Systematic review: Effects, design choices, and context of pay-for-performance in health care

Improving quality and performance in substance use treatment programs: What is being done and why is it so hard?

SUMMARY

As states plan to implement system-wide change of any kind, it is important to understand program directors' perspectives on challenges they face. This is especially true with quality improvement reforms. Much research has focused on quality improvement in medicine, but there is a gap in our knowledge about programs that treat individuals with drug or alcohol use. From 2007 to 2016, Maine contracted with selected substance use treatment programs using financial incentives to improve quality, with focus on treatment access, engagement, retention, and completion as measures of quality. Using surveys and in-depth interviews, this research documents strategies that programs used to improve performance and challenges faced in implementing reforms. Only programs that received federal block grant funding through the state to provide substance use treatment were eligible for an incentive contract, creating a natural experiment with non-block grant programs (non-incentive). Directors were interviewed in incentive (n=13) and non-incentive programs (n=12).

FINDINGS

Thematic analysis revealed that: 1) programs focused on QI, but those eligible for incentives focused on different quality measures, 2) most of the reforms in both groups targeted improving treatment access and retention, and 3) programs faced substantial challenges in undertaking reforms. Despite efforts, many programs could not meet quality measures consistently over time and faced barriers over which they had little control.

APPLICATIONS

Policy makers and program administrators will benefit from knowing the challenges of undertaking QI initiatives and provide support for the programs.

Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis

BACKGROUND

This study investigated if the evidence on the success of the Pay for Performance (P4P) schemes in healthcare is changing as the schemes continue to evolve by updating a previous systematic review.

METHODS

A meta-regression analysis using 116 studies evaluating P4P schemes published between January 2010 to February 2018. The effects of the research design, incentive schemes, use of incentives, and the size of the payment to revenue ratio on the proportion of statically significant effects in each study were examined.

RESULTS

There was evidence of an increase in the range of countries adopting P4P schemes and weak evidence that the proportion of studies with statistically significant effects have increased. Factors hypothesized to influence the success of schemes have not changed. Studies evaluating P4P schemes which made payments for improvement over time, were associated with a lower proportion of statistically significant effects. There was weak evidence of a positive association between the incentives' size and the proportion of statistically significant effects.

CONCLUSION

The evidence on the effectiveness of P4P schemes is evolving slowly, with little evidence that lessons are being learned concerning the design and evaluation of P4P schemes.

The effect of pay-for-performance program on infection events and mortality rate in diabetic patients: a nationwide population-based cohort study

Background

Diabetes mellitus is a known risk factor for infection. Pay for Performance (P4P) program is designed to enhance the comprehensive patient care. The aim of this study is to evaluate the effect of the P4P program on infection incidence in type 2 diabetic patients.

Methods

This is a retrospective longitudinal cohort study using data from the National Health Insurance Research Database in Taiwan. Diabetic patients between 1 January 2002 and 31 December 2013 were included. Primary outcomes analyzed were patient emergency room (ER) infection events and deaths.

Results

After propensity score matching, there were 337,184 patients in both the P4P and non-P4P cohort. The results showed that patients’ completing one-year P4P program was associated with a decreased risk of any ER infection event (27.2% vs. 29%; subdistribution hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.86–0.88). While the number needed to treat was 58 for the non-P4P group, it dropped to 28 in the P4P group. The risk of infection-related death was significantly lower in the P4P group than in the non-P4P group (4.1% vs. 7.6%; HR 0.46, 95% CI 0.45–0.47). The effect of P4P on ER infection incidence and infection-related death was more apparent in the subgroups of patients who were female, had diabetes duration ≥5 years, chronic kidney disease, higher Charlson’s Comorbidity Index scores and infection-related hospitalization in the previous 3 years.

Conclusions

The P4P program might reduce risk of ER infection events and infection-related deaths in type 2 diabetic patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06091-2.

Payment methods for healthcare providers working in outpatient healthcare settings

BACKGROUND

Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services.

OBJECTIVES

To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes.

MAIN RESULTS

We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies.

AUTHORS' CONCLUSIONS

For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis

Incentive-based pay-for-performance (P4P) models have been introduced during the last 2 decades as a mechanism to improve the delivery of evidence-based care that ensures clinical quality and improves health outcomes. There is mixed evidence that P4P has a positive effect on health outcomes and researchers cite lack of engagement from health care professionals as a limiting factor. This qualitative metasynthesis of existing qualitative research was conducted to integrate health care professionals’ perceptions of P4P in clinical practice. Four themes emerged during the research process: positive perceptions of the value of performance measurement and associated financial incentives; negative perceptions of the performance measurement and associated financial incentives; perceptions of how P4P programs influence the quality/appropriateness of care; and perceptions of the influence of P4P program on professional roles and workplace dynamics. Identifying factors that influence health care professionals’ perceptions about this type of value-based payment model will guide future research.

Integrative Review of Managed Entry Agreements: Chances and Limitations

BACKGROUND AND OBJECTIVE

Managed entry agreements (MEAs) consist of a set of instruments to reduce the uncertainty and the budget impact of new high-priced medicines; however, there are concerns. There is a need to critically appraise MEAs with their planned introduction in Brazil. Accordingly, the objective of this article is to identify and appraise key attributes and concerns with MEAs among payers and their advisers, with the findings providing critical considerations for Brazil and other high- and middle-income countries.

METHODS

An integrative review approach was adopted. This involved a review of MEAs across countries. The review question was 'What are the health technology MEAs that have been applied around the world?' This review was supplemented with studies not retrieved in the search known to the senior-level co-authors including key South American markets. It also involved senior-level decision makers and advisers providing guidance on the potential advantages and disadvantages of MEAs and ways forward.

RESULTS

Twenty-five studies were included in the review. Most MEAs included medicines (96.8%), focused on financial arrangements (43%) and included mostly antineoplastic medicines. Most countries kept key information confidential including discounts or had not published such data. Few details were found in the literature regarding South America. Our findings and inputs resulted in both advantages including reimbursement and disadvantages including concerns with data collection for outcome-based schemes.

CONCLUSIONS

We are likely to see a growth in MEAs with the continual launch of new high-priced and often complex treatments, coupled with increasing demands on resources. Whilst outcome-based MEAs could be an important tool to improve access to new innovative medicines, there are critical issues to address. Comparing knowledge, experiences, and practices across countries is crucial to guide high- and middle-income countries when designing their future MEAs.

Characterization and analysis of the basic elements of health payment mechanisms and their most frequent types

Introduction Healthcare systems are developed in imperfect scenarios, in which there are constant failures (uncertainty, information asymmetry, agency relationship problem, and supply-induced demand). These failures, based on the imperfection of the sector, determine the relationships and incentives between the actors. It is within this context that payment mechanisms regulate aspects of the system behavior and incentives, acting as instruments for the purchasing of health care from providers, mediated by health insurance on behalf of users. Objective To characterize the basic elements of most frequent payment mechanisms to help providers in their relationship with payers. Methods A review of the evidence was conducted in PubMed, Google, Google Scholar, and strategic snowball selection. Payment mechanisms consist of three classical microeconomics variables, fixed or variable: price, quantity, and expense. Time dimensions are used to analyze their attributes and effects. Different mechanisms emerge from the combination of these variables. Results Among the most used are: Fee-For-Service, Global Budget, Bundled Payments, Diagnosis-Related Groups, Per-capita, Performance Pay, and Risk-Sharing Agreements. A fourth has also gained importance: Financial Risk. Conclusions Payment mechanisms are essential to link health efforts with clinical practice. They make it possible to regulate relationships between insurers, providers, and users, which, depending on the architecture of the mechanism, can become beneficial or hinder the fulfillment of the objectives of the health system.

