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Han KT, Kim S, Kim GO, Lee S, Kwon YU. Medical institutions' quality control efforts: The impacts of a value-based payment system on medical staff and healthcare-associated infections. J Hosp Infect 2024:S0195-6701(24)00260-3. [PMID: 39094740 DOI: 10.1016/j.jhin.2024.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 06/07/2024] [Accepted: 06/18/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND In South Korea, various quality assessments have been introduced to improve the quality of care; thus, the overall quality level of medical institutions has improved. However, gaps still exist between medical institutions. AIM This study evaluated the impact of medical institutions' quality management efforts on securing medical staff and healthcare-associated infections in intensive care units (ICUs). METHODS This study used data from the second and third ICU quality assessments conducted by the Health Insurance Review and Assessment Service, which included 265 hospitals and 39,096 inpatients. The continuous quality improvement efforts of medical institutions were measured according to changes in their grade based on quality assessment results. We also measured healthcare-associated infection rates, including rates for ventilator-associated pneumonia and catheter-associated infections. The incidence rate ratio (IRR) was calculated using generalized estimating equation Poisson regression models that included hospital and patient characteristics. RESULTS Healthcare-associated infections occurred in approximately 2% of patients with ventilators or catheters. Ventilator-associated pneumonia significantly increased in institutions with a decline in grade (IRR: 2.038, 95% CI: 1.426‒2.915). In institutions with an upgrade in grade, infections associated with the central venous catheter (IRR: 0.484; 95% CI: 0.330‒0.711) and urinary catheter (IRR: 0.587, 95% CI: 0.398‒0.866) decreased. CONCLUSIONS Although quality assessment has been introduced in ICUs in South Korea, some gaps remain among medical institutions. Differences were observed in securing medical resources through the quality management efforts of medical institutions, and the infection rate was low in hospitals with high-quality management and high in hospitals with low-quality management.
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Affiliation(s)
- Kyu-Tae Han
- Division of Cancer Control & Policy, National Cancer Control Institute, National Cancer Center, Goyang, Republic of Korea.
| | - Seungju Kim
- Department of Health System, College of Nursing, The Catholic University of Korea, Seoul, Republic of Korea; Research Institute for Hospice/Palliative care, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Gui Ok Kim
- Department of Quality assessment, Health Insurance Review and Assessment Service, Wonju, Republic of Korea.
| | - Syalrom Lee
- Department of Quality assessment, Health Insurance Review and Assessment Service, Wonju, Republic of Korea.
| | - Yong Uk Kwon
- Healthcare Review and Assessment Committee, Health Insurance Review and Assessment Service, Wonju, Republic of Korea.
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Harris A, Philbin S, Post B, Jordan N, Beestrum M, Epstein R, McHugh M. Cost, Quality, and Utilization After Hospital-Physician and Hospital-Post Acute Care Vertical Integration: A Systematic Review. Med Care Res Rev 2024:10775587241247682. [PMID: 38708895 DOI: 10.1177/10775587241247682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Vertical integration of health systems-the common ownership of different aspects of the health care system-continues to occur at increasing rates in the United States. This systematic review synthesizes recent evidence examining the association between two types of vertical integration-hospital-physician (n = 43 studies) and hospital-post-acute care (PAC; n = 10 studies)-and cost, quality, and health services utilization. Hospital-physician integration is associated with higher health care costs, but the effect on quality and health services utilization remains unclear. The effect of hospital-PAC integration on these three outcomes is ambiguous, particularly when focusing on hospital-SNF integration. These findings should raise some concern among policymakers about the trajectory of affordable, high-quality health care in the presence of increasing hospital-physician vertical integration but perhaps not hospital-PAC integration.
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Affiliation(s)
- Alexandra Harris
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Sarah Philbin
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Brady Post
- Northeastern University, Boston, MA, USA
| | - Neil Jordan
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Molly Beestrum
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Richard Epstein
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Megan McHugh
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Khoo JEJ, Lim CW, Lai YF. Performance management of generalist care for hospitalised multimorbid patients-a scoping review for value-based care. FRONTIERS IN HEALTH SERVICES 2024; 3:1147565. [PMID: 38469170 PMCID: PMC10925702 DOI: 10.3389/frhs.2023.1147565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 12/29/2023] [Indexed: 03/13/2024]
Abstract
Objectives Given the shift towards value-based healthcare and the increasing recognition of generalist care, enacting value-based healthcare for generalist care is critical. This work aims to shed light on how to conduct performance management of generalist care to facilitate value-based care, with a focus on medical care of hospitalised patients. Design and setting A scoping review of published literature was conducted. 30 publications which were relevant to performance management of generalist medical inpatient care were included in the review. Outcome measures The performance measures used across the studies were analysed and other qualitative findings were also obtained. Results We report an overall lack of research on performance management methods for generalist inpatient care. Relevant performance measures found include both outcome and process of care measures and both clinical and reported measures, with clinical outcome measures the most frequently reported. Length of stay, readmission rates and mortality were the most frequently reported. The insights from the papers emphasise the relevance of process of care measures for performance management, the advantages and disadvantages of types of measures and provide suggestions relevant for performance management of generalist inpatient care. Conclusion The findings of this scoping review outline a variety of performance measures valuable for generalist inpatient care including clinical outcome measures, reported outcome measures and process of care measures. The findings also suggest directions for implementation of such performance management, including emphasis on physician level performance management and the importance of documentation training. Further research for selecting and operationalising the measures for specific contexts and developing a comprehensive performance management system involving these measures will be important for achieving value-based healthcare for generalist inpatient care.
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Affiliation(s)
- Jia En Joy Khoo
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Department of Life Sciences, Faculty of Science, National University of Singapore, Singapore, Singapore
| | - Cher Wee Lim
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Yi Feng Lai
- Ministry of Health (MOH) Office for Healthcare Transformation, Singapore, Singapore
- Department of Pharmacy, Faculty of Science, National University of Singapore, Singapore, Singapore
- School of Public Health, University of Illinois at Chicago, Chicago, IL, United States
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Garner BR, Tueller S, Bradshaw M, Speck K, Satre D, Rash C, Donohoe T, Mungo J, Philbrick S, Ruwala R, Roosa M, Zehner M, Ford J. Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a cluster-randomized type 3 hybrid trial. RESEARCH SQUARE 2023:rs.3.rs-3685134. [PMID: 38196639 PMCID: PMC10775385 DOI: 10.21203/rs.3.rs-3685134/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Background Substance use disorders (SUDs) have a serious adverse impact on people living with HIV. Previously, using a 39-site dual-randomized type 2 hybrid trial design, findings from the Substance Abuse Treatment to HIV Care Project supported the Implementation and Sustainment Facilitation (ISF) strategy to improve implementation and effectiveness of a motivational interviewing brief intervention (MIBI) for SUD within HIV service settings across the United States (US). Building on this trial, this cluster-randomized type 3 hybrid trial aimed to test the incremental effectiveness of a pay-for-performance (P4P), a form of the "alter incentive/allowance structures" strategy. Methods Twenty-six HIV service organizations, their staff participants (N=87), and their client participants (N=341) were cluster-randomized to one of two implementation conditions. The control condition included staff-focused training, feedback, and consultation (TFC) and team-focused implementation and sustainment (ISF). The experimental condition included TFC+ISF as well as P4P (TFC+ISF+P4P). P4P used financial incentives to reward MIBI implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined. Results The addition of P4P had a large and significant effect on the number of MIBIs implemented (d=1.30, p<.05) and reduction in anxiety (d=-1.54), but there was no impact on days of substance use. P4P had large effects on MIBI quality (d=1.24) and MIBI implementation effectiveness (d=1.28), but these were not significant (p<.10). Conclusions P4P is a form of the "alter incentive/allowance structures" strategy Its function is to reward the implementation of a clinical innovation. Rewarding implementation is consistent with the theory of implementation effectiveness, which suggests implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded) is a key antecedent of implementation effectiveness (i.e., the consistency and quality of implementation). We found that P4P had a significant, positive impact on MIBI implementation in HIV service settings, but client-level outcomes were mixed. Future research should examine the cost-effectiveness of this strategy, as well as to examine the effectiveness of P4P to improve the implementation of other evidence-based innovations. Trial registration ClinicalTrials.gov: NCT04687917. Registered 12/18/2020.
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Affiliation(s)
- Bryan R Garner
- The Ohio State University College of Medicine and Public Health: The Ohio State University College of Medicine
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Grimley RS, Collyer TA, Andrew NE, Dewey HM, Horton ES, Cadigan G, Cadilhac DA. Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2023; 41:100921. [PMID: 37842642 PMCID: PMC10568297 DOI: 10.1016/j.lanwpc.2023.100921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/04/2023] [Accepted: 09/15/2023] [Indexed: 10/17/2023]
Abstract
Background Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke. Methods We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in 2012. Findings We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference -0.16%/month (95% CI -0.29, -0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality -0.18%, (95% CI -0.34, -0.02). Interpretation This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design. Funding Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.
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Affiliation(s)
- Rohan S. Grimley
- School of Medicine and Dentistry, Griffith University, Birtinya, Queensland 4575, Australia
- State-Wide Stroke Clinical Network, Clinical Excellence Queensland, Queensland Department of Health, Brisbane, Queensland 4001, Australia
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton 3168, Australia
| | - Taya A. Collyer
- Peninsula Clinical School Central, Central Clinical School, Monash University, Frankston, Victoria 3199, Australia
| | - Nadine E. Andrew
- Peninsula Clinical School, Central Clinical School and National Centre for Healthy Ageing, Monash University, Frankston, Victoria 3199, Australia
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton 3168, Australia
| | - Helen M. Dewey
- Eastern Health Clinical School, Monash University, Box Hill, Victoria 3128, Australia
| | - Eleanor S. Horton
- State-Wide Stroke Clinical Network, Clinical Excellence Queensland, Queensland Department of Health, Brisbane, Queensland 4001, Australia
- University of Sunshine Coast, Maroochydore, Queensland 4558, Australia
| | - Greg Cadigan
- Healthcare Improvement Unit, Clinical Excellence Queensland, Queensland Department of Health, Brisbane, Queensland 4001, Australia
| | - Dominique A. Cadilhac
- Stroke and Ageing Research, Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton 3168, Australia
- Stroke Division, The Florey Institute of Neuroscience and Mental Health, Victoria, Australia
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Salet N, Buijck BI, van Dam-Nolen DHK, Hazelzet JA, Dippel DWJ, Grauwmeijer E, Schut FT, Roozenbeek B, Eijkenaar F. Factors Influencing the Introduction of Value-Based Payment in Integrated Stroke Care: Evidence from a Qualitative Case Study. Int J Integr Care 2023; 23:7. [PMID: 37601033 PMCID: PMC10437137 DOI: 10.5334/ijic.7566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 07/31/2023] [Indexed: 08/22/2023] Open
Abstract
Background To address issues related to suboptimal insight in outcomes, fragmentation, and increasing costs, stakeholders are experimenting with value-based payment (VBP) models, aiming to facilitate high-value integrated care. However, insight in how, why and under what circumstances such models can be successful is limited. Drawing upon realist evaluation principles, this study identifies context factors and associated mechanisms influencing the introduction of VBP in stroke care. Methods Existing knowledge on context-mechanism relations impacting the introduction of VBP programs (in real-world settings) was summarized from literature. These relations were then tested, refined, and expanded based on a case study comprising interviews with representatives from organizations involved in the introduction of a VBP model for integrated stroke care in Rotterdam, the Netherlands. Results Facilitating factors were pre-existing trust-based relations, shared dissatisfaction with the status quo, regulatory compatibility and simplicity of the payment contract, gradual introduction of down-side risk for providers, and involvement of a trusted third party for data management. Yet to be addressed barriers included friction between short- and long-term goals within and among organizations, unwillingness to forgo professional and organizational autonomy, discontinuity in resources, and limited access to real-time data for improving care delivery processes. Conclusions Successful payment and delivery system reform require long-term commitment from all stakeholders stretching beyond the mere introduction of new models. Careful consideration of creating the 'right' contextual circumstances remains crucially important, which includes willingness among all involved providers to bear shared financial and clinical responsibility for the entire care chain, regardless of where care is provided.
