Performance measurement and equity

Low-value care: antipsychotic medication use among community-dwelling medicare beneficiaries with Alzheimer's disease and related dementias and without severe mental illness

Background: Antipsychotic medication use among elderly with Alzheimer's disease and related dementias (ADRD) and without severe mental illness is considered as low-value care. Our objective was to assess the factors associated with this inappropriate use of antipsychotic medications among community-dwelling Medicare beneficiaries with ADRD and without severe mental illness.Methods: This study used a retrospective cross-sectional design. Data for this study were derived from the nationally representative Medicare Current Beneficiary Survey (MCBS) and linked Medicare claims. Logistic regression models were used to examine factors associated with low-value care.Results: Overall 8.5% had low-value care. In the final adjusted logistic regression model, race other than Hispanic or Non-Hispanic White (AOR =0.54, 95% CI = [0.30,0.98]), individuals over 80 years of age (AOR =0.53, 95% CI = [0.36,0.76]), and obese individuals (AOR =0.55, 95% CI = [0.35,0.85]) had significantly lower odds of receiving low-value care. Those with depression (AOR =1.71, 95% CI = [1.21, 2.43]), who lived in the Midwest (AOR =1.7, 95% CI = [1.08,2.68]), and with a higher number of ADL limitations (AOR =1.28, 95% CI = [1.19,1.38]) had significantly higher odds of low-value care.Conclusions: There were subgroup differences in low-value care. Interventions may target these subgroups to reduce low-value care.

The (Missed) Potential of the Patient-centered Medical Home for Disparities

BACKGROUND

Disparities in health care and health outcomes are a significant problem in the United States. Delivery system reforms such as the patient-centered medical home (PCMH) could have important implications for disparities.

OBJECTIVES

To investigate what role disparities play in current PCMH initiatives and how their set-up might impact on disparities.

RESEARCH DESIGN

We selected 4 state-based PCMH initiatives (Colorado, Massachusetts, Pennsylvania, and Rhode Island), 1 regional initiative in New Orleans, and 1 multistate initiative. We interviewed 30 key actors in these initiatives and 3 health policy experts on disparities in the context of PCMH. Interview data were coded using the constant comparative method.

RESULTS

We find that disparities are not an explicit priority in PCMH initiatives. Nevertheless, many policymakers, providers, and initiative leaders believe that the model has the potential to reduce disparities. However, because of the funding structure of initiatives and the lack of adjustment of quality metrics, health policy experts do not share this optimism and safety-net providers report concerns and frustration.

CONCLUSION

Even though disparities are currently not a priority in the PCMH community, the design of initiatives has important implications for disparities.

Socioeconomic Status and Hospitalization Costs for Children with Brain and Spinal Cord Injury

OBJECTIVE

To determine if household income is associated with hospitalization costs for severe traumatic brain injury (TBI) and spinal cord injury (SCI).

STUDY DESIGN

Retrospective cohort study of inpatient, nonrehabilitation hospitalizations at 43 freestanding children's hospitals for patients <19 years old with unintentional severe TBI and SCI from 2009-2012. Standardized cost of care for hospitalizations was modeled using mixed-effects methods, adjusting for age, sex, race/ethnicity, primary payer, presence of chronic medical condition, mechanism of injury, injury severity, distance from residence to hospital, and trauma center level. Main exposure was zip code level median annual household income.

RESULTS

There were 1061 patients that met inclusion criteria, 833 with TBI only, 227 with SCI only, and 1 with TBI and SCI. Compared with those with the lowest-income zip codes, patients from the highest-income zip codes were more likely to be older, white (76.7% vs 50.4%), have private insurance (68.9% vs 27.9%), and live closer to the hospital (median distance 26.7 miles vs 81.2 miles). In adjusted models, there was no significant association between zip code level household income and hospitalization costs.

CONCLUSIONS

Children hospitalized with unintentional, severe TBI and SCI showed no difference in standardized hospital costs relative to a patient's home zip code level median annual household income. The association between household income and hospitalization costs may vary by primary diagnosis.

