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Does a pay-for-performance health service model improve overall and rural–urban inequity in vaccination rates? A difference-in-differences analysis from the Gambia. Vaccine X 2022; 12:100206. [PMID: 36051748 PMCID: PMC9424534 DOI: 10.1016/j.jvacx.2022.100206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 06/05/2022] [Accepted: 08/11/2022] [Indexed: 11/20/2022] Open
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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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Kovacs R, Maia Barreto JO, da Silva EN, Borghi J, Kristensen SR, Costa DRT, Bezerra Gomes L, Gurgel GD, Sampaio J, Powell-Jackson T. Socioeconomic inequalities in the quality of primary care under Brazil's national pay-for-performance programme: a longitudinal study of family health teams. LANCET GLOBAL HEALTH 2021; 9:e331-e339. [PMID: 33607031 PMCID: PMC7900523 DOI: 10.1016/s2214-109x(20)30480-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 10/16/2020] [Accepted: 10/30/2020] [Indexed: 12/05/2022]
Abstract
Background Many governments have introduced pay-for-performance programmes to incentivise health providers to improve quality of care. Evidence on whether these programmes reduce or exacerbate disparities in health care is scarce. In this study, we aimed to assess socioeconomic inequalities in the performance of family health teams under Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ). Methods For this longitudinal study, we analysed data on the quality of care delivered by family health teams participating in PMAQ over three rounds of implementation: round 1 (November, 2011, to March, 2013), round 2 (April, 2013, to September, 2015), and round 3 (October, 2015, to December, 2019). The primary outcome was the percentage of the maximum performance score obtainable by family health teams (the PMAQ score), based on several hundred (ranging from 598 to 914) indicators of health-care delivery. Using census data on household income of local areas, we examined the PMAQ score by income ventile. We used ordinary least squares regressions to examine the association between PMAQ scores and the income of each local area across implementation rounds, and we did an analysis of variance to assess geographical variation in PMAQ score. Findings Of the 40 361 family health teams that were registered as ever participating in PMAQ, we included 13 934 teams that participated in the three rounds of PMAQ in our analysis. These teams were located in 11 472 census areas and served approximately 48 million people. The mean PMAQ score was 61·0% (median 61·8, IQR 55·3–67·9) in round 1, 55·3% (median 56·0, IQR 47·6–63·4) in round 2, and 61·6% (median 62·7, IQR 54·4–69·9) in round 3. In round 1, we observed a positive socioeconomic gradient, with the mean PMAQ score ranging from 56·6% in the poorest group to 64·1% in the richest group. Between rounds 1 and 3, mean PMAQ performance increased by 7·1 percentage points for the poorest group and decreased by 0·8 percentage points for the richest group (p<0·0001), with the gap between richest and poorest narrowing from 7·5 percentage points (95% CI 6·5 to 8·5) to –0·4 percentage points over the same period (–1·6 to 0·8). Interpretation Existing income inequalities in the delivery of primary health care were eliminated during the three rounds of PMAQ, plausibly due to a design feature of PMAQ that adjusted financial payments for socioeconomic inequalities. However, there remains an important policy agenda in Brazil to address the large inequities in health. Funding UK Medical Research Council, Newton Fund, and CONFAP (Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa).
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Affiliation(s)
- Roxanne Kovacs
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK.
| | | | | | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Søren Rud Kristensen
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, London, UK; Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | | | - Luciano Bezerra Gomes
- Department of Health Promotion, Federal University of Paraiba, João Pessoa, Paraiba, Brazil
| | - Garibaldi D Gurgel
- Oswaldo Cruz Foundation-Fiocruz, Pernambuco, Brazil; Ministry of Health of Brazil, Brasília, Brazil
| | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraiba, João Pessoa, Paraiba, Brazil
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
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Incentive schemes to increase dementia diagnoses in primary care in England: a retrospective cohort study of unintended consequences. Br J Gen Pract 2019; 69:e154-e163. [PMID: 30803980 DOI: 10.3399/bjgp19x701513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/27/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The UK government introduced two financial incentive schemes for primary care to tackle underdiagnosis in dementia: the 3-year Directed Enhanced Service 18 (DES18) and the 6-month Dementia Identification Scheme (DIS). The schemes appear to have been effective in boosting dementia diagnosis rates, but their unintended effects are unknown. AIM To identify and quantify unintended consequences associated with the DES18 and DIS schemes. DESIGN AND SETTING A retrospective cohort quantitative study of 7079 English primary care practices. METHOD Potential unintended effects of financial incentive schemes, both positive and negative, were identified from a literature review. A practice-level dataset covering the period 2006/2007 to 2015/2016 was constructed. Difference-in-differences analysis was employed to test the effects of the incentive schemes on quality measures from the Quality and Outcomes Framework (QOF); and four measures of patient experience from the GP Patient Survey (GPPS): patient-centred care, access to care, continuity of care, and the doctor-patient relationship. The researchers controlled for effects of the contemporaneous hospital incentive scheme for dementia and for practice characteristics. RESULTS National practice participation rates in DES18 and DIS were 98.5% and 76% respectively. Both schemes were associated not only with a positive impact on QOF quality outcomes, but also with negative impacts on some patient experience indicators. CONCLUSION The primary care incentive schemes for dementia appear to have enhanced QOF performance for the dementia review, and have had beneficial spillover effects on QOF performance in other clinical areas. However, the schemes may have had negative impacts on several aspects of patient experience.
