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Assessment of a pay-for-performance program in primary care designed by target users.

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Journal Family practice
Year 2013
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This article is included in 3 Systematic reviews Systematic reviews (3 references)

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BACKGROUND: Evidence for pay-for-performance (P4P) has been searched for in the last decade as financial incentives increased to influence behaviour of health care professionals to improve quality of care. The effectiveness of P4P is inconclusive, though some reviews reported significant effects. OBJECTIVE: To assess changes in performance after introducing a participatory P4P program. DESIGN: An observational study with a pre- and post-measurement. Setting and subjects. Sixty-five general practices in the south of the Netherlands. Intervention. A P4P program designed by target users containing indicators for chronic care, prevention, practice management and patient experience (general practitioner's [GP] functioning and organization of care). Quality indicators were calculated for each practice. A bonus with a maximum of 6890 Euros per 1000 patients was determined by comparing practice performance with a benchmark. MAIN OUTCOME MEASURES: Quality indicators for clinical care (process and outcome) and patient experience. RESULTS: We included 60 practices. After 1 year, significant improvement was shown for the process indicators for all chronic conditions ranging from +7.9% improvement for cardiovascular risk management to +11.5% for asthma. Five outcome indicators significantly improved as well as patients' experiences with GP's functioning and organization of care. No significant improvements were seen for influenza vaccination rate and the cervical cancer screening uptake. The clinical process and outcome indicators, as well as patient experience indicators were affected by baseline measures. Smaller practices showed more improvement. CONCLUSIONS: A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with GP's functioning and the organization of care.

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Variation in HbA1c prescription for patients with diabetes in French general practice: an observational study prior to the implementation of a P4P programme.

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Journal European journal of public health
Year 2013
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This article is included in 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: Prior to a large diffusion of a pay-for-performance programme (P4P) in primary care in France, it seemed of particular interest to identify, the doctors not performing optimally who could be the main target of this programme. Based on the example of HbA1c prescription for patients with diabetes, this study examined the impact of general practitioner's (GPs) characteristics on the variation of a P4P indicator for diabetes care, i.e. the percentage of patients undergoing three or four HbA1c tests during one year. METHODS: We used a large database from the national health insurance fund for salaried workers in Brittany to select a cohort of patients with diabetes who had been attended to by their doctors for 1 year. In all, 2545 GPs attending to 41,453 patients with diabetes were included. A two-level hierarchical logistic model was used to analyse the data. RESULTS: Thirty-six per cent (SD = 22.3) of patients with diabetes underwent three or four HbA1c tests during the year (the target objective was 65% in a patient list). There was a large variability between GPs, even after adjusting for patient characteristics. Doctors who were female, young, working in a group practice, participating in quality-control groups, and who had a lower patient load prescribed the three or four recommended tests more often. DISCUSSION: The results indicate a target group of doctors which require attention. There is still room to improve the quality of care for patients with diabetes in general practice, notably by encouraging doctors to train better and practice in groups.

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Chronic disease detection and access: does access improve detection, or does detection make access more difficult?

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Journal The British journal of general practice : the journal of the Royal College of General Practitioners
Year 2012
Links Pubmed DOI PubMed Central

This article is included in 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: The recorded detection of chronic disease by practices is generally lower than the prevalence predicted by population surveys. AIM: To determine whether patient-reported access to general practice predicts the recorded detection rates of chronic diseases in that setting. DESIGN AND SETTING: A cross-sectional study involving 146 general practices in Leicestershire and Rutland, England. METHOD: The numbers of patients recorded as having chronic disease (coronary heart disease, chronic obstructive pulmonary disease, hypertension, diabetes) were obtained from Quality and Outcomes Framework (QOF) practice disease registers for 2008-2009. Characteristics of practice populations (deprivation, age, sex, ethnicity, proportion reporting poor health, practice turnover, list size) and practice performance (achievement of QOF disease indicators, patient experience of being able to consult a doctor within 2 working days and book an appointment >2 days in advance) were included in regression models. RESULTS: Patient characteristics (deprivation, age, poor health) and practice characteristics (list size, turnover, QOF achievement) were associated with recorded detection of more than one of the chronic diseases. Practices in which patients were more likely to report being able to book appointments had reduced recording rates of chronic disease. Being able to consult a doctor within 2 days was not associated with levels of recorded chronic disease. CONCLUSION: Practices with high levels of deprivation and older patients have increased rates of recorded chronic disease. As the number of patients recorded with chronic disease increased, the capacity of practices to meet patients' requests for appointments in advance declined. The capacity of some practices to detect and manage chronic disease may need improving.