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Affiliation(s)
- Newel Salet
- Erasmus School of Health Policy & Management, Erasmus University, NL
| | - Bianca I. Buijck
- Rotterdam Stroke Service, The Netherlands
- Erasmus MC University Medical Center, Department of Neurology, Rotterdam, NL
| | - Dianne H. K. van Dam-Nolen
- Erasmus MC University Medical Center, Department of Neurology, Rotterdam, The Netherlands
- Erasmus MC University Medical Center, Department of Radiology & Nuclear Medicine, NL
| | - Jan A. Hazelzet
- Erasmus MC University Medical Center, Department of Public Health, NL
| | | | - Erik Grauwmeijer
- Rijndam Rehabilitation, The Netherlands
- Erasmus MC University Medical Center, Department of Rehabilitation, Rotterdam, NL
| | - F. T. Schut
- Erasmus School of Health Policy & Management, Erasmus University, NL
| | - Bob Roozenbeek
- Erasmus MC University Medical Center, Department of Neurology, Rotterdam, NL
| | - Frank Eijkenaar
- Erasmus School of Health Policy & Management, Erasmus University, NL
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Lu JFR, Chen YI, Eggleston K, Chen CH, Chen B. Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:717-733. [PMID: 35995886 DOI: 10.1007/s10198-022-01504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 07/26/2022] [Indexed: 05/20/2023]
Abstract
Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.
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Affiliation(s)
- Jui-Fen Rachel Lu
- Graduate Institute of Business and Management and Department of Health Care Management, College of Management, Chang Gung University, Taoyuan City, Taiwan
- Department of Radiation Oncology, Chang Gung Memorial Hospital in Linkou, Taoyuan City, Taiwan
| | - Ying Isabel Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Karen Eggleston
- Shorenstein Asia-Pacific Research Center, Freeman Spogli Institute for International Studies, Stanford University, and NBER, Stanford, CA, USA
| | - Chih-Hung Chen
- Division of Metabolism, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Brian Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
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Elwyn G, Sierpe A, Forcino R. Do payment programs incentivize shared decision making in US healthcare? PATIENT EDUCATION AND COUNSELING 2023; 113:107798. [PMID: 37224594 DOI: 10.1016/j.pec.2023.107798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Glyn Elwyn
- The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, WTRB, 1 Medical Center Drive, Lebanon, NH 03766, USA.
| | - Ailyn Sierpe
- The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, WTRB, 1 Medical Center Drive, Lebanon, NH 03766, USA
| | - Rachel Forcino
- The Dartmouth Institute for Health Policy & Clinical Practice, Level 5, WTRB, 1 Medical Center Drive, Lebanon, NH 03766, USA
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Patey AM, Soong C. Top-down and bottom-up approaches to low-value care. BMJ Qual Saf 2023; 32:65-68. [PMID: 36517225 DOI: 10.1136/bmjqs-2022-014977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Andrea M Patey
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada .,School of Epidemiology and Public Health, University of Ottawa, Ottawa, Ontario, Canada
| | - Christine Soong
- Division of General Internal Medicine, Sinai Health, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Center for Quality Improvement and Patient Safety, University of Toronto, Toronto, Ontario, Canada
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Rasooly A, Pan Y, Tang Z, Jiangjiang H, Ellen ME, Manor O, Hu S, Davidovitch N. Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China. Int J Health Policy Manag 2022; 11:3019-3031. [PMID: 35942954 PMCID: PMC10105207 DOI: 10.34172/ijhpm.2022.6372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation. METHODS In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis. RESULTS Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs. CONCLUSION The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.
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Affiliation(s)
- Alon Rasooly
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yancen Pan
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Zhenqing Tang
- Shanghai Health Development Research Center, Shanghai, China
| | - He Jiangjiang
- Shanghai Health Development Research Center, Shanghai, China
| | - Moriah E. Ellen
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Orly Manor
- Braun School of Public Health and Community Medicine, Hebrew University, Jerusalem, Israel. 5 School of Public Health, Fudan University, Shanghai, China
| | - Shanlian Hu
- School of Public Health, Fudan University, Shanghai, China
| | - Nadav Davidovitch
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Ray-Barruel G, Horowitz J, McLaughlin E, Flanders S, Chopra V. Barriers and facilitators for implementing peripherally inserted central catheter (PICC) appropriateness guidelines: A longitudinal survey study from 34 Michigan hospitals. PLoS One 2022; 17:e0277302. [PMID: 36331967 PMCID: PMC9635738 DOI: 10.1371/journal.pone.0277302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 10/22/2022] [Indexed: 11/06/2022] Open
Abstract
Peripherally inserted central catheters (PICCs) are prevalent devices for medium-to-long-term intravenous therapy but are often associated with morbid and potentially lethal complications. This multi-center study sought to identify barriers and facilitators of implementing evidence-based appropriateness criteria to improve PICC safety and patient outcomes in a pay-for-performance model. Participating hospitals received an online toolkit with five recommendations: establishing a vascular access committee; implementing a clinical decision tool for PICC appropriateness; avoiding short-term PICC use (≤5 days); increasing use of single-lumen PICCs; and avoiding PICC placement in patients with chronic kidney disease. Longitudinal online surveys conducted biannually October 2014–November 2018 tracked implementation efforts. A total of 306 unique surveys from 34 hospitals were completed. The proportion of hospitals with a dedicated committee overseeing PICC appropriateness increased from 53% to 97%. Overall, 94% of hospitals implemented an initiative to reduce short-term and multi-lumen PICC use, and 91% integrated kidney function into PICC placement decisions. Barriers to implementation included: achieving agreement from diverse disciplines, competing hospital priorities, and delays in modifying electronic systems to enable appropriate PICC ordering. Provision of quarterly benchmarking reports, a decision algorithm, access to an online toolkit, and presence of local champion support were cited as crucial in improving practice. Structured quality improvement efforts including a multidisciplinary vascular access committee, clear targets, local champions, and support from an online education toolkit have led to sustained PICC appropriateness and improved patient safety.
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Affiliation(s)
- Gillian Ray-Barruel
- School of Nursing, Midwifery and Social Work, The University of Queensland, St Lucia, Queensland, Australia
- Herston Infectious Diseases Institute, The University of Queensland, Herston, Queensland, Australia
- Alliance for Vascular Access Teaching and Research, School of Nursing and Midwifery, Griffith University, Nathan, Queensland, Australia
- * E-mail:
| | - Jennifer Horowitz
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
| | - Elizabeth McLaughlin
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
| | - Scott Flanders
- Division of Hospital Medicine, Department of Internal Medicine, Michigan Medicine, Ann Arbor, Michigan, United States of America
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
| | - Vineet Chopra
- The Michigan Hospital Medicine Safety Consortium, Ann Arbor, Michigan, United States of America
- Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colorado, United States of America
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Pashchenko O, Bromberg DJ, Dumchev K, LaMonaca K, Pykalo I, Filippovych M, Esserman D, Polonsky M, Galvez de Leon SJ, Morozova O, Dvoriak S, Altice FL. Preliminary analysis of self-reported quality health indicators of patients on opioid agonist therapy at specialty and primary care clinics in Ukraine: A randomized control trial. PLOS GLOBAL PUBLIC HEALTH 2022; 2:e0000344. [PMID: 36962514 PMCID: PMC10021202 DOI: 10.1371/journal.pgph.0000344] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Accepted: 08/29/2022] [Indexed: 11/07/2022]
Abstract
International agencies recommend integrating addiction treatment into primary care for people who inject drugs (PWID) with opioid use disorder (OUD). Empirical data supporting integration that incorporates comprehensive health outcomes, however, are not known. For this randomized controlled trial in Ukraine, adult PWID with OUD were randomized to receive opioid agonist therapy (OAT) in specialty addiction treatment clinics (SATC) or to primary care clinics (PCCs). For those randomized to PCC, they were subsequently allocated to PCCs where clinicians received pay-for-performance (P4P) incentives (PCC with P4P) or not (PCC without P4P). Participating cities had one of each of the three intervention sites to control for geographic variation. Ongoing tele-education specialty training (OAT, HIV, tuberculosis) was provided to all PCCs. While the primary outcome for the parent trial focuses on patient medical record data, this preliminary analysis focuses on assessment of self-reported achievement of nationally recommended quality health indicators (QHIs) which is summed as a composite QHI score. Secondary outcomes included specialty and primary care QHI subscores. This study occurred from 01/20/2018-11/1/2020 with 818 of 990 randomized participants having complete self-reported data for analysis. Relative to SATC (treatment as usual), the mean composite QHI score was 12.7 (95% CI: 10.1-15.3; p<0.001) percentage points higher at PCCs; similar and significantly higher scores were observed in PCCs compared to SATCs for both primary care (PCC vs SATC: 18.4 [95% CI: 14.8-22.0; p<0.001] and specialty (PCC vs SATC: 5.9 [95% CI: 2.6-9.2; p<0.001] QHI scores. Additionally, the mean composite QHI score was 4.6 (95% CI: 2.0-7.2; p<0.001) points higher in participants with long term (>3 months) experience with OAT compared to participants newly initiating OAT. In summary, PWID with OUD receive greater primary care and specialty healthcare services when receiving OAT at PCCs supported by tele-education relative to treatment as usual provided in SATCs. Clinical trial registration: This trial was registered at clinicaltrials.gov and can be found using the following registration number: NCT04927091.
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Affiliation(s)
| | - Daniel J. Bromberg
- Department of Social and Behavioral Sciences, Yale School of Public Health, Yale University, New Haven, CT, United States of America
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America
| | | | - Katherine LaMonaca
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
| | - Iryna Pykalo
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
- European Institute on Public Health Policy, Kyiv, Ukraine
| | | | - Denise Esserman
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Maxim Polonsky
- Keck Graduate Institute, Claremont, CA, United States of America
| | | | - Olga Morozova
- Department of Public Health Sciences, Biological Sciences Division, University of Chicago, Chicago, IL, United States of America
| | - Sergii Dvoriak
- Ukrainian Institute on Public Health Policy, Kyiv, Ukraine
| | - Frederick L. Altice
- Yale Center for Interdisciplinary Research on AIDS, Yale University, New Haven, CT, United States of America
- Yale School of Medicine, Yale University, New Haven, CT, United States of America
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Laberge M, Brundisini FK, Champagne M, Daniel I. Hospital funding reforms in Canada: a narrative review of Ontario and Quebec strategies. Health Res Policy Syst 2022; 20:76. [PMID: 35761397 PMCID: PMC9235246 DOI: 10.1186/s12961-022-00879-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
Background In the early 2000s, Ontario and Quebec, two provinces of Canada, began to introduce hospital payment reforms to improve quality and access to care. This paper (1) critically reviews patient-based funding (PBF) implementation approaches used by Quebec and Ontario over 15 years, and (2) identifies factors that support or limit PBF implementation to inform future decisions regarding the use of PBF models in both provinces. Methods We adopted a narrative review approach to document and critically analyse Quebec and Ontario experiences with the implementation of patient-based funding. We searched for documents in the scientific and grey literature and contacted key stakeholders to identify relevant policy documents. Results Both provinces targeted similar hospital services—aligned with nationwide policy goals—fulfilling in part patient-based funding programmes’ objectives. We identified four factors that played a role in ensuring the successful—or not—implementation of these strategies: (1) adoption supports, (2) alignment with programme objectives, (3) funding incentives and (4) stakeholder engagement. Conclusions This review provides lessons in the complexity of implementing hospital payment reforms. Implementation is enabled by adoption supports and funding incentives that align with policy objectives and by engaging stakeholders in the design of incentives.
