Enhancing mammography referral in primary care

Characteristics and impact of interventions to support healthcare providers' compliance with guideline recommendations for breast cancer: a systematic literature review

BACKGROUND

Breast cancer clinical practice guidelines (CPGs) offer evidence-based recommendations to improve quality of healthcare for patients. Suboptimal compliance with breast cancer guideline recommendations remains frequent, and has been associated with a decreased survival. The aim of this systematic review was to characterize and determine the impact of available interventions to support healthcare providers' compliance with CPGs recommendations in breast cancer healthcare.

METHODS

We searched for systematic reviews and primary studies in PubMed and Embase (from inception to May 2021). We included experimental and observational studies reporting on the use of interventions to support compliance with breast cancer CPGs. Eligibility assessment, data extraction and critical appraisal was conducted by one reviewer, and cross-checked by a second reviewer. Using the same approach, we synthesized the characteristics and the effects of the interventions by type of intervention (according to the EPOC taxonomy), and applied the GRADE framework to assess the certainty of evidence.

RESULTS

We identified 35 primary studies reporting on 24 different interventions. Most frequently described interventions consisted in computerized decision support systems (12 studies); educational interventions (seven), audit and feedback (two), and multifaceted interventions (nine). There is low quality evidence that educational interventions targeted to healthcare professionals may improve compliance with recommendations concerning breast cancer screening, diagnosis and treatment. There is moderate quality evidence that reminder systems for healthcare professionals improve compliance with recommendations concerning breast cancer screening. There is low quality evidence that multifaceted interventions may improve compliance with recommendations concerning breast cancer screening. The effectiveness of the remaining types of interventions identified have not been evaluated with appropriate study designs for such purpose. There is very limited data on the costs of implementing these interventions.

CONCLUSIONS

Different types of interventions to support compliance with breast cancer CPGs recommendations are available, and most of them show positive effects. More robust trials are needed to strengthen the available evidence base concerning their efficacy. Gathering data on the costs of implementing the proposed interventions is needed to inform decisions about their widespread implementation.

TRIAL REGISTRATION

CRD42018092884 (PROSPERO).

Cautionary study on the effects of pay for performance on quality of care: a pilot randomised controlled trial using standardised patients

BACKGROUND

Due to the difficulty of studying incentives in practice, there is limited empirical evidence of the full-impact pay-for-performance (P4P) incentive systems.

OBJECTIVE

To evaluate the impact of P4P in a controlled, simulated environment.

DESIGN

We employed a simulation-based randomised controlled trial with three standardised patients to assess advanced practice providers' performance. Each patient reflected one of the following: (A) indicated for P4P screenings, (B) too young for P4P screenings, or (C) indicated for P4P screenings, but screenings are unrelated to the reason for the visit. Indication was determined by the 2016 Centers for Medicare and Medicaid Services quality measures.

INTERVENTION

The P4P group was paid $150 and received a bonus of $10 for meeting each of five outcome measures (breast cancer, colorectal cancer, pneumococcal, tobacco use and depression screenings) for each of the three cases (max $300). The control group received $200.

SETTING

Learning resource centre.

PARTICIPANTS

35 advanced practice primary care providers (physician assistants and nurse practitioners) and 105 standardised patient encounters.

MEASUREMENTS

Adherence to incentivised outcome measures, interpersonal communication skills, standards of care, and misuse.

RESULTS

patient was more likely to be prescribed screenings not indicated, but highlighted by P4P: breast cancer screening (47% P4P vs 0% control, p<0.01) and colorectal cancer screening (24% P4P vs 0% control, p=0.03). The P4P group over-reported completion of incentivised measures resulting in overpayment (average of $9.02 per patient).

LIMITATIONS

A small sample size and limited variability in patient panel limit the generalisability of findings.

CONCLUSIONS

Our findings caution the adoption of P4P by highlighting the unintended consequences of the incentive system.

Manually-generated reminders delivered on paper: effects on professional practice and patient outcomes

BACKGROUND

Health professionals sometimes do not use the best evidence to treat their patients, in part due to unconscious acts of omission and information overload. Reminders help clinicians overcome these problems by prompting them to recall information that they already know, or by presenting information in a different and more accessible format. Manually-generated reminders delivered on paper are defined as information given to the health professional with each patient or encounter, provided on paper, in which no computer is involved in the production or delivery of the reminder. Manually-generated reminders delivered on paper are relatively cheap interventions, and are especially relevant in settings where electronic clinical records are not widely available and affordable. This review is one of three Cochrane Reviews focused on the effectiveness of reminders in health care.

OBJECTIVES

1. To determine the effectiveness of manually-generated reminders delivered on paper in changing professional practice and improving patient outcomes. 2. To explore whether a number of potential effect modifiers influence the effectiveness of manually-generated reminders delivered on paper.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL and two trials registers on 5 December 2018. We searched grey literature, screened individual journals, conference proceedings and relevant systematic reviews, and reviewed reference lists and cited references of included studies.

SELECTION CRITERIA

We included randomised and non-randomised trials assessing the impact of manually-generated reminders delivered on paper as a single intervention (compared with usual care) or added to one or more co-interventions as a multicomponent intervention (compared with the co-intervention(s) without the reminder component) on professional practice or patients' outcomes. We also included randomised and non-randomised trials comparing manually-generated reminders with other quality improvement (QI) interventions.

DATA COLLECTION AND ANALYSIS

Two review authors screened studies for eligibility and abstracted data independently. We extracted the primary outcome as defined by the authors or calculated the median effect size across all reported outcomes in each study. We then calculated the median percentage improvement and interquartile range across the included studies that reported improvement related outcomes, and assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We identified 63 studies (41 cluster-randomised trials, 18 individual randomised trials, and four non-randomised trials) that met all inclusion criteria. Fifty-seven studies reported usable data (64 comparisons). The studies were mainly located in North America (42 studies) and the UK (eight studies). Fifty-four studies took place in outpatient/ambulatory settings. The clinical areas most commonly targeted were cardiovascular disease management (11 studies), cancer screening (10 studies) and preventive care (10 studies), and most studies had physicians as their target population (57 studies). General management of a clinical condition (17 studies), test-ordering (14 studies) and prescription (10 studies) were the behaviours more commonly targeted by the intervention. Forty-eight studies reported changes in professional practice measured as dichotomous process adherence outcomes (e.g. compliance with guidelines recommendations), 16 reported those changes measured as continuous process-of-care outcomes (e.g. number of days with catheters), eight reported dichotomous patient outcomes (e.g. mortality rates) and five reported continuous patient outcomes (e.g. mean systolic blood pressure). Manually-generated reminders delivered on paper probably improve professional practice measured as dichotomous process adherence outcomes) compared with usual care (median improvement 8.45% (IQR 2.54% to 20.58%); 39 comparisons, 40,346 participants; moderate certainty of evidence) and may make little or no difference to continuous process-of-care outcomes (8 comparisons, 3263 participants; low certainty of evidence). Adding manually-generated paper reminders to one or more QI co-interventions may slightly improve professional practice measured as dichotomous process adherence outcomes (median improvement 4.24% (IQR -1.09% to 5.50%); 12 comparisons, 25,359 participants; low certainty of evidence) and probably slightly improve professional practice measured as continuous outcomes (median improvement 0.28 (IQR 0.04 to 0.51); 2 comparisons, 12,372 participants; moderate certainty of evidence). Compared with other QI interventions, manually-generated reminders may slightly decrease professional practice measured as process adherence outcomes (median decrease 7.9% (IQR -0.7% to 11%); 14 comparisons, 21,274 participants; low certainty of evidence). We are uncertain whether manually-generated reminders delivered on paper, compared with usual care or with other QI intervention, lead to better or worse patient outcomes (dichotomous or continuous), as the certainty of the evidence is very low (10 studies, 13 comparisons). Reminders added to other QI interventions may make little or no difference to patient outcomes (dichotomous or continuous) compared with the QI alone (2 studies, 2 comparisons). Regarding resource use, studies reported additional costs per additional point of effectiveness gained, but because of the different currencies and years used the relevance of those figures is uncertain. None of the included studies reported outcomes related to harms or adverse effects.

