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.
BACKGROUND: Government interventions are critical to addressing the global tobacco epidemic, a major public health problem that continues to deepen. We systematically synthesize research evidence on the effectiveness of government tobacco control policies promoted by the Framework Convention on Tobacco Control (FCTC), supporting the implementation of this international treaty on the tenth anniversary of it entering into force.
METHODS: An overview of systematic reviews was prepared through systematic searches of five electronic databases, published up to March 2014. Additional reviews were retrieved from monthly updates until August 2014, consultations with tobacco control experts and a targeted search for reviews on mass media interventions. Reviews were assessed according to predefined inclusion criteria, and ratings of methodological quality were either extracted from source databases or independently scored.
RESULTS: Of 612 reviews retrieved, 45 reviews met the inclusion criteria and 14 more were identified from monthly updates, expert consultations and a targeted search, resulting in 59 included reviews summarizing over 1150 primary studies. The 38 strong and moderate quality reviews published since 2000 were prioritized in the qualitative synthesis. Protecting people from tobacco smoke was the most strongly supported government intervention, with smoke-free policies associated with decreased smoking behaviour, secondhand smoke exposure and adverse health outcomes. Raising taxes on tobacco products also consistently demonstrated reductions in smoking behaviour. Tobacco product packaging interventions and anti-tobacco mass media campaigns may decrease smoking behaviour, with the latter likely an important part of larger multicomponent programs. Financial interventions for smoking cessation are most effective when targeted at smokers to reduce the cost of cessation products, but incentivizing quitting may be effective as well. Although the findings for bans on tobacco advertising were inconclusive, other evidence suggests they remain an important intervention.
CONCLUSION: When designing and implementing tobacco control programs, governments should prioritize smoking bans and price increases of tobacco products followed by other interventions. Additional studies are needed on the various factors that can influence a policy's effectiveness and feasibility such as cost, local context, political barriers and implementation strategies.
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.