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Affiliation(s)
- Maude Laberge
- Department of Operations and Decision Systems, Faculty of Administration, Université Laval, 2325, rue de la Terrasse, Bureau #2519, Quebec City, QC, G1V 0A6, Canada. .,Vitam, centre de recherche en santé durable, Université Laval, Quebec City, Canada. .,Centre de Recherche du CHU de Québec, Université Laval, Quebec City, Canada.
| | - Francesca Katherine Brundisini
- Department of Operations and Decision Systems, Faculty of Administration, Université Laval, 2325, rue de la Terrasse, Bureau #2519, Quebec City, QC, G1V 0A6, Canada.,Vitam, centre de recherche en santé durable, Université Laval, Quebec City, Canada
| | - Myriam Champagne
- Department of Operations and Decision Systems, Faculty of Administration, Université Laval, 2325, rue de la Terrasse, Bureau #2519, Quebec City, QC, G1V 0A6, Canada
| | - Imtiaz Daniel
- Institute of Health Policy, Management and Evaluation, University of Toronto Health Sciences Building, 155 College Street, Suite 425, Toronto, ON, M5T 3M6, Canada.,Ontario Hospital Association, Toronto, Canada
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Effectiveness of pay for performance to non-physician health care providers: a systematic review. Health Policy 2022; 126:592-602. [DOI: 10.1016/j.healthpol.2022.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 03/10/2022] [Accepted: 03/11/2022] [Indexed: 11/19/2022]
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Association of Primary Care Physician Compensation Incentives and Quality of Care in the United States, 2012-2016. J Gen Intern Med 2022; 37:359-366. [PMID: 33852143 PMCID: PMC8811085 DOI: 10.1007/s11606-021-06617-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/07/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Physician compensation incentives may have positive or negative effects on clinical quality. OBJECTIVE To assess the association between various physician compensation incentives on technical indicators of primary care quality. DESIGN Cross-sectional, nationally representative retrospective analysis. PARTICIPANTS Visits by adults to primary care physicians in the National Ambulatory Medical Care Survey from 2012-2016. We analyzed 49,580 sampled visits, representing 1.45 billion primary care visits. MAIN MEASURES We assessed the association between 5 compensation incentives - quality measure performance, patient experience scores, individual productivity, practice financial performance, or practice efficiency - and 10 high-value and 7 low-value care measures as well as high-value and low-value care composites. KEY RESULTS Quality measure performance was an incentive in 22% of visits; patient experience scores, 17%; individual productivity, 57%; practice financial performance, 63%; and practice efficiency, 12%. In adjusted models, none of the compensation incentives were consistently associated with individual high- and low-value measures. None of the compensation incentives were associated with high- or low-value care composites. For example, quality measure performance compensation was not significantly associated with high-value care (visits with quality incentive, 47% of eligible measures met; without quality incentive, 43%; adjusted odds ratio [aOR], 1.02; 95% confidence interval [CI], 0.91 to 1.15) or low-value care (aOR, 0.99; 95% CI, 0.82-1.19). Physician compensation incentives that might be expected to increase low-value care did not: patient experience (aOR for low-value care composite, 0.83; 95% CI, 0.65-1.05), individual productivity (aOR, 1.03; 95% CI, 0.88-1.22), and practice financial performance (aOR, 1.05; 95% CI, 0.81-1.36). CONCLUSION In this retrospective, cross-sectional, nationally representative analysis of care in the United States, physician compensation incentives were not generally associated with more or less high- or low-value care.
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Frenkel Rutenberg T, Aizer A, Levi A, Naftali N, Zeituni S, Velkes S, Aka Zohar A. Antibiotic prophylaxis as a quality of care indicator: does it help in the fight against surgical site infections following fragility hip fractures? Arch Orthop Trauma Surg 2022; 142:239-245. [PMID: 33216182 DOI: 10.1007/s00402-020-03682-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2020] [Accepted: 11/04/2020] [Indexed: 01/19/2023]
Abstract
INTRODUCTION Fragility hip fractures are associated with increased morbidity, mortality, and costs. To improve patient care, quality indicator programs were introduced. Yet, the efficacy of these programs and specific quality indicators are questioned. We aimed to determine whether defining prophylactic pre-surgical antibiotic treatment as a quality indicator affected hip fracture outcomes. MATERIALS AND METHODS A retrospective study comparing consecutive patients, 65 years and older, who were operated for fragility hip fractures between 01/01/2011 and 30/06/2016, before and after the prophylactic pre-surgical antibiotic treatment quality indicator, which was introduced in 01/2014. Primary outcomes were 1-year surgical site infections (SSI). Secondary outcomes were meeting the quality index and mortality rates, either within a hospital or during the first post-operative year. RESULTS 904 patients, ages 82.5 ± 7.2 years were operated for fragility hip fractures. 403 patients presented before the antibiotic prophylaxis quality indicator, and 501 following its administration. Patients demographics were comparable. In the pre-quality indicator period, documentation of prophylactic antibiotic treatment was lacking. Only 19.6% had a record for antibiotic administration in their surgical records and for merely 10.4% the type of antibiotic was stated. However, in the post-quality indicator period, 97.0% of patients had a registered prophylactic antibiotic regimen in the hour preceding the surgical incision (p < 0.001). Post-operative SSI rates were equivalent, and as were in-hospital infections, mortality and recurrent hospitalizations CONCLUSIONS: The introduction of the pre-operative antibiotic treatment quality indicator increased the documentation of antibiotic administration yet failed to influence the incidence of post-operative orthopaedic and medical infections in fragility hip fracture patients.
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Affiliation(s)
- Tal Frenkel Rutenberg
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Aviv University, Tel Aviv, Israel.
| | - Anat Aizer
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Avraham Levi
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Noa Naftali
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Shelly Zeituni
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
| | - Steven Velkes
- Orthopedic Department, Rabin Medical Center, Beilinson Hospital, Petah Tikva, Israel, affiliated to the Sackler Faculty of Medicine, Aviv University, Tel Aviv, Israel
| | - Anat Aka Zohar
- Department of Management, Bar Ilan University, Public Health MHA Program, Ramat Gan, Israel
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Thayer AJ, Cook CR, Davis C, Brown EC, Locke J, Ehrhart MG, Aarons GA, Picozzi E, Lyon AR. Construct validity of the school-implementation climate scale. IMPLEMENTATION RESEARCH AND PRACTICE 2022; 3:26334895221116065. [PMID: 37091097 PMCID: PMC9924285 DOI: 10.1177/26334895221116065] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Implementation climate is an organizational construct theorized to facilitate the adoption and delivery of evidence-based practices. Within schools, teachers often are tasked with implementing universal prevention programs. Therefore, they are ideal informants when assessing school implementation climate for initial and continuous implementation improvement efforts. The purpose of this study was to examine the construct validity (i.e., factor structure and convergent/divergent validity) of a school-adapted measure of strategic implementation climate called the School Implementation Climate Scale (SICS). Methods Confirmatory factor analyses of SICS data, collected from 441 teachers in 52 schools, were used to compare uncorrelated and correlated first-order factor models and a second-order hierarchical model. Correlations with other school measures were examined to assess SICS convergent and divergent validities. Results Results demonstrated acceptable internal consistency for each SICS subscale ( αs > 0.80 for all subscales) and construct validity of the hypothesized factor structure of the SICS with three new scales. The hierarchical second-order factor structure with eight first-order factors was found to best model the SICS data. Correlations with other school measures were in the expected direction and magnitude. Conclusions Results from this study provide psychometric evidence that supports the use of the SICS to inform the implementation research and practice in schools. Plain Language Summary Schools are busy trying to implement various universal programs and systems to help support kids in their growth. Beginning and sustaining these efforts is quite challenging, and there is need for tools and ideas to help those implementation efforts. One concept is implementation climate, which is broadly the school staff’s perception of the implementation support for a given practice. However, no measure currently exists to help schools assess their implementation climate. The goal of our study was to adapt a measure of implementation climate used in other settings to the school environment. We used feedback from educational experts to make changes and used various analyses to determine if the newly adapted measure was psychometrically sound. Findings suggest the new measure is usable to guide implementation efforts in schools.
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Affiliation(s)
- Andrew J. Thayer
- Department of Psychology, University of Nebraska Medical Center, Omaha, NE, USA
| | - Clayton R. Cook
- Department of Educational Psychology, University of Minnesota, Minneapolis, MN, USA
| | - Chayna Davis
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | | | - Jill Locke
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Mark G. Ehrhart
- Department of Psychology, University of Central Florida, Orlando, FL, USA
| | - Gregory A. Aarons
- Department of Psychiatry, University of California San Diego, La Jolla, CA, USA
| | - Elissa Picozzi
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
| | - Aaron R. Lyon
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA
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Cabreira FDS, Hugo FN, Celeste RK. Pay-for-performance and dental procedures: A longitudinal analysis of the Brazilian Program for the Improvement of Access and Quality of Dental Specialities Centres. Community Dent Oral Epidemiol 2021; 50:4-10. [PMID: 34967967 DOI: 10.1111/cdoe.12717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/21/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Evaluate the impact of a pay-for-performance program on changes in the number of dental procedures performed by public secondary dental care services in Brazil. METHODS A longitudinal study was carried out with 932 public Dental Specialities Centres (Centro de Especialidades Odontológicas - CEO) that participated in the pay-for-performance Program for the Improvement of Access and Quality of Dental Specialities Centres Services (PMAQ/CEO) and 379 non-CEO centres with secondary dental production. The non-CEO and a group of CEOs did not receive financial incentives from the PMAQ-CEO and served as control groups. Three CEOs groups received additional financial incentives of 20%, 60% or 100% over maintenance values, based on their performance scores. The outcome was the increase (yes/no) in the number of dental procedures between 2011/2013 and 2015/2017. Analyses were carried out using logistic regressions. RESULTS The number of specialized procedures increased in 48.4% of the services, 44.6% among non-CEO, 52.3% among CEO with no financial incentive and 59.1% among CEO with 100% incentive. The fully adjusted model showed that CEOs receiving 100% of the financial incentive had greater odds of increasing the production of dental procedures (OR = 1.65, 95%CI: 1.09-2.51). Services that increased the number of specialist dentists had (OR = 2.35, 95%CI 1.88-2.94). Municipalities that increased in coverage of private dental insurance had OR = 0.98 (95%CI: 0.94-1.02), and those with higher coverage of primary dental care had OR = 1.02 (95%CI: 0.99-1.05). CONCLUSION Pay-for-performance may increase the production of dental procedures by CEOs, and mechanisms explaining it must be further investigated.