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Family doctor responses to changes in incentives for influenza immunization under the U.K. Quality and Outcomes Framework pay-for-performance scheme.

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Journal Health services research
Year 2012
Links Pubmed DOI PubMed Central

This article is included in 2 Systematic reviews Systematic reviews (2 references)

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OBJECTIVE: To analyze the effect of setting higher targets, in a primary care pay-for-performance scheme, on rates of influenza immunization and exception reporting. STUDY SETTING: The U.K. Quality and Outcomes Framework links financial rewards for family practices to four separate influenza immunization rates for patients with coronary heart disease (CHD), chronic obstructive pulmonary disease, diabetes, and stroke. There is no additional payment for immunization rates above an upper threshold. Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate. DATA: Practice-level information on immunizations and exceptions extracted from electronic records of all practices in England 2004/05 to 2009/10 (n=8,212-8,403). STUDY DESIGN: Longitudinal random effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07. PRINCIPAL FINDINGS: The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients (0.41 percent, CI: 0.25-0.56 percent), and exception was reported (0.26 percent, CI: 0.12-0.40 percent). CONCLUSIONS: Making quality targets more demanding can not only lead to improvement in quality of care but can also have other consequences.

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Incentive payments are not related to expected health gain in the pay for performance scheme for UK primary care: cross-sectional analysis.

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Journal BMC health services research
Year 2012
Links Pubmed DOI PubMed Central

This article is included in 1 Systematic review Systematic reviews (1 reference)

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BACKGROUND: The General Medical Services primary care contract for the United Kingdom financially rewards performance in 19 clinical areas, through the Quality and Outcomes Framework. Little is known about how best to determine the size of financial incentives in pay for performance schemes. Our aim was to test the hypothesis that performance indicators with larger population health benefits receive larger financial incentives. METHODS: We performed cross sectional analyses to quantify associations between the size of financial incentives and expected health gain in the 2004 and 2006 versions of the Quality and Outcomes Framework. We used non-parametric two-sided Spearman rank correlation tests. Health gain was measured in expected lives saved in one year and in quality adjusted life years. For each quality indicator in an average sized general practice we tested for associations first, between the marginal increase in payment and the health gain resulting from a one percent point improvement in performance and second, between total payment and the health gain at the performance threshold for maximum payment. RESULTS: Evidence for lives saved or quality adjusted life years gained was found for 28 indicators accounting for 41% of the total incentive payments. No statistically significant associations were found between the expected health gain and incentive gained from a marginal 1% increase in performance in either the 2004 or 2006 version of the Quality and Outcomes Framework. In addition no associations were found between the size of financial payment for achievement of an indicator and the expected health gain at the performance threshold for maximum payment measured in lives saved or quality adjusted life years. CONCLUSIONS: In this subgroup of indicators the financial incentives were not aligned to maximise health gain. This disconnection between incentive and expected health gain risks supporting clinical activities that are only marginally effective, at the expense of more effective activities receiving lower incentives. When designing pay for performance programmes decisions about the size of the financial incentive attached to an indicator should be informed by information on the health gain to be expected from that indicator.

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Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study.

Journal BMJ (Clinical research ed.)
Year 2011
Links Pubmed DOI PubMed Central

This article is included in 5 Systematic reviews Systematic reviews (5 references)

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OBJECTIVE: To assess the impact of a pay for performance incentive on quality of care and outcomes among UK patients with hypertension in primary care. DESIGN: Interrupted time series. SETTING: The Health Improvement Network (THIN) database, United Kingdom. PARTICIPANTS: 470 725 patients with hypertension diagnosed between January 2000 and August 2007. INTERVENTION: The UK pay for performance incentive (the Quality and Outcomes Framework), which was implemented in April 2004 and included specific targets for general practitioners to show high quality care for patients with hypertension (and other diseases). MAIN OUTCOME MEASURES: Centiles of systolic and diastolic blood pressures over time, rates of blood pressure monitoring, blood pressure control, and treatment intensity at monthly intervals for baseline (48 months) and 36 months after the implementation of pay for performance. Cumulative incidence of major hypertension related outcomes and all cause mortality for subgroups of newly treated (treatment started six months before pay for performance) and treatment experienced (started treatment in year before January 2001) patients to examine different stages of illness. RESULTS: After accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval -3.04 to 4.74, P=0.669 and trend change -0.01, -0.24 to 0.21, P=0.615), control (-1.19, -2.06 to 1.09, P=0.109 and -0.01, -0.06 to 0.03, P=0.569), or treatment intensity (0.67, -1.27 to 2.81, P=0.412 and 0.02, -0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups. CONCLUSIONS: Good quality of care for hypertension was stable or improving before pay for performance was introduced. Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes. Generous financial incentives, as designed in the UK pay for performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.

