̽��ֱ�� of Cambridge - Stefan Scholtes

Having a ‘regular doctor’ can significantly reduce GP workload, study finds

sc604 — Fri, 23 Feb 2024 01:11:40 +0000

In one of the largest studies of its kind, researchers from the ̽��ֱ�� of Cambridge and INSEAD analysed data from more than 10 million consultations in 381 English primary care practices over a period of 11 years.

̽��ֱ��results, reported in the journal Management Science, suggest that a long-term relationship between a patient and their doctor could both improve patient health and reduce workload for GPs.

̽��ֱ��researchers found that when patients were able to see their regular doctor for a consultation – a model known as continuity of care – they waited on average 18% longer between visits, compared to patients who saw a different doctor. ̽��ֱ��productivity benefit of continuity of care was larger for older patients, those with multiple chronic conditions, and individuals with mental health conditions.

Although it will not always be possible for a patient to see their regular GP, this productivity differential would translate to an estimated 5% reduction in consultations if all practices in England were providing the level of care continuity of the best 10% of practices.

Primary care in the UK is under enormous strain: patients struggle to get appointments, GPs are retiring early, and financial pressures are causing some practices to close. According to the Health Foundation and the Nuffield Trust, there is a significant shortfall of GPs in England, with a projected 15% increase required in the workforce. ̽��ֱ��problem is not limited to UK, however: the Association of American Medical Colleges estimates a shortfall of between 21,400 and 55,200 primary care physicians in the US by 2033.

“Productivity is a huge problem across all the whole of the UK – we wanted to see how that’s been playing out in GP practices,” said Dr Harshita Kajaria-Montag, the study’s lead author, who is now based at the Kelley School of Business at Indiana ̽��ֱ��. “Does the rapid access model make GPs more productive?”

“You can measure the productivity of GP surgeries in two ways: how many patients can you see in a day, or how much health can you provide in a day for those patients,” said co-author Professor Stefan Scholtes from Cambridge Judge Business School. “Some GP surgeries are industrialised in their approach: each patient will get seven or ten minutes before the GP has to move on to the next one.”

At English GP practices, roughly half of all appointments are with a patient’s regular doctor, but this number has been steadily declining over the past decade as GP practices come under increasing strain.

̽��ֱ��researchers used an anonymised dataset from the UK Clinical Practice Research Datalink, consisting of more than 10 million GP visits between 1 January 2007 and 31 December 2017. Using statistical models to account for confounding and selection bias, and restricting the sample to consultations with patients who had at least three consultations over the past two years, the researchers found that the time to a patient’s next visit is substantially longer when the patient sees the doctor they have seen most frequently over the past two years, while there is no operationally meaningful difference in consultation duration.

“ ̽��ֱ��impact is substantial: it could be the equivalent of increasing the GP workforce by five percent, which would significantly benefit both patients and the NHS,” said Scholtes. “Better health translates into less demand for future consultations. Prioritising continuity of care is crucial in enhancing productivity.”

“ ̽��ֱ��benefits of continuity of care are obvious from a relationship point of view,” said Kajaria-Montag. “If you’re a patient with complex health needs, you don’t want to have to explain your whole health history at every appointment. If you have a regular doctor who’s familiar with your history, it’s a far more efficient use of time, for doctor and patient.”

“A regular doctor may have a larger incentive to take more time to treat her regular patients thoroughly than a transactional provider,” said Scholtes. “Getting it right the first time will reduce her future workload by preventing revisits, which would likely be her responsibility, while a transactional provider is less likely to see the patient for her next visit.”

̽��ֱ��researchers emphasise that continuity of care does not only have the known benefits of better patient outcomes, better patient and GP experience, and reduced secondary care use, but also provides a surprisingly large productivity benefit for the GP practices themselves.

Reference:
Harshita Kajaria-Montag, Michael Freeman, Stefan Scholtes. ‘Continuity of Care Increases Physician Productivity in Primary Care.’ Management Science (2024). DOI: 10.1287/mnsc.2021.02015

If all GP practices moved to a model where patients saw the same doctor at each visit, it could significantly reduce doctor workload while improving patient health, a study suggests.

