Data and Outcomes - International Programs

Multiple Country International Articles: 413, 435

Articles by country:

Afghanistan: 421

Bosnia and Herzegovina: 336

Burkina Faso: 367

Canada: 356, 381

France: 355

Germany: 341, 362

Nigeria: 417

Sweden: 270, 368

Taiwan: 349, 363, 365, 375, 418, 419, 436

United Kingdom: 189, 320, 369, 379, 425, 429

 

International Data and Outcomes Literature by Country

 

Multiple Country Studies

(413) Tsiachristas et al. Impact of financial agreements in European chronic care on health care expenditure growth. Health Policy. 2016 Apr;120(4):420-30. doi: 10.1016/j.healthpol.2016.02.012. Epub 2016 Mar 2.

PMID: 26971018

Summary:

  • Integrated chronic care and healthcare expenditure growth was compared between 9 European intervention countries who had implemented financial agreements with an emphasis on healthcare delivery coordination and 16 control countries with traditional financial structures such as fee-for-service
  • Examined financial agreements included  pay-for-coordination (PFC), P4P, or all-inclusive payments (bundled or global payments)
  • OECD and WHO data from 1996-2013 showed:
    • PFC and all-inclusive payment countries had reduced outpatient expenditure growth immediately after implementation
      • 216.60 US$ per capita for those with all-inclusive payments
    • P4P countries had decreased hospital and administrative cost growth immediately after implementation
    • In the total 4-year period after implementation of financial agreements, P4P administrative expenditure growth. All-inclusive payments continued to show reduced outpatient expenditure growth.

Significance to Literature:

Large scale healthcare financial agreements composed of aspects for PFC, P4P, and all-inclusive payments could be used to reduce rising healthcare costs.

 

(435) Das A, Gopalan SS, Chandramohan D. Effect of pay for performance to improve quality of maternal and child care in low- and middle-income countries: a systematic review. BMC Public Health. 2016 Apr 14;16:321. doi: 10.1186/s12889-016-2982-4.

PMID: 27074711

Summary:

  • Systematic review of eight studies (1990-2014) analyzing the effect of P4P programs on quality of maternal and child health (MCH) in low- and middle-income countries (LMICs)
    • LMICs included were Burundi, Democratic Republic of Congo, Egypt, the Philippines, and Rwanda
  • Review indicated that P4P is “effective to improve process quality of antenatal care” but evidence was weak for any positive effective on improving structural quality, customer satisfaction, out-of-pocket expenses, and MCH status
  • Some negative effects on structural quality (reduction in availability of drugs and equipment) were even found

Significance to Literature:

P4P’s impact on MCH in LMICs is mixed and modest thus far.

 

Afghanistan

(421) Engineer et al. Effectiveness of a pay-for-performance intervention to improve maternal and child health services in Afghanistan: a cluster-randomized trial. Int J Epidemiol. 2016 Apr;45(2):451-9. doi: 10.1093/ije/dyv362. Epub 2016 Feb 13.

PMID: 26874927

Summary:

  • Cluster randomized-trial to determine P4P effect on maternal and child health services in Afghanistan
  • Surveys showed no significant difference in any of the five maternal and child health measures including modern contraception, antenatal care, skilled birth attendance, postnatal care, and childhood vaccination
  • P4P did not have an effect on the equity of care use
  • Providers in the P4P program did spend more time with patients, conduct more complete histories and physical examinations, and offer more counseling to patients

Significance to Literature:

P4P intervention had minimal effect on use of maternal and child health services, and contextual factors contributing to failed P4P intervention need to be further explored

 

Bosnia and Herzegovina

(336) Hrabac B, Huseinagic S, Bosnjak, R. Prevention and Promotion Program Performance-Based Payment Effects on the Federation of Bosnia and Herzegovina Family Medicine Teams’ Work. Mater Sociomed. 2015 Oct; 27(5): 300-304. doi:10.5455/msm.2015.27.300-304

Link: http://www.scopemed.org/?mno=203852

Summary:

  • Effects of P4P preventive-promotive program in Bosnia and Herzegovina within family medicine teams
  • Concept of preventive treatment included detecting and monitoring chronic disease risk factors such as hypertension, obesity, smoking, physical inactivity, dyslipidemia, and diabetes mellitus
  • Performance criteria included total risk factors targeted in first visits as well as the number of subsequent clinic and home visits
  • Family medicine teams reimbursed by bonus payment demonstrated higher performance compared to those reimbursed by flat rate payment
  • Showed no tendency towards “good risk selection phenomena”

Significance to Literature:

Prevention and promotion tasks within family medicine can be increased significantly when tied to bonus payment.  