AUTHORS' CONCLUSIONS

Manually-generated reminders delivered on paper as a single intervention probably lead to small to moderate increases in outcomes related to adherence to clinical recommendations, and they could be used as a single QI intervention. It is uncertain whether reminders should be added to other QI intervention already in place in the health system, although the effects may be positive. If other QI interventions, such as patient or computerised reminders, are available, they should be preferred over manually-generated reminders, but under close evaluation in order to decrease uncertainty about their potential effect.

Turning the oil tanker: a novel approach to shifting perspectives in medical practice

Although health care is encouraged to follow an evidence-based approach, there are perceived instances where suboptimal practice persists in the presence of better options due to an inherent resistance to change within many health care systems. To continue striving for clinical excellence, it is important to identify deficient practices and make appropriate corrections by implementing new and improved techniques and treatments. Bringing about change, however, tends to be a long, arduous process consisting of several small and successive deviations from the norm, analogous to "turning the oil tanker". Analyzing the methods employed by successful health care innovators has allowed the development of a "three-pronged" approach to overcoming resistance to change: 1) a determined opinion leader with a network or like-minded opinion leaders; 2) the presentation of hard evidence with adequate praise for current practice and the generation of clearly worded, specific guidelines; and 3) the use of simple reminders and continuous analysis of outcomes. Employing this three-pronged approach could lead to faster and more successful implementation of change within the health care system.

Insights on the effectiveness of reward schemes from 10-year longitudinal case studies in 2 Italian regions

BACKGROUND

Pay for performance (P4P) programs have been widely analysed in literature, and the results regarding their impact on performance are mixed. Moreover, in the real-life setting, reward schemes are designed combining multiple elements altogether, yet, it is not clear what happens when they are applied using different combinations.

OBJECTIVES

To provide insights on how P4P programs are influenced by 5 key elements: whom, what, how, how many targets, and how much to reward.

METHODS

A qualitative longitudinal analysis of 10 years of P4P reward schemes adopted by the regional administrations of Tuscany and Lombardy (Italy) was conducted. The effects of the P4P features on performance are discussed considering both overall and specific indicators.

RESULTS

Both regions applied financial reward schemes for General Managers by linking the variable pay to performance. While Tuscany maintained a relatively stable financial incentive design and governance tools, Lombardy changed some elements of the design and introduced, in 2012, a P4P program aimed to reward the providers. The main differences between the 2 cases regard the number of targets (how many), the type (what), and the method applied to set targets (how).

CONCLUSION

Considering the overall performance obtained by the 2 regions, it seems that whom, how, and how much to reward are not relevant in the success of P4P programs; instead, the number (how many) and the type (what) of targets set may influence the performance improvement processes driven by financial reward schemes.

Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data

BACKGROUND

A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP.

OBJECTIVE

Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old.

METHODS

Based on an administrative database of 50,752 women aged 50-74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use).

RESULTS

Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41-2.35 %)], but the effect was not significantly different following the implementation of the contract.

CONCLUSION

The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.

Effect of Financial Incentives to Physicians, Patients, or Both on Lipid Levels: A Randomized Clinical Trial

IMPORTANCE

Financial incentives to physicians or patients are increasingly used, but their effectiveness is not well established.

OBJECTIVE

To determine whether physician financial incentives, patient incentives, or shared physician and patient incentives are more effective than control in reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk.

DESIGN, SETTING, AND PARTICIPANTS

Four-group, multicenter, cluster randomized clinical trial with a 12-month intervention conducted from 2011 to 2014 in 3 primary care practices in the northeastern United States. Three hundred forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25,627 potentially eligible patients of those PCPs, 1503 enrolled. Patients aged 18 to 80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had an FRS of 10% to 20% with LDL-C levels of 140 mg/dL or greater. Investigators were blinded to study group, but participants were not.

INTERVENTIONS

Primary care physicians were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation.

MAIN OUTCOMES AND MEASURES

Change in LDL-C level at 12 months.

RESULTS

Patients in the shared physician-patient incentives group achieved a mean reduction in LDL-C of 33.6 mg/dL (95% CI, 30.1-37.1; baseline, 160.1 mg/dL; 12 months, 126.4 mg/dL); those in physician incentives achieved a mean reduction of 27.9 mg/dL (95% CI, 24.9-31.0; baseline, 159.9 mg/dL; 12 months, 132.0 mg/dL); those in patient incentives achieved a mean reduction of 25.1 mg/dL (95% CI, 21.6-28.5; baseline, 160.6 mg/dL; 12 months, 135.5 mg/dL); and those in the control group achieved a mean reduction of 25.1 mg/dL (95% CI, 21.7-28.5; baseline, 161.5 mg/dL; 12 months, 136.4 mg/dL; P < .001 for comparison of all 4 groups). Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5 mg/dL; 95% CI, 3.8-13.3; P = .002).

CONCLUSIONS AND RELEVANCE

In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months. This reduction was modest, however, and further information is needed to understand whether this approach represents good value.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01346189.

Physician response to pay-for-performance: evidence from a natural experiment

This study exploits a natural experiment in the province of Ontario, Canada, to identify the impact of pay-for-performance (P4P) incentives on the provision of targeted primary care services and whether physicians' responses differ by age, size of patient population, and baseline compliance level. We use administrative data that cover the full population of Ontario and nearly all the services provided by primary care physicians. We employ a difference-in-differences approach that controls for selection on observables and selection on unobservables that may cause estimation bias. We implement a set of robustness checks to control for confounding from other contemporaneous interventions of the primary care reform in Ontario. The results indicate that responses were modest and that physicians responded to the financial incentives for some services but not others. The results provide a cautionary message regarding the effectiveness of employing P4P to increase the quality of health care.

Evaluating the impact of public health initiatives on trends in fecal occult blood test participation in Ontario

BACKGROUND

Since the publication of two randomized controlled trials (RCT) in 1996 demonstrating the effectiveness of fecal occult blood test (FOBT) in reducing colorectal cancer (CRC) mortality, several public health initiatives have been introduced in Ontario to promote FOBT participation. We examined the effect of these initiatives on FOBT participation and evaluated temporal trends in participation between 1994 and 2012.

