Effectiveness of UK provider financial incentives on quality of care: a systematic review

Information provision and financial incentives in Catalonia's public primary care (2010-2019): an interrupted time series analysis

Background

The relative efficacy of information provision versus financial incentives in improving primary care quality remains a critical, unresolved question. We investigated these two strategies in Catalonia's public primary care system from 2010 to 2019: an innovative online platform providing real-time quality indicator information and targeted economic incentives for achieving indicator goals.

Methods

We conducted a comprehensive interrupted time series regression analysis on data from 272 primary care practices (5,628,080 patients). This analysis used linear regression models with Newey-West standard errors, and a sensitivity analysis including logit transformations to address ceiling effects. We evaluated 1) immediate post-intervention changes (step changes) in indicator results and inter-practice variability (coefficient of variation, CV), and 2) shifts in pre-intervention trends (slopes). We scrutinized 39 indicators after rigorous quality control: 23 novel (12 informed, 11 incentivized) and 16 derived from existing incentivized indicators. Robustness checks included 14 consistently incentivized and 10 non-intervened indicators. Overall, we assessed 63 indicators: 18 control, 13 follow-up, 9 quaternary prevention, 7 treatment, 7 diagnosis, 6 screening and 3 vaccination indicators.

Findings

Informed indicators showed positive impacts in 75% (9/12) of cases, and incentivized indicators in 64% (7/11) of cases. Incentivized indicators displayed improvements in annual trends ranging from 6.66 to 1.25 percentage points, with step changes up to 8.87 percentage points. Information led to step changes ranging from 19.67 to 1.07 percentage points, along with trend improvements between 1.09 and 0.34 percentage points annually. Both interventions were associated with step reductions in variability (up to -0.18 CV reduction) and significant trend improvements. Derived indicators showed limited improvements in results or variability (31%, 5/16), with minor step increases up to 2.22 percentage points.

Interpretation

Our findings reveal that information provision alone can match or even surpass the impact of financial incentives in improving care quality and reducing practice variability. This challenges conventional wisdom and offers a cost-effective, scalable approach to primary care quality enhancement, with far-reaching implications for global health policy.

Funding

European Union, Horizon Europe.

Strategies to improve the implementation of preventive care in primary care: a systematic review and meta-analysis

BACKGROUND

Action on smoking, obesity, excess alcohol, and physical inactivity in primary care is effective and cost-effective, but implementation is low. The aim was to examine the effectiveness of strategies to increase the implementation of preventive healthcare in primary care.

METHODS

CINAHL, CENTRAL, The Cochrane Database of Systematic Reviews, Dissertations & Theses - Global, Embase, Europe PMC, MEDLINE and PsycINFO were searched from inception through 5 October 2023 with no date of publication or language limits. Randomised trials, non-randomised trials, controlled before-after studies and interrupted time series studies comparing implementation strategies (team changes; changes to the electronic patient registry; facilitated relay of information; continuous quality improvement; clinician education; clinical reminders; financial incentives or multicomponent interventions) to usual care were included. Two reviewers screened studies, extracted data, and assessed bias with an adapted Cochrane risk of bias tool for Effective Practice and Organisation of Care reviews. Meta-analysis was conducted with random-effects models. Narrative synthesis was conducted where meta-analysis was not possible. Outcome measures included process and behavioural outcomes at the closest point to 12 months for each implementation strategy.

RESULTS

Eighty-five studies were included comprising of 4,210,946 participants from 3713 clusters in 71 cluster trials, 6748 participants in 5 randomised trials, 5,966,552 participants in 8 interrupted time series, and 176,061 participants in 1 controlled before after study. There was evidence that clinical reminders (OR 3.46; 95% CI 1.72-6.96; I2 = 89.4%), clinician education (OR 1.89; 95% CI 1.46-2.46; I2 = 80.6%), facilitated relay of information (OR 1.95, 95% CI 1.10-3.46, I2 = 88.2%), and multicomponent interventions (OR 3.10; 95% CI 1.60-5.99, I2 = 96.1%) increased processes of care. Multicomponent intervention results were robust to sensitivity analysis. There was no evidence that other implementation strategies affected processes of care or that any of the implementation strategies improved behavioural outcomes. No studies reported on interventions specifically designed for remote consultations. Limitations included high statistical heterogeneity and many studies did not account for clustering.

