Reflux symptoms – functional and structural diseases The approach from the general practitioner (GP)

2021 ◽  
Author(s):  
Lászloó Herszényi
Keyword(s):  
Primary Care ◽  
Cost Effective ◽  
Effective Control ◽  
Patient Centered ◽  
Use Of Resources ◽  
Reflux Symptoms ◽  
Therapeutic Decisions ◽  
Recurrent Gerd ◽  
Step Down

A primary care management strategy of gastroesophageal reflux disease (GERD) should pay attention to the epidemiology, prevalence and distribution of reflux-like symptoms in the community, to the special characteristics of patients presenting for the first time with reflux symptoms in primary care. General practitioners (GPs) encounter daily challenges to make cost-effective differential diagnostic and therapeutic decisions, avoiding needless and costly investigation or referral. They should provide long-term effective control of symptoms and esophageal healing in a personalized, symptom based, patient-centered and evidence-based manner. GPs should use a practical system of triage, in order to distinguish the high majority of patients with self-limiting conditions, from the minority with alarm symptoms with potentially severe disorder. They should also discriminate between troublesome and non-troublesome reflux symptoms. Most GERD is uncomplicated and can be treated using management algorithms that make the best use of resources. Some strategies such as “step-down”, “intermittent” or “on-demand” therapy can cost-effectively improve the long-term management and quality of life of patients with recurrent GERD. The accurate interpretation of “step-down” therapeutic strategy and a careful interpretation of proton pump inhibitor refractoriness are also essential.

scholarly journals Implementation of a novel primary care pathway for patients with severe and enduring mental illness

2017 ◽  
Vol 41 (6) ◽  
pp. 314-319 ◽  
Author(s):  
Frank Röhricht ◽  
Gopal Krishan Waddon ◽  
Paul Binfield ◽  
Rhiannon England ◽  
Richard Fradgley ◽  
...  
Keyword(s):  
Primary Care ◽  
Mental Illness ◽  
Secondary Care ◽  
Care Pathway ◽  
Care Service ◽  
Significant Proportion ◽  
Cost Effective ◽  
Care Patient ◽  
Care Models

Aims and methodNew collaborative care models with an emphasis on primary care are required for long-term management of patients with severe and enduring mental illness (SMI). We conducted a descriptive evaluation of clinical outcomes of the first 3 years of a novel enhanced primary care (EPC) service. Data from 2818 patients and staff survey results were analysed.Results2310 patients were discharged to EPC (508 not assessed as clinically suitable or patients/general practitioners declined the transfer); mean length of stay with secondary care service of the cohort was 9.8 years (range 0–24). 717 patients (31%) have been discharged to primary care only out of the EPC services and 233 patients (10%) have been transferred back to secondary care. Patient and staff satisfaction with the new EPC model was high. No severe untoward incidents were recorded.Clinical implicationsThe data suggest that EPC can be safely provided for a significant proportion of patients with SMI, who traditionally received long-term secondary care support. The novel EPC model can be utilised as a template for the provision of cost-effective, recovery-oriented and non-stigmatising care in the community.

scholarly journals Cost-effective Analysis of Proton Pump Inhibitors in Long-term Management of Gastroesophageal Reflux Disease: A Narrative Review

2019 ◽  
Vol 55 (5) ◽  
pp. 292-305
Author(s):  
Shazia Jamshed ◽  
Akshaya Srikanth Bhagavathula ◽  
Sheikh Muhammad Zeeshan Qadar ◽  
Umaira Alauddin ◽  
Sana Shamim ◽  
...  
Keyword(s):  
Cost Effectiveness ◽  
Gastroesophageal Reflux Disease ◽  
Cost Effective ◽  
The Other ◽  
Cost Effectiveness Ratio ◽  
On Demand ◽  
Step Down ◽  
The Cost ◽  
Term Management