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Doctor examining a patient

̽��ֱ��text in this work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Images, including our videos, are Copyright © ̽��ֱ�� of Cambridge and licensors/contributors as identified. All rights reserved. We make our image and video content available in a number of ways – on our main website under its Terms and conditions, and on a range of channels including social media that permit your use and sharing of our content under their respective Terms.

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How new model boosts supply and lowers prices for generic drugs

Anonymous — Thu, 21 Sep 2023 15:31:28 +0000

Civica Rx, a not-for-profit drug manufacturer founded by seven US health systems and three philanthropic organisations, increased supply security and lowered cost on aggregate for 20 drug products, according to the first empirical evidence of Civica’s impact published in the journal NEJM Catalyst.

“Results show that Civica was able to improve generic drug access above the wholesaler model,” says the article in NEJM Catalyst, a publication that is part of the New England Journal of Medicine family. “Chronic drug shortages have been an extremely challenging problem and elusive to sustainable improvement in the past. This makes these early results highly promising.”

̽��ֱ��NEJM Catalyst article (entitled “Vaccinating Health Care Supply Chains Against Market Failure: ̽��ֱ��Case of Civica Rx”) – is co-authored by the co-founders of the Healthcare Utility Initiative at Cambridge Judge Business School: Carter Dredge, Senior Vice President and Lead Futurist at SSM Health in St. Louis, Missouri (one of Civica’s founding health systems), who is a Business Doctorate candidate at Cambridge Judge, and by Stefan Scholtes, Dennis Gillings Professor of Health Management at Cambridge Judge.

Key breakthrough is structural rather than technological

“ ̽��ֱ��results of this study are very encouraging for patients and health systems,” says Carter Dredge. “ ̽��ֱ��innovation of Civica is not technological but rather structural: a new business model that injects a new type of supplier into a decades-old market for generic drugs in order to address a market failure.”

Civica is based on new business model called a health care utility (HCU) that prioritises access over profit. It was founded in 2018 to address generic drug shortages and high prices that have plagued health systems in the US and elsewhere, and now provides more than 75 critical medications at risk for shortages to US health systems.

Government intervention hasn’t solved problems in cost and supply

“Some problems in health care are so complex that traditional private-sector or governmental interventions alone have not been able to solve the problems,” the study says. “Although competition increases quality and reduces the cost of goods and services across a wide spectrum of industries, health care seems intractably resistant to standard forms of competition — particularly in its hyperspecialized supply chains.”

For example, the study says that the average price in 2022 for the uninsured for a box of five pen cartridges of insulin used to manage diabetes was more than $500, which results in 25% of Americans who rely on insulin being forced to ration their medications because of cost.

Study favourably compared Civica to 62 drug wholesalers

̽��ֱ��study focused on a cohort of 14 critical and shortage-prone hospital drugs that represented 20 distinct products (some medicines have multiple products due to different dose and vial size) between 2020 and 2022. Data comes from internal hospital pharmacy operations systems, supply chain purchasing databases, wholesaler product information, the American Society of Health System Pharmacists, and Civica.

̽��ֱ��authors estimated that Civica fulfilled its contractually guaranteed volume at 96%, whereas the wholesalers fulfilled their orders at 86%, with the difference being statistically significant (p=0.03). Further, Civica offered an additional product access benefit of 43% above the contractual minimum volume.

In addition, wholesaler prices at the order level were estimated to be on average 46% above the Civica price for the same product in the same year; however, through highly proactive health system purchasing efforts to buy more volume when prices were low from the 62 non-Civica manufacturers, this closed the actual achieved cost-savings gap between the wholesalers and Civica to 2.7% in aggregate, with Civica still being the lower-cost option.

( ̽��ֱ��14 medicines are: bivalirudin to prevent blood clotting, the antibiotic daptomycin, anti-inflammatory dexamethasone, narcotic pain medicine fentanyl, pre-surgery medicine katamine, labetalol for hypertension, local anesthetic lidocaine, seizure medication lorazepam, naloxone to treat opioid overdose, neostigmine for anesthesia reversal, ondansetron to prevent nausea, rocuronium bromide for general anesthesia, sodium bicarbonate for cardiac arrest, and the antibiotic vancomycin.)

