Impact of financial incentives on alcohol screening and brief intervention (ASBI) delivery in English primary care

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1 Impact of financial incentives on alcohol screening and brief intervention (ASBI) delivery in English primary care Dr Amy O Donnell & Professor Eileen Kaner Institute of Health and Society Newcastle University, UK amy.odonnell@newcastle.ac.uk

Dr Amy O Donnell & Professor Eileen Kaner Institute of

2 Introduction > Background to the research > Key findings from: Analysis of primary care data on ASBI delivery between Mixed methods doctoral research exploring the value of using routine GP data to assess ASBI implementation > Conclusions and policy implications No conflict of interest; UK Economic and Social Research Council & Newcastle University IMPACT Accelerator Grant

routine GP data to assess ASBI implementation > Conclusions and policy implications No conflict

3 Encouraging alcohol screening and brief intervention (ASBI) implementation in England > Despite robust evidence of effectiveness, delivery of ASBI remains sporadic > Recent policy interventions: 2008 Financial incentives: (national) Directed Enhanced Service; Local Enhanced Service 2010 NICE guidelines 2012 Government Alcohol Strategy 2014 NHS Health Checks for 40+

interventions: 2008 Financial incentives: (national) Directed Enhanced Service; Local

4 Measuring impact of incentives in primary care > Routine health data provide a comprehensive, costeffective and unobtrusive evaluative tool > GP Read Code records = standardised source of primary care data in the UK > Financial incentives require primary care providers to Read Code when an eligible patient: Screened for risky drinking (AUDIT C/FAST) Receives a brief intervention or advice for alcohol Aim: To use routine Read Code data to measure the impact of financial incentives on ASBI delivery in English primary care

care providers to Read Code when an eligible patient: Screened for risky drinking (AUDIT C/FAST) Receives a brief intervention or

5 Study 1: Trends in ASBI delivery in English primary care between > Descriptive statistics based on THIN (The Health Improvement Network) data > Numbers of eligible patients* recorded as: a) Screened for risky drinking b) Receiving any form of brief alcohol advice or intervention * Patients 16+ registered between 1/4/ /3/2014

of eligible patients* recorded as: a) Screened for risky drinking b) Receiving any

6 Brief alcohol screening test administration Fig 1: No. patients screened with FAST or AUDIT C during

7 Delivery of brief alcohol advice/intervention Fig 1: No. patients given brief alcohol advice or intervention during

8 Study 2: Mixed methods investigation of impact of financial incentives on ASBI delivery > Phase 1: Comparison of incentivised v nonincentivised ASBI rates: 16 practices in Northern England Extracted practice level Read Code on ASBI delivery Compared rates using Cochrane s Q test for heterogeneity ID No Incentives National incentives only National & local incentives No. patients No. GPs P P P P P P P P P P P P P P P P TOTALS

National & local incentives No. patients No.

9 Patients screened by incentive status: > 0.05% (95% CI: ) in non incentivized practices > 3.56% (95% CI: ) in national + locally incentivized practices > 3.92% (95% CI: ) in national scheme only practices > Q= , d.f. = 2 (p<0.001).

74) in national + locally incentivized practices > 3.92% (95% CI: 3.

10 Patients receiving brief alcohol interventions by incentive status: > 4.73% (95% CI: ) in nonincentivized practices > 8.32% (95% CI: ) in national & locally incentivized practices > 9.23% (95% CI: ) in national scheme only practices > Q= , d.f. = 2 (p<0.001)

32% (95% CI: 8.06 8.58) in national & locally incentivized practices > 9.

11 Study 2: Mixed methods investigation of impact of financial incentives on ASBI delivery > Phase 2: semi structured interviews with GPs: 14 participants based in Northern England Varied gender, years in experience, practice size, incentive status Interviews explored experiences of delivering and recording ASBI in routine practice N (14) Gender Male 7 Female 7 Experience >5 years years 3 >15 years 7 Employment Partner 7 Salaried GP 6 Registrar 1 Location Area A 7 Area B 7 Incentive status No incentives 3 National incentives only 4 National & local incentives 7

delivering and recording ASBI in routine practice N (14) Gender Male 7 Female 7 Experience >5 years 4 5 15 years 3 >15 years 7 Employment

12 Theme 1: The limited functionality of the Read Code system > Challenge of navigating through the Read code system; > General aversion to coding templates; > Simple, quantifiable = more code able; > Lack of coding applicability to common complex general practice situations. Doctors, by their very nature, do not like templates You know, it s just a cultural thing. We feel hemmed in, I think. GP8, male, DES + LES

coding applicability to common complex general practice situations.

13 Theme 2: Impact of financial incentives on GPs coding priorities > Financial incentives drive coding BUT not all incentive schemes are created equal; > GPs prioritised recording of screening over other components of ASBI due to Enhanced Service requirements. as long as I know somebody s drinking 50 units and I know that I ve talked them through it and I know that they re coming back to see me about it, whether I ve coded it on the system or not, so what? The intervention s been done. GP5, female, DES

14 Limitations > Employed limited set of Read Codes to assess ASBI delivery rates > Relied on GP narratives on ASBI delivery and recording > Broader issues around use of routine data for research: Many coders + varied coding systems = heterogeneous coding practices Routine data as proxy measure of delivery? Distorting impact of incentivising routine data recording

for research: Many coders + varied coding systems = heterogeneous coding practices Routine

15 Summary and conclusions > National trend and practice level data suggest that financial incentives have increased ASBI delivery in English primary care; but activity rates remain low > Range of factors shape GPs delivery and recording of ASBI, including the design of the incentive and Read Code systems > Implications for policy and practice: Need to rationalize the UK Read Code system Need to incentivize preventative medicine

delivery and recording of ASBI, including the design of the incentive and Read Code systems > Implications

16 Thank you Dr Amy O Donnell amy.odonnell@newcastle.ac.uk Acknowledgements

Effectiveness of Brief Alcohol Intervention strategies. Eileen Kaner

Effectiveness of Brief Alcohol Intervention strategies Eileen Kaner Professor of Public Health and Primary Care Research eileen.kaner@newcastle.ac.uk Introduction Scope of alcohol harm Preventive paradox