Does a local financial incentive scheme reduce inequalities in the delivery of clinical care in a socially deprived community? A longitudinal data analysis

BACKGROUND

Socioeconomic deprivation is associated with inequalities in health care and outcomes. Despite concerns that the Quality and Outcomes Framework pay-for-performance scheme in the UK would exacerbate inequalities in primary care delivery, gaps closed over time. Local schemes were promoted as a means of improving clinical engagement by addressing local health priorities. We evaluated equity in achievement of target indicators and practice income for one local scheme.

METHODS

We undertook a longitudinal survey over four years of routinely recorded clinical data for all 83 primary care practices. Sixteen indicators were developed that covered five local clinical and public health priorities: weight management; alcohol consumption; learning disabilities; osteoporosis; and chlamydia screening. Clinical indicators were logit transformed from a percentage achievement scale and modelled allowing for clustering of repeated measures within practices. This enabled our study of target achievements over time with respect to deprivation. Practice income was also explored.

RESULTS

Higher practice deprivation was associated with poorer performance for five indicators: alcohol use registration (OR 0.97; 95 % confidence interval 0.96,0.99); recorded chlamydia test result (OR 0.97; 0.94,0.99); osteoporosis registration (OR 0.98; 0.97,0.99); registration of repeat prednisolone prescription (OR 0.98; 0.96,0.99); and prednisolone registration with record of dual energy X-ray absorptiometry (DEXA) scan/referral (OR 0.92; 0.86,0.97); practices in deprived areas performed better for one indicator (registration of osteoporotic fragility fracture (OR 1.26; 1.04,1.51). The deprivation-achievement gap widened for one indicator (registered females aged 65-74 with a fracture referred for a DEXA scan; OR 0.97; 0.95,0.99). Two other indicators indicated a similar trend over two years before being withdrawn (registration of fragility fracture and over-75 s with a fragility fracture assessed and treated for osteoporosis risk). For one indicator the deprivation-achievement gap reduced over time (repeat prednisolone prescription (OR 1.01; 1.01,1.01). Larger practices and those serving more affluent areas earned more income per patient than smaller practices and those serving more deprived areas (t = -3.99; p =0.0001).

CONCLUSIONS

Any gaps in achievement between practices were modest but mostly sustained or widened over the duration of the scheme. Given that financial rewards may not reflect the amount of work undertaken by practices serving more deprived patients, future pay-for-performance schemes also need to address fairness of rewards in relation to workload.

'Just another incentive scheme': a qualitative interview study of a local pay-for-performance scheme for primary care

BACKGROUND

A range of policy initiatives have addressed inequalities in healthcare and health outcomes. Local pay-for-performance schemes for primary care have been advocated as means of enhancing clinical ownership of the quality agenda and better targeting local need compared with national schemes such as the UK Quality and Outcomes Framework (QOF). We investigated whether professionals' experience of a local scheme in one English National Health Service (NHS) former primary care trust (PCT) differed from that of the national QOF in relation to the goal of reducing inequalities.

METHODS

We conducted retrospective semi-structured interviews with primary care professionals implementing the scheme and those involved in its development. We purposively sampled practices with varying levels of population socio-economic deprivation and achievement. Interviews explored perceptions of the scheme and indicators, likely mechanisms of influence on practice, perceived benefits and harms, and how future schemes could be improved. We used a framework approach to analysis.

RESULTS

Thirty-eight professionals from 16 general practices and six professionals involved in developing local indicators participated. Our findings cover four themes: ownership, credibility of the indicators, influences on behaviour, and exacerbated tensions. We found little evidence that the scheme engendered any distinctive sense of ownership or experiences different from the national scheme. Although the indicators and their evidence base were seldom actively questioned, doubts were expressed about their focus on health promotion given that eventual benefits relied upon patient action and availability of local resources. Whilst practices serving more affluent populations reported status and patient benefit as motivators for participating in the scheme, those serving more deprived populations highlighted financial reward. The scheme exacerbated tensions between patient and professional consultation agendas, general practitioners benefitting directly from incentives and nurses who did much of the work, and practices serving more and less affluent populations which faced different challenges in achieving targets.