Delivering maternal and childcare at primary healthcare level: The role of PMAQ as a pay for performance strategy in Brazil

Background

Improving access and quality in health care is a pressing issue worldwide and pay for performance (P4P) strategies have emerged as an alternative to enhance structure, process and outcomes in health. In 2011, Brazil adopted its first P4P scheme at national level, the National Programme for Improving Primary Care Access and Quality (PMAQ). The contribution of PMAQ in achieving the Sustainable Development Goals related to maternal and childcare remains under investigated in Brazil.

Objective

To estimate the association of PMAQ with the provision of maternal and childcare in Brazil, controlling for socioeconomic, geographic and family health team characteristics.

Method

We used cross-sectional quantile regression (QR) models for two periods, corresponding to 33,368 Family Health Teams (FHTs) in the first cycle and 39,211 FHTs in the second cycle of PMAQ. FHTs were analysed using data from the Brazilian Ministry of Health (SIAB and CNES) and the Brazilian Institute for Geography and Statistics (IBGE).

Results

The average number of antenatal consultations per month were positively associated with PMAQ participating teams, with larger effect in the lower tail (10^th and 25^th quantiles) of the conditional distribution of the response variable. There was a positive association between PMAQ and the average number of consultations under 2 years old per month in the 10^th and 25^th quantiles, but a negative association in the upper tail (75^th and 90^th quantiles). For the average number of physician consultations for children under 1 year old per month, PMAQ participating teams were positively associated with the response variable in the lower tail, but different from the previous models, there is no clear evidence that the second cycle gives larger coefficients compared with first cycle.

Conclusion

PMAQ has contributed to increase the provision of care to pregnant women and children under 2 years at primary healthcare level. Teams with lower average number of antenatal or child consultations benefited the most by participating in PMAQ, which suggests that PMAQ might motivate worse performing health providers to catch up.

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

BACKGROUND

Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important.

OBJECTIVES

The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups.

METHODS

In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections.

RESULTS

We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included.

CONCLUSIONS

Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.

The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage

BACKGROUND

Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce.

METHODS

A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence.

FINDINGS

Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients' sex with the policy intervention. Few (15%) of the studies controlled for the provider's sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity).

CONCLUSIONS

There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.

Effects of pay-for-performance on prescription of hypertension drugs among public and private primary care providers in Sweden

This study exploits policy reforms in Swedish primary care to examine the effect of pay-for-performance (P4P) on compliance with hypertension drug guidelines among public and private health care providers. Using provider-level outcome data for 2005-2013 from the Swedish Prescription Register, providers in regions using P4P were compared to providers in other regions in a difference-in-differences analysis. The results indicate that P4P improved guideline compliance regarding prescription of angiotensin converting enzyme inhibitors and angiotensin receptor blockers. The effect was mainly driven by private providers, suggesting that policy makers should take ownership into account when designing incentives for health care providers.

Performance payment challenges for family physician program

CONTEXT

Payment mechanisms are one of the effective tools for achieving optimal results in health system. Pay for performance (P4P) is one of the best programs to enhance the quality of health services through financial incentives. Considering of implementing family physician program in Iran and the P4P system, it is essential to address the challenges of implementing P4P system in the family physician program.

AIMS

This study aimed to investigate the challenges of implementation of P4P system in family physician program.

SETTINGS AND DESIGN

The qualitative study was carried out at areas covered by Iran University of Medical Sciences in Tehran, Iran.

MATERIALS AND METHODS

The semi-structured interview was conducted on 32 key informants in 2019. The sampling method was determined based on purposeful sampling. The topic guide of interviews was experiences in implementing of family physician program and challenges of implementing P4P system. Participants had least 5-year experience in the family physician program.

STATISTICAL ANALYSIS USED

A framework analysis was used to analyze the data using the software MAXQDA 10.

RESULTS

The current study identified 7 themes, 14 subthemes, and 46 items related to the challenges to successful implementation of P4P systems in the family physician program including family physicians' workload, family physician training, promoting family physician program, paying to the family physician team, assessment and monitoring systems, information management, and the level of authority of family physicians.

CONCLUSION

The study results demonstrated notable challenges for successful implementation of P4P system which can helpful to managers and policymakers.

Can Pay-for Performance Incentive Levels be Determined Using a Cost-Effectiveness Framework?

BACKGROUND

Healthcare payers in the United States are increasingly tying provider payments to quality and value using pay-for-performance policies. Cost-effectiveness analysis quantifies value in healthcare but is not currently used to design or prioritize pay-for-performance strategies or metrics. Acute ischemic stroke care provides a useful application to demonstrate how simulation modeling can be used to determine cost-effective levels of financial incentives used in pay-for-performance policies and associated challenges with this approach.

METHODS AND RESULTS

Our framework requires a simulation model that can estimate quality-adjusted life years and costs resulting from improvements in a quality metric. A monetary level of incentives can then be back-calculated using the lifetime discounted quality-adjusted life year (which includes effectiveness of quality improvement) and cost (which includes incentive payments and cost offsets from quality improvements) outputs from the model. We applied this framework to an acute ischemic stroke microsimulation model to calculate the difference in population-level net monetary benefit (willingness-to-pay of $50 000 to $150 000/quality-adjusted life year) accrued under current Medicare policy (stroke payment not adjusted for performance) compared with various hypothetical pay-for-performance policies. Performance measurement was based on time-to-thrombolytic treatment with tPA (tissue-type plasminogen activator). Compared with current payment, equivalent population-level net monetary benefit was achieved in pay-for-performance policies with 10-minute door-to-needle time reductions (5057 more acute ischemic stroke cases/y in the 0-3-hour window) incentivized by increasing tPA payment by as much as 18% to 44% depending on willingness-to-pay for health.

CONCLUSIONS

Cost-effectiveness modeling can be used to determine the upper bound of financial incentives used in pay-for-performance policies, although currently, this approach is limited due to data requirements and modeling assumptions. For tPA payments in acute ischemic stroke, our model-based results suggest financial incentives leading to a 10-minute decrease in door-to-needle time should be implemented but not exceed 18% to 44% of current tPA payment. In general, the optimal level of financial incentives will depend on willingness-to-pay for health and other modeling assumptions around parameter uncertainty and the relationship between quality improvements and long-run quality-adjusted life expectancy and costs.

Family physician model in the health system of selected countries: A comparative study summary

BACKGROUND

In the 21st century, with the epidemiological and demographic transition and the changing nature of diseases and the increase in the burden of chronic diseases, the need to strengthen primary health care and the development of the family medical program as a strategy is felt significantly.

AIM

The purpose of this study is to compare the model of implementation of family physician program (FPP) in the United States, England, Germany, Singapore, Turkey, Egypt, and Iran.

