BACKGROUND: The funding of primary care is subject to intense debate internationally. Three main funding models predominate: capitation, pay-for-performance, and fee-for-service. A number of systematic reviews regarding the effect of primary care funding structures have been published, but not synthesized through an equity lens. Given the urgent need for evaluating funding models and addressing inequalities, a reliable, synthesized evidence base concerning the effects of funding on inequalities is imperative.
AIMS: This umbrella review aims to systematically evaluate all systematic reviews available on the effect of different primary care funding models in high-income countries on inequalities in funding, access, outcomes, or experience from inception until 2024.
METHODS: Three databases (MEDLINE, EMBASE, Cochrane) and a machine learning living evidence map were searched. Abstracts and titles were double screened, before two authors independently screened full texts, extracted data, and performed quality assessments utilizing the AMSTAR2 tool.
FINDINGS: The search identified 2480 unique articles, of which 14 were included in the final review. Only one review compared reimbursement systems; capitation systems were more equitable between ethnic groups compared to pay-for-performance in terms of primary care access, continuity, and quality. Twelve reviews reviewed the impact of the introduction of pay-for-performance models, predominantly focusing on the Quality and Outcomes Framework (QOF) in the UK. Synthesized findings suggest that QOF's introduction coincided with reduced socioeconomic health inequalities in the UK overall, but not in Scotland. Overall, inequalities in age narrowed, but inequalities measured by sex widened. One review found evidence that targeting funding for minority groups, with poorer health, was effective. A further review found that introducing privately provided general practices in Sweden and allowing patients to choose these over public-owned options generally benefitted those with higher income and lower health needs. We identify a range of gaps in the literature, which should inform future research.
The COVID-19 pandemic identifies the problems of preventing respiratory illnesses in seniors, especially frail multimorbidity seniors in nursing homes and Long-Term Care Facilities (LCTFs). Medline and Embase were searched for nursing homes, long-term care facilities, respiratory tract infections, disease transmission, infection control, mortality, systematic reviews and meta-analyses. For seniors, there is strong evidence to vaccinate against influenza, SARS-CoV-2 and pneumococcal disease, and evidence is awaited for effectiveness against COVID-19 variants and when to revaccinate. There is strong evidence to promptly introduce comprehensive infection control interventions in LCFTs: no admissions from inpatient wards with COVID-19 patients; quarantine and monitor new admissions in single-patient rooms; screen residents, staff and visitors daily for temperature and symptoms; and staff work in only one home. Depending on the vaccination situation and the current risk situation, visiting restrictions and meals in the residents' own rooms may be necessary, and reduce crowding with individual patient rooms. Regional LTCF administrators should closely monitor and provide staff and PPE resources. The CDC COVID-19 tool measures 33 infection control indicators. Hand washing, social distancing, PPE (gowns, gloves, masks, eye protection), enhanced cleaning of rooms and high-touch surfaces need comprehensive implementation while awaiting more studies at low risk of bias. Individual ventilation with HEPA filters for all patient and common rooms and hallways is needed.
BACKGROUND: One target of the Sustainable Development Goals is to achieve "universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". A fundamental concern of governments in striving for this goal is how to finance such a health system. This concern is very relevant for low-income countries.
OBJECTIVES: To provide an overview of the evidence from up-to-date systematic reviews about the effects of financial arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on financial arrangements, and informing refinements in the framework for financial arrangements presented in the overview.
METHODS: We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language, or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of financial arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment, or financial burden of patients, e.g. out-of-pocket payment, catastrophic disease expenditure) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.
