Effects of pay for performance in health care: A systematic review of systematic reviews

Additive effects of Pre-pregnancy body mass index and gestational diabetes on health outcomes and costs

OBJECTIVE

Pre-pregnancy obesity and gestational diabetes mellitus (GDM) are increasingly prevalent independent risk factors for maternal and infant morbidities. However, there is a paucity of information on their joint effects on health outcomes and healthcare costs.

METHODS

A population-based retrospective cohort study was conducted in Florida using a validated statewide database covering 1,057,647 infants born between 2004 and 2009. Using generalized linear modeling, joint associations between levels of pre-pregnancy body mass index (BMI) and GDM and maternal complications of pregnancy, adverse birth outcomes, and healthcare costs were examined. The relative excess risk due to interaction was used to describe the direction and magnitude of the BMI-GDM interaction on the additive scale.

RESULTS

Increasing pre-pregnancy BMI conferred increasing odds of adverse consequences, as did GDM, and the BMI-GDM interaction was greater than additive for 9 of 14 outcomes. The cost for infants born to women with GDM/obesity-III was 34% higher during the first year compared with those born to women with normal BMI and without GDM. The costs of maternal and infant inpatient care associated with overweight/obesity and GDM totaled over $351 million.

CONCLUSIONS

These findings provide further evidence of the importance of lifestyle modifications to decrease rates of obesity and risk factors from GDM.

Taking hospital treatments home: a mixed methods case study looking at the barriers and success factors for home dialysis treatment and the influence of a target on uptake rates

Background

Despite healthcare policies and evidence which promote home dialysis, uptake rates have been falling for over 10 years in England. A target introduced by commissioners in the West Midlands provided a unique opportunity to study how hospitals can increase home-based treatment for a group of patients with complex life-threatening conditions.

Methods

Quantitative changes in home treatment uptake rates in seven hospitals in the West Midlands were compared with the rest of England for 3 years pre and post the introduction of the target in 2010, using a logistic regression model. Qualitative interviews in four hospitals with 96 clinical and managerial staff and 93 dialysis patients explored the barriers and facilitators to increasing the uptake of home treatment and the impact of the target.

Results

Home treatment uptake rates increased significantly in the seven study hospitals compared with the 3 years prior to the introduction of the target and compared with the rest of England where rates remained static. The four main factors facilitating increased uptake were as follows: the commissioner’s target, linked to financial penalties; additional funding for specialist staff and equipment; committed, visible clinical champions and good systems for patient training and ongoing healthcare support at home. The three main barriers were as follows: lack of training for non-specialist staff, poorly developed patient education and considerable unrecognised and unmet emotional and psychological patient needs.

Conclusions

This study shows the impact of using targets with financial penalties to achieve change and how hospitals can increase significantly the uptake of home-based self-care for a group of patients with complex medical needs. It provides useful pointers to the main barriers and facilitators, which are likely to be relevant to other groups of patients who could be treated at home. It also highlights two neglected areas which need to improve if patients with life-threatening long-term conditions are to be encouraged to take up home treatment: individualised patient education which allows exploration of the impacts of treatment options and the provision of ongoing emotional support.

Is There a Relationship Between Value-Based Purchasing and Hospital Profitability? An Exploratory Study of Missouri Hospitals

Recent US legislation is attempting to transition inpatient Medicare payments to a value-based purchasing (VBP) program. The VBP program is a pay-for-performance (P4P) system that incentivizes hospitals to improve patient satisfaction, health outcomes, and adherence to clinical protocols while simultaneously holding down costs. Our study evaluates (1) the impact of financial performance on the VBP adjustments and (2) whether there is a correlation between the VBP adjustment and the financial performance of Missouri hospitals that opted into the program. While upward and downward adjustments to the inpatient base rate may be related to hospital financial performance, prior financial performance may also be related to the adjustments. Financial health may allow facilities to invest and position the hospital for favorable future P4P adjustments. The results of our analysis indicate the VBP adjustment to the inpatient base rate is very small (±0.18%), clustered around zero, and is not correlated with financial performance. We also find that financial performance and improvement in the years prior to the adjustment are not related to the VBP adjustment or its respective components. This suggests that CMS is avoiding penalizing less profitable facilities, but the adjustment is also so small and tightly clustered around zero that it is failing to provide an adequate incentive to hospitals. The costs of improving patient satisfaction, clinical process adherence, health care outcomes, and efficiency above that of peers coupled with the growing number of metrics being used to calculate the VBP adjustments call into question the financial incentives of the hospital VBP program.

Matching comprehensive health insurance reimbursements to their real costs: the case of antenatal care visits in a region of Peru

BACKGROUND

Prepaid contributory systems are increasingly being recognized as key mechanisms in achieving universal health coverage in low and middle-income countries. Peru created the Seguro Integral de Salud (SIS) to increase health service use amongst the poor by removing financial barriers. The SIS transfers funds on a fee-for-service basis to the regional health offices to cover recurrent cost (excluding salaries) of pre-specified packages of interventions. We aim to estimate the full cost of antenatal care (ANC) provision in the Ventanilla District (Callao-Peru) and to compare the actual cost to the reimbursement rates provided by SIS.

METHODS

The economic costs of ANC provision in 2011 in 8 of the 15 health centres in Ventanilla District were estimated from a provider perspective and the actual costs of those services covered by the SIS fee of $3.8 for each ANC visit were calculated. A combination of step-down and bottom-up costing methodologies was used. Sensitivity analysis was conducted to test the uncertainty around estimated parameters and model assumptions. Results are reported in 2011 US$.

RESULTS

The total economic cost of ANC provision in all 8 health centres was $569,933 with an average cost per ANC visit of $31.3 (95 % CI $29.7-$33.5). Salaries comprised 74.4 % of the total cost. The average cost of the services covered by the SIS fee was $3.4 (95 % CI $3.0-$3.8) per ANC visit. Sensitivity analysis showed that the probability of the cost of an ANC visit being above the SIS reimbursed fee is 1.4 %.

CONCLUSION

Our analysis suggests that the fee reimbursed by the SIS will cover the cost that it supposed to cover. However, there are significant threats to medium and longer term sustainability of this system as fee transfers represent a small fraction of the total cost of providing ANC. Increasing ANC coverage requires the other funding sources of the Regional Health Office (DIRESA) to adapt to increasing demand.

Effect of Paying for Performance on Utilisation, Quality, and User Costs of Health Services in Tanzania: A Controlled Before and After Study

BACKGROUND

Despite widespread implementation across Africa, there is limited evidence of the effect of payment for performance (P4P) schemes in low income countries on the coverage of quality services and affordability, consistent with universal health coverage objectives. We examined the effect of a government P4P scheme on utilisation, quality, and user costs of health services in Tanzania.