METHOD

Using administrative databases, we identified 18 annual cohorts of individuals age 50 to 74 years eligible for CRC screening and identified those who received FOBT in each quarter of a year. We used negative binomial segmented regression to examine the effect of initiatives on trends and Joinpoint regression to evaluate temporal trends in FOBT participation.

RESULTS

Quarterly FOBT participation increased from 6.5 per 1000 in quarter 1 to 41.6 per 1000 in quarter 72 (January-March 2012). Segmented regression indicated increases following the publication of the RCTs in 1996 (Δ slope = 6%, 95% CI = 4.3-7.9), the primary care physician financial incentives announcement in 2005 (Δ slope = 2.2%, 95% CI = 0.68-3.7), the launch of the ColonCancerCheck (CCC) Program (Δ intercept = 35.4%, 95% CI = 18.3 -54.9), and the CCC Program 2-year anniversary (Δ slope = 7.2%, 95% CI = 3.9 - 10.5). Joinpoint validated these findings and identified the specific points when changes occurred.

CONCLUSION

Although observed increases in FOBT participation cannot be definitively attributed to the various initiatives, the results of the two statistical approaches suggest a causal association between the observed increases in FOBT participation and most of these initiatives.

The ABCs of incentive-based treatment in health care: a behavior analytic framework to inform research and practice

Behavior plays an important role in health promotion. Exercise, smoking cessation, medication adherence, and other healthy behavior can help prevent, or even treat, some diseases. Consequently, interventions that promote healthy behavior have become increasingly common in health care settings. Many of these interventions award incentives contingent upon preventive health-related behavior. Incentive-based interventions vary considerably along several dimensions, including who is targeted in the intervention, which behavior is targeted, and what type of incentive is used. More research on the quantitative and qualitative features of many of these variables is still needed to inform treatment. However, extensive literature on basic and applied behavior analytic research is currently available to help guide the study and practice of incentive-based treatment in health care. In this integrated review, we discuss how behavior analytic research and theory can help treatment providers design and implement incentive-based interventions that promote healthy behavior.

The role of primary care in early detection and follow-up of cancer

Primary care providers have important roles across the cancer continuum, from encouraging screening and accurate diagnosis to providing care during and after treatment for both the cancer and any comorbid conditions. Evidence shows that higher cancer screening participation rates are associated with greater involvement of primary care. Primary care providers are pivotal in reducing diagnostic delay, particularly in health systems that have long waiting times for outpatient diagnostic services. However, so-called fast-track systems designed to speed up hospital referrals are weakened by significant variation in their use by general practitioners (GPs), and affect the associated conversion and detection rates. Several randomized controlled trials have shown primary care-led follow-up care to be equivalent to hospital-led care in terms of patient wellbeing, recurrence rates and survival, and might be less costly. For primary care-led follow-up to be successful, appropriate guidelines must be incorporated, clear communication must be provided and specialist care must be accessible if required. Finally, models of long-term cancer follow-up are needed that provide holistic care and incorporate management of co-morbid conditions. We discuss all these aspects of primary care, focusing on the most common cancers managed at the GP office-breast, colorectal, prostate, lung and cervical cancers.

A systematic review of the use of theory in randomized controlled trials of audit and feedback

BACKGROUND

Audit and feedback is one of the most widely used and promising interventions in implementation research, yet also one of the most variably effective. Understanding this variability has been limited in part by lack of attention to the theoretical and conceptual basis underlying audit and feedback. Examining the extent of theory use in studies of audit and feedback will yield better understanding of the causal pathways of audit and feedback effectiveness and inform efforts to optimize this important intervention.

METHODS

A total of 140 studies in the 2012 Cochrane update on audit and feedback interventions were independently reviewed by two investigators. Variables were extracted related to theory use in the study design, measurement, implementation or interpretation. Theory name, associated reference, and the location of theory use as reported in the study were extracted. Theories were organized by type (e.g., education, diffusion, organization, psychology), and theory utilization was classified into seven categories (justification, intervention design, pilot testing, evaluation, predictions, post hoc, other).

RESULTS

A total of 20 studies (14%) reported use of theory in any aspect of the study design, measurement, implementation or interpretation. In only 13 studies (9%) was a theory reportedly used to inform development of the intervention. A total of 18 different theories across educational, psychological, organizational and diffusion of innovation perspectives were identified. Rogers' Diffusion of Innovations and Bandura's Social Cognitive Theory were the most widely used (3.6% and 3%, respectively).

CONCLUSIONS

The explicit use of theory in studies of audit and feedback was rare. A range of theories was found, but not consistency of theory use. Advancing our understanding of audit and feedback will require more attention to theoretically informed studies and intervention design.

Computer-generated reminders delivered on paper to healthcare professionals; effects on professional practice and health care outcomes

BACKGROUND

Clinical practice does not always reflect best practice and evidence, partly because of unconscious acts of omission, information overload, or inaccessible information. Reminders may help clinicians overcome these problems by prompting the doctor to recall information that they already know or would be expected to know and by providing information or guidance in a more accessible and relevant format, at a particularly appropriate time.

OBJECTIVES

To evaluate the effects of reminders automatically generated through a computerized system and delivered on paper to healthcare professionals on processes of care (related to healthcare professionals' practice) and outcomes of care (related to patients' health condition).

SEARCH METHODS

For this update the EPOC Trials Search Co-ordinator searched the following databases between June 11-19, 2012: The Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Library (Economics, Methods, and Health Technology Assessment sections), Issue 6, 2012; MEDLINE, OVID (1946- ), Daily Update, and In-process; EMBASE, Ovid (1947- ); CINAHL, EbscoHost (1980- ); EPOC Specialised Register, Reference Manager, and INSPEC, Engineering Village. The authors reviewed reference lists of related reviews and studies. 

SELECTION CRITERIA

We included individual or cluster-randomized controlled trials (RCTs) and non-randomized controlled trials (NRCTs) that evaluated the impact of computer-generated reminders delivered on paper to healthcare professionals on processes and/or outcomes of care.

DATA COLLECTION AND ANALYSIS

Review authors working in pairs independently screened studies for eligibility and abstracted data. We contacted authors to obtain important missing information for studies that were published within the last 10 years. For each study, we extracted the primary outcome when it was defined or calculated the median effect size across all reported outcomes. We then calculated the median absolute improvement and interquartile range (IQR) in process adherence across included studies using the primary outcome or median outcome as representative outcome.

MAIN RESULTS

In the 32 included studies, computer-generated reminders delivered on paper to healthcare professionals achieved moderate improvement in professional practices, with a median improvement of processes of care of 7.0% (IQR: 3.9% to 16.4%). Implementing reminders alone improved care by 11.2% (IQR 6.5% to 19.6%) compared with usual care, while implementing reminders in addition to another intervention improved care by 4.0% only (IQR 3.0% to 6.0%) compared with the other intervention. The quality of evidence for these comparisons was rated as moderate according to the GRADE approach. Two reminder features were associated with larger effect sizes: providing space on the reminder for provider to enter a response (median 13.7% versus 4.3% for no response, P value = 0.01) and providing an explanation of the content or advice on the reminder (median 12.0% versus 4.2% for no explanation, P value = 0.02). Median improvement in processes of care also differed according to the behaviour the reminder targeted: for instance, reminders to vaccinate improved processes of care by 13.1% (IQR 12.2% to 20.7%) compared with other targeted behaviours. In the only study that had sufficient power to detect a clinically significant effect on outcomes of care, reminders were not associated with significant improvements.