MAIN RESULTS: We identified 7272 reviews and included 15 in this overview, on: collection of funds (2 reviews), insurance schemes (1 review), purchasing of services (1 review), recipient incentives (6 reviews), and provider incentives (5 reviews). The reviews were published between 2008 and 2015; focused on 13 subcategories; and reported results from 276 studies: 115 (42%) randomised trials, 11 (4%) non-randomised trials, 23 (8%) controlled before-after studies, 51 (19%) interrupted time series, 9 (3%) repeated measures, and 67 (24%) other non-randomised studies. Forty-three per cent (119/276) of the studies included in the reviews took place in low- and middle-income countries. Collection of funds: the effects of changes in user fees on utilisation and equity are uncertain (very low-certainty evidence). It is also uncertain whether aid delivered under the Paris Principles (ownership, alignment, harmonisation, managing for results, and mutual accountability) improves health outcomes compared to aid delivered without conforming to those principles (very low-certainty evidence). Insurance schemes: community-based health insurance may increase service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). It is uncertain whether social health insurance improves utilisation of health services or health outcomes (very low-certainty evidence). Purchasing of services: it is uncertain whether increasing salaries of public sector healthcare workers improves the quantity or quality of their work (very low-certainty evidence). Recipient incentives: recipient incentives may improve adherence to long-term treatments (low-certainty evidence), but it is uncertain whether they improve patient outcomes. One-time recipient incentives probably improve patient return for start or continuation of treatment (moderate-certainty evidence) and may improve return for tuberculosis test readings (low-certainty evidence). However, incentives may not improve completion of tuberculosis prophylaxis, and it is uncertain whether they improve completion of treatment for active tuberculosis. Conditional cash transfer programmes probably lead to an increase in service utilisation (moderate-certainty evidence), but their effects on health outcomes are uncertain. Vouchers may improve health service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). Introducing a restrictive cap may decrease use of medicines for symptomatic conditions and overall use of medicines, may decrease insurers' expenditures on medicines (low-certainty evidence), and has uncertain effects on emergency department use, hospitalisations, and use of outpatient care (very low-certainty evidence). Reference pricing, maximum pricing, and index pricing for drugs have mixed effects on drug expenditures by patients and insurers as well as the use of brand and generic drugs. Provider incentives: the effects of provider incentives are uncertain (very low-certainty evidence), including: the effects of provider incentives on the quality of care provided by primary care physicians or outpatient referrals from primary to secondary care, incentives for recruiting and retaining health professionals to serve in remote areas, and the effects of pay-for-performance on provider performance, the utilisation of services, patient outcomes, or resource use in low-income countries.
AUTHORS' CONCLUSIONS: Research based on sound systematic review methods has evaluated numerous financial arrangements relevant to low-income countries, targeting different levels of the health systems and assessing diverse outcomes. However, included reviews rarely reported social outcomes, resource use, equity impacts, or undesirable effects. We also identified gaps in primary research because of uncertainty about applicability of the evidence to low-income countries. Financial arrangements for which the effects are uncertain include external funding (aid), caps and co-payments, pay-for-performance, and provider incentives. Further studies evaluating the effects of these arrangements are needed in low-income countries. Systematic reviews should include all outcomes that are relevant to decision-makers and to people affected by changes in financial arrangements.
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 Low- and middle-income countries (LMICs) rely on available evidence when devising and implementing pharmaceutical policies. Aim of the review To provide a critical overview of systematic reviews of pharmaceutical policies, with particular focus on the relevance of such reviews in low- and middle-income countries. Methods A search for systematic reviews (SRs) of studies of the interventions of interest was conducted until May 2009 in MEDLINE, EconLit, CINAHL, the Cochrane site, ProQuest, EMBASE, JOLIS, ISI Web of Science, International Pharmaceutical Abstracts, International Network for Rational Use of Drugs, National Technical Information Service, Public Affairs Information Service, SourceOECD, the System for Information on Grey Literature in Europe, and the WHO library database. The search was updated to July 2013, based on the yields of the initial search strategy. Results 20 SRs that met all inclusion criteria were retrieved in full text. Four SRs were subsequently rejected on the basis of quality considerations and the findings of 16 SRs were extracted and their applicability in LMICs considered. Of these, 5 were Cochrane Reviews. All included SRs were published in English. SRs related to registration and classification policies, marketing policies, prescribing policies, reimbursement policies, policies on price and payments, co-payments and caps and multi-component policies were retrieved. No SRs related to patent and profit policies, sales and dispensing policies, policies that regulate the provision of health insurance, or policies on patient information were retrieved. Conclusion Only one of the systematic reviews retrieved utilised a study conducted in a developing country. The direct applicability of the evidence from these SRs in LMICs is limited. However, as middle-income countries move towards universal health coverage, the multi-component policies that govern reimbursement for medicines, and which impose caps on payments and co-payments by patients, may become more applicable. As such they will have direct implications for the practice of clinical pharmacy in such settings. Considerable effort will be needed to systemically review the available primary evidence from studies conducted in developing country settings, where such data exist.
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.
BACKGROUND: Many systematic reviews exist on interventions to improve safe and effective medicines use by consumers, but research is distributed across diseases, populations and settings. The scope and focus of such reviews also vary widely, creating challenges for decision-makers seeking to inform decisions by using the evidence on consumers’ medicines use.