METHODS

We evaluated the effects of a P4P scheme on utilisation of all maternal and child immunization services targeted by the scheme, and non-targeted general outpatient service use. We also evaluated effects on patient satisfaction with care and clinical content of antenatal care, and user costs. The evaluation was done in 150 facilities across all 7 intervention districts and 4 comparison districts with two rounds of data collection over 13-months in January 2012 and February 2013. We sampled 3000 households of women who had delivered in the 12 months prior to interview; 1500 patients attending health facilities for targeted and non-targeted services at each round of data collection. Difference-in-difference regression analysis was employed.

FINDINGS

We estimated a significant positive effect on two out of eight targeted indicators. There was an 8.2% (95% CI: 3.6% to 12.8%) increase in coverage of institutional deliveries among women in the intervention area, and a 10.3% (95% CI: 4.4% to 16.1%) increase in the provision of anti-malarials during pregnancy. Use of non-targeted services reduced at dispensaries by 57.5 visits per month among children under five (95% CI: -110.2 to -4.9) and by 90.8 visits per month for those aged over five (95% CI: -156.5 to -25.2). There was no evidence of an effect of P4P on patient experience of care for targeted services. There was a 0.05 (95% CI: 0.01 to 0.10) increase in the patient satisfaction score for non-targeted services. P4P was associated with a 5.0% reduction in those paying out of pocket for deliveries (95% CI: -9.3% to -0.7%) but there was no evidence of an effect on the average amount paid.

CONCLUSION

This study adds to the very limited evidence on the effects of P4P at scale and highlights the potential risks of such schemes in relation to non-targeted service use. Further consideration of the design of P4P schemes is required to enhance progress towards universal health coverage, and close monitoring of effects on non-targeted services and user costs should be encouraged.

Young doctors' preferences for payment systems: the influence of gender and personality traits

OBJECTIVE

Activity-based payment contracts are common among doctors, but to what extent are they preferred? The aim of this paper is to elicit young doctors' preferences for alternative payment systems before they have adapted to an existing system. We examine the existence of gender differences and the extent to which personality traits determine preferences.

METHODS

A cross-sectional survey of all final-year medical students and all interns in Norway examined the extent to which preferences for different payment systems depend on gender and personality traits. Data analysis relied on one-way ANOVA and multinomial logistic regression.

RESULTS

The current activity-based payment systems were the least preferred, both in hospitals (16.6%) and in general practice (19.7%). The contrasting alternative "fixed salary" achieved similar relative support. Approximately half preferred the hybrid alternative. When certainty associated with a payment system increased, its appeal rose for women and individuals who are less prestige-oriented, risk-tolerant or effort-tolerant. Activity-based systems were preferred among status- and income-oriented respondents.

CONCLUSION

The vast majority of young doctors prefer payment systems that are less activity-based than the current contracts offered in the Norwegian health service. Recruitment and retention in less prestigious medical specialities might improve if young doctors could choose payment systems corresponding with their diverse preferences.

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories. Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care. Financial incentives seeking to influence prescribers' behaviour include budgetary arrangements at primary care and hospital settings (pharmaceutical budget caps or targets), financial rewards for target behaviours or outcomes (pay for performance interventions) and reduced benefit margin for prescribers based on medicine sales and prescriptions (pharmaceutical reimbursement rate reduction policies). This is the first update of the original version of this review.

OBJECTIVES

To determine the effects of pharmaceutical policies using financial incentives to influence prescribers' practices on drug use, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (searched 29/01/2015); MEDLINE, Ovid SP (searched 29/01/2015); EMBASE, Ovid SP (searched 29/01/2015); International Network for Rational Use of Drugs (INRUD) Bibliography (searched 29/01/2015); National Health Service (NHS) Economic Evaluation Database (searched 29/01/2015); EconLit - ProQuest (searched 02/02/2015); and Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge (citation search for included studies searched 10/02/2015). We screened the reference lists of relevant reports and contacted study authors and organisations to identify additional studies.

SELECTION CRITERIA

We included policies that intend to affect prescribing by means of financial incentives for prescribers. Included in this category are pharmaceutical budget caps or targets, pay for performance and drug reimbursement rate reductions and other financial policies, if they were specifically targeted at prescribing or drug utilisation. Policies in this review were defined as laws, rules, regulations and financial and administrative orders made or implemented by payers such as national or local governments, non-government organisations, private or social insurers and insurance-like organisations. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes or costs. The study had to be a randomised or non-randomised trial, an interrupted time series (ITS) analysis, a repeated measures study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies and risks of bias using Cochrane Effective Practice and Organisation of Care (EPOC) criteria and extracted data from the included studies. For CBA studies, we reported relative effects (e.g. adjusted relative change). The review team re-analysed all ITS results. When possible, the review team also re-analysed CBA data as ITS data.

MAIN RESULTS

Eighteen evaluations (six new studies) of pharmaceutical policies from six high-income countries met our inclusion criteria. Fourteen studies evaluated pharmaceutical budget policies in the UK (nine studies), two in Germany and Ireland and one each in Sweden and Taiwan. Three studies assessed pay for performance policies in the UK (two) and the Netherlands (one). One study from Taiwan assessed a reimbursement rate reduction policy. ITS analyses had some limitations. All CBA studies had serious limitations. No study from low-income or middle-income countries met the inclusion criteria.Pharmaceutical budgets may lead to a modest reduction in drug use (median relative change -2.8%; low-certainty evidence). We are uncertain of the effects of the policy on drug costs or healthcare utilisation, as the certainty of such evidence has been assessed as very low. Effects of this policy on health outcomes were not reported. Effects of pay for performance policies on drug use and health outcomes are uncertain, as the certainty of such evidence has been assessed as very low. Effects of this policy on drug costs and healthcare utilisation have not been measured. Effects of the reimbursement rate reduction policy on drug use and drug costs are uncertain, as the certainty of such evidence has been assessed as very low. No included study assessed the effects of this policy on healthcare utilisation or health outcomes. Administration costs of the policies were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Although financial incentives are considered an important element in strategies to change prescribing patterns, limited evidence of their effects can be found. Effects of policies, including pay for performance policies, in improving quality of care and health outcomes remain uncertain. Because pharmaceutical policies have uncertain effects, and because they might cause harm as well as benefit, proper evaluation of these policies is needed. Future studies should consider the impact of these policies on health outcomes, drug use and overall healthcare expenditures, as well as on drug expenditures.

