Payment incentives for community-based psychiatric care in Ontario, Canada

A Randomized Controlled Trial of a Pay-for-Performance Initiative to Reduce Costs of Care for High-Need Psychiatric Patients

OBJECTIVE

Pay-for-performance (P4P) initiatives hold promise for improving health care delivery but are rarely applied to behavioral health or tested in randomized controlled trials (RCTs). This RCT examined the effectiveness of a P4P initiative to reduce total cost of 24-hour care among patients with high needs for psychiatric care in a large county in California.

METHODS

From August 2016 to March 2022, a total of 652 adult residents of Santa Clara County, California, were enrolled in a P4P initiative (mean±SD age=46.7±13.3 years, 61% male, 51% White, and 60% diagnosed as having a bipolar or psychotic disorder). Participants were randomly assigned to usual full-service partnerships from the county (N=327) or a comparable level of care from a contractor who agreed to a schedule of financial penalties and rewards based on whether enrollees (N=325) used more or less care than a historical cohort of similar county patients. The primary outcome was total cost of 24-hour psychiatric services. Secondary outcomes were costs of each of the 24-hour care services.

RESULTS

The proportion of the total sample that used 24-hour psychiatric services decreased over the 36-month study period. Intent-to-treat analyses revealed no differences between the two study conditions in total care costs during the follow-up period. No significant care utilization differences were observed between the two conditions in most of the individual 24-hour services.

CONCLUSIONS

A P4P initiative for high-need patients was no more effective than usual care for reducing costs of 24-hour psychiatric care.

Pan-Canadian study of psychiatric care (PCPC): protocol for a mixed-methods study

INTRODUCTION

The Canadian population has poor and inequitable access to psychiatric care despite a steady per-capita supply of psychiatrists in most provinces. There is some quantitative evidence that practice style and characteristics vary substantially among psychiatrists. However, how this compares across jurisdictions and implications for workforce planning require further study. A qualitative exploration of psychiatrists' preferences for practice style and the practice choices that result is also lacking. The goal of this study is to inform psychiatrist workforce planning to improve access to psychiatric care by: (1) developing and evaluating comparable indicators of supply of psychiatric care across provinces, (2) analysing variations and changes in the characteristics of the psychiatrist workforce, including demographics and practice style and (3) studying psychiatrist practice choices and intentions, and the factors that lead to these choices.

METHODS AND ANALYSIS

A cross-provincial mixed-methods study will be conducted in the Canadian provinces of British Columbia, Manitoba, Ontario and Nova Scotia. We will analyse linked-health administrative data within three of the four provinces to develop comparable indicators of supply and characterise psychiatric services at the regional level within provinces. We will use latent profile analysis to estimate the probability that a psychiatrist is in a particular practice style and map the geographical distribution of psychiatrist practices overlayed with measures of need for psychiatric care. We will also conduct in-depth, semistructured qualitative interviews with psychiatrists in each province to explore their preferences and practice choices and to inform workforce planning.

ETHICS AND DISSEMINATION

This study was approved by Ontario Tech University Research Ethics Board (16637 and 16795) and institutions affiliated with the study team. We built a team comprising experienced researchers, psychiatrists, medical educators and policymakers in mental health services and workforce planning to disseminate knowledge that will support effective human resource policies to improve access to psychiatric care in Canada.

The role of geography and distance on physician follow-up after a first hospitalization with a diagnosis of a schizophrenia spectrum disorder: A retrospective population-based cohort study in Ontario, Canada

BACKGROUND

Timely follow-up after hospitalization for a schizophrenia spectrum disorder (SSD) is an important quality indicator. We examined the proportion of individuals who received physician follow-up within 7 and 30 days post-discharge by health region and estimated the effect of distance between a person's residence and discharging hospital on follow-up.

METHODS

We created a retrospective population-based cohort of incident hospitalizations with a discharge diagnosis of a SSD between 01/01/2012 and 30/03/2019. The proportion of follow-up with a psychiatrist and family physician within 7 and 30 days were calculated for each region. The effect of distance between a person's residence and discharging hospital on follow-up was estimated using adjusted multilevel logistic regression models.

