Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed 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).

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

This is an update of the Cochrane review published in Issue 5, 2011. Worldwide, cervical cancer is the fourth commonest cancer affecting women. High-risk human papillomavirus (HPV) infection is causative in 99.7% of cases. Other risk factors include smoking, multiple sexual partners, the presence of other sexually transmitted diseases and immunosuppression. Primary prevention strategies for cervical cancer focus on reducing HPV infection via vaccination and data suggest that this has the potential to prevent nearly 90% of cases in those vaccinated prior to HPV exposure. However, not all countries can afford vaccination programmes and, worryingly, uptake in many countries has been extremely poor. Secondary prevention, through screening programmes, will remain critical to reducing cervical cancer, especially in unvaccinated women or those vaccinated later in adolescence. This includes screening for the detection of pre-cancerous cells, as well as high-risk HPV. In the UK, since the introduction of the Cervical Screening Programme in 1988, the associated mortality rate from cervical cancer has fallen. However, worldwide, there is great variation between countries in both coverage and uptake of screening. In some countries, national screening programmes are available whereas in others, screening is provided on an opportunistic basis. Additionally, there are differences within countries in uptake dependent on ethnic origin, age, education and socioeconomic status. Thus, understanding and incorporating these factors in screening programmes can increase the uptake of screening. This, together with vaccination, can lead to cervical cancer becoming a rare disease.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical screening.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), Issue 6, 2020. MEDLINE, Embase and LILACS databases up to June 2020. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed risk of bias. Where possible, the data were synthesised in a meta-analysis using standard Cochrane methodology.

MAIN RESULTS

Comprehensive literature searches identified 2597 records; of these, 70 met our inclusion criteria, of which 69 trials (257,899 participants) were entered into a meta-analysis. The studies assessed the effectiveness of invitational and educational interventions, lay health worker involvement, counselling and risk factor assessment. Clinical and statistical heterogeneity between trials limited statistical pooling of data. Overall, there was moderate-certainty evidence to suggest that invitations appear to be an effective method of increasing uptake compared to control (risk ratio (RR) 1.71, 95% confidence interval (CI) 1.49 to 1.96; 141,391 participants; 24 studies). Additional analyses, ranging from low to moderate-certainty evidence, suggested that invitations that were personalised, i.e. personal invitation, GP invitation letter or letter with a fixed appointment, appeared to be more successful. More specifically, there was very low-certainty evidence to support the use of GP invitation letters as compared to other authority sources' invitation letters within two RCTs, one RCT assessing 86 participants (RR 1.69 95% CI 0.75 to 3.82) and another, showing a modest benefit, included over 4000 participants (RR 1.13, 95 % CI 1.05 to 1.21). Low-certainty evidence favoured personalised invitations (telephone call, face-to-face or targeted letters) as compared to standard invitation letters (RR 1.32, 95 % CI 1.11 to 1.21; 27,663 participants; 5 studies). There was moderate-certainty evidence to support a letter with a fixed appointment to attend, as compared to a letter with an open invitation to make an appointment (RR 1.61, 95 % CI 1.48 to 1.75; 5742 participants; 5 studies). Low-certainty evidence supported the use of educational materials (RR 1.35, 95% CI 1.18 to 1.54; 63,415 participants; 13 studies) and lay health worker involvement (RR 2.30, 95% CI 1.44 to 3.65; 4330 participants; 11 studies). Other less widely reported interventions included counselling, risk factor assessment, access to a health promotion nurse, photo comic book, intensive recruitment and message framing. It was difficult to deduce any meaningful conclusions from these interventions due to sparse data and low-certainty evidence. However, having access to a health promotion nurse and attempts at intensive recruitment may have increased uptake. One trial reported an economic outcome and randomised 3124 participants within a national screening programme to either receive the standard screening invitation, which would incur a fee, or an invitation offering screening free of charge. No difference in the uptake at 90 days was found (574/1562 intervention versus 612/1562 control, (RR 0.94, 95% CI: 0.86 to 1.03). The use of HPV self-testing as an alternative to conventional screening may also be effective at increasing uptake and this will be covered in a subsequent review. Secondary outcomes, including cost data, were incompletely documented. The majority of cluster-RCTs did not account for clustering or adequately report the number of clusters in the trial in order to estimate the design effect, so we did not selectively adjust the trials. It is unlikely that reporting of these trials would impact the overall conclusions and robustness of the results. Of the meta-analyses that could be performed, there was considerable statistical heterogeneity, and this should be borne in mind when interpreting these findings. Given this and the low to moderate evidence, further research may change these findings. The risk of bias in the majority of trials was unclear, and a number of trials suffered from methodological problems and inadequate reporting. We downgraded the certainty of evidence because of an unclear or high risk of bias with regards to allocation concealment, blinding, incomplete outcome data and other biases.

AUTHORS' CONCLUSIONS

There is moderate-certainty evidence to support the use of invitation letters to increase the uptake of cervical screening. Low-certainty evidence showed lay health worker involvement amongst ethnic minority populations may increase screening coverage, and there was also support for educational interventions, but it is unclear what format is most effective. The majority of the studies were from developed countries and so the relevance of low- and middle-income countries (LMICs), is unclear. Overall, the low-certainty evidence that was identified makes it difficult to infer as to which interventions were best, with exception of invitational interventions, where there appeared to be more reliable evidence.

Effectiveness of guideline dissemination and implementation strategies on health care professionals' behaviour and patient outcomes in the cancer care context: a systematic review

BACKGROUND

Health care professionals (HCPs) use clinical practice guidelines (CPGs) to make evidence-informed decisions regarding patient care. Although a large number of cancer-related CPGs exist, it is unknown which CPG dissemination and implementation strategies are effective for improving HCP behaviour and patient outcomes in a cancer care context. This review aimed to determine the effectiveness of CPG dissemination and/or implementation strategies among HCPs in a cancer care context.