Background: Gastroesophageal reflux disease (GERD) is a common gastrointestinal disorder that results from regurgitation of acid from the stomach into the esophagus. Treatment available for GERD includes lifestyle changes, antacids, histamine-2 receptor antagonists (H2RAs), proton pump inhibitors (PPIs), and anti-reflux surgery. Aim: The aim of this review is to assess the cost-effectiveness of the use of PPIs in the long-term management of patients with GERD. Method: We searched in PubMed to identify related original articles with close consideration based on inclusion and exclusion criteria to choose the best studies for this narrative review. The first section compares the cost-effectiveness of PPIs with H2RAs in long-term heartburn management. The other sections shall only discuss the cost-effectiveness of PPIs in 5 different strategies, namely, continuous (step-up, step-down, and maintenance), on-demand, and intermittent therapies. Results: Of 55 articles published, 10 studies published from 2000 to 2015 were included. Overall, PPIs are more effective in relieving heartburn in comparison with ranitidine. The use of PPIs in managing heartburn in long-term consumption of nonsteroidal anti-inflammatory drug (NSAID) has higher cost compared with H2RA. However, if the decision-maker is willing to pay more than US$174 788.60 per extra quality-adjusted life year (QALY), then the optimal strategy is traditional NSAID (tNSAID) and PPIs. The probability of being cost-effective was also highest for NSAID and PPI co-therapy users. On-demand PPI treatment strategy showed dominant with an incremental cost-effectiveness ratio of US$2197 per QALY gained and was most effective and cost saving compared with all the other treatments. The average cost-effectiveness ratio was lower for rabeprazole therapy than for ranitidine therapy. Conclusion: Our review revealed that long-term treatment with PPIs is effective but costly. To achieve long-term cost-effective approach, we recommend on-demand approach to treat heartburn symptoms, but if the symptoms persist, treatment with continuous step-down therapy should be applied.

A Generic Simulation Model of the Relative Cost-Effectiveness of ICU Versus Step-Down (IMCU) Expansion

2017 ◽  
Vol 35 (2) ◽  
pp. 191-202
Author(s):  
Amin Mahmoudian-Dehkordi ◽  
Somayeh Sadat
Keyword(s):  
Intensive Care ◽  
Cost Effectiveness ◽  
Simulation Model ◽  
Cost Effective ◽  
Capacity Expansion ◽  
Baseline Scenario ◽  
Relative Cost ◽  
Relative Cost Effectiveness ◽  
Step Down

Background: Many jurisdictions are facing increased demand for intensive care. There are two long-term investment options: intensive care unit (ICU) versus step-down or intermediate care unit (IMCU) capacity expansion. Relative cost-effectiveness of the two investment strategies with regard to patient lives saved has not been studied to date. Methods: We expand a generic system dynamics simulation model of emergency patient flow in a typical hospital, populated with empirical evidence found in the medical and hospital administration literature, to estimate the long-term effects of expanding ICU versus IMCU beds on patient lives saved under a common assumption of 2.1% annual increase in hospital arrivals. Two alternative policies of expanding ICU by two beds versus introducing a two-bed IMCU are compared over a ten-year simulation period. Russel equation is used to calculate total cost of patients’ hospitalization. Using two possible values for the ratio of ICU to IMCU cost per inpatient day and four possible values for the percentage of patients transferred from ICU to IMCU found in the literature, nine scenarios are compared against the baseline scenario of no capacity expansion. Results: Expanding ICU capacity by two beds is demonstrated as the most cost-effective scenario with an incremental cost-effectiveness ratio of 3684 (US $) per life saved against the baseline scenario. Sensitivity analyses on the mortality rate of patients in IMCU, direct transfer of IMCU-destined patients to the ward upon completing required IMCU length of stay in the ICU, admission of IMCU patient to ICU, adding two ward beds, and changes in hospital size do not change the superiority of ICU expansion over other scenarios. Conclusions: In terms of operational costs, ICU beds are more cost effective for saving patients than IMCU beds. However, capital costs of setting up ICU versus IMCU beds should be considered for a complete economic analysis.