AUTHORS' CONCLUSIONS

There is moderate quality evidence that computer-generated reminders delivered on paper to healthcare professionals achieve moderate improvement in process of care. Two characteristics emerged as significant predictors of improvement: providing space on the reminder for a response from the clinician and providing an explanation of the reminder's content or advice. The heterogeneity of the reminder interventions included in this review also suggests that reminders can improve care in various settings under various conditions.

Effectiveness of interventions to increase screening for breast, cervical, and colorectal cancers: nine updated systematic reviews for the guide to community preventive services

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.

Audit and feedback: effects on professional practice and healthcare outcomes

BACKGROUND

Audit and feedback is widely used as a strategy to improve professional practice either on its own or as a component of multifaceted quality improvement interventions. This is based on the belief that healthcare professionals are prompted to modify their practice when given performance feedback showing that their clinical practice is inconsistent with a desirable target. Despite its prevalence as a quality improvement strategy, there remains uncertainty regarding both the effectiveness of audit and feedback in improving healthcare practice and the characteristics of audit and feedback that lead to greater impact.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes and to examine factors that may explain variation in the effectiveness of audit and feedback.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) 2010, Issue 4, part of The Cochrane Library. www.thecochranelibrary.com, including the Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register (searched 10 December 2010); MEDLINE, Ovid (1950 to November Week 3 2010) (searched 09 December 2010); EMBASE, Ovid (1980 to 2010 Week 48) (searched 09 December 2010); CINAHL, Ebsco (1981 to present) (searched 10 December 2010); Science Citation Index and Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 12-15 September 2011).

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as a summary of clinical performance over a specified period of time) that reported objectively measured health professional practice or patient outcomes. In the case of multifaceted interventions, only trials in which audit and feedback was considered the core, essential aspect of at least one intervention arm were included.

DATA COLLECTION AND ANALYSIS

All data were abstracted by two independent review authors. For the primary outcome(s) in each study, we calculated the median absolute risk difference (RD) (adjusted for baseline performance) of compliance with desired practice compliance for dichotomous outcomes and the median percent change relative to the control group for continuous outcomes. Across studies the median effect size was weighted by number of health professionals involved in each study. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: format of feedback, source of feedback, frequency of feedback, instructions for improvement, direction of change required, baseline performance, profession of recipient, and risk of bias within the trial itself. We also conducted exploratory analyses to assess the role of context and the targeted clinical behaviour. Quantitative (meta-regression), visual, and qualitative analyses were undertaken to examine variation in effect size related to these factors.

MAIN RESULTS

We included and analysed 140 studies for this review. In the main analyses, a total of 108 comparisons from 70 studies compared any intervention in which audit and feedback was a core, essential component to usual care and evaluated effects on professional practice. After excluding studies at high risk of bias, there were 82 comparisons from 49 studies featuring dichotomous outcomes, and the weighted median adjusted RD was a 4.3% (interquartile range (IQR) 0.5% to 16%) absolute increase in healthcare professionals' compliance with desired practice. Across 26 comparisons from 21 studies with continuous outcomes, the weighted median adjusted percent change relative to control was 1.3% (IQR = 1.3% to 28.9%). For patient outcomes, the weighted median RD was -0.4% (IQR -1.3% to 1.6%) for 12 comparisons from six studies reporting dichotomous outcomes and the weighted median percentage change was 17% (IQR 1.5% to 17%) for eight comparisons from five studies reporting continuous outcomes. Multivariable meta-regression indicated that feedback may be more effective when baseline performance is low, the source is a supervisor or colleague, it is provided more than once, it is delivered in both verbal and written formats, and when it includes both explicit targets and an action plan. In addition, the effect size varied based on the clinical behaviour targeted by the intervention.

AUTHORS' CONCLUSIONS

Audit and feedback generally leads to small but potentially important improvements in professional practice. The effectiveness of audit and feedback seems to depend on baseline performance and how the feedback is provided. Future studies of audit and feedback should directly compare different ways of providing feedback.

Physician practice responses to financial incentive programs: exploring the concept of implementation mechanisms

PURPOSE

To develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate incentive program goals into their specific office setting. Understanding how new financial incentives fit with the structure of physician practices and individual providers' work may shed some insight on the variable effects of physician incentives documented in numerous reviews and meta-analyses.

DESIGN/METHODOLOGY/APPROACH

Reviewing select articles on pay-for-performance evaluations to identify and characterize the presence of implementation mechanisms for designing, communicating, implementing, and maintaining financial incentive programs as well as recognizing participants' success and effects on patient care.

FINDINGS

Although uncommonly included in evaluations, evidence from 26 articles reveals financial incentive program sponsors and participants utilized a variety of strategies to facilitate communication about program goals and intentions, to provide feedback about participants' progress, and to assist-practices in providing recommended services. Despite diversity in programs' geographic locations, clinical targets, scope, and market context, sponsors and participants deployed common strategies. While these methods largely pertained to communication between program sponsors and participants and the provision of information about performance through reports and registries, they also included other activities such as efforts to engage patients and ways to change staff roles.

LIMITATIONS

This review covers a limited body of research to develop a conceptual framework for future research; it did not exhaustively search for new articles and cannot definitively link particular implementation mechanisms to outcomes.

PRACTICAL IMPLICATIONS

Our results underscore the effects implementation mechanisms may have on how practices incorporate new programs into existing systems of care which implicates both the potential rewards from small changes as well as the resources which may be required to obtain buy-in and support.

ORIGINALITY/VALUE

We identify gaps in previous research regarding actual changes occurring in physician practices in response to physician incentive programs. We offer suggestions for future evaluation by proposing a framework for understanding implementation. Our model will assist future scholars in translating site-specific experiences with incentive programs into more broadly relevant guidance for practices by facilitating comparisons across seemingly disparate programs.

An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes

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.

[The life cycle of general practitioners' professional motivations: the case of prevention]

BACKGROUND

The analysis of "professional motivations", mainly through the possible crowding-out effects between extrinsic and intrinsic motivations, has become an issue of great concern in the economic literature. This paper aims at applying this topic to the healthcare professions where the proper scaling up of pay-for-performance (P4P) policies by public authorities is at stake.

METHODS

We used a panel of 528 self-employed general practitioners in the "Provence-Alpes-Côte d'Azur" region in France to provide an interpersonal statistical decomposition between extrinsic and intrinsic motivations with regard to preventive actions. Then, we applied a Tobit model in order to specify the main explicative variables of the share of intrinsic motivations entering into physicians' total motivations.

RESULTS

The relative share of intrinsic motivations was quite high among physicians paid with fixed fees. We found a significant effect of age on intrinsic motivations describing a U-shaped curve which can be interpreted as being the result of a "life cycle of medical motivations" or a generational effect.

CONCLUSION

The cross-sectional nature of the data does not allow us to draw any conclusions concerning the predominance of the generational effect or the "life cycle effect" on the evolution of the relative share of physician's intrinsic motivations. Nevertheless, the U-shaped relation between intrinsic motivations and age questions the suitability of using uniformly P4P mechanisms. The generations or age groups of self-employed physicians who seem to be less responsive to extrinsic motivations are more likely to favour the introduction of other types of payment schemes (capitation or salary systems) or regulation tools such as clinical practice guidelines.