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Affiliation(s)
- Fabiana da Silva Cabreira
- Department of Preventive and Social Dentistry, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Federal Institute of Education, Science and Technology Farroupilha - IFFar, Alegrete, Brazil.,Prefeitura Municipal de Alegrete, Alegrete, Brazil
| | - Fernando Neves Hugo
- Department of Preventive and Social Dentistry, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Roger Keller Celeste
- Department of Preventive and Social Dentistry, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Asaad M, Selber JC, Adelman DM, Baumann DP, Hassid VJ, Crosby MA, Liu J, Butler CE, Clemens MW. Allograft vs Xenograft Bioprosthetic Mesh in Tissue Expander Breast Reconstruction: A Blinded Prospective Randomized Controlled Trial. Aesthet Surg J 2021; 41:NP1931-NP1939. [PMID: 33693461 DOI: 10.1093/asj/sjab115] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND With the increased use of acellular dermal matrix (ADM) in breast reconstruction, the number of available materials has increased. There is a relative paucity of high-quality outcomes data for use of different ADMs. OBJECTIVES The goal of this study was to compare the outcomes between a human (HADM) and a bovine ADM (BADM) in implant-based breast reconstruction. METHODS A prospective, single-blinded, randomized controlled trial was conducted to evaluate differences in outcomes between HADM and BADM for patients undergoing immediate tissue expander breast reconstruction. Patients with prior radiation to the index breast were excluded. Patient and surgical characteristics were collected and analyzed. RESULTS From April 2011 to June 2016, a total of 90 patients were randomized to a mesh group, with 68 patients (HADM, 36 patients/55 breasts; BADM, 32 patients/48 breasts) included in the final analysis. Baseline characteristics were similar between the 2 groups. No significant differences in overall complication rates were identified between HADM (n = 14, 25%) and BADM (n = 13, 27%) (P = 0.85). Similar trends were identified for major complications and complications requiring reoperation. Tissue expander loss was identified in 7% of HADM patients (n = 4) and 17% of BADM patients (n = 8) (P = 0.14). CONCLUSIONS Similar complication and implant loss rates were found among patients undergoing immediate tissue expander breast reconstruction with HADM or BADM. Regardless of what material is used, careful patient selection and counseling, and cost consideration, help to improve outcomes and sustainability in immediate breast reconstruction. LEVEL OF EVIDENCE: 2
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Affiliation(s)
- Malke Asaad
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jesse C Selber
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - David M Adelman
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Donald P Baumann
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Victor J Hassid
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Melissa A Crosby
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jun Liu
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Charles E Butler
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mark W Clemens
- Department of Plastic Surgery, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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20
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Richard C, Urick BY, Pathak S, Jackson J, Livet M. Performance-based pharmacy payment models: key components and critical implementation considerations for successful uptake and integration. J Manag Care Spec Pharm 2021; 27:1568-1578. [PMID: 34714107 PMCID: PMC10390937 DOI: 10.18553/jmcp.2021.27.11.1568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: In the United States, the shift towards value-based health care seeks to improve patient outcomes while reducing health care spending. Although the federal government has led the implementation of performance-based models for physicians and health care systems, commercial entities have largely been responsible for the development of similar models within pharmacy. For the purposes of this study, performance-based pharmacy payment models (PBPPMs) were defined as prescription drug payment models that determine reimbursement or fees for community pharmacies based in part on measured performance. These PBPPMs incentivize pharmacies to improve patient care by linking reimbursement to performance measures. However, the design and implementation of PBPPMs lack transparency and have not been described in the literature. OBJECTIVES: To (1) describe the structure of PBPPMs in the United States and (2) identify contextual and motivational influences that need to be considered for successful uptake and integration of these models. METHODS: A search of peer-reviewed and grey literature was undertaken. In addition, semi-structured stakeholder interviews were conducted with a convenience sample of 17 individuals who were community pharmacists, payers, quality measure developers and vendors, academics, and pharmacy advocacy organization leaders. Data were analyzed to understand the current structure of PBPPMs and opportunities for improvement, as well as implementation considerations that included facilitators, barriers, and key insights. RESULTS: This study identified 4 major components of US PBPPMs: attribution, performance and quality measures, incentive structures, and patient care services. A number of barriers (eg, lack of alignment) and recommendations to improve the current structure of PBPPMs (eg, the need for adequate incentives to facilitate change) were highlighted. Notable implementation considerations centered around (1) establishing common ground among stakeholders to avoid misalignment and encourage engagement; (2) the importance of a quality-driven, innovative, and flexible organizational culture with access to data infrastructure, adjusted workflows, and relevant trainings; (3) supporting the cultural transition to value-based health care; and (4) application of financial incentives at the pharmacy or pharmacist level. CONCLUSIONS: To better develop and implement PBPPMs, it is first critical to understand the key components that define these models and the needed changes to their structure. In addition, identifying the contextual and motivational factors that influence their successful integration can improve future uptake. This study illustrates the landscape of PBPPMs in the United States, as well as makes recommendations for improvement in their design. To improve future development and implementation of these models, the following recommendations are highlighted: (1) increase transparency and alignment of measures with the incentive structure; (2) embrace innovative business models; (3) carefully plan and use roadmaps that outline successful uptake and implementation; and (4) foster culture of quality at all levels of health care. DISCLOSURES: This study was sponsored by Pharm-Alliance, an alliance between the pharmacy schools of the University of North Carolina at Chapel Hill, Monash University, and University College London. Urick reports consulting fees from Pharmacy Quality Solutions and Cardinal Health, unrelated to this work. The other authors have nothing to disclose. This study was a podium presentation under the title "What Makes Performance-Based Pharmacy Payment Models Work?" at AMCP Nexus Virtual, October 2020.
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Affiliation(s)
- Chloe Richard
- Center for Medication Optimization (CMO), Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - Benjamin Y Urick
- Center for Medication Optimization (CMO), Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - Shweta Pathak
- Center for Medication Optimization (CMO), Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
| | - John Jackson
- Center for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia
| | - Melanie Livet
- Center for Medication Optimization (CMO), Division of Practice Advancement and Clinical Education, Eshelman School of Pharmacy, University of North Carolina at Chapel Hill
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Khedmati Morasae E, Rose TC, Gabbay M, Buckels L, Morris C, Poll S, Goodall M, Barnett R, Barr B. Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study. Med Care Res Rev 2021; 79:394-403. [PMID: 34323143 PMCID: PMC9052704 DOI: 10.1177/10775587211035280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
National financial incentive schemes for improving the quality of primary care
have come under criticism in the United Kingdom, leading to calls for localized
alternatives. This study investigated whether a local general practice
incentive-based quality improvement scheme launched in 2011 in a city in the
North West of England was associated with a reduction in all-cause emergency
hospital admissions. Difference-in-differences analysis was used to compare the
change in emergency admission rates in the intervention city, to the change in a
matched comparison population. Emergency admissions rates fell by 19 per 1,000
people in the years following the intervention (95% confidence interval [17,
21]) in the intervention city, relative to the comparison population. This
effect was greater among more disadvantaged populations, narrowing socioeconomic
inequalities in emergency admissions. The findings suggest that similar
approaches could be an effective component of strategies to reduce unplanned
hospital admissions elsewhere.
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Affiliation(s)
| | | | | | - Laura Buckels
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Sharon Poll
- Liverpool Clinical Commissioning Group, Liverpool, UK
| | | | - Rob Barnett
- Liverpool Local Medical Committee, Liverpool, UK
| | - Ben Barr
- University of Liverpool, Liverpool, UK
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22
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Mousaloo A, Amir-Behghadami M, Janati A, Gholizadeh M. Exploring the challenges and features of implementing performance-based payment plan in hospitals: a protocol for a systematic review. Syst Rev 2021; 10:114. [PMID: 33863372 PMCID: PMC8052724 DOI: 10.1186/s13643-021-01657-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 03/29/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Implementing performance-based payment (PBP) plan has led to developing a number of significant potentialities such as performance improvement and effectiveness, quality improvement of provided services, and decline in health system expenditure in hospitals. Despite the fact that PBP plan has a variety of potential advantages, its implementation still may face some challenges. Hence, it seems crucial to identify these barriers and challenges in order to devise some strategies and interventions to pave the way for better implementation of PBP in hospitals. The aim of this proposed protocol is to identify, summarize, and synthesize the existing evidence by undertaking a systematic review to explore the challenges, barriers, and features of implementing PBP in hospitals. METHODS AND ANALYSIS An inclusive search of the literature will be conducted in seven international and national databases including PubMed/MEDLINE, Scopus, Cochrane Library and Web of Science, Magiran, Scientific Information Database (SID), and Barakat knowledge network system (BKNS). The search will be limited to the studies published in English or Persian language. Database search will be supplemented by hand-search of citation, reference lists, and grey literature sources. Based on the pre-established criteria in all steps of the review, two researchers will independently screen all of the retrieved studies. Any discrepancies will be resolved through a discussion between two researchers. In cases where consensus is not reached, it will be referred to a third researcher. The methodological quality of all the included studies will be appraised using the Mixed Methods Appraisal Tool (MMAT). The data will be extracted by means of using a data extraction form, which will be developed and piloted by the research team. The findings will be synthesized through directed content analysis method. DISCUSSION With the growth and development of payment systems all over the world, it is expected that recognizing the challenges of implementing a PBP plan in hospitals will be useful in developing and designing strategies to better implement this plan. SYSTEMATIC REVIEW REGISTRATION PROSPERO registration number CRD42020152569.
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Affiliation(s)
- Asieh Mousaloo
- Student Research Committee (SRC), Tabriz University of Medical Sciences, Tabriz, Iran
- Iranian Center of Excellence in Health Management (IceHM), Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, University Rd, Golbad, EAZN, Tabriz, 5165665811, Iran
| | - Mehrdad Amir-Behghadami
- Student Research Committee (SRC), Tabriz University of Medical Sciences, Tabriz, Iran.
- Iranian Center of Excellence in Health Management (IceHM), Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, University Rd, Golbad, EAZN, Tabriz, 5165665811, Iran.
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran.
| | - Ali Janati
- Student Research Committee (SRC), Tabriz University of Medical Sciences, Tabriz, Iran
- Iranian Center of Excellence in Health Management (IceHM), Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, University Rd, Golbad, EAZN, Tabriz, 5165665811, Iran
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Masoumeh Gholizadeh
- Student Research Committee (SRC), Tabriz University of Medical Sciences, Tabriz, Iran
- Iranian Center of Excellence in Health Management (IceHM), Department of Health Service Management, School of Management and Medical Informatics, Tabriz University of Medical Sciences, University Rd, Golbad, EAZN, Tabriz, 5165665811, Iran
- Tabriz Health Services Management Research Center, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
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Hadian M, Rezapour A, Mazaheri E, Asiabar AS. Barriers in the performance-based payment in Iran health system: Challenges and solutions. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2021; 10:106. [PMID: 34084853 PMCID: PMC8150088 DOI: 10.4103/jehp.jehp_797_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/04/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND One of the main goals of hospital management is to attract, maintain, and increase the number of qualified and efficient human resources, and one of the key and most important factors in achieving this goal is to design and implement a fair and efficient payment system. The purpose of this project is to determine the challenges of the performance-based payment system and provide solutions to overcome its obstacles in the city of Tehran. MATERIALS AND METHODS This qualitative research sought to perform content analysis so as to explore the experiences and perceptions of a purposeful group of specialists and managers of Tehran's educational and medical centers (n = 10). Data were collected using in-depth semi-structured interviews and were ongoing until the point of saturation. RESULTS On analysis of data by Specialists and managers of Tehran's educational and medical centers, three main themes including behavior, organization, rules and regulation were defined alongside seven subthemes includes scheduling, platform, education, quantity-oriented, motivation, implementation, and payment system. CONCLUSION In general, it can be concluded that for the successful implementation of any project, the necessary infrastructure must be provided for implementation. In this plan, despite the challenges in the field of behavior, organization, and rules and regulations, the need for necessary training before implementing the plan, special attention to quality instead of quantity, motivating employees to cooperate in implementing the plan as successfully as possible, creating a platform Appropriate before the implementation of the plan and most importantly, the pilot implementation of the plan before its widespread implementation seems necessary.
