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Chehal PK, Uppal TS, Ng BP, Alva M, Ali MK. Trends and Race/Ethnic Disparities in Diabetes-Related Hospital Use in Medicaid Enrollees: Analyses of Serial Cross-sectional State Data, 2008-2017. J Gen Intern Med 2023; 38:2279-2288. [PMID: 36385411 PMCID: PMC10406763 DOI: 10.1007/s11606-022-07842-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/06/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND Race/ethnic disparities in preventable diabetes-specific hospital care may exist among adults with diabetes who have Medicaid coverage. OBJECTIVE To examine race/ethnic disparities in utilization of preventable hospital care by adult Medicaid enrollees with diabetes across nine states over time. DESIGN Using serial cross-sectional state discharge records for emergency department (ED) visits and inpatient (IP) hospitalizations from the Healthcare Cost and Utilization Project, we quantified race/ethnicity-specific, state-year preventable diabetes-specific hospital utilization. PARTICIPANTS Non-Hispanic Black, non-Hispanic White, and Hispanic adult Medicaid enrollees aged 18-64 with a diabetes diagnosis (excluding gestational or secondary diabetes) who were discharged from hospital care in Arizona, Iowa, Kentucky, Florida, Maryland, New Jersey, New York, North Carolina, and Utah for the years 2008, 2011, 2014, and 2017. MAIN MEASURES Non-Hispanic Black-over-White and Hispanic-over-White rate ratios constructed using age- standardized state-year, race/ethnicity-specific ED, and IP diabetes-specific utilization rates. KEY RESULTS The ratio of Black-over-White ED utilization rates for preventable diabetes-specific hospital care increased across the 9 states in our sample from 1.4 (CI 95, 1.31-1.50) in 2008 to 1.73 (CI 95, 1.68-1.78) in 2017. The cross-year-state average non-Hispanic Black-over-White IP rate ratio was 1.46 (CI 95, 1.42-1.50), reflecting increases in some states and decreases in others. The across-state-year average Hispanic-over-White rate ratio for ED utilization was 0.67 (CI 95, 0.63-0.71). The across-state-year average Hispanic-over-White IP hospitalization rate ratio was 0.72 (CI 95, 0.69-0.75). CONCLUSIONS Hospital utilization by non-Hispanic Black Medicaid enrollees with diabetes was consistently greater and often increased relative to utilization by White enrollees within state programs between 2008 and 2017. Hispanic enrollee hospital utilization was either lower or indistinguishable relative to White enrollee hospital utilization in most states, but Hispanic utilization increased faster than White utilization in some states. Among broader patterns, there is heterogeneity in the magnitude of race/ethnic disparities in hospital utilization trends across states.
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Affiliation(s)
- Puneet Kaur Chehal
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, GA, 30322, USA.
| | - Tegveer S Uppal
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Boon Peng Ng
- College of Nursing, University of Central Florida, Orlando, FL, USA
- Disability, Aging and Technology Cluster, University of Central Florida, Orlando, FL, USA
| | - Maria Alva
- Massive Data Institute, McCourt School of Public Policy, Georgetown University, Washington, DC, USA
| | - Mohammed K Ali
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- Department of Family and Preventive Medicine, School of Medicine, Emory University, Atlanta, GA, USA
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Farcher R, Graber SM, Thüring N, Blozik E, Huber CA. Does the implementation of an incentive scheme increase adherence to diabetes guidelines? A retrospective cohort study of managed care enrollees. BMC Health Serv Res 2023; 23:707. [PMID: 37386491 PMCID: PMC10308744 DOI: 10.1186/s12913-023-09694-z] [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: 10/24/2022] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND A novel incentive scheme based on a joint agreement of a large Swiss health insurance with 56 physician networks was implemented in 2018. This study evaluated the effect of its implementation on adherence to evidence-based guidelines among patients with diabetes in managed care models. METHODS We performed a retrospective cohort study, using health care claims data from patients with diabetes enrolled in a managed care plan (2016-2019). Guideline adherence was assessed by four evidence-based performance measures and four hierarchically constructed adherence levels. Generalized multilevel models were used to examine the effect of the incentive scheme on guideline adherence. RESULTS A total of 6'273 patients with diabetes were included in this study. The raw descriptive statistics showed minor improvements in guideline adherence after the implementation. After adjusting for underlying patient characteristics and potential differences between physician networks, the likelihood of receiving a test was moderately but consistently higher after the implementation of the incentive scheme for most performance measures, ranging from 18% (albuminuria: OR, 1.18; 95%-CI, 1.05-1.33) to 58% (HDL cholesterol: OR, 1.58; 95%-CI, 1.40-1.78). Full adherence was more likely after implementation of the incentive scheme (OR, 1.37; 95%-CI, 1.20-1.55), whereas level 1 significantly decreased (OR, 0.74; 95%-CI, 0.65 - 0.85). The proportions of the other adherence levels were stable. CONCLUSION Incentive schemes including transparency of the achieved performance may be able to improve guideline adherence in patients with diabetes and are promising to increase quality of care in this patient population.
