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Hsu CC, Tai TY. Long-term glycemic control by a diabetes case-management program and the challenges of diabetes care in Taiwan. Diabetes Res Clin Pract 2014; 106 Suppl 2:S328-32. [PMID: 25550062 DOI: 10.1016/s0168-8227(14)70738-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIMS This study aimed to evaluate the long-term effects on glycemic control of a diabetes care program focusing on case management and to discuss challenges in the quality of diabetes care in Taiwan. METHODS We randomized 1,060 study subjects recruited from the Diabetes Management through an Integrated Delivery System project in 2003-2005 into intervention (n = 789 from 27 clinics) and control (n = 271 from 7 clinics) groups. The quarterly self-care and nutrition-education program in the intervention group was delivered by case managers, and standard care was provided to the control group. The intervention program was conducted during 2003-2007. A multivariate mixed model analysis was used to assess the 3.5-year intervention effects on glycemic control. RESULTS Glycated hemoglobin (HbA1c) level in the intervention group (especially for those with a baseline HbA1c level of 7-9% and >9%) was significantly lower than that in the control group 6 months after recruitment and remained lower through the subsequent three intervention years. CONCLUSIONS The current findings provide evidence that case management provided in the pay-for-performance (P4P) diabetes care program in Taiwan was effective at improving glycemic control for at least 3 years. However, previous research indicated poverty is associated with not only higher diabetes incidence but also inequality of diabetes care in Taiwan despite universal health coverage. Those with a more severe condition were less likely to be enrolled in the P4P diabetes care program. Additional cost-effectiveness studies and more health policy reforms are needed to optimize diabetes care in Taiwan.
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Affiliation(s)
- Chih-Cheng Hsu
- Institute of Population Health Sciences, National Health Research Institutes, Zhunan, Taiwan; Department of Health Services Administration, China Medical University, Taichung, Taiwan.
| | - Tong-Yuan Tai
- Taipei Jen-Chi Relief Institution, Taipei, Taiwan; Formosan Diabetes Care Foundation, Taipei, Taiwan
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Abstract
Type 2 diabetes mellitus (T2DM) is a global health-care and national policy issue. As fluctuating glycemic control in diabetes often results in serious complications, we must encourage the diabetes educators' efforts at long-term follow-up among patients with T2DM. Therefore, certified diabetes educators (CDEs) play the most pivotal roles as life-long protectors for patients with T2DM. In the past 15 years, more than 4,000 CDEs have been trained and qualified, including health professionals such as physicians, nurses, dieticians, and pharmacists. The most important initiation of diabetes share care in Taiwan was originated in I-Lan County. Initiated to provide regional diabetes care, the name of this program is the Lan-Yang Diabetes Shared Care System. In 2006, the Taiwanese Association of Diabetes Educators (TADE) carried out a nationwide survey to evaluate the status of diabetes control in Taiwan, focusing on the "ABC" goal (A: HbA1c <7.0%, B: blood pressure <130/80 mmHg, C: LDL-cholesterol <100 mg/dl/total cholesterol <160 mg/dl). The results revealed that the percentage of patients with diabetes who fulfilled all ABC goals was only 4.1%. Five years later, in 2011, TADE compared two nationwide surveys and found total ABC attainment rates of 4.1% and 8.6%, respectively. The team-care approach to T2DM has been underway for over 20 years in Taiwan. Future interventions and treatment algorithms with team-based education should aim at preventing acute and chronic complications, which remains a long-term challenge in Taiwan.
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Affiliation(s)
- Chih-Yuan Wang
- Department of Internal Medicine, Far-Eastern Memorial Hospital and National Taiwan University Hospital, Taipei.
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Performance-based financial incentives for diabetes care: an effective strategy? Can J Diabetes 2014; 39:83-7. [PMID: 25444683 DOI: 10.1016/j.jcjd.2014.06.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 04/10/2014] [Accepted: 06/11/2014] [Indexed: 01/02/2023]
Abstract
The use of financial incentives provided to primary care physicians who achieve target management or clinical outcomes has been advocated to support the fulfillment of care recommendations for patients with diabetes. This article explores the characteristics of incentive models implemented in the context of universal healthcare systems in the United Kingdom, Australia, Taiwan and Canada; the extent to which these interventions have been successful in improving diabetes outcomes; and the key challenges and concerns around implementing incentive models. Research in the effect of incentives in the United Kingdom demonstrates some improvements in process outcomes and achievement of cholesterol, blood pressure and glycated hemoglobin (A1C) targets. Evidence of the efficacy of programs implemented outside of the United Kingdom is very limited but suggests that physicians participating in these enhanced billing incentive programs were already completing the guideline-recommended care prior to the introduction of the incentive. A shift to pay-for-performance programs may have important implications for professionalism and patient-centred care. In the absence of definitive evidence that financial incentives drive the quality of diabetes management at the level of primary care, policy makers should proceed with caution. It is important to look beyond simply modifying physicians' behaviours and address the factors and systemic barriers that make it challenging for patients and physicians to manage diabetes in partnership.