The effectiveness of providing peer benchmarked feedback to hip replacement surgeons based on patient-reported outcome measures--results from the PROFILE (Patient-Reported Outcomes: Feedback Interpretation and Learning Experiment) trial: a cluster randomised controlled study

OBJECTIVE

To test whether providing surgeons with peer benchmarked feedback about patient-reported outcomes is effective in improving patient outcomes.

DESIGN

Cluster randomised controlled trial.

SETTING

Secondary care--Ireland.

PARTICIPANTS

Surgeons were recruited through the Irish Institute of Trauma and Orthopaedic Surgery, and patients were recruited in hospitals prior to surgery. We randomly allocated 21 surgeons and 550 patients.

INTERVENTION

Surgeons in the intervention group received peer benchmarked patient-reported outcome measures (PROMs) feedback and education.

MAIN OUTCOME VARIABLE

Postoperative Oxford Hip Score (OHS).

RESULTS

Primary outcome data were available for 11 intervention surgeons with responsibility for 230 patients and 10 control surgeons with responsibility for 228 patients. The mean postoperative OHS for the intervention group was 40.8 (95% CI 39.8 to 41.7) and for the control group was 41.9 (95% CI 41.1 to 42.7). The adjusted effect estimate was -1.1 (95% CI -2.4 to 0.2, p=0.09). Secondary outcomes were the Hip Osteoarthritis Outcome Score (HOOS), EQ-5D and the proportion of patients reporting a problem after surgery. The mean postoperative HOOS for the intervention group was 36.2 and for the control group was 37.1. The adjusted effect estimate was -1.1 (95% CI -2.4 to 0.3, p=0.1). The mean postoperative EQ-5D for the intervention group was 0.85 and for the control group was 0.87. The adjusted effect estimate was -0.02 (95% CI -0.05 to 0.008, p=0.2). 27% of intervention patients and 24% of control patients reported at least one complication after surgery (adjusted OR=1.2, 95% CI 0.6 to 2.3, p=0.6).

CONCLUSIONS

Outcomes for patients operated on by surgeons who had received peer benchmarked PROMs data were not statistically different from the outcomes of patients operated on by surgeons who did not receive feedback. PROMs information alone seems to be insufficient to identify opportunities for quality improvement.

TRIAL REGISTRATION NUMBER

ISRCTN 69032522.

Patients' views on pay for performance in France: a qualitative study in primary care

BACKGROUND

Pay for performance was implemented in 2009 in France. The system was optional at first and then became widespread. Since 2012, it has been standard for most GPs. Several studies have attempted to investigate its efficiency and the GP's opinion of the system, but few studies have yet to examine the patient's view.

AIM

To gain an understanding of the views of French family practice patients about pay for performance.

DESIGN AND SETTING

Forty patients were interviewed between March and July 2013 in the Île-de-France region, of France.

METHOD

A qualitative study using semi-structured individual interviews, in primary care.

RESULTS

Most of the patients did not know what pay for performance was and stated that they had not noticed any change in care since the system began. Some patients noted the possible benefits in the quality of care, such as an improvement in follow-up and prevention, better information provided by the GP, and a decrease in the volume of prescriptions and therefore health costs. Other patients were concerned about potential downsides, such as an overprescription of unnecessary medical treatments, an increase in health costs, patient selection, and standardised consultations that do not necessarily take into account the patient's individual concerns.

CONCLUSION

Since implementation of pay for performance, patients had not noticed any modification in their medical care. They could understand the need for change in the remuneration policy and expressed their agreement about performance-based remuneration if, and only if, it is not the cause of depersonalised health care.

WITHDRAWN: Quality Measurement in Gastroenterology: Confessions of a Realist

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://dx.doi.org/10.1016/j.cgh.2015.07.033. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at http://www.elsevier.com/locate/withdrawalpolicy.

Cost-Effectiveness of a Diabetes Pay-For-Performance Program in Diabetes Patients with Multiple Chronic Conditions

Pay for performance (P4P) has been used as a strategy to improve quality for patients with chronic illness. Little was known whether care provided to individuals with multiple chronic conditions in a P4P program were cost-effective. This study investigated cost effectiveness of a diabetes P4P program for caring patients with diabetes alone (DM alone) and diabetes with comorbid hypertension and hyperlipidemia (DMHH) from a single payer perspective in Taiwan. Analyzing data using population-based longitudinal databases, we compared costs and effectiveness between P4P and non-P4P diabetes patient groups in two cohorts. Propensity score matching (PSM) was used to match comparable control groups for intervention groups. Outcomes included life-years, quality-adjusted life-years (QALYs), program intervention costs, cost-savings and incremental cost-effectiveness ratios (ICERs). QALYs for P4P patients and non-P4P patients were 2.80 and 2.71 for the DM alone cohort and 2.74 and 2.66 for the DMHH patient cohort. The average incremental intervention costs per QALYs was TWD$167,251 in the DM alone cohort and TWD$145,474 in the DMHH cohort. The average incremental all-cause medical costs saved by the P4P program per QALYs were TWD$434,815 in DM alone cohort and TWD$506,199 in the DMHH cohort. The findings indicated that the P4P program for both cohorts were cost-effective and the resulting return on investment (ROI) was 2.60:1 in the DM alone cohort and 3.48:1 in the DMHH cohort. We conclude that the diabetes P4P program in both cohorts enabled the long-term cost-effective use of resources and cost-savings, especially for patients with multiple comorbid conditions.

The Challenge of Cardiovascular Diseases and Diabetes to Public Health: A Study Based on Qualitative Systemic Approach

The most common modeling approaches to understanding incidence, prevalence and control of chronic diseases in populations, such as statistical regression models, are limited when it comes to dealing with the complexity of those problems. Those complex adaptive systems have characteristics such as emerging properties, self-organization and feedbacks, which structure the system stability and resistance to changes. Recently, system science approaches have been proposed to deal with the range, complexity, and multifactor nature of those public health problems. In this paper we applied a multilevel systemic approach to create an integrated, coherent, and increasingly precise conceptual framework, capable of aggregating different partial or specialized studies, based on the challenges of the Longitudinal Study of Adult Health - ELSA-Brasil. The failure to control blood pressure found in several of the study's subjects was discussed, based on the proposed model, analyzing different loops, time lags, and feedback that influence this outcome in a population with high educational level, with reasonably good health services access. We were able to identify the internal circularities and cycles that generate the system's resistance to change. We believe that this study can contribute to propose some new possibilities of the research agenda and to the discussion of integrated actions in the field of public health.

Effects of Changes in Diabetes Pay-for-Performance Incentive Designs on Patient Risk Selection

OBJECTIVE

Taiwan's National Health Insurance (NHI) Program implemented a Diabetes Pay-for-Performance Program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was reformed to also include achievement of intermediate health outcomes. This study examined how the change in design affected patient risk selection.