This is an update of a 2011 overview of systematic reviews, which synthesises the evidence, irrespective of disease, medicine type, population or setting, on the effectiveness of interventions to improve consumers' medicines use.
OBJECTIVES: To assess the effects of interventions which target healthcare consumers to promote safe and effective medicines use, by synthesising review-level evidence.
SEARCH METHODS: We included systematic reviews published on the Cochrane Database of Systematic Reviews and the Database of Abstracts of Reviews of Effects. We identified relevant reviews by handsearching databases from their start dates to March 2012.
SELECTION CRITERIA: We screened and ranked reviews based on relevance to consumers’ medicines use, using criteria developed for this overview.
DATA COLLECTION AND ANALYSIS: We used standardised forms to extract data, and assessed reviews for methodological quality using the AMSTAR tool. We used standardised language to summarise results within and across reviews; and gave bottom-line statements about intervention effectiveness. Two review authors screened and selected reviews, and extracted and analysed data. We used a taxonomy of interventions to categorise reviews and guide syntheses.
MAIN RESULTS: We included 75 systematic reviews of varied methodological quality. Reviews assessed interventions with diverse aims including support for behaviour change, risk minimisation and skills acquisition. No reviews aimed to promote systems-level consumer participation in medicines-related activities. Medicines adherence was the most frequently-reported outcome, but others such as knowledge, clinical and service-use outcomes were also reported. Adverse events were less commonly identified, while those associated with the interventions themselves, or costs, were rarely reported.
Looking across reviews, for most outcomes, medicines self-monitoring and self-management programmes appear generally effective to improve medicines use, adherence, adverse events and clinical outcomes; and to reduce mortality in people self-managing antithrombotic therapy. However, some participants were unable to complete these interventions, suggesting they may not be suitable for everyone.
Other promising interventions to improve adherence and other key medicines-use outcomes, which require further investigation to be more certain of their effects, include:
· simplified dosing regimens: with positive effects on adherence;
· interventions involving pharmacists in medicines management, such as medicines reviews (with positive effects on adherence and use, medicines problems and clinical outcomes) and pharmaceutical care services (consultation between pharmacist and patient to resolve medicines problems, develop a care plan and provide follow-up; with positive effects on adherence and knowledge).
Several other strategies showed some positive effects, particularly relating to adherence, and other outcomes, but their effects were less consistent overall and so need further study. These included:
· delayed antibiotic prescriptions: effective to decrease antibiotic use but with mixed effects on clinical outcomes, adverse effects and satisfaction;
· practical strategies like reminders, cues and/or organisers, reminder packaging and material incentives: with positive, although somewhat mixed effects on adherence;
· education delivered with self-management skills training, counselling, support, training or enhanced follow-up; information and counselling delivered together; or education/information as part of pharmacist-delivered packages of care: with positive effects on adherence, medicines use, clinical outcomes and knowledge, but with mixed effects in some studies;
· financial incentives: with positive, but mixed, effects on adherence.
Several strategies also showed promise in promoting immunisation uptake, but require further study to be more certain of their effects. These included organisational interventions; reminders and recall; financial incentives; home visits; free vaccination; lay health worker interventions; and facilitators working with physicians to promote immunisation uptake. Education and/or information strategies also showed some positive but even less consistent effects on immunisation uptake, and need further assessment of effectiveness and investigation of heterogeneity.
There are many different potential pathways through which consumers' use of medicines could be targeted to improve outcomes, and simple interventions may be as effective as complex strategies. However, no single intervention assessed was effective to improve all medicines-use outcomes across all diseases, medicines, populations or settings.
Even where interventions showed promise, the assembled evidence often only provided part of the picture: for example, simplified dosing regimens seem effective for improving adherence, but there is not yet sufficient information to identify an optimal regimen.
In some instances interventions appear ineffective: for example, the evidence suggests that directly observed therapy may be generally ineffective for improving treatment completion, adherence or clinical outcomes.
In other cases, interventions may have variable effects across outcomes. As an example, strategies providing information or education as single interventions appear ineffective to improve medicines adherence or clinical outcomes, but may be effective to improve knowledge; an important outcome for promoting consumers' informed medicines choices.
Despite a doubling in the number of reviews included in this updated overview, uncertainty still exists about the effectiveness of many interventions, and the evidence on what works remains sparse for several populations, including children and young people, carers, and people with multimorbidity.