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Affiliation(s)
- Renato Farcher
- Department of Health Sciences, Helsana Group, P.O. Box, Zürich, Switzerland
| | - Sereina M. Graber
- Department of Health Sciences, Helsana Group, P.O. Box, Zürich, Switzerland
| | - Nicole Thüring
- Department of Managed Care, Helsana Group, P.O. Box, Zürich, Switzerland
| | - Eva Blozik
- Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland
| | - Carola A. Huber
- Department of Health Sciences, Helsana Group, P.O. Box, Zürich, Switzerland
- Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland
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Jin Y, Tian W, Yu Y, Pan W, Yuan B. Incentives Promoting Contracted Family Doctor Service Policy to Improve Continuity and Coordination in Diabetes Patient Management Care in China. Front Public Health 2022; 10:843217. [PMID: 35910878 PMCID: PMC9334846 DOI: 10.3389/fpubh.2022.843217] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAs the first step toward building a gatekeeping system in China, the governments have introduced a contracted family doctor service (CFDS) policy in primary healthcare (PHC) facilities. This study was to examine the association between apply of incentive to improve the implementation of CFDS and the performance on diabetes management care.MethodsWe conducted a cross-sectional study in 72 PHC facilities in 6 cities that piloted the CFDS. Multivariate regression models were applied, based on a sample of 827 PHC providers and 420 diabetic patients.ResultsPHC providers who reported the performance being linked with increased income were 168.1 and 78.0% more likely to have good continuity and coordination of diabetes patient management care, respectively. Additional one-point percentage of PHC providers whose performance on CFDS was assessed was associated with 7.192 times higher probability of patients with control of blood glucose.DiscussionInclusion of incentives rewarding better performance on CFDS were associated with better delivery process and outcome performance on diabetes management care.ConclusionDesign and implementation of the incentive should be accompanied with the policy of CFDS, in order to increase the proportion of performance-related income of PHC providers, thereby improving the quality of diabetes management care.
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Affiliation(s)
- Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing, China
| | - Wenya Tian
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yahang Yu
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
| | - Wen Pan
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
| | - Beibei Yuan
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
- *Correspondence: Beibei Yuan
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de Jong M, Peters SAE, de Ritter R, van der Kallen CJH, Sep SJS, Woodward M, Stehouwer CDA, Bots ML, Vos RC. Sex Disparities in Cardiovascular Risk Factor Assessment and Screening for Diabetes-Related Complications in Individuals With Diabetes: A Systematic Review. Front Endocrinol (Lausanne) 2021; 12:617902. [PMID: 33859615 PMCID: PMC8043152 DOI: 10.3389/fendo.2021.617902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 02/11/2021] [Indexed: 11/24/2022] Open
Abstract
Background Insight in sex disparities in the detection of cardiovascular risk factors and diabetes-related complications may improve diabetes care. The aim of this systematic review is to study whether sex disparities exist in the assessment of cardiovascular risk factors and screening for diabetes-related complications. Methods PubMed was systematically searched up to April 2020, followed by manual reference screening and citations checks (snowballing) using Google Scholar. Observational studies were included if they reported on the assessment of cardiovascular risk factors (HbA1c, lipids, blood pressure, smoking status, or BMI) and/or screening for nephropathy, retinopathy, or performance of feet examinations, in men and women with diabetes separately. Studies adjusting their analyses for at least age, or when age was considered as a covariable but left out from the final analyses for various reasons (i.e. backward selection), were included for qualitative analyses. No meta-analyses were planned because substantial heterogeneity between studies was expected. A modified Newcastle-Ottawa Quality Assessment Scale for cohort studies was used to assess risk of bias. Results Overall, 81 studies were included. The majority of the included studies were from Europe or North America (84%).The number of individuals per study ranged from 200 to 3,135,019 and data were extracted from various data sources in a variety of settings. Screening rates varied considerably across studies. For example, screening rates for retinopathy ranged from 13% to 90%, with half the studies reporting screening rates less than 50%. Mixed findings were found regarding the presence, magnitude, and direction of sex disparities with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, with some evidence suggesting that women, compared with men, may be more likely to receive retinopathy screening and less likely to receive foot exams. Conclusion Overall, no consistent pattern favoring men or women was found with regard to the assessment of cardiovascular risk factors and screening for diabetes-related complications, and screening rates can be improved for both sexes.
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Affiliation(s)
- Marit de Jong
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Sanne A. E. Peters
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- The George Institute for Global Health, Imperial College London, London, United Kingdom
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Rianneke de Ritter
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Carla J. H. van der Kallen
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Simone J. S. Sep
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
- Centre of Expertise in Rehabilitation and Audiology, Adelante, Hoensbroek, Netherlands
| | - Mark Woodward
- The George Institute for Global Health, Imperial College London, London, United Kingdom
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Department of Epidemiology, Johns Hopkins University, Baltimore, MD, United States
| | - Coen D. A. Stehouwer
- Department of Internal Medicine, Maastricht University Medical Center, Maastricht, Netherlands
- CARIM Cardiovascular Research Institute Maastricht, Maastricht University, Maastricht, Netherlands
| | - Michiel L. Bots
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Rimke C. Vos
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
- Department Public Health and Primary Care / LUMC-Campus The Hagua, Leiden University Medical Center, Hague, Netherlands
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Thavam T, Devlin RA, Thind A, Zaric GS, Sarma S. The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1279-1293. [PMID: 32676753 DOI: 10.1007/s10198-020-01216-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 06/25/2020] [Indexed: 06/11/2023]
Abstract
Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.
