Effects of pay-for-performance system on tuberculosis default cases control and treatment in Taiwan

Pay-for-performance in Taiwan: A systematic review and meta-analysis of the empirical literature

OBJECTIVES

This study aimed to assess the impact of pay-for-performance (P4P) programmes on healthcare in Taiwan.

STUDY DESIGN

This was a systematic review and meta-analysis.

METHODS

A systematic literature search was performed using the PubMed, Medline, Embase, Cochrane review, Scopus, Web of Science and PsycINFO databases up to July 2023. Meta-analysis of the available outcomes was conducted using a random-effects model.

RESULTS

The search yielded 85 studies, of which 58 investigated the programme for diabetes mellitus (DM), eight looked at the programme for chronic kidney disease (CKD), and the remaining studies examined programmes for breast cancer, tuberculosis, schizophrenia and chronic obstructive pulmonary disease. The DM P4P programme was a cost-effective strategy associated with reduced hospitalisation and subsequent complications. The CKD P4P was associated with a lower risk of dialysis initiation. The P4P programme also improved outcomes in breast cancer, cure rates in tuberculosis, reduced admissions for schizophrenia and reduced acute exacerbation in chronic obstructive pulmonary disease. The meta-analysis revealed that the P4P programme for DM (odds ratio [OR] = 0.59; 95% confidence interval [CI] = 0.48-0.73) and CKD (OR = 0.73; 95% CI = 0.67-0.81) significantly reduced mortality risk. However, participation rate in the DM P4P programme was only 19% in 2014.

CONCLUSIONS

P4P programmes in Taiwan improve quality of care. However, participation was voluntary and the participation rate was very low, raising the concern of selective enrolment of participants (i.e. 'cherry-picking' behaviour) by physicians. Future programme reforms should focus on well-designed features with the aim of reducing healthcare disparities.

The intersection of TB and health financing: defining needs and opportunities

TB is an airborne public health threat, so the reponse to TB has been defined mainly through the lens of vertical, public-sector national TB programs (NTPs). However, TB exists within a broader health systems and health financing context. Here, we examine the intersection between the particular needs of TB programs and the broader health financing landscape. This includes the strategies needed to finance both the clinical and public health aspects of the TB response. In high-burden countries, the resource mobilization and strategic purchasing approaches described here will be critical if we are to maximize the reach and impact of the TB response.

Estimating the budget impact of a Tuberculosis strategic purchasing pilot study in Medan, Indonesia (2018-2019)

BACKGROUND

Indonesia has the world's second-highest tuberculosis (TB) burden, with 969,000 annual TB infections. In 2017, Indonesia faced significant challenges in TB care, with 18% of cases missed, 29% of diagnosed cases unreported, and 55.4% of positive results not notified. The government is exploring a new approach called "strategic purchasing" to improve TB detection and treatment rates and offer cost-effective service delivery.

OBJECTIVES

We aimed to analyze the financial impact of implementing a TB purchasing pilot in the city of Medan and assess the project's affordability and value for money.

METHODS

We developed a budget impact model to estimate the cost-effectiveness of using strategic purchasing to improve TB reporting and treatment success rates. We used using data from Medan's budget impact model and the Ministry of Health's guidelines to predict the total cost and the cost per patient.

RESULTS

The model showed that strategic purchasing would improve TB reporting by 63% and successful treatments by 64%. While this would lead to a rise in total spending on TB care by 60%, the cost per patient would decrease by 3%. This is because more care would be provided in primary healthcare settings, which are more cost-effective than hospitals.

CONCLUSIONS

While strategic purchasing may increase overall spending, it could improve TB care in Indonesia by identifying more cases, treating them more effectively, and reducing the cost per patient. This could potentially lead to long-term cost savings and improved health outcomes.

Factors Associated with Medication Adherence in Elderly Individuals with Tuberculosis: A Qualitative Study

Methods

This qualitative study was conducted in two phases, using an integrative literature review and individual interviews. Studies were gathered without time restriction from MEDLINE databases, Institute for Scientific Information (ISI), Google Scholar, Scopus, and EMBASE, as well as national databases, including Scientific Information Database and Magiran. The findings of 38 studies that met the inclusion criteria were analyzed through the conventional content analysis method based on the ecological approach. After reviewing and forming the data matrix, purposive sampling was performed among healthcare professionals, elderly tuberculosis patients aged 60 and over, and family caregivers of elderly patients to conduct individual interviews. Data obtained from 20 interviews were analyzed using the directed content analysis method. After coding, the data from individual interviews were entered based on similarity and difference in the categories of data matrix obtained from the literature review.

