The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach

Nadine E. Andrew; David Ung; Muideen T. Olaiya; Lachlan L. Dalli; Joosup Kim; Leonid Churilov; Vijaya Sundararajan; Amanda G. Thrift; Dominique A. Cadilhac; Mark R. Nelson; Natasha A. Lannin; Rebecca Barnden; Velandai Srikanth; Monique F. Kilkenny

doi:10.1016/j.lanwpc.2023.100723

The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach

Nadine E. Andrew, David Ung, Muideen T. Olaiya, Lachlan L. Dalli, Joosup Kim, Leonid Churilov, Vijaya Sundararajan, Amanda G. Thrift, Dominique A. Cadilhac, Mark R. Nelson, Natasha A. Lannin, Rebecca Barnden, Velandai Srikanth, Monique F. Kilkenny

Research output: Contribution to journal › Article › Research › peer-review

13 Citations (Scopus)

Abstract

Background: Governments are investing in primary care policies that support chronic disease management. Large scale population-based evaluations are lacking. We aim to determine the effectiveness of government-funded chronic disease management policies to improve long-term outcomes (survival, hospital presentations, and preventive medication adherence) following stroke/Transient Ischemic Attack (TIA). Methods: Using a population-based cohort we utilized the target trial methodology. Participants were identified through the Australian Stroke Clinical Registry (January 2012–December 2016) from 42 hospitals in the states of Victoria and Queensland and linked with state and national hospital, primary care, pharmaceutical, aged care, and death datasets. Registrants living in the community, not receiving palliative care and who survived to 18 months following stroke/TIA were included. The comparison was a Medicare claim for policy-supported chronic disease management, 7–18 months following stroke/TIA versus usual care. Outcomes were modelled using multi-level, mixed-effects inverse probability of treatment weighted regression. Findings: 12,368 registrants were eligible (42% female, median age 70 years, 26% TIA), 45% had a chronic disease management claim. The difference in mean outcomes for participants with a claim, compared to those without, showed a 26% lesser mortality rate (adjusted hazard ratio [aHR]: 0.74, 95% confidence interval [CI]: 0.62, 0.87) and a greater adjusted Odds Ratio [aOR] of being adherent with preventive medications: antithrombotics (aOR: 1.16, 95% CI: 1.07, 1.26); lipid-lowering (aOR: 1.23, 95% CI: 1.13, 1.33). Impacts on hospital presentations were variable. Interpretation: Government policies that financially support primary care physicians to provide structured chronic disease management improve survival in the long-term following stroke/TIA.

Original language	English
Article number	100723
Number of pages	13
Journal	The Lancet Regional Health - Western Pacific
Volume	34
DOIs	https://doi.org/10.1016/j.lanwpc.2023.100723
Publication status	Published - May 2023

Keywords

Chronic disease management
Data linkage
Primary care
Stroke
Target trial

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/j.lanwpc.2023.100723Licence: CC BY-NC-ND

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Andrew, N. E., Ung, D., Olaiya, M. T., Dalli, L. L., Kim, J., Churilov, L., Sundararajan, V., Thrift, A. G., Cadilhac, D. A., Nelson, M. R., Lannin, N. A., Barnden, R., Srikanth, V., & Kilkenny, M. F. (2023). The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach. The Lancet Regional Health - Western Pacific, 34, Article 100723. https://doi.org/10.1016/j.lanwpc.2023.100723

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title = "The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach",

abstract = "Background: Governments are investing in primary care policies that support chronic disease management. Large scale population-based evaluations are lacking. We aim to determine the effectiveness of government-funded chronic disease management policies to improve long-term outcomes (survival, hospital presentations, and preventive medication adherence) following stroke/Transient Ischemic Attack (TIA). Methods: Using a population-based cohort we utilized the target trial methodology. Participants were identified through the Australian Stroke Clinical Registry (January 2012–December 2016) from 42 hospitals in the states of Victoria and Queensland and linked with state and national hospital, primary care, pharmaceutical, aged care, and death datasets. Registrants living in the community, not receiving palliative care and who survived to 18 months following stroke/TIA were included. The comparison was a Medicare claim for policy-supported chronic disease management, 7–18 months following stroke/TIA versus usual care. Outcomes were modelled using multi-level, mixed-effects inverse probability of treatment weighted regression. Findings: 12,368 registrants were eligible (42% female, median age 70 years, 26% TIA), 45% had a chronic disease management claim. The difference in mean outcomes for participants with a claim, compared to those without, showed a 26% lesser mortality rate (adjusted hazard ratio [aHR]: 0.74, 95% confidence interval [CI]: 0.62, 0.87) and a greater adjusted Odds Ratio [aOR] of being adherent with preventive medications: antithrombotics (aOR: 1.16, 95% CI: 1.07, 1.26); lipid-lowering (aOR: 1.23, 95% CI: 1.13, 1.33). Impacts on hospital presentations were variable. Interpretation: Government policies that financially support primary care physicians to provide structured chronic disease management improve survival in the long-term following stroke/TIA.",

