Impact of financial incentives on the implementation of asthma self-management in primary care in Northern Ireland: a mixed methods programme of work

Abstract

INTRODUCTION: Asthma is a common chronic respiratory condition which is responsible for substantial morbidity and economic impact. Supported self-management including asthma action plans improves asthma control, minimises exacerbations and reduces the use of emergency healthcare resources. Despite this evidence an Asthma UK survey (2013) identified that less than a quarter of people with asthma owned an action plan. The exception is Northern Ireland, where a Local Enhanced Service (LES) introduced in 2008 has provided financial incentives to primary care practices for providing asthma action plans; ownership was reported by 63% of individuals with asthma surveyed.

AIMS AND OBJECTIVES: The aim of this PhD was to 1) systematically review the evidence investigating the impact of financial incentives on implementation outcomes, health outcomes and individual behaviour outcomes for individuals with asthma or diabetes 2) observe trends in implementation and health outcomes associated with the introduction of the LES and 3) explore the process by which organisational change was implemented in primary care in Northern Ireland from the perspective of primary care staff.

METHODS: The programme of work proceeded in three phases: 1. Following Cochrane methodology, I systematically reviewed the evidence investigating the impact of financial incentives on provision of supported self-management in asthma and diabetes (another long-term condition with a robust evidence base) on implementation outcomes (action plan ownership); health outcomes (asthma control/attacks) and individual behaviour outcomes (self-efficacy). I used a Population, Intervention, Comparison, Outcome and Setting (PICOS) search strategy and duplicate screening, data extraction and Downs’ and Black’s (1998) quality assessment. Studies were weighted by robustness of design, number of participants and the quality score. Narrative synthesis was conducted due to heterogeneity of studies.

2. I explored the context of Northern Ireland and its healthcare system using routine data to observe trends in: asthma-related hospitalisations; asthma-related deaths and asthma action plan provision across Northern Ireland over a five-year period.

3. In the qualitative phase, I conducted telephone interviews with a representative involved with delivering the LES in up to 20 primary care practices and undertook four case studies involving in-depth interviews with clinical and administrative staff members and document analysis. The Adams et al (2014) financial incentives framework underpinned the topic guide; interviews were recorded, transcribed verbatim and analysed using two approaches:

a. Grounded Theory approach to explore primary care staff perceptions of the LES and self-management for asthma.

b. Framework approach informed by the Normalization Process Theory (NPT) (May et al., 2009).

RESULTS: 1. I included 12 studies (from 2,541 initial hits) in the systematic review. Results were mixed. Delivery of care improved in three diabetes studies; was unchanged in six and deteriorated in one. There were fewer hospitalisations/emergency department visits in one diabetes study. In the one asthma study, the proportion of patients receiving an action plan increased from 4% to 88%, but health outcomes were not measured. Authors highlighted the importance of context when implementing a financial incentive scheme.

2. Routine LES data were available from 2011; deaths since 2008. Asthma action plan provision has remained high in Northern Ireland since 2011/2012 with primary care reporting 76% of eligible patients having been provided an asthma action plan. Asthma related hospital admissions have increased between 2011/12 and 2015/16 by over 300 admissions/year. There were 31 deaths in 2008 and this has fluctuated over the years with no clear trend.

3. Fifteen semi-structured telephone interviews, six individual in-depth interviews and two group interviews were conducted with 23 participants (five general practitioners; five nurses; 13 administrative staff) from 15 primary care practices. Four of the participants in the scoping semi-structured interviews also took part in either an individual in-depth interview or a group interview. Themes were agreed in discussion with a multi-disciplinary group which included contributions from the primary care, secondary care and patient perspective.

a. Themes clustered around targeting poor asthma control; communicating with patients; strategies for achieving targets; financial incentives. All participants highlighted the difficulty of getting patients with asthma to attend appointments, with some expressing feelings of frustration at lack of patient involvement and uncertainty of how to improve patient engagement, particularly in patients with poorly controlled asthma.

b. Processes created since the introduction of the LES appear successfully embedded into primary care practice routines.

Working together in multi-disciplinary teams was frequently discussed by participants in relation to the scheme, from inception to implementation and delivery in primary care practices. Significant support from the Public Health Agency and pharmaceutical companies in providing funding and training for nurses was acknowledged as a key to the successful embedding of new processes for asthma self-management, but there was concern regarding reduction in funding from both of these sources and the impact on the future provision of asthma self-management education in primary care.

Asthma care was identified as a nurse-led process. Participants were generally positive about receiving financial incentives for the extra work undertaken, however the payments were viewed as necessary in able to complete the additional work required by the financial incentive scheme. Providing the best quality of care for patients, however, was the frequently cited as the main motivator for clinical staff.

CONCLUSIONS: Financial incentive schemes have inconsistent impact on implementation and health outcomes; context is likely to be an important factor in determining success. In Northern Ireland, three quarters of people with asthma have been provided with an action plan over the last five years of the LES; alongside a possible trend to an increase in asthma-related hospital admissions and deaths. The financial incentives of the LES were received positively by primary care staff; however patient health was the highest priority when delivering care. Primary care staff identified multi-disciplinary teamwork throughout the lifespan of the LES as key to its “normalization”, which was now so embedded that concerns were expressed regarding threats to funding and withdrawal of external support. Understanding how practices reacted to the LES and normalized this healthcare scheme could inform further policy on similar initiatives.