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Huang LY, Shau WY, Yeh HL, Chen TT, Hsieh JY, Su S, Lai MS. A model measuring therapeutic inertia and the associated factors among diabetes patients: A nationwide population-based study in Taiwan. J Clin Pharmacol 2014; 55:17-24. [DOI: 10.1002/jcph.367] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/16/2014] [Indexed: 11/06/2022]
Affiliation(s)
- Li-Ying Huang
- Division of Health Technology Assessment; Center for Drug Evaluation; Taipei Taiwan Republic of China
- Graduate Institute of Health Care Organization Administration; College of Public Health, National Taiwan University; Taipei Taiwan Republic of China
| | - Wen-Yi Shau
- Division of Health Technology Assessment; Center for Drug Evaluation; Taipei Taiwan Republic of China
| | - Hseng-Long Yeh
- School of Public Health; College of Public Health and Nutrition, Taipei Medical University; Taipei Taiwan Republic of China
- Department of Cardiology; Sijhih Cathay General Hospital; Taipei Taiwan Republic of China
| | - Tsung-Tai Chen
- Department of Public Health; College of Medicine, Fu-Jen Catholic University; New Taipei City Taiwan Republic of China
| | - Jun Yi Hsieh
- Department of Social and Public Affairs; Taipei Municipal University of Education; Taipei City Taiwan Republic of China
| | - Syi Su
- The School of Healthcare and Management; Kainan University; Taoyuan County Taiwan Republic of China
| | - Mei-Shu Lai
- Institute of Epidemiology and Preventive Medicine; College of Public Health, National Taiwan University; Taipei Taiwan Republic of China
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Economic Burden of Diabetes Mellitus on Patients with Respiratory Failure Requiring Mechanical Ventilation during Hospitalizations. Value Health Reg Issues 2014; 3:33-38. [PMID: 29702934 DOI: 10.1016/j.vhri.2014.02.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
OBJECTIVES To examine the economic burden of diabetes mellitus (DM) on medical expenditure among patients with respiratory failure (RF) requiring mechanical ventilation during hospitalization. METHODS We extracted the data from Taiwan National Health Research Insurance Database for those adult patients on their first hospitalization for RF requiring mechanical ventilation between 2004 and 2010. We examined associations between medical expenditure and the presence of comorbid DM. We performed independent t tests, chi-square tests, and multivariate linear regression analysis to identify factors associated with excess medical expenditure. RESULTS Of 347,961 patients hospitalized with first occurrence of RF requiring mechanical ventilation, 123,023 (35.36%) patients were documented to have a previous diagnosis of DM. Patients with RF and DM were sicker and consumed more health care resources than did patients with RF without DM. After adjusting for the specified covariates, mechanically ventilated patients with RF and DM consumed at least US $618 more of total inpatient medical expenditure than did patients with RF without DM. There were statistically significant interactions between age and DM on their total inpatient medical expenditure regardless of discharge status. CONCLUSIONS DM was associated with more severe disease status and higher consumption of medical expenditure during hospitalizations among mechanically ventilated patients due to first occurrence of RF in Taiwan. These findings provide scientific evidence to facilitate appropriate resource allocation and formulate programs for higher quality of care in the future in Taiwan and other countries.