 

 

Burkina Faso

(367) Ye et al. Health worker preferences for performance-based payment schemes in a rural health district in Burkina Faso. Glob Health Action. 2016 Jan 5;9:29103. doi: 10.3402/gha.v9.29103. eCollection 2016.

PMID: 26739784

Summary:

  • Study aimed to analyze providers’ preferences for a potential performance-based incentive program focused on improving maternal and child health care in Nouna, Burkina Faso.
  • Qualitative and quantitative survey of 94 providers and in-depth interviews with 33 participants
  • Only one respondent was a medical doctor; most were nurses
  • 85% of health workers supported locally adapted performance-based incentives and most preferred financial bonuses to alternative types of incentives
  • Participants sighted same concerns as physicians typically do such as reduction in intrinsic motivation, cultural change in healthcare workforce, demoralization...
  • Most were in favor of team-based incentives over individual-based

Significance to Literature:

Survey results indicate non-physician providers largely (85%) support P4P in principle (they did not currently have a P4P system in place).


 

Canada

(189) Millett C, Gray J, Saxena S, Netuveli G, Majeed A. Impact of pay-for-performance incentive on support for smoking cessation and on smoking prevalence among people with diabetes. Journal of the Canadian Medical Association. 2007: 176(12) 1705-1710.

Link: http://www.cmaj.ca/cgi/content/full/176/12/1717

Summary:

  • A longitudinal study of prevalence of offering smoking cessation advice and smoking cessation in diabetes patients from 2003 and in 2005 after P4P was implemented in the UK.
  • In those two years, smoking prevalence decreased from 20.0% to 16.2% and cessation advice given increased from 48.0% to 83.5%.

Significance to Literature:

The implementation of P4P in the UK seemed to correlate with a substantial increase in smoking cessation advice and smoking cessation amongst diabetes patients.

 

 

(356) Vermeulen MJ et al. The Effect of Pay for Performance in the Emergency Department on Patient Waiting Times and Quality of Care in Ontario, Canada: A Difference-in-Difference Analysis. Annals of Emergency Medicine. 2016 Apr;67(4):496-505.e7. doi: 10.1016/j.annemergmed.2015.06.028. Epub 2015 Jul 26.

PMID: 26215670

Summary:

  • Pay-for-performance programs implemented in sequential waves in Ontario emergency departments (EDs) in 2008 rewarding hospitals for decreasing ED length of stay
  • Pay-for-performance hospitals showed overall reduction in ED length of stay in admitted and nonadmitted patients
  • This effect was attenuated with each additional group of hospitals added to the program

Significance to Literature:

Pay-for-performance models associated with modest reduction of ED length of stay without compromising quality of care. Confirms an “all boats rise” effect once QI is rewarded within a community.

 

 

(381) Kiran et al. Effect of Payment Incentive on Cancer Screening in Ontario Primary Care. Ann Fam Med. 2014 Jul;12(4):317-23. doi: 10.1370/afm.1664.

PMID: 25024239

Summary:

  • Evaluated cervical, breast, and colorectal cancer screening rates before and after the introduction of a province-wide primary care P4P scheme in Ontario
  • Age- and sex-standardized screening rates showed no significant step change immediately after P4P implementation in any of the three cancers
  • Screening for colorectal cancer showed the most improvement, but the authors attributed this to a lower base-line screening rate

Significance to Literature:

P4P was associated with little or no improvement in cancer screening rates despite significant cost of incentives over the course of the study.  We (the authors of this website) note that the total incentives for achieving the highest targets on all three screening areas amounted to only 3% of the physician’s gross income.


 

France

(355) Saint-Lary 0 et al. Patients’ views on pay for performance in France: a qualitative study in primary care. British Journal of General Practice. 2015 Aug;65(637):e552-9. doi: 10.3399/bjgp15X686149.

PMID: 26212852

Summary:

  • Evaluation patients’ experience with pay-for-performance healthcare via interview of 40 French primary care patients in 2013.
  • Most patients did not know what pay-for-performance was and had not noticed any change in their medical care since implementation
  • Patients expressed possible benefits such as improvement in follow-up and prevention as well as possible negatives such as depersonalized healthcare.