scholarly journals Investigating the Use of Telemedicine for Digitally Mediated Delegation in Team-based Primary Care: A Mixed-method Study (Preprint)

2021 ◽  
Author(s):  
Michael Knop ◽  
Marius Mueller ◽  
Bjoern Niehaves
Keyword(s):  
Primary Care ◽  
Technology Use ◽  
Online Survey ◽  
Cost Effective ◽  
Innovative Technology ◽  
Patient Centered ◽  
Team Members ◽  
Innovative Technologies ◽  
Daily Work ◽  
Centered Care

BACKGROUND Due to shortages of medical professionals, as well as demographic and structural challenges, new care models have emerged for finding innovative solutions to counter medical undersupply. Team-based primary care utilizing medical delegation appears to be a promising approach to address these challenges, but demands efficient communication structures and mechanisms to reinsure patients and caregivers receiving a delegated, treatment-related task. Here, digital healthcare technologies hold the potential to render these novel processes effective and demand-driven. OBJECTIVE The goal of this study is to recreate the daily work routines of general practitioners (GPs) and medical assistants (MAs) in order to explore promising approaches for the digital moderation of delegation processes and to deepen the understanding of subjective and perceptual factors that influence their technology assessment and use. METHODS In total, 19 interviews with 12 GPs and 14 MAs were conducted, seeking to identify relevant technologies for delegation purposes as well as the stakeholders’ perceptions of their effectiveness. Further, an online survey was conducted asking the interviewees to order identified technologies by their assessed applicability in multi-actor patient care. Interview data was analyzed using a three-fold inductive coding procedure. Multidimensional scaling was applied to analyze and visualize survey data, leading to a triangulation of results. RESULTS Our results suggest that digital mediation of delegation underlies complex, reciprocal processes and biases that need to be identified and analyzed in order to improve the development and distribution of innovative technologies, as well as to improve our understanding of technology use in team-based primary care. Nevertheless, medical delegation enhanced by digital technologies, such as video consultation, portable electrocardiograms (ECGs), or telemedical stethoscopes, is able to counteract current challenges in primary care due to its unique ability to ensure both personal, patient-centered care for patients and create efficient and needs-based treatment processes. CONCLUSIONS Technology-mediated delegation appears to be a promising approach to implement innovative, case-sensitive, and cost-effective ways to treat patients within the paradigm of primary care. The relevance for such innovative approaches increases at times of tremendous need for differentiated and effective care, like during the ongoing COVID-19 pandemic. For successful and sustainable adoption of innovative technologies, MAs represent essential team members. In their role of mediators between GPs and patients, MAs are potentially able to counteract resistance towards using innovative technology on both sides and compensate for patients’ limited access to technology and care facilities.

Benefits and feasibility of local elimination of possum populations

2006 ◽  
Vol 33 (7) ◽  
pp. 605 ◽  
Author(s):  
D. R. Morgan ◽  
G. Nugent ◽  
B. Warburton
Keyword(s):  
Control Strategies ◽  
Cost Effective ◽  
Population Characteristics ◽  
Effective Control ◽  
Brushtail Possum ◽  
Control Approach ◽  
Initial Cost ◽  
Regulatory Status ◽  
The Cost