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Affiliation(s)
- Marziye Hadian
- Health Management and Economics Research Center, Student Research Committee, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Aziz Rezapour
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
| | - Elaheh Mazaheri
- Health Information Technology Research Center, Student Research Committee, Department of Medical Library and Information Sciences, School of Management and Medical Information Sciences, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Ali Sarabi Asiabar
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
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Urick BY, Pathak S, Hughes TD, Ferreri SP. Design and effect of performance-based pharmacy payment models. J Manag Care Spec Pharm 2021; 27:306-315. [PMID: 33645246 PMCID: PMC10391031 DOI: 10.18553/jmcp.2021.27.3.306] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Community pharmacy participation in performance-based payment models has increased in recent years. Despite this, there has been neither much research done to evaluate the effect of these models on health care quality and spending nor is there extensive literature on the design of these models. OBJECTIVES: To (a) describe the types of measures used in performance-based pharmacy payment models (PBPPMs); (b) describe the financial impact of PBPPMs on pharmacies; (3) explore pharmacy owners' perceptions of PBPPMs; and (4) describe any practice changes made in response to PBPPMs. METHODS: This is a cross-sectional study that surveyed independent community pharmacy owners between November 2019 and January 2020. The survey included 45 items split into 5 sections that covered respondent characteristics and the 4 domain objectives. Descriptive statistics were used for quantitative responses, and free-text responses were assessed for themes. RESULTS: Of the 68 individuals who responded to the survey, 42 were community pharmacy owners who met the study eligibility criteria, and 30 responded to most survey items. Owners expressed frustration at the design of PBPPMs, with 90% stating that they did not feel that the actions necessary to meet or exceed performance standards were within their control, and 90% also reported a loss of revenue because of these models. In addition, large numbers of respondents felt that they did not have enough information on how performance measures were computed (76.7%) or how cut-points were determined (86.7%). Despite negative feelings, most owners reported implementing changes in service offerings as a result of these models. CONCLUSIONS: PBPPMs appear to be commonplace and put substantial financial burden on community pharmacies. Study results suggest that greater education by payers could improve pharmacist engagement, as could involvement of pharmacies in the design and maintenance of PBPPMs. DISCLOSURES: This work was supported by a grant from the American Association of Colleges of Pharmacy, which was not involved in the collection, analysis, and interpretation of data; writing of the report; or the decision to submit this article for publication. Urick reports consulting fees from Pharmacy Quality Solutions. The other authors declare no conflicts of interest with respect to the research, authorship, and/or publication of this article.
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Affiliation(s)
- Benjamin Y Urick
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Shweta Pathak
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
| | - Tamera D Hughes
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill
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Kim KM, Max W, White JS, Chapman SA, Muench U. Do penalty-based pay-for-performance programs improve surgical care more effectively than other payment strategies? A systematic review. Ann Med Surg (Lond) 2020; 60:623-630. [PMID: 33304576 PMCID: PMC7711081 DOI: 10.1016/j.amsu.2020.11.060] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 11/22/2020] [Indexed: 11/16/2022] Open
Abstract
Background The aim of this systematic review is to assess if penalty-based pay-for-performance (P4P) programs are more effective in improving quality and cost outcomes compared to two other payment strategies (i.e., rewards and a combination of rewards and penalties) for surgical care in the United States. Penalty-based programs have gained in popularity because of their potential to motivate behavioral change more effectively than reward-based programs to improve quality of care. However, little is known about whether penalties are more effective than other strategies. Materials and methods A systematic literature review was conducted according to the PRISMA guideline to identify studies that evaluated the effects of P4P programs on quality and cost outcomes for surgical care. Five databases were used to search studies published from 2003 to March 1, 2020. Studies were selected based on the PRISMA guidelines. Methodological quality of individual studies was assessed based on ROBINS-I with GRADE approach. Results This review included 22 studies. Fifteen cross-sectional, 1 prospective cohort, 4 retrospective cohort, and 2 case-control studies were found. We identified 11 unique P4P programs: 5 used rewards, 3 used penalties, and 3 used a combination of rewards and penalties as a payment strategy. Five out of 10 studies reported positive effects of penalty-based programs, whereas evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null. Conclusions This review highlights that P4P programs with a penalty design could be more effective than programs using rewards or a combination of rewards and penalties to improve quality of surgical care. Evidence on the effectiveness of pay-for-performance programs in quality improvement is mixed. Five out of 10 studies reported positive effects of penalty-based programs. Evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null. The increasing use of penalty-based pay-for-performance programs has the potential to improve surgical care quality. Penalties may induce stronger provider and hospital behavioral change than other payment strategies.
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Affiliation(s)
- Kyung Mi Kim
- Clinical Excellence Research Center, School of Medicine, Stanford University, 365 Lasuen St Stanford, CA, 94305, United States
| | - Wendy Max
- Institute for Health & Aging, University of California, 3333 California Street, Suite 340, San Francisco, CA, 94118, United States
| | - Justin S White
- Philip R. Lee Institute for Health Policy Studies & Department of Epidemiology & Biostatistics, School of Medicine, University of California, 3333 California Street, Suite 265, San Francisco, CA, 94118, United States
| | - Susan A Chapman
- Department of Social and Behavioral Sciences, School of Nursing, University of California, 3333 California Street, Room 455Q UCSF Box 0612, San Francisco, CA, 94118, United States
| | - Ulrike Muench
- Department of Social and Behavioral Sciences & Philip R. Lee Institute for Health Policy Studies, School of Nursing, University of California, San Francisco, 3333 California Street, Room 455H UCSF Box 0612, San Francisco, CA, 94118, United States
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Dow AW, Chopski B, Cyrus JW, Paletta-Hobbs LE, Qayyum R. A STEEEP Hill to Climb: A Scoping Review of Assessments of Individual Hospitalist Performance. J Hosp Med 2020; 15:599-605. [PMID: 32966195 DOI: 10.12788/jhm.3445] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 04/11/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although ensuring high-quality care requires assessment of individual hospitalist performance, current assessment approaches lack consistency and coherence. The Institute of Medicine's STEEEP framework for quality healthcare conceptualizes quality through domains of "Safe," "Timely," "Effective," "Efficient," "Equitable," and "Patient Centered." This framework may be applicable to assessing individual hospitalists. OBJECTIVE This scoping review sought to identify studies that describe variation in individual hospitalist performance and to code this data to the domains of the STEEEP framework. METHODS Via a systematic search of peer-reviewed literature that assessed the performance of individual hospitalists in the Medline database, we identified studies that described measurement of individual hospitalist performance. Forty-two studies were included in the final review and coded into one or more domains of the STEEEP framework. RESULTS Studies in the Safe domain focused on transitions of care, both at discharge and within the hospital. Many studies were coded to more than one domain, especially Timely, Effective, and Efficient. Examples include adherence to evidence-based guidelines or Choosing Wisely recommendations. The Patient Centered domain was most frequently coded, but approaches were heterogeneous. No included studies addressed the domain Equitable. CONCLUSIONS Applying the STEEEP framework to the published literature on assessment of individual hospitalist performance revealed strengths and weaknesses. Areas of strength were assessments of transitions of care and application of consensus guidelines. Other areas, such as equity and some components of safe practice, need development. All domains would benefit from more practical approaches. These findings should stimulate future work on feasibility of multidimensional assessment approaches.
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Affiliation(s)
- Alan W Dow
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Benjamin Chopski
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - John W Cyrus
- Tompkins-McCaw Library for the Health Sciences, Virginia Commonwealth University, Richmond, Virginia
| | - Laura E Paletta-Hobbs
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
| | - Rehan Qayyum
- Division of Hospital Medicine, Department of Internal Medicine, Virginia Commonwealth University, Richmond, Virginia
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Uptake of the Heart Failure Management Incentive Billing Code by Family Physicians in Ontario, Canada: A Retrospective Cohort Study. Can J Cardiol 2020; 37:508-512. [PMID: 32882329 DOI: 10.1016/j.cjca.2020.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 11/24/2022] Open
Abstract
In 2008, the Ontario Ministry of Health and Long-Term Care (MOHLTC) implemented an incentive payment, Q050A billing code, to family physicians for provision of comprehensive guideline-based care for patients with heart failure in the community. Our objective was to report on the uptake of this program from fiscal years 2008-2014. We determined the numbers of claims billed per year and the proportion of eligible patients with congestive heart failure (CHF) for whom a physician billed. The code was billed by 10.4% of all family physicians in 2008-2009, which increased to 15.1% in 2014-2015. The code was claimed for 4.1% of all identified patients with CHF in 2008-2009 and 5.9% of patients with CHF in 2014-2015. Given these findings, it is estimated that MOHLTC paid an additional CAD$10,118,514 to family physicians managing patients with CHF. This is the first study to examine the uptake of a CHF-specific incentive program, which will help to inform health policy makers in implementing such programs in Ontario.
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Delgoshaei B, Vatankhah S, Sarabandi A. Performance payment challenges for family physician program. JOURNAL OF EDUCATION AND HEALTH PROMOTION 2020; 9:225. [PMID: 33062758 PMCID: PMC7530424 DOI: 10.4103/jehp.jehp_257_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Accepted: 05/05/2020] [Indexed: 06/11/2023]
Abstract
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.
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Affiliation(s)
- Bahram Delgoshaei
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Soudabeh Vatankhah
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
| | - Amin Sarabandi
- Department of Health Services Management, School of Health Management and Information Sciences, Iran University of Medical Sciences, Tehran, Iran
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Eriksson T, Tropp H, Wiréhn AB, Levin LÅ. A pain relieving reimbursement program? Effects of a value-based reimbursement program on patient reported outcome measures. BMC Health Serv Res 2020; 20:805. [PMID: 32847579 PMCID: PMC7450562 DOI: 10.1186/s12913-020-05578-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/24/2020] [Indexed: 01/22/2023] Open
Abstract
Background Value-based reimbursement programs have become increasingly common. However, little is known about the effect of such programs on patient reported outcomes. Thus, the aim of this study was to analyze the effect of introducing a value-based reimbursement program on patient reported outcome measures and to explore whether a selection bias towards less complicated patients occurred. Methods This is a retrospective observational study with a before and after design based on the introduction of a value-based reimbursement program in Region Stockholm, Sweden. We analyzed patient level data from inpatient and outpatient care of patients undergoing lumbar spine surgery during 2006–2015. Patient reported outcome measures used was Global Assessment, EQ-5D-3L and Oswestry Disability Index. The case-mix of surgically treated patients was analyzed using medical and socioeconomic factors. Results The value-based reimbursement program did not have any effect on targeted or non-targeted patient reported outcome measures. Moreover, the share of surgically treated patients with risk factors such as having comorbidities and being born outside of Europe increased after the introduction. Hence, the value-based reimbursement program did not encourage discrimination against sicker patients. However, the income was higher among patients surgically treated after the introduction of the value-based reimbursement. This indicates that a value-based reimbursement program may contribute to increased inequalities in access to healthcare. Conclusions The value-based reimbursement program did not have any effect on patient reported outcome measures. Our study contributes to the understanding of the effects of a value-based reimbursement program on patient reported outcome measures and to what extent cherry-picking arises.