CONCLUSIONS

Multicomponent interventions may be the most effective implementation strategy. There was no evidence that implementation interventions improved behavioural outcomes.

TRIAL REGISTRATION

PROSPERO CRD42022350912.

The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care

AIM

The aim of this research was to explore the experiences of uncertainty amongst Musculoskeletal First Contact Practitioners working in primary care.

BACKGROUND

The Musculoskeletal First Contact Practitioner role involves advanced physiotherapists providing an alternative to the GP by acting as first point of contact for people presenting to primary care with musculoskeletal conditions. Limited research into the role exists but the first-contact aspect, clinical complexity and time pressures are deemed to contribute to uncertainty within the role.

METHOD

A qualitative research design was undertaken using a hermeneutic interpretative phenomenological approach. Data was collected using semi-structured interviews with subsequent thematic analysis of the data.

FINDINGS

Eight participants working as Musculoskeletal First Contact Practitioners across England were recruited using purposive sampling. Five themes were identified: (1) Role clarity within primary care, (2) Burden of responsibility, (3) Preparedness for the primary care environment, (4) 'I'm not really sure how long I am going to stay in this role', (5) Mitigating uncertainty.

CONCLUSION

This study demonstrates the multifaceted phenomenon of uncertainty amongst Musculoskeletal First Contact Practitioners. Uncertainty appeared to be influenced by the primary care environment, preparedness for the role and perceived burden of responsibility. Diagnostic uncertainty was prevalent with concerns of missing serious pathology evident. The impact of uncertainty on wellbeing was linked to possible burnout and retention issues. Consultation approaches, access to support networks and a cultural shift in tolerating uncertainty were reported to mitigate uncertainty. Further research into possible differences in experiences related to employment models appears warranted.

Motivating factors for frontline healthcare workers during the COVID-19 pandemic: A survey in Japan

Healthcare workers (HCWs), who are at the frontline of the COVID-19 pandemic, treated COVID-19 patients under many types of stress for over a year. As an external motivating factor, incentives could be important for HCWs dealing with COVID-19. However, there has been no research regarding the change in the consciousness of HCWs during the unrelenting waves of COVID-19. Therefore, we conducted a survey of HCWs during different waves of COVID-19 (the second and fourth waves in Japan). An open web-based survey was conducted among HCWs who wore PPE while treating COVID-19 patients. The first survey of HCWs in Japan was conducted from August 27 to September 9, 2020, while the second survey was conducted from April 7 to May 10, 2021, during the second and fourth waves, respectively. The first and second surveys had 157 and 125 participants, respectively. There were no significant differences in the characteristics of the participants in the first and second survey groups regarding the types of occupation, age, sex, or full-time status. The percentage of HCWs who required financial incentives to maintain motivation remained high (88.5% vs. 82.7%). In addition, most frontline HCWs hope for regular SARS-CoV-2 PCR testing, which will be provided free of charge, as a necessary incentive. External motivating factors, such as financial and other incentives, were important to maintain the motivation of HCWs during the second and fourth waves of the COVID-19 pandemic in Japan.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12144-022-04177-6.

Did paying drugs misuse treatment providers for outcomes lead to unintended consequences for hospital admissions? Difference-in-differences analysis of a pay-for-performance scheme in England

AIMS

To estimate how a scheme to pay substance misuse treatment service providers according to treatment outcomes affected hospital admissions.

DESIGN

A controlled, quasi-experimental (difference-in-differences) observational study using negative binomial regression.

SETTING

Hospitals in all 149 organisational areas in England for the period 2009-2010 to 2015-2016.

