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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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Ahmed K, Hashim S, Khankhara M, Said I, Shandakumar AT, Zaman S, Veiga A. What drives general practitioners in the UK to improve the quality of care? A systematic literature review. BMJ Open Qual 2021; 10:e001127. [PMID: 33574115 PMCID: PMC7880106 DOI: 10.1136/bmjoq-2020-001127] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/22/2020] [Accepted: 01/21/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND In the UK, the National Health Service has various incentivisation schemes in place to improve the provision of high-quality care. The Quality Outcomes Framework (QOF) and other Pay for Performance (P4P) schemes are incentive frameworks that focus on meeting predetermined clinical outcomes. However, the ability of these schemes to meet their aims is debated. OBJECTIVES (1) To explore current incentive schemes available in general practice in the UK, their impact and effectiveness in improving quality of care and (2) To identify other types of incentives discussed in the literature. METHODS This systematic literature review was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Six databases were searched: Cochrane, PubMed, National Institute for Health and Care Excellence Evidence, Health Management Information Consortium, Embase and Health Management. Articles were screened according to the selection criteria, evaluated against critical appraisal checklists and categorised into themes. RESULTS 35 articles were included from an initial search result of 22087. Articles were categorised into the following three overarching themes: financial incentives, non-financial incentives and competition. DISCUSSION The majority of the literature focused on QOF. Its positive effects included reduced mortality rates, better data recording and improved sociodemographic inequalities. However, limitations involved decreased quality of care in non-incentivised activities, poor patient experiences due to tick-box exercises and increased pressure to meet non-specific targets. Findings surrounding competition were mixed, with limited evidence found on the use of non-financial incentives in primary care. CONCLUSION Current research looks extensively into financial incentives, however, we propose more research into the effects of intrinsic motivation alongside existing P4P schemes to enhance motivation and improve quality of care.
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Affiliation(s)
- Kanwal Ahmed
- School of Medicine, Imperial College London, London, London, UK
| | - Salma Hashim
- School of Medicine, Imperial College London, London, London, UK
| | | | - Ilhan Said
- School of Medicine, Imperial College London, London, London, UK
| | | | - Sadia Zaman
- School of Medicine, Imperial College London, London, London, UK
| | - Andre Veiga
- Business School, Imperial College London, London, London, UK
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Martin B, Jones J, Miller M, Johnson-Koenke R. Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020917491. [PMID: 32448014 PMCID: PMC7249558 DOI: 10.1177/0046958020917491] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Incentive-based pay-for-performance (P4P) models have been introduced during the
last 2 decades as a mechanism to improve the delivery of evidence-based care
that ensures clinical quality and improves health outcomes. There is mixed
evidence that P4P has a positive effect on health outcomes and researchers cite
lack of engagement from health care professionals as a limiting factor. This
qualitative metasynthesis of existing qualitative research was conducted to
integrate health care professionals’ perceptions of P4P in clinical practice.
Four themes emerged during the research process: positive perceptions of the
value of performance measurement and associated financial incentives; negative
perceptions of the performance measurement and associated financial incentives;
perceptions of how P4P programs influence the quality/appropriateness of care;
and perceptions of the influence of P4P program on professional roles and
workplace dynamics. Identifying factors that influence health care
professionals’ perceptions about this type of value-based payment model will
guide future research.
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Affiliation(s)
| | | | - Matthew Miller
- University of Colorado, Aurora, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, USA
| | - Rachel Johnson-Koenke
- University of Colorado, Aurora, USA.,Rocky Mountain Regional VA Medical Center, Denver, CO, USA
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Khan N, Rudoler D, McDiarmid M, Peckham S. A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK. BMC FAMILY PRACTICE 2020; 21:142. [PMID: 32660427 PMCID: PMC7359468 DOI: 10.1186/s12875-020-01208-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff. METHODS We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis. RESULTS We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems. CONCLUSIONS Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.