Results

In general, the aforementioned codes were placed in four main categories, including individual factors (i.e., biological factors, affective-emotional factors, behavioral factors, cognitive factors, tuberculosis-related factors, and economic factors), interpersonal factors (i.e., patient's relationship with treatment team and family-related factors), factors related to healthcare service provider centers (i.e., medical centers' facilities and capacity building in healthcare service provider), and extraorganizational factors (i.e., social factors and health policymaking).

Conclusion

The results of this study showed that medication adherence in elderly patients with tuberculosis was a complex and multidimensional phenomenon. Therefore, society, policymakers, and healthcare providers should scrutinize the factors affecting medication adherence in this group of patients to plan and implement more effective interventions.

Financial strategies targeting healthcare providers to promote the prudent use of antibiotics: a systematic review of the evidence

Improving prudent use of antibiotics is one way to limit the spread of antimicrobial resistance (AMR). The objective of this systematic review was to assess the effects of financial strategies targeting healthcare providers on the prudent use of antibiotics. A systematic review of the literature was conducted searching PubMed, Embase and Cochrane databases, and the grey literature. Search terms related to antibacterial agents, drug resistance, financial strategies, and healthcare providers and/or prescribers. Twenty-two articles were included in the review, reporting on capitation and salary reimbursement, cost containment interventions, pay-for-performance initiatives, penalties, and a one-off bonus payment. There was substantial variation in the reported outcomes describing prescribing behaviours, including proportion of patients prescribed antibiotics, antibiotic prescriptions per patient, and number of cases treated with recommended antibiotic therapy. All financial strategies were associated with improvements in the appropriate prescription of antibiotics in the short-term, although the magnitude of observed effects varied across financial strategies. Financial penalties were associated with the greatest decreases in inappropriate antibiotic prescriptions, followed by capitation models and pay-for-performance schemes that paid bonuses upon achievement of performance targets. However, the risk of bias across studies must be noted. Findings point to the viability of financial strategies to promote the prudent use of antibiotics. Measuring the downstream impact of prescriber behaviour changes is key to estimating the true value of such interventions to tackle AMR. Research efforts should continue to build the evidence on causal mechanisms driving provider prescribing patterns for antibiotics and the long-term impact on antibiotic prescriptions.

Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies

BACKGROUND

Incomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes.

METHODS AND FINDINGS

We systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions.

CONCLUSION

TB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.

Financial Incentives to Encourage Value-Based Health Care

This article reviews the literature on the use of financial incentives to improve the provision of value-based health care. Eighty studies of 44 schemes from 10 countries were reviewed. The proportion of positive and statistically significant outcomes was close to .5. Stronger study designs were associated with a lower proportion of positive effects. There were no differences between studies conducted in the United States compared with other countries; between schemes that targeted hospitals or primary care; or between schemes combining pay for performance with rewards for reducing costs, relative to pay for performance schemes alone. Paying for performance improvement is less likely to be effective. Allowing payments to be used for specific purposes, such as quality improvement, had a higher likelihood of a positive effect, compared with using funding for physician income. Finally, the size of incentive payments relative to revenue was not associated with the proportion of positive outcomes.

The effectiveness of payment for performance in health care: A meta-analysis and exploration of variation in outcomes

BACKGROUND

Pay for performance (P4P) incentive schemes are increasingly used world-wide to improve health system performance but results of evaluations vary considerably. A systematic analysis of this variation in the effects of P4P schemes is needed.

METHODS

Evaluations of P4P schemes from any country were identified by searching for and updating systematic reviews of P4P schemes in health care in four bibliographic databases. Outcomes using different measures of effect were converted into standardized effect sizes (standardized mean difference, SMD) and each study was categorized as to whether or not it found a positive effect. Subgroup analysis, meta-regression and multilevel logistic regression were used to investigate factors explaining heterogeneity. Random-effects models were used because they take into account heterogeneity likely to be due to differences between studies rather than just chance. Sensitivity analysis was used to test the effect of different assumptions.

FINDINGS

96 primary studies were identified; 37 were included in the meta-analysis and meta-regression and all 96 in the logistic regression. The proportion of observed variation in study results that can be explained by true heterogeneity (I²) was 99.9%. Estimates of effect of P4P schemes were lower in evaluations using randomized controlled trials (SMD=0.08; 95% CI: 0.01-0.15) compared to no controls (0.15; 95% CI: 0.09-0.21), and lower for those measuring outcomes (e.g., smoking cessation) (SMD=0.0; 95% CI: -0.01 to 0.01) compared to process measures (e.g., giving cessation advice) (0.18; 95% CI: 0.06-0.31). Adjusting for other design features and the evaluation method, the odds of showing a positive effect was three times higher for schemes with larger incentives (>5% of salary/usual budget) (OR=3.38; 95% CI: 1.07-10.64). There were non-statistically significant increases in the odds of success if the incentive is paid to individuals (as opposed to groups) (OR=2.0; 95% CI: 0.62-6.56) and if there is a lower perceived risk of not earning the incentive (OR=2.9; 95% CI: 0.78-10.83). Schemes evaluated using less rigorous designs were 24 times more likely to have positive estimates of effect than those using randomized controlled trials (OR=24; 95% CI: 6.3-92.8).

