HMS: Identifying and Measuring Spillover Effects of Changes to Healthcare Organisation and Delivery

医疗保健服务组织和提供方式的变化，不仅对患者或所针对的服务有更广泛的影响。这种范围更广的变化被称为溢出效应。它们可能有积极的影响，因为受益的患者比最初预期的要多，也可能有消极的影响，因为更多的注意力放在了一些患者和活动上，而牺牲了其他患者和活动。数量有限的研究表明，这些溢出效应可能是巨大的。它们可能是实质性的，足以影响服务组织的拟议变革是否物有所值。因此，需要一种识别和衡量溢出效应的系统方法。我们的目标是制定结构化指导，将溢出效应纳入对卫生保健组织和服务变化的评估。我们的建议包含三个工作包。第一个工作包将审查已发表的文献，以确定和总结在以前的研究中如何考虑和衡量溢出效应。第二个工作包将使用三个案例研究的示例来开发方法。第一个案例研究将集中在为全科医生（gp）引入的新系统上，根据该系统，他们可以因改善一系列质量指标而获得财政奖励。第二个案例研究的重点是改变医院的收费方式，鼓励他们在同一天让病人出院，而不是让他们在医院过夜。我们之前已经表明，这两项举措都如预期的那样改变了活动，并改善了目标患者的预后。然而，对其他活动和其他患者的更广泛影响尚未考虑。第三个案例研究将侧重于向民众提供每周7天全科医生服务的举措。预计这将增加全科医疗服务的使用，并改善患者的便利性。还希望这将改善人口的健康状况，并减少到急诊科就诊的相对较小的投诉，这些投诉最好由全科医生处理。然而，这些变化的总体影响将取决于周末的可用性是否会导致一周内对全科医生的访问减少，对急诊科的需求减少的程度，对继续访问急诊科的病情更严重的患者的好处以及补偿全科医生在非工作时间开放的成本。我们将利用我们的溢出效应框架来估计这些更广泛的后果，并对扩大全科医生服务的可及性进行全面评估。我们将重新审视每一项政策变化，并检验它们是否具有溢出效应。我们将考虑这些溢出效应如何影响这些政策变化的总体成本和收益。在第三个也是最后一个工作包中，我们将制定结构化的方法指导，以评估保健服务的各种变化。我们将与一个包括决策者、保健专业人员和学术专家在内的项目咨询小组合作，确定潜在的溢出效应，制定方法，并确保指导是全面、权威和方便使用的。这项工作将提供一种一致的方法来评估改变为某些患者组织保健和社会护理服务的方式对所有患者的更广泛影响。我们将在三个重要的政策变化中展示这些方法，并研究溢出效应的考虑如何影响服务变化的设计以及评估这些变化的方式。我们将在整个项目中与决策者、专业人员和评估人员合作，制定指导方针，确保广泛认识到潜在的溢出效应，并将其纳入对护理服务组织和提供方式变化的评估。

Changes to the way in which healthcare services are organised and delivered have wider consequences beyond the patients or the services targeted. These types of wider changes are called spillovers. They may have positive effects, because more patients benefit than was originally intended, and/or they may have negative effects, because more attention is paid to some patients and activities at the expense of others. A limited amount of research has shown that these spillover effects can be substantial. They may be substantial enough to affect whether a proposed change in service organisation is good value-for-money. There is therefore a need for a systematic method of identifying and measuring spillover effects.Our aim is to develop structured guidance for incorporating spillovers in the evaluation of changes to health care organisation and delivery. Our proposal contains three work packages. The first work package will review the published literature to identify and summarise how spillovers have been considered and measured in previous studies. The second work package will use the example of three case studies to develop the methods. The first case study will focus on a new system introduced for General Practitioners (GPs) under which they received financial bonuses for improving a wide range of quality measures. The second case study will focus on a change to the way hospitals were paid to encourage them to discharge patients on the same day rather than keep them in hospital overnight. We have previously shown that both of these initiatives changed activity as intended and improved the outcomes for the patients that were targeted. However, the wider consequences for other activities and other patients have not been considered. The third case study will focus on the initiative to provide the population with access to GPs seven-days a week. This is expected to increase the use of general practice services and improve convenience for patients. It is also hoped that it will improve the health of the population and lead to a reduction in visits to Accident and Emergency departments for relatively minor complaints that would be better dealt with by GPs. However, the overall impact of these changes will depend on whether availability at the weekend leads to reduced access to GPs during the week, the size of the reduction in demand on A&E, the benefits to the patients with more severe conditions who continue to visit A&E and the costs of compensating GPs for opening out-of-hours. We will estimate these wider consequences using our spillovers framework and provide an overall assessment of extending access to GP services. We will re-visit each of these policy changes and examine whether they had spillover effects. We will consider how these spillover effects influence the overall costs and benefits of these policy changes.In the third and final work package, we will generate structured methodological guidance to evaluate diverse changes to health services. We will work with a project advisory group including decision-makers, health care professionals and academic experts to identify the potential for spillovers, develop the methods and ensure the guidance is comprehensive, authoritative and user-friendly. The work will provide a consistent way of assessing the wider effects on all patients of changing the way that health and social care services are organised for some patients. We will demonstrate these methods on three important policy changes and examine how considerations of spillovers affect the design of service changes and the way these are evaluated. We will work with decision-makers, professionals and evaluators throughout the project to create guidance that will ensure that the potential for spillover effects is widely recognised and that they are included in the evaluation of changes to the way care services are organised and delivered.