New model sells drugs at same transparent price to all health systems

̽��ֱ��healthcare utility model is governed by stewards rather than owned, and pricing is uniform for all customers in a bid to maximise access rather than profits. Civica members purchase Civica medications at the same transparent price, as determined by the lowest appropriate cost necessary to sustainably provide the drugs over a 5-year period.

̽��ֱ��seven large US health systems that founded Civica are: Catholic Health Initiatives, now CommonSpirit Health; HCA Healthcare; Intermountain Healthcare; Mayo Clinic; Providence St. Joseph Health; SSM Health; and Trinity Health. ̽��ֱ��three founding philanthropies are the Gary and Mary West Foundation, the Laura and John Arnold Foundation, and the Peterson Center on Healthcare.

Civica now serves more than 50 US health systems

̽��ֱ��seven founding health systems have since been joined by more than 50 other health systems covering more than 1,500 hospitals and about 225,000 hospital beds. Through July 2023, more than 56 million cumulative patient doses of Civica medicines have been administered.

In conclusion, the authors say:

“ ̽��ֱ��problems we face in health care are daunting, but many of them are solvable with the right approach. In learning from Civica’s experience, some of the most fundamental answers may already be at our fingertips.

“This article provides the first empirical evidence that this approach is working.”

First empirical evidence for Civica Rx, a health care utility, finds increased supply security and reduced costs for health systems, says study in NEJM Catalyst authored by two Cambridge Judge Business School academics.

Eggy Sayoga via Getty Images

Pills and a capsule on pastel pink colored background. 3D rendered image.

̽��ֱ��text in this work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Images, including our videos, are Copyright © ̽��ֱ�� of Cambridge and licensors/contributors as identified. All rights reserved. We make our image and video content available in a number of ways – as here, on our main website under its Terms and conditions, and on a range of channels including social media that permit your use and sharing of our content under their respective Terms.

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Admitting practices of junior doctors may be behind ‘weekend effect’ in hospitals, study suggests

Anonymous — Wed, 06 Nov 2019 05:00:00 +0000

̽��ֱ��'weekend effect' of increased hospital mortality has been well documented, including a 2015 study linking this to 11,000 extra UK deaths annually, which led to controversial contract changes for junior doctors as the UK government sought a 'seven-day' National Health Service.

But the underlying causes have been poorly understood: are hospitals really less safe on weekends or do other factors lead to a comparison-skewing weekday reduction of the risk of mortality?

A new study led by ̽��ֱ�� of Cambridge researchers, based on nearly 425,000 emergency department attendances over seven years at Addenbrooke’s Hospital in Cambridge, confirms the weekend effect. This appears to be because junior doctors are more likely to admit patients with lower mortality risk during the week. ̽��ֱ��results are reported in the Emergency Medicine Journal.

̽��ֱ��research found that junior doctors (qualified doctors still in training) based in the emergency department admitted less-sick patients at half the rate at weekends compared to weekdays, diluting the risk pool of weekday mortality and contributing to the weekend effect.

In contrast, the admitting patterns of senior doctors was the same on weekends and weekdays, and the data did not provide evidence of a weekend effect among patients admitted by senior doctors.

̽��ֱ��researchers found that the weekend effect was associated with seniority of the physician working in the emergency department, that the case-mix of patients at the weekend was of a higher acuity and that junior doctors admitted fewer standard patients at the weekend than on weekdays.

“There has been previous research on how physician-level factors influence patient care, but our study instead focuses specifically on how seniority affects admitting patterns and in turn how this relates to the weekend effect,” said co-author Stefan Scholtes, Dennis Gillings Professor of Health Management at Cambridge Judge Business School. “It’s clear that the admitting patterns of junior doctors changes at the weekend.”

In a commentary about the new study, also published in Emergency Medicine Journal, the President of the Royal College of Emergency Medicine, Dr Katherine Henderson, said the study had “given us a lot to think about” – describing as “surprising” the finding that junior doctors admitted more relatively well patients on weekdays.

“ ̽��ֱ��NHS needs to use its resources as effectively as possible,” she wrote. “We should only admit patients who need to be admitted. This paper suggests it would be a good idea to make sure we are using our senior decision makers where they can be most valuable – seeing sick patients and actively evaluating all borderline admission/discharge decisions.”