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Beadles CA, Hassmiller Lich K, Viera AJ, Greene SB, Brookhart MA, Weinberger M. A non-experimental study of oral anticoagulation therapy initiation before and after national patient safety goals. BMJ Open 2014; 4:e003960. [PMID: 24525389 PMCID: PMC3927813 DOI: 10.1136/bmjopen-2013-003960] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVES The Joint Commission revised its National Patient Safety Goals (NPSGs) to include oral anticoagulation therapy (OAT) in 2008. We sought to examine the effect of including OAT in The Joint Commission's NPSGs on historically low rates of OAT initiation for individuals with incident atrial fibrillation (AF). SETTING Southeastern state in the USA. PARTICIPANTS North Carolina State Health Plan claims data from 944 500 individuals enrolled between 1 January 2006 and 31 December 2010, supplemented with data from the Area Resource File and Online Survey, Certification and Reporting data network. We evaluated OAT initiation before and after the 2008 NPSGs revisions in a retrospective cohort new user design with an AF intervention group and two control groups: a positive control-patients estimated to be at very high risk of thromboembolism (mechanical heart valve and pulmonary embolism); and a negative control-patients with very low perceived risk of thromboembolism (paroxysmal AF). We developed multivariable models using a difference-in-difference parameterisation. Effects were estimated with generalised estimating equations. PRIMARY OUTCOME MEASURE OAT initiation, a binary outcome defined as having a prescription drug claim for warfarin within 30 days of the index claim. RESULTS OAT initiation was low (26.8%) for eligible individuals with incident AF in 2006-2008 but increased after NPSGs implementation (31.7%, p=0.022). OAT initiation was high but decreased in the positive control group (67.5% vs 62.0%, p=0.003). Multivariate analysis resulted in a relative 11% (95% CI (4% to 18%), p<0.01) increase in OAT initiation for incident AF patients. CONCLUSIONS We document a substantial increase in guideline concordant OAT initiation in incident AF after the establishment of NPSGs, suggesting that regulatory healthcare agency initiatives can influence clinical practice.
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Affiliation(s)
- Christopher A Beadles
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Durham, North Carolina, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Veterans Affairs Medical Center, Center for Health Services Research in Primary Care, Durham, North Carolina, USA
| | - Kristen Hassmiller Lich
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anthony J Viera
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sandra B Greene
- Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Durham, North Carolina, USA
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - M Alan Brookhart
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Morris Weinberger
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Veterans Affairs Medical Center, Center for Health Services Research in Primary Care, Durham, North Carolina, USA
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Clement M, Harvey B, Rabi DM, Roscoe RS, Sherifali D. Organisation des soins du diabète. Can J Diabetes 2013. [DOI: 10.1016/j.jcjd.2013.07.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Hirsch AG, Scheck McAlearney A. Measuring Diabetes Care Performance Using Electronic Health Record Data: The Impact of Diabetes Definitions on Performance Measure Outcomes. Am J Med Qual 2013; 29:292-9. [PMID: 24006028 DOI: 10.1177/1062860613500808] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective was to examine the use of electronic health record (EHR) data for diabetes performance measurement. Data were extracted from the EHR of a health system to identify patients with diabetes using 8 different EHR data-based methods of identification. These EHR-based methods were compared to the gold standard of a manual medical record review. The study team then assessed whether the method of identifying patients with diabetes could affect performance measurement scores. The sensitivity of the 8 EHR-based methods of identifying patients with diabetes ranged from moderate to high. The use of certain data elements in the EHR to identify patients with diabetes selectively identified those who had better performance measures. Diabetes performance measures are influenced by the data elements used to identify patients. As EHR data are used increasingly to measure performance, continuing to improve our understanding of how EHR data are collected and used will be critical.
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Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan? Qual Life Res 2013; 23:687-96. [PMID: 23975377 DOI: 10.1007/s11136-013-0502-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2013] [Indexed: 02/07/2023]
Abstract
PURPOSE In October 2001, a pay-for-performance (P4P) program for diabetes was implemented by the National Health Insurance (NHI), a single-payer program, in Taiwan. However, only limited information is available regarding the influence of this program on the patient's health-related quality of life. The aim of this study was to estimate the costs and consequences of enrolling patients in the P4P program from a single-payer perspective. METHODS A retrospective observational study of 529 diabetic patients was conducted between 2004 and 2005. The data used in the study were obtained from the National Health Interview Survey (NHIS) in Taiwan. Direct cost data were obtained from NHI claims data, which were linked to respondents in the NHIS using scrambled individual identification. The generic SF36 health instrument was employed to measure the quality-of-life-related health status and transformed into a utility index. Patients enrolled in the P4P program for at least 3 months were categorized as the P4P group. Following propensity score matching, 260 patients were included in the study. Outcomes included life-years, quality-adjusted life-years (QALYs), diabetes-related medical costs, overall medical costs, and incremental cost-effectiveness ratios (ICERs). A single-payer perspective was assumed, and costs were expressed in US dollars. Nonparametric bootstrapping was conducted to estimate confidence intervals for cost-effectiveness ratios. RESULTS Following matching, no significant difference was noted between two groups with regard to the patients' age, gender, education, family income, smoking status, BMI, or whether insulin was used. The P4P group had an increase of 0.08 (95 % CI 0.077-0.080) in QALYs, and the additional diabetes-related medical cost was US$422.74 (95 % CI US$413.58-US$435.05), yielding an ICER of US$5413.93 (95 % CI US$5226.83-US$5562.97) per QALY gained. CONCLUSIONS Our results provides decision makers with valuable information regarding the impact of the P4P program of diabetes care through a direct comparison of equivalent groups of patients receiving regular care. Under the single-payer NHI system, the use of financial incentives under the DM-P4P program may be an effective means to ensure the quality of follow-up treatment.