RESULTS

We identified 6,382 incident hospitalizations for a SSD. Only 14.2% and 49.2% of people received follow-up care with a psychiatrist within 7 and 30 days of discharge, respectively, and these proportions varied between regions. Although distance from hospital was not associated with follow-up within 7 days of discharge, increasing distance was associated with lower odds of follow-up with a psychiatrist within 30 days.

CONCLUSION

Post-discharge follow-up is poor across the province. Geospatial factors may impact post-discharge care and should be considered in further evaluation of quality of care.

Physician Financial Incentives for Use of Outpatient Intravenous Antimicrobial Therapy: An Interrupted Time Series Analysis

BACKGROUND

In 2011, policymakers in British Columbia introduced a fee-for-service payment to incentivize infectious diseases physicians to supervise outpatient parenteral antimicrobial therapy (OPAT). Whether this policy increased use of OPAT remains uncertain.

METHODS

We conducted a retrospective cohort study using population-based administrative data over a 14-year period (2004-2018). We focused on infections that required intravenous antimicrobials for ≥10 days (eg, osteomyelitis, joint infection, endocarditis) and used the monthly proportion of index hospitalizations with a length of stay shorter than the guideline-recommended "usual duration of intravenous antimicrobials" (LOS < UDIVA) as a surrogate for population-level OPAT use. We used interrupted time series analysis to determine whether policy introduction increased the proportion of hospitalizations with LOS < UDIVA.

RESULTS

We identified 18 513 eligible hospitalizations. In the pre-policy period, 82.3% of hospitalizations exhibited LOS < UDIVA. Introduction of the incentive was not associated with a change in the proportion of hospitalizations with LOS < UDIVA, suggesting that the policy intervention did not increase OPAT use (step change, -0.06%; 95% confidence interval [CI], -2.69% to 2.58%; P = .97 and slope change, -0.001% per month; 95% CI, -.056% to .055%; P = .98).

CONCLUSIONS

The introduction of a financial incentive for physicians did not appear to increase OPAT use. Policymakers should consider modifying the incentive design or addressing organizational barriers to expanded OPAT use.

Help-seeking behavior among adults who attempted or died by suicide in Ontario, Canada

INTRODUCTION

This study aims to determine the relationship between rurality and help-seeking behavior prior to a suicide or suicide attempt.

METHODS

Data from 2007 to 2017 were obtained from administrative databases held at ICES, which capture all hospital, emergency department (ED), and general practitioner (GP) visits across Ontario. Rurality was defined using the Rurality Index of Ontario scores. Help-seeking was based on accessing health services 1 year prior to the event.

RESULTS

Among those who died by suicide (N = 9848), those living in rural areas were less likely to seek help from a psychiatrist (rural males: AOR = 0.42, 95% CI = 0.31-0.57; rural females: AOR = 0.46, 95% CI = 0.29-0.97) compared with those living in urban areas. We found a similar association among those who attempted suicide (N = 82,480) (rural males: AOR = 0.49, 95% CI = 0.43-0.56; rural females: AOR = 0.51, 95% CI = 0.46-0.57). Rural males and females were more likely to seek care from an ED for mental health reasons compared with urban males and females.

CONCLUSIONS

Among people who died by suicide, those living in rural areas are generally less likely to access psychiatrists and GPs and more likely to access EDs, suggesting that people living in rural areas may have less access to care than their urban counterparts.

Association of physician financial incentives with primary care enrolment of adults with serious mental illnesses in Ontario: a retrospective observational population-based study

BACKGROUND

Financial incentives may improve primary care access for adults with schizophrenia or bipolar disorder (serious mental illness [SMI]). We studied the association between receipt of the SMI financial premium paid to primary care physicians and rostering of adults with SMI in different patient enrolment models (PEMs), including enhanced fee-for-service and capitation-based models with and without interdisciplinary team-based care.