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Affiliation(s)
- Thérèse Eriksson
- Department of Health, Medicine and Caring Sciences (HMV), Centre for Medical Technology Assessment (CMT), Linköping University, SE-581 83, Linköping, Sweden.
| | - Hans Tropp
- Department of Biomedical and Clinical Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Ann-Britt Wiréhn
- Research and Development Unit in Region Östergötland and Department of Medical and Health Sciences, Linköping University, SE-581 83 Linköping, Sweden
| | - Lars-Åke Levin
- Department of Health, Medicine and Caring Sciences (HMV), Centre for Medical Technology Assessment (CMT), Linköping University, SE-581 83, Linköping, Sweden
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Collaboration in Hand Surgery: Experiences From Silicone Arthroplasty in Rheumatoid Arthritis, Finger Replantation and Amputation Challenges in Assessing Impairment, Satisfaction, and Effectiveness, Wrist and Radius Injury Surgical Trial, and Surgery of the Ulnar Nerve. J Am Acad Orthop Surg 2020; 28:e670-e678. [PMID: 32732659 DOI: 10.5435/jaaos-d-20-00102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
Outcomes research has historically been driven by single-center investigations. However, multicenter studies represent an opportunity to overcome challenges associated with single-center studies, including generalizability and adequate power. In hand surgery, most clinical trials are single-center studies, with few having randomized controls and blinding of both participants and assessors. This pervasive issue jeopardizes the integrity of evidence-based practice in the field. Because healthcare payers emphasize applying the best available evidence to justify medical services, multicenter research collaborations are increasingly recognized as an avenue for efficiently generating high-quality evidence. Although no study design is perfect, the potential advantages of multicenter trials include generalizability of the results, larger sample sizes, and a collaboration of experienced investigators poised to optimize protocol development and study conduct. As the era of single-center studies shifts toward investment in multicenter trials and clinical registries, investigators will inevitably be faced with the challenges of conducting or contributing to multicenter research collaborations. We present our experiences in conducting multicenter investigations to provide insight into this demanding and rewarding frontier of research.
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Leighton C, Fields B, Rodakowski JL, Feiler C, Hawk M, Bellon JE, James AE. A Multisite Case Study of Caregiver Advise, Record, Enable Act Implementation. THE GERONTOLOGIST 2020; 60:776-786. [PMID: 30726908 DOI: 10.1093/geront/gnz011] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The Commonwealth of Pennsylvania passed the Caregiver Advise, Record, Enable (CARE) Act on April 20, 2016. We designed a study to explore early implementation at a large, integrated delivery financing system. Our goal was to assess the effects of system-level decisions on unit implementation and the incorporation of the CARE Act's three components into routine care delivery. RESEARCH DESIGN AND METHODS We conducted a multisite, ethnographic case study at three different hospitals' medical-surgical units. We conducted observations and semi-structured interview to understand the implementation process and the approach to caregiver identification, notification, and education. We used thematic analysis to code interviews and observations and linked findings to the Promoting Action on Research Implementation in Health Services framework. RESULTS Organizational context and electronic health record capability were instrumental to the CARE Act implementation and integration into workflow. The implementation team used a decentralized strategy and a variety of communication modes, relying on local hospital units to train staff and make the changes. We found that the system facilitated the CARE Act implementation by placing emphasis on the documentation and charting to demonstrate compliance with the legal requirements. DISCUSSION AND IMPLICATIONS General acute hospitals will be making or have made similar decisions on how to operationalize the regulatory components and demonstrate compliance with the CARE Act. This study can help to inform others as they design and improve their compliance and implementation strategies.
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Affiliation(s)
- Cassandra Leighton
- Department of Health Policy and Management, University of Pittsburgh, Pennsylvania
- Health Policy Institute, University of Pittsburgh, Pennsylvania
| | - Beth Fields
- Health Policy Institute, University of Pittsburgh, Pennsylvania
- Center for Health Equity and Research Promotion, Pittsburgh, Pennsylvania
| | - Juleen L Rodakowski
- Department of Occupational Therapy, University of Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, University of Pittsburgh, Pennsylvania
| | | | - Mary Hawk
- Department of Behavioral and Community Health Sciences, University of Pittsburgh, Pennsylvania
| | | | - A Everette James
- Department of Health Policy and Management, University of Pittsburgh, Pennsylvania
- Health Policy Institute, University of Pittsburgh, Pennsylvania
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Moro Visconti R, Morea D. Healthcare Digitalization and Pay-For-Performance Incentives in Smart Hospital Project Financing. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E2318. [PMID: 32235517 PMCID: PMC7177756 DOI: 10.3390/ijerph17072318] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 03/23/2020] [Accepted: 03/25/2020] [Indexed: 12/15/2022]
Abstract
This study aims to explore the impact of healthcare digitalization on smart hospital project financing (PF) fostered by pay-for-performance (P4P) incentives. Digital platforms are a technology-enabled business model that facilitates exchanges between interacting agents. They represent a bridging link among disconnected nodes, improving the scalable value of networks. Application to healthcare public-private partnerships (PPPs) is significant due to the consistency of digital platforms with health issues and the complexity of the stakeholder's interaction. In infrastructural PPPs, public and private players cooperate, usually following PF patterns. This relationship is complemented by digitized supply chains and is increasingly patient-centric. This paper reviews the literature, analyzes some supply chain bottlenecks, addresses solutions concerning the networking effects of platforms to improve PPP interactions, and investigates the cost-benefit analysis of digital health with an empirical case. Whereas diagnostic or infrastructural technology is an expensive investment with long-term payback, leapfrogging digital applications reduce contingent costs. "Digital" savings can be shared by key stakeholders with P4P schemes, incentivizing value co-creation patterns. Efficient sharing may apply network theory to a comprehensive PPP ecosystem where stakeholding nodes are digitally connected. This innovative approach improves stakeholder relationships, which are re-engineered around digital platforms that enhance patient-centered satisfaction and sustainability. Digital technologies are useful even for infectious disease surveillance, like that of the coronavirus pandemic, for supporting massive healthcare intervention, decongesting hospitals, and providing timely big data.
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Affiliation(s)
- Roberto Moro Visconti
- Department of Business Management, Catholic University of Sacred Heart, Via Ludovico Necchi, 7, 20123 Milan, Italy
| | - Donato Morea
- Faculty of Economics, Universitas Mercatorum, Piazza Mattei, 10, 00186 Rome, Italy
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O'Donnell A, Angus C, Hanratty B, Hamilton FL, Petersen I, Kaner E. Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis. Addiction 2020; 115:49-60. [PMID: 31599022 DOI: 10.1111/add.14778] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Revised: 04/24/2019] [Accepted: 08/06/2019] [Indexed: 12/24/2022]
Abstract
AIM To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. DESIGN Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. SETTING England. PARTICIPANTS Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723). MEASUREMENTS The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption. FINDINGS There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month. CONCLUSIONS Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.
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Affiliation(s)
- Amy O'Donnell
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Colin Angus
- Sheffield Alcohol Research Group, School of Health and Related Research, The University of Sheffield, Sheffield, UK
| | - Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona L Hamilton
- Primary Care and Population Health, University College London, London, UK
| | - Irene Petersen
- Primary Care and Population Health, University College London, London, UK
| | - Eileen Kaner
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Implementation of government-directed policy in the hospital setting: a modified Delphi study. Health Res Policy Syst 2019; 17:91. [PMID: 31775771 PMCID: PMC6880558 DOI: 10.1186/s12961-019-0500-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Accepted: 10/24/2019] [Indexed: 11/24/2022] Open
Abstract
Background In the last 20 years governments have sought to introduce policy that improves the quality of care provided in hospitals, yet little research has been done to understand how these policies are implemented, factors that affect the implementation process or what should be considered by decision-makers during policy development or implementation planning. Experts with real-life experience in the introduction and implementation of policy are best placed to provide valuable insight into practical issues that affect implementation and the associated outcomes of these policies. Methods A modified Delphi study of experts in hospital policy development and implementation was undertaken to investigate factors influencing the implementation of government-directed policy in the hospital setting. This study built on the findings of two previous studies — a qualitative study of clinician perspectives of policy implementation and a systematic review and meta-synthesis, in which common contextual factors and policy characteristics associated with policy implementation were ascertained. International experts with extensive experience in government-directed policy implementation at global, national, corporate, jurisdictional and organisational levels were asked to provide opinions on predetermined factors and the feasibility of considering these in policy development and implementation planning. Survey design and analysis was guided by the Consolidated Framework for Implementation Research. Results Eleven experts from four countries and with different health system perspectives participated in the study. Consensus was reached on the importance of all predetermined factors in the first survey round with additional factors for investigation highlighted by participants for examination in subsequent rounds. On study completion, expert consensus was reached on 24 factors of importance; only 20 of these factors reached consensus for feasibility. Conclusions Study findings indicated that, whilst there are multiple factors of importance in policy implementation across all Consolidated Framework for Implementation Research domains, some factors, such as establishment of roles and responsibilities for implementation and organisational lines of accountability, are feasible for consideration at a hospital level only. In addition, four factors did not reach consensus in terms of feasibility, indicating that it may not be practical to consider all factors of importance when implementing policy; this has important implications for implementation planning and resource allocation.
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Strehlenert H, Hansson J, Nyström ME, Hasson H. Implementation of a national policy for improving health and social care: a comparative case study using the Consolidated Framework for Implementation Research. BMC Health Serv Res 2019; 19:730. [PMID: 31640680 PMCID: PMC6805604 DOI: 10.1186/s12913-019-4591-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 10/09/2019] [Indexed: 11/10/2022] Open
Abstract
Background Comprehensive policies are becoming common for addressing wicked problems in health and social care. Success of these policies often varies between target organizations. This variation can often be attributed to contextual factors. However, there is a lack of knowledge about the conditions for successful policy implementation and how context influences this process. The aim of this study was to investigate county-level actors’ perspectives on the implementation of a comprehensive national policy in three Swedish counties. The policy focused on developing quality of care for elderly based on the use of national quality registries (NQRs) and to improve coordination of care. Methods A comparative case study approach was used. Data was collected longitudinally through documents and interviews. The Consolidated Framework for Implementation Research (CFIR) guided the analysis. Results All three counties shared the view that the policy addressed important issues. Still, there was variation regarding how it was perceived and managed. Adaptable features—i.e., NQRs and improvement coaches—were perceived as relevant and useful. However, the counties differed in their perceptions of another policy component—i.e., senior management program—as an opportunity or a disturbance. This program, while tackling complex issues of collaboration, fell short in recognizing the counties’ pre-existing conditions and needs and also offered few opportunities for adaptations. Performance bonuses and peer pressure were strong incentives for all counties to implement the policy, despite the poor fit of policy content and local context. Conclusions Comprehensive health policies aiming to address wicked problems have better chances of succeeding if the implementation includes assessments of the target organizations’ implementation capacity as well as the implicit quid pro quos involved in policy development. Special attention is warranted regarding the use of financial incentives when dealing with wicked problems since the complexity makes it difficult to align incentives with the goals and to assess potential consequences. Other important aspects in the implementation of such policies are the use of collaborative approaches to engage stakeholders with differing perspectives, and the tailoring of policy communication to facilitate shared understanding and commitment.