PARTICIPANTS

572 545 patients admitted to hospital with a diagnosis indicating drug misuse, defined based on International Classification of Diseases 10th Revision (ICD-10) diagnosis codes (37 964 patients in 8 intervention areas and 534 581 in 141 comparison areas).

INTERVENTION AND COMPARATORS

Linkage of provider payments to recovery outcome indicators in 8 intervention organisational areas compared with all 141 comparison organisational areas in England. Outcome indicators included: abstinence from presenting substance, abstinent completion of treatment and non-re-presentation to treatment in the 12 months following completion.

MEASUREMENTS

Annual counts of hospital admissions, emergency admissions and admissions including a diagnosis indicating drugs misuse. Covariates included age, sex, ethnic origin and deprivation.

FINDINGS

For 37 245 patients in the intervention areas, annual emergency admissions were 1.073 times higher during the operation of the scheme compared with non-intervention areas (95% CI = 1.049; 1.097). There were an estimated additional 3 352 emergency admissions in intervention areas during the scheme. These findings were robust to a range of secondary analyses.

CONCLUSION

A programme in England from 2012 to 2014 to pay substance misuse treatment service providers according to treatment outcomes appeared to increase emergency hospital admissions.

Evaluating the Effectiveness of a Local Primary Care Incentive Scheme: A Difference-in-Differences Study

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.

Conditions and barriers for quality improvement work: a qualitative study of how professionals and health centre managers experience audit and feedback practices in Swedish primary care

Background

High quality primary care is expected to be the basis of many health care systems. Expectations on primary care are rising as societies age and the burden of chronic disease grows. To stimulate adherence to guidelines and quality improvement, audit and feedback to professionals is often used, but the effects vary. Even with carefully designed audit and feedback practices, barriers related to contextual conditions may prevent quality improvement efforts. The purpose of this study was to explore how professionals and health centre managers in Swedish primary care experience existing forms of audit and feedback, and conditions and barriers for quality improvement, and to explore views on the future use of clinical performance data for quality improvement.

Methods

We used an explorative qualitative design. Focus groups were conducted with health centre managers, physicians and other health professionals at seven health centres. The interviews were audio recorded, transcribed and analysed using qualitative content analysis.

Results

Four different types of audit and feedback that regularly occurred at the health centres were identified. The main part of the audit and feedback was “external”, from the regional purchasers and funders, and from the owners of the health centres. This audit and feedback focused on non-clinical measures such as revenues, utilisation of resources, and the volume of production. The participants in our study did not perceive that existing audit and feedback practices contributed to improved quality in general. This, along with lack of time for quality improvement, lack of autonomy and lack of quality improvement initiatives at the system (macro) level, were considered barriers to quality improvement at the health centres.

Conclusions

Professionals and health centre managers did not experience audit and feedback practices and existing conditions in Swedish primary care as supportive of quality improvement work. From a professional perspective, audit and feedback with a focus on clinical measures, as well as autonomy for professionals, are necessary to create motivation and space for quality improvement work. Such initiatives also need to be supported by quality improvement efforts at the system (macro) level, which favour transformation to a primary care based system.

Guidance impact on primary care prescribing rates of simple analgesia: an interrupted time series analysis in England

BACKGROUND

In March 2018, NHS England published guidance for clinical commissioning groups (CCGs) to encourage implementation of policy to reduce primary care prescriptions of over-the-counter medications, including simple analgesia.

AIM

To investigate the impact of guidance publication on prescribing rates of simple analgesia (oral paracetamol, oral ibuprofen, and topical non-steroidal anti-inflammatory drugs) in primary care; CCG guidance implementation intentions; and whether the guidance has created health inequality based on socioeconomic status.

DESIGN AND SETTING

Interrupted time series analysis of primary care prescribing data in England.

