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

Lancet Reg Health West Pac. 2023 Mar 10:34:100723. doi: 10.1016/j.lanwpc.2023.100723. eCollection 2023 May.

Authors

Nadine E Andrew^{1

2}, David Ung^{1

2}, Muideen T Olaiya^{3

4}, Lachlan L Dalli^{3

4}, Joosup Kim^{3

4}, Leonid Churilov⁵, Vijaya Sundararajan⁶, Amanda G Thrift³, Dominique A Cadilhac^{3

4}, Mark R Nelson⁷, Natasha A Lannin^{8

9}, Rebecca Barnden¹, Velandai Srikanth^{1

2}, Monique F Kilkenny^{3

4}

Affiliations

¹ Department of Medicine, Peninsula Clinical School, Central Clinical School, Monash University, Frankston, Victoria, Australia.
² National Centre for Healthy Ageing, Frankston, Victoria, Australia.
³ Department of Medicine, Stroke and Ageing Research, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia.
⁴ Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Victoria, Australia.
⁵ Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia.
⁶ Department of Medicine, St Vincent's Hospital, University of Melbourne, Fitzroy, Victoria, Australia.
⁷ Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.
⁸ Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.
⁹ Alfred Health, Melbourne, Australia.

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.

Funding: National Health and Medical Research Council Australia.

Keywords: Chronic disease management; Data linkage; Primary care; Stroke; Target trial.