Significance to Literature:

Qualitative assessment of French primary care patients views on pay-for-performance.

 

Germany

(341) Keser C, Peterle E, Schnitzler C. Money Talks - Paying Physicians for Performance. Social Science Research Network. 2014 Oct 14.

Link: http://ssrn.com/abstract=2357326

Summary:

  • Study comparing physician provision behavior and patient benefit between traditional fee-for-service (FFS) and a hybrid pay-for-performance and FFS system.
  • Results showed under the hybrid payment system patients were significantly more likely to receive optimal treatment.
  • Some evidence that Hybrid system decrease inappropriate overservice and underservice.

Significance to Literature:

Experimental model support that physicians respond to P4P incentives in both utilization and quality metrics within a hybrid P4P and fee-for-service payment system.  

 

 

(362) Krauth C et al. Would German physicians opt for pay-for-performance programs? A willingness-to-accept experiment in a large general practitioners sample. Health Policy. 2016 Feb; 120(2):148-58. doi: 10.1016/j.healthpol.2016.01.009. Epub 2016 Jan 21.

PMID: 26852868

Summary:

  • Mail survey with questionnaire and willingness-to-accept experiment was conducted among German general practitioners (GPs) to determine if, and at what required bonus, GP’s would participate in a P4P program
  • Results showed divided views of P4P with theoretical participation rates ranging from 28% to 50% when performance bonuses were increased from 2.5% to 20%
  • Main reasons for reservation on participation included feasibility of program and fear of unintended consequences

Significance to Literature:

Better evidence for P4P effectiveness and proper tailoring of P4P programs through communication with providers are both necessary to increase P4P participation willingness

 

Nigeria

(417) Ogundeji et al. Pay for performance in Nigeria: the influence of context and implementation on results. Health Policy Plan. 2016 Apr 1. pii: czw016. [Epub ahead of print].

PMID: 27036415

Summary:

  • Significant variation has been seen between P4P implementation sites in Nigeria
  • Semi-structured interviews were conducted with 36 health workers to explore contextual factors that influenced the implementation of P4P schemes
  • Four main themes summarized the interviewees’ comments on the effectiveness of P4P implementation:
    • Uncertainty in obtaining the incentive because of delays in payment and ineffective communication
    • Health workers’ (not including physicians) knowledge of the P4P scheme
    • Role of the health facility manager in implementation
    • Factors which affected motivation and performance under the P4P scheme
  • Authors offer recommendations to improve P4P implementation and management

Significance to Literature:

Certain implementation factors, including target payments to administrators and nurses, “can affect the impact of P4P schemes on top of the main design features”

 

Sweden

(270) Forsberg E, Axelsson R, Arnetz B. Financial incentives in health care. The impact of performance-based reimbursement. Health Policy. 2001: 58 243-262.

PMID: 11641002

Summary:

  • Swedish study comparing performance-based reimbursement (PBR) in one county with 10 traditionally reimbursed counties.
  • PBR focused on cost contaiment rather than quality improvement.
  • PBR resulted in greater cost awareness and shorter length of hospital stay, but a strong cost awareness was found to be a negative predictor of quality care.

Significance to Literature:

Swedish physicians found both positive and negative effects of performance reimbursement aimed at cost containment.

 

 

(368) Odesjo et al. Short-term effects of a pay-for-performance programme for diabetes in a primary setting: an observational study. Scand J Prim Health Care. 2015;33(4):291-7. doi: 10.3109/02813432.2015.1118834. Epub 2015 Dec 15.

PMID: 26671067

Summary:

  • Analysis of the effect of a primary care P4P program introduced in Sweden on data entry practice and comparability of patient data for 84,053 patients with diabetes mellitus
  • Completeness of data as well as goal achievement/level of HbA1c, blood pressure, and LDL cholesterol was measured
  • Newly recruited patients to the P4P programs had more complete data entry than historically
  • With incentives for reaching target levels, data entry showed an increased preference for sub-target values and a decreased incidence of zero end-digit readings, especially for blood pressure
  • Missing patient data may result in result in overestimation of performance

Significance to Literature:

When considering implementation of P4P programs, one should expect more complete data entry and potential gaming of subjectively collected data such as blood pressure.

