Lopez Bernal James A, Lu Christine Y, Gasparrini Antonio, Cummins Steven, Wharam J Frank, Soumerai Steven B
Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts, United States of America.
PLoS Med. 2017 Nov 14;14(11):e1002427. doi: 10.1371/journal.pmed.1002427. eCollection 2017 Nov.
The 2012 Health and Social Care Act (HSCA) in England led to among the largest healthcare reforms in the history of the National Health Service (NHS). It gave control of £67 billion of the NHS budget for secondary care to general practitioner (GP) led Clinical Commissioning Groups (CCGs). An expected outcome was that patient care would shift away from expensive hospital and specialist settings, towards less expensive community-based models. However, there is little evidence for the effectiveness of this approach. In this study, we aimed to assess the association between the NHS reforms and hospital admissions and outpatient specialist visits.
We conducted a controlled interrupted time series analysis to examine rates of outpatient specialist visits and inpatient hospitalisations before and after the implementation of the HSCA. We used national routine hospital administrative data (Hospital Episode Statistics) on all NHS outpatient specialist visits and inpatient hospital admissions in England between 2007 and 2015 (with a mean of 26.8 million new outpatient visits and 14.9 million inpatient admissions per year). As a control series, we used equivalent data on hospital attendances in Scotland. Primary outcomes were: total, elective, and emergency hospitalisations, and total and GP-referred specialist visits. Both countries had stable trends in all outcomes at baseline. In England, after the policy, there was a 1.1% (95% CI 0.7%-1.5%; p < 0.001) increase in total specialist visits per quarter and a 1.6% increase in GP-referred specialist visits (95% CI 1.2%-2.0%; p < 0.001) per quarter, equivalent to 12.7% (647,000 over the 5,105,000 expected) and 19.1% (507,000 over the 2,658,000 expected) more visits per quarter by the end of 2015, respectively. In Scotland, there was no change in specialist visits. Neither country experienced a change in trends in hospitalisations: change in slope for total, elective, and emergency hospitalisations were -0.2% (95% CI -0.6%-0.2%; p = 0.257), -0.2% (95% CI -0.6%-0.1%; p = 0.235), and 0.0% (95% CI -0.5%-0.4%; p = 0.866) per quarter in England. We are unable to exclude confounding due to other events occurring around the time of the policy. However, we limited the likelihood of such confounding by including relevant control series, in which no changes were seen.
Our findings suggest that giving control of healthcare budgets to GP-led CCGs was not associated with a reduction in overall hospitalisations and was associated with an increase in specialist visits.
2012年英国《健康与社会照护法案》（HSCA）引发了国民医疗服务体系（NHS）历史上规模最大的医疗改革之一。该法案将670亿英镑的NHS二级医疗预算控制权交给了由全科医生（GP）主导的临床委托小组（CCG）。预期结果是患者护理将从昂贵的医院和专科环境转向成本较低的社区模式。然而，几乎没有证据表明这种方法的有效性。在本研究中，我们旨在评估NHS改革与住院和门诊专科就诊之间的关联。
我们进行了一项对照中断时间序列分析，以检查HSCA实施前后的门诊专科就诊率和住院率。我们使用了2007年至2015年期间英格兰所有NHS门诊专科就诊和住院的国家常规医院管理数据（医院事件统计）（平均每年有2680万次新的门诊就诊和1490万次住院）。作为对照序列，我们使用了苏格兰医院就诊的等效数据。主要结果包括：总住院、择期住院和急诊住院，以及总专科就诊和全科医生转诊的专科就诊。两国在基线时所有结果的趋势都很稳定。在英格兰，政策实施后，每季度总专科就诊增加了1.1%（95%置信区间0.7%-1.5%；p<0.001），全科医生转诊的专科就诊每季度增加了1.6%（95%置信区间1.2%-2.0%；p<0.001），到2015年底，分别相当于每季度多就诊12.7%（在预期的510.5万次基础上增加64.7万次）和19.1%（在预期的265.8万次基础上增加50.7万次）。在苏格兰，专科就诊没有变化。两国的住院趋势都没有变化：英格兰总住院、择期住院和急诊住院的斜率变化分别为每季度-0.2%（95%置信区间-0.6%-0.2%；p=0.257）、-0.2%（95%置信区间-0.6%-0.1%；p=0.235）和0.0%（95%置信区间-0.5%-0.4%；p=0.866）。我们无法排除政策实施前后其他事件造成的混杂因素。然而，我们通过纳入相关对照序列来限制这种混杂的可能性，在对照序列中没有观察到变化。
我们的研究结果表明，将医疗预算控制权交给由全科医生主导的CCG与总体住院率的降低无关，且与专科就诊的增加有关。
Zotero 插件