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Affiliation(s)
- Thaksha Thavam
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, ON, Canada
| | - Amardeep Thind
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada
- Ivey School of Business, University of Western Ontario, London, ON, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Schulich School of Medicine and Dentistry, University of Western Ontario, London, ON, N6A 5C1, Canada.
- ICES, Toronto, ON, Canada.
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Bamimore MA, Devlin RA, Zaric GS, Garg AX, Sarma S. Quality of Diabetes Care in Blended Fee-for-Service and Blended Capitation Payment Systems. Can J Diabetes 2020; 45:261-268.e11. [PMID: 33162371 DOI: 10.1016/j.jcjd.2020.09.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/25/2020] [Accepted: 09/01/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVES In the middle to late 2000s, many family physicians switched from a Family Health Group (FHG; a blended fee-for-service model) to a Family Health Organization (FHO; a blended capitation model) in Ontario, Canada. The evidence on the link between physician remuneration schemes and quality of diabetes care is mixed in the literature. We examined whether physicians who switched from the FHG to FHO model provided better care for individuals living with diabetes relative to those who remained in the FHG model. METHODS Using longitudinal health administrative data from 2006 to 2016, we investigated the impact of physicians switching from FHG to FHO on 8 quality indicators related to diabetes care. Because FHO physicians are likely to be systematically different from FHGs, we employed propensity-score-based inverse probability-weighted fixed-effects regression models. All analyses were conducted at the physician level. RESULTS We found that FHO physicians were more likely to provide glycated hemoglobin testing by 2.75% (95% confidence interval [CI], 1.89% to 3.60%), lipid assessment by 2.76% (CI, 1.95% to 3.57%), nephropathy screening by 1.08% (95% CI, 0.51% to 1.66%) and statin prescription by 1.08% (95% CI, 0.51% to 1.66%). Patients under FHOs had a lower estimated risk of mortality by 0.0124% (95% CI, 0.0123% to 0.0126%) per physician per year. However, FHG and FHO physicians were similar for annual eye examination, prescription of angiotensin-converting enzyme inhibitors (or angiotensin II receptor blockers) and patients' risk of avoidable diabetes-related hospitalizations. CONCLUSIONS Compared with blended fee-for-service, blended capitation payment is associated with a small, but statistically significant, improvement in some aspects of diabetes care.
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Affiliation(s)
- Mary Aderayo Bamimore
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, Ontario, Canada
| | - Gregory S Zaric
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada; Ivey Business School, Western University, London, Ontario, Canada
| | - Amit X Garg
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada; Department of Medicine, Western University, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada; Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada.
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Vlaanderen FP, Tanke MA, Bloem BR, Faber MJ, Eijkenaar F, Schut FT, Jeurissen PPT. Design and effects of outcome-based payment models in healthcare: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:217-232. [PMID: 29974285 PMCID: PMC6438941 DOI: 10.1007/s10198-018-0989-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 06/22/2018] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. METHODS We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. RESULTS We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. DISCUSSION Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.
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Affiliation(s)
- F P Vlaanderen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands.
| | - M A Tanke
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
| | - B R Bloem
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands
| | - M J Faber
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboudumc, Nijmegen, The Netherlands
| | - F Eijkenaar
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - F T Schut
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - P P T Jeurissen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
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Improvement of the quality payment program by improving data reporting process: an action research. BMC Health Serv Res 2018; 18:692. [PMID: 30189897 PMCID: PMC6128004 DOI: 10.1186/s12913-018-3472-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 08/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Successful implementation of pay-for-quality (P4Q) programs mostly depends upon a valid, timely, and reliable data about quality measures generated by providers, and interpreted by payers. The aim of this study was to establish a data reporting method for P4Q program through an action research. METHODS Qualitative method was used to align theory with action through a three-cycle action research. The study was conducted in September 15, 2015 to March 15, 2017, in East-Azerbaijan, Iran. The purposeful sampling was used to select participants. The participants included healthcare providers, staff in district health centers (DHC), experts, and managers in the provincial primary health center (PPHC). Data was collected by interviews, focus group discussions, and expert panels. Content analysis was used to synthesize the data. In each step, decisions about data reporting methods were made through a consensus of expert panel members. RESULTS The most important dimensions of data reporting method were data entry and accuracy, data reporting, data analysis and interpretations, the flexibility of method, and training. By establishment of an online data reporting system for the P4Q program, a major improvement was observed in the documentation of performance data, the satisfaction of health care providers and staff (e.g. either in DHCs or PPHC), improvement of the P4Q program and acceptance of the P4Q program by providers. Following the present study, the online system was expanded in Iran's public health system for data collection and estimating the amount of incentive payments in P4Q program. Moreover, more improvements were achieved by linking the system to EMRs and also, providing automated feedback to providers about their own performance. CONCLUSIONS A web-based computerized system with the capability of linking medical record and also its ability to provide feedback to healthcare providers was identified as an appropriate method of data reporting in the P4Q program from the viewpoints of participants in this study.