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Eijkenaar F, van Vliet RCJA. Performance profiling in primary care: does the choice of statistical model matter? Med Decis Making 2013; 34:192-205. [PMID: 23920433 DOI: 10.1177/0272989x13498825] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Profiling is increasingly being used to generate input for improvement efforts in health care. For these efforts to be successful, profiles must reflect true provider performance, requiring an appropriate statistical model. Sophisticated models are available to account for the specific features of performance data, but they may be difficult to use and explain to providers. OBJECTIVE To assess the influence of the statistical model on the performance profiles of primary care providers. Data Source. Administrative data (2006–2008) on 2.8 million members of a Dutch health insurer who were registered with 1 of 4396 general practitioners. METHODS Profiles are constructed for 6 quality measures and 5 resource use measures, controlling for differences in case mix. Models include ordinary least squares, generalized linear models, and multilevel models. Separately for each model, providers are ranked on z scores and classified as outlier if belonging to the 10% with the worst or best performance. The impact of the model is evaluated using the weighted kappa for rankings overall, percentage agreement on outlier designation, and changes in rankings over time. RESULTS Agreement among models was relatively high overall (kappa typically .0.85). Agreement on outlier designation was more variable and often below 80%, especially for high outliers. Rankings were more similar for processes than for outcomes and expenses. Agreement among annual rankings per model was low for all models. CONCLUSIONS Differences among models were relatively small, but the choice of statistical model did affect the rankings. In addition, most measures appear to be driven largely by chance, regardless of the model that is used. Profilers should pay careful attention to the choice of both the statistical model and the performance measures.
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Affiliation(s)
- Frank Eijkenaar
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
| | - René C J A van Vliet
- Institute of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, the Netherlands
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Yu HC, Tsai WC, Kung PT. Does the pay-for-performance programme reduce the emergency department visits for hypoglycaemia in type 2 diabetic patients? Health Policy Plan 2013; 29:732-41. [DOI: 10.1093/heapol/czt056] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
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Effects of pay for performance in health care: A systematic review of systematic reviews. Health Policy 2013; 110:115-30. [DOI: 10.1016/j.healthpol.2013.01.008] [Citation(s) in RCA: 250] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/09/2013] [Accepted: 01/11/2013] [Indexed: 12/25/2022]
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Abstract
Pay-for-performance schemes explicitly link provider remuneration to the quality of care provided, with the aims of modifying provider behavior and improving patient outcomes. If successful, pay-for-performance schemes could drive improvements in quality and efficiency of care. However, financial incentives could also erode providers' intrinsic motivation, narrow their focus, promote unethical behavior, and ultimately increase health care inequalities. Evidence from schemes implemented to date suggests that carefully designed pay-for-performance schemes that align sufficient rewards with clinical priorities can produce modest but significant improvements in processes of diabetic care and intermediate outcomes. There is limited evidence, however, on whether improvements in processes of care result in improved outcomes, in terms of patient satisfaction, reduced complications, and greater longevity. The lack of adequate control groups has limited research findings to date, and more robust studies are needed to explore both the potential long-term benefits of pay-for-performance schemes and their unintended consequences.
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Affiliation(s)
- Tim Doran
- Institute of Population Health, University of Manchester, Williamson Building Oxford Road, Manchester, M13 9PL, UK.
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Eijkenaar F. Key issues in the design of pay for performance programs. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2013; 14:117-31. [PMID: 21882009 PMCID: PMC3535413 DOI: 10.1007/s10198-011-0347-6] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Accepted: 08/09/2011] [Indexed: 05/19/2023]
Abstract
Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance. However, evidence on P4P effectiveness remains inconclusive. Flaws in program design may have contributed to this limited success. Based on a synthesis of relevant theoretical and empirical literature, this paper discusses key issues in P4P-program design. The analysis reveals that designing a fair and effective program is a complex undertaking. The following tentative conclusions are made: (1) performance is ideally defined broadly, provided that the set of measures remains comprehensible, (2) concerns that P4P encourages "selection" and "teaching to the test" should not be dismissed, (3) sophisticated risk adjustment is important, especially in outcome and resource use measures, (4) involving providers in program design is vital, (5) on balance, group incentives are preferred over individual incentives, (6) whether to use rewards or penalties is context-dependent, (7) payouts should be frequent and low-powered, (8) absolute targets are generally preferred over relative targets, (9) multiple targets are preferred over single targets, and (10) P4P should be a permanent component of provider compensation and is ideally "decoupled" form base payments. However, the design of P4P programs should be tailored to the specific setting of implementation, and empirical research is needed to confirm the conclusions.