DESIGNS/STUDY POPULATIONS

Study populations were identified from a 2002 to 2003 period (Phase 1) and a 2007 to 2008 period (Phase 2), spanning pre- and postimplementation of reforms in the P4P incentive design. Phase 1 had 74,529 newly enrolled P4P patients and 215,572 non-P4P patients, and Phase 2 had 76,901 newly enrolled P4P patients and 299,573 non-P4P patients. Logistic regression models were used to estimate the effect of changes in design on P4P patient selection.

PRINCIPAL FINDINGS

Patients with greater disease severity and comorbidity were more likely to be excluded from the P4P program in both phases. Furthermore, the additional financial incentive for patients' intermediate outcomes moderately worsened patient risk selection.

CONCLUSIONS

Policy makers need to carefully monitor the care of the diabetes patients with more severe and complex disease statuses after the changes of P4P financial incentive design.

Performance-related-pay in the UK public sector

Purpose

– The purpose of this paper is to provide an up-to-date, comprehensive, independent and credible assessment of relevant academic and other literature since 2007, on the effectiveness and value for money of performance-related-pay (PRP) in the public sector.

Design/methodology/approach

– PRP was studied using both economics-based literature and literature from the organisational and management field (including human resources, management sociology and psychology). An initial search of databases identified 7,401 documents regarding PRP in the public sector, which was reduced to 57 final papers included in the study (27 in the health sector, 16 in the education sector and 16 in the civil service) after abstract and full paper screening.

Findings

– The review found some evidence that PRP schemes can be effective across the three domains of the public sector for which there was evidence available (health, education and the civil service), but findings within and between the sectors are mixed, with scheme effectiveness often dependent on scheme design and organisational context.

Research limitations/implications

– The research highlights the importance of considering both economics-based and organisational literature when discussing PRP in the public sector, and the implications for motivation and PRP design.

Practical implications

– The results indicated that the design of PRP schemes could influence their effectiveness and outcomes, and the research suggests how the challenges of designing and implementing PRP schemes can be overcome in the public sector.

Social implications

– The review highlights that when implementing PRP schemes there may be gender differences in their overall effectiveness (especially in education) and there must be consideration for how fairly the PRP scheme is perceived.

Originality/value

– The paper uses literature from economics and behavioural sciences when looking at the motivational implications for PRP in the public sector.

Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system

INTRODUCTION

Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension.

METHODS

This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme.

RESULTS

Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63-0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64-0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation.

CONCLUSION

This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.

Working under a clinic-level quality incentive: primary care clinicians' perceptions

BACKGROUND

A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to-individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team's performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians' perceptions of a team-based quality incentive awarded at the clinic level.

METHODS

This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians' perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives.

RESULTS

Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient "dumping," or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians' lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model's impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance.

CONCLUSION

The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.

Measuring health system performance: A new approach to accountability and quality improvement in New Zealand

In February 2014, the New Zealand Ministry of Health released a new framework for measuring the performance of the New Zealand health system. The two key aims are to strengthen accountability to taxpayers and to lift the performance of the system's component parts using a 'whole-of-system' approach to performance measurement. Development of this new framework--called the Integrated Performance and Incentive Framework (IPIF)--was stimulated by a need for a performance management framework which reflects the health system as a whole, which encourages primary and secondary providers to work towards the same end, and which incorporates the needs and priorities of local communities. Measures within the IPIF will be set at two levels: the system level, where measures are set nationally, and the local district level, where measures which contribute towards the system level indicators will be selected by local health alliances. In the first year, the framework applies only at the system level and only to primary health care services. It will continue to be developed over time and will gradually be extended to cover a wide range of health and disability services. The success of the IPIF in improving health sector performance depends crucially on the willingness of health sector personnel to engage closely with the measurement process.

Should English healthcare providers be penalised for failing to collect patient-reported outcome measures? A retrospective analysis

OBJECTIVE

The best practice tariff for hip and knee replacement in the English National Health Service (NHS) rewards providers based on improvements in patient-reported outcome measures (PROMs) collected before and after surgery. Providers only receive a bonus if at least 50% of their patients complete the preoperative questionnaire. We determined how many providers failed to meet this threshold prior to the policy introduction and assessed longitudinal stability of participation rates.

DESIGN

Retrospective observational study using data from Hospital Episode Statistics and the national PROM programme from April 2009 to March 2012. We calculated participation rates based on either (a) all PROM records or (b) only those that could be linked to inpatient records; constructed confidence intervals around rates to account for sampling variation; applied precision weighting to allow for volume; and applied risk adjustment.

SETTING

NHS hospitals and private providers in England.

PARTICIPANTS

NHS patients undergoing elective unilateral hip and knee replacement surgery.

MAIN OUTCOME MEASURES

Number of providers with participation rates statistically significantly below 50%.

RESULTS

Crude rates identified many providers that failed to achieve the 50% threshold but there were substantially fewer after adjusting for uncertainty and precision. While important, risk adjustment required restricting the analysis to linked data. Year-on-year correlation between provider participation rates was moderate.

CONCLUSIONS

Participation rates have improved over time and only a small number of providers now fall below the threshold, but administering preoperative questionnaires remains problematic in some providers. We recommend that participation rates are based on linked data and take into account sampling variation.

[Contract for improving professional practices: What is the impact perceived by GPs?]

BACKGROUND

The CAPI (contract for improving professional practices) is a voluntary pay for performance scheme for primary care physicians introduced in France in 2009. Our objective was to analyze general practitioners' (GPs) perceptions of the impact of the CAPI on their healthcare practices.

METHOD

The methodology was both qualitative, using thematic analysis of responses to three items of a questionnaire mailed to GPs in 2011, and quantitative using thematic multiple correspondence analysis of responses together with cluster analysis based on the ward aggregation criterion.

RESULTS

A total of 1050 general practitioners answered, 31% had signed a CAPI. For CAPI-participating GPs, the contract was mostly related to changing practices for drug prescription. GPs who did not participate in the CAPI focused on ethical issues. They denounced a conflict of interest between the doctor and the patient and also the risk of patient selection. They connected these concepts to selected indicators. Due to their relationship with the health insurance fund, they feared their freedom of practice would be restricted.

CONCLUSION

GP involvement in designing indicators would favor better balance between economic goals and values of care. The patients' viewpoint should be studied. Pay for performance has been renewed in the 2011. Further studies will analyze the impact of this new scheme in a medical and economic perspective.

