The Effect of Financial Incentives on Quality Measures in the Treatment of Diabetes Mellitus: a Randomized Controlled Trial

BACKGROUND

Financial incentives are often used to improve quality of care in chronic care patients. However, the evidence concerning the effect of financial incentives is still inconclusive.

OBJECTIVE

To test the effect of financial incentives on quality measures (QMs) in the treatment of patients with diabetes mellitus in primary care. We incentivized a clinical QM and a process QM to test the effect of financial incentives on different types of QMs and to investigate the spill-over effect on non-incentivized QMs.

DESIGN/PARTICIPANTS

Parallel cluster randomized controlled trial based on electronic medical records database involving Swiss general practitioners (GPs). Practices were randomly allocated.

INTERVENTION

All participants received a bimonthly feedback report. The intervention group additionally received potential financial incentives on GP level depending on their performance.

MAIN MEASURES

Between-group differences in proportions of patients fulfilling incentivized QM (process QM of annual HbA1c measurement and clinical QM of blood pressure level below 140/95 mmHg) after 12 months.

KEY RESULTS

Seventy-one GPs (median age 52 years, 72% male) from 43 different practices and subsequently 3838 patients with diabetes mellitus (median age 70 years, 57% male) were included. Proportions of patients with annual HbA1c measurements remained unchanged (intervention group decreased from 79.0 to 78.3%, control group from 81.5 to 81.0%, OR 1.09, 95% CI 0.90-1.32, p = 0.39). Proportions of patients with blood pressure below 140/95 improved from 49.9 to 52.5% in the intervention group and decreased from 51.2 to 49.0% in the control group (OR 1.16, 95% CI 0.99-1.36, p = 0.06). Proportions of non-incentivized process QMs increased significantly in the intervention group.

CONCLUSION

GP level financial incentives did not result in more frequent HbA1c measurements or in improved blood pressure control. Interestingly, we could confirm a spill-over effect on non-incentivized process QMs. Yet, the mechanism of spill-over effects of financial incentives is largely unclear.

TRIAL REGISTRATION

ISRCTN13305645.

Long-Term Effects of Financial Incentives for General Practitioners on Quality Indicators in the Treatment of Patients With Diabetes Mellitus in Primary Care-A Follow-Up Analysis of a Cluster Randomized Parallel Controlled Trial

Background: The effect of financial incentives on the quality of primary care is of high interest, and so is its sustainability after financial incentives are withdrawn.

Objective: To assess both long-term effects and sustainability of financial incentives for general practitioners (GPs) in the treatment of patients with diabetes mellitus based on quality indicators (QIs) calculated from routine data from electronic medical records.

Design/Participants: Randomized controlled trial using routine data from electronic medical records of patients with diabetes mellitus of Swiss GPs.

Intervention: During the study period of 24 months, all GPs received bimonthly feedback reports with information on their actual treatment as reflected in QIs. In the intervention group, the reports were combined with financial incentives for quality improvement. The incentive was stopped after 12 months.

Measurements: Proportion of patients meeting the process QI of annual HbA1c measurements and the clinical QI of blood pressure levels below 140/85 mmHg.

Results: A total of 71 GPs from 43 different practices were included along with 3,854 of their patients with diabetes mellitus. Throughout the study, the proportion of patients with annual HbA1c measurements was stable in the intervention group (78.8–78.9%) and decreased slightly in the control group (81.5–80.2%) [odds ratio (OR): 1.21; 95% CI: 1.04–1.42, p < 0.05]. The proportion of patients achieving blood pressure levels below 140/85 mmHg decreased in the control group (51.2–47.2%) and increased in the intervention group (49.7–51.9%) (OR: 1.18; 95% CI: 1.04–1.35, p < 0.05) where it peaked at 54.9% after 18 months and decreased steadily over the last 6 months.

Conclusion: After the withdrawal of financial incentives for the GPs after 12 months, some QIs still improved, indicating that 1 year might be too short to observe the full effect of such interventions. The decrease in QI achievement rates after 18 months suggests that the positive effects of time-limited financial incentives eventually wane.