Introduction of the brushtail possum (Trichosurus vulpecula) to New Zealand has resulted in serious ecological and economic impacts and considerable control efforts. Recovery of possum populations after control occurs through immigration from adjacent areas and breeding of survivors and immigrants. If complete local elimination can be achieved, the recovery of populations will depend solely on immigration and therefore should be substantially slowed (particularly in very large areas). To compare the cost-effectiveness of four control strategies over the long term (60 years), we constructed a deterministic bioeconomic model based on 23 variables describing population characteristics, sizes of the sink (i.e. area controlled) and source (of reinfestation) areas, and costs. Sensitivity analysis showed that the most influential variables related primarily to cost and effectiveness of control, whereas factors describing immigration after control had relatively little influence. When the most influential variables were varied, the model predicted that local elimination of possums followed by ‘perimeter’ control is likely to be a more cost-effective control strategy under most scenarios than the current ‘knockdown-then-maintenance-control’ approach. Possum-control technology and its application have improved greatly in the last three decades such that it now appears that local elimination is, technically, a realistic goal, and is possibly already being achieved occasionally. Constraining factors include unreliable monitoring/detection at ultralow densities, inappropriate selection and use of control options, lack of incentive under the present contracting system, initial cost, contracting capacity, and the future regulatory status of poisons. However, these difficulties can be overcome, facilitating the adoption of long-term local elimination strategies that are better suited to managing possum populations in perpetuity.

scholarly journals Quality conceptualization in the era of measurement: A qualitative study of primary care physicians in Medicare’s Merit-Based Incentive Payment System

2020 ◽  
Author(s):  
Carl Thomas Berdahl ◽  
Molly C Easterlin ◽  
Gery Ryan ◽  
Jack Needleman ◽  
Teryl K Nuckols
Keyword(s):  
Primary Care ◽  
Primary Care Physicians ◽  
Pay For Performance ◽  
Patient Centered Care ◽  
Payment System ◽  
Incentive Payment ◽  
Patient Centered ◽  
Centered Care ◽  
Quality In Healthcare

Abstract Background: While governmental programs seeking to improve the quality and value of healthcare through pay-for-performance initiatives have good intentions, participating physicians may be reluctant to participate for various reasons, including poor program alignment with considerations relevant to daily clinical practice. In this study, we sought to characterize how primary care physicians (PCPs) participating in Medicare’s Merit-Based Incentive Payment System (MIPS) conceptualize the quality of healthcare to help inform future measurement strategies that physicians would understand and appreciate.Methods: We performed semi-structured qualitative interviews with a nationwide sample of 20 PCPs participating in MIPS who were trained in internal medicine or family medicine. We asked PCPs how they would characterize quality in healthcare and what distinguished exceptional, good, and poor quality from one another. Interviews were transcribed and two coders independently read transcripts, allowing data to emerge from the interviews and developing theories about the data. The coders met intermittently to discuss findings, harmonize the coding scheme, develop a final list of themes and sub-themes, and aggregate a list of representative quotations.Results: Participants described quality in healthcare as consisting of two components: (1) evidence-based care that is safe, which included appropriate health maintenance and chronic disease control, accurate diagnoses, and adherence to guidelines and (2) patient-centered care, which included spending enough time with patients, responding to patient concerns, and establishing long-term patient-physician relationships that were founded upon trust. Conclusions: PCPs consider patient-centered care to be necessary for the provision of exceptional quality in healthcare. Program administrators for quality measurement and pay-for-performance programs should explore new ways to reward PCPs for providing outstanding patient-centered care. Future research should be undertaken to determine whether patient-centered activities such as forging long-term, favorable patient-physician relationships, are associated with improved health outcomes.

scholarly journals Exploring the cost–utility of stratified primary care management for low back pain compared with current best practice within risk-defined subgroups

2012 ◽  
Vol 71 (11) ◽  
pp. 1796-1802 ◽  
Author(s):  
David G T Whitehurst ◽  
Stirling Bryan ◽  
Martyn Lewis ◽  
Jonathan Hill ◽  
Elaine M Hay
Keyword(s):  
Primary Care ◽  
Low Back Pain ◽  
Back Pain ◽  
High Risk ◽  
Best Practice ◽  
Cost Effective ◽  
Cost Utility ◽  
Low Back ◽  
Use Of Resources ◽  
Medium Risk