Pay-for-performance policy and data-driven decision making within nursing homes: a qualitative study

INTRODUCTION

Health systems globally and within the USA have introduced nursing home pay-for-performance (P4P) programmes in response to the need for improved nursing home quality. Central to the challenge of administering effective P4P is the availability of accurate, timely and clinically appropriate data for decision making. We aimed to explore ways in which data were collected, thought about and used as a result of participation in a P4P programme.

METHODS

Semistructured interviews were conducted with 232 nursing home employees from within 70 nursing homes that participated in P4P-sponsored quality improvement (QI) projects. Interview data were analysed to identify themes surrounding collecting, thinking about and using data for QI decision making.

RESULTS

The term 'data' appeared 247 times in the interviews, and over 92% of these instances (228/247) were spontaneous references by nursing home staff. Overall, 34% of respondents (79/232) referred directly to 'data' in their interviews. Nursing home leadership more frequently discussed data use than direct care staff. Emergent themes included using data to identify a QI problem, gathering data in new ways at the local level, and measuring outcomes in response to P4P participation. Alterations in data use as a result of policy change were theoretically consistent with the revised version of the Promoting Action on Research Implementation in Health Services framework, which posits that successful implementation is a function of evidence, context and facilitation.

CONCLUSIONS

Providing a reimbursement context that facilitates the collection and use of reliable local evidence may be an important consideration to others contemplating the adaptation of P4P policies.

Cost-effectiveness of diabetes pay-for-performance incentive designs

BACKGROUND

Taiwan's National Health Insurance (NHI) Program implemented a diabetes pay-for-performance program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was revised to also include achievement of intermediate health outcomes.

OBJECTIVES

This study examined to what extent these 2 P4P incentive designs have been cost-effective and what the difference in effect may have been.

RESEARCH DESIGN AND METHOD

Analyzing data using 3 population-based longitudinal databases (NHI's P4P dataset, NHI's claims database, and Taiwan's death registry), we compared costs and effectiveness between P4P and non-P4P diabetes patient groups in each phase. Propensity score matching was used to match comparable control groups for intervention groups. Outcomes included life-years, quality-adjusted life-years (QALYs), program intervention costs, cost-savings, and incremental cost-effectiveness ratios.

RESULTS

QALYs for P4P patients and non-P4P patients were 2.08 and 1.99 in phase 1 and 2.08 and 2.02 in phase 2. The average incremental intervention costs per QALYs was TWD$335,546 in phase 1 and TWD$298,606 in phase 2. The average incremental all-cause medical costs saved by the P4P program per QALYs were TWD$602,167 in phase 1 and TWD$661,163 in phase 2. The findings indicated that both P4P programs were cost-effective and the resulting return on investment was 1.8:1 in phase 1 and 2.0:1 in phase 2.

CONCLUSIONS

We conclude that the diabetes P4P program in both phases enabled the long-term cost-effective use of resources and cost-savings regardless of whether a bonus for intermediate outcome improvement was added to a process-based P4P incentive design.

International comparison of preoperative testing and assessment protocols and best practices to reduce surgical care costs: a systematic literature review

PURPOSE

Health care institutions in many Western countries have developed preoperative testing and assessment guidelines to improve surgical outcomes and reduce cost of surgical care. The aims of this chapter are to (1) summarize the literature on the effect of preoperative testing on clinical outcomes, efficiency, and cost; and (2) to compare preoperative testing guidelines developed in the United States, the United Kingdom, and Canada.

DESIGN/METHODOLOGY/APPROACH

We reviewed the literature from 1975 to 2014 for studies and preoperative testing guidelines.

FINDINGS

We identified 29 empirical studies and 8 country-specific guidelines for review. Most studies indicate that preoperative testing is overused and comes at a high cost. Guidelines are tied to payment only in one country studied. This is the most recent review of the literature on preoperative testing and assessment with a focus on quality of care, efficiency, and cost outcomes. In addition, this chapter provides an international comparison of preoperative guidelines.

Ranking games

BACKGROUND

Research rankings based on bibliometrics today dominate governance in academia and determine careers in universities.

METHOD

Analytical approach to capture the incentives by users of rankings and by suppliers of rankings, both on an individual and an aggregate level.

RESULT

Rankings may produce unintended negative side effects. In particular, rankings substitute the "taste for science" by a "taste for publication." We show that the usefulness of rankings rests on several important assumptions challenged by recent research.

CONCLUSION

We suggest as alternatives careful socialization and selection of scholars, supplemented by periodic self-evaluations and awards. The aim is to encourage controversial discourses in order to contribute meaningful to the advancement of science.

Short-term effects of a pay-for-performance programme for diabetes in a primary care setting: an observational study

OBJECTIVE

A pay-for-performance (P4P) programme for primary care was introduced in 2011 by a Swedish county (with 1.6 million inhabitants). Effects on register entry practice and comparability of data for patients with diabetes mellitus were assessed.

DESIGN AND SETTING

Observational study analysing short-term outcomes before and after introduction of a P4P programme in the study county as compared with a reference county.

SUBJECTS

A total of 84 053 patients reported to the National Diabetes Register by 349 primary care units.

MAIN OUTCOME MEASURES

Completeness of data, level and target achievement of glycated haemoglobin (HbA1c), blood pressure (BP), and LDL cholesterol (LDL).

RESULTS

In the study county, newly recruited patients who were entered during the incentive programme were less well controlled than existing patients in the register - they had higher HbA1c (54.9 [54.5-55.4] vs. 53.7 [53.6-53.9] mmol/mol), BP, and LDL. The percentage of patients with entry of BP, HbA1c, LDL, albuminuria, and smoking increased in the study county but not in the reference county (+26.3% vs -1.5%). In the study county, with an incentive for BP < 130/80 mmHg, BP data entry behaviour was altered with an increased preference for sub-target BP values and a decline in zero end-digit readings (38.3% vs. 33.7%, p < 0.001).

CONCLUSION

P4P led to increased register entry, increased completeness of data, and altered BP entry behaviour. Analysis of newly added patients and data shows that missing patients and data can cause performance to be overestimated. Potential effects on reporting quality should be considered when designing payment programmes. Key points A pay-for-performance programme, with a focus on data entry, was introduced in a primary care region in Sweden. Register data entry in the National Diabetes Register increased and registration behaviour was altered, especially for blood pressure. Newly entered patients and data during the incentive programme were less well controlled. Missing data in a quality register can cause performance to be overestimated.

The use of outcome and process indicators to incentivize integrated care for frail older people: a case study of primary care services in Sweden

Background

A number of reforms have been implemented in Swedish health care to support integrated care for frail older people and to reduce utilization of hospital care by this group. Outcomes and process indicators have been used in pay-for-performance (P4P) schemes by both national and local governments to support developments.