METHODS

We conducted a retrospective cohort study involving Ontario adults (≥18 yr) with SMI in PEM practices, in fiscal years 2016/17 and 2017/18. Using negative binomial models, we examined relations between rostering and the primary care model and the contribution of the incentive. Similar models were developed for adults with type 1 or 2 diabetes mellitus and the general population.

RESULTS

Among 9730 physicians in PEM practices, 4866 (50.0%) received a premium and 448 319 (88.4%) people with SMI in PEMs were rostered. Compared with enhanced fee for service, the likelihood of rostering people with SMI was 3.0% higher for patients in capitation with team-based care (adjusted relative risk [RR] 1.03, 95% confidence interval [CI] 1.02-1.04), with similar results for capitation without team-based care (adjusted RR 1.00 95% CI 0.99-1.01). Rostering for people with diabetes was similar in team-based care (adjusted RR 1.02, 95% CI 1.02-1.03) but higher in capitation without team-based care (adjusted RR 1.03, 95% CI 1.02-1.03) and slightly higher for the Ontario population (team-based care 1.04, 95% CI 1.04-1.05, capitation without team-based care 1.03, 95% CI 1.03-1.04).

INTERPRETATION

Rostering of people with SMI was lower than for the general population. Additional policy measures are needed to address persisting inequities and to promote rostering of this underserved population with complex needs.

Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis

BACKGROUND

In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge.

OBJECTIVE

To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions.

DESIGN

Interrupted time series analysis of population-based hospitalization data.

PARTICIPANTS

Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017.

MAIN MEASURES

The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy.

KEY RESULTS

A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval.

CONCLUSION

The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere.

TRIAL REGISTRATION

ClinicalTrials.gov ID, NCT03256734.

Examining equity in the utilisation of psychiatric inpatient care among patients with severe mental illness (SMI) in Ontario, Canada

BACKGROUND

Severe mental illness (SMI) comprises a range of chronic and disabling conditions, such as schizophrenia, bipolar disorder and other psychoses. Despite affecting a small percentage of the population, these disorders are associated with poor outcomes, further compounded by disparities in access, utilisation, and quality of care. Previous research indicates there is pro-poor inequality in the utilisation of SMI-related psychiatric inpatient care in England (in other words, individuals in more deprived areas have higher utilisation of inpatient care than those in less deprived areas). Our objective was to determine whether there is pro-poor inequality in SMI-related psychiatric admissions in Ontario, and understand whether these inequalities have changed over time.

METHODS

We selected all adult psychiatric admissions from April 2006 to March 2011. We identified changes in socio-economic equity over time across deprivation groups and geographic units by modeling, through ordinary least squares, annual need-expected standardised utilisation as a function of material deprivation and other relevant variables. We also tested for changes in socio-economic equity of utilisation over years, where the number of SMI-related psychiatric admissions for each geographic unit was modeled using a negative binomial model.

RESULTS

We found pro-poor inequality in SMI-related psychiatric admissions in Ontario. For every one unit increase in deprivation, psychiatric admissions increased by about 8.1%. Pro-poor inequality was particularly present in very urban areas, where many patients with SMI reside, and very rural areas, where access to care is problematic. Our main findings did not change with our sensitivity analyses. Furthermore, this inequality did not change over time.

CONCLUSIONS

Individuals with SMI living in more deprived areas of Ontario had higher psychiatric admissions than those living in less deprived areas. Moreover, our findings suggest this inequality has remained unchanged over time. Despite the debate around whether to make more or less use of inpatient versus other care, policy makers should seek to address suboptimal supply of primary, community or social care for SMI patients. This may potentially be achieved through the elimination of barriers to access psychiatrist care and the implementation of universal coverage of psychotherapy.

Does physician compensation for declaration of involuntary status increase the likelihood of involuntary admission? A population-level cross-sectional linked administrative database study

BACKGROUND

There is substantial variability in involuntary psychiatric admission rates across countries and sub-regions within countries that are not fully explained by patient-level factors. We sought to examine whether in a government-funded health care system, physician payments for filling forms related to an involuntary psychiatric hospitalization were associated with the likelihood of an involuntary admission.

