Guiding patients to the best point of service

Peter C. SmithImperial College London and European Observatory on Health Systems and

Policieswith

Marina KaranikolosLondon School of Hygiene and Tropical Medicine and European Observatory on

Health Systems and Policies

Some key questions

1. What is the ‘appropriate’ (efficient) setting for care?2. On what basis do citizens currently make their choices to seek

care?3. What technologies exist to affect those choices?4. Is use of those technologies effective?

– For which groups of patients?– What are the preconditions for success?

5. Who should provide the guidance?– Government, professions, patient groups, private sector?

6. Are the providers of care willing and able to provide relevant services?

7. Are there unintended consequences of introducing the new instruments?

1. What is the ‘appropriate’ (efficient) setting for care?

What is the scale of the A&E problem?

• Estimate that up to 13.7 percent of all ED visits could be seen in a Retail Clinic (nurse-staffed pharmacy)

• An additional 13.4 percent of ED visits could be seen at an Urgent Care Centre.

• Overall, a total of between 13.7 and 27.1 percentof all ED visits could be managed at a RC or UCC.

• Potential savings to the health care system would be approximately $4.4 billion annually, or 0.2 percent of national health care spending.

Weinick RM, Burns RM, Mehrotra A. How Many Emergency Department Visits Could be Managed at Urgent Care Centers and Retail Clinics? Health Affairs. 2010;29(9):1630-1636. doi:10.1377/hlthaff.2009.0748.

2. On what basis do citizens currently make their choices to seek care?

• Convenience

• Cost

• Quality of alternatives (eg waiting times for ambulatory care)

• Confusion about where to go

• Risk aversion

• Professional advice

• Friends, family, social media

• Websites and other media

Top ten ‘ridiculous’ reasons

1. Broken false finger nail that wouldn't come off

2. Splinter in finger

3. Needing emergency contraception

4. Shaving cut, that wasn't visible

5. Paper cut

6. Months of back pain, but not seen a GP

7. Sore throat

8. Hiccups

9. Unable to sleep

10. Run out of medication

Source: The Independent, 26 March 2016

Uscher-Pines L, Pines J, Kellermann A, Gillen E, Mehrotra A. Deciding to Visit the Emergency Department for Non-Urgent Conditions: A Systematic Review of the Literature. The American Journal of Managed Care. 2013;19(1):47-59.

Rising, K. L., Hudgins, A., Reigle, M., Hollander, J. E., & Carr, B. G. (2016) “I'm Just a Patient”: Fear and Uncertainty as Drivers of Emergency Department Use in Patients

With Chronic Disease. Annals of Emergency Medicine. doi:http://dx.doi.org/10.1016/j.annemergmed.2016.03.053

MotivationUnable to determine whether emergency But I just know that things can happen that you don’t—and I’m

not a doctor. So, I could have hit my head and feel fine now, and

then something could happen hours later. So, I figured [it was in]

my [best] interest to come.Yeah, I didn’t know it get infected or

what. I didn’t want to take a chance, because I’m no doctor. I’m no

nurse. I’m just a patient.

Stories of loved ones with bad outcomes And to be honest with you, I really thought I was having an

aneurysm because the pain wouldn’t go away. And I had a friend

that passed away from an aneurysm…. And he died from an

aneurysm, and I don’t want that to happen to me so I came here…

Usual medicine not working When the symptoms that usually would go away by me self-

medicating, when those symptoms didn't dissipate, I kinda got

nervous and so I let the professionals handle it.

Untreated symptoms I was scared because of the shortness of breath, but I knew what it

was. But I don’t have a machine at home, so I knew I had to come

in.

Unable to physically get to PCP I was gonna drive to my doctor’s office…. So I was going to actually

try to hobble in there, but it was too much pain.

Unable to make timely PCP appointment She [PCP] only in on Wednesdays. So tomorrow would have been

Wednesday, but I couldn't make it—wait until tomorrow. I had to

come in.

Behavior driven by previous experience

with being sent to ED by PCP

Like the last time, I went and told my situation to my doctor; she

told me go to the hospital when you leave here.

3. What technologies exist to affect those choices?

• The web: information provision

• Web tools: algorithmic guidance for patients

• Expert systems for clinicians (shared decision-making)

• Tele-consultation

• Phone apps, including real-time biomedical monitoring

http://www.choosewellwales.org.uk

http://www.choosewellwales.org.uk

http://mapofmedicine.com/

4. Is use of those technologies effective?

• Intrinsically difficult to evaluate

• Important to assess which population groups are affected, and for which groups technology is ineffective

• Two examples:

– Web based NHS Choices

– Telephone-based 111 services

Murray J, Majeed A, Khan MS, Lee JT, Nelson P. Use of the NHS Choices website for primary care consultations: results from online and general practice surveys. JRSM Short Reports. 2011;2(7):56. doi:10.1258/shorts.2011.011078.