̽��ֱ��study is co-authored by Larry Han of Cambridge Judge Business School and Harvard ̽��ֱ��’s Department of Biostatistics; Jason Fine of the ̽��ֱ�� of North Carolina; Susan M. Robinson and Adrian A. Boyle of the Emergency Department at Cambridge ̽��ֱ�� Hospitals NHS Foundation Trust; Michael Freeman of Cambridge Judge Business School and INSEAD Singapore; and Stefan Scholtes of Cambridge Judge Business School.

Reference:
Larry Han et al. 'Is seniority of emergency physician associated with the weekend mortality effect? An exploratory analysis of electronic health records in the UK.' Emergency Medicine Journal (2019). DOI: 10.1136/emermed-2018-208114

Study links the ‘weekend effect’ of increased hospital mortality to junior doctors admitting a lower proportion of healthy patients at the weekend compared to weekdays.

It’s clear that the admitting behaviour of junior doctors changes at the weekend

Stefan Scholtes

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Physician, heal thyself: engineering a new National Health Service

Anonymous — Tue, 19 Mar 2019 11:00:00 +0000

Alongside the Chinese People’s Liberation Army, Indian Railways and Walmart, the NHS ranks among the world’s largest employers. In England, it treats more than 1.4 million patients every 24 hours and will this year spend £126 billion. But as communities gathered to celebrate the NHS’s 70th birthday in 2018, reports continued to emerge on the ailing health of this much-loved national institution.

Analysis by another national treasure, the BBC, revealed that nearly one in five hospital trusts were failing to hit any of their key waiting-time targets. Hospitals seemed to be lurching towards over-crowded A&Es, bed shortages and queuing ambulances unable to hand over their patients.

Two ̽��ֱ�� of Cambridge researchers have a grand vision to rethink the system to make it fit for the next 70 years – a vision that’s rooted in research with local patients and doctors.

Professor Stefan Scholtes works at Cambridge Judge Business School and Dr Alexander Komashie is at the ̽��ֱ��’s Engineering Design Centre. Both are engineers by training, both have spent the past 10 years studying different parts of the local healthcare system and both are passionate believers that, as researchers, they can help make the NHS better.

System design

̽��ֱ��NHS faces numerous challenges but the real test, says Komashie, is understanding how to design better delivery systems by working with patients. “That’s where engineering comes in,” he says. “Engineers excel in designing large systems that work well, from worldwide telecommunications networks to the Airbus A380. What motivates me is translating the engineering practice of a systems approach into healthcare.”

̽��ֱ��first step is understanding the system requirements. “It sounds obvious, but to design a system to do something you need to understand what it is you want,” Komashie explains. “In engineering, a lot of effort goes into defining what the system should do. When you understand that, you can ask how the system is set up to deliver it.”

Komashie has applied this systems engineering approach to adult mental health services within the Cambridgeshire and Peterborough NHS Foundation Trust (CPFT), and ran a series of workshops for patients and clinicians. Patients’ stories allow him to unpack each component of the delivery system and represent them in visual diagrams so that services can be improved in a systematic way. ̽��ֱ��project was funded and supported by the National Institute for Health Research (NIHR) East of England Collaboration for Leadership in Applied Health Research and Care (CLAHRC), hosted by CPFT.

“My goal is developing a new way of describing the system, and hearing people talk about their experience of care helps me understand it. If through patient and public involvement, we can get rich enough stories, it gives us a window into the system behind the story,” says Komashie, who has recently been awarded an interdisciplinary fellowship for research into health systems visualisation at ̽��ֱ��Healthcare Improvement Studies Institute (THIS Institute). “Hearing patients’ accounts of what matters most helps to ensure the system designs and delivers the support they need.”

Sarah Rae, CPFT Expert by Experience, worked closely with Komashie in bridging the gap between the academic researcher and the patient participants. “As workshop co-facilitator I gave the participants a better understanding of the research by helping them to make the connection between systems engineering and mental health,” she says. “Sharing my own lived experience of mental health also helped the participants feel more comfortable about describing their experiences authentically.”

Komashie is now taking the tools he developed in mental health and applying them to vascular surgery and spinal cord injuries at Addenbrooke’s Hospital in Cambridge and holistic neuropsychological rehabilitation at ̽��ֱ��Princess of Wales Hospital’s Oliver Zangwill Centre in Ely.