METHODS

A comprehensive search of five electronic databases was conducted. Studies were limited to the dissemination and/or implementation of a CPG targeting both medical and/or allied HCPs in cancer care. Two reviewers independently coded strategies using the Mazza taxonomy, extracted study findings, and assessed study quality.

RESULTS

The search strategy identified 33 studies targeting medical and/or allied HCPs. Across the 33 studies, 23 of a possible 49 strategies in the Mazza taxonomy were used, with a mean number of 3.25 (SD = 1.45) strategies per intervention. The number of strategies used per intervention was not associated with positive outcomes. Educational strategies (n = 24), feedback on guideline compliance (n = 11), and providing reminders (n = 10) were the most utilized strategies. When used independently, providing reminders and feedback on CPG compliance corresponded with positive significant changes in outcomes. Further, when used as part of multi-strategy interventions, group education and organizational strategies (e.g. creation of an implementation team) corresponded with positive significant changes in outcomes.

CONCLUSIONS

Future CPG dissemination and implementation interventions for cancer care HCPs may benefit from utilizing the identified strategies. Research in this area should aim for better alignment between study objectives, intervention design, and evaluation measures, and should seek to incorporate theory in intervention design, so that behavioural antecedents are considered and measured; doing so would enhance the field's understanding of the causal mechanisms by which interventions lead, or do not lead, to changes in outcomes at all levels.

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.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

Application of Unit-Level Cost Transparency, Education, Enhanced Audit, and Feedback of Anonymized Peer Ranking to Promote Judicious Use of 25% Albumin in Critical Care Units

Objective: Hyperoncotic 25% albumin is widely used for fluid resuscitation in intensive care units. However, this practice remains controversial. By 2012 in our intensive care unit, annual 25% albumin expenditures had steadily increased to exceed $1 million. This prompted efforts to promote more judicious use. Design: Prospective time series cohort analysis using statistical process control charts. Setting: Seventy-six-bed quaternary level cardiovascular surgical intensive care unit (CVICU), organized into 6 adjacent units. Patients: Adult cardiac, thoracic, and vascular surgery patients admitted postoperatively to the CVICU during the study period. Interventions: Over 12 months starting March 2013, we sequentially implemented unit-level 25% albumin cost transparency, provider education, and individualized audit and feedback of anonymized peer ranking of albumin prescriptions. Measurements and Main Results: C control charts were used for analysis of monthly unit-level direct albumin costs for 20 months. Balance measures including red cell transfusions, number of diagnoses of pleural effusions, and length of stay were also tracked. Monthly average albumin expenditures had decreased 61% by December 2014, and there was no evidence of adverse changes in any of the balance measures. These reductions have been sustained. Conclusion: Sequential implementation of multimodal strategies can alter clinician practices to achieve substantial unit-level reduction in 25% albumin utilization without harm to patients.

Why Money Alone Can’t (Always) “Nudge” Physicians

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

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.

Payment incentives for community-based psychiatric care in Ontario, Canada

BACKGROUND

In September 2011, the government of Ontario implemented payment incentives to encourage the delivery of community-based psychiatric care to patients after discharge from a psychiatric hospital admission and to those with a recent suicide attempt. We evaluated whether these incentives affected supply of psychiatric services and access to care.

METHODS

We used administrative data to capture monthly observations for all psychiatrists who practised in Ontario between September 2009 and August 2014. We conducted interrupted time-series analyses of psychiatrist-level and patient-level data to evaluate whether the incentives affected the quantity of eligible outpatient services delivered and the likelihood of receiving follow-up care.

RESULTS

Among 1921 psychiatrists evaluated, implementation of the incentive payments was not associated with increased provision of follow-up visits after discharge from a psychiatric hospital admission (mean change in visits per month per psychiatrist 0.0099, 95% confidence interval [CI] -0.0989 to 0.1206; change in trend 0.0032, 95% CI -0.0035 to 0.0095) or after a suicide attempt (mean change -0.0910, 95% CI -0.1885 to 0.0026; change in trend 0.0102, 95% CI 0.0045 to 0.0159). There was also no change in the probability that patients received follow-up care after discharge (change in level -0.0079, 95% CI -0.0223 to 0.0061; change in trend 0.0007, 95% CI -0.0003 to 0.0016) or after a suicide attempt (change in level 0.0074, 95% CI -0.0094 to 0.0366; change in trend 0.0006, 95% CI -0.0007 to 0.0022).

INTERPRETATION

Our results suggest that implementation of the incentives did not increase access to follow-up care for patients after discharge from a psychiatric hospital admission or after a suicide attempt, and the incentives had no effect on supply of psychiatric services. Further research to guide design and implementation of more effective incentives is warranted.

Impact of caregiver incentives on child health: Evidence from an experiment with Anganwadi workers in India

This paper tests the effectiveness of performance pay and bonuses among government childcare workers in India. In a controlled study of 160 ICDS centers serving over 4000 children, we randomly assign workers to either fixed bonuses or payments based on the nutritional status of children in their care, and also collect data from a control group receiving only standard salaries. In all three study arms mothers receive nutrition information. We find that performance pay reduces underweight prevalence by about 5 percentage points over 3 months, and height improves by about one centimeter. Impacts on weight continue when incentives are renewed and return to parallel trends thereafter. Fixed bonuses are less expensive but lead to smaller and less precisely estimated effects than performance pay, especially for children near malnutrition thresholds. Both treatments improve worker effort and communication with mothers, who in turn feed a more calorific diet to children at home.