Objective

To analyse limitations in the use of outcome and process indicators to incentivize integrated care for elderly patients with significant health care needs in the context of primary care.

Method

Data were collected from the Region Skåne county council. Eight primary care providers and associated community services were compared in a ranking exercise based on information from interviews and registered data. Registered data from 150 primary care providers were analysed in regression models.

Results and conclusion

Both the ranking exercise and regression models revealed important problems related to risk-adjustment, attribution, randomness and measurement fixation when using indicators in P4P schemes and for external accountability purposes. Instead of using indicators in incentive schemes targeting individual providers, indicators may be used for diagnostic purposes and to support development of new knowledge, targeting local systems that move beyond organizational boundaries.

Factors related to clinical quality improvement for small practices using an EHR

OBJECTIVE

To analyze the impact of three primary care practice transformation program models on performance: Meaningful Use (MU), Patient-Centered Medical Home (PCMH), and a pay-for-performance program (eHearts).

DATA SOURCES/STUDY SETTING

Data for seven quality measures (QM) were retrospectively collected from 192 small primary care practices between October 2009 and October 2012; practice demographics and program participation status were extracted from in-house data.

STUDY DESIGN

Bivariate analyses were conducted to measure the impact of individual programs, and a Generalized Estimating Equation model was built to test the impact of each program alongside the others.

DATA COLLECTION/EXTRACTION METHODS

Monthly data were extracted via a structured query data network and were compared to program participation status, adjusting for variables including practice size and patient volume. Seven QMs were analyzed related to smoking prevention, blood pressure control, BMI, diabetes, and antithrombotic therapy.

PRINCIPAL FINDINGS

In bivariate analysis, MU practices tended to perform better on process measures, PCMH practices on more complex process measures, and eHearts practices on measures for which they were incentivized; in multivariate analysis, PCMH recognition was associated with better performance on more QMs than any other program.

CONCLUSIONS

Results suggest each of the programs can positively impact performance. In our data, PCMH appears to have the most positive impact.

The effect of performance-based financial incentives on improving health care provision in Burundi: a controlled cohort study

To strengthen the health care delivery, the Burundian Government in collaboration with international NGOs piloted performance-based financing (PBF) in 2006. The health facilities were assigned - by using a simple matching method - to begin PBF scheme or to continue with the traditional input-based funding. Our objective was to analyse the effect of that PBF scheme on the quality of health services between 2006 and 2008. We conducted the analysis in 16 health facilities with PBF scheme and 13 health facilities without PBF scheme. We analysed the PBF effect by using 58 composite quality indicators of eight health services: Care management, outpatient care, maternity care, prenatal care, family planning, laboratory services, medicines management and materials management. The differences in quality improvement in the two groups of health facilities were performed applying descriptive statistics, a paired non-parametric Wilcoxon Signed Ranks test and a simple difference-in-difference approach at a significance level of 5%. We found an improvement of the quality of care in the PBF group and a significant deterioration in the non-PBF group in the same four health services: care management, outpatient care, maternity care, and prenatal care.

The findings suggest a PBF effect of between 38 and 66 percentage points (p<0.001) in the quality scores of care management, outpatient care, prenatal care, and maternal care. We found no PBF effect on clinical support services: laboratory services, medicines management, and material management.

The PBF scheme in Burundi contributed to the improvement of the health services that were strongly under the control of medical personnel (physicians and nurses) in a short time of two years. The clinical support services that did not significantly improved were strongly under the control of laboratory technicians, pharmacists and non-medical personnel.

Activity-based funding of hospitals and its impact on mortality, readmission, discharge destination, severity of illness, and volume of care: a systematic review and meta-analysis

Background

Activity-based funding (ABF) of hospitals is a policy intervention intended to re-shape incentives across health systems through the use of diagnosis-related groups. Many countries are adopting or actively promoting ABF. We assessed the effect of ABF on key measures potentially affecting patients and health care systems: mortality (acute and post-acute care); readmission rates; discharge rate to post-acute care following hospitalization; severity of illness; volume of care.

Methods

We undertook a systematic review and meta-analysis of the worldwide evidence produced since 1980. We included all studies reporting original quantitative data comparing the impact of ABF versus alternative funding systems in acute care settings, regardless of language. We searched 9 electronic databases (OVID MEDLINE, EMBASE, OVID Healthstar, CINAHL, Cochrane CENTRAL, Health Technology Assessment, NHS Economic Evaluation Database, Cochrane Database of Systematic Reviews, and Business Source), hand-searched reference lists, and consulted with experts. Paired reviewers independently screened for eligibility, abstracted data, and assessed study credibility according to a pre-defined scoring system, resolving conflicts by discussion or adjudication.

Results

Of 16,565 unique citations, 50 US studies and 15 studies from 9 other countries proved eligible (i.e. Australia, Austria, England, Germany, Israel, Italy, Scotland, Sweden, Switzerland). We found consistent and robust differences between ABF and no-ABF in discharge to post-acute care, showing a 24% increase with ABF (pooled relative risk  = 1.24, 95% CI 1.18–1.31). Results also suggested a possible increase in readmission with ABF, and an apparent increase in severity of illness, perhaps reflecting differences in diagnostic coding. Although we found no consistent, systematic differences in mortality rates and volume of care, results varied widely across studies, some suggesting appreciable benefits from ABF, and others suggesting deleterious consequences.

Conclusions

Transitioning to ABF is associated with important policy- and clinically-relevant changes. Evidence suggests substantial increases in admissions to post-acute care following hospitalization, with implications for system capacity and equitable access to care. High variability in results of other outcomes leaves the impact in particular settings uncertain, and may not allow a jurisdiction to predict if ABF would be harmless. Decision-makers considering ABF should plan for likely increases in post-acute care admissions, and be aware of the large uncertainty around impacts on other critical outcomes.

Impact of a pay for performance programme on French GPs' consultation length

BACKGROUND

In 2009, a voluntary-based pay for performance scheme targeting general practitioners (GPs) was introduced in France through the 'Contract for Improving Individual Practices' (CAPI).

OBJECTIVE

To study the impact of the CAPI on French GPs' consultation length.

METHODS

Univariate analysis, and multilevel regression analyses were performed to disentangle the different sources of the consultation length variability (intra and inter physician). The dependant variable was the logarithm of the consultation length. Independent variables included patient's sociodemographics as well as the characteristics of GPs and their medical activity.

RESULTS

Between November 2011 and April 2012, 128 physicians were recruited throughout France and generated 20,779 consultations timed by residents. The average consultation length in the sample was 16.8 min. After adjusting for patients' characteristics only, the consultation length of CAPI signatories was 14.1% lower than that observed for non signatories (p<0.001). After adjusting for GPs' characteristics and the case mix, the CAPI was no longer a significant predictor of the consultation length. The results did not change significantly from one type of consultation to another.