METHODS

This is a population-based, cross-sectional study in Ontario, Canada of all adult psychiatric inpatients in Ontario (2009-2015, n = 122 851). We examined the association between the proportion of standardized forms for involuntary admissions that were financially compensated and the odds of a patient being involuntarily admitted. We controlled for socio-demographic characteristics, clinical severity, past-health care system utilization and system resource factors.

RESULTS

Involuntary admission rates increased from the lowest (Q1, 70.8%) to the highest (Q5, 81.4%) emergency department (ED) quintiles of payment, with the odds of involuntary admission in Q5 being nearly significantly higher than the odds of involuntary admission in Q1 after adjustment (aOR 1.73, 95% CI 0.99-3.01). With payment proportion measured as a continuous variable, the odds of involuntary admission increased by 1.14 (95% CI 1.03-1.27) for each 10% absolute increase in the proportion of financially compensated forms at that ED.

CONCLUSIONS

We found that involuntary admission was more likely to occur at EDs with increasing likelihood of financial compensation for invoking involuntary status. This highlights the need to better understand how physician compensation relates to the ethical balance between the right to safety and autonomy for some of the world's most vulnerable patients.

Is the evidence on the effectiveness of pay for performance schemes in healthcare changing? Evidence from a meta-regression analysis

BACKGROUND

This study investigated if the evidence on the success of the Pay for Performance (P4P) schemes in healthcare is changing as the schemes continue to evolve by updating a previous systematic review.

METHODS

A meta-regression analysis using 116 studies evaluating P4P schemes published between January 2010 to February 2018. The effects of the research design, incentive schemes, use of incentives, and the size of the payment to revenue ratio on the proportion of statically significant effects in each study were examined.

RESULTS

There was evidence of an increase in the range of countries adopting P4P schemes and weak evidence that the proportion of studies with statistically significant effects have increased. Factors hypothesized to influence the success of schemes have not changed. Studies evaluating P4P schemes which made payments for improvement over time, were associated with a lower proportion of statistically significant effects. There was weak evidence of a positive association between the incentives' size and the proportion of statistically significant effects.

CONCLUSION

The evidence on the effectiveness of P4P schemes is evolving slowly, with little evidence that lessons are being learned concerning the design and evaluation of P4P schemes.

Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study

Background

The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction.

Methods

Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010–2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics.

Results

At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%).

Interpretation

This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.

Ontario's response to COVID-19 shows that mental health providers must be integrated into provincial public health insurance systems

The fear, grief, social isolation, and financial and occupational losses from COVID-19 have created a mental health crisis. Ontario’s response highlights the shortcomings of its physician-only public healthcare system that limits public access to appropriate and sustainable mental healthcare. Specifically, Ontario’s attempt to rapidly expand mental healthcare access in response to COVID-19 includes new Ontario Health Insurance Program (OHIP) billing codes that enable physicians to provide telephonic trauma counselling and patient self-serve online tools while psychologist and other registered mental health provider services have been largely left out of the provincial response. Why? Non-physician mental health providers operate outside of the provincial healthcare infrastructure, including the provincial payer (i.e., OHIP) that facilitated the provincial physician response. A physician-centric mental healthcare system limits public access to quality, sustainable, evidence-based mental health services because most physicians do not have the capacity, training, or desire to provide mental health services. To improve public access to needed mental health services, provinces should integrate psychologists and other registered mental health providers directly into their public health insurance systems. Integrated providers can be strategically and sustainably mobilized to respond to COVID-19 and future mental health crises.