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Gini R, Schuemie MJ, Pasqua A, Carlini E, Profili F, Cricelli I, Dazzi P, Barletta V, Francesconi P, Lapi F, Donatini A, Dal Co G, Visca M, Bellentani M, Sturkenboom M, Klazinga N. Monitoring compliance with standards of care for chronic diseases using healthcare administrative databases in Italy: Strengths and limitations. PLoS One 2017; 12:e0188377. [PMID: 29232365 PMCID: PMC5726627 DOI: 10.1371/journal.pone.0188377] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Accepted: 11/06/2017] [Indexed: 12/04/2022] Open
Abstract
Background A recent comprehensive report on healthcare quality in Italy published by the Organization of Economic Co-operation and Development (OECD) recommended that regular monitoring of quality of primary care by means of compliance with standards of care for chronic diseases is performed. A previous ecological study demonstrated that compliance with standards of care could be reliably estimated on regional level using administrative databases. This study compares estimates based on administrative data with estimates based on GP records for the same persons, to understand whether ecological fallacy played a role in the results of the previous study. Methods We compared estimates of compliance with diagnostic and therapeutic standards of care for type 2 diabetes (T2DM), hypertension and ischaemic heart disease (IHD) from administrative data (IAD) with estimates from medical records (MR) for the same persons registered with 24 GP’s in 2012. Data were linked at an individual level. Results 32,688 persons entered the study, 12,673 having at least one of the three diseases according to at least one data source. Patients not detected by IAD were many, for all three conditions: adding MR increased the number of cases of T2DM, hypertension, and IHD by +40%, +42%, and +104%, respectively. IAD had imperfect sensitivity in detecting population compliance with therapies (adding MR increased the estimate, from +11.5% for statins to +14.7% for antithrombotics), and, more substantially, with diagnostic recommendations (adding MR increased the estimate, from +23.7% in glycated hemoglobin tests, to +50.5% in electrocardiogram). Patients not detected by IAD were less compliant with respect to those that IAD correctly identified (from -4.8 percentage points in proportion of IHD patients compliant with a yearly glycated hemoglobin test, to -40.1 points in the proportion of T2DM patients compliant with the same recommendation). IAD overestimated indicators of compliance with therapeutic standards (significant differences ranged from 3.3. to 3.6 percentage points) and underestimated indicators of compliance with diagnostic standards (significant differences ranged from -2.3 to -14.1 percentage points). Conclusion IAD overestimated the percentage of patients compliant with therapeutic standards by less than 6 percentage points, and underestimated the percentage of patients compliant with diagnostic standards by a maximum of 14 percentage points. Therefore, both discussions at local level between GP's and local health unit managers and discussions at central level between national and regional policy makers can be informed by indicators of compliance estimated by IAD, which, based on those results, have the ability of signalling critical or excellent clusters. However, this study found that estimates are partly flawed, because a high number of patients with chronic diseases are not detected by IAD, patients detected are not representative of the whole population of patients, and some categories of diagnostic tests are markedly underrecorded in IAD (up to 50% in the case of electrocardiograms). Those results call to caution when interpreting IAD estimates. Audits based on medical records, on the local level, and an interpretation taking into account information external to IAD, on the central level, are needed to assess a more comprehensive compliance with standards.
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Affiliation(s)
- Rosa Gini
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
- Department of Medical Informatics, Erasmus Medical Center, Rotterdam, The Netherlands
- * E-mail:
| | - Martijn J. Schuemie
- Janssen Research & Development, Epidemiology, Titusville, New Jersey, United States of America
- Observational Health Data Sciences and Informatics (OHDSI), New York, New York, United States of America
| | - Alessandro Pasqua
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | - Emanuele Carlini
- Consiglio Nazionale delle Ricerche, Istituto di Scienza e Tecnologie dell'Informazione, Pisa, Italy
| | - Francesco Profili
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
| | | | - Patrizio Dazzi
- Consiglio Nazionale delle Ricerche, Istituto di Scienza e Tecnologie dell'Informazione, Pisa, Italy
| | - Valentina Barletta
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
| | - Paolo Francesconi
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
| | - Francesco Lapi
- Health Search, Italian College of General Practitioners and Primary Care, Florence, Italy
| | | | - Giulia Dal Co
- Agenzia Nazionale per il Servizi Sanitari Regionali, Rome, Italy
| | - Modesta Visca
- Agenzia Nazionale per il Servizi Sanitari Regionali, Rome, Italy
| | | | - Miriam Sturkenboom
- Agenzia regionale di sanità della Toscana, Osservatorio di epidemiologia, Florence, Italy
| | - Niek Klazinga
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
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The impact of financial incentives on the implementation of asthma or diabetes self-management: A systematic review. PLoS One 2017; 12:e0187478. [PMID: 29107955 PMCID: PMC5673190 DOI: 10.1371/journal.pone.0187478] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 10/20/2017] [Indexed: 12/21/2022] Open
Abstract
Introduction Financial incentives are utilised in healthcare systems in a number of countries to improve quality of care delivered to patients by rewarding practices or practitioners for achieving set targets. Objectives To systematically review the evidence investigating the impact of financial incentives for implementation of supported self-management on quality of care including: organisational process outcomes, individual behavioural outcomes, and health outcomes for individuals with asthma or diabetes; both conditions with an extensive evidence base for self-management. Methods We followed Cochrane methodology, using a PICOS search strategy to search eight databases in November 2015 (updated May 2017) including a broad range of implementation methodologies. Studies were weighted by robustness of methodology, number of participants and the quality score. We used narrative synthesis due to heterogeneity of studies. Results We identified 2,541 articles; 12 met our inclusion criteria. The articles were from the US (n = 7), UK (n = 4) and Canada (n = 1). Measured outcomes were HbA1c tests undertaken and/or the level achieved (n = 10), written action plans for asthma (n = 1) and hospital/emergency department visits (n = 1). Three of the studies were part of a larger incentive scheme including many conditions; one focused on asthma; eight focussed on diabetes. In asthma, the proportion receiving ‘perfect care’ (including providing a written action plan) increased from 4% to 88% in one study, and there were fewer hospitalisations/emergency department visits in another study. Across the diabetes studies, quality-of-care/GP performance scores improved in three, were unchanged in six and deteriorated in one. Conclusions Results for the impact of financial incentives for the implementation of self-management were mixed. The evidence in diabetes suggests no consistent impact on diabetic control. There was evidence from a single study of improved process and health outcomes in asthma. Further research is needed to confirm these findings and understand the process by which financial incentives may impact (or not) on care. Trial registration Protocol registration number: CRD42016027411