keywords = "Chronic disease management, Data linkage, Primary care, Stroke, Target trial",

author = "Andrew, {Nadine E.} and David Ung and Olaiya, {Muideen T.} and Dalli, {Lachlan L.} and Joosup Kim and Leonid Churilov and Vijaya Sundararajan and Thrift, {Amanda G.} and Cadilhac, {Dominique A.} and Nelson, {Mark R.} and Lannin, {Natasha A.} and Rebecca Barnden and Velandai Srikanth and Kilkenny, {Monique F.}",

note = "Funding Information: Funding: This work was funded through the National Health and Medical Research Council Australia Project Grant Scheme. The following authors received Research Fellowship support from the National Health and Medical Research Council of Australia during this research: NEA ( 1072053 ), MFK ( 1109426 ), AGT ( 1042600 ), and DAC ( 1154273 ). MFK ( 105737 ) and NAL ( 102055 ) are supported by Future Leader Fellowships from the National Heart Foundation of Australia . LLD is supported by a Research Training Program scholarship from the Australian Government . The study funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Publisher Copyright: {\textcopyright} 2023 The Author(s)",

year = "2023",

month = may,

doi = "10.1016/j.lanwpc.2023.100723",

language = "English",

volume = "34",

journal = "The Lancet Regional Health - Western Pacific",

issn = "2666-6065",

publisher = "Elsevier",

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Andrew, NE, Ung, D, Olaiya, MT , Dalli, LL , Kim, J, Churilov, L, Sundararajan, V, Thrift, AG , Cadilhac, DA, Nelson, MR, Lannin, NA, Barnden, R, Srikanth, V & Kilkenny, MF 2023, 'The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach', The Lancet Regional Health - Western Pacific, vol. 34, 100723. https://doi.org/10.1016/j.lanwpc.2023.100723

The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach. / Andrew, Nadine E.; Ung, David; Olaiya, Muideen T. et al.
In: The Lancet Regional Health - Western Pacific, Vol. 34, 100723, 05.2023.

Research output: Contribution to journal › Article › Research › peer-review

TY - JOUR

T1 - The population effect of a national policy to incentivize chronic disease management in primary care in stroke

T2 - a population-based cohort study using an emulated target trial approach

AU - Andrew, Nadine E.

AU - Ung, David

AU - Olaiya, Muideen T.

AU - Dalli, Lachlan L.

AU - Kim, Joosup

AU - Churilov, Leonid

AU - Sundararajan, Vijaya

AU - Thrift, Amanda G.

AU - Cadilhac, Dominique A.

AU - Nelson, Mark R.

AU - Lannin, Natasha A.

AU - Barnden, Rebecca

AU - Srikanth, Velandai

AU - Kilkenny, Monique F.

N1 - Funding Information: Funding: This work was funded through the National Health and Medical Research Council Australia Project Grant Scheme. The following authors received Research Fellowship support from the National Health and Medical Research Council of Australia during this research: NEA ( 1072053 ), MFK ( 1109426 ), AGT ( 1042600 ), and DAC ( 1154273 ). MFK ( 105737 ) and NAL ( 102055 ) are supported by Future Leader Fellowships from the National Heart Foundation of Australia . LLD is supported by a Research Training Program scholarship from the Australian Government . The study funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication. Publisher Copyright: © 2023 The Author(s)