METHOD

Practice-level prescribing data from January 2015 to March 2019 were obtained from NHS Digital. Interrupted time series analyses were used to assess the association of guidance publication with prescribing rates. The association between practice-level prescribing rates and Index of Multiple Deprivation scores before and after publication was quantified using multivariable Poisson regression. Freedom of information requests were submitted to all CCGs.

RESULTS

There was a statistically significant 4.4% reduction in prescribing of simple analgesia following guidance publication (adjusted incidence rate ratio 0.96, 95% CI = 0.92 to 0.99, P = 0.027), adjusting for underlying time trend and seasonality. There was considerable diversity across CCGs in whether or how they chose to implement the guidance. Practice-level prescribing rates were greater in more deprived areas.

CONCLUSION

Guidance publication was associated with a small reduction in the prescribing rates of simple analgesia across England, without evidence of creating additional health inequality. Careful implementation by CCGs would be required to optimise cost saving to the NHS.

What drives general practitioners in the UK to improve the quality of care? A systematic literature review

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.

Framework for patient, family-centred care within an Australian Community Hospital: development and description

OBJECTIVE

To describe the development of a patient and family-centred care (PFCC) conceptual framework within a small community Australian Hospital.

METHODS

A scoping review of scientific and grey literature and community hospital stakeholder discussions were used to identify and design a conceptual framework for PFCC across five core pillars of leadership, engagement, service delivery, learning and environment.

RESULTS

107 publications were identified and 76 were included for data extraction. A draft framework was constructed and modified following consultation with hospital stakeholders across a small Australian Community Hospital. The 'Caring Together' framework outlines three core layers: (1) the focus of our care is the experiences of our consumers and staff; (2) concepts of leadership, environment, service delivery, engagement and learning; and (3) the overarching fundamental values of being heard, respected, valued and supported by staff and consumers at all levels in an organisation.

CONCLUSIONS

The conceptual Caring Together framework structures key PFCC concepts across organisational priority areas within an Australian healthcare setting and can be used to guide implementation of PFCC at other small hospital facilities. Changes to national and state healthcare funding may help facilitate improved hospital facility implementation of PFCC, and ultimately improve consumer healthcare satisfaction and clinical outcomes.

Implementation strategies to overcome barriers to diabetes-related footcare delivery in primary care: a qualitative study

The aim of this study is to identify, from the perspectives of key health policy decision-makers, strategies that address barriers to diabetes-related footcare delivery in primary care, and outline key elements required to support implementation into clinical practice. The study utilised a qualitative design with inductive analysis approach. Seven key health policy decisions-makers within Australia were interviewed. Practical strategies identified to support provision and delivery of foot care in primary care were: (a) building on current incentivisation structures through quality improvement projects; (b) enhancing education and community awareness; (c) greater utilisation and provision of resources and support systems; and (d) development of collaborative models of care and referral pathways. Key elements reported to support effective implementation of footcare strategies included developing and implementing strategies based on co-design, consultation, collaboration, consolidation and co-commissioning. To the authors' knowledge, this is the first Australian study to obtain information from key health policy decision-makers, identifying strategies to support footcare delivery in primary care. Implementation of preventative diabetes-related footcare strategies into 'routine' primary care clinical practice requires multiparty co-design, consultation, consolidation, collaboration and co-commissioning. The basis of strategy development will influence implementation success and thus improve outcomes for people living with diabetes.

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Qualitative Study of Practices and Challenges of Stepping Down Asthma Medication in Primary Care Across the UK

Background

Guidelines recommend that asthma treatment should be stepped down to the minimally effective dose that achieves symptom control to prevent medication side effects and reduce unnecessary costs. Little is known about the practice of stepping down and the challenges in primary care, where most asthma patients are managed.

Objective

To explore views, experiences, barriers and ideas, of doctors, nurses and pharmacists working in primary care, related to step down of asthma medication.