MATERIALS AND METHODS

This is a comparative study that examines the model of family physician implementation in selected countries. Data for each country were gathered from the valid databases, were compared according to the comparative table, and analyzed by a framework approach. In order to assure the validity of data, the researchers referred to the websites of the selected nations' Ministry of Health and also cross-checked the findings with reports published by the World Health Organization.

RESULTS

In this study, we used the Control Knobs framework to compare countries' FPPs because the framework can demonstrate all necessary features of national health system programs. This framework includes governance and organization, regulation, financing, payment, and behavior in each country. The results of this study show that although the principles of FPP in the selected countries are almost common, they use different methods in FPP implementation.

CONCLUSIONS

As the success of any policy depends on the political, economic, social, and cultural context of each country, considering these factors and reinforcing each of the control knobs are critical to the success of the family physician's policy implementation.

Volatility and Persistence of Value-Based Purchasing Adjustments: A Challenge to Integrating Population Health and Community Benefit Into Business Operations

With the passage of the Deficit Reduction Act of 2005 and the Patient Protection and Affordable Care Act in 2010, Medicare's Inpatient Prospective Payment System (IPPS) began a transition to value-based purchasing (VBP) that rewards or penalizes hospitals based on patient satisfaction, clinical processes of care, outcomes, and efficiency metrics. However, hospital-level volatility vs. persistence in value-based payments year-over-year could result in unpredictable cash flows that negatively influence investment behavior, drive underinvestment in community benefit/population health management initiatives, and make management of the factors that drive the VBP adjustment more challenging. To evaluate the volatility and persistence of hospital VBP adjustments, the sample includes VBP adjustments and the associated domain scores for the 2,547 hospitals that participated in the program from 2013 to 2016. The sample includes urban (74%), teaching (29.1%), system affiliated (46.5%), and not-for-profit (63.6%) facilities. Volatility was measured using basic descriptive statistics, relative risk ratios, and a fixed effect, autoregressive, dynamic panel model that robust-clustered the standard errors. There is substantial change in a given facility's total VBP score with an average standard deviation of 10.74 (on a 100-point scale) that is driven by significant volatility in all metrics but particularly by efficiency and outcomes metrics. Relative risk ratios have dropped substantially over the life of the program, and there is low persistence of VBP scores from one period to the next. Findings indicate that if hospitals receive a positive adjustment in 1 year, they are almost as likely to receive a negative adjustment as a positive adjustment the following year. Furthermore, using a fixed-effect dynamic panel model that controls for autocorrelation, we find that only 13.5% of a facility's prior year IPPS adjustment (positive or negative) carries forward to the next year. The low persistence makes investment in population health management and community benefit more challenging.

Literature review of managerial levers in primary care

PURPOSE

This study aims to analyze the managerial levers previously considered in literature in the setting of the provision of primary care and community services (in particular for patients with long-term conditions being treated also at home) as well as those scarcely explored that could potentially be adopted in the future.

DESIGN/METHODOLOGY/APPROACH

This study was a structured literature review. The authors retrieved papers, published from 2005-2020, from electronic databases (i.e. ABI/INFORM Complete, Jstor, PubMed and Scopus). Each selected paper was assigned to a framework category, and a thematic analysis was performed.

FINDINGS

Topics scarcely explored in literature were related to logistics/supply chain, economic evaluations, performance management and customer satisfaction. Some papers embraced more than one management topic, confirming the multidisciplinary nature of territorial healthcare services. The majority of research, however, focused on only one aspect of primary care services, and a lack of an integrated view regarding the provision of those services emerged.

ORIGINALITY/VALUE

This study represents a first attempt to rationalize the fragmented body of knowledge on the topic of the provision of primary and community care services. This study enabled some light to be shed on the managerial levers already explored previously in literature and also identifies a number of trajectories for future research.

The effect of 'paying for performance' on the management of type 2 diabetes mellitus: a cross-sectional observational study

Background

The ‘cycle of care’ (COC) pay for performance (PFP) programme, introduced in 2015, has resourced Irish GPs to provide structured care to PCRS eligible patients with type 2 diabetes mellitus (T2DM).

Aim

To investigate the effect of COC on management processes.

Design &setting

Cross-sectional observational study undertaken with two points of comparison (2014 and 2017) in participating practices (Republic of Ireland general practices), with comparator data from the United Kingdom National Diabetes Audit (UKNDA) 2015–2016.

Method

Invitations to participate were sent to practices using a discussion forum for Health One clinical software. Participating practices provided data on the processes of care in the management of patients with T2DM. Data on PCRS eligible patients was extracted from the electronic medical record system of participating practices using secure customised software. Descriptive analysis, using IBM SPSS Statistics for Windows (version 25), was performed.

Results

Of 250 practices invited, 41 practices participated (16.4%), yielding data from 3146 patients. There were substantial improvements in the rates of recording of glycosylated haemoglobin ([HbA1c] 53.1%–98.3%), total cholesterol ([TC] 59.2%–98.8%), urinary albumin:creatinine ratio ([ACR] 9.9%–42.3%), blood pressure ([BP] 61.4%–98.2%), and body-mass index ([BMI] 39.8%–97.4%) from 2014 to 2017. For the first time, rates of retinopathy screening (76.3%), foot review (64.9%), and influenza immunisation (69.9%) were recorded. Comparison of 2017 data with UKNDA 2015–2016 was broadly similar.

Conclusion

The COC demonstrated much improved rates of recording of clinical and biochemical parameters, and improved achievement of targets in TC and BP, but not HbA1c. Results demonstrate substantial improvements in the processes and quality of care in the management of patients with T2DM.

Human resources for health interventions in high- and middle-income countries: findings of an evidence review

Many high- and middle-income countries face challenges in developing and maintaining a health workforce which can address changing population health needs. They have experimented with interventions which overlap with but have differences to those documented in low- and middle-income countries, where many of the recent literature reviews were undertaken. The aim of this paper is to fill that gap. It examines published and grey evidence on interventions to train, recruit, retain, distribute, and manage an effective health workforce, focusing on physicians, nurses, and allied health professionals in high- and middle-income countries. A search of databases, websites, and relevant references was carried out in March 2019. One hundred thirty-one reports or papers were selected for extraction, using a template which followed a health labor market structure. Many studies were cross-cutting; however, the largest number of country studies was focused on Canada, Australia, and the United States of America. The studies were relatively balanced across occupational groups. The largest number focused on availability, followed by performance and then distribution. Study numbers peaked in 2013-2016. A range of study types was included, with a high number of descriptive studies. Some topics were more deeply documented than others-there is, for example, a large number of studies on human resources for health (HRH) planning, educational interventions, and policies to reduce in-migration, but much less on topics such as HRH financing and task shifting. It is also evident that some policy actions may address more than one area of challenge, but equally that some policy actions may have conflicting results for different challenges. Although some of the interventions have been more used and documented in relation to specific cadres, many of the lessons appear to apply across them, with tailoring required to reflect individuals' characteristics, such as age, location, and preferences. Useful lessons can be learned from these higher-income settings for low- and middle-income settings. Much of the literature is descriptive, rather than evaluative, reflecting the organic way in which many HRH reforms are introduced. A more rigorous approach to testing HRH interventions is recommended to improve the evidence in this area of health systems strengthening.