 

 

Taiwan

(349) Hsieh HM, Gu SM, Shin SJ, Kao HY, Lin YC, Chiu HC. Cost-Effectiveness of a Diabetes Pay-For-Performance Program in Diabetes Patients with Multiple Chronic Conditions. PLoS ONE. 2015;10(7):e0133163. doi:10.1371/journal.pone.0133163.

PMID: 26173086

Summary:

  • Investigation of cost effectiveness of a diabetes P4P program in two cohorts; diabetes patients with and without comorbid hypertension and hyperlipidemia.
  • Outcomes included life-years, quality-adjusted life-years, program intervention costs, cost-savings, and incremental cost-effectiveness ratios.
  • P4P program for both cohorts indicated cost-effectiveness and significant return on investment compared to non-P4P patients.

Significance to Literature:

Evidence for cost-effectiveness of performance-based programs for patients with chronic illness and (mild) comorbidities.

 

 

(363) Chiu et al. Patient assessment of diabetes care in a pay-for-performance program. Int J Qual Health Care. 2016 Apr;28(2):183-90. doi: 10.1093/intqhc/mzv120. Epub 2016 Jan 26.\

PMID: 26819445

Summary:

  • Examination of patient perception of diabetes chronic care between those enrolled and not enrolled in a P4P program across 18 healthcare institutions in Taiwan
  • The Chinese version of the Patient Assessment of Chronic Illness Care (PACIC), as well as five subscales, was measured and clinical outcome data was collected
  • Subscales included patient activation, delivery system design/system support, goal setting/tailoring, problem solving/contextual, and follow-up coordination
  • Patients enrolled in P4P programs had higher overall PACIC scores, including on each of the five subscales, as well as better clinical processes of care and intermediate outcomes

Significance to Literature:

P4P programs may result in more patient-centered care, and better perception of care is associated with better clinical processes and outcomes

 

 

(365) Yen et al. Factors Related to Continuing Care and Interruption of P4P Program Participation in Patients With Diabetes. Am J Manag Care. 2016 Jan 1;22(1):e18-30.

PMID: 26799201

Summary:

  • Retrospective cohort analysis of data from Taiwan's National Health Insurance Research Database attempting to identify factors that influence continued or interrupted clinical care for patients with diabetes enrolled in a P4P program (“enrolled” in P4P like patients can be “enrolled” in medical homes.)
  • Patients with a newly confirmed type 2 diabetes diagnosis from 2001-2008 who opted for enrollment were matched for multiple factors (age, physician and organization characteristics, health status…) with non-enrollees.
  • Diabetic patients enrolled in a P4P program were 4.27 times more likely to participate in continuing care.

Significance to Literature:

Enrollment of diabetic patients through P4P programs is strongly associated with continuity of care



 

(375) Hsieh et al. Cost-Effectiveness of Diabetes Pay-for-Performance Incentive Designs. Med Care. 2015 Feb;53(2):106-15. doi: 10.1097/MLR.0000000000000264.

PMID: 25397966

Summary:

  • Taiwan’s National Health Insurance (NHI) Program has implemented diabetes P4P programs for both process-of-care measures (2001, Phase 1) and intermediate health outcomes (2006, Phase 2)
  • Examination of cost-effectiveness of both P4P designs by analyzing data from Taiwan’s NHI P4P dataset, claims database, and death registry to compare costs between diabetes P4P and non-P4P patient groups
  • Average all-cause medical costs per quality-adjusted life years saved by the P4P program demonstrated a return on investment was 1.8:1 in phase 1 and 2:1 in phase 2

Significance to Literature:

P4P diabetes programs may prove cost-effective whether incentives are based on process-of-care or intermediate health outcomes

 

(418) Chen CC, Cheng SH. Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system. Health Policy Plan. 2016 Feb;31(1):83-90. doi: 10.1093/heapol/czv024. Epub 2015 May 5.