CONCLUSIONS

The contentious nature of pay-for-performance was not necessarily reduced by local adaptation. Those developing future schemes should consider differential rewards and supportive resources for practices serving more deprived populations, and employing a wider range of levers to promote professional understanding and ownership of indicators.

Quality indicators as a tool in improving the introduction of new medicines

Quality indicators are increasingly used as a tool to achieve safe and quality clinical care, cost-effective therapy, for professional learning, remuneration, accreditation and financial incentives. A substantial number focus on drug therapy but few address the introduction of new medicines even though this is a burning issue. The objective was to describe the issues and challenges in designing and implementing a transparent indicator framework and evaluation protocol for the introduction of new medicines and to provide guidance on how to apply quality indicators in the managed entry of new medicines. Quality indicators need to be developed early to assess whether new medicines are introduced appropriately. A number of key factors need to be addressed when developing, applying and evaluating indicators including dimensions of quality, suggested testing protocols, potential data sources, key implementation factors such as intended and unintended consequences, budget impact and cost-effectiveness, assuring the involvement of the medical professions, patients and the public, and reliable and easy-to-use computerized tools for data collection and management. Transparent approaches include the need for any quality indicators developed to handle conflict of interests to enhance their validity and acceptance. The suggested framework and indicator testing protocol may be useful in assessing the applicability of indicators for new medicines and may be adapted to healthcare settings worldwide. The suggestions build on existing literature to create a field testing methodology that can be used to produce country-specific quality indicators for new medicines as well as a cross international approach to facilitate access to new medicines.

Health systems performance assessment in low-income countries: learning from international experiences

BACKGROUND

The study aimed at developing a set of attributes for a 'good' health system performance assessment (HSPA) framework from literature and experiences in different contexts and using the attributes for a structured approach to lesson learning for low-income countries (LICs).

METHODS

Literature review to identify relevant attributes for a HSPA framework; attribute validation for LICs in general, and for Uganda in particular, via a high-level Ugandan expert group; and, finally, review of a selection of existing HSPA frameworks using these attributes.

RESULTS

Literature review yielded six key attributes for a HSPA framework: an inclusive development process; its embedding in the health system's conceptual model; its relation to the prevailing policy and organizational set-up and societal context; the presence of a concrete purpose, constitutive dimensions and indicators; an adequate institutional set-up; and, its capacity to provide mechanisms for eliciting change in the health system. The expert group contextualized these attributes and added one on the adaptability of the framework.Lessons learnt from the review of a selection of HSPA frameworks using the attributes include: it is possible and beneficial to involve a range of stakeholders during the process of development of a framework; it is important to make HSPA frameworks explicit; policy context can be effectively reflected in the framework; there are marked differences between the structure and content of frameworks in high-income countries, and low- and middle-income countries; champions can contribute to put HSPA high on the agenda; and mechanisms for eliciting change in the health system should be developed alongside the framework.

CONCLUSION

It is possible for LICs to learn from literature and the experience of HSPA in other contexts, including HICs. In this study a structured approach to lesson learning included the development of a list of attributes for a 'good' HSPA framework. The attributes thus derived can be utilized by LICs like Uganda seeking to develop/adjust their HSPA frameworks as guidelines or a check list, while taking due consideration of the specific context. The review of frameworks from varied contexts, highlighted varied experiences which provide lessons for LICs.

Why did most French GPs choose not to join the voluntary national pay-for-performance program?

BACKGROUND

In 2009, a voluntary pay for performance (P4P) scheme for primary care physicians was introduced in France through the 'Contract for Improving Individual Practice' (CAPI). Although the contract could be interrupted at any time and without any penalty, two-thirds of French general practitioners chose not to participate. We studied what factors motivated general practitioners not to subscribe to the P4P contract, and particularly their perception of the ethical risks that may be associated with adhering to a CAPI.