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Abstract
BACKGROUND Outpatient care facilities provide a variety of basic healthcare services to individuals who do not require hospitalisation or institutionalisation, and are usually the patient's first contact. The provision of outpatient care contributes to immediate and large gains in health status, and a large portion of total health expenditure goes to outpatient healthcare services. Payment method is one of the most important incentive methods applied by purchasers to guide the performance of outpatient care providers. OBJECTIVES To assess the impact of different payment methods on the performance of outpatient care facilities and to analyse the differences in impact of payment methods in different settings. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2016, Issue 3, part of the Cochrane Library (searched 8 March 2016); MEDLINE, OvidSP (searched 8 March 2016); Embase, OvidSP (searched 24 April 2014); PubMed (NCBI) (searched 8 March 2016); Dissertations and Theses Database, ProQuest (searched 8 March 2016); Conference Proceedings Citation Index (ISI Web of Science) (searched 8 March 2016); IDEAS (searched 8 March 2016); EconLit, ProQuest (searched 8 March 2016); POPLINE, K4Health (searched 8 March 2016); China National Knowledge Infrastructure (searched 8 March 2016); Chinese Medicine Premier (searched 8 March 2016); OpenGrey (searched 8 March 2016); ClinicalTrials.gov, US National Institutes of Health (NIH) (searched 8 March 2016); World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (searched 8 March 2016); and the website of the World Bank (searched 8 March 2016).In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via ISI Web of Science to find other potentially relevant studies. We also contacted authors of the main included studies regarding any further published or unpublished work. SELECTION CRITERIA Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for outpatient health facilities. We defined outpatient care facilities in this review as facilities that provide health services to individuals who do not require hospitalisation or institutionalisation. We only included methods used to transfer funds from the purchaser of healthcare services to health facilities (including groups of individual professionals). These include global budgets, line-item budgets, capitation, fee-for-service (fixed and unconstrained), pay for performance, and mixed payment. The primary outcomes were service provision outcomes, patient outcomes, healthcare provider outcomes, costs for providers, and any adverse effects. DATA COLLECTION AND ANALYSIS At least two review authors independently extracted data and assessed the risk of bias. We conducted a structured synthesis. We first categorised the comparisons and outcomes and then described the effects of different types of payment methods on different categories of outcomes. We used a fixed-effect model for meta-analysis within a study if a study included more than one indicator in the same category of outcomes. We used a random-effects model for meta-analysis across studies. If the data for meta-analysis were not available in some studies, we calculated the median and interquartile range. We reported the risk ratio (RR) for dichotomous outcomes and the relative change for continuous outcomes. MAIN RESULTS We included 21 studies from Afghanistan, Burundi, China, Democratic Republic of Congo, Rwanda, Tanzania, the United Kingdom, and the United States of health facilities providing primary health care and mental health care. There were three kinds of payment comparisons. 1) Pay for performance (P4P) combined with some existing payment method (capitation or different kinds of input-based payment) compared to the existing payment methodWe included 18 studies in this comparison, however we did not include five studies in the effects analysis due to high risk of bias. From the 13 studies, we found that the extra P4P incentives probably slightly improved the health professionals' use of some tests and treatments (adjusted RR median = 1.095, range 1.01 to 1.17; moderate-certainty evidence), and probably led to little or no difference in adherence to quality assurance criteria (adjusted percentage change median = -1.345%, range -8.49% to 5.8%; moderate-certainty evidence). We also found that P4P incentives may have led to little or no difference in patients' utilisation of health services (adjusted RR median = 1.01, range 0.96 to 1.15; low-certainty evidence) and may have led to little or no difference in the control of blood pressure or cholesterol (adjusted RR = 1.01, range 0.98 to 1.04; low-certainty evidence). 2) Capitation combined with P4P compared to fee-for-service (FFS)One study found that compared with FFS, a capitated budget combined with payment based on providers' performance on antibiotic prescriptions and patient satisfaction probably slightly reduced antibiotic prescriptions in primary health facilities (adjusted RR 0.84, 95% confidence interval 0.74 to 0.96; moderate-certainty evidence). 3) Capitation compared to FFSTwo studies compared capitation to FFS in mental health centres in the United States. Based on these studies, the effects of capitation compared to FFS on the utilisation and costs of services were uncertain (very low-certainty evidence). AUTHORS' CONCLUSIONS Our review found that if policymakers intend to apply P4P incentives to pay health facilities providing outpatient services, this intervention will probably lead to a slight improvement in health professionals' use of tests or treatments, particularly for chronic diseases. However, it may lead to little or no improvement in patients' utilisation of health services or health outcomes. When considering using P4P to improve the performance of health facilities, policymakers should carefully consider each component of their P4P design, including the choice of performance measures, the performance target, payment frequency, if there will be additional funding, whether the payment level is sufficient to change the behaviours of health providers, and whether the payment to facilities will be allocated to individual professionals. Unfortunately, the studies included in this review did not help to inform those considerations.Well-designed comparisons of different payment methods for outpatient health facilities in low- and middle-income countries and studies directly comparing different designs (e.g. different payment levels) of the same payment method (e.g. P4P or FFS) are needed.