Murray et al conclusions

• The annual cost for core services of NHS Choices was estimated at around £25 million a year (population 55 million). – Includes content production, data and directories, technical hosting,

project management, contract value plus other costs.

• Net cost saving of NHS Choices for GP consultations is £94,715,200. • This estimate does not include

– the additional cost savings as a result of reduced consultation times due to patients having a better understanding of their condition

– the potential cost savings for the NHS if users adopt the health advice provided by the website.

• “NHS Choices has proved to be a popular and effective decision support tool permitting more efficient self-management and self-triage by the public, reducing the need to involve health professionals and thus reducing avoidable consultations for diagnostic decision support.”

Turner J, O’Cathain A, Knowles E, et al. Impact of the urgent care telephoneservice NHS 111 pilot sites: a controlled before and after study, BMJ Open

2013;3:e003451. doi:10.1136/bmjopen-2013-003451

• NHS 111, a 24 h 7 day a week telephone service for non-emergency health problems, operated by trained non-clinical call handlers with clinical support from nurse advisors, using software to triage calls to different services and home care.

• NHS 111 triaged 277 163 calls in the first year of operation for a population of 1.8 million.

• There was no change overall in emergency ambulance calls, emergency department attendances or urgent care use.

• There was a 19.3% reduction in calls to NHS Direct (95% CI −24.6% to −14.0%) and a 2.9% increase in emergency ambulance incidents (95% CI 1.0% to 4.8%).

• There was an increase in activity overall in the emergency and urgent care system in each site ranging 4.7–12%.

Who used NHS Direct (telephone triage)?

Cook EJ, Randhawa G, Large S, Guppy A, Chater AM, Pang D. Who uses NHS Direct? Investigating the impact of ethnicity on the uptake of telephone based healthcare. International Journal for Equity in Health. 2014;13:99. doi:10.1186/s12939-014-0099-x.

• Mixed ethnic groups (White and Black Caribbean, White and Black African, White and Asian) all had a higher than expected uptake of NHS Direct which held consistent across all age groups.

• Lower than expected uptake was found for Black (African/Caribbean) and Asian (Bangladeshi/Indian/Chinese) ethnic groups which held consistent by age and gender.

• For the Pakistani ethnic group usage was higher than expected in adults aged 40 years and older although was lower than expected in younger age groups (0– 39).

Erica Jane Cook, Gurch Randhawa, Shirley Large, Andy Guppy, Angel Chater, Who uses telephone based helplines? Relating deprivation indices to users of NHS Direct, Health Policy and Technology, Volume 2, Issue 2, June 2013, Pages 69-74, ISSN 2211-8837, http://dx.doi.org/10.1016/j.hlpt.2013.03.002.

• The authors found - in general - higher utilization amongst more deprived population groups.

5. Who should provide the guidance?

• Government, professions, patient groups, private sector?

• Legal liability?

• Patient confidentiality?

• Consistency of messages

• Commercial interests

https://www.asthma.org.uk/advice/manage-your-asthma/

https://www.asthma.org.uk/

6. Are the providers of care willing and able to provide relevant services?

• All arrangements dependent on preparedness of providers to offer intended services with satisfactory reliability and levels of quality

• May require design of incentives, information, and other instruments

• Reluctance of primary care physicians to provide ‘out of hours’ care a major reason for increased emergency care demand

• May require comparative information on quality

Provider performance reports

• Effective at improving reported performance

• Little used by patients

• Major impact is on provider behaviour

• Concern about reliability of many metrics and suitable risk adjustment

• Concern that publication may affect provider behaviour (e.g. ‘cherry-picking’ healthier patients)

7. Are there unintended consequences of introducing the new technologies?

• Unintended side-effects a major consideration, underlining need for proper pilots and evaluation

• Often new systems must be run alongside existing triage systems, so net increase in service delivery costs

• New service providers may require reimbursement for increased activity

• Demand for services may increase– Easier access to advice stimulates demand– Risk averse advisors may refer to higher level of care– May improve health but increase costs

• May have differential implications for different population groups –equity concerns

• Legal liability and confidentiality are issues that must be addressed.

Concluding comments

• Electronic information sources will increase in importance, and are demanded by patients and caregivers

• Technology changing fast – eg real-time monitoring of biomedical status

• Technology offers the potential for more focused and ‘intelligent’ use of health services, improved effectiveness, increased personalization, better population health

• However, not clear that it always leads to cost reductions or efficiency savings

• May be provided by public sector, for-profit or NFP – should there be regulation or control?

• Clear need for well-designed experiments and evaluation, but NB rapidly changing technologies