Gilvarry, Don Lavoie, Damian Mitchell, Julia Sinclair, John Strang, and Alex Whincup Summary o What is Payment by Results Alcohol Drugs Stakeholders o Evidence for incentivised treatment Types of incentives Weaknesses of treatment outcome measurement o Measuring addiction outcomes Types of measures Substance use
Societal impact measures Secondary outcome measures Payment by Results Quality and Outcomes Indicators Report for Product Review Group Quality & Outcomes Sub Group. October 2011 PbR for mental illness based on tariffs for 21 clusters Outcomes: HoNOS, GAD7, PHQ9, Recovery Star, Carers and Users Expectations of Service (CUES), and possible 21 indicators/outcomes (incl. employment, % on CPA etc) Developed the Alcohol PbR Reflects an evidence based approach fits with mental illness PbR Outcomes tbd but will include Q/F as key measure Developed the Drug PbR Reflects a political agenda different to other PbRs Outcomes are all recorded on TOP (rater completed) ...independent view to DH/NTA of Drug PbR... 100% PbR not required 5-10% more typical if too high likely to lead to gaming (fraud, manipulation, overestimation) 1. Free from drugs of dependence - abstinence TOP scores rater completed not objective 2. Employment dropped 3. Offending if based on group values local patterns greater influence 4. Health and wellbeing inj: NFA: HepB: wellbeing TOP scores rater completed not objective Local Area Single Assessment and Referral System (LASARS) assess
and refer clients and set their tariffs expensive, not SU friendly Making Payment by Results work in 2012 Center for Policy Studies research fellow Kathy Gyngell suggests reforms to the Payment by Results for drug treatment Offering the addict the real choice of a) a replacement prescription conditional on regular clean illicit drug use and alcohol tests, or b) a breaking free of dependence option. Payment conditional on sustained drugs tested sobriety (abstinence from opiate substitute drugs, all illicit drugs and alcohol). Payments progressive starting at one month sobriety (25%), a second at three months (25%) and the (50%) at six months Pre and Post Performance Based Contracting in Maine effect on public sector take up of most severe cases Take up of more severe problem drinkers Pre-PBC Post-PBC diff Out-patient Public 27% 20% -7% Medicaid 24% 26% +2% In-patient Public
44% 64% +20% Medicaid 47% 58% +11% Incentives based on 3 efficiency, 13 effectiveness, 9 population standards Source: Shen (2003) Health Services Research Payment by Results Quality and Outcomes Indicators Group set criteria..... The indicator demonstrably reflects quality or outcomes that are relevant to the service user, practitioner, provider or commissioner. Data is available at all levels and can be fed back to practitioner/teams Evidence / proof that the data required to demonstrate the indicators can be collected & evaluated They must support the high-level indicators which are likely to include employment, mortality, suicide and recovery That they have nationally agreed definitions They should fit with Commissioning for Quality and Innovation scheme (CQUIN). See Glossary for more detailed description. They are specific to currency group(s) A link can be made between needs (both physical & mental health), interventions and outcomes That other similar processes that may be trying to do achieve the same end should be evaluated, for example work on clinical indicator.
.....but didnt find any perfect measures 1st Key point Recognise that different Payment by Results stakeholders want different things from the Result o Service users and carers abstinence o Politicians and commissioners costs and benefits o Practitioners Health workers physical and mental health Criminal justice workers offending behaviour Social workers safeguarding children ......so, there is no ideal measure, just the mix of measures that best suits the purpose. What do service users and carers think being better means? 1. Abstinence incl. no scrip drugs 2. Being with nondrinking/drug using people Source Thurgood et al. (in prep) CLAHRC Understand different types of measure choose the best mix 2nd Key point Generic Measures (Health) Is treatment cost effective? How ill are people with addiction problems compared to other users of health care? How complex are the health problems? What is the illness profile of people with addictions? Dimension Measures (Addiction) How severe is the addiction? How difficult is treatment likely to be? How good is one addiction service compared to another? Do problems persist?
