Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data

Background: The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK’s pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. ‘Population achievement’ describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. Methods: We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. Results: Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010–2011; 7.02% in 2011–2012 and 6.92% in 2012–2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010–2011; 0.88% in 2011–2012 and 0.96% in 2012–2013). Median population achievement was 83.5% (83.51% in 2010–2011; 83.41% in 2011–2012 and 83.63% in 2012–2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland’s most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83–2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices. Conclusions: Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the ‘hard to reach’ if inequalities in healthcare delivery are to be tackled

Filial obligations: A contextual, pluralist model

In this article I investigate the nature and extent of filial obligations. The question what (adult) children owe their parents is not only philosophically interesting, but also of increasing relevance in ageing societies. Its answer matters to elderly people and their adult children, and is relevant to social policy issues in various ways. I present the strongest arguments for and against three models of filial obligations: the 'past parental sacrifices' model, the 'special relationship' model, and the conventionalist model. There is something to be said-and after consideration of objections something remains to be said-for all three models. In other words: filial obligations have more than one source, and an adequate model of filial obligations should reflect this. On its own, each of the above models is one-sided. They also fail to show the connections between the question of filial obligations and various other issues, such as issues of gender justice, the extent of institutionalization of eldercare, and social conventions regarding filial responsibility. Therefore, I integrate what I think we should keep from the aforementioned models into a contextual, pluralist model, which places filial obligations in a broader social and cultural context and relates them to issues of social justice. The model also highlights the difference between general and specific filial obligations, and the factors that determine their nature and extent, thus enabling a deeper and more comprehensive understanding of filial obligations. © 2012 The Author(s)

Does Pet-Keeping Modify the Association of Delivery Mode with Offspring Body Size?

OBJECTIVES: Caesarean-section (CS) delivery increases risk of childhood obesity, and is associated with a distinct early-life gut microbiome, which may contribute to obesity. Household pets may alter human gut microbiome composition. We examined if pet-keeping modified the association of CS with obesity at age 2 years in 639 Wayne County Health, Environment, Allergy and Asthma Longitudinal Study (WHEALS) birth cohort participants. METHODS: Pet-keeping was defined as having a dog or cat (indoors ≥1 hour/day) at child age 2 years. We used logistic regression to test for an interaction between CS and pet-keeping with obesity (BMI≥95(th) percentile) at age 2 years, adjusted for maternal obesity. RESULTS: A total of 328 (51.3%) children were male; 367 (57.4%) were African American; 228 (35.7%) were born by CS; and 55 (8.6%) were obese. After adjusting for maternal obesity, CS-born children had a non-significant (P=0.25) but elevated 1.4 (95% CI: 0.8, 2.5) higher odds of obesity compared to those born vaginally. There was evidence of effect modification between current pet-keeping and delivery mode with obesity at age 2 years (interaction P=0.054). Compared to children born vaginally without a pet currently in the home, children born via CS without a pet currently in the home had a statistically significant (P=0.043) higher odds (odds ratio=2.00; 95% CI: 1.02, 3.93) of being obese at age 2 years. CONCLUSIONS: Pets modified the CS-BMI relationship; whether the underlying mechanism is through effects on environmental or gut microbiome requires specific investigation