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Affiliation(s)
- Beibei Yuan
- Peking UniversityChina Center for Health Development Studies (CCHDS)38 Xueyuan RoadBeijingBeijingChina100191
| | - Li He
- Peking UniversityChina Center for Health Development Studies (CCHDS)38 Xueyuan RoadBeijingBeijingChina100191
| | - Qingyue Meng
- Peking UniversityChina Center for Health Development Studies (CCHDS)38 Xueyuan RoadBeijingBeijingChina100191
| | - Liying Jia
- Shandong UniversityCenter for Health Management and Policy, Key Lab for Health Economics and Policy Research, Ministry of HealthJinanShandongChina250012
- Ministry of HealthKey Lab for Health Economics and Policy ResearchShandongChina
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Abstract
Research on the effects of pay-for-performance (P4P) in health care indicates largely disappointing results. This central finding, however, may mask important heterogeneity in the effects of P4P. We conducted a literature review to assess whether hospital and physician performance in P4P vary by patient and catchment area factors, organizational and structural capabilities, and P4P program characteristics. Several findings emerged: organizational size, practice type, teaching status, and physician age and gender modify performance in P4P. For physician practices and hospitals, a higher proportion of poor and minority patients is consistently associated with worse performance. Other theoretically influential characteristics-including information technology and staffing levels-yield mixed results. Inconsistent and contradictory effects of bonus likelihood, bonus size, and marginal costs on performance in P4P suggest organizations have not responded strategically to financial incentives. We conclude that extant heterogeneity in the effects of P4P does not fundamentally alter current assessments about its effectiveness.
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Influence of a Pay-for-Performance Program on Glycemic Control in Patients Living with Diabetes by Family Physicians in a Canadian Province. Can J Diabetes 2016; 41:190-196. [PMID: 27908559 DOI: 10.1016/j.jcjd.2016.09.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/02/2016] [Accepted: 09/21/2016] [Indexed: 11/23/2022]
Abstract
OBJECTIVES We evaluated the influence of the introduction of a pay-for-performance program implemented in 2010 for family physicians on the glycemic control of patients with diabetes. METHODS Administrative data for all 583 eligible family physicians and 83,580 adult patients with diabetes in New Brunswick over 10 years were used. We compared the probability of receiving at least 2 tests for glycated hemoglobin (A1C) levels and achieving glycemic control before (2005-2009) and after (2010-2014) the implementation of the program and between patients divided based on whether a physician claimed the incentive or did not. RESULTS Patients living with diabetes showed greater odds of receiving at least 2 A1C tests per year if the detection of their diabetes occurred after (vs. before) the implementation of the program (OR, 99% CI=1.23, 1.18 to 1.28), if a physician claimed the incentive (vs. not claiming it) for their care (1.92, 1.87 to 1.96) in the given year, and if they were followed by a physician who ever (vs. never) claimed the incentive (1.24, 1.15 to 1.34). In a cohort-based analysis, patients for whom an incentive was claimed (vs. not claimed) had greater odds of receiving at least 2 A1C tests per year before implementation of the incentive, and these odds increased by 56% (1.49 to 1.62) following its implementation. However, there was no difference in A1C values among the various comparison groups. CONCLUSIONS Introduction of the incentive was associated with greater odds of having a minimum of 2 A1C tests per year, which may suggest that it led physicians to provide better follow-up care for patients with diabetes. However, the incentive program has not been associated with differences in glycemic control.
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Abstract
This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.