Characterization and effectiveness of pay-for-performance in ophthalmology: a systematic review

Background

To identify, characterize and compare existing pay-for-performance approaches and their impact on the quality of care and efficiency in ophthalmology.

Methods

A systematic evidence-based review was conducted. English, French and German written literature published between 2000 and 2015 were searched in the following databases: Medline (via PubMed), NCBI web site, Scopus, Web of Knowledge, Econlit and the Cochrane Library. Empirical as well as descriptive articles were included. Controlled clinical trials, meta-analyses, randomized controlled studies as well as observational studies were included as empirical articles. Systematic characterization of identified pay-for-performance approaches (P4P approaches) was conducted according to the “Model for Implementing and Monitoring Incentives for Quality” (MIMIQ). Methodological quality of empirical articles was assessed according to the Critical Appraisal Skills Programme (CASP) checklists.

Results

Overall, 13 relevant articles were included. Eleven articles were descriptive and two articles included empirical analyses. Based on these articles, four different pay-for-performance approaches implemented in the United States were identified. With regard to quality and incentive elements, systematic comparison showed numerous differences between P4P approaches. Empirical studies showed isolated cost or quality effects, while a simultaneous examination of these effects was missing.

Conclusion

Research results show that experiences with pay-for-performance approaches in ophthalmology are limited. Identified approaches differ with regard to quality and incentive elements restricting comparability. Two empirical studies are insufficient to draw strong conclusions about the effectiveness and efficiency of these approaches.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-017-2333-x) contains supplementary material, which is available to authorized users.

The Impact of a Pay-for-Performance Program on Central Line-Associated Blood Stream Infections in Pennsylvania

Healthcare associated infections have significantly contributed to the rising cost of hospital care in the United States. The implementation of pay-for-performance (P4P) programs has been one approach to improve quality at a reduced cost. We quantify the impact of Highmark's Quality Blue (QB) hospital P4P program on central line-associated blood stream infections (CLABSI) in Pennsylvania. The impact of years of participation in QB on CLABSI is also evaluated. Data from 149 Pennsylvania hospitals on CLABSI from 2008-2013 are used. Negative binomial regression and fixed effects panel regression are performed. Hospitals participating in QB have 0.727 times the CLABSI as those hospitals that do not participate. Hospitals participating for four or more years have on average 3.13 fewer CLABSI per year compared to those participating for less than four years. Highmark's P4P program has shown improved outcomes with regards to CLABSI, but further research is needed to determine if QB is cost effective.

Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care

The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy. (PsycINFO Database Record

Payment methods for outpatient care facilities

BACKGROUND

Outpatient care facilities provide a variety of basic healthcare services to individuals who do not require hospitalisation or institutionalisation, and are usually the patient's first contact. The provision of outpatient care contributes to immediate and large gains in health status, and a large portion of total health expenditure goes to outpatient healthcare services. Payment method is one of the most important incentive methods applied by purchasers to guide the performance of outpatient care providers.

OBJECTIVES

To assess the impact of different payment methods on the performance of outpatient care facilities and to analyse the differences in impact of payment methods in different settings.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), 2016, Issue 3, part of the Cochrane Library (searched 8 March 2016); MEDLINE, OvidSP (searched 8 March 2016); Embase, OvidSP (searched 24 April 2014); PubMed (NCBI) (searched 8 March 2016); Dissertations and Theses Database, ProQuest (searched 8 March 2016); Conference Proceedings Citation Index (ISI Web of Science) (searched 8 March 2016); IDEAS (searched 8 March 2016); EconLit, ProQuest (searched 8 March 2016); POPLINE, K4Health (searched 8 March 2016); China National Knowledge Infrastructure (searched 8 March 2016); Chinese Medicine Premier (searched 8 March 2016); OpenGrey (searched 8 March 2016); ClinicalTrials.gov, US National Institutes of Health (NIH) (searched 8 March 2016); World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (searched 8 March 2016); and the website of the World Bank (searched 8 March 2016).In addition, we searched the reference lists of included studies and carried out a citation search for the included studies via ISI Web of Science to find other potentially relevant studies. We also contacted authors of the main included studies regarding any further published or unpublished work.

SELECTION CRITERIA

Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for outpatient health facilities. We defined outpatient care facilities in this review as facilities that provide health services to individuals who do not require hospitalisation or institutionalisation. We only included methods used to transfer funds from the purchaser of healthcare services to health facilities (including groups of individual professionals). These include global budgets, line-item budgets, capitation, fee-for-service (fixed and unconstrained), pay for performance, and mixed payment. The primary outcomes were service provision outcomes, patient outcomes, healthcare provider outcomes, costs for providers, and any adverse effects.

DATA COLLECTION AND ANALYSIS

At least two review authors independently extracted data and assessed the risk of bias. We conducted a structured synthesis. We first categorised the comparisons and outcomes and then described the effects of different types of payment methods on different categories of outcomes. We used a fixed-effect model for meta-analysis within a study if a study included more than one indicator in the same category of outcomes. We used a random-effects model for meta-analysis across studies. If the data for meta-analysis were not available in some studies, we calculated the median and interquartile range. We reported the risk ratio (RR) for dichotomous outcomes and the relative change for continuous outcomes.