The role of physician involvement in Latinas' mammography screening adherence

BACKGROUND

Disparities in breast cancer (BC) screening continue to affect Latinas significantly, but the factors that explain these disparities remain unclear.

OBJECTIVE

The objective of this study was to investigate whether physician's instruction on breast examination and mammography recommendations predicted Latinas' adherence to mammography screening above and beyond other influential variables.

METHODS

A cross-sectional, descriptive design was utilized. Convenience and snowball sampling techniques were followed to recruit 344 Latinas aged 41 years and older from predominantly Latino neighborhoods in Denver, Colorado.

MAIN OUTCOME MEASURES

Latinas' adherence to mammography screening recommendations by the American Cancer Society.

RESULTS

Characteristics that were significantly associated with mammography adherence were age, Pap smear adherence, physician's breast examination instructions, and physician's mammography recommendations.

CONCLUSION

The study provides evidence that the BC screening disparities that significantly affect Latinas can be addressed by increasing physician's involvement through BC screening instruction and referral.

Optimal care of patients with non-small cell lung cancer reduces perioperative morbidity

OBJECTIVE

The objective is to test the concept of "pay for performance" for patients with non-small cell lung cancer.

METHODS

We constructed 53 benchmark performance standards (10 labeled "critical") and prospectively assessed the effect of adherence to these standards on morbidity and mortality for patients undergoing resection of non-small cell lung cancer.

RESULTS

Between January 1, 2007, and December 31, 2009, 778 patients with non-small cell lung cancer underwent thoracotomy by 1 surgeon. Ninety-seven percent of patients received all 26 of the "day of surgery" and "intraoperative" benchmarks, and those were the easiest to deliver. The 469 patients who had all 53 benchmarks delivered, compared with the 309 who did not, had a lower mortality (2.0% vs 2.3%) and morbidity (16% vs 44%; P < .001). The 693 patients who received all 10 "critical" benchmarks, compared with the 85 who did not, had a lower mortality (1.9% vs 4.7%) and morbidity (25% vs 41%; P = .003). Low household income and fewer than 2 people in the household were predictors of overall morbidity on univariate analysis.

CONCLUSIONS

Most benchmarks, especially "day of surgery" and "intraoperative" ones, can be delivered in more than 97% of patients. The delivery of benchmarks reduces perioperative morbidity but not mortality. Socioeconomic factors are predictors of overall morbidity. Operative mortality is related to the "quality of the patient" and the "quality of the health care provider."

Systematic review: Effects, design choices, and context of pay-for-performance in health care

BACKGROUND

Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.

METHODS

The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.

RESULTS

One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.

CONCLUSIONS

P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

An official American Thoracic Society policy statement: pay-for-performance in pulmonary, critical care, and sleep medicine

RATIONALE

Pay-for-performance is a model for health care financing that seeks to link reimbursement to quality. The American Thoracic Society and its members have a significant stake in the development of pay-for-performance programs.

OBJECTIVES

To develop an official ATS policy statement addressing the role of pay-for-performance in pulmonary, critical care and sleep medicine.

METHODS

The statement was developed by the ATS Health Policy Committee using an iterative consensus process including an expert workshop and review by ATS committees and assemblies.

MEASUREMENTS AND MAIN RESULTS

Pay-for-performance is increasingly utilized by health care purchasers including the United States government. Published studies generally show that programs result in small but measurable gains in quality, although the data are heterogeneous. Pay-for-performance may result in several negative consequences, including the potential to increase costs, worsen health outcomes, and widen health disparities, among others. Future research should be directed at developing reliable and valid performance measures, increasing the efficacy of pay-for-performance programs, minimizing negative unintended consequences, and examining issues of costs and cost-effectiveness. The ATS and its members can play a key role in the design and evaluation of these programs by advancing the science of performance measurement, regularly developing quality metrics alongside clinical practice guidelines, and working with payors to make performance improvement a routine part of clinical practice.

CONCLUSIONS

Pay-for-performance programs will expand in the coming years. Pulmonary, critical care and sleep practitioners can use these programs as an opportunity to partner with purchasers to improve health care quality.

A systematic review of the use of theory in the design of guideline dissemination and implementation strategies and interpretation of the results of rigorous evaluations

BACKGROUND

There is growing interest in the use of cognitive, behavioural, and organisational theories in implementation research. However, the extent of use of theory in implementation research is uncertain.

METHODS

We conducted a systematic review of use of theory in 235 rigorous evaluations of guideline dissemination and implementation studies published between 1966 and 1998. Use of theory was classified according to type of use (explicitly theory based, some conceptual basis, and theoretical construct used) and stage of use (choice/design of intervention, process/mediators/moderators, and post hoc/explanation).

RESULTS

Fifty-three of 235 studies (22.5%) were judged to have employed theories, including 14 studies that explicitly used theory. The majority of studies (n = 42) used only one theory; the maximum number of theories employed by any study was three. Twenty-five different theories were used. A small number of theories accounted for the majority of theory use including PRECEDE (Predisposing, Reinforcing, and Enabling Constructs in Educational Diagnosis and Evaluation), diffusion of innovations, information overload and social marketing (academic detailing).

CONCLUSIONS

There was poor justification of choice of intervention and use of theory in implementation research in the identified studies until at least 1998. Future research should explicitly identify the justification for the interventions. Greater use of explicit theory to understand barriers, design interventions, and explore mediating pathways and moderators is needed to advance the science of implementation research.

Intervention to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers a systematic review of provider reminders

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet, not all people who should be screened are screened regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of provider reminder/recall interventions to increase screening for breast, cervical, and colorectal cancers. These interventions involve using systems to inform healthcare providers when individual clients are due (reminder) or overdue (recall) for specific cancer screening tests. Evidence in this review of studies published from 1986 through 2004 indicates that reminder/recall systems can effectively increase screening with mammography, Pap, fecal occult blood tests, and flexible sigmoidoscopy. Additional research is needed to determine if provider reminder/recall systems are effective in increasing colorectal cancer screening by colonoscopy. Specific areas for further research are also suggested.

Organizational factors and the cancer screening process

Cancer screening is a process of care consisting of several steps and interfaces. This article reviews what is known about the association between organizational factors and cancer screening rates and examines how organizational strategies can address the steps and interfaces of cancer screening in the context of both intraorganizational and interorganizational processes. We reviewed 79 studies assessing the relationship between organizational factors and cancer screening. Screening rates are largely driven by strategies to 1) limit the number of interfaces across organizational boundaries; 2) recruit patients, promote referrals, and facilitate appointment scheduling; and 3) promote continuous patient care. Optimal screening rates can be achieved when health-care organizations tailor strategies to the steps and interfaces in the cancer screening process that are most critical for their organizations, the providers who work within them, and the patients they serve.

Continuing medical education effect on practice performance: effectiveness of continuing medical education: American College of Chest Physicians Evidence-Based Educational Guidelines

BACKGROUND

There has been sizable debate and widespread skepticism about the effect of continuing medical education (CME) on the performance of physicians in the practice setting. This portion of the review was undertaken to examine that effect.