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Affiliation(s)
- Anthony Scott
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Miao Liu
- The University of Melbourne, Melbourne, Victoria, Australia
| | - Jongsay Yong
- The University of Melbourne, Melbourne, Victoria, Australia
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Chen YC, Lee CTC, Lin BJ, Chang YY, Shi HY. Impact of pay-for-performance on mortality in diabetes patients in Taiwan: A population-based study. Medicine (Baltimore) 2016; 95:e4197. [PMID: 27399144 PMCID: PMC5058873 DOI: 10.1097/md.0000000000004197] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The impact of pay-for-performance (P4P) programs on long-term mortality for chronic illnesses, especially diabetes mellitus, has been rarely reported. Several studies described the favorable impact of P4P for diabetes mellitus on medical utilizations or intermediate outcomes. Therefore, this study aimed to investigate the impact of a P4P program on mortality in patients with type 2 diabetes. METHODS The P4P group in this population-based cohort study was 2090 individuals with a primary diagnosis of type 2 diabetes who had been newly enrolled in the P4P program of Taiwan between January 1, 2004 and December 31, 2004. Matched by 1:1 ratio, patients in the non-P4P group were selected by propensity score matching (PSM) for sex, age, the first year of diagnosis as diabetes, and 32 other potential confounding factors. Mean (SD) age was 60.91 (12.04) years when diabetes was first diagnosed and mean (SD) duration of diabetes was 4.3 (1.9) years at baseline. The time-dependent Cox regression model was used to explore the impact of P4P on all-cause mortality. RESULTS During a mean of 5.13 years (SD = 1.07 years) of follow-up, 206 and 263 subjects died in the P4P group and the non-P4P group, respectively. After adjusting for the potential confounding factors at baseline, survival was significantly longer in the P4P group than in the non-P4P group (hazard ratio, 0.76 [95% confidence interval, 0.64-0.92], P = 0.004, by log-rank test). This decrease in mortality is equivalent to one less death for every 37 patients who were treated in the P4P program for 5.13 years. In this study, the P4P program significantly increased the medical utilization of physician visits and diabetes-related examinations, improved the adherence of oral hypoglycemic drugs during the first 3 years and that of insulin during the second 3 years, and was negatively associated with risk of cancer and chronic kidney disease. In annual health expense, there was no significant difference between P4P and non-P4P groups, P = 0.430. CONCLUSIONS As compared with control, pay-for-performance program significantly improved survival in patients with diabetes without increasing the medical cost. The P4P group had significantly lower risk of cancer and chronic kidney disease.
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Affiliation(s)
- Yu-Ching Chen
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung
| | - Charles Tzu-Chi Lee
- Department of Health Promotion and Health Education, National Taiwan Normal University, Taipei
| | - Boniface J. Lin
- College of Medicine, Fu Jen Catholic University, New Taipei
- College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yong-Yuan Chang
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung
| | - Hon-Yi Shi
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung
- Correspondence: Hon-Yi Shi, Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan, 100-Shih-Chun 1st Road, Kaohsiung 80708, Taiwan (e-mail: )
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Chiu HC, Hsieh HM, Lin YC, Kuo SJ, Kao HY, Yeh SCJ, Chang WH, Hsiao PJ, Chen YS, Lin SL, Lo GH, Ker CG, Hung YH, Cheng HA, Chou TH, Chou SY, Wang JH, Wang CF. Patient assessment of diabetes care in a pay-for-performance program. Int J Qual Health Care 2016; 28:183-90. [PMID: 26819445 DOI: 10.1093/intqhc/mzv120] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/02/2015] [Indexed: 12/25/2022] Open
Affiliation(s)
- Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan Research Education and Epidemiology Center, Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 500-06, Taiwan
| | - Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Yi-Chieh Lin
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Shou-Jen Kuo
- Changhua Christian Hospital, 135 Nan-Hsiao Street, Changhua 500-06, Taiwan
| | - Hao-Yun Kao
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Shu-Chuan Jennifer Yeh
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan Department of Business Management, College of Management, National Sun Yat-sen University, 70 Lian Hai Road, Kaohsiung, 80424 Taiwan
| | - Wen-Hsin Chang
- MacKay Memorial Hospital, No. 92, Section 2, Zhongshan North Road, Zhongshan District, Taipei City 104, Taiwan
| | - Pi-Jung Hsiao
- College of Medicine, Kaohsiung Medical University, Division of Endocrinology and Metabolism, Department of Internal Medicine, Kaohsiung Medical University Hospital, 100 Shih-Chuan 1st Road, Kaohsiung 80708, Taiwan
| | - Yao-Shen Chen
- Department of Internal Medicine, Kaohsiung Veterans General Hospital, No. 386, Dazhong 1st Road, Zuoying District, Kaohsiung City 813, Taiwan
| | - Shoei-Loong Lin
- President Superintendent, Choninn Healthcare System, No. 196, Sec. 1, Wenhua Rd., BanqiaoDist. New Taipei City 22041, Taiwan
| | - Gin-Ho Lo
- E-DA Hospital; School of Medicine for International Students, I-Shou University 1 ,Yi-Da Road, Yanchao district, Kaohsiung, 82445 Taiwan
| | - Chen-Guo Ker
- Department of Surgery, Yuan's General Hospital, 162, Chen-Kong 1st Road, Kaohsiung 80249, Taiwan
| | - Yu-Han Hung
- Yuan's General Hospital, No. 162, Cheng gong 1st Road, Ling ya District, Kaohsiung City 80249, Taiwan
| | - Hsien-An Cheng
- Department of Neurology, Yuan's General Hospital, 162, Chen-Kun 1st Road, Kaohsiung 80249, Taiwan