MAIN RESULTS

We included 21 studies from Afghanistan, Burundi, China, Democratic Republic of Congo, Rwanda, Tanzania, the United Kingdom, and the United States of health facilities providing primary health care and mental health care. There were three kinds of payment comparisons. 1) Pay for performance (P4P) combined with some existing payment method (capitation or different kinds of input-based payment) compared to the existing payment methodWe included 18 studies in this comparison, however we did not include five studies in the effects analysis due to high risk of bias. From the 13 studies, we found that the extra P4P incentives probably slightly improved the health professionals' use of some tests and treatments (adjusted RR median = 1.095, range 1.01 to 1.17; moderate-certainty evidence), and probably led to little or no difference in adherence to quality assurance criteria (adjusted percentage change median = -1.345%, range -8.49% to 5.8%; moderate-certainty evidence). We also found that P4P incentives may have led to little or no difference in patients' utilisation of health services (adjusted RR median = 1.01, range 0.96 to 1.15; low-certainty evidence) and may have led to little or no difference in the control of blood pressure or cholesterol (adjusted RR = 1.01, range 0.98 to 1.04; low-certainty evidence). 2) Capitation combined with P4P compared to fee-for-service (FFS)One study found that compared with FFS, a capitated budget combined with payment based on providers' performance on antibiotic prescriptions and patient satisfaction probably slightly reduced antibiotic prescriptions in primary health facilities (adjusted RR 0.84, 95% confidence interval 0.74 to 0.96; moderate-certainty evidence). 3) Capitation compared to FFSTwo studies compared capitation to FFS in mental health centres in the United States. Based on these studies, the effects of capitation compared to FFS on the utilisation and costs of services were uncertain (very low-certainty evidence).

AUTHORS' CONCLUSIONS

Our review found that if policymakers intend to apply P4P incentives to pay health facilities providing outpatient services, this intervention will probably lead to a slight improvement in health professionals' use of tests or treatments, particularly for chronic diseases. However, it may lead to little or no improvement in patients' utilisation of health services or health outcomes. When considering using P4P to improve the performance of health facilities, policymakers should carefully consider each component of their P4P design, including the choice of performance measures, the performance target, payment frequency, if there will be additional funding, whether the payment level is sufficient to change the behaviours of health providers, and whether the payment to facilities will be allocated to individual professionals. Unfortunately, the studies included in this review did not help to inform those considerations.Well-designed comparisons of different payment methods for outpatient health facilities in low- and middle-income countries and studies directly comparing different designs (e.g. different payment levels) of the same payment method (e.g. P4P or FFS) are needed.

Effect of pay-for-performance on cervical cancer screening participation in France

Pay-for-performance (P4P) has been increasingly used across different healthcare settings to incentivize the provision of targeted services. In this study, we investigated the effect of a nationwide P4P scheme for general practitioners implemented in 2012 in France, on cervical cancer screening practices. Using data from a nationally representative permanent sample of health insurance beneficiaries, we analyzed smear test use of eligible women for the years 2006-2014. Our longitudinal sample was an unbalanced panel comprising 180,167 women eligible from 1 to 9 years each. We took into account that during our study period some women were exposed to another incentive for screening participation: the implementation in 2010 of organized screening (OS) in a limited number of areas. To evaluate the effect of P4P, we defined three different measures of smear utilization. For each measure, we specified binary panel-data models to estimate annual probabilities and to compare each estimate to the 2011 baseline level. To explore the combined effect of P4P and OS in areas exposed to both incentives, we computed interaction terms between year dummies and area of residence. We found that P4P had a modest positive effect on recommended screening participation. This effect is likely to be transient as annual smear use, both for the whole sample and among women overdue for screening, increased only in 2013 and decreased again in 2014. The combined effect of P4P and OS on screening participation was not cumulative during the first years of coexistence.

Will Financial Incentives Stimulate Quality Improvement? Reactions From Frontline Physicians

Pay-for-performance is being applied at the physician level to stimulate improvements in quality of care and cost efficiency; however, little is known about how physicians will respond. We interviewed physicians exposed to a financial incentive program in California to identify possible barriers to the successful application of financial incentives by exploring physicians' opinions of and experiences with pay-for-performance programs. Reasons physicians cited for quality deficiencies included insurance coverage limitations and lack of patient compliance, time, and proper physician oversight. Physicians believe that they play a significant role and have a moderate to high degree of control over quality of care and that it is important to self-monitor. Physicians expressed the need for accurate and timely data, peer comparisons, and more patient time, staff support, and consultations with colleagues to successfully monitor and deliver quality care. Many support increased pay for delivering high-quality care but question measurement accuracy, bonus payment financing, and health plan involvement.

Medicaid Pay for Performance Programs and Childhood Immunization Status

INTRODUCTION

Although pay for performance (P4P) programs are being increasingly used by state Medicaid programs to provide incentives for managed care plans to provide high-quality care, no national study has examined the effects of these plans on commonly targeted outcomes such as childhood immunization rates.

METHODS

Information from the 1999-2011 National Immunization Survey combined with information on state Medicaid P4P programs from the Centers for Medicare and Medicaid Services was used to study the effect of Medicaid P4P programs on the immunization status of children aged 19-35 months. Difference-in-difference-in-difference models were used to study whether adoption of Medicaid P4P programs was associated with higher immunization rates among Medicaid-eligible children relative to non-Medicaid eligible children within states that adopted Medicaid P4P programs compared with states that did not. Linear probability models were used in all estimations, and models controlled for demographic factors.

RESULTS

The study found no overall effect of Medicaid P4P on the chance that children aged 19-35 months had completed the 4:3:1:3:3:1 vaccination series. However, there was a 4 percentage point increase in the chance that a child 19-23 months had completed the series.

CONCLUSIONS

This study provides some evidence that Medicaid P4P programs may be helpful in improving childhood vaccination rates. Further study of the effects on other targeted outcomes as well as the effects of different P4P program designs may increase understanding of the potential role of these programs in improving the quality of health care.

Pay for Performance in Medicaid: Evidence from Three Natural Experiments

OBJECTIVE

To examine the impact of pay for performance in Medicaid on the quality and utilization of care.