METHODS

The guideline panel used data from a comprehensive review of the effectiveness of CME developed by The Johns Hopkins Evidence-based Practice Center, focusing on the effect of CME on clinical performance.

RESULTS

The review found 105 studies, which evaluated the impact of CME on short- and long-term physician practice performance. Nearly 60% met objectives relative to changing clinical performance in prescribing; screening; counseling about smoking cessation, diet, and sexual practices; guideline adherence; and other topics. Single live and multiple media appeared to be generally positive in their effect, print media much less so. Multiple educational techniques were more successful at changing provider performance than single techniques. The amount or frequency of exposure to CME activities appeared to have little effect on behavior change.

CONCLUSIONS

Overall, CME, especially using live or multiple media and multiple educational techniques, is generally effective in changing physician performance. More research, however, is needed that focuses on the specific types of media and educational techniques that lead to the greatest improvements in performance.

Does pay-for-performance influence the quality of care?

PURPOSE OF REVIEW

To summarize studies of pay-for-performance programmes designed to address clinical quality of care markers in ambulatory settings at the level of the physician group or individual physician.

RECENT FINDINGS

Seven randomized controlled trials and 15 nonrandomized studies were reviewed. Less than half of the randomized controlled trials showed positive results, whereas all but one of the nonrandomized studies showed positive or mixed results. Characteristics of the quality measures, incentives, providers, patients, and concurrent interventions probably influenced the results. Study methodology problems such as small sample sizes, selection bias, and inadequate control for confounders were common. Asthma quality of care markers were included in three nonrandomized studies, two of which showed positive results and one of which was negative.

SUMMARY

The data reviewed in this article suggest that pay-for-performance programmes can improve markers of quality, though not always. Even when studies suggest positive effects, the designs often do not permit assurance that the effects are due to the incentives as compared with other factors. More and better-designed studies are needed to determine the actual effectiveness of incentives themselves isolated from other factors, circumstances that promote effectiveness, effectiveness relative to other strategies, and cost-effectiveness.

Interventions to increase recommendation and delivery of screening for breast, cervical, and colorectal cancers by healthcare providers systematic reviews of provider assessment and feedback and provider incentives

Most major medical organizations recommend routine screening for breast, cervical, and colorectal cancers. Screening can lead to early detection of these cancers, resulting in reduced mortality. Yet not all people who should be screened are screened, either regularly or, in some cases, ever. This report presents results of systematic reviews of effectiveness, applicability, economic efficiency, barriers to implementation, and other harms or benefits of two provider-directed intervention approaches to increase screening for breast, cervical, and colorectal cancers. These approaches, provider assessment and feedback, and provider incentives encourage providers to deliver screening services at appropriate intervals. Evidence in these reviews indicates that provider assessment and feedback interventions can effectively increase screening by mammography, Pap test, and fecal occult blood test. Health plans, healthcare systems, and cancer control coalitions should consider such evidence-based findings when implementing interventions to increase screening use. Evidence was insufficient to determine the effectiveness of provider incentives in increasing use of any of these tests. Specific areas for further research are suggested in this report, including the need for additional research to determine whether provider incentives are effective in increasing use of any of these screening tests, and whether assessment and feedback interventions are effective in increasing other tests for colorectal cancer (i.e., flexible sigmoidoscopy, colonoscopy, or double-contrast barium enema).

Selecting effective incentive structures in health care: A decision framework to support health care purchasers in finding the right incentives to drive performance

BACKGROUND

The Ontario health care system is devolving planning and funding authority to community based organizations and moving from steering through rules and regulations to steering on performance. As part of this transformation, the Ontario Ministry of Health and Long-Term Care (MOHLTC) are interested in using incentives as a strategy to ensure alignment - that is, health service providers' goals are in accord with the goals of the health system. The objective of the study was to develop a decision framework to assist policymakers in choosing and designing effective incentive systems.

METHODS

The first part of the study was an extensive review of the literature to identify incentives models that are used in the various health care systems and their effectiveness. The second part was the development of policy principles to ensure that the used incentive models are congruent with the values of the Ontario health care system. The principles were developed by reviewing the Ontario policy documents and through discussions with policymakers. The validation of the principles and the suggested incentive models for use in Ontario took place at two meetings. The first meeting was with experts from the research and policy community, the second with senior policymakers from the MOHLTC. Based on the outcome of those two meetings, the researchers built a decision framework for incentives. The framework was send to the participants of both meetings and four additional experts for validation.

RESULTS

We identified several models that have proven, with a varying degree of evidence, to be effective in changing or enabling a health provider's performance. Overall, the literature suggests that there is no single best approach to create incentives yet and the ability of financial and non-financial incentives to achieve results depends on a number of contextual elements. After assessing the initial set of incentive models on their congruence with the four policy principles we defined nine incentive models to be appropriate for use in Ontario and potentially other health care systems that want to introduce incentives to improve performance. Subsequently, the models were incorporated in the resulting decision framework.

CONCLUSION

The design of an incentive must reflect the values and goals of the health care system, be well matched to the performance objectives and reflect a range of contextual factors that can influence the effectiveness of even well-designed incentives. As a consequence, a single policy recommendation around incentives is inappropriate. The decision framework provides health care policymakers and purchasers with a tool to support the selection of an incentive model that is the most appropriate to improve the targeted performance.

A pediatric-focused review of the performance incentive literature

PURPOSE OF REVIEW

This article seeks to provide a pediatric-focused review of the performance incentive literature. The article will begin with an overview of the performance incentive literature within and outside of healthcare. The review will then detail the pediatric-specific literature, reflect on the breadth and focus of this literature compared with that for adult programs in medicine and school/teacher accountability efforts, and identify three concerning knowledge gaps.

RECENT FINDINGS

The pediatric performance incentive literature is small, totaling five empirical studies. This literature indicates that performance incentives alone have not been effective at improving incentivized aspects of pediatric healthcare. Only one study evaluates whether pediatric performance incentives improve healthcare for children with significant health conditions. No studies investigate whether this strategy yields negative unintended consequences for children and adolescents or how risk adjustment can augment pediatric performance incentive efforts or attenuate unintended effects.

SUMMARY

If approached to participate in or inform performance incentive efforts, pediatricians should appreciate the limitations of the existing empirical literature and ask proponents about their plans for monitoring and/or guarding against potentially negative unintended consequences. Numerous stakeholders are optimistic that this strategy will improve healthcare quality, but the empirical evidence suggests that skepticism is appropriate.

Colorectal cancer screening, intentions, and predictors in Jewish and Arab Israelis: a population-based study

Random samples of 358 Jews and 162 Arabs in Israel aged 50 to 75 were compared by telephone survey for colorectal cancer (CRC) screening performance and intentions. Participants completed questionnaires on CRC screening, health beliefs, health locus of control, and CRC worries; rate of CRC screening and intention to be screened proved lower among Arabs. They received fewer recommendations from physicians, perceived lower severity of CRC and lower benefits of early detection of CRC, and had lower cancer worries, lower internal health locus of control, and higher external health locus of control. Jewish/Arab ethnicity predicted ever undergoing screening and screening intention before cognitive perceptions and worries were entered. After that, perceiving higher susceptibility and more benefits to screening, and having lower external health locus of control predicted CRC screening and screening intention, which was associated with higher cancer worries. Programs should be tailored to address ethnic groups' different health beliefs.