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Evaluation of implementation strategies of the Best Practices Spotlight Organisations (BPSO) Project in Spain

OBJECTIVE

To identify favourable elements and barriers to implementation in the Program of Best Practice Spotlight Organization® that establish clinical practice guidelines of the Registered Nurse' Association of Ontario, so that future experiences could benefit from the assessments presented here.

METHOD

Evaluation research study of the process of implementing guidelines in institutions that make up the first two cohorts of the programme in Spain, through analysis of contents of implantation reports and inductive process, reading, interpretation, coding and categorized according to SWOT structure: Strengths, weaknesses, opportunities and threats.

RESULTS

Reports from 18 centres in 12 Autonomous Communities have been analyzed, including 22 different guidelines. As weaknesses, problems related to information systems and their exploitation stand out for frequency and intensity. Other elements related to dissemination of results, to professionals, care and factors related to the institution are presented. Standing out as threats are the instability of staff and continued changes in Senior Management or corporate policies. Among the strengths, the exclusive dedication of personnel to the project and its link to institutional objectives are distinguished. As opportunities, the possibility of standardized comparison of own results with others, as well as the dissemination of results are highlighted.

CONCLUSION

A useful pattern is set up to approach implementation in other scenarios, where changes in professional culture, training, communication and leadership, as well as aligning interests of managers and politicians, facilitate ideal conditions for Evidence-Based Practice.

Quality performance and associated factors in Swiss diabetes care - A cross-sectional study

INTRODUCTION

Quality indicators and pay-for-performance schemes aim to improve processes and outcomes in clinical practice. However, general practitioner and patient characteristics influence quality indicator performance. In Switzerland, no data on the pay-for-performance approach exists and the use of quality indicators has been marginal. The aim of this study was to describe quality indicator performance in diabetes care in Swiss primary care and to analyze associations of practice, general practitioner and patient covariates with quality indicator performance.

METHODS

For this cross-sectional study, we used medical routine data from an electronic medical record database. Data from 71 general practitioners and all their patients with diabetes were included. Starting in July 2018, we retrieved 12-month retrospective data about practice, general practitioner and patient characteristics, laboratory values, comorbidities and co-medication. Based on this data, we assessed quality indicator performance of process and intermediate outcomes for glycated hemoglobin, blood pressure, cholesterol and associations of practice, general practitioner and patient characteristics with individual and cumulative quality indicator performance. We calculated odds ratios (OR) and 95% confidence intervals (CI) using regression methods.

RESULTS

We assessed 3,383 patients with diabetes (57% male, mean age 68.3 years). On average, patients fulfilled 3.56 (standard deviation: 1.89) quality indicators, whereas 17.2% of the patients fulfilled all six quality indicators. On practice and general practitioner level, we found no associations with cumulative quality indicator performance. On patient level, gender (ref = male) (OR: 0.83, CI: 0.78-0.88), number of treating general practitioners (OR: 0.94, CI: 0.91-0.97), number of comorbidities (OR: 1.43, CI: 1.38-1.47) and number of consultations (OR: 1.02, CI: 1.02-1.02) were associated with cumulative quality indicator performance.

CONCLUSION

The influence of practice, general practitioner and patient characteristics on quality indicator performance was surprisingly small and room for improvement in quality indicator performance of Swiss general practitioners seems to exist in diabetes care.

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

BACKGROUND

Pay for performance (P4P) schemes provide financial incentives to health workers or facilities based on the achievement of pre-specified performance targets and have been widely implemented in health systems across low and middle-income countries (LMICs). The growing evidence base on P4P highlights that (i) there is substantial variation in the effect of P4P schemes on outcomes and (ii) there appears to be heterogeneity in incentive design. Even though scheme design is likely a key determinant of scheme effectiveness, we currently lack systematic evidence on how P4P schemes are designed in LMICs.

METHODS

We develop a typology to classify the design of P4P schemes in LMICs, which highlights different design features that are a priori likely to affect the behaviour of incentivised actors. We then use results from a systematic literature review to classify and describe the design of P4P schemes that have been evaluated in LMICs. To capture academic publications, Medline, Embase, and EconLit databases were searched. To include relevant grey literature, Google Scholar, Emerald Insight, and websites of the World Bank, WHO, Cordaid, Norad, DfID, USAID and PEPFAR were searched.

RESULTS

We identify 41 different P4P schemes implemented in 29 LMICs. We find that there is substantial heterogeneity in the design of P4P schemes in LMICs and pinpoint precisely how scheme design varies across settings. Our results also highlight that incentive design is not adequately being reported on in the literature - with many studies failing to report key design features.

CONCLUSIONS

We encourage authors to make a greater effort to report information on P4P scheme design in the future and suggest using the typology laid out in this paper as a starting point.

Review of 128 quality of care mechanisms: A framework and mapping for health system stewards

Health system stewards have the critical task to identify quality of care deficiencies and resolve underlying system limitations. Despite a growing evidence-base on the effectiveness of certain mechanisms for improving quality of care, frameworks to facilitate the oversight function of stewards and the use of mechanisms to improve outcomes remain underdeveloped. This review set out to catalogue a wide range of quality of care mechanisms and evidence on their effectiveness, and to map these in a framework along two dimensions: (i) governance subfunctions; and (ii) targets of quality of care mechanisms. To identify quality of care mechanisms, a series of searches were run in Health Systems Evidence and PubMed. Additional grey literature was reviewed. A total of 128 quality of care mechanisms were identified. For each mechanism, searches were carried out for systematic reviews on their effectiveness. These findings were mapped in the framework defined. The mapping illustrates the range and evidence for mechanisms varies and is more developed for some target areas such as the health workforce. Across the governance sub-functions, more mechanisms and with evidence of effectiveness are found for setting priorities and standards and organizing and monitoring for action. This framework can support system stewards to map the quality of care mechanisms used in their systems and to uncover opportunities for optimization backed by systems thinking.

The quality of preventive care for pre-school aged children in Australian general practice

BACKGROUND

Variable and poor care quality are important causes of preventable patient harm. Many patients receive less than recommended care, but the extent of the problem remains largely unknown. The CareTrack Kids (CTK) research programme sought to address this evidence gap by developing a set of indicators to measure the quality of care for common paediatric conditions. In this study, we focus on one clinical area, 'preventive care' for pre-school aged children. Our objectives were two-fold: (i) develop and validate preventive care quality indicators and (ii) apply them in general medical practice to measure adherence.

METHODS

Clinical experts (n = 6) developed indicator questions (IQs) from clinical practice guideline (CPG) recommendations using a multi-stage modified Delphi process, which were pilot tested in general practice. The medical records of Australian children (n = 976) from general practices (n = 80) in Queensland, New South Wales and South Australia identified as having a consultation for one of 17 CTK conditions of interest were retrospectively reviewed by trained paediatric nurses. Statistical analyses were performed to estimate percentage compliance and its 95% confidence intervals.

RESULTS

IQs (n = 43) and eight care 'bundles' were developed and validated. Care was delivered in line with the IQs in 43.3% of eligible healthcare encounters (95% CI 30.5-56.7). The bundles of care with the highest compliance were 'immunisation' (80.1%, 95% CI 65.7-90.4), 'anthropometric measurements' (52.7%, 95% CI 35.6-69.4) and 'nutrition assessments' (38.5%, 95% CI 24.3-54.3), and lowest for 'visual assessment' (17.9%, 95% CI 8.2-31.9), 'musculoskeletal examinations' (24.4%, 95% CI 13.1-39.1) and 'cardiovascular examinations' (30.9%, 95% CI 12.3-55.5).