ObjectivesStratified management for low back pain according to patients' prognosis and matched care pathways has been shown to be an effective treatment approach in primary care. The aim of this within-trial study was to determine the economic implications of providing such an intervention, compared with non-stratified current best practice, within specific risk-defined subgroups (low-risk, medium-risk and high-risk).MethodsWithin a cost–utility framework, the base-case analysis estimated the incremental healthcare cost per additional quality-adjusted life year (QALY), using the EQ-5D to generate QALYs, for each risk-defined subgroup. Uncertainty was explored with cost–utility planes and acceptability curves. Sensitivity analyses were performed to consider alternative costing methodologies, including the assessment of societal loss relating to work absence and the incorporation of generic (ie, non-back pain) healthcare utilisation.ResultsThe stratified management approach was a cost-effective treatment strategy compared with current best practice within each risk-defined subgroup, exhibiting dominance (greater benefit and lower costs) for medium-risk patients and acceptable incremental cost to utility ratios for low-risk and high-risk patients. The likelihood that stratified care provides a cost-effective use of resources exceeds 90% at willingness-to-pay thresholds of £4000 (≈ 4500; $6500) per additional QALY for the medium-risk and high-risk groups. Patients receiving stratified care also reported fewer back pain-related days off work in all three subgroups.ConclusionsCompared with current best practice, stratified primary care management for low back pain provides a highly cost-effective use of resources across all risk-defined subgroups.

scholarly journals Short-term and long-term cost-effectiveness of a pedometer-based exercise intervention in primary care: a within-trial analysis and beyond-trial modelling

BMJ Open ◽  
2018 ◽  
Vol 8 (10) ◽  
pp. e021978 ◽  
Author(s):  
Nana Anokye ◽  
Julia Fox-Rushby ◽  
Sabina Sanghera ◽  
Derek G Cook ◽  
Elizabeth Limb ◽  
...  
Keyword(s):  
Primary Care ◽  
Cost Effectiveness ◽  
Health Service ◽  
Incremental Cost ◽  
Service Use ◽  
Cost Effective ◽  
Health Service Use ◽  
Secondary Outcome ◽  
Short Term

ObjectivesA short-term and long-term cost-effectiveness analysis (CEA) of two pedometer-based walking interventions compared with usual care.Design(A) Short-term CEA: parallel three-arm cluster randomised trial randomised by household. (B) Long-term CEA: Markov decision model.SettingSeven primary care practices in South London, UK.Participants(A) Short-term CEA: 1023 people (922 households) aged 45–75 years without physical activity (PA) contraindications. (b) Long-term CEA: a cohort of 100 000 people aged 59–88 years.InterventionsPedometers, 12-week walking programmes and PA diaries delivered by post or through three PA consultations with practice nurses.Primary and secondary outcome measuresAccelerometer-measured change (baseline to 12 months) in average daily step count and time in 10 min bouts of moderate to vigorous PA (MVPA), and EQ-5D-5L quality-adjusted life-years (QALY).MethodsResource use costs (£2013/2014) from a National Health Service perspective, presented as incremental cost-effectiveness ratios for each outcome over a 1-year and lifetime horizon, with cost-effectiveness acceptability curves and willingness to pay per QALY. Deterministic and probabilistic sensitivity analyses evaluate uncertainty.Results(A) Short-term CEA: At 12 months, incremental cost was £3.61 (£109)/min in ≥10 min MVPA bouts for nurse support compared with control (postal group). At £20 000/QALY, the postal group had a 50% chance of being cost saving compared with control. (B) Long-term CEA: The postal group had more QALYs (+759 QALYs, 95% CI 400 to 1247) and lower costs (−£11 million, 95% CI −12 to −10) than control and nurse groups, resulting in an incremental net monetary benefit of £26 million per 100 000 population. Results were sensitive to reporting serious adverse events, excluding health service use, and including all participant costs.ConclusionsPostal delivery of a pedometer intervention in primary care is cost-effective long term and has a 50% chance of being cost-effective, through resource savings, within 1 year. Further research should ascertain maintenance of the higher levels of PA, and its impact on quality of life and health service use.Trial registration numberISRCTN98538934; Pre-results.

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