CONCLUSION

Although the CAPI was extended to all GPs in 2012, our results provide a cautionary message to regulators about its ability to generate higher quality of care.

What explains the quality and price of GP services? An investigation using linked survey and administrative data

We examine patient socioeconomic status, the strength of the patient-doctor relationship and local area competition as determinants of the quality and price of GP services. We exploit a large-sample patient data set in Australia and its linkage to administrative databases. The sample contains over 260,000 patients and over 12,600 GPs, observed between 2005 and 2010. Controlling for GP fixed effects and patient health, we find no strong evidence that quality differs by patient age, gender, country of origin, health concession card status and income, but quality is increased by stronger patient-doctor relationship. Using a competition measure that is defined at the individual GP level and not restricted to a local market, we find that competition lowers quality. Price is increasing in patient income, whereas competition has a small impact on price.

Long-term effect of hospital pay for performance on mortality in England

BACKGROUND

A pay-for-performance program based on the Hospital Quality Incentive Demonstration was introduced in all hospitals in the northwest region of England in 2008 and was associated with a short-term (18-month) reduction in mortality. We analyzed the long-term effects of this program, called Advancing Quality.

METHODS

We analyzed 30-day in-hospital mortality among 1,825,518 hospital admissions for eight conditions, three of which were covered by the financial-incentive program. The hospitals studied included the 24 hospitals in the northwest region that were participating in the program and 137 elsewhere in England that were not participating. We used difference-in-differences regression analysis to compare risk-adjusted mortality for an 18-month period before the program was introduced with subsequent mortality in the short term (the first 18 months of the program) and the longer term (the next 24 months).

RESULTS

Throughout the short-term and the long-term periods, the performance of hospitals in the incentive program continued to improve and mortality for the three conditions covered by the program continued to fall. However, the reduction in mortality among patients with these conditions was greater in the control hospitals (those not participating in the program) than in the hospitals that were participating in the program (by 0.7 percentage points; 95% confidence interval [CI], 0.3 to 1.2). By the end of the 42-month follow-up period, the reduced mortality in the participating hospitals was no longer significant (-0.1 percentage points; 95% CI, -0.6 to 0.3). From the short term to the longer term, the mortality for conditions not covered by the program fell more in the participating hospitals than in the control hospitals (by 1.2 percentage points; 95% CI, 0.4 to 2.0), raising the possibility of a positive spillover effect on care for conditions not covered by the program.

CONCLUSIONS

Short-term relative reductions in mortality for conditions linked to financial incentives in hospitals participating in a pay-for-performance program in England were not maintained.

Accountable care organizations in the USA: types, developments and challenges

A historically fragmented U.S. health care system, where care has been delivered by multiple providers with little or no coordination, has led to increasing issues with access, cost, and quality. The Affordable Care Act included provisions to use Medicare, the U.S. near universal public coverage program for older adults, to broadly implement Accountable Care Organization (ACO) models with a triple aim of improving the experience of care, the health of populations, and reducing per capita costs. Private payers in the U.S. are also embracing ACO models. Various European countries are experimenting with similar reforms, particularly those in which coordinated (or integrated) care from a network of providers is reimbursed with bundled payments and/or shared savings. The challenges for these reforms remain formidable and include: (1) overcoming incentives for ACOs to engage in rationing and denial of care and taking on too much financial risk, (2) collecting meaningful data that capture quality and enable rewarding quality improvement and not just volume reduction, (3) creating incentives for ACOs that do not accept much risk to engage in prevention and health promotion, and (4) creating effective governance and IT structures that are patient-centered and integrate care.

Impacts of pay for performance on the quality of primary care

Increasingly, financial incentives are being used in health care as a result of increasing demand for health care coupled with fiscal pressures. Financial incentive schemes are one approach by which the system may incentivize providers of health care to improve productivity and/or adapt to better quality provision. Pay for performance (P4P) is an example of a financial incentive which seeks to link providers’ payments to some measure of performance. This paper provides a discussion of the theoretical underpinnings of P4P, gives an overview of the health P4P evidence base, and provide a detailed case study of a particularly large scheme from the English National Health Service. Lessons are then drawn from the evidence base. Overall, we find that the evidence for the effectiveness of P4P for improving quality of care in primary care is mixed. This is to some extent due to the fact that the P4P schemes used in primary care are also mixed. There are many different schemes that incentivize different aspects of care in different ways and in different settings, making evaluation problematic. The Quality and Outcomes Framework in the United Kingdom is the largest example of P4P in primary care. Evidence suggests incentivized quality initially improved following the introduction of the Quality and Outcomes Framework, but this was short-lived. If P4P in primary care is to have a long-term future, the question about scheme effectiveness (perhaps incorporating the identification and assessment of potential risk factors) needs to be answered robustly. This would require that new schemes be designed from the onset to support their evaluation: control and treatment groups, coupled with before and after data.

Adaptive approaches to licensing, health technology assessment, and introduction of drugs and devices

BACKGROUND

Adaptive approaches to the introduction of drugs and medical devices involve the use of an evolving evidence base rather than conventional single-point-in-time evaluations as a proposed means to promote patient access to innovation, reduce clinical uncertainty, ensure effectiveness, and improve the health technology development process.

METHODS

This report summarizes a Health Technology Assessment International (HTAi) Policy Forum discussion, drawing on presentations from invited experts, discussions among attendees about real-world case examples, and background paper.

RESULTS

For adaptive approaches to be understood, accepted, and implemented, the Forum identified several key issues that must be addressed. These include the need to define the goals of and to set priorities for adaptive approaches; to examine evidence collection approaches; to clarify the roles and responsibilities of stakeholders; to understand the implications of adaptive approaches on current legal and ethical standards; to determine costs of such approaches and how they will be met; and to identify differences in applying adaptive approaches to drugs versus medical devices. The Forum also explored the different implications of adaptive approaches for various stakeholders, including patients, regulators, HTA/coverage bodies, health systems, clinicians, and industry.

CONCLUSIONS

A key outcome of the meeting was a clearer understanding of the opportunities and challenges adaptive approaches present. Furthermore, the Forum brought to light the critical importance of recognizing and including a full range of stakeholders as contributors to a shared decision-making model implicit in adaptive pathways in future discussions on, and implementation of, adaptive approaches.

Perceptions and experiences of financial incentives: a qualitative study of dialysis care in England

OBJECTIVE

The objective of the study was to understand the extent to which financial incentives such as Payment by Results and other payment mechanisms motivate kidney centres in England to change their practices.