CONCLUSIONS

This study is the first known attempt to develop specific preventive care quality indicators and measure their delivery to Australian children in general practice. Our findings that preventive care is not reliably delivered to all Australian children and that there is substantial variation in adherence with the IQs provide a starting point for clinicians, researchers and policy makers when considering how the gap between recommended and actual care may be narrowed. The findings may also help inform the development of specific improvement interventions, incentives and national standards.

Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review

BACKGROUND

Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems.

METHODS

Studies were identified by searching ten databases (01/2000-04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs.

RESULTS

We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term-when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts.

CONCLUSION

Evidence of the effectiveness of P4P depends on whether physicians' incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.

Designing and using incentives to support recruitment and retention in clinical trials: a scoping review and a checklist for design

Background

Recruitment and retention of participants are both critical for the success of trials, yet both remain significant problems. The use of incentives to target participants and trial staff has been proposed as one solution. The effects of incentives are complex and depend upon how they are designed, but these complexities are often overlooked. In this paper, we used a scoping review to ‘map’ the literature, with two aims: to develop a checklist on the design and use of incentives to support recruitment and retention in trials; and to identify key research topics for the future.

Methods

The scoping review drew on the existing economic theory of incentives and a structured review of the literature on the use of incentives in three healthcare settings: trials, pay for performance, and health behaviour change. We identified the design issues that need to be considered when introducing an incentive scheme to improve recruitment and retention in trials. We then reviewed both the theoretical and empirical evidence relating to each of these design issues. We synthesised the findings into a checklist to guide the design of interventions using incentives.

Results

The issues to consider when designing an incentive system were summarised into an eight-question checklist. The checklist covers: the current incentives and barriers operating in the system; who the incentive should be directed towards; what the incentive should be linked to; the form of incentive; the incentive size; the structure of the incentive system; the timing and frequency of incentive payouts; and the potential unintended consequences. We concluded the section on each design aspect by highlighting the gaps in the current evidence base.

Conclusions

Our findings highlight how complex the design of incentive systems can be, and how crucial each design choice is to overall effectiveness. The most appropriate design choice will differ according to context, and we have aimed to provide context-specific advice. Whilst all design issues warrant further research, evidence is most needed on incentives directed at recruiters, optimal incentive size, and testing of different incentive structures, particularly exploring repeat arrangements with recruiters.

An evaluation of a multifaceted, local Quality Improvement Framework for long-term conditions in UK primary care

BACKGROUND

The evidence that large pay-for-performance schemes improve the health of populations is mixed-evidence regarding locally implemented schemes is limited.

OBJECTIVE

This study evaluates the effects in Stoke-on-Trent of a local, multifaceted Quality Improvement Framework including pay for performance in general practice introduced in 2009 in the context of the national Quality and Outcomes Framework that operated from 2004.

METHODS

We compared age-standardized mortality data from all 326 local authorities in England with the rates in Stoke-on-Trent using Difference-in-Differences, estimating a fixed-effects linear regression model with an interaction effect.

RESULTS

In addition to the existing downward trend in cardiovascular deaths, we find an additional annual reduction of 36 deaths compared with the national mean for coronary heart disease and 13 deaths per 100000 from stroke in Stoke-on-Trent. Compared with the national mean, there was an additional reduction of 9 deaths per 100000 people per annum for coronary heart disease and 14 deaths per 100000 people per annum for stroke following the introduction of the 2009 Stoke-on-Trent Quality Improvement Framework.

CONCLUSION

There are concerns about the unintended consequences of large pay-for-performance schemes in health care, but in a population with a high prevalence of disease, they may at least initially be beneficial. This study also provides evidence that a local, additional scheme may further improve the health of populations. Such schemes, whether national or local, require periodic review to evaluate the balance of their benefits and risks.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

GP incentives to design hypertension and atrial fibrillation local quality-improvement schemes: a controlled before-after study in UK primary care

BACKGROUND

Financial incentives in the UK such as the Quality and Outcomes Framework (QOF) reward GP surgeries for achievement of nationally defined targets. These have shown mixed results, with weak evidence for some measures, but also possible unintended negative effects.

AIM

To look at the effects of a local intervention for atrial fibrillation (AF) and hypertension, with surgeries rewarded financially for work, including appointing designated practice leads, attendance at peer review workshops, and producing their own protocols.

DESIGN AND SETTING

A controlled before-after study comparing surgery performance measures in UK primary care.

METHOD

This study used published QOF data to analyse changes from baseline in mean scores per surgery relating to AF and hypertension prevalence and management at T1 (12 months) and T2 (24 months) for the intervention group, which consisted of all 58 surgeries in East Lancashire Clinical Commissioning Group (CCG), compared to the control group, which consisted of all other surgeries in north-west England.

RESULTS

There was a small acceleration between T0 (baseline) and T2 in recorded prevalence of hypertension in the intervention group compared to the controls, difference 0.29% (95% confidence interval [CI] = 0.05 to 0.53), P = 0.017, but AF prevalence did not increase more in the intervention group. Improvement in quality of management of AF was significantly better in the intervention group, difference 3.24% (95% CI = 1.37 to 5.12), P = 0.001.

CONCLUSION

This intervention improved diagnosis rates of hypertension but not AF, though it did improve quality of AF management. It indicates that funded time to develop quality-improvement measures targeted at a local population and involving peer support can engage staff and have the potential to improve quality.

Motivating provision of high quality care: it is not all about the money

Mylène Lagarde, Luis Huicho, and Irene Papanicolas discuss different strategies policy makers can use to motivate health providers in order to improve quality of care

A Randomized Trial of External Practice Support to Improve Cardiovascular Risk Factors in Primary Care

PURPOSE

We conducted a randomized controlled trial to compare the effectiveness of adding various forms of enhanced external support to practice facilitation on primary care practices' clinical quality measure (CQM) performance.

METHODS

Primary care practices across Washington, Oregon, and Idaho were eligible if they had fewer than 10 full-time clinicians. Practices were randomized to practice facilitation only, practice facilitation and shared learning, practice facilitation and educational outreach visits, or practice facilitation and both shared learning and educational outreach visits. All practices received up to 15 months of support. The primary outcome was the CQM for blood pressure control. Secondary outcomes were CQMs for appropriate aspirin therapy and smoking screening and cessation. Analyses followed an intention-to-treat approach.

RESULTS

Of 259 practices recruited, 209 agreed to be randomized. Only 42% of those offered educational outreach visits and 27% offered shared learning participated in these enhanced supports. CQM performance improved within each study arm for all 3 cardiovascular disease CQMs. After adjusting for differences between study arms, CQM improvements in the 3 enhanced practice support arms of the study did not differ significantly from those seen in practices that received practice facilitation alone (omnibus P = .40 for blood pressure CQM). Practices randomized to receive both educational outreach visits and shared learning, however, were more likely to achieve a blood pressure performance goal in 70% of patients compared with those randomized to practice facilitation alone (relative risk = 2.09; 95% CI, 1.16-3.76).