Physician-dispensing as a determinant of clinical and process measurements in patients at increased cardiovascular risk: A cross-sectional study in Swiss general practice

AIMS

In some healthcare systems, physicians are allowed to dispense drugs; in others, drug-dispensing is restricted to pharmacists. Whether physician-dispensing affects patient health is unknown. Thus, we aimed to investigate associations between physician-dispensing and clinical and process measurements in patients with selected long-term conditions indicating increased cardiovascular risk.

METHODS

Retrospective cross-sectional study in 2018 based on data from electronic medical records of 22405 patients (73.6% physician-dispensing) in Switzerland with medications for diabetes mellitus, arterial hypertension, or lipid-related disorders. We used multilevel regression models to determine the associations between physician-dispensing and clinical measurements (glycated hemoglobin [HbA1c], systolic blood pressure [sBP], low-density lipoprotein cholesterol [LDL-C]) or process measurements (number of annual clinical measurements, consultations, and drug prescriptions).

RESULTS

Median (interquartile range) HbA1c value was 6.8% (6.3-7.5) both for the physician-dispensing and pharmacist-dispensing group, sBP was 137 (126-150) and 136 mmHg (126-149), and LDL-C was 2.3 (1.8-3.0) and 2.5 mmol/L (1.9-3.2). After adjustments, the physician-dispensing group had 4% lower LDL-C levels (p = 0.041), 12% more frequent HbA1c measurements (p = 0001), 16% higher annual consultation rates (p < 0.05 for all conditions), and equal number of different drugs, compared to the pharmacist-dispensing group.

CONCLUSIONS

We found no relevant differences in selected clinical measurements between physician- and pharmacist-dispensing, and mixed results in process measurements. Our results do not indicate that one drug-dispensing channel is superior to the other.

Potentially inappropriate proton-pump inhibitor prescription in the general population: a claims-based retrospective time trend analysis

BACKGROUND

Proton-pump inhibitors (PPI) are among the most prescribed drugs worldwide, and a large body of evidence raises concerns about their inappropriate use. Previous estimates of inappropriate use varied due to different definitions and study populations.

AIMS

We aimed to measure the population-based incidence and time trends of PPI and potentially inappropriate PPI prescriptions (PIPPI) with a novel method, continuously assessing excessive cumulative doses based on clinical practice guidelines. We also assessed association of patient characteristics with PPI prescriptions and PIPPI.

METHODS

This was an observational study based on a large insurance claims database of persons aged >18 years with continuous claims records of ⩾12 months. The observation period was January 2012 to December 2017. We assessed the incidence and time trends of PPI prescriptions and PIPPI based on doses prescribed, defining ⩾11.5 g of pantoprazole dose equivalents during any consecutive 365 days (average daily dose >31 mg) as inappropriate.

RESULTS

Among 1,726,491 eligible persons, the annual incidence of PPI prescriptions increased from 19.7% (2012) to 23.0% (2017), (p = <0.001), and the incidence of PIPPI increased from 4.8% (2013) to 6.4% (2017), (p = <0.001). Age, male gender, drugs with bleeding risk and multimorbidity were independent determinants of PIPPI (p = <0.001 for all).

CONCLUSIONS

This study provides evidence that one of the most prescribed drug groups is commonly prescribed inappropriately in the general population and that this trend is increasing. Multimorbidity and drugs with bleeding risks were strong determinants of PIPPI. Addressing PPI prescriptions exceeding guideline recommendations could reduce polypharmacy and improve patient safety.

The impact of financial incentives to improve quality indicators in patients with diabetes in Swiss primary care: a protocol for a cluster randomised controlled trial

INTRODUCTION

There is only limited and conflicting evidence on the effectiveness of Pay-for-Performance (P4P) programmes, although they might have the potential to improve guideline adherence and quality of care. We therefore aim to test a P4P intervention in Swiss primary care practices focusing on quality indicators (QI) achievement in the treatment of patients with diabetes.