Governance of mental healthcare: Fragmented accountability

Within international healthcare systems the neglect of mental health and challenge in shifting from institutional to community care have been recurrent themes. In analysing the challenges, we focus on the case study of Canada by exploring the manner in which health law and policy evolved to inhibit community-based mental healthcare, and compare the resulting funding landscape from an international perspective. The historical institutionalist analysis draws on the literature and healthcare finance data. As a spending statute, the Canada Health Act defines the terms on which the federal government finances publicly insured provincial healthcare. Despite the goal to support physical and mental well-being by removing financial barriers to access health services, exclusion of community care offered by non-physicians (such as psychotherapy) from the terms of the Act inhibited its fulfilment. Diminished federal transfers deepened the disincentive for provinces to establish community care: mental health declined from 11 to 7 percent of provincial healthcare spending from 1979 to 2014. Governance oversight was passed to provinces whose competing demands on diminished resources limited their capacity to extend care. Accountability was found fragmented as neither government stepped-in to ensure the continuum of care, even as federal transfers were restored and evidence of cost-effectiveness grew. Although American and Canadian funding patterns are similar, other OECD countries invest between 13 and 18 percent of healthcare expenditures on mental health. Lessons from the Canadian case are the manner in which its federal structure and intergovernmental dynamics shaped health policy, and the importance of ensuring representation from a range of perspectives in policy development. Federal financial incentives were also found to profoundly impact the expansion of community-based mental healthcare. Evidence shows that public insurance for community supports would reduce healthcare expenditures and employer productivity loss, resulting in savings of $255 billion over 30 years.

Sahaj Samadhi Meditation versus a Health Enhancement Program for depression in chronic pain: protocol for a randomized controlled trial and implementation evaluation

Background

Despite the high prevalence of comorbid chronic pain and depression, this comorbidity remains understudied. Meditation has demonstrated efficacy for both chronic pain and depression independently, yet there have been few studies examining its effectiveness when both conditions are present concurrently. Furthermore, while meditation is generally accepted as a safe and effective health intervention, little is known about how to implement meditation programs within or alongside the health care system.

Methods

We will conduct a hybrid type 1 effectiveness–implementation evaluation. To measure effectiveness, we will conduct a randomized controlled trial comparing Sahaj Samadhi Meditation and the Health Enhancement Program in 160 people living with chronic pain, clinically significant depressive symptoms, and on long-term opioid therapy. Changes in depressive symptoms will be our primary outcome; pain severity, pain-related function, opioid use, and quality of life will be the secondary outcomes. The primary end point will be at 12 weeks with a secondary end point at 24 weeks to measure the sustainability of acute effects. Patients will be recruited from a community-based chronic pain clinic in a large urban center in Mississauga, Canada. The meditation program will be delivered in the clinical environment where patients normally receive their chronic pain care by certified meditation teachers who are not regulated health care providers. We will use a mixed-methods design using the multi-level framework to understand the implementation of this particular co-location model.

Discussion

Results of this hybrid evaluation will add important knowledge about the effectiveness of meditation for managing depressive symptoms in people with chronic pain. The implementation evaluation will inform both effectiveness outcomes and future program development, scalability, and sustainability.

Trial registration

ClinicalTrials.gov: NCT04039568. Registered on 31 July 2019.

Physician-based availability of psychotherapy in Ontario: a population-based retrospective cohort study

BACKGROUND

Psychotherapy is recommended as a first-line treatment for the management of common psychiatric disorders. The objective of this study was to evaluate the availability of publicly funded psychotherapy provided by physicians in Ontario by describing primary care physicians (PCPs) and psychiatrists whose practices focus on psychotherapy and comparing them to PCPs and psychiatrists whose practices do not.

METHODS

This was a population-based retrospective cohort study. We included all PCPs and psychiatrists in Ontario who submitted at least 1 billing claim to the Ontario Health Insurance Plan between Apr. 1, 2015, and Mar. 31, 2016, and categorized them as psychotherapists if at least 50% of their outpatient billings were related to the provision of psychotherapy. We measured practice characteristics such as total number of patients and new patients, and average visit frequency for 4 physician categories: PCP nonpsychotherapists, PCP psychotherapists, psychiatrist nonpsychotherapists and psychiatrist psychotherapists. We also measured access to care for people with urgent need for mental health services.