Health promotion for people aged over 65 years in hospitals: nurses’ perceptions about their role

AIM

To identify nurses' beliefs about health promotion and its delivery in routine care of people aged over 65 years.

BACKGROUND

Regardless of age, health promotion interventions can enhance health and, in general, older people are motivated to take such preventive action. The National Service Framework for Older People sets the promotion of healthy living as a standard for UK National Health Service Trusts. However, the delivery of health promotion is 'haphazard'; patients aged over 65 years rarely report receiving health promotion, and reports from nurses suggest they are unsure how to deliver effective health promotion.

METHOD

A theory-based survey of all nurses working in a department specializing in the care of people aged over 65 years, 41% of questionnaires were returned.

RESULTS

The majority of nurses identified examples of health promotion and 88% judged health promotion to be effective and worthwhile. Three quarters of the sample viewed health promotion as part of their role and most of the respondents were confident in their ability to provide health promotion. However, the respondents also reported that health promotion was not appropriate for all their patients and considered it an increasingly difficult task as people got older. Organizational barriers to the routine provision of health promotion were identified.

CONCLUSION

Nurses working on wards for people aged over 65 years are mostly positive about integrating health promotion into their everyday work. However, for health promotion to be routinely implemented, all nursing staff need to feel confident in undertaking the task and believe it is worthwhile. Health promotion needs to be awarded greater importance by hospital management to ensure that it does not conflict with other work priorities. Until this happens the provision of health promotion in hospitals will remain sporadic and lack conviction.

RELEVANCE TO CLINICAL PRACTICE

With an increasing older population nurses need to be confident and proficient at implementing health promotion to patients aged over 65 years. This survey demonstrates that nurses need more training and support to achieve this.

Health beliefs and rates of breast cancer screening among Arab women

OBJECTIVES

To examine the relationship between health beliefs and participation in breast cancer screening among Arab women in Israel.

METHODS

A random sample of 568 Arab women, aged 20-60, belonging to three religious groups, Muslim, Christian, and Druze, was recruited. Participants answered a telephone questionnaire regarding attendance for mammography screening and clinical breast examination (CBE) and health beliefs.

RESULTS

Christian women had undergone more mammography screening and CBE than Druze and Muslim women. They perceived more benefits and fewer barriers to screening practices and had greater perception of the severity of breast cancer. Perception of susceptibility was similar across groups. The barriers that were significant for the Druze and Muslim women were feelings of discomfort and embarrassment, the belief that there was no cure in the case of a positive finding, perceiving mammography as hazardous to health, and perceiving CBE as painful. Logistic regression revealed that age, group, and having a first-degree relative with breast cancer predicted participation in early detection screening. Physician's recommendation predicted mammography, and level of participants' religiosity predicted CBE.

CONCLUSIONS

Diversity in health beliefs and behaviors exists in religious subgroups. Health communications should be modified to suit women in different groups in order to increase participation in screening. In addition, physicians have to be made keenly aware of their pivotal role in motivating women to participate in early detection screening.

Strategies for improving pneumococcal vaccination in eligible patients

Despite the fact that invasive Streptococcus pneumoniae remains a leading cause of death, current levels of immunization in the at risk population remain low and well below the 90% goal for Healthy People 2010. A number of intervention strategies to increase immunization rates (for influenza and pneumonia) have been demonstrated to be effective in increasing these rates when used alone or in combination. A summary of this literature is presented including recent data on the effectiveness of pay-for-performance approaches for increasing preventive care. Data are also presented on intervention strategies judged to be most effective in a large health care system, the Veterans Health Administration, which has essentially reached the Healthy People 2010 goal for pneumococcal immunization.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not consistently been found to be effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register and pending file up to January 2004.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken. For each comparison we calculated the risk difference (RD) and risk ratio (RR), adjusted for baseline compliance when possible, for dichotomous outcomes and the percentage and the percent change relative to the control group average after the intervention, adjusted for baseline performance when possible, for continuous outcomes. We investigated the following factors as possible explanations for the variation in the effectiveness of interventions across comparisons: the type of intervention (audit and feedback alone, audit and feedback with educational meetings, or multifaceted interventions that included audit and feedback), the intensity of the audit and feedback, the complexity of the targeted behaviour, the seriousness of the outcome, baseline compliance and study quality.

MAIN RESULTS

Thirty new studies were added to this update, and a total of 118 studies are included. In the primary analysis 88 comparisons from 72 studies were included that compared any intervention in which audit and feedback is a component compared to no intervention. For dichotomous outcomes the adjusted risk difference of compliance with desired practice varied from - 0.16 (a 16 % absolute decrease in compliance) to 0.70 (a 70% increase in compliance) (median = 0.05, inter-quartile range = 0.03 to 0.11) and the adjusted risk ratio varied from 0.71 to 18.3 (median = 1.08, inter-quartile range = 0.99 to 1.30). For continuous outcomes the adjusted percent change relative to control varied from -0.10 (a 10 % absolute decrease in compliance) to 0.68 (a 68% increase in compliance) (median = 0.16, inter-quartile range = 0.05 to 0.37). Low baseline compliance with recommended practice and higher intensity of audit and feedback were associated with larger adjusted risk ratios (greater effectiveness) across studies.

AUTHORS' CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The relative effectiveness of audit and feedback is likely to be greater when baseline adherence to recommended practice is low and when feedback is delivered more intensively.

Economic incentives and physicians' delivery of preventive care: a systematic review

A systematic review of the randomized trial literature examining the impact of financial incentives on provider preventive care delivery was conducted. English-language studies published between 1966 and 2002 that addressed primary or secondary preventive care or health promotion behaviors were included in the review. Six studies that met the inclusion criteria were identified, which generated eight different findings. The literature is sparse. Of the eight financial interventions reviewed, only one led to a significantly greater provision of preventive services. The lack of a significant relationship does not necessarily imply that financial incentives cannot motivate physicians to provide more preventive care. The rewards offered in these studies tend to be small. Therefore, the results suggest that small rewards will not motivate doctors to change their preventive care routines.

Changing clinical behaviour by making guidelines specific

Efforts to get doctors to follow guidelines have overlooked the importance of clear and concise recommendations

Breast and cervical cancer screening for women between 50 and 69 years of age: what prompts women to screen?

The objective of this study was to examine mammography and cervical cancer screening rates among women aged 50 to 69 and to understand which prompts are effective for improving screening compliance. A self-administered survey was sent to 800 randomly selected participants in a health region in a relatively poor, rural province in Eastern Canada with a universal health care system. Since 1995, New Brunswick has instituted a biannual self-referral mammography screening program for women between 50 and 69 years of age. The response rate to the survey was 66%. Mammography screening compliance was 73% and was most significantly associated with annual clinical breast examinations, compliance with cervical cancer screening, and physician suggestion (p <.001). Cervical cancer screening compliance was 91% and was significantly associated with annual clinical breast examinations, compliance with mammography screening, and physician suggestion (p<.001). Contact with a physician is most effective for promoting screening compliance.