METHODS AND ANALYSIS

This is a cluster-randomised, two-armed intervention study with the primary care practice as unit of randomisation. The control group will receive bimonthly feedback reports containing last data of blood pressure and glycated haemoglobin (HbA1c) measurements. The intervention group will additionally be informed about a financial incentive for each percentage point improved in QI achievement. Primary outcomes are differences in process (measurement of HbA1c) and clinical QI (blood pressure control) between the two groups. Furthermore, we investigate the effect on non-incentivised QIs and on sustainability of the financial incentives. Swiss primary care practices participating in the FIRE (Family Medicine ICPC Research using Electronic Medical Record) research network are eligible for participation. The FIRE database consists of anonymised structured medical routine data from Swiss primary care practices. According to power calculations, 70 of the general practitioners contributing to the database will be randomised in either of the groups.

ETHICS AND DISSEMINATION

According to the Local Ethics Committee of the Canton of Zurich, the project does not fall under the scope of the law on human research and therefore no ethical consent is necessary. Results will be published in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

ISRCTN13305645; Pre-results.

Versorgungsforschung: das richtige Mass an Medizin, zum richtigen Zeitpunkt für den richtigen Patienten

Zusammenfassung. Der rasante medizinische Fortschritt des letzten Jahrhunderts hat nicht nur die Lebenserwartung steigen lassen, sondern auch die Anzahl chronischer Erkrankungen und multimorbider Patienten. Parallel dazu hat die zunehmende Spezialisierung zu einer hohen Fragmentierung des Gesundheitssystems geführt. Eine fragmentierte und unkoordinierte Versorgung birgt die Gefahr einer medizinischen Fehl- oder Überversorgung, wie auch der ökonomischen Ineffizienz. Dieser Herausforderung ist nicht allein durch weitere diagnostische und therapeutische Fortschritte und damit durch Grundlagen- und klinische Forschung zu begegnen. Es bedarf vielmehr einer Forschung, die untersucht, wie Versorgungszusammenhänge unter Alltagsbedingungen idealerweise zu gestalten sind, um zu einem optimalen Ergebnis auf Patientenebene zu gelangen: das richtige Mass an Medizin, zum richtigen Zeitpunkt, für den richtigen Patienten. Anhand eines Beispiels wird in diesem Artikel dargestellt, wie die Diabetesbetreuung in der Schweiz durch Versorgungsforschung optimiert wird.

Venous Thromboembolism Prophylaxis with Rivaroxaban in Elective Foot and Ankle Surgery

Category:

Other

Introduction/Purpose:

Oral application for prophylaxis of venous thromboembolism (VTE) after total hip and knee arthroplasty has high acceptance among patients due to its non-invasive nature, when compared to traditional subcutaneous application of low- molecular-weight heparin (LMWH). Approximately 10% of the patients in our clinic receive oral thrombosis prophylaxis (rivaroxaban), the remaining patients receive subcutaneous prophylaxis with LMWH (dalteparin). However, no clinical data exists describing the use of oral prophylaxis in elective orthopedic foot and ankle surgery. The aims of this study where: 1. To assess the incidence of VTE after oral prophylaxis after elective foot and ankle procedures. 2. To identify risk factors for VTE after oral prophylaxis after elective foot and ankle procedures.

Methods:

A retrospective chart review of patients undergoing elective foot and ankle surgery between January 2010 and 2013 was performed. The type of medicamentous thrombosis prophylaxis was noted. All patients receiving oral antithrombotic medication (rivaroxaban, Xarelto©, Bayer, Germany) were included in the study. Location, length and type of surgery and tourniquet time were assessed. Co-morbidities (e.g. diabetes, coagulopathy, ASA classification) were noted. Patients previously treated with phenprocoumon or clopidrogel were excluded. A phone interview was performed and patients were asked whether a thromboembolic incident occurred or not. If an incidence was confirmed, the report of the diagnostic findings was obtained from the general practitioner.

Results:

450 patients were included. Two thromboembolic incidents occurred (0.4%; deep venous thrombosis confirmed by ultrasound). Both patients had a history of previous deep venous thrombosis and a positive family history for VTE. Due to the low percentage of patients with VTE, a multivariate analysis could not be performed.

Conclusion:

The incidence of VTE after oral thrombosis prophylaxis with rivaroxaban is low and comparable with the incidence after subcutaneous application of LMWH.