Impact of Medicare's Nonpayment Program on Venous Thromboembolism Following Hip and Knee Replacements

Pay-for-performance and patient safety in acute care: A systematic review

Pay-for-performance (p4p) has been tried in all healthcare settings to address ongoing deficiencies in the quality and outcomes of care. The evidence for the effect of these policies has been inconclusive, especially in acute care. This systematic review focused on patient safety p4p in the hospital setting. Using the PRISMA guidelines, we searched five biomedical databases for quantitative studies using at least one outcome metric from database inception to March 2023, supplemented by reference tracking and internet searches. We identified 6,122 potential titles of which 53 were included: 39 original investigations, eight literature reviews and six grey literature reports. Only five system-wide p4p policies have been implemented, and the quality of evidence was low overall. Just over half of the studies (52 %) included failed to observe improvement in outcomes, with positive findings heavily skewed towards poor quality evaluations. The exception was the Fragility Hip Fracture Best Practice Tariff (BPT) in England, where sustained improvement was observed across various evaluations. All policies had a miniscule impact on total hospital revenue. Our findings underscore the importance of simple and transparent design, involvement of the clinical community, explicit links to other quality improvement initiatives, and gradual implementation of p4p initatives. We also propose a research agenda to lift the quality of evidence in this field.

Do penalty-based pay-for-performance programs improve surgical care more effectively than other payment strategies? A systematic review

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.

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Evidence on the effectiveness of pay-for-performance programs in quality improvement is mixed.

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Five out of 10 studies reported positive effects of penalty-based programs.

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Evidence from studies evaluating P4P programs with a reward design or combination of rewards and penalties was little or null.

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The increasing use of penalty-based pay-for-performance programs has the potential to improve surgical care quality.

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Penalties may induce stronger provider and hospital behavioral change than other payment strategies.

Evaluation of the nature, severity, likelihood and preventability of medication-related hospital-acquired complications

Objective Pricing for safety and quality was introduced into Australian hospitals using a defined list of hospital-acquired complications (HACs). Medication-related HACs include drug-related respiratory complications (DRRC), haemorrhagic disorder due to circulating anticoagulants (HDDCA) and hypoglycaemia. The aim of this study was to determine the probability, severity and preventability of medication-related HACs, common contributory medications and themes, and whether medication-related HACs are a suitable data source to inform risk associated with medicines use. Methods Medical notes were reviewed retrospectively for all patients discharged from a tertiary referral metropolitan hospital between 1 July and 31 December 2018 who were flagged as experiencing a medication-related HAC. Naranjo, Hartwig's and Schumock and Thornton tools were used to assess the probability, severity and preventability of medication-related HACs. Results Over the 6-month period, 88 patients experienced a medication-related HAC. An HAC was not identified in five (5.7%) patient charts. The most common HAC was hypoglycaemia (n=59; 67%), followed by HDDCA (n=23; 26%) and DRRC (n=6; 7%). Fifteen patients (17%) flagged with a hypoglycaemia HAC were not on a medicine associated with hypoglycaemia. Overall, 6% (n=4) of HACs were severe, 72% (n=49) were moderate and 22% (n=15) were mild. Where the HAC and causal medication(s) were identified (n=68), over half were probable (51.5%, n=35) and 44.1% (n=30) were possible causes of the adverse drug reaction; only two (2.9%) were definite causes. None of the DRRC HACs was preventable. Over half the HDDCA HACs (52.2%; n=12) and almost half the hypoglycaemia HACs (46.2%; n=18) were not preventable. Common themes included appropriate anticoagulant agent, dose and monitoring, as well as periprocedural hypoglycaemic management, which considers oral intake and comorbidities. Conclusion Not all patients who experience medication-related HACs were on causative medications. Of those who were, medications were probable causal agents in over 50% of cases. Only a small number of HACs were severe and under half of medication-related HACs were preventable. What is known about the topic? The relationship between pricing for safety and quality and improvements in patient outcomes has shown mixed results. Medication-related harm is a problem within Australia and system-wide changes should be considered to improve patient care. What does this paper add? This paper adds evidence to the use of medication-related HACs as a source of data to inform risk associated with medicines use and provides details on the preventability and severity of medication-related HACs and the likelihood that medicines contribute to these complications. What are the implications for practitioners? This paper provides clinicians and policy makers details on the utility of using medication-related HACs as a measure of risk associated with medicines use. It discusses merit in using HACs as a source for quality improvement, but recommends that definitions may need to be reviewed to enhance utility.