DESIGN

The study followed a qualitative design. Data collection involved 32 in-depth semistructured interviews with healthcare professionals and managers, focusing on their subjective experience of payment structures.

PARTICIPANTS

Participants were kidney healthcare professionals, clinical directors, kidney centre managers and finance managers. Healthcare commissioners from different parts of England were also interviewed.

SETTING

Participants worked at five kidney centres from across England. The selection was based on the prevalence of home haemodialysis, ranging from low (<3%), medium (5-8%) and high (>8%) prevalence, with at least one centre in each one of these categories at the time of selection.

RESULTS

While the tariff for home haemodialysis is not a clear incentive for its adoption due to uncertainty about operational costs, Commissioning for Quality and Innovation (CQUIN) targets and the Best Practice Tariff for vascular access were seen by our case study centres as a motivator to change practices.

CONCLUSIONS

The impact of financial incentives designed at a policy level is influenced by the understanding of cost and benefits at the local operational level. In a situation where costs are unclear, incentives which are based on the improvement of profit margins have a smaller impact than incentives which provide an additional direct payment, even if this extra financial support is relatively small.

Take the money and run: the challenges of designing and evaluating financial incentives in healthcare; Comment on "Paying for performance in healthcare organisations"

Many countries are turning their attention to the use of explicit financial incentives to drive desired improvements in healthcare performance. However, we have only a weak evidence-base to inform policy in this area. The research challenge is to generate robust evidence on what financial incentives work, under what circumstances, for whom and with what intended and unintended consequences.

Use of guideline-based antibiotic prophylaxis in women undergoing gynecologic surgery

OBJECTIVE

To examine guideline-based use of prophylactic antibiotics in patients who underwent gynecologic surgery.

METHODS

We identified women who underwent gynecologic surgery between 2003 and 2010. Procedures were stratified as antibiotic-appropriate (abdominal, vaginal, or laparoscopically assisted vaginal hysterectomy) or antibiotic-inappropriate (oophorectomy, cystectomy, tubal ligation, dilation and curettage, myomectomy, and tubal ligation). Antibiotic use was examined using hierarchical regression models.

RESULTS

Among 545,332 women who underwent procedures for which antibiotics were recommended, 87.1% received appropriate antibiotic prophylaxis, 2.3% received nonguideline-recommended antibiotics, and 10.6% received no prophylaxis. Use of antibiotics increased from 88.0% in 2003 to 90.7% in 2010 (P<.001). Among 491,071, who underwent operations for which antibiotics were not recommended, antibiotics were administered to 197,226 (40.2%) women. Use of nonguideline-based antibiotics also increased over time from 33.4% in 2003 to 43.7% in 2010 (P<.001). Year of diagnosis, surgeon and hospital procedural volume, and area of residence were the strongest predictors of guideline-based and nonguideline-based antibiotic use.

CONCLUSION

Although use of antibiotics is high for women who should receive antibiotics, antibiotics are increasingly being administered to women for whom the drugs are of unproven benefit.

LEVEL OF EVIDENCE

: III.

Impact of the Iranian hospital grading system on hospitals' adherence to audited standards: an examination of possible mechanisms

INTRODUCTION

All Iranian hospitals have been subject to a grading system which determines the payments they can charge. We examined all possible pathways through which the grading system could influence hospitals' adherence to audited standards.

METHODS

Using a mixed methods study we examined five stakeholder groups: hospital staff, patients, general practitioners, health insurance organisations and surveyor organisations. Data were collected via semi-structured interviews, a questionnaire survey, observation and documentary analysis.

FINDINGS

Patients and general practitioners were generally unaware of the hospital grading. Hospital staff and insurance organisations were informed, but this was not found to influence the hospital staff's choice of where to work nor the insurance organisations contracting behaviour. The grading system was criticised for the performance standards' validity and the validity of hospitals' awarded results. Hospitals responded to financial and reputational incentives for achieving better grades, although gaming and misrepresentation was also reported.

CONCLUSION

Pay-for-performance was the main influential factor in shaping hospitals' adherence to audit standards. Other potential mechanisms for influencing hospital behaviour, the selection mechanism and intrinsic motives, were not found to be sufficient to affect hospital behaviour.

Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial

IMPORTANCE

Most evaluations of pay-for-performance (P4P) incentives have focused on large-group practices. Thus, the effect of P4P in small practices, where many US residents receive care, is largely unknown. Furthermore, whether electronic health records (EHRs) with chronic disease management capabilities support small-practice response to P4P has not been studied.

OBJECTIVE

To assess the effect of P4P incentives on quality in EHR-enabled small practices in the context of an established quality improvement initiative.

DESIGN, SETTING, AND PARTICIPANTS

A cluster-randomized trial of small (<10 clinicians) primary care clinics in New York City from April 2009 through March 2010. A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance.

INTERVENTIONS

Incentivized clinics were paid for each patient whose care met the performance criteria, but they received higher payments for patients with comorbidities, who had Medicaid insurance, or who were uninsured (maximum payments: $200/patient; $100,000/clinic). Quality reports were given quarterly to both the intervention and control groups.

MAIN OUTCOMES AND MEASURES

Comparison of differences in performance improvement, from the beginning to the end of the study, between control and intervention clinics for aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation interventions. Mixed-effects logistic regression was used to account for clustering of patients within clinics, with a treatment by time interaction term assessing the statistical significance of the effect of the intervention.

RESULTS

Participating clinics (n = 42 for each group) had similar baseline characteristics, with a mean of 4592 (median, 2500) patients at the intervention group clinics and 3042 (median, 2000) at the control group clinics. Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs 6.1%, difference: 6.0% [95% CI, 2.2% to 9.7%], P = .001 for interaction term), blood pressure control (no comorbidities: 9.7% vs 4.3%, difference: 5.5% [95% CI, 1.6% to 9.3%], P = .01 for interaction term; with diabetes mellitus: 9.0% vs 1.2%, difference: 7.8% [95% CI, 3.2% to 12.4%], P = .007 for interaction term; with diabetes mellitus or ischemic vascular disease: 9.5% vs 1.7%, difference: 7.8% [95% CI, 3.0% to 12.6%], P = .01 for interaction term), and in smoking cessation interventions (12.4% vs 7.7%, difference: 4.7% [95% CI, -0.3% to 9.6%], P = .02 for interaction term). Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control, but no differences were statistically significant.

CONCLUSIONS AND RELEVANCE

Among small EHR-enabled clinics, a P4P incentive program compared with usual care resulted in modest improvements in cardiovascular care processes and outcomes. Because most proposed P4P programs are intended to remain in place more than a year, further research is needed to determine whether this effect increases or decreases over time.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00884013.