CONCLUSIONS

Although we found no significant differences in CQM performance across study arms, the ability of a practice to reach a target level of performance may be enhanced by adding both educational outreach visits and shared learning to practice facilitation.

Pay for performance for hospitals

BACKGROUND

Pay-for-Performance (P4P) is a payment model that rewards health care providers for meeting pre-defined targets for quality indicators or efficacy parameters to increase the quality or efficacy of care.

OBJECTIVES

Our objective was to assess the impact of P4P for in-hospital delivered health care on the quality of care, resource use and equity. Our objective was not only to answer the question whether P4P works in general (simple perspective) but to provide a comprehensive and detailed overview of P4P with a focus on analyzing the intervention components, the context factors and their interrelation (more complex perspective).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, three other databases and two trial registers on 27 June 2018. In addition, we searched conference proceedings, gray literature and web pages of relevant health care institutions, contacted experts in the field, conducted cited reference searches and performed cross-checks of included references and systematic reviews on the same topic.

SELECTION CRITERIA

We included randomized trials, cluster randomized trials, non-randomized clustered trials, controlled before-after studies, interrupted time series and repeated measures studies that analyzed hospitals, hospital units or groups of hospitals and that compared any kind of P4P to a basic payment scheme (e.g. capitation) without P4P. Studies had to analyze at least one of the following outcomes to be eligible: patient outcomes; quality of care; utilization, coverage or access; resource use, costs and cost shifting; healthcare provider outcomes; equity; adverse effects or harms.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened all citations for inclusion, extracted study data and assessed risk of bias for each included study. Study characteristics were extracted by one reviewer and verified by a second.We did not perform meta-analysis because the included studies were too heterogenous regarding hospital characteristics, the design of the P4P programs and study design. Instead we present a structured narrative synthesis considering the complexity as well as the context/setting of the intervention. We assessed the certainty of evidence using the GRADE approach and present the results narratively in 'Summary of findings' tables.

MAIN RESULTS

We included 27 studies (20 CBA, 7 ITS) on six different P4P programs. Studies analyzed between 10 and 4267 centers. All P4P programs targeted acute or emergency physical conditions and compared a capitation-based payment scheme without P4P to the same capitation-based payment scheme combined with a P4P add-on. Two P4P program used rewards or penalties; one used first rewards and than penalties; two used penalties only and one used rewards only. Four P4P programs were established and evaluated in the USA, one in England and one in France.Most studies showed no difference or a very small effect in favor of the P4P program. The impact of each P4P program was as follows.Premier Hospital Quality Incentive Demonstration Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events, quality of care, equity or resource use as the certainty of the evidence was very low.Value-Based Purchasing Program: It is uncertain whether this program, which used rewards for some hospitals and penalties for others, has an impact on mortality, adverse clinical events or quality of care as the certainty of the evidence was very low. Equity and resource use outcomes were not reported in the studies, which evaluated this program.Non-payment for Hospital-Acquired Conditions Program: It is uncertain whether this penalty-based program has an impact on adverse clinical events as the certainty of the evidence was very low. Mortality, quality of care, equity and resource use outcomes were not reported in the studies, which evaluated this program.Hospital Readmissions Reduction Program: None of the studies that examined this penalty-based program reported mortality, adverse clinical events, quality of care (process quality score), equity or resource use outcomes.Advancing Quality Program: It is uncertain whether this reward-/penalty-based program has an impact on mortality as the certainty of the evidence was very low. Adverse clinical events, quality of care, equity and resource use outcomes were not reported in any study.Financial Incentive to Quality Improvement Program: It is uncertain whether this reward-based program has an impact on quality of care, as the certainty of the evidence was very low. Mortality, adverse clinical events, equity and resource use outcomes were not reported in any study.Subgroup analysis (analysis of modifying design and context factors)Analysis of P4P design factors provides some hints that non-payments compared to additional payments and payments for quality attainment (e.g. falling below specified mortality threshold) compared to quality improvement (e.g. reduction of mortality by specified percent points within one year) may have a stronger impact on performance.

AUTHORS' CONCLUSIONS

It is uncertain whether P4P, compared to capitation-based payments without P4P for hospitals, has an impact on patient outcomes, quality of care, equity or resource use as the certainty of the evidence was very low (or we found no studies on the outcome) for all P4P programs. The effects on patient outcomes of P4P in hospitals were at most small, regardless of design factors and context/setting. It seems that with additional payments only small short-term but non-sustainable effects can be achieved. Non-payments seem to be slightly more effective than bonuses and payments for quality attainment seem to be slightly more effective than payments for quality improvement.

The Association Between Primary Care Physician Compensation and Patterns of Care Delivery, 2012-2015

As health systems seek to incentivize physicians to deliver high-value care, the relationship between physician compensation and health care delivery is an important knowledge gap. To examine physician compensation nationally and its relationship with care delivery, we examined 2012-2015 cross-sectional data on ambulatory primary care physician visits from the National Ambulatory Medical Care Survey. Among 175 762 office visits with 3826 primary care physicians, 15.4% of primary care physicians reported salary-based, 4.5% productivity-based, and 12.9% "mixed" compensation, while 61.4% were practice owners. After adjustment, delivery of out-of-visit/office care was more common for practice owners and "mixed" compensation primary care physicians, while there was little association between compensation type and rates of high- or low-value care delivery. Despite early health reform efforts, the overall landscape of physician compensation has remained strongly tethered to fee-for-service. The lack of consistent association between compensation and care delivery raises questions about the potential impact of payment reform on individual physicians' behavior.

Gendered effects of pay for performance among family physicians for chronic disease care: an economic evaluation in a context of universal health coverage

BACKGROUND

Despite increasing popularity among health organizations of pay for performance (P4P) for the provision of comprehensive care for chronic non-communicable diseases, evidence of its effectiveness in improving health system outcomes is weak. An important void in the evidence base is whether there are gendered differences in P4P uptake and in related outcomes amenable to healthcare improvement. This study assesses the gender-specific effects of P4P among family physicians on diabetes healthcare costs in a context of universal health coverage.

METHODS

We use population-based linked longitudinal administrative datasets on chronic disease cases, physician billings, hospital discharge abstracts, and physician and resident registries in the province of New Brunswick, Canada. We estimate the effects of introduction of a P4P scheme on excess public healthcare costs among cohorts of adult diabetes patients using propensity score-adjusted difference-in-differences regressions stratified by physician's gender.

RESULTS

We observed greater male physician uptake of incentive payments, seemingly exacerbating gender gaps in professional remuneration. Regression results indicated P4P did not lead to improved outcomes in terms of preventing hospitalization costs among patients, only measurable increases in compensation for both the male and female physician workforce.

CONCLUSIONS

While P4P was not attributed in this study to reduced hospital burden and enhanced sustainability of healthcare financing, incentive payments were found to be related to earning gaps by physician's gender. Decision-makers should consider that benefits of P4P be monitored not only for patient metrics but also for provider metrics in terms of gender equality especially given feminization of primary care medical workforces.