Working with GP practices

Headlines about NHS waiting times, bed shortages and ambulance queues invariably focus on capacity, which Scholtes argues is a misdiagnosis. “People say we’ve got a capacity problem but that’s wrong. We have a complexity problem. There are so many things going on simultaneously but pulling in different directions. Complexity is killing hospitals.”

At Addenbrooke’s, for example, where Scholtes spent three sabbaticals over the past 10 years, the hospital does everything from pulling wisdom teeth to multiple organ transplants. He argues that delivering this breadth of services in a system already at full stretch is impossible. Instead, hospitals need to be “decomplexified” by delivering most of their routine services in community settings.

It sounds simple, but it’s not. “ ̽��ֱ��problem is that there’s no landing space. We have 92 GP practices locally, so how can you move work currently centralised in a large hospital to 92 small businesses? It’s impossible. ̽��ֱ��only way to make headway is to scale up primary care so that it can take on more responsibility,” says Scholtes.

This is exactly what he’s doing with Granta Medical Practices, a large Cambridgeshire GP practice where he spent his most recent sabbatical evaluating the practice’s innovative operational and business model.

A critical barrier to change in primary care is the traditional GP partnership model, he says. By leaving GP partners with unlimited liability, the model creates risk aversion and hampers transformative change. In response, Granta is developing an innovative business model – an employee-owned trust akin to the John Lewis Partnership – which could enable it to deliver 70% of routine outpatient activity in the community and cut by 25% the number of emergency bed days among its patients.

Dr James Morrow, CEO of Granta Medical Practices, describes how Granta Medical Practices has gained enormously from working closely with Sholtes and his colleagues at the Cambridge Judge Business School: “Several of our senior clinicians have participated in formal educational programmes through the Judge and have brought back insights and skills from other sectors. Stefan’s sabbatical with the practice has refined and clarified our thinking around not just service delivery and user-experience but also helped with developing our longer term strategic goals as we embark on a period of rapid health system reform.”

But how can transforming Granta help the NHS as a whole? This is where the ̽��ֱ�� comes in, says Scholtes, who hopes to establish a Primary Care Innovation Academy, drawing on research expertise from across the ̽��ֱ��.

̽��ֱ��Academy would provide leadership and management training for GPs, practice managers and lead nurses, and also ensure that interventions taken to transform the local primary care system are robustly evaluated. As such, it would add to the ̽��ֱ��’s increasing capacity in creating the evidence base for improving healthcare. For instance, THIS Institute is focusing on how to improve quality and safety across the system.

A “radically different” NHS

Addenbrooke’s Hospital itself has been transformed over the past three decades with a major emphasis on recruiting clinical academics in partnership with the ̽��ֱ��, who split their time between practising medicine and carrying out research.

Professor Patrick Maxwell, Head of the School of Clinical Medicine, explains: “Clinical academics have been central to the development of tertiary referral services and a major trauma centre. This has helped to create an excellent district and regional hospital with outcomes that are among the best in the country. Currently our priorities include improving prevention and early diagnosis of diseases, so that fewer patients need hospital services.”

Meanwhile, in January 2019, the NHS released its new 10-year plan, which included aims to boost ‘out-of-hospital’ care through increased investment in primary medical and community health services.

All in all, Scholtes believes that, by the time the NHS reaches its 80th birthday, it could look radically different: hospitals could be doing 60% of what they do now by focusing on cases that can only be treated in hospital and on cutting-edge treatments and research, while more integrated, scaled-up primary care practices will be taking full responsibility for out-of-hospital care.

“If this work is successful, it has the potential to bring the local health economy back onto a sustainable path by establishing a new model of primary care that can be scaled throughout the NHS,” he concludes. “It’s ambitious – but we can do it.”

̽��ֱ��National Health Service turned 70 in 2018 – but, amid the celebrations, its health is faltering. By working closely with local hospitals and GPs, researchers at Cambridge ̽��ֱ�� are developing bold new ideas they believe will help the NHS thrive for decades to come.

If this work is successful, it has the potential to bring the local health economy back onto a sustainable path by establishing a new model of primary care that can be scaled throughout the NHS

Stefan Scholtes

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