Pay-for-performance (P4P) has been widely used around the world seeking to improve health outcomes, and in Brazil it is the basis of the National Program for Improving Access and Quality (PMAQ). The literature published between 1998 and January 2013 that evaluated the effectiveness of P4P to produce results or patterns of access and quality in health was scrutinized. A total of 138 studies, with the inclusion of a further 41 studies (14 systematic reviews, 07 clinical trials and 20 observational studies) were retrieved and analyzed Among the more rigorous studies, favorable conclusions for P4P were less frequent, whereas observational studies were more favorable to positive effects of P4P on the quality of, and access to, health services. Methodological limitations of observational studies may have contributed to these results, but the range of results is more linked to the conceptual and contextual aspects of the use of the P4P schemes reviewed, the heterogeneity of P4P models and results. P4P can be helpful in promoting the achievement of objectives in health care systems, especially in the short term and for specific actions requiring less effort of health care providers, but should be used with caution and with a rigorous planning model, also considering undesirable or adverse effects.
CONTEXT: Screening reduces mortality from breast, cervical, and colorectal cancers. The Guide to Community Preventive Services previously conducted systematic reviews on the effectiveness of 11 interventions to increase screening for these cancers. This article presents results of updated systematic reviews for nine of these interventions.
EVIDENCE ACQUISITION: Five databases were searched for studies published during January 2004-October 2008. Studies had to (1) be a primary investigation of one or more intervention category; (2) be conducted in a country with a high-income economy; (3) provide information on at least one cancer screening outcome of interest; and (4) include screening use prior to intervention implementation or a concurrent group unexposed to the intervention category of interest. Forty-five studies were included in the reviews.
EVIDENCE SYNTHESIS: Recommendations were added for one-on-one education to increase screening with fecal occult blood testing (FOBT) and group education to increase mammography screening. Strength of evidence for client reminder interventions to increase FOBT screening was upgraded from sufficient to strong. Previous findings and recommendations for reducing out-of-pocket costs (breast cancer screening); provider assessment and feedback (breast, cervical, and FOBT screening); one-on-one education and client reminders (breast and cervical cancer screening); and reducing structural barriers (breast cancer and FOBT screening) were reaffirmed or unchanged. Evidence remains insufficient to determine effectiveness for the remaining screening tests and intervention categories.
CONCLUSIONS: Findings indicate new and reaffirmed interventions effective in promoting recommended cancer screening, including colorectal cancer screening. Findings can be used in community and healthcare settings to promote recommended care. Important research gaps also are described.
KEY MESSAGES: - There is now extensive evidence demonstrating that there is a gap between the health care that patients receive and the practice that is recommended. In both primary and secondary care there are unwarranted variations in practice and in resulting outcomes that cannot be explained by the characteristics of patients.
- While it is difficult to find examples of measures for addressing this issue from all 53 countries of the World Health Organization’s European Region, there are interventions that can be identified in the 27 Member States of the European Union. However, the nature of these measures and the extent to which they are implemented vary considerably.
- Audit and feedback defined as “any summary of clinical performance of health care over a specified period of time aimed at providing information to health professionals to allow them to assess and adjust their performance” is an overarching term used to describe some of the measures that are used to improve professional practice.
- Audit and feedback can be used in all health care settings, involving all health professionals, either as individual professions or in multiprofessional teams.
- In practical terms, health professionals can receive feedback on their performance based on data derived from their routine practice. Health professionals involved in audit and feedback may work either in a team or individually and in primary, secondary or tertiary care.
- While it seems intuitive that health care professionals would be prompted to modify their clinical practice if receiving feedback that it was inconsistent with that of their peers or accepted guidelines, this is in fact not always the case.
- The available evidence suggests that audit and feedback may be effective in improving professional practice but that the effects are generally small to moderate. Nonetheless, depending on the context, such small effects, particularly if shown to be cost-effective, may still be regarded as worthwhile.
- The benefits of audit and feedback measures are most likely to occur where existing practice is furthest away from what is desired, and when feedback is more intensive.
- Even on the basis of the best evidence available, no strong recommendations can be given regarding the best way to introduce audit and feedback into routine practice. However, decisions about if, and how, this approach can Policy summary be used to improve professional practice must be guided by pragmatism and the consideration of local circumstances. The following scenarios, for example, might indicate suitability for such an approach: the known (or anticipated) level of initial adherence to guidelines or desired practice is low; it is feasible to conduct an audit and the associated costs of collecting the data are low; routinely collected data are reliable and appropriate for use in an audit; and small to moderate improvements in quality would be worthwhile.
- The cost of audit and feedback is highly variable and is determined by local conditions, including the availability of reliable routinely collected data and personnel costs.
- The impact of audit and feedback, with or without additional interventions, should be monitored routinely by auditing practice after the intervention.
Pay-for-performance (P4P) has been widely used around the world seeking to improve health outcomes, and in Brazil it is the basis of the National Program for Improving Access and Quality (PMAQ). The literature published between 1998 and January 2013 that evaluated the effectiveness of P4P to produce results or patterns of access and quality in health was scrutinized. A total of 138 studies, with the inclusion of a further 41 studies (14 systematic reviews, 07 clinical trials and 20 observational studies) were retrieved and analyzed Among the more rigorous studies, favorable conclusions for P4P were less frequent, whereas observational studies were more favorable to positive effects of P4P on the quality of, and access to, health services. Methodological limitations of observational studies may have contributed to these results, but the range of results is more linked to the conceptual and contextual aspects of the use of the P4P schemes reviewed, the heterogeneity of P4P models and results. P4P can be helpful in promoting the achievement of objectives in health care systems, especially in the short term and for specific actions requiring less effort of health care providers, but should be used with caution and with a rigorous planning model, also considering undesirable or adverse effects.