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Affiliation(s)
| | - David Rudoler
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Unit UA3000, Oshawa, ON, L1H 7K4, Canada
| | - Mary McDiarmid
- Ontario Shores Centre for Mental Health Sciences, 700 Gordon Street, Whitby, ON, L1N 5S9, Canada
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent, Kent, Canterbury, CT2 7NF, UK
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Korlén S, Richter A, Amer-Wåhlin I, Lindgren P, von Thiele Schwarz U. The development and validation of a scale to explore staff experience of governance of economic efficiency and quality (GOV-EQ) of health care. BMC Health Serv Res 2018; 18:963. [PMID: 30541537 PMCID: PMC6292102 DOI: 10.1186/s12913-018-3765-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 11/23/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In publicly funded health care systems, governance models are developed to push public service providers to use tax payers' money more efficiently and maintain a high quality of service. Although this implies change in staff behaviors, evaluation studies commonly focus on organizational outputs. Unintended consequences for staff have been observed in case studies, but theoretical and methodological development is necessary to enable studies of staff experience in larger populations across various settings. The aim of the study is to develop a self-assessment scale of staff experience of the governance of economic efficiency and quality of health care and to assess its psychometric properties. METHODS Factors relevant to staff members' experience of economic efficiency and quality requirements of health care were identified in the literature and through interviews with practitioners, and then compared to a theoretical model of behavior change. Relevant experiences were developed into sub-factors and items. The scale was tested in collaboration with the Department of Rehabilitation Medicine at a university hospital. 93 staff members participated. The scale's psychometric properties were assessed using exploratory factor analysis, analysis of internal consistency and criterion-related validity. RESULTS The analysis revealed an eight factor structure (including sub-factors knowledge and awareness, opportunity to influence, motivation, impact on professional autonomy and organizational alignment), and items showed strong factor loadings and high internal consistency within sub-factors. Sub-factors were interrelated and contributed to the prediction of impact on clinical behavior (criterion). CONCLUSIONS The scale clearly distinguishes between various experiences regarding economic efficiency and quality requirements among health care staff, and shows satisfactory psychometric quality. The scale has broad applications for research and practice, as it serves as a tool for capturing staff members' perspectives when evaluating and improving health care governance. The scale could also be useful for understanding the underlying processes of changes in provider performance and for adapting management strategies to engage staff in driving change that contributes to increased economic efficiency and quality, for the benefit of health care systems, patients and staff.
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Affiliation(s)
- Sara Korlén
- Medical Management Centre, LIME, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Anne Richter
- Medical Management Centre, LIME, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Isis Amer-Wåhlin
- Medical Management Centre, LIME, Karolinska Institutet, 171 77 Stockholm, Sweden
| | - Peter Lindgren
- Medical Management Centre, LIME, Karolinska Institutet, 171 77 Stockholm, Sweden
- The Swedish Institute for Health Economics, Box 2017, 220 02 Lund, Sweden
| | - Ulrica von Thiele Schwarz
- Medical Management Centre, LIME, Karolinska Institutet, 171 77 Stockholm, Sweden
- School of Health, Care and Social Welfare, Mälardalen University, Box 883, 721 23 Västerås, Sweden
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Culhane-Pera KA, Ortega LM, Thao MS, Pergament SL, Pattock AM, Ogawa LS, Scandrett M, Satin DJ. Primary care clinicians' perspectives about quality measurements in safety-net clinics and non-safety-net clinics. Int J Equity Health 2018; 17:161. [PMID: 30404635 PMCID: PMC6222992 DOI: 10.1186/s12939-018-0872-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 10/10/2018] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Quality metrics, pay for performance (P4P), and value-based payments are prominent aspects of the current and future American healthcare system. However, linking clinic payment to clinic quality measures may financially disadvantage safety-net clinics and their patient population because safety-net clinics often have worse quality metric scores than non-safety net clinics. The Minnesota Safety Net Coalition's Quality Measurement Enhancement Project sought to collect data from primary care providers' (PCPs) experiences, which could assist Minnesota policymakers and state agencies as they create a new P4P system. Our research study aims are to identify PCPs' perspectives about 1) quality metrics at safety net clinics and non-safety net clinics, 2) how clinic quality measures affect patients and patient care, and 3) how payment for quality measures may influence healthcare. METHODS Qualitative interviews with 14 PCPs (4 individual interviews and 3 focus groups) who had worked at both safety net and non-safety net primary care clinics in Minneapolis-St Paul Minnesota USA metropolitan area. Qualitative analyses identified major themes. RESULTS Three themes with sub-themes emerged. Theme #1: Minnesota's current clinic quality scores are influenced more by patients and clinic systems than by clinicians. Theme #2: Collecting data for a set of specific quality measures is not the same as measuring quality healthcare. Subtheme #2.1: Current quality measures are not aligned with how patients and clinicians define quality healthcare. Theme #3: Current quality measures are a product of and embedded in social and structural inequities in the American health care system. Subtheme #3.1: The current inequitable healthcare system should not be reinforced with financial payments. Subtheme #3.2: Health equity requires new metrics and a new healthcare system. Overall, PCPs felt that the current inequitable quality metrics should be replaced by different metrics along with major changes to the healthcare system that could produce greater health equity. CONCLUSION Aligning payment with the current quality metrics could perpetuate and exacerbate social inequities and health disparities. Policymakers should consider PCPs' perspectives and create a quality-payment framework that does not disadvantage patients who are affected by social and structural inequities as well as the clinics and providers who serve them.