Does payment for performance increase performance inequalities across health providers? A case study of Tanzania

The impact of payment-for-performance (P4P) schemes in the health sector has been documented, but there has been little attention to the distributional effects of P4P across health facilities. We examined the distribution of P4P payouts over time and assessed whether increased service coverage due to P4P differed across facilities in Tanzania. We used two service outcomes that improved due to P4P [facility-based deliveries and provision of antimalarials during antenatal care (ANC)], to also assess whether incentive design matters for performance inequalities. We used data from 150 facilities from intervention and comparison areas in January 2012 and 13 months later. Our primary data were gathered through facility survey and household survey, while data on performance payouts were obtained from the programme administrator. Descriptive inequality measures were used to examine the distribution of payouts across facility subgroups. Difference-in-differences regression analyses were used to identify P4P differential effects on the two service coverage outcomes across facility subgroups. We found that performance payouts were initially higher among higher-level facilities (hospitals and health centres) compared with dispensaries, among facilities with more medical commodities and among facilities serving wealthier populations, but these inequalities declined over time. P4P had greater effects on coverage of institutional deliveries among facilities with low baseline performance, serving middle wealth populations and located in rural areas. P4P effects on antimalarials provision during ANC was similar across facilities. Performance inequalities were influenced by the design of incentives and a range of facility characteristics; however, the nature of the service being targeted is also likely to have affected provider response. Further research is needed to examine in more detail the effects of incentive design on outcomes and researchers should be encouraged to report on design aspects in their evaluations of P4P and systematically monitor and report subgroup effects across providers.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Are value-based incentives driving behavior change to improve value?

OBJECTIVES

To understand physician organization (PO) responses to financial incentives for quality and total cost of care among POs that were exposed to a statewide multipayer value-based payment (VBP) program, and to identify challenges that POs face in advancing the goals of VBP.

STUDY DESIGN

Semistructured qualitative interviews and survey.

METHODS

We drew a stratified random sample of 40 multispecialty California POs (25% of the POs that were eligible for incentives). In-person interviews were conducted with physician leaders and a survey was administered on actions being taken to reduce costs and redesign care and to discuss the challenges to improving value. We performed a thematic analysis of interview transcripts to identify common actions taken and challenges to reducing costs.

RESULTS

VBP helps to promote care delivery transformation among POs, although efforts varied across organizations. Investments are occurring primarily in strategies to control hospital costs and redesign primary care, particularly for chronically ill patients; specialty care redesign is largely absent. Physician payment incentives for value remain small relative to total compensation, with continued emphasis on productivity. Challenges cited include the lack of a single enterprisewide electronic health records platform for information exchange, limited ability to influence specialists who were not exclusive to the organization, lack of payer cost and utilization data to manage costs, inability to recoup care redesign investments given the small size of VBP incentives, and lack of physician cost awareness.

CONCLUSIONS

Transformation could be advanced by strengthening financial incentives for value; engaging specialists in care redesign and delivering value; enhancing partnerships among POs, hospitals, and payers to align quality and cost actions; strengthening information exchange across providers; and applying other strategies to influence physician behavior.

Effect of Financial Bonus Size, Loss Aversion, and Increased Social Pressure on Physician Pay-for-Performance: A Randomized Clinical Trial and Cohort Study

Importance

Despite limited effectiveness of pay-for-performance (P4P), payers continue to expand P4P nationally.

Objective

To test whether increasing bonus size or adding the behavioral economic principles of increased social pressure (ISP) or loss aversion (LA) improves the effectiveness of P4P.

Design, Setting, and Participants

Parallel studies conducted from January 1 to December 31, 2016, consisted of a randomized clinical trial with patients cluster-randomized by practice site to an active control group (larger bonus size [LBS] only) or to groups with 1 of 2 behavioral economic interventions added and a cohort study comparing changes in outcomes among patients of physicians receiving an LBS with outcomes in propensity-matched physicians not receiving an LBS. A total of 8118 patients attributed to 66 physicians with 1 of 5 chronic conditions were treated at Advocate HealthCare, an integrated health system in Illinois. Data were analyzed using intention to treat and multiple imputation from February 1, 2017, through May 31, 2018.

Interventions

Physician participants received an LBS increased by a mean of $3355 per physician (LBS-only group); prefunded incentives to elicit LA and an LBS; or increasing proportion of a P4P bonus determined by group performance from 30% to 50% (ISP) and an LBS.

Main Outcomes and Measures

The proportion of 20 evidence-based quality measures achieved at the patient level.

Results

A total of 86 physicians were eligible for the randomized trial. Of these, 32 were excluded because they did not have unique attributed patients. Fifty-four physicians were randomly assigned to 1 of 3 groups, and 33 physicians (54.5% male; mean [SD] age, 57 [10] years) and 3747 patients (63.6% female; mean [SD] age, 64 [18] years) were included in the final analysis. Nine physicians and 864 patients were randomized to the LBS-only group, 13 physicians and 1496 patients to the LBS plus ISP group, and 11 physicians and 1387 patients to the LBS plus LA group. Physician characteristics did not differ significantly by arm, such as mean (SD) physician age ranging from 56 (9) to 59 (9) years, and sex (6 [46.2%] to 6 [66.7%] male). No differences were found between the LBS-only and the intervention groups (adjusted odds ratio [aOR] for LBS plus LA vs LBS-only, 0.86 [95% CI, 0.65-1.15; P = .31]; aOR for LBS plus ISP vs LBS-only, 0.95 [95% CI, 0.64-1.42; P = .81]; and aOR for LBS plus ISP vs LBS plus LA, 1.10 [95% CI, 0.75-1.61; P = .62]). Increased bonus size was associated with a greater increase in evidence-based care relative to the comparison group (risk-standardized absolute difference-in-differences, 3.2 percentage points; 95% CI, 1.9-4.5 percentage points; P < .001).

Conclusions and Relevance

Increased bonus size was associated with significantly improved quality of care relative to a comparison group. Adding ISP and opportunities for LA did not improve quality.

Trial Registration

ClinicalTrials.gov Identifier: NCT02634879.

Using behaviour change theory to train health workers on tobacco cessation support for tuberculosis patients: a mixed-methods study in Bangladesh, Nepal and Pakistan

Background

Low- and middle-income countries (LMICs) are disproportionately impacted by interacting epidemics of tuberculosis (TB) and tobacco consumption. Research indicates behavioural support delivered by health workers effectively promotes tobacco cessation. There is, however, a paucity of training to support LMIC health workers deliver effective tobacco cessation behavioural support. The TB and Tobacco Consortium undertook research in South Asia to understand factors affecting TB health workers’ delivery of tobacco cessation behavioural support, and subsequently developed a training package for LMICs.

Methods

Using the “capability, opportunity, and motivation as determinants of behaviour” (COM-B) framework to understand any issues facing health worker delivery of behaviour support, we analysed 25 semi-structured interviews and one focus group discussion with TB health workers, facility in-charges, and national tuberculosis control programme (NTP) staff members in each country. Results were integrated with findings of an adapted COM-B questionnaire on health worker confidence in tobacco cessation support delivery, administered to 36 TB health workers. Based on findings, we designed a guide and training programme on tobacco cessation support for health workers.