DATA SOURCES

Medicaid claims and encounter data in three intervention states (Pennsylvania, Minnesota, and Alabama) and three comparison states.

STUDY DESIGN

Difference-in-difference analysis with propensity score-matched comparison group. Primary outcomes of interest were Healthcare Effectiveness Data and Information Set (HEDIS)-like process measures of quality, utilization by service category, and ambulatory care-sensitive admissions and emergency department visits.

PRINCIPAL FINDINGS

In Pennsylvania, there was a statistically significant reduction of 88 ambulatory visits per 1,000 enrollee months compared with Florida. In Minnesota, there was a significant decrease of 7.2 hospital admissions per thousand enrollee months compared with Wisconsin. In Alabama, where incentives were not paid out until the end of a 2-year waiver period, there was a decline of 1.6 hospital admissions per thousand member months, and an increase of 59 ambulatory visits per 1,000 enrollees compared with Georgia. No significant quality improvements in intervention relative to control states.

CONCLUSIONS

Our findings are mixed, with no measurable quality improvements across the three states, but reductions in hospital admissions in two programs. As states move to value-based payment for patient-centered medical homes and Accountable Care Organizations, lessons learned from these pioneering states should inform program design.

[Pay-for-performance in health care services: a review of the best evidence available]

Pay-for-performance (P4P) has been widely used around the world seeking to improve health outcomes, and in Brazil it is the basis of the National Program for Improving Access and Quality (PMAQ). The literature published between 1998 and January 2013 that evaluated the effectiveness of P4P to produce results or patterns of access and quality in health was scrutinized. A total of 138 studies, with the inclusion of a further 41 studies (14 systematic reviews, 07 clinical trials and 20 observational studies) were retrieved and analyzed Among the more rigorous studies, favorable conclusions for P4P were less frequent, whereas observational studies were more favorable to positive effects of P4P on the quality of, and access to, health services. Methodological limitations of observational studies may have contributed to these results, but the range of results is more linked to the conceptual and contextual aspects of the use of the P4P schemes reviewed, the heterogeneity of P4P models and results. P4P can be helpful in promoting the achievement of objectives in health care systems, especially in the short term and for specific actions requiring less effort of health care providers, but should be used with caution and with a rigorous planning model, also considering undesirable or adverse effects.

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.

Impacts of pay for performance on the quality of primary care

Increasingly, financial incentives are being used in health care as a result of increasing demand for health care coupled with fiscal pressures. Financial incentive schemes are one approach by which the system may incentivize providers of health care to improve productivity and/or adapt to better quality provision. Pay for performance (P4P) is an example of a financial incentive which seeks to link providers’ payments to some measure of performance. This paper provides a discussion of the theoretical underpinnings of P4P, gives an overview of the health P4P evidence base, and provide a detailed case study of a particularly large scheme from the English National Health Service. Lessons are then drawn from the evidence base. Overall, we find that the evidence for the effectiveness of P4P for improving quality of care in primary care is mixed. This is to some extent due to the fact that the P4P schemes used in primary care are also mixed. There are many different schemes that incentivize different aspects of care in different ways and in different settings, making evaluation problematic. The Quality and Outcomes Framework in the United Kingdom is the largest example of P4P in primary care. Evidence suggests incentivized quality initially improved following the introduction of the Quality and Outcomes Framework, but this was short-lived. If P4P in primary care is to have a long-term future, the question about scheme effectiveness (perhaps incorporating the identification and assessment of potential risk factors) needs to be answered robustly. This would require that new schemes be designed from the onset to support their evaluation: control and treatment groups, coupled with before and after data.

A Qualitative Evaluation of the Performance-based Supplementary Payment System in Turkey

The Ministry of Health of Turkey introduced performance-based supplementary payment (PBSP) system in 2004. The importance of feedbacks from healthcare providers regarding the implementation of alternative health policies has been recognized in the literature. This study reports the perceptions of physicians about the PBSP system in Turkey. A qualitative analysis has been conducted in two hospitals in the Western province of Turkey, Balıkesir. Analysis results suggest that physicians have limited awareness about the pay for performance system. They agree that the PBSP system has not achieved the objectives of enhancing productivity, efficiency and quality of care. The major contributing factors to the limited success of the system have been identified as increased workload, stress and competition among the physicians. Thus revisions have been suggested for the proper implementation of the programme, which include the determination of a maximum number of medical examinations.

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.

Provider payment methods and health worker motivation in community-based health insurance: a mixed-methods study

In a community-based health insurance (CBHI) introduced in 2004 in Nouna health district, Burkina Faso, poor perceived quality of care by CBHI enrollees has been a key factor in observed high drop-out rates. The poor quality perceptions have been previously attributed to health worker dissatisfaction with the provider payment method used by the scheme and the resulting financial risk of health centers. This study applied a mixed-methods approach to investigate how health workers working in facilities contracted by the CBHI view the methods of provider payment used by the CBHI. In order to analyze these relationships, we conducted 23 in-depth interviews and a quantitative survey with 98 health workers working in the CBHI intervention zone. The qualitative in-depth interviews identified that insufficient levels of capitation payments, the infrequent schedule of capitation payment, and lack of a payment mechanism for reimbursing service fees were perceived as significant sources of health worker dissatisfaction and loss of work-related motivation. Combining qualitative interview and quantitative survey data in a mixed-methods analysis, this study identified that the declining quality of care due to the CBHI provider payment method was a source of significant professional stress and role strain for health workers. Health workers felt that the following five changes due to the provider payment methods introduced by the CBHI impeded their ability to fulfill professional roles and responsibilities: (i) increased financial volatility of health facilities, (ii) dissatisfaction with eligible costs to be covered by capitation; (iii) increased pharmacy stock-outs; (iv) limited financial and material support from the CBHI; and (v) the lack of mechanisms to increase provider motivation to support the CBHI. To address these challenges and improve CBHI uptake and health outcomes in the targeted populations, the health care financing and delivery model in the study zone should be reformed. We discuss concrete options for reform based on the study findings.