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Judah G, Darzi A, Vlaev I, Gunn L, King D, King D, Valabhji J, Bishop L, Brown A, Duncan G, Fogg A, Harris G, Tyacke P, Bicknell C. Incentives in Diabetic Eye Assessment by Screening (IDEAS) trial: a three-armed randomised controlled trial of financial incentives. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05150] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThe UK national diabetic eye screening (DES) programme invites diabetic patients aged > 12 years annually. Simple and cost-effective methods are needed to increase screening uptake. This trial tests the impact on uptake of two financial incentive schemes, based on behavioural economic principles.ObjectivesTo test whether or not financial incentives encourage screening attendance. Secondarily to understand if the type of financial incentive scheme used affects screening uptake or attracts patients with a different sociodemographic status to regular attenders. If financial incentives were found to improve attendance, then a final objective was to test cost-effectiveness.DesignThree-armed randomised controlled trial.SettingDES clinic within St Mary’s Hospital, London, covering patients from the areas of Kensington, Chelsea and Westminster.ParticipantsPatients aged ≥ 16 years, who had not attended their DES appointment for ≥ 2 years.Interventions(1) Fixed incentive – invitation letter and £10 for attending screening; (2) probabilistic (lottery) incentive – invitation letter and 1% chance of winning £1000 for attending screening; and (3) control – invitation letter only.Main outcome measuresThe primary outcome was screening attendance. Rates for control versus fixed and lottery incentive groups were compared using relative risk (RR) and risk difference with corresponding 95% confidence intervals (CIs).ResultsA total of 1274 patients were eligible and randomised; 223 patients became ineligible before invite and 1051 participants were invited (control,n = 435; fixed group,n = 312; lottery group,n = 304). Thirty-four (7.8%, 95% CI 5.29% to 10.34%) control, 17 (5.5%, 95% CI 2.93% to 7.97%) fixed group and 10 (3.3%, 95% CI 1.28% to 5.29%) lottery group participants attended. Participants offered incentives were 44% less likely to attend screening than controls (RR 0.56, 95% CI 0.34 to 0.92). Examining incentive groups separately, the lottery group were 58% less likely to attend screening than controls (RR 0.42, 95% CI 0.18 to 0.98). No significant differences were found between fixed incentive and control groups (RR 0.70, 95% CI 0.35 to 1.39) or between fixed and lottery incentive groups (RR 1.66, 95% CI 0.65 to 4.21). Subgroup analyses showed no significant associations between attendance and sociodemographic factors, including gender (female vs. male, RR 1.25, 95% CI 0.77 to 2.03), age (≤ 65 years vs. > 65 years, RR 1.26, 95% CI 0.77 to 2.08), deprivation [0–20 Index of Multiple Deprivation (IMD) decile vs. 30–100 IMD decile, RR 1.12, 95% CI 0.69 to 1.83], years registered [mean difference (MD) –0.13, 95% CI –0.69 to 0.43], and distance from screening location (MD –0.18, 95% CI –0.65 to 0.29).LimitationsDespite verification, some address details may have been outdated, and high ethnic diversity may have resulted in language barriers for participants.ConclusionsThose receiving incentives were not more likely to attend a DES than those receiving a usual invitation letter in patients who are regular non-attenders. Both fixed and lottery incentives appeared to reduce attendance. Overall, there is no evidence to support the use of financial incentives to promote diabetic retinopathy screening. Testing interventions in context, even if they appear to be supported by theory, is important.Future workFuture research, specifically in this area, should focus on identifying barriers to screening and other non-financial methods to overcome them.Trial registrationCurrent Controlled Trials ISRCTN14896403.FundingThis project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full inHealth Services and Delivery Research; Vol. 5, No. 15. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gaby Judah
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ara Darzi
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Ivo Vlaev
- Warwick Business School, University of Warwick, Coventry, UK
| | - Laura Gunn
- Public Health Program, Stetson University, DeLand, FL, USA
| | - Derek King
- Personal Social Services Research Unit, London School of Economics and Political Science, London, UK
| | - Dominic King
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jonathan Valabhji
- Imperial College Healthcare NHS Trust, St Mary’s Hospital, London, UK
| | | | | | | | - Anna Fogg
- 1st Retinal Screen Ltd, Sandbach, UK
| | | | | | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
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Katz A, Enns JE, Chateau D, Lix L, Jutte D, Edwards J, Brownell M, Metge C, Nickel N, Taylor C, Burland E. Does a pay-for-performance program for primary care physicians alleviate health inequity in childhood vaccination rates? Int J Equity Health 2015; 14:114. [PMID: 26616228 PMCID: PMC4663722 DOI: 10.1186/s12939-015-0231-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/02/2015] [Indexed: 12/02/2022] Open
Abstract
Introduction Childhood vaccination rates in Manitoba populations with low socioeconomic status (SES) fall significantly below the provincial average. This study examined the impact of a pay-for-performance (P4P) program called the Physician Integrated Network (PIN) on health inequity in childhood vaccination rates. Methods The study used administrative data housed at the Manitoba Centre for Health Policy. We included all children born in Manitoba between 2003 and 2010 who were patients at PIN clinics receiving P4P funding matched with controls at non-participating clinics. We examined the rate of completion of the childhood primary vaccination series by age 2 across income quintiles (Q1–Q5). We estimated the distribution of income using the Gini coefficient, and calculated concentration indices for vaccination to determine whether the P4P program altered SES-related differences in vaccination completion. We compared these measures between study cohorts before and after implementation of the P4P program, and over the course of the P4P program in each cohort. Results The PIN cohort included 6,185 children. Rates of vaccination completion at baseline were between 0.53 (Q1) and 0.69 (Q5). Inequality in income distribution was present at baseline and at study end in PIN and control cohorts. SES-related inequity in vaccination completion worsened in non-PIN clinics (difference in concentration index 0.037; 95 % CI 0.013, 0.060), but remained constant in P4P-funded clinics (difference in concentration index 0.006; 95 % CI 0.008, 0.021). Conclusions The P4P program had a limited impact on vaccination rates and did not address health inequity.