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Affiliation(s)
| | - Luis Martin Ortega
- West Side Community Health Services, Inc., 895 E 7th St., Saint Paul, MN 55106 USA
| | - Mai See Thao
- Family and Community Medicine, Medical College of Wisconsin, 8701 Watertown Plank Road, PO Box 26509, Milwaukee, WI 53226 USA
| | - Shannon L. Pergament
- West Side Community Health Services, Inc., 895 E 7th St., Saint Paul, MN 55106 USA
| | - Andrew M. Pattock
- Department of Family and Community Medicine, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455 USA
| | - Lynne S. Ogawa
- West Side Community Health Services, Inc., 895 E 7th St., Saint Paul, MN 55106 USA
| | - Michael Scandrett
- Minnesota Health Care Safety Net Coalition, 1113 East Franklin Ave #202B, Minneapolis, MN 55404 USA
| | - David J. Satin
- Department of Family and Community Medicine, University of Minnesota, 420 Delaware Street SE, Minneapolis, MN 55455 USA
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Qureshi N, Weng S, Hex N. The role of cost-effectiveness analysis in the development of indicators to support incentive-based behaviour in primary care in England. J Health Serv Res Policy 2016; 21:263-71. [PMID: 27207081 DOI: 10.1177/1355819616650912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
In England, general practitioners are incentivized through a national pay-for-performance scheme to adopt evidence-based quality improvement initiatives using a portfolio of Quality and Outcomes Framework (QOF) indicators. We describe the development of the methods used to assess the cost-effectiveness of these pay-for-performance indicators and how they have contributed to the development of new indicators. Prior to analysis of new potential indicators, an economic subgroup of the National Institute for Health and Care Excellence (NICE) Indicator Advisory Committee is formed to assess evidence on the cost-effectiveness of potential indicators in terms of the health benefits gained, compared to the cost of the intervention and the cost of the incentive. The expert subgroup is convened to reach consensus on the amounts that could potentially be paid to general practices for achieving new indicators. Indicators are also piloted in selected general practices and evidence gathered about their practical implementation. The methods used to assess economic viability of new pilot indicators represent a pragmatic and effective way of providing information to inform recommendations. Current policy to reduce QOF funding could shift the focus from national (QOF) to local schemes, with economic appraisal remaining central.
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Affiliation(s)
- Nadeem Qureshi
- Clinical Professor of Primary Care, Division of Primary Care, School of Medicine, University of Nottingham, UK
| | - Stephen Weng
- NIHR Research Fellow (School for Primary Care Research), Division of Primary Care, School of Medicine, University of Nottingham, UK
| | - Nick Hex
- Associate Director of York Health Economics Consortium Ltd, University of York, UK
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Glidewell L, West R, Hackett JEC, Carder P, Doran T, Foy R. Does a local financial incentive scheme reduce inequalities in the delivery of clinical care in a socially deprived community? A longitudinal data analysis. BMC FAMILY PRACTICE 2015; 16:61. [PMID: 25971774 PMCID: PMC4438433 DOI: 10.1186/s12875-015-0279-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 05/07/2015] [Indexed: 11/10/2022]
Abstract
BACKGROUND Socioeconomic deprivation is associated with inequalities in health care and outcomes. Despite concerns that the Quality and Outcomes Framework pay-for-performance scheme in the UK would exacerbate inequalities in primary care delivery, gaps closed over time. Local schemes were promoted as a means of improving clinical engagement by addressing local health priorities. We evaluated equity in achievement of target indicators and practice income for one local scheme. METHODS We undertook a longitudinal survey over four years of routinely recorded clinical data for all 83 primary care practices. Sixteen indicators were developed that covered five local clinical and public health priorities: weight management; alcohol consumption; learning disabilities; osteoporosis; and chlamydia screening. Clinical indicators were logit transformed from a percentage achievement scale and modelled allowing for clustering of repeated measures within practices. This enabled our study of target achievements over time with respect to deprivation. Practice income was also explored. RESULTS Higher practice deprivation was associated with poorer performance for five indicators: alcohol use registration (OR 0.97; 95 % confidence interval 0.96,0.99); recorded chlamydia test result (OR 0.97; 0.94,0.99); osteoporosis registration (OR 0.98; 0.97,0.99); registration of repeat prednisolone prescription (OR 0.98; 0.96,0.99); and prednisolone registration with record of dual energy X-ray absorptiometry (DEXA) scan/referral (OR 0.92; 0.86,0.97); practices in deprived areas performed better for one indicator (registration of osteoporotic fragility fracture (OR 1.26; 1.04,1.51). The deprivation-achievement gap widened for one indicator (registered females aged 65-74 with a fracture referred for a DEXA scan; OR 0.97; 0.95,0.99). Two other indicators indicated a similar trend over two years before being withdrawn (registration of fragility fracture and over-75 s with a fragility fracture assessed and treated for osteoporosis risk). For one indicator the deprivation-achievement gap reduced over time (repeat prednisolone prescription (OR 1.01; 1.01,1.01). Larger practices and those serving more affluent areas earned more income per patient than smaller practices and those serving more deprived areas (t = -3.99; p =0.0001). CONCLUSIONS Any gaps in achievement between practices were modest but mostly sustained or widened over the duration of the scheme. Given that financial rewards may not reflect the amount of work undertaken by practices serving more deprived patients, future pay-for-performance schemes also need to address fairness of rewards in relation to workload.
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Affiliation(s)
- Liz Glidewell
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK.
| | - Robert West
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK.
| | - Julia E C Hackett
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK.
| | - Paul Carder
- Yorkshire and Humber Commissioning Support Unit, Douglas Mill, Bowling Old Lane, Bradford, UK.
| | - Tim Doran
- Department of Health Sciences, University of York, Rowntree Building, York, UK.
| | - Robbie Foy
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK.
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