Results

Qualitative results highlighted gaps in the majority of health workers’ knowledge on tobacco cessation and TB and tobacco interaction, inadequate training on patient communication, insufficient resources and staff support, and NTPs’ non-prioritization of tobacco cessation in all three countries. Questionnaire results reiterated the knowledge deficits and low confidence in patient communication. Participants suggested strengthening knowledge, skills, and competence through training and professional incentives. Based on findings, we developed an interactive two-day training and TB health worker guide adaptable for LMICs, focusing on evidence of best practice on TB and tobacco cessation support, communication, and rapport building with patients.

Conclusions

TB health workers are essential in addressing the dual burden of TB and tobacco faced by many LMICs. Factors affecting their delivery of tobacco cessation support can be identified using the COM-B framework, and include issues such as individuals’ knowledge and skills, as well as structural barriers like professional support through monitoring and supervision. While structural changes are needed to tackle the latter, we have developed an adaptable and engaging health worker training package to address the former that can be delivered in routine TB care.

Trial registration

ISRCTN43811467.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-3909-4) contains supplementary material, which is available to authorized users.

Physician Empathy Is Not Associated with Laboratory Outcomes in Diabetes: a Cross-sectional Study

BACKGROUND

One widely cited study suggested a link between physician empathy and laboratory outcomes in patients with diabetes, but its findings have not been replicated. While empathy has a positive impact on patient experience, its impact on other outcomes remains unclear.

OBJECTIVE

To assess associations between physician empathy and glycosylated hemoglobin (HgbA1c) as well as low-density lipoprotein (LDL) levels in patients with diabetes.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Patients with diabetes who received care at a large integrated health system in the USA between January 1, 2011, and May 31, 2014, and their primary care physicians.

MAIN MEASURES

The main independent measure was physician empathy, as measured by the Jefferson Scale of Empathy (JSE). The JSE is scored on a scale of 20-140, with higher scores indicating greater empathy. Dependent measures included patient HgbA1c and LDL. Mixed-effects linear regression models adjusting for patient sociodemographic characteristics, comorbidity index, and physician characteristics were used to assess the association between physician JSE scores and their patients' HgbA1c and LDL.

KEY RESULTS

The sample included 4176 primary care patients who received care with one of 51 primary care physicians. Mean physician JSE score was 118.4 (standard deviation (SD) = 12). Median patient HgbA1c was 6.7% (interquartile range (IQR) = 6.2-7.5) and median LDL concentration was 83 (IQR = 66-104). In adjusted analyses, there was no association between JSE scores and HgbA1c (β = - 0.01, 95%CI = - 0.04, 0.02, p = 0.47) or LDL (β = 0.41, 95%CI = - 0.47, 1.29, p = 0.35).

CONCLUSION

Physician empathy was not associated with HgbA1c or LDL. While interventions to increase physician empathy may result in more patient-centered care, they may not improve clinical outcomes in patients with diabetes.

Influence of financial and reputational incentives on primary care performance: a longitudinal study

BACKGROUND

The Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time.

AIM

To determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme.

DESIGN AND SETTING

Observational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013.

METHOD

The authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards.

RESULTS

Both the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from -0.121 percentage points per quality point (95% CI = -0.220 to -0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013.

CONCLUSION

In the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.

Effects of Pay-for-Performance for Primary Care Physicians on Preventable Diabetes-Related Hospitalization Costs Among Adults in New Brunswick, Canada: A Quasiexperimental Evaluation

OBJECTIVES

In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs.

METHODS

We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive.

RESULTS

Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes.

CONCLUSIONS

The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.

Integrating evidence, models and maps to enhance Chagas disease vector surveillance

BACKGROUND

Until recently, the Chagas disease vector, Triatoma infestans, was widespread in Arequipa, Perú, but as a result of a decades-long campaign in which over 70,000 houses were treated with insecticides, infestation prevalence is now greatly reduced. To monitor for T. infestans resurgence, the city is currently in a surveillance phase in which a sample of houses is selected for inspection each year. Despite extensive data from the control campaign that could be used to inform surveillance, the selection of houses to inspect is often carried out haphazardly or by convenience. Therefore, we asked, how can we enhance efforts toward preventing T. infestans resurgence by creating the opportunity for vector surveillance to be informed by data?

METHODOLOGY/PRINCIPAL FINDINGS

To this end, we developed a mobile app that provides vector infestation risk maps generated with data from the control campaign run in a predictive model. The app is intended to enhance vector surveillance activities by giving inspectors the opportunity to incorporate the infestation risk information into their surveillance activities, but it does not dictate which houses to surveil. Therefore, a critical question becomes, will inspectors use the risk information? To answer this question, we ran a pilot study in which we compared surveillance using the app to the current practice (paper maps). We hypothesized that inspectors would use the risk information provided by the app, as measured by the frequency of higher risk houses visited, and qualitative analyses of inspector movement patterns in the field. We also compared the efficiency of both mediums to identify factors that might discourage risk information use. Over the course of ten days (five with each medium), 1,081 houses were visited using the paper maps, of which 366 (34%) were inspected, while 1,038 houses were visited using the app, with 401 (39%) inspected. Five out of eight inspectors (62.5%) visited more higher risk houses when using the app (Fisher's exact test, p < 0.001). Among all inspectors, there was an upward shift in proportional visits to higher risk houses when using the app (Mantel-Haenszel test, common odds ratio (OR) = 2.42, 95% CI 2.00-2.92), and in a second analysis using generalized linear mixed models, app use increased the odds of visiting a higher risk house 2.73-fold (95% CI 2.24-3.32), suggesting that the risk information provided by the app was used by most inspectors. Qualitative analyses of inspector movement revealed indications of risk information use in seven out of eight (87.5%) inspectors. There was no difference between the app and paper maps in the number of houses visited (paired t-test, p = 0.67) or inspected (p = 0.17), suggesting that app use did not reduce surveillance efficiency.

CONCLUSIONS/SIGNIFICANCE

Without staying vigilant to remaining and re-emerging vector foci following a vector control campaign, disease transmission eventually returns and progress achieved is reversed. Our results suggest that, when provided the opportunity, most inspectors will use risk information to direct their surveillance activities, at least over the short term. The study is an initial, but key, step toward evidence-based vector surveillance.

Incentives in a public addiction treatment system: Effects on waiting time and selection

Program-level financial incentives are used by some payers as a tool to improve quality of substance use treatment. However, evidence of effectiveness is mixed and performance contracts may have unintended consequences such as creating barriers for more challenging clients who are less likely to meet benchmarks. This study investigates the impact of a performance contract on waiting time for substance use treatment and client selection. Admission and discharge data from publicly funded Maine outpatient (OP) and intensive outpatient (IOP) substance use treatment programs (N = 38,932 clients) were used. In a quasi-experimental pre-post design, pre-period (FY 2005-2007) admission data from incentivized (IC) and non-incentivized (non-IC) programs were compared to post-period (FY 2008-2012) using propensity score matching and multivariate difference-in-difference regression. Dependent variables were waiting time (incentivized) and client selection (severity: history of mental disorders and substance use severity, not incentivized). Despite financial incentives designed to reduce waiting time for substance use treatment among state-funded outpatient programs, average waiting time for treatment increased in the post period for both IC and non-IC groups, as did client severity. There were no significant differences in waiting time between IC and non-IC groups over time. Increases in client severity over time, with no group differences, indicate that programs did not restrict access for more challenging clients. Adequate funding and other approaches to improve quality may be beneficial.