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Affiliation(s)
- Frank Eijkenaar
- Institute of Health Policy and Management, Erasmus University Rotterdam, Burgemeester Oudlaan 50, 3000 DR Rotterdam, The Netherlands.
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Chen TT, Lai MS. The unintended consequences of pay-for-performance. Health Aff (Millwood) 2012; 31:1127; author reply 1128. [PMID: 22566457 DOI: 10.1377/hlthaff.2012.0375] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Abstract
Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.
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Scott A, Sivey P, Ait Ouakrim D, Willenberg L, Naccarella L, Furler J, Young D. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database Syst Rev 2011:CD008451. [PMID: 21901722 DOI: 10.1002/14651858.cd008451.pub2] [Citation(s) in RCA: 240] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The use of blended payment schemes in primary care, including the use of financial incentives to directly reward 'performance' and 'quality' is increasing in a number of countries. There are many examples in the US, and the Quality and Outcomes Framework (QoF) for general practitioners (GPs) in the UK is an example of a major system-wide reform. Despite the popularity of these schemes, there is currently little rigorous evidence of their success in improving the quality of primary health care, or of whether such an approach is cost-effective relative to other ways to improve the quality of care. OBJECTIVES The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians (PCPs) and to identify:i) the different types of financial incentives that have improved quality;ii) the characteristics of patient populations for whom quality of care has been improved by financial incentives; andiii) the characteristics of PCPs who have responded to financial incentives. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care (EPOC) Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library), MEDLINE, HealthSTAR, EMBASE, CINAHL, PsychLIT, and ECONLIT. Searches of Internet-based economics and health economics working paper collections were also conducted. Finally, studies were identified through the reference lists of retrieved articles, websites of key organisations, and from direct contact with key authors in the field. Articles were included if they were published from 2000 to August 2009. SELECTION CRITERIA Randomised controlled trials (RCT), controlled before and after studies (CBA), and interrupted time series analyses (ITS) evaluating the impact of different financial interventions on the quality of care delivered by primary healthcare physicians (PCPs). Quality of care was defined as patient reported outcome measures, clinical behaviours, and intermediate clinical and physiological measures. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and assessed study quality, in consultation with two other review authors where there was disagreement. For each included study, we reported the estimated effect sizes and confidence intervals. MAIN RESULTS Seven studies were included in this review. Three of the studies evaluated single-threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups' performance (tournament-based pay), one study examined a mix of tournament-based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment. Three cluster RCTs examined smoking cessation; one CBA examined patients' assessment of the quality of care; one CBA examined cervical screening, mammography screening, and HbA1c; one ITS focused on four outcomes in diabetes; and one controlled ITS (a difference-in-difference design) examined cervical screening, mammography screening, HbA1c, childhood immunisation, chlamydia screening, and appropriate asthma medication. Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. One study found no effect on quality of care. Poor study design led to substantial risk of bias in most studies. In particular, none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme or health plan. AUTHORS' CONCLUSIONS The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing. However, there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be more carefully designed before implementation. In addition to basing incentive design more on theory, there is a large literature discussing experiences with these schemes that can be used to draw out a number of lessons that can be learned and that could be used to influence or modify the design of incentive schemes. More rigorous study designs need to be used to account for the selection of physicians into incentive schemes. The use of instrumental variable techniques should be considered to assist with the identification of treatment effects in the presence of selection bias and other sources of unobserved heterogeneity. In randomised trials, care must be taken in using the correct unit of analysis and more attention should be paid to blinding. Studies should also examine the potential unintended consequences of incentive schemes by having a stronger theoretical basis, including a broader range of outcomes, and conducting more extensive subgroup analysis. Studies should more consistently describe i) the type of payment scheme at baseline or in the control group, ii) how payments to medical groups were used and distributed within the groups, and iii) the size of the new payments as a percentage of total revenue. Further research comparing the relative costs and effects of financial incentives with other behaviour change interventions is also required.
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Affiliation(s)
- Anthony Scott
- Melbourne Institute of Applied Economic and Social Research, The University of Melbourne, Level 7, Alan Gilbert Building, Barry Street, Carlton, Melbourne, VIC, Australia, 3053
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