METHOD

A cross-sectional survey among French general practitioners using an online questionnaire based on focus group discussion results. Descriptive and multivariate statistical analyses with logistic regression.

RESULTS

A sample of 1,016 respondents, representative of French GPs. The variables that were associated with the probability of not signing a CAPI were "discomfort that patients were not informed of the signing of a P4P contract by their doctors" (OR = 8.24, 95% CI = 4.61-14.71), "the risk of conflicts of interest" (OR = 4.50, 95% CI = 2.42-8.35), "perceptions by patients that doctors may risk breaching professional ethics" (OR = 4. 35, 95% CI = 2.43-7.80) and "the risk of excluding the poorest patients" (OR = 2.66, 95% CI = 1.53-4.63).

CONCLUSION

The perception of ethical risks associated with P4P may have hampered its success. Although the CAPI was extended to all GPs in 2012, our results question the relevance of the program itself by shedding light on potential adverse effects.

Towards a performance measurement system for health equity in a local health integration network

While there is a growing literature on building performance measurement systems for health equities, this literature for the most part has not dealt with the challenges of coordinating the various parts of the system, the heterogeneous nature of such systems, or how evaluations and measurement can themselves improve performance. This paper describes the initial steps taken to build a performance measurement system to coordinate health equity across 18 hospitals led by the Toronto Central Local Health Integration Network, which is a regional health authority serving a population of more than 2.5 million residents (near in population to Chicago and Rome) and the most socially diverse urban network in Ontario, Canada. This paper also describes some principles that can help inform a performance measurement system. The innovative aspect of this paper is that these principles were developed through feedback by the hospitals.

Decision making and physician prescribing characteristics: a pilot study of Japanese physicians

The factors that affect physicians' prescribing remain unclear. Although previous reports suggest that prescription decisions are associated with various clinical situation, most of these studies analyzed simulated patient models rather than actual clinical practice. Here, we retrospectively analyzed actual cases of statin prescription for hyperlipidemia at Tohoku University Hospital between Apr 1, 2004 and Mar 31, 2008. Twelve physicians (6 cardiologists, 3 nephrologist, and 3 diabetologist) made decisions on whether to prescribe statins to 187 patients in 788 visits. As expected, cardiologists started prescribing statins at significantly lower serum total cholesterol levels than other specialists (221.7mg/dL vs. 244.7mg/dL, P<0.05). Interestingly, the total cholesterol levels that triggered prescribing differed significantly among cardiologists (p<0.05). These results suggested that prescription decisions differed not only among specialties but also among individuals.

Impact of pay for performance on ethnic disparities in intermediate outcomes for diabetes: a longitudinal study

OBJECTIVE

The purpose of this study was to examine the impact of a major pay for performance incentive on trends in the quality of diabetes care in white, black, and South Asian ethnic groups in an urban setting in the U.K.

RESEARCH DESIGN AND METHODS

We developed longitudinal models examining the quality of diabetes care in a cohort of ethnically diverse patients in Southwest London using electronic family practice records. Outcome measures were mean blood pressure and A1C values between 2000 and 2005.

RESULTS

The introduction of pay for performance was associated with reductions in mean systolic and diastolic blood pressure, which were significantly greater than those predicted by the underlying trend in the white (-5.8 and -4.2 mmHg), black (-2.5 and -2.4 mmHg), and South Asian (-5.5 and -3.3 mmHg) groups. Reductions in A1C levels were significantly greater than those predicted by the underlying trend in the white group (-0.5%) but not in the black (-0.3%) or South Asian (-0.4%) groups. Ethnic group disparities in annual measurement of blood pressure and A1C were abolished before the introduction of pay for performance.

CONCLUSIONS

The introduction of a pay for performance incentive in U.K. primary care was associated with improvements in the intermediate outcomes of diabetes care for all ethnic groups. However, the magnitude of improvement appeared to differ between ethnic groups, thus potentially widening existing disparities in care. Policy makers should consider the potential impacts of pay for performance incentives on health disparities when designing and evaluating such programs.