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Affiliation(s)
- Alan Katz
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada.
| | - Jennifer Emily Enns
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada.
| | - Dan Chateau
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada.
| | - Lisa Lix
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada.
| | - Doug Jutte
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,School of Public Health, University of California, 50 University Hall, #7360, Berkeley, CA, 94720-7360, USA.
| | - Jeanette Edwards
- Winnipeg Regional Health Authority, Primary Health Care and Chronic Disease, 496 Hargrave St, Winnipeg, MB, R3A 0X7, Canada.
| | - Marni Brownell
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada.
| | - Colleen Metge
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,Winnipeg Regional Health Authority, 200-1155 Concordia Ave, Winnipeg, MB, R2K 2M9, Canada.
| | - Nathan Nickel
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada. .,Department of Community Health Sciences, University of Manitoba, S113-750 Bannatyne Ave, Winnipeg, MB, R3E 0W3, Canada.
| | - Carole Taylor
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada.
| | - Elaine Burland
- Manitoba Centre for Health Policy, 408-727 McDermot Ave, Winnipeg, MB, R3E 3P5, Canada.
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Hackett J, Glidewell L, West R, Carder P, Doran T, Foy R. 'Just another incentive scheme': a qualitative interview study of a local pay-for-performance scheme for primary care. BMC FAMILY PRACTICE 2014; 15:168. [PMID: 25344735 PMCID: PMC4213492 DOI: 10.1186/s12875-014-0168-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Accepted: 10/06/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND A range of policy initiatives have addressed inequalities in healthcare and health outcomes. Local pay-for-performance schemes for primary care have been advocated as means of enhancing clinical ownership of the quality agenda and better targeting local need compared with national schemes such as the UK Quality and Outcomes Framework (QOF). We investigated whether professionals' experience of a local scheme in one English National Health Service (NHS) former primary care trust (PCT) differed from that of the national QOF in relation to the goal of reducing inequalities. METHODS We conducted retrospective semi-structured interviews with primary care professionals implementing the scheme and those involved in its development. We purposively sampled practices with varying levels of population socio-economic deprivation and achievement. Interviews explored perceptions of the scheme and indicators, likely mechanisms of influence on practice, perceived benefits and harms, and how future schemes could be improved. We used a framework approach to analysis. RESULTS Thirty-eight professionals from 16 general practices and six professionals involved in developing local indicators participated. Our findings cover four themes: ownership, credibility of the indicators, influences on behaviour, and exacerbated tensions. We found little evidence that the scheme engendered any distinctive sense of ownership or experiences different from the national scheme. Although the indicators and their evidence base were seldom actively questioned, doubts were expressed about their focus on health promotion given that eventual benefits relied upon patient action and availability of local resources. Whilst practices serving more affluent populations reported status and patient benefit as motivators for participating in the scheme, those serving more deprived populations highlighted financial reward. The scheme exacerbated tensions between patient and professional consultation agendas, general practitioners benefitting directly from incentives and nurses who did much of the work, and practices serving more and less affluent populations which faced different challenges in achieving targets. CONCLUSIONS The contentious nature of pay-for-performance was not necessarily reduced by local adaptation. Those developing future schemes should consider differential rewards and supportive resources for practices serving more deprived populations, and employing a wider range of levers to promote professional understanding and ownership of indicators.
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Affiliation(s)
- Julia Hackett
- />Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah Building, 101 Clarendon Road, Leeds, UK
| | - 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
| | - Paul Carder
- />West and South Yorkshire and Bassetlaw 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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