PY - 2023/5

Y1 - 2023/5

N2 - Background: Governments are investing in primary care policies that support chronic disease management. Large scale population-based evaluations are lacking. We aim to determine the effectiveness of government-funded chronic disease management policies to improve long-term outcomes (survival, hospital presentations, and preventive medication adherence) following stroke/Transient Ischemic Attack (TIA). Methods: Using a population-based cohort we utilized the target trial methodology. Participants were identified through the Australian Stroke Clinical Registry (January 2012–December 2016) from 42 hospitals in the states of Victoria and Queensland and linked with state and national hospital, primary care, pharmaceutical, aged care, and death datasets. Registrants living in the community, not receiving palliative care and who survived to 18 months following stroke/TIA were included. The comparison was a Medicare claim for policy-supported chronic disease management, 7–18 months following stroke/TIA versus usual care. Outcomes were modelled using multi-level, mixed-effects inverse probability of treatment weighted regression. Findings: 12,368 registrants were eligible (42% female, median age 70 years, 26% TIA), 45% had a chronic disease management claim. The difference in mean outcomes for participants with a claim, compared to those without, showed a 26% lesser mortality rate (adjusted hazard ratio [aHR]: 0.74, 95% confidence interval [CI]: 0.62, 0.87) and a greater adjusted Odds Ratio [aOR] of being adherent with preventive medications: antithrombotics (aOR: 1.16, 95% CI: 1.07, 1.26); lipid-lowering (aOR: 1.23, 95% CI: 1.13, 1.33). Impacts on hospital presentations were variable. Interpretation: Government policies that financially support primary care physicians to provide structured chronic disease management improve survival in the long-term following stroke/TIA.

AB - Background: Governments are investing in primary care policies that support chronic disease management. Large scale population-based evaluations are lacking. We aim to determine the effectiveness of government-funded chronic disease management policies to improve long-term outcomes (survival, hospital presentations, and preventive medication adherence) following stroke/Transient Ischemic Attack (TIA). Methods: Using a population-based cohort we utilized the target trial methodology. Participants were identified through the Australian Stroke Clinical Registry (January 2012–December 2016) from 42 hospitals in the states of Victoria and Queensland and linked with state and national hospital, primary care, pharmaceutical, aged care, and death datasets. Registrants living in the community, not receiving palliative care and who survived to 18 months following stroke/TIA were included. The comparison was a Medicare claim for policy-supported chronic disease management, 7–18 months following stroke/TIA versus usual care. Outcomes were modelled using multi-level, mixed-effects inverse probability of treatment weighted regression. Findings: 12,368 registrants were eligible (42% female, median age 70 years, 26% TIA), 45% had a chronic disease management claim. The difference in mean outcomes for participants with a claim, compared to those without, showed a 26% lesser mortality rate (adjusted hazard ratio [aHR]: 0.74, 95% confidence interval [CI]: 0.62, 0.87) and a greater adjusted Odds Ratio [aOR] of being adherent with preventive medications: antithrombotics (aOR: 1.16, 95% CI: 1.07, 1.26); lipid-lowering (aOR: 1.23, 95% CI: 1.13, 1.33). Impacts on hospital presentations were variable. Interpretation: Government policies that financially support primary care physicians to provide structured chronic disease management improve survival in the long-term following stroke/TIA.

KW - Chronic disease management

KW - Data linkage

KW - Primary care

KW - Stroke

KW - Target trial

UR - http://www.scopus.com/inward/record.url?scp=85149897915&partnerID=8YFLogxK

U2 - 10.1016/j.lanwpc.2023.100723

DO - 10.1016/j.lanwpc.2023.100723

M3 - Article

C2 - 37283975

AN - SCOPUS:85149897915

SN - 2666-6065

VL - 34

JO - The Lancet Regional Health - Western Pacific

JF - The Lancet Regional Health - Western Pacific

M1 - 100723

ER -

The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach

Abstract

Keywords

UN SDGs

Access to Document

Other files and links

National Stroke Data Linkage Program: Using big data to improve diagnostic coding, clinical management and long-term outcomes after stroke

Conducting efficacy and implementation trials to improve the evidence-base of stroke rehabilitation to improve participation outcomes

Improving the cost-effectiveness of care and outcomes of stroke through innovation, capacity building and leveraging data platforms.

Cite this

The population effect of a national policy to incentivize chronic disease management in primary care in stroke: a population-based cohort study using an emulated target trial approach

Abstract

Keywords

UN SDGs

Access to Document

Other files and links

Projects

National Stroke Data Linkage Program: Using big data to improve diagnostic coding, clinical management and long-term outcomes after stroke

Conducting efficacy and implementation trials to improve the evidence-base of stroke rehabilitation to improve participation outcomes

Improving the cost-effectiveness of care and outcomes of stroke through innovation, capacity building and leveraging data platforms.

Cite this