AUTHORS' CONCLUSIONS: This overview presents evidence from 75 reviews that have synthesised trials and other studies evaluating the effects of interventions to improve consumers' medicines use.
Systematically assembling the evidence across reviews allows identification of effective or promising interventions to improve consumers’ medicines use, as well as those for which the evidence indicates ineffectiveness or uncertainty.
Decision makers faced with implementing interventions to improve consumers' medicines use can use this overview to inform decisions about which interventions may be most promising to improve particular outcomes. The intervention taxonomy may also assist people to consider the strategies available in relation to specific purposes, for example, gaining skills or being involved in decision making. Researchers and funders can use this overview to identify where more research is needed and assess its priority. The limitations of the available literature due to the lack of evidence for important outcomes and important populations, such as people with multimorbidity, should also be considered in practice and policy decisions.
BACKGROUND: A vast amount of literature on effects of pay-for-performance (P4P) in health care has been published. However, the evidence has become fragmented and it has become challenging to grasp the information included in it. OBJECTIVES: To provide a comprehensive overview of effects of P4P in a broad sense by synthesizing findings from published systematic reviews. METHODS: Systematic literature search in five electronic databases for English, Spanish, and German language literature published between January 2000 and June 2011, supplemented by reference tracking and Internet searches. Two authors independently reviewed all titles, assessed articles' eligibility for inclusion, determined a methodological quality score for each included article, and extracted relevant data. RESULTS: Twenty-two reviews contain evidence on a wide variety of effects. Findings suggest that P4P can potentially be (cost-)effective, but the evidence is not convincing; many studies failed to find an effect and there are still few studies that convincingly disentangled the P4P effect from the effect of other improvement initiatives. Inequalities among socioeconomic groups have been attenuated, but other inequalities have largely persisted. There is some evidence of unintended consequences, including spillover effects on unincentivized care. Several design features appear important in reaching desired effects. CONCLUSION: Although data is available on a wide variety of effects, strong conclusions cannot be drawn due to a limited number of studies with strong designs. In addition, relevant evidence on particular effects may have been missed because no review has explicitly focused on these effects. More research is necessary on the relative merits of P4P and other types of incentives, as well as on the long-term impact on patient health and costs.
BACKGROUND: There is considerable interest in the effectiveness of financial incentives in the delivery of health care. Incentives may be used in an attempt to increase the use of evidence-based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive, diagnostic and treatment decisions, or both. Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way. Since there are numerous reviews performed within the healthcare area describing the effects of various types of financial incentives, it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals' behaviour and patient outcomes. OBJECTIVES: To conduct an overview of systematic reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes. METHODS: We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting. MAIN RESULTS: We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review). AUTHORS' CONCLUSIONS: Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.
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.
The funding of primary care is subject to intense debate internationally. Three main funding models predominate: capitation, pay-for-performance, and fee-for-service. A number of systematic reviews regarding the effect of primary care funding structures have been published, but not synthesized through an equity lens. Given the urgent need for evaluating funding models and addressing inequalities, a reliable, synthesized evidence base concerning the effects of funding on inequalities is imperative.
AIMS:
This umbrella review aims to systematically evaluate all systematic reviews available on the effect of different primary care funding models in high-income countries on inequalities in funding, access, outcomes, or experience from inception until 2024.
METHODS:
Three databases (MEDLINE, EMBASE, Cochrane) and a machine learning living evidence map were searched. Abstracts and titles were double screened, before two authors independently screened full texts, extracted data, and performed quality assessments utilizing the AMSTAR2 tool.
FINDINGS:
The search identified 2480 unique articles, of which 14 were included in the final review. Only one review compared reimbursement systems; capitation systems were more equitable between ethnic groups compared to pay-for-performance in terms of primary care access, continuity, and quality. Twelve reviews reviewed the impact of the introduction of pay-for-performance models, predominantly focusing on the Quality and Outcomes Framework (QOF) in the UK. Synthesized findings suggest that QOF's introduction coincided with reduced socioeconomic health inequalities in the UK overall, but not in Scotland. Overall, inequalities in age narrowed, but inequalities measured by sex widened. One review found evidence that targeting funding for minority groups, with poorer health, was effective. A further review found that introducing privately provided general practices in Sweden and allowing patients to choose these over public-owned options generally benefitted those with higher income and lower health needs. We identify a range of gaps in the literature, which should inform future research.