Methods

Primary care practitioners from across the UK participated in a survey and/or semi-structured interview. Questions explored four main areas: how asthma medication is reviewed, views on asthma guidelines, perceived barriers faced by healthcare workers and facilitators of stepping down. Qualitative content analysis enabled data coding of interview transcripts to identify major themes.

Results

A total of 274 participants responded to the survey, 29 participated in an interview (12 doctors, 9 nurses, and 8 pharmacists), working in GP practices from across the UK. Nearly half of the survey participants infrequently step down asthma medication (doctors=42.7%, nurses=46.3%). Four major themes related to barriers to stepping down were (i) lack of awareness of the need to step down, (ii) inertia to step down, driven by low confidence in ability, fear of consequences, and concern for who is responsible for stepping down, (iii) self-efficacy of ability to step down, influenced by lack of clear, applied guidance and limited training, and (iv) feasibility of step down, driven by a lack of systematic acceptance of stepping down and time. Strategies proposed to reduce overtreatment included education and training, improved gathering of evidence and guidance, and integrating step down into routine asthma care.

Conclusion

Failure to implement this guideline recommendation into everyday asthma management is influenced by several contributing factors. Future directions should include addressing evidence gaps, implementing clear and practical guidance, integration of step-down assessment into the asthma review, and education of professionals and patients.

The effect of 'paying for performance' on the management of type 2 diabetes mellitus: a cross-sectional observational study

Background

The ‘cycle of care’ (COC) pay for performance (PFP) programme, introduced in 2015, has resourced Irish GPs to provide structured care to PCRS eligible patients with type 2 diabetes mellitus (T2DM).

Aim

To investigate the effect of COC on management processes.

Design &setting

Cross-sectional observational study undertaken with two points of comparison (2014 and 2017) in participating practices (Republic of Ireland general practices), with comparator data from the United Kingdom National Diabetes Audit (UKNDA) 2015–2016.

Method

Invitations to participate were sent to practices using a discussion forum for Health One clinical software. Participating practices provided data on the processes of care in the management of patients with T2DM. Data on PCRS eligible patients was extracted from the electronic medical record system of participating practices using secure customised software. Descriptive analysis, using IBM SPSS Statistics for Windows (version 25), was performed.

Results

Of 250 practices invited, 41 practices participated (16.4%), yielding data from 3146 patients. There were substantial improvements in the rates of recording of glycosylated haemoglobin ([HbA1c] 53.1%–98.3%), total cholesterol ([TC] 59.2%–98.8%), urinary albumin:creatinine ratio ([ACR] 9.9%–42.3%), blood pressure ([BP] 61.4%–98.2%), and body-mass index ([BMI] 39.8%–97.4%) from 2014 to 2017. For the first time, rates of retinopathy screening (76.3%), foot review (64.9%), and influenza immunisation (69.9%) were recorded. Comparison of 2017 data with UKNDA 2015–2016 was broadly similar.

Conclusion

The COC demonstrated much improved rates of recording of clinical and biochemical parameters, and improved achievement of targets in TC and BP, but not HbA1c. Results demonstrate substantial improvements in the processes and quality of care in the management of patients with T2DM.

Hospital performance and payment: impact of integrating pay-for-performance on healthcare effectiveness in Lebanon

Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.

Effect of a national primary care reform on avoidable hospital admissions (2000-2015): A difference-in-difference analysis