INTERPRETATION

Estimates of the effectiveness of incentive schemes on health outcomes are probably inflated due to poorly designed evaluations and a focus on process measures rather than health outcomes. Larger incentives and reducing the perceived risk of non-payment may increase the effect of these schemes on provider behavior.

Does Pay-For-Performance Program Increase Providers Adherence to Guidelines for Managing Hepatitis B and Hepatitis C Virus Infection in Taiwan?

Background

Many people are concerned about that the quality of preventive care for patients with hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is suboptimal. Taiwan, a hyperendemic area of chronic HBV and HCV infection, implemented a nationwide pay-for-performance (P4P) program in 2010, which aimed to improve the preventive care provided to HBV and HCV patients by increasing physicians’ adherence to guidelines through financial incentives. The objective of this study was to evaluate the early effects of the P4P program on utilization of preventive services by HBV and HCV patients.

Methods

Using a quasi-experimental design with propensity score matching method, we matched the HBV and HCV patients enrolled in the P4P program with non-enrollees in 2010, resulting in 21,643 patients in each group. Generalized estimating equations was applied to examine the difference-in-difference effects of P4P program enrollment on the utilization of three guideline-recommended preventive services (regular outpatient follow-up visits, abdominal ultrasonography (US) examinations, and aspartate aminotransferase and alanine aminotransferase (AST/ALT) tests by HBV and HCV patients.

Results

The P4P program enrollees were significantly more likely to attend twice-annual follow-up visits, to receive recommended US examinations and AST/ALT tests, than non-enrollees.

Conclusions

The results of our preliminary assessment indicate that financial incentives offered by the P4P program was associated with a modest improvement in adherence to guidelines for better chronic HBV and HBC management.

A mathematical study of a TB Model with treatment interruptions and two latent periods

A TB transmission model which incorporates treatment interruptions and two latent periods is presented. The threshold parameter known as the control reproduction number and the equilibria for the model are determined, and the global asymptotical stabilities of the equilibria are studied by constructing the proper Lyapunov functions. The reproduction numbers and numerical simulations show that treatment of active TB cases always helps to control the TB epidemic, while treatment interruptions may have a negative, positive, or no effect on combating TB epidemic.

Effectiveness of a government-organized and hospital-initiated treatment for multidrug-resistant tuberculosis patients--a retrospective cohort study

BACKGROUND

In contrast to the conventional model of hospital-treated and government directly observed treatment (DOT) for multidrug-resistant tuberculosis (MDR-TB) patient care, the Taiwan MDR-TB Consortium (TMTC) was launched in May 2007 with the collaboration of five medical care groups that have provided both care and DOT. This study aimed to determine whether the TMTC provided a better care model for MDR-TB patients than the conventional model.

METHODS AND FINDINGS

A total of 651 pulmonary MDR-TB patients that were diagnosed nation-wide from January 2000-August 2008 were enrolled. Of those, 290 (45%) MDR-TB patients whose initial sputum sample was taken in January 2007 or later were classified as patients in the TMTC era. All others were classified as patients in the pre-TMTC era. The treatment success rate at 36 months was better in the TMTC era group (82%) than in the pre-TMTC era group (61%) (p<0.001). With multiple logistic regressions, diagnosis in the TMTC era (adjusted odds ratio (aOR) 2.8, 95% confidence interval (CI) 1.9-4.2) was an independent predictor of a higher treatment success rate at 36 months. With the time-dependent proportional hazards method, a higher treatment success rate was still observed in the TMTC era group compared to the pre-TMTC era group (adjusted hazard ratio 6.3, 95% CI 4.2-9.5).

CONCLUSION

The improved treatment success observed in the TMTC era compared to the pre-TMTC era is encouraging. The detailed TMTC components that contribute the most to the improved outcome will need confirmation in follow-up studies with large numbers of MDR-TB patients.

Pay for Performance in Health Care

Pay for performance (P4P) has become a popular approach to performance improvement in health care. Most of the P4P literature has focused on the United States and there is limited insight in the characteristics of major programs initiated in other countries. This article systematically describes and reviews P4P programs outside the United States. Our literature search identified 13 programs initiated in 9 countries. Although the programs share many similarities, they differ in several important respects, also when compared with the typical P4P program in the United States. In addition, there are clearly possibilities to increase incentive strength and minimize incentives for undesired behavior. In part, observed heterogeneity will be a consequence of contextual differences, but design choices often also seem to be made arbitrarily. In designing their programs, purchasers are hampered by limited knowledge of the influence of specific design choices and effective strategies to mitigate undesired behavior.