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.

Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan? Qual Life Res. 2014;23:687-696. [PMID: 23975377 DOI: 10.1007/s11136-013-0502-x]

PURPOSE

In October 2001, a pay-for-performance (P4P) program for diabetes was implemented by the National Health Insurance (NHI), a single-payer program, in Taiwan. However, only limited information is available regarding the influence of this program on the patient's health-related quality of life. The aim of this study was to estimate the costs and consequences of enrolling patients in the P4P program from a single-payer perspective.

METHODS

A retrospective observational study of 529 diabetic patients was conducted between 2004 and 2005. The data used in the study were obtained from the National Health Interview Survey (NHIS) in Taiwan. Direct cost data were obtained from NHI claims data, which were linked to respondents in the NHIS using scrambled individual identification. The generic SF36 health instrument was employed to measure the quality-of-life-related health status and transformed into a utility index. Patients enrolled in the P4P program for at least 3 months were categorized as the P4P group. Following propensity score matching, 260 patients were included in the study. Outcomes included life-years, quality-adjusted life-years (QALYs), diabetes-related medical costs, overall medical costs, and incremental cost-effectiveness ratios (ICERs). A single-payer perspective was assumed, and costs were expressed in US dollars. Nonparametric bootstrapping was conducted to estimate confidence intervals for cost-effectiveness ratios.

RESULTS

Following matching, no significant difference was noted between two groups with regard to the patients' age, gender, education, family income, smoking status, BMI, or whether insulin was used. The P4P group had an increase of 0.08 (95 % CI 0.077-0.080) in QALYs, and the additional diabetes-related medical cost was US$422.74 (95 % CI US$413.58-US$435.05), yielding an ICER of US$5413.93 (95 % CI US$5226.83-US$5562.97) per QALY gained.

CONCLUSIONS

Our results provides decision makers with valuable information regarding the impact of the P4P program of diabetes care through a direct comparison of equivalent groups of patients receiving regular care. Under the single-payer NHI system, the use of financial incentives under the DM-P4P program may be an effective means to ensure the quality of follow-up treatment.

Motivating health workers for the provision of directly observed treatment to TB patients in rural China: does cash incentive work? A qualitative study

As a key component of DOTS (directly observed treatment, short course) strategy, DOT is essential in the prevention of drug-resistant tuberculosis. However, DOT had very poor implementation in rural areas of China. One major reason to this problem was the lack of incentives for DOT providers. In 2005, the Chinese Minister of Health released an incentive strategy that aimed to improve the DOT performance of rural health workers by providing allowances. Our study used a qualitative method to explore the practical impact of this incentive strategy in motivating rural DOT providers, and searched for other potential incentive measures as well. A total of 16 focus group discussions were carried out among 102 rural health workers in eight counties of China. A semi-structured theme outline was used to collect the perception, attitude and experiences of health workers toward the DOT implementation as well as the cash incentive strategy. Findings showed that DOT allowance had some incentive effect to DOT providers, but its extent was circumscribed by the small amount and operational problems. Raising DOT allowance and removing existing barriers to DOT provision might result in a greater motivational impact, particularly in less developed areas of China, where health workers were more likely to encounter financial and other obstacles in delivering DOT services to TB patients in rural areas.

Key issues in the design of pay for performance programs

Pay for performance (P4P) is increasingly being used to stimulate healthcare providers to improve their performance. However, evidence on P4P effectiveness remains inconclusive. Flaws in program design may have contributed to this limited success. Based on a synthesis of relevant theoretical and empirical literature, this paper discusses key issues in P4P-program design. The analysis reveals that designing a fair and effective program is a complex undertaking. The following tentative conclusions are made: (1) performance is ideally defined broadly, provided that the set of measures remains comprehensible, (2) concerns that P4P encourages "selection" and "teaching to the test" should not be dismissed, (3) sophisticated risk adjustment is important, especially in outcome and resource use measures, (4) involving providers in program design is vital, (5) on balance, group incentives are preferred over individual incentives, (6) whether to use rewards or penalties is context-dependent, (7) payouts should be frequent and low-powered, (8) absolute targets are generally preferred over relative targets, (9) multiple targets are preferred over single targets, and (10) P4P should be a permanent component of provider compensation and is ideally "decoupled" form base payments. However, the design of P4P programs should be tailored to the specific setting of implementation, and empirical research is needed to confirm the conclusions.

Building theories of knowledge translation interventions: use the entire menu of constructs

Background

In the ongoing effort to develop and advance the science of knowledge translation (KT), an important question has emerged around how theory should inform the development of KT interventions.

Discussion

Efforts to employ theory to better understand and improve KT interventions have until recently mostly involved examining whether existing theories can be usefully applied to the KT context in question. In contrast to this general theory application approach, we propose a ‘menu of constructs’ approach, where individual constructs from any number of theories may be used to construct a new theory. By considering the entire menu of available constructs, rather than limiting choice to the broader level of theories, we can leverage knowledge from theories that would never on their own provide a complete picture of a KT intervention, but that nevertheless describe components or mechanisms relevant to it. We can also avoid being forced to adopt every construct from a particular theory in a one-size-fits-all manner, and instead tailor theory application efforts to the specifics of the situation. Using audit and feedback as an example KT intervention strategy, we describe a variety of constructs (two modes of reasoning, cognitive dissonance, feed forward, desirable difficulties and cognitive load, communities of practice, and adaptive expertise) from cognitive and educational psychology that make concrete suggestions about ways to improve this class of intervention.