| | - Tiang-Hong Chou
- Mennonite Christian Hospital, 44, Min-Chuan Road, Hualien 970, Taiwan
| | - Sze-Yuan Chou
- Cheng Ching General Hospital, 139 Ping Tien Street, Taichung, Taiwan
| | - Jao-Hsien Wang
- Department of Education and Research, Jiannren Hospital, 136 Nanyang Road, Kaohsiung 811, Taiwan
| | - Chien-Fu Wang
- Division of Physical Therapy, Taitung Christian Hospital, 350 Kai-Feng Street, Taitung City, Taitung County 950, Taiwan
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Bailey S, O’Malley JP, Gold R, Heintzman J, Likumahuwa S, DeVoe JE. Diabetes care quality is highly correlated with patient panel characteristics. J Am Board Fam Med 2013; 26:669-79. [PMID: 24204063 PMCID: PMC3922763 DOI: 10.3122/jabfm.2013.06.130018] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION Health care reimbursement is increasingly based on quality. Little is known about how clinic-level patient characteristics affect quality, particularly in community health centers (CHCs). METHODS Using data from electronic health records for 4019 diabetic patients from 23 primary care CHCs in the OCHIN practice-based research network, we calculated correlations between a clinic's patient panel characteristics and rates of delivery of diabetes preventive services in 2007. Using regression models, we estimated the proportion of variability in clinics' preventive services rates associated with the variability in the clinics' patient panel characteristics. We also explored whether clinics' performance rates were affected by how patient panel denominators were defined. RESULTS Clinic rates of hemoglobin testing, influenza immunizations, and lipid screening were positively associated with the percentage of patients with continuous health insurance coverage and negatively associated with the percentage of uninsured patients. Microalbumin screening rates were positively associated with the percentage of racial minorities in a clinic's panel. Associations remained consistent with different panel denominators. CONCLUSIONS Clinic variability in delivery rates of preventive services correlates with differences in clinics' patient panel characteristics, particularly the percentage of patients with continuous insurance coverage. Quality scores that do not account for these differences could create disincentives to clinics providing diabetes care for vulnerable patients.
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Affiliation(s)
- Steffani Bailey
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Jean P. O’Malley
- Oregon Health & Science University, Department of Public Health and Preventive Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Rachel Gold
- Kaiser Permanente Northwest Center for Health Research, 3800 N. Interstate Ave., Portland, OR 97227
| | - John Heintzman
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Sonja Likumahuwa
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239
| | - Jennifer E. DeVoe
- Oregon Health & Science University, Department of Family Medicine, 3181 SW Sam Jackson Park Rd., Mailcode: FM, Portland, OR 97239, Ph: 503-494-8936
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Affiliation(s)
- Stephen T Higgins
- Department of Psychiatry, University of Vermont, University Health Center Campus, 1 S. Prospect St, Burlington, VT 05401, USA.
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Chien AT, Wroblewski K, Damberg C, Williams TR, Yanagihara D, Yakunina Y, Casalino LP. Do physician organizations located in lower socioeconomic status areas score lower on pay-for-performance measures? J Gen Intern Med 2012; 27:548-54. [PMID: 22160817 PMCID: PMC3326117 DOI: 10.1007/s11606-011-1946-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2011] [Revised: 10/18/2011] [Accepted: 10/31/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Physician organizations (POs)--independent practice associations and medical groups--located in lower socioeconomic status (SES) areas may score poorly in pay-for-performance (P4P) programs. OBJECTIVE To examine the association between PO location and P4P performance. DESIGN Cross-sectional study; Integrated Healthcare Association's (IHA's) P4P Program, the largest non-governmental, multi-payer program for POs in the U.S. PARTICIPANTS 160 POs participating in 2009. MAIN MEASURES We measured PO SES using established methods that involved geo-coding 11,718 practice sites within 160 POs to their respective census tracts and weighting tract-specific SES according to the number of primary care physicians at each site. P4P performance was defined by IHA's program and was a composite mainly representing clinical quality, but also including measures of patient experience, information technology and registry use. KEY RESULTS The area-based PO SES measure ranged from -11 to +11 (mean 0, SD 5), and the IHA P4P performance score ranged from 23 to 86 (mean 69, SD 15). In bivariate analysis, there was a significant positive relationship between PO SES and P4P performance (p < 0.001). In multivariate analysis, a one standard deviation increase in PO SES was associated with a 44% increase (relative risk 1.44, 95%CI, 1.22-1.71) in the likelihood of a PO being ranked in the top two quintiles of performance (p < 0.001). CONCLUSIONS Physician organizations' performance scores in a major P4P program vary by the SES of the areas in which their practice sites are located. P4P programs that do not account for this are likely to pay higher bonuses to POs in higher SES areas, thus increasing the resource gap between these POs and POs in lower SES areas, which may increase disparities in the care they provide.
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Affiliation(s)
- Alyna T Chien
- Division of General Pediatrics, Children's Hospital Boston, and Department of Pediatrics, Harvard Medical School, 21 Autumn Street-Room 223, Boston, MA 02215, USA.
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