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Affiliation(s)
- Helena Strehlenert
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.
| | - Johan Hansson
- Department of Public Health Analysis and Data Management, Public Health Agency of Sweden, SE 171 82, Solna, Sweden
| | - Monica Elisabeth Nyström
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.,Department of Public Health and Clinical Medicine, Epidemiology and Global Health, Umeå University, SE 901 87, Umeå, Sweden
| | - Henna Hasson
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, SE 171 77, Stockholm, Sweden.,Center for Epidemiology and Community Medicine, Stockholm County Council, SE 171 29, Stockholm, Sweden
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Abstract
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.
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Affiliation(s)
- Tim Mathes
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Dawid Pieper
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Johannes Morche
- Federal Joint CommitteeMedical Consultancy DepartmentWegelystraße 8BerlinGermany
| | - Stephanie Polus
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Thomas Jaschinski
- University Witten/HerdeckeInstitute for Research in Operative Medicine (IFOM) ‐ Department for Evidence‐based Health Services ResearchOstmerheimer Str. 200 (House 38)CologneGermany51109
| | - Michaela Eikermann
- Medical advisory service of social health insurance (MDS)Department of Evidence‐based medicineTheodor‐Althoff‐Straße 47EssenNorth Rhine WestphaliaGermany51109
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An Analysis of Pay-for-Performance Schemes and Their Potential Impacts on Health Systems and Outcomes for Patients. Crit Care Res Pract 2019; 2019:8943972. [PMID: 31321097 PMCID: PMC6607710 DOI: 10.1155/2019/8943972] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/29/2019] [Accepted: 06/02/2019] [Indexed: 01/17/2023] Open
Abstract
Pay-for-performance (P4P) programs have been introduced into the Canadian medical system in the last decades. This paper examines the underlying characteristics of P4P and describes both their advantages and drawbacks. Most P4P programs provide the advantage of rewarding medical acts, thus providing an incentive to take on complex patients. There is a variety of nuanced P4P initiatives, which provide financial incentive according to differing criteria, based on quality measures, incentives, and/or benchmark structures. However, there is no conclusive evidence demonstrating that P4P programs provide better value for money than traditional pay schemes, regardless of particular structural choices. Some evidence has even shown that P4P may be detrimental, especially in disadvantaged and high-risk populations. Additionally, there are a number of ethical and practical concerns that arise with the use of P4P, such as the risk of financial incentives being misused or misinterpreted and patients being refused or referred during treatment. P4P initiatives require careful examination and the creation of solid, evidence-based criteria for evaluation and implementation in Canadian medical systems.
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Garabedian LF, Ross-Degnan D, Wharam JF. Provider Perspectives on Quality Payment Programs Targeting Diabetes in Primary Care Settings. Popul Health Manag 2019; 22:248-254. [PMID: 30204544 PMCID: PMC6555171 DOI: 10.1089/pop.2018.0093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Public and private insurers increasingly use quality payment programs as a tool to improve quality of care in primary care settings. However, little is known about primary care providers' perspectives on whether and how quality payment programs improve diabetes quality of care. In this qualitative study, the authors conducted semi-structured interviews and focus groups with 23 providers from March to June 2015. Transcripts were analyzed to identify key themes using the immersion-crystallization method. Almost all of the providers believed that insurers play a meaningful role in improving quality of care for diabetes patients. Most thought that insurers' efforts are more effective when channeled through providers and delivery systems rather than directed at patients. Providers generally believed that quality payment programs have had a positive impact on quality of diabetes care, although provider views were not evidence based. Providers in practices in which quality payment programs were believed to have had a positive impact stated that the programs provided financial incentives and resources for improved population health management systems and additional staff. Conversely, most providers did not believe that quality payment programs have had any impact via direct financial incentives to individual physicians. A few providers were skeptical about the impact of quality payment programs and noted negative consequences that they had observed. Providers recommended strategies to improve quality payment programs (eg, refine quality measures, provide regular feedback on quality and costs) and additional strategies that insurers could consider to address provider- and patient-level barriers to high-quality diabetes care.
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Affiliation(s)
- Laura F. Garabedian
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - Dennis Ross-Degnan
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
| | - James F. Wharam
- Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, Boston, Massachusetts
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Damberg CL, Silverman M, Burgette L, Vaiana ME, Ridgely MS. Are value-based incentives driving behavior change to improve value? THE AMERICAN JOURNAL OF MANAGED CARE 2019; 25:e26-e32. [PMID: 30763040 PMCID: PMC8502100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
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.
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Foster A, Croot L, Brazier J, Harris J, O'Cathain A. The facilitators and barriers to implementing patient reported outcome measures in organisations delivering health related services: a systematic review of reviews. J Patient Rep Outcomes 2018; 2:46. [PMID: 30363333 PMCID: PMC6170512 DOI: 10.1186/s41687-018-0072-3] [Citation(s) in RCA: 183] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 09/21/2018] [Indexed: 12/26/2022] Open
Abstract
Background There is increasing interest in using Patient Reported Outcome Measures (PROMs) within organisations delivering health related services. However, organisations have had mixed success in implementing PROMs and there is little understanding about why this may be. Thus, the purpose of this study was to identify the facilitators and barriers to implementing PROMs in organisations. Method A systematic review of reviews was undertaken. Searches were conducted of five electronic databases: MEDLINE, EMBASE, CINAHL, PsycINFO and the Cochrane Database of Systematic Reviews, during the week of the 20th February 2017. Additional search methods included website searching and reference checking. To be included, a publication had to be a review of the literature, describe its methods and include information related to implementing PROMs. The reviews were extracted using a standardised form and assessed for their risk of bias using the Risk of Bias in Systematic Reviews tool. The findings were synthesised using the Consolidated Framework for Implementation Research. The protocol was registered on the International Prospective Register of Systematic Reviews database (PROSPERO) (CRD42017057491). Results Initially 2047 records were identified. After assessing eligibility, six reviews were included. These reviews varied in their review type and focus. Different issues arose at distinct stages of the implementation process. Organisations needed to invest time and resources in two key stages early in the implementation process: ‘designing’ the processes for using PROMs within an organisation; and ‘preparing’ an organisation and its staff. The ‘designing’ stage involved organisations planning not just which PROMs to use and how to administer them, but also how the data would be used for clinical purposes. The ‘preparing’ stage involved getting an organisation and its staff ready to use PROMs, particularly persuading clinicians of the validity and value of PROMs, delivering training, and developing electronic systems. Having an implementation lead overseeing the process and developing the process based on feedback were also identified as facilitating implementation. Conclusion Organisations implementing PROMs need to invest time and resources in ‘designing’ the PROMs strategy and ‘preparing’ the organisation to use PROMs. Focusing on these earlier stages may prevent problems arising when PROMs are used in practice. Electronic supplementary material The online version of this article (10.1186/s41687-018-0072-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alexis Foster
- School of Health and Related Research, University of Sheffield, Regents Court, Regents Street, S1 4DA, Sheffield, UK
| | - Liz Croot
- School of Health and Related Research, University of Sheffield, Regents Court, Regents Street, S1 4DA, Sheffield, UK
| | - John Brazier
- School of Health and Related Research, University of Sheffield, Regents Court, Regents Street, S1 4DA, Sheffield, UK
| | - Janet Harris
- School of Health and Related Research, University of Sheffield, Regents Court, Regents Street, S1 4DA, Sheffield, UK
| | - Alicia O'Cathain
- School of Health and Related Research, University of Sheffield, Regents Court, Regents Street, S1 4DA, Sheffield, UK
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Sheen YJ, Kung PT, Kuo WY, Chiu LT, Tsai WC. Impact of the pay-for-performance program on lower extremity amputations in patients with diabetes in Taiwan. Medicine (Baltimore) 2018; 97:e12759. [PMID: 30313085 PMCID: PMC6203477 DOI: 10.1097/md.0000000000012759] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Patients with diabetes are at a high risk of lower extremity amputations and may have a reduced life expectancy. Taiwan has implemented a diabetes pay-for-performance (P4P) program providing team care to improve the control of disease and avoid subsequent complications. Few studies investigated the effects of adopting a nationalized policy to decrease amputation risk in diabetes previously. Our study aimed to analyze the impact of the P4P programs on the incidence of lower extremity amputations in Taiwanese patients with diabetes.This was a population-based cohort study using the Taiwan National Health Insurance Research Database (which provided coverage for 98% of the total population in Taiwan) from 1998 to 2007. Patients with diabetes were identified based on the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) diagnostic codes. We linked procedure codes to inpatient claims to identify patients hospitalized for nontraumatic lower extremity amputations.A total of 9738 patients with diabetes with amputations were enrolled (mean age ± standard deviation: 64.4 ± 14.5 years; men: 63.9%). The incidence of nontraumatic diabetic lower extremity amputations decreased over the time period studied (3.79-2.27 per 1000 persons with diabetes). Based on the Cox proportional hazard regression model, male sex (hazard ratio: 1.83, 95% confidence interval [CI] 1.76-1.92), older age, and low socioeconomic status significantly interact with diabetes with respect to the risks of amputation. Patients who did not join the P4P program for diabetes care had a 3.46-fold higher risk of amputation compared with those who joined (95% CI 3.19-3.76).The amputation rate in Taiwanese diabetic patients decreased over the time period observed. Diabetes in patients with low socioeconomic status is associated with an increased risk of amputations. Our findings suggested that in addition to medical interventions and self-management educations, formulate and implement of medical policies, such as P4P program, might have a significant effect on decreasing the diabetes-related amputation rate.
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Affiliation(s)
- Yi-Jing Sheen
- Department of Health Services Administration
- Department of Public Health, China Medical University
- Division of Endocrinology and Metabolism, Department of Internal Medicine, Taichung Veterans General Hospital
| | - Pei-Tseng Kung
- Department of Healthcare Administration, Asia University, Taichung, Taiwan
| | - Wei-Yin Kuo
- Department of Health Services Administration
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Lopes J, Palmier AC, Werneck MAF, Matta-Machado ATGD, Abreu MHNGD. A Survey About Dental Instruments at the Primary Health Care in Brazil. Braz Dent J 2018; 29:500-506. [DOI: 10.1590/0103-6440201801969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 07/30/2018] [Indexed: 11/22/2022] Open
Abstract
Abstract This study describes the structure of oral health services in primary health care in Brazil and the instruments available for the provision of oral health care and to compare the number of instruments according to organizational characteristics of health services and among the macroregions. Of the 23,251 oral health teams (OHTs) in the Public Health System, 17,513 (75.3%) participated in this study. Trained researchers observed the structures of the health services and determined the presence of and whether a sufficient quantity of 36 dental instruments existed. The score of each oral health service was determined by the sum of the number of dental instruments present in sufficient quantity (0 to 36). Central tendency measures were compared along with the variability in these scores according to the organizational characteristics of the services and according to the Brazilian macroregion. No instrument was found to be present in all evaluated services. Basic, surgical and restorative instruments were the most frequently found. Periodontal, endodontic and prosthetic instruments exhibited the lowest percentages. The mean and median numbers of dental instruments were higher for teams that operated over more shifts, those with an oral health technician and those in the South and Southeast regions. The oral health services were equipped with basic, surgical and restorative instruments. Instruments designed for periodontal diagnosis, emergency care and denture rehabilitation were less frequently found in these services. The worst infrastructure conditions existed in the OHTs with the worst forms of care organization and in regions with greater social issues.