Summary

The ‘menu of constructs’ notion suggests an approach whereby a wider range of theoretical constructs, including constructs from cognitive theories with scope that makes the immediate application to the new context challenging, may be employed to facilitate development of more effective KT interventions.

Physician-targeted financial incentives and primary care physicians' self-reported ability to provide high-quality primary care

OBJECTIVE

High-quality primary care is envisaged as the centerpiece of the emerging health care delivery system under the Affordable Care Act. Reengineering the US health care system into a primary care-driven model will require widespread, rapid changes in the management and organization of primary care physicians (PCPs). Financial incentives to influence physician behavior have been attempted with various approaches, without empirical evidence of their effectiveness in improving care quality. This study examines the above research question adjusting for the patient-centeredness of the practice climate, a major contextual factor affecting PCPs' ability to provide high-quality care.

METHODS

Secondary data on a sample of salaried PCPs (n = 1733) from the nation-wide Community Tracking Study Physician Survey 2004-2005 were subject to generalized multinomial logit modeling to examine associations between financial incentives and PCPs' self-reported ability to provide quality care.

RESULTS

After adjusting for patient-centered medical home (PCMH)-consistent practice environment, financial incentive aligned with care quality/care content is positively associated with PCPs' ability to provide high-quality care. An encouraging finding was that financial incentives aligned with clinic productivity/profitability do not to impede high-quality care in a PCMH practice environment.

CONCLUSION

Financial incentives targeted to care quality or content indicators may facilitate rapid transformation of the health system to a primary care-driven system. The study provides empirical evidence of the utility of practically deployable financial incentives to facilitate high-quality primary care.

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.

Lessons from healthcare providers' attitudes toward pay-for-performance: what should purchasers consider in designing and implementing a successful program?

We conducted a systematic review to summarize providers' attitudes toward pay-for-performance (P4P), focusing on their general attitudes, the effects of P4P, their favorable design and implementation methods, and concerns. An electronic search was performed in PubMed and Scopus using selected keywords including P4P. Two reviewers screened target articles using titles and abstract review and then read the full version of the screened articles for the final selections. In addition, one reference of screened articles and one unpublished report were also included. Therefore, 14 articles were included in this study. Healthcare providers' attitudes on P4P were summarized in two ways. First, we gathered their general attitudes and opinions regarding the effects of P4P. Second, we rearranged their opinions regarding desirable P4P design and implementation methods, as well as their concerns. This study showed the possibility that some healthcare providers still have a low level of awareness about P4P and might prefer voluntary participation in P4P. In addition, they felt that adequate quality indicators and additional support for implementation of P4P would be needed. Most healthcare providers also had serious concerns that P4P would induce unintended consequences. In order to conduct successful implementation of P4P, purchaser should make more efforts such as increasing providers' level of awareness about P4P, providing technical and educational support, reducing their burden, developing a cooperative relationship with providers, developing more accurate quality measures, and minimizing the unintended consequences.

The use of three strategies to improve quality of care at a national level

BACKGROUND

Improving the quality of care is essential and a priority for patients, surgeons, and healthcare providers. Strategies to improve quality have been proposed at the national level either through accreditation standards or through national payment schemes; however, their effectiveness in improving quality is controversial.

QUESTIONS/PURPOSES

The purpose of this review was to address three questions: (1) does pay-for-performance improve the quality of care; (2) do surgical safety checklists improve the quality of surgical care; and (3) do practice guidelines improve the quality of care? These three strategies were chosen because there has been some research assessing their effectiveness in improving quality, and implementation had been attempted on a large scale such as entire countries.

METHODS

We performed a literature review from 1950 forward using Medline to identify Level I and II studies. We evaluated the three strategies and their effects on processes and outcomes of care. When possible, we examined strategy implementation, patients, and systems, including provider characteristics, which may affect the relationship between intervention and outcomes with a focus on factors that may have influenced effect size.

RESULTS

Pay-for-performance improved the process and to a lesser extent the outcome of care. Surgical checklists reduced morbidity and mortality. Explicit practice guidelines influenced the process and to a lesser extent the outcome of care. Although not definitively showed, clinician involvement during development of intervention and outcomes, with explicit strategies for communication and implementation, appears to increase the likelihood of positive results.

CONCLUSION

Although the cost-effectiveness of these three strategies is unknown, quality of care could be enhanced by implementing pay-for-performance, surgical safety checklists, and explicit practice guidelines. However, this review identified that the effectiveness of these strategies is highly context-specific.

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.

Factors influencing colorectal cancer screening participation. Gastroenterol Res Pract. 2012;2012:483417. [PMID: 22190913 PMCID: PMC3235570 DOI: 10.1155/2012/483417]

Colorectal cancer (CRC) is a major health problem worldwide. Although population-based CRC screening is strongly recommended in average-risk population, compliance rates are still far from the desirable rates. High levels of screening uptake are necessary for the success of any screening program. Therefore, the investigation of factors influencing participation is crucial prior to design and launches a population-based organized screening campaign. Several studies have identified screening behaviour factors related to potential participants, providers, or health care system. These influencing factors can also be classified in non-modifiable (i.e., demographic factors, education, health insurance, or income) and modifiable factors (i.e., knowledge about CRC and screening, patient and provider attitudes or structural barriers for screening). Modifiable determinants are of great interest as they are plausible targets for interventions. Interventions at different levels (patient, providers or health care system) have been tested across the studies with different results. This paper analyzes factors related to CRC screening behaviour and potential interventions designed to improve screening uptake.

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.