In 2006 a major primary care reform was initiated in Portugal. The most significant aspect of this reform was the creation of a new organizational model of primary care provision: Family Health Units (FHUs), consisting of small voluntarily constituted multidisciplinary teams that have functional autonomy and are partly financed through capitation and pay-for-performance. The creation of FHUs sought to increase access to care and to chronic disease management by improving the long-term relationship between health professionals and patients. The objectives of this study are to evaluate the impact of the FHUs implementation on population health outcomes, measured by the rate of hospitalizations for ambulatory care sensitive conditions (ACSC), i.e. avoidable hospital inpatient admissions, and to explore the effectiveness of the pay-for-performance in primary care by analysing the subset of disease specific hospitalizations for ACSC related to the financial incentives. Using data from 276 Portuguese municipalities from 2000 to 2015 (n = 4416) and exploiting the gradual introduction of the FHUs over time, we used a difference-in-differences approach contrasting the evolution of the hospitalization rate for ACSC in municipalities that implemented or not the FHUs. We then explored heterogeneous effects by incentivized (diabetes and hypertension) and non-incentivized disease-specific rates of hospitalizations for ACSC. During the period under analysis, 448 FHUs were created in 126 municipalities. No significant impact of the FHUs implementation on the reduction of the hospitalization rate for ACSC was found. This result also held for the incentivized hospitalizations for ACSC. We only found a statistically significant effect of the FHUs implementation in the reduction of one non-incentivized area (the rate of urinary tract infection ACSC). Our results question the capacity of this payment mechanism to achieve better health outcomes, and invites a more careful and evidence-based action toward its wider diffusion.

A comparison of methods for health policy evaluation with controlled pre-post designs

Objective

To compare interactive fixed effects (IFE) and generalized synthetic control (GSC) methods to methods prevalent in health policy evaluation and re‐evaluate the impact of the hip fracture best practice tariffs introduced for hospitals in England in 2010.

Data Sources

Simulations and Hospital Episode Statistics.

Study Design

Best practice tariffs aimed to incentivize providers to deliver care in line with guidelines. Under the scheme, 62 providers received an additional payment for each hip fracture admission, while 49 providers did not. We estimate the impact using difference‐in‐differences (DiD), synthetic control (SC), IFE, and GSC methods. We contrast the estimation methods' performance in a Monte Carlo simulation study.

Principal Findings

Unlike DiD, SC, and IFE methods, the GSC method provided reliable estimates across a range of simulation scenarios and was preferred for this case study. The introduction of best practice tariffs led to a 5.9 (confidence interval: 2.0 to 9.9) percentage point increase in the proportion of patients having surgery within 48 hours and a statistically insignificant 0.6 (confidence interval: −1.4 to 0.4) percentage point reduction in 30‐day mortality.

Conclusions

The GSC approach is an attractive method for health policy evaluation. We cannot be confident that best practice tariffs were effective.

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis

AIM

To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care.

DESIGN

Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points.

SETTING

England.

PARTICIPANTS

Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723).

MEASUREMENTS

The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption.

FINDINGS

There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month.

CONCLUSIONS

Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.

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.

Financial incentives linked to quality improvement projects in Swedish primary care: a model for improving quality of care

Background

Quality improvement (QI) is necessary in all healthcare, but quality of healthcare is hard to measure. To use financial incentives to improve care is difficult and may even be harmful. However, conducting QI projects is a well-established way to increase quality in healthcare.

Problem

In 2015, there were few QI projects conducted in primary care in the Stockholm Region, Sweden. There was no structured support or way to share the QI projects with other general practitioner (GP) practices. To use financial incentives could increase the number of projects performed and could possibly improve the quality of care. The aim was to increase the number of GP practices performing QI projects in the Stockholm Region through financial incentives.

Method

To study QI projects performed during 2016 and 2017 in the Region Stockholm. This was compared with 2015 in Stockholm and with the Region Jönköping in Sweden during 2016 and 2017.

Interventions

First, the healthcare administration started to reimburse GP practices for conducting and reporting QI projects in 2016. Second, a 4-hour course in QI was offered. Third, feedback on plans for QI projects was given. The year after the projects were prerformed, they were published online to stimulate sharing and inspiration between the GP practices.

Results

For 2016, there were 166 (80%) of the GP practices that presented a QI project and in 2017, 164 (79%) did so. The number of projects in Stockholm increased almost by 100 per years compared with 2015.

Conclusion

QI work has increased in Stockholm since 2016, probably because of the financial incentives from the Stockholm Region.

The development and validation of a scale to explore staff experience of governance of economic efficiency and quality (GOV-EQ) of health care

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.