Primary study

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Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care.

Journal CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne
Year 2011
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This article is included in 4 Systematic reviews Systematic reviews (4 references)

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BACKGROUND: Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management. METHODS: We conducted a retrospective open-cohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154,945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA(1c)) levels and total cholesterol. RESULTS: We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA(1c) level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19). INTERPRETATION: We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-for-performance programs appear to benefit both large and small practices to a similar extent.

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Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study.

Journal BMJ (Clinical research ed.)
Year 2011
Links Pubmed DOI PubMed Central

This article is included in 1 Systematic review Systematic reviews (1 reference)

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OBJECTIVE: To describe the quality of care for chronic diseases among older people in care homes (nursing and residential) compared with the community in a pay for performance system. DESIGN: Retrospective analysis of The Health Improvement Network (THIN), a large primary care database. SETTING: 326 English and Welsh general practices, 2008-9. PARTICIPANTS: 10,387 residents of care homes and 403,259 residents in the community aged 65 to 104 and registered for 90 or more days with their general practitioner. MAIN OUTCOME MEASURE: 16 process quality indicators for chronic disease management appropriate for vulnerable older people for conditions included in the UK Quality and Outcomes Framework. RESULTS: After adjustment for age, sex, dementia, and length of registration, attainment of quality indicators was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators. The largest differences were for prescribing in heart disease (β blockers in coronary heart disease, relative risk 0.70, 95% confidence interval 0.65 to 0.75) and monitoring of diabetes (retinal screening, 0.75, 0.71 to 0.80). Monitoring hypothyroidism (0.93, 0.90 to 0.95), blood pressure in people with stroke (0.92, 0.90 to 0.95), and electrolytes for those receiving loop diuretics (0.89, 0.87 to 0.92) showed smaller differences. Attainment was lower in nursing homes than in residential homes. Residents of care homes were more likely to be identified by their doctor as unsuitable or non-consenting for all Quality and Outcomes Framework indicators for a condition allowing their exclusion from targets; 33.7% for stroke and 34.5% for diabetes. CONCLUSION: There is scope for improving the management of chronic diseases in care homes, but high attainment of some indicators shows that pay for performance systems do not invariably disadvantage residents of care homes compared with those living in the community. High use of exception reporting may compromise care for vulnerable patient groups. The Quality and Outcomes Framework, and other pay for performance systems, should monitor attainment and exception reporting in vulnerable populations such as residents of care homes and consider measures that deal with the specific needs of older people.

Primary study

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The unintended consequence of diabetes mellitus pay-for-performance (P4P) program in Taiwan: are patients with more comorbidities or more severe conditions likely to be excluded from the P4P program?

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Authors Chen TT , Chung KP , Lin IC , Lai MS
Journal Health services research
Year 2011
Links Pubmed DOI PubMed Central

This article is included in 1 Systematic review Systematic reviews (1 reference)

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OBJECTIVE: Taiwan has instituted a pay-for-performance (P4P) program for diabetes mellitus (DM) patients that rewards doctors based in part on outcomes for their DM patients. Doctors are permitted to choose which of their DM patients are included in the P4P program. We test whether seriously ill DM patients are disproportionately excluded from the P4P program. DATA SOURCE/STUDY SETTING: This study utilizes data from the National Health Insurance (NHI) database in Taiwan for the period of January 2007 to December 2007. Our sample includes 146,481 DM-P4P patients (16.56 percent of the total) and 737,971 non-DM-P4P patients. DATA COLLECTION/EXTRACTION METHODS: We use logistic and multilevel models to estimate the effects of patient and hospital characteristics on P4P selection. PRINCIPAL FINDINGS: The results show that older patients and patients with more comorbidities or more severe conditions are prone to be excluded from P4P programs. CONCLUSIONS: We found that DM patients are disproportionately excluded from P4P programs. Our results point to the importance of mandated participation and risk adjustment measures in P4P programs.

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Can you get what you pay for? Pay-for-performance and the quality of healthcare providers.

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Journal The Rand journal of economics
Year 2011
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This article is included in 2 Systematic reviews Systematic reviews (2 references)

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Despite the popularity of pay-for-performance (P4P) among health policymakers and private insurers as a tool for improving quality of care, there is little empirical basis for its effectiveness. We use data from published performance reports of physician medical groups contracting with a large network HMO to compare clinical quality before and after the implementation of P4P, relative to a control group. We consider the effect of P4P on both rewarded and unrewarded dimensions of quality. In the end, we fail to find evidence that a large P4P initiative either resulted in major improvement in quality or notable disruption in care.