"All the money in the world …" patient perspectives regarding the influence of financial incentives

OBJECTIVE

To analyze patient perspectives of the use of financial incentives in a hypertension intervention. Study Setting. Twelve Veterans Affairs primary care clinics over a 9-month period.

STUDY DESIGN

Qualitative semistructured interviews conducted with 54 hypertensive veterans participating in an intervention to promote guideline-consistent therapy. Intervention components included an intervention letter requesting patients talk with their providers, an offer of U.S.$20 to bring in the letter to their provider, and a health educator phone call.

DATA COLLECTION METHODS

Semistructured interviews were conducted. Transcripts were coded for thematic content. The financial incentive theme was then subcoded for more detailed analysis.

PRINCIPLE FINDINGS

Most participants (n=48; 88.9 percent) stated the incentive had (or would have) no effect on their decision to initiate a discussion with their provider. Some participants articulated reservations about the effectiveness and/or appropriateness of financial incentives in health care decisions; however, a few expressed the opinion that there may be some potential benefits to the use of financial incentives if they encourage patients to be active in their health care.

CONCLUSION

The findings of this study raise questions about the appropriateness and unintended consequences of employing patient-directed financial incentives in health care settings.

Interventions targeted at women to encourage the uptake of cervical screening

BACKGROUND

World-wide, cervical cancer is the second most common cancer in women. Increasing the uptake of screening, alongside increasing informed choice is of great importance in controlling this disease through prevention and early detection.

OBJECTIVES

To assess the effectiveness of interventions aimed at women, to increase the uptake, including informed uptake, of cervical cancer screening.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Issue 1, 2009. MEDLINE, EMBASE and LILACS databases up to March 2009. We also searched registers of clinical trials, abstracts of scientific meetings, reference lists of included studies and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of interventions to increase uptake/informed uptake of cervical cancer screening.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias. Where possible the data were synthesised in a meta-analysis.

MAIN RESULTS

Thirty-eight trials met our inclusion criteria. These trials assessed the effectiveness of invitational and educational interventions, counselling, risk factor assessment and procedural interventions. Heterogeneity between trials limited statistical pooling of data. Overall, however, invitations appear to be effective methods of increasing uptake. In addition, there is limited evidence to support the use of educational materials. Secondary outcomes including cost data were incompletely documented so evidence was limited. Most trials were at moderate risk of bias. Informed uptake of cervical screening was not reported in any trials.

AUTHORS' CONCLUSIONS

There is evidence to support the use of invitation letters to increase the uptake of cervical screening. There is limited evidence to support educational interventions but it is unclear what format is most effective. The majority of the studies are from developed countries and so the relevance to developing countries is unclear.

[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.

Are primary care providers uncomfortable providing routine preventive care for inflammatory bowel disease patients?

BACKGROUND AND AIMS

Those with chronic diseases, including inflammatory bowel disease (IBD), often do not receive preventive care at the same rate as the general population. Attitudes of primary care providers could be key factors in the receipt of preventive care.

METHODS

We surveyed attendees of a family medicine review course. The survey contained nine demographic items, four items to assess exposure to and comfort level with IBD, and six clinical vignettes.

RESULTS

Of surveys, 36% (61/169) were returned. The large majority were males practicing outpatient family medicine. Mean age was 51 years, and 48% reported a mostly rural practice. Of subjects, 10% reported either having IBD themselves or having a close associate or relative with IBD. Only 37% of subjects felt comfortable providing primary care across a range of illness severity. Forty-six percent reported moderate or high exposure to IBD. For the case vignettes, the overall highest rate of endorsement of the active role was 84% for a case related to stage I hypertension, while the lowest rate was 30% for an item relating to vaccination for immunosuppressed persons. We assessed the following predictors of comfort level and active role responses and found no significant associations: age, gender, years of medical practice, and close contact with IBD.

CONCLUSIONS

Our study suggests that family medicine practitioners often do not feel comfortable providing care to IBD patients. Lack of familiarity with IBD medications may be a key factor.

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."

Reimbursement policy and androgen-deprivation therapy for prostate cancer

BACKGROUND

The Medicare Modernization Act led to moderate reductions in reimbursement for androgen-deprivation therapy (ADT) for prostate cancer, starting in 2004 and followed by substantial changes in 2005. We hypothesized that these reductions would lead to decreases in the use of ADT for indications that were not evidence based.

METHODS

Using the Surveillance, Epidemiology, and End Results (SEER) Medicare database, we identified 54,925 men who received a diagnosis of incident prostate cancer from 2003 through 2005. We divided these men into groups according to the strength of the indication for ADT use. The use of ADT was deemed to be inappropriate as primary therapy for men with localized cancers of a low-to-moderate grade (for whom a survival benefit of such therapy was improbable), appropriate as adjuvant therapy with radiation therapy for men with locally advanced cancers (for whom a survival benefit was established), and discretionary for men receiving either primary or adjuvant therapy for localized but high-grade tumors. The proportion of men receiving ADT was calculated according to the year of diagnosis for each group. We used modified Poisson regression models to calculate the effect of the year of diagnosis on the use of ADT.

RESULTS

The rate of inappropriate use of ADT declined substantially during the study period, from 38.7% in 2003 to 30.6% in 2004 to 25.7% in 2005 (odds ratio for ADT use in 2005 vs. 2003, 0.72; 95% confidence interval [CI], 0.65 to 0.79). There was no decrease in the appropriate use of adjuvant ADT (odds ratio, 1.01; 95% CI, 0.86 to 1.19). In cases involving discretionary use, there was a significant decline in use in 2005 but not in 2004.

CONCLUSIONS

Changes in the Medicare reimbursement policy in 2004 and 2005 were associated with reductions in ADT use, particularly among men for whom the benefits of such therapy were unclear. (Funded by the American Cancer Society.).

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.