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Affiliation(s)
- Joyce Lopes
- Universidade Federal de Minas Gerais, Brazil
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Konetzka RT, Stuart EA, Werner RM. The effect of integration of hospitals and post-acute care providers on Medicare payment and patient outcomes. JOURNAL OF HEALTH ECONOMICS 2018; 61:244-258. [PMID: 29428772 PMCID: PMC6081263 DOI: 10.1016/j.jhealeco.2018.01.005] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2016] [Revised: 12/14/2017] [Accepted: 01/19/2018] [Indexed: 05/08/2023]
Abstract
In this paper we examine empirically the effect of integration on Medicare payment and rehospitalization. We use 2005-2013 data on Medicare beneficiaries receiving post-acute care (PAC) in the U.S. to examine integration between hospitals and the two most common post-acute care settings: skilled nursing facilities (SNFs) and home health agencies (HHA), using two measures of integration-formal vertical integration and informal integration representing preferential relationships between providers without formal relationships. Our identification strategy is twofold. First, we use longitudinal models with a fixed effect for each hospital-PAC pair in a market to test how changes in integration impact patient outcomes. Second, we use an instrumental variable approach to account for patient selection into integrated providers. We find that vertical integration between hospitals and SNFs increases Medicare payments and reduces rehospitalization rates. However, vertical integration between hospitals and HHAs has little effect, nor does informal integration between hospitals and either PAC setting.
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Affiliation(s)
- R Tamara Konetzka
- Department of Public Health Sciences, University of Chicago, United States
| | - Elizabeth A Stuart
- Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, United States
| | - Rachel M Werner
- Division of General Internal Medicine, University of Pennsylvania, United States; Center for Health Equity Research and Promotion, Crescenz VA Medical Center, Philadelphia, PA, United States.
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Gondi S, Soled D, Jha A. The problem with pay-for-performance schemes. BMJ Qual Saf 2018; 28:511-513. [DOI: 10.1136/bmjqs-2018-008088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2018] [Indexed: 11/04/2022]
Abstract
‘The Problem with…’ series covers controversial topics related to efforts to improve healthcare quality, including widely recommended but deceptively difficult strategies for improvement and pervasive problems that seem to resist solution.
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Vokes RA, Bearman G, Bazzoli GJ. Hospital-Acquired Infections Under Pay-for-Performance Systems: an Administrative Perspective on Management and Change. Curr Infect Dis Rep 2018; 20:35. [PMID: 30051191 DOI: 10.1007/s11908-018-0638-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to explore the impact of hospital-acquired infection on payment under pay-for-performance systems, and provide perspective on the role of administrators in infection prevention. RECENT FINDINGS Hospital-acquired infections continue to pose a serious threat to patient safety and to the fiscal viability of healthcare facilities under pay-for-performance systems. There is mixed evidence that use of pay-for-performance systems leads to prevention of hospital-acquired conditions. Use of evidence-based guidelines has been shown to reduce hospital-acquired infections. Increasing use of pay-for-performance (PFP) systems results in potential loss of reimbursement for healthcare organizations that fail to prevent hospital-acquired infections (HAI). Healthcare administrators must work with front-line providers and infection control staff to establish and maintain evidence-based infection prevention policy. Additionally, infection control policy should be regularly updated to reflect best practices, and proper change management techniques should be employed in order to mobilize and empower staff to increase their ability to prevent hospital-acquired infections.
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Affiliation(s)
- Rebecca A Vokes
- Department of Health Administration, Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Gloria J Bazzoli
- Department of Health Administration, Virginia Commonwealth University, Richmond, VA, USA
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Kondo KK, Wyse J, Mendelson A, Beard G, Freeman M, Low A, Kansagara D. Pay-for-Performance and Veteran Care in the VHA and the Community: a Systematic Review. J Gen Intern Med 2018; 33:1155-1166. [PMID: 29700789 PMCID: PMC6025676 DOI: 10.1007/s11606-018-4444-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 03/09/2018] [Accepted: 04/10/2018] [Indexed: 10/17/2022]
Abstract
BACKGROUND Although pay-for-performance (P4P) strategies have been used by the Veterans Health Administration (VHA) for over a decade, the long-term benefits of P4P are unclear. The use of P4P is further complicated by the increased use of non-VHA healthcare providers as part of the Veterans Choice Program. We conducted a systematic review and key informant interviews to better understand the effectiveness and potential unintended consequences of P4P, as well as the implementation factors and design features important in both VHA and non-VHA/community settings. METHODS We searched PubMed, PsycINFO, and CINAHL through March 2017 and reviewed reference lists. We included trials and observational studies of P4P targeting Veteran health. Two investigators abstracted data and assessed study quality. We interviewed VHA stakeholders to gain further insight. RESULTS The literature search yielded 1031 titles and abstracts, of which 30 studies met pre-specified inclusion criteria. Twenty-five examined P4P in VHA settings and 5 in community settings. There was no strong evidence supporting the effectiveness of P4P in VHA settings. Interviews with 17 key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in the VHA. Key informants' views on P4P in community settings included the need to develop relationships with providers and health systems with records of strong performance, to improve coordination by targeting documentation and data sharing processes, and to troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population. DISCUSSION The evidence to support the effectiveness of P4P on Veteran health is limited. Key informants recognize the potential for unintended consequences, such as overtreatment in VHA settings, and suggest that implementation of P4P in the community focus on relationship building and target areas such as documentation and coordination of care.
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Affiliation(s)
- Karli K Kondo
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA.
- Oregon Health and Science University, Portland, OR, USA.
| | - Jessica Wyse
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | | | - Gabriella Beard
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Michele Freeman
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Allison Low
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
| | - Devan Kansagara
- Portland VA Health Care System, Evidence-based Synthesis Program, Portland, OR, USA
- Oregon Health and Science University, Portland, OR, USA
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Herbst T, Foerster J, Emmert M. The impact of pay-for-performance on the quality of care in ophthalmology: Empirical evidence from Germany. Health Policy 2018; 122:667-673. [DOI: 10.1016/j.healthpol.2018.03.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 01/04/2018] [Accepted: 03/14/2018] [Indexed: 11/29/2022]
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Rinker J, Dickinson JK, Litchman ML, Williams AS, Kolb LE, Cox C, Lipman RD. The 2017 Diabetes Educator and the Diabetes Self-Management Education National Practice Survey. DIABETES EDUCATOR 2018; 44:260-268. [DOI: 10.1177/0145721718765446] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose The American Association of Diabetes Educators conducts the National Practice Survey (NPS) biennially to document current practice in diabetes education in the United States. The purpose of the study is to obtain insight about factors influencing the work of the diabetes educator. Method The 2017 NPS was comprised of 100 questions covering diabetes educator demographics, profile populations of people with diabetes, practice information, program accreditation, program curriculum, staffing, education delivery methods, data collection, and reporting. The basic survey consisted of 22 questions using branch logic, from which respondents were then directed to questions tailored to their particular practice setting, enabling them to answer only a relevant subset of the remaining questions. The web-based survey was sent to approximately 32 000 individuals who were either members of the American Association of Diabetes Educators (AADE) or Certified Diabetes Educators (CDE) with the National Certification Board for Diabetes Educators (NCBDE) but not AADE members. Weekly reminder e-mails were sent to recipients who had not yet responded. The outreach efforts resulted in the survey being completed by 4696 individuals, a 17% response rate yielding 95% confidence that these responses are within ±5% accuracy. Results Diabetes Self-Management Education and Support (DSMES) continues to be a field dominated by women (95%). Diabetes educators represent a diverse health care profession, with educators indicating most commonly that their primary discipline is nursing (48%), nutrition (38%), and pharmacy (7%). When asked about credentials, 82.6% indicated that they held a CDE, 3.8% held the Board Certified-Advanced Diabetes Management (BC-ADM) credential, and 16.5% held neither the CDE nor the BC-ADM. Nearly 75% characterized their role as a diabetes educator as providing direct patient care. DSMES continued to be provided in a varied array of settings to educationally, socioeconomically, and racially diverse patient populations. DSMES was delivered using a number of different educational strategies. Diabetes educators have direct influence in care and services that people with diabetes receive. Conclusions The results of the 2017 NPS demonstrate that diabetes educators are meeting the needs of varied populations in various practice settings. They are working with individuals with type 1 and type 2 diabetes, those at risk for diabetes, and women with gestational diabetes and are involved in recommending, implementing, and providing key referrals and recommendations for diabetes care, including insulin initiation, titration, medication adjustments, recommendations on devices, and technology. Identified areas for improvement include needs for increased racial and ethnic diversity in the workforce, recruiting young professionals, drawing practice approaches from related disciplines (eg, mental health and disability rehabilitation), and encouraging tracking of more areas of outcomes data. Diabetes educators are playing an increasingly central role within multidisciplinary care teams with people at risk for diabetes, those who have diabetes, and those with other chronic conditions.
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Affiliation(s)
- Joanne Rinker
- American Association of Diabetes Educators (AADE), Chicago, Illinois
| | | | | | | | - Leslie E. Kolb
- American Association of Diabetes Educators, Chicago, Illinois
| | - Carla Cox
- Providence Medical Group, Providence, Montana
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Conrad DA, Milgrom P, Shirtcliff RM, Bailit HL, Ludwig S, Dysert J, Allen G, Cunha-Cruz J. Pay-for-performance incentive program in a large dental group practice. J Am Dent Assoc 2018. [PMID: 29526260 DOI: 10.1016/j.adaj.2017.11.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance. METHODS The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics. RESULTS The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges. CONCLUSIONS This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address. PRACTICAL IMPLICATIONS Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.
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Serneels P, Lievens T. Microeconomic institutions and personnel economics for health care delivery: a formal exploration of what matters to health workers in Rwanda. HUMAN RESOURCES FOR HEALTH 2018; 16:7. [PMID: 29373966 PMCID: PMC5787262 DOI: 10.1186/s12960-017-0261-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 12/04/2017] [Indexed: 06/07/2023]
Abstract
BACKGROUND Most developing countries face important challenges regarding the quality of health care, and there is a growing consensus that health workers play a key role in this process. Our understanding as to what are the key institutional challenges in human resources, and their underlying driving forces, is more limited. A conceptual framework that structures existing insights and provides concrete directions for policymaking is also missing. METHODS To gain a bottom-up perspective, we gather qualitative data through semi-structured interviews with different levels of health workers and users of health services in rural and urban Rwanda. We conducted discussions with 48 health workers and 25 users of health services in nine different groups in 2005. We maximized within-group heterogeneity by selecting participants using specific criteria that affect health worker performance and career choice. The discussion were analysed electronically, to identify key themes and insights, and are documented with a descriptive quantitative analysis relating to the associations between quotations. The findings from this research are then revisited 10 years later making use of detailed follow-up studies that have been carried out since then. RESULTS The original discussions identified both key challenges in human resources for health and driving forces of these challenges, as well as possible solutions. Two sets of issues were highlighted: those related to the size and distribution of the workforce and those related to health workers' on-the-job performance. Among the latter, four categories were identified: health workers' poor attitudes towards patients, absenteeism, corruption and embezzlement and lack of medical skills among some categories of health workers. The discussion suggest that four components constitute the deeper causal factors, which are, ranked in order of ease of malleability, incentives, monitoring arrangements, professional and workplace norms and intrinsic motivation. Three institutional innovations are identified that aim at improving performance: performance pay, community health workers and increased attention to training of health workers. Revisiting the findings from this primary research making use of later in-depth studies, the analysis demonstrates their continued relevance and usefulness. We discuss how the different factors affect the quality of care by impacting on health worker performance and labour market choices, making use of insights from economics and development studies on the role of institutions. CONCLUSION The study results indicate that health care quality to an important degree depends on four institutional factors at the microlevel that strongly impact on health workers' performance and career choice, and which deserve more attention in applied research and policy reform. The analysis also helps to identify ways forwards, which fit well with the Ministry's most recent strategic plan.
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