RESULTS

Of 12 772 PCPs, 404 (3.2%) were PCP psychotherapists; of 2150 psychiatrists, 586 (27.3%) were psychotherapists. Primary care physician nonpsychotherapists had the highest number of patients and number of new patients, followed by psychiatrist nonpsychotherapists, PCP psychotherapists and psychiatrist psychotherapists. Primary care physician nonpsychotherapists had the lowest average annual number of visits per patient, whereas both types of psychotherapists had a much greater number of visits per patient. Primary care physician and psychiatrist nonpsychotherapists saw about 25% of patients with urgent needs for mental health services, whereas PCP and psychiatrist psychotherapists saw 1%-3% of these patients.

INTERPRETATION

Physicians who provide publicly funded psychotherapy in Ontario see a small number of patients, and they see few of those with urgent need for mental health services. Our findings suggest that improving access to psychotherapy will require the development of alternative strategies.

Closed for Business? Using a Mixture Model to Explore the Supply of Psychiatric Care for New Patients

OBJECTIVE

To investigate the degree to which psychiatrists are accessible to new outpatients and the factors that predict whether psychiatrists will see new outpatients.

METHODS

We used administrative health data on all practicing full-time psychiatrists in Ontario, Canada, over a 5-year period (2009-2010 to 2013-2014). We used a regression model to estimate the number of new outpatients seen, accounting for case mix, outpatient volume, and psychiatrist practice characteristics.

RESULTS

Approximately 10% of full-time psychiatrists are seeing 1 or fewer new outpatients per month, and another 10% are seeing between 1 and 2 new outpatients per month. Our model identified psychiatrists in 3 distinct practice styles. One practice style (representing 29% of psychiatrists), on average, saw fewer than 2 new outpatients per month and 69 unique outpatients annually. Relative to other practice styles, they tended to see fewer patients with a previous psychiatric hospitalization and fewer patients who lived in lower income neighbourhoods.

CONCLUSIONS

Nearly 1 in 3 full-time psychiatrists in Ontario see very few new outpatients. This has implications for access to care, particularly for outpatients with newly diagnosed mental illness. It also highlights the continued need to address access issues by assessing the role of psychiatrists within the Canadian health care system.

Do Financial Incentives Change Length-of-stay Performance in Emergency Departments? A Retrospective Study of the Pay-for-performance Program in Metro Vancouver

BACKGROUND

Pay-for-performance (P4P) programs have been implemented in various forms to reduce emergency department (ED) patient length of stay (LOS). This retrospective study investigated to what extent the timing of patient disposition in Metro Vancouver EDs was influenced by a LOS-based P4P program.

METHODS

We analyzed ED visit records of four major hospitals in Metro Vancouver, Canada. For each ED, we individually tested whether LOS was distributed discontinuously at the LOS target before and after the P4P program was terminated. For the P4P effective period, we examined whether patients discharged just prior to the LOS target had a higher 7-day return-and-admission (RA) rate-the probability that a patient, after being discharged home, returned to any ED within 7 days and was admitted to an inpatient unit-than patients discharged just after the target.

RESULTS

Prior to the termination of the P4P program, in all four EDs, the LOS density of admitted patients was discontinuous and had a significant drop at the P4P 10-hours admission LOS target; a similar phenomenon was observed among discharged patients at the 4-hours discharge LOS target, but only in the two lower-volume EDs. Furthermore, in a lower-volume ED, patients who were discharged right before the 4-hours P4P LOS target had a higher 7-day RA rate than patients discharged right after the LOS target. After the termination of the discharge incentive, the discontinuity at the discharge LOS target became less evident, but patients were still more frequently admitted just before 10 hours in three of the four EDs as the local health authority continued to support the admission incentive scheme after the government terminated the P4P program.

CONCLUSIONS

The LOS-based financial incentive scheme appears to have influenced the timing of ED patient dispositions. The results suggest mixed consequences of the P4P program-it can reduce access block for admitted patients but may also lead to discharges associated with return visits and admissions.