Condition Specific Measures (Depression, Pregnancy) How severe is the specific condition? How do services targeting the condition compare? How effective is treatment for this specific problem? Societal Impact Measures (Service level) Source: Fitzpatrick et al. (1998) Health Technology Assessment Societal Impact Measures - SIMs Treating the individual has benefits at the societal level SIMs are service level Political interest is in societal costs (a research exercise) SIMs are a headline contribution SIMs need to be: objective, easy to collect, capable of showing variability, reflect the impact of the service in the fewest possible measures............... Pregnancy and Parenting i) birth weight ii) child with mother at 12months Hospital In-reach i) A&E attendances ii) in-patient admissions in last 12months Detoxification i) % completing ii) % supervised disulfiram A Quality Framework for Outcome Scales Self completion scales are the gold standard Scales evaluated by scoring for: Evidence Base (including independent evaluations) Psychometric Properties Normative Data Availability (free and supported by website) Ease of Use Universality (all substances and all socio-economic groups) Service User Evaluations Source: NIMHE (2009) Scales that best match quality criteria... EQ-5D health LDQ dependence CORE-10 mental health SSQ
satisfaction APQ problems HoNOS mental health PHQ9 depression GAD7 anxiety IRS impulsivity FMQ family coping PCQ parenting Evidence (0-2) Number of validation publications Psychometric properties (0-6) Availability (0-2) Practicality (0-3) Universality (0-2) Population norms (0-2) 2 tbc 6
1 1 2 2 3 2 0 Domains (or components) of Addiction Justification for substance use as the primary outcome measure....... Viewed by service users as most important Viewed by careers as most important Most convincing for general public and policy makers Substance misuse is the condition Correlation with societal costs Correlations with Societal Costs example data for units of alcohol and health status health as % of best possible health 100 moderate drinking not associated with major health problems 90 80 70 60 one2one increase decrease 50 40
health may not recover once damage is done 30 20 10 0 0 10 20 30 40 50 60 weekly units of alcohol There is a scientific and political case for the primacy of substance use as an outcome measure.... Correlations with Substance Use.... Baseline EQ5D LDQ Follow-up CORE SSQ EQ5D LDQ CORE SSQ Alcohol freq
Source: unpublished CLAHRC clinical sample but.... substance use is difficult to measure LDQ good proxy other scales are needed to paint a picture of outcome.... Factor analysis with #4 factor solution EQ5D LDQ CORE-10 SSQ F#1 F#2 F#3 F#4 F#1 F#2 F#3 F#4 F#1 F#2 F#3 F#4 F#1 F#2 F#3
17% of variance 9% of variance Relationship between EQ5D LDQ CORE SSQ LDQ and CORE close to each other. Predicts if dependence is treated then mental health improves. SSQ is most separated. Predicts it will change most differently to other measures. EQ5D is generic but independent and between the other measures. Has less influence than LDQ on mental health more on social satisfaction. Clinically Significant Change - Gold Standard Jacobson et al. (1999) proposed that in order to take account of baseline scores and measuring error, clinically significant change should a) be statistically reliable b) end scores be in a well functioning population range Reliable Change Score Well Functioning Population LDQ >= 4 < 12 CORE-10 >= 6 < 14
SSQ >= 4 > 10 Source: CLAHRC submitted S e S 1 1 r retest Sdiff 2(Se )2 RC eanean LDQ t1 eanean LDQ t0 S diff RC = reliable change 95% probability if RC >=1.28 Sdiff = standard error of difference between means of LDQ scores Se = standard error of measurement of LDQ S1 = standard deviation of mean1 rretest = test/retest reliabilty of LDQ Clinically Significant Change - example well functioning population is 2standard deviation above general population mean LDQ<12 reliable change >=4 if pushed into well functioning population range then Clinically Significant Change achieved Reliable (RC) and clinically significant (CS) change (n-925).... LDQ % CORE % SSQ % RC improved 61.0
46.0 36.7 RC worse 4.6 5.7 12.0 Too small for RC 14.3 6.1 5.2 CS improvement 50.1 30.5 31.9 n=925 95% probability of real change clinically significant change at 3mth (drinking n=396)..... CSC is a tough test of improvement The GOLD standard CS change % Yes
No Yes No Yes No Drinking 22.0 31.1 13.4 39.6 16.7 36.4 Abstinent 35.4 11.6 24.2 22.7 17.7 29.3 P<.001 P<.001 n.s.
social situation most difficult to recover abstinence associated with the most CSC. LDQ works across drinking outcomes Payment by Results as a package.... Payment by practitioner competence eg %competent on video recorded practice by process rating 3rd Key point Payment for effective management eg pay for participation in approved addiction service business improvement Payment for quality/added value practice eg smoking cessation, health checks (as QoF in primary care) and SIMs Give service users purchasing power eg vouchers, personal development budget Payment for in-treatment performance eg abstinence, secondary measures, socital impacts Source: Humphreys & McLellan (2011) Addiction
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