Effectiveness of women's telephone counseling and physician education to improve mammography screening among women who underuse mammography

The effect on women's breast cancer screening utilization of a barrier-specific telephone counseling (BSTC) intervention, with and without a concurrent continuing medical education (CME) activity for their physicians, was evaluated. All participants (50-80 years of age) were not regular mammography users at baseline. A 4-arm quasi-experimental design was employed. Women were randomized to the BSTC or no BSTC group and assigned (with their physicians) to the CME or no CME group based on place of residence. Pre- and postintervention data were obtained for 1,601 women using telephone interviews conducted during 1995 and 1998, respectively. Among women who had ever used mammography at baseline, those who received BSTC were more likely than the control group to become regular mammography users at follow-up (OR = 1.4, p = .033). Greater reductions in perceived barriers to mammography, from baseline to follow-up, were significantly associated with receiving BSTC compared with the control group (p = .001), among women with previous mammography experience. Findings suggest that CME may have potential for initiating mammography use among women who never had a previous mammogram. However, because of the small sample available for analyses of the CME intervention and differential attrition among women who never had a previous mammogram, further study is needed to confirm this hypothesis.

Breast cancer screening beliefs by practice location

BACKGROUND

This study examines variations in breast cancer screening among primary care clinicians by geographic location of clinical practice.

METHODS

A cross-sectional survey design was used to examine approaches to breast cancer screening among physicians, nurse practitioners, and physician assistants involved in primary care practice. A summary index of beliefs about breast cancer screening was created by summing the total number of responses in agreement with each of four survey items; values for this summary variable ranged between zero and four. Respondents were classified into urban, rural and suburban categories based upon practise location.

RESULTS

Among the 428 respondents, agreement with "correct" responses ranged from 50% to 71% for the individual survey items; overall, half agreed with three or more of the four breast cancer screening items. While no significant differences were noted by practice location, variation in responses were evident. Reported use of written breast cancer guidelines was less in both suburban (OR = 0.51) and urban areas (OR = 0.56) when compared to clinicians in rural areas.

CONCLUSION

Development of an evidence-based consensus statement regarding breast cancer screening would support a single set of unambiguous guidelines for implementation in all primary care settings, thus decreasing variations in how breast cancer screening is approached across varied clinical settings.

Audit and feedback: effects on professional practice and health care outcomes

BACKGROUND

Audit and feedback continues to be widely used as a strategy to improve professional practice. It appears logical that healthcare professionals would be prompted to modify their practice if given feedback that their clinical practice was inconsistent with that of their peers or accepted guidelines. Yet, audit and feedback has not been found to be consistently effective.

OBJECTIVES

To assess the effects of audit and feedback on the practice of healthcare professionals and patient outcomes.

SEARCH STRATEGY

We searched the Cochrane Effective Practice and Organisation of Care Group's register up to January 2001. This was supplemented with searches of MEDLINE and reference lists, which did not yield additional relevant studies.

SELECTION CRITERIA

Randomised trials of audit and feedback (defined as any summary of clinical performance over a specified period of time) that reported objectively measured professional practice in a healthcare setting or healthcare outcomes.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and assessed study quality. Quantitative (meta-regression), visual and qualitative analyses were undertaken.

MAIN RESULTS

We included 85 studies, 48 of which have been added to the previous version of this review. There were 52 comparisons of dichotomous outcomes from 47 trials with over 3500 health professionals that compared audit and feedback to no intervention. The adjusted RDs of non-compliance with desired practice varied from 0.09 (a 9% absolute increase in non-compliance) to 0.71 (a 71% decrease in non-compliance) (median = 0.07, inter-quartile range = 0.02 to 0.11). The one factor that appeared to predict the effectiveness of audit and feedback across studies was baseline non-compliance with recommended practice.

REVIEWER'S CONCLUSIONS

Audit and feedback can be effective in improving professional practice. When it is effective, the effects are generally small to moderate. The absolute effects of audit and feedback are more likely to be larger when baseline adherence to recommended practice is low.

Screening mammography: Is it suitably targeted to older women who are most likely to benefit?

OBJECTIVES

To determine whether screening mammography is suitably targeted to older women who are most likely to benefit.

DESIGN

Prospective cohort study.

SETTING

New Haven County, Connecticut.

PARTICIPANTS

Eight hundred forty-four community-dwelling older women were interviewed as part of the 1990 New Haven Established Populations for the Epidemiologic Study of the Elderly (EPESE) program.

MEASUREMENTS

Mammography use was ascertained from Medicare Part B claims data. A four-level prognostic mortality index was developed using items previously shown to be predictive of mortality. Mammography use and all-cause mortality were evaluated by prognostic stage over a 5-year period, January 1, 1991, to December 31, 1995.

RESULTS

Five-year mortality increased steadily with each prognostic stage (12% to 68%, P = .001), whereas the 5-year mammography use rate declined (48% to 7%, P = .001). Over half the women (53%) in the most favorable prognostic group did not receive a mammogram, whereas 13% in the two worst prognostic groups received at least one mammogram.

CONCLUSION

Screening mammography may be underutilized among older women who are the most likely to benefit and overutilized among those who are unlikely to benefit.

The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites

OBJECTIVE

To determine whether the implementation of the Put Prevention Into Practice (PPIP) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics.

METHODS

Chart review was conducted before (n=372) and 33 to 39 months after (n=376) the implementation of the PPIP office-based system in two community health centers and three family practice residency programs in Texas. The population included all adult patients aged > or = 19 years who had presented to the clinic during the study periods.

RESULTS

Documentation of timely cholesterol screening increased from 70% to 84%; smoking assessment, from 56% to 80%; for women, up-to-date Papanicolaou smear, from 70% to 81%; annual mammograms (women aged > or =51), from 30% to 48%; and up-to-date tetanus-diphtheria immunizations, from 19% to 59%. For adults aged > or =66 years, documentation of pneumococcal immunization increased from 22% to 48%, while influenza immunizations improved, although not significantly (45% to 49%). Blood pressure screening was almost universal (99%) at baseline and at 33- to 39-month follow-up.

CONCLUSION

PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services.

The association of race/ethnicity, socioeconomic status, and physician recommendation for mammography: who gets the message about breast cancer screening?

OBJECTIVES

This study investigated the association between physician recommendation for mammography and race/ethnicity, socioeconomic status, and other characteristics in a rural population.

METHODS

In 1993 through 1994, we surveyed 1933 Black women and White women 52 years and older in 10 rural counties.

RESULTS

Fifty-three percent of the women reported a physician recommendation in the past year. White women reported recommendations significantly more often than did Black women (55% vs 45%; odds ratio = 1.49). Controlling for educational attainment and income eliminated the apparent racial/ethnic difference. After control for 5 personal, 4 health, and 3 access characteristics, recommendation for mammography was found to be more frequent among women who had access to the health care system (i.e., had a regular physician and health insurance). Recommendation was less frequent among women who were vulnerable (i.e., were older, had lower educational attainment, had lower annual family income).

CONCLUSIONS

Socioeconomic status, age, and other characteristics--but not race/ethnicity--were related to reports of a physician recommendation, a precursor strongly associated with mammography use. Efforts to increase physician recommendation should include complementary efforts to help women address socioeconomic and other barriers to mammography use.