PMID: 25944704

Summary:

  • Examination of the effects of a diabetes P4P program on health care utilization, continuity of care, and hospital admissions/ED visits for patients with and without comorbid hypertension in Taiwan
  • The number of necessary examinations/tests increased and the continuity of care improved for those patients with and without hypertension in the diabetes P4P program
  • The program also significantly reduced diabetes-related hospital admissions and emergency department visits for patients with and without hypertension (odds ratio 0.71 and 0.74, respectively)
  • Impacts of the program diminished in the second year after its implementation

Significance to Literature:

Evidence that P4P programs can improve health care provision, continuity of care, and diabetes health care outcomes in Taiwan

 

(419) Hsieh et al. The association between participation in pay-for-performance program and macrovascular complications in patients with type 2 diabetes in Taiwan: A nationwide population-based cohort study. Prev Med. 2016 Apr;85:53-9. doi: 10.1016/j.ypmed.2015.12.013. Epub 2015 Dec 29.

PMID: 26740347

Summary:

  • Study analyzed the impact of a diabetes P4P program on reducing the risk of macrovascular complications in type 2 diabetes patients from 2007-2012 in Taiwan
  • Results showed a significantly lower hazard ratios and risks for macrovascular complications including stroke (HR 0.84), myocardial infarction (HR 0.83), atrial fibrillation (HR 0.72), heart failure (HR 0.93), gangrene (HR 0.61) and ulcer of the lower limbs (HR 0.83) for P4P patients
  • No significant difference was indicated for transient ischemic attacks

Significance to Literature:

P4P programs may help in reducing macrovascular complications for patients with type 2 diabetes

 

(436) Chi et al. Effects and Factors Related to Adherence to A Diabetes Pay-for-Performance Program: Analyses of a National Health Insurance Claims Database. J Am Med Dir Assoc. 2016 Jul 1;17(7):613-9. doi: 10.1016/j.jamda.2016.02.033. Epub 2016 Apr 9.

PMID: 27073041

Summary:

  • Review of Taiwan’s National Health Insurance claims database for patients diagnosed with diabetes in 2001 to compare the effects of a diabetes P4P program on healthcare utilization/expenses (through 2011) between patients who adhered to the program and those that did not
    • The first-stage of the diabetes P4P program requires one comprehensive claim report during initial enrollment, two more annual evaluations, and five or more total follow-up visits
    • Nonadherence group was defined as those who did not satisfy these requirements after three years
  • While diabetes-related care was higher, total annual healthcare expenses spent by the adherence group were significantly lower than those of the nonadherence group
    • The adherence group had a significantly higher average number and cost of physician visits, but a significantly lower average number of hospitalizations compared to the nonadherence group
  • Males with a recent diabetes diagnosis were most associated with nonadherence

Significance to Literature:

Success within P4P programs is impacted by patient adherence, and interventions and strategies to improve adherence should be incorporated to improve outcomes.

 

United Kingdom

Key Article

(320) Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of Pay for Performance on Quality of Primary Care in England. NEJM. 361(4) 368-378.

PMID: 19625717

Summary:

  • Time-series analysis of 42 family practices in the United Kingdom of the clinical quality scores pre- (1998 and 2003) and post- (2005 and 2007) P4P (QOF) implementation in 2004.
  • Measured clinical care in coronary heart disease, asthma, and diabetes. Measured patients' perceptions in communication with physicians, access to care, and continuity of care.
  • Clinical quality of care increased for diabetes and asthma from 2003 to 2005, but by 2007 improvement had slowed. While improvement for heart disease was marginal from 2003 to 2005, and similar in 2007 compared to 2005.
  • Patients' perceptions of care regarding access and interpersonal aspects remained similar throughout,while continuity of care decreased immediately following P4P implementation, but remained steady at a reduced level in 2007.
  • Structure of P4P program did not reward for further improvement once targets had been achieved.
  • Meanwhile, two non-incentivized quality of care measures decreased in both asthma and heart disease treatment.

Significance to Literature:

Once quality targets were met, quality improvement was slowed, while quality of care for non-incentivized conditions decreased.

 

 

Key Article

(369) Roland M. Should doctors be able to exclude patients from pay-for-performance schemes? BMJ Qual Saf. 2015 Dec 30. pii: bmjqs-2015-005003. doi: 10.1136/bmjqs-2015-005003. [Epub ahead of print]

PMID: 26717988

Summary:

  • United Kingdom’s pay-for-performance program, Quality and Outcomes Framework, allows for general practitioners to exclude patients from quality calculations without financial penalty
  • This practice, known as exception reporting, was designed to allow providers to use clinical judgement to exempt patients from evidence-based guidelines when not applicable and protect physicians from patient non-compliance, but has been controversial.
  • Notable points include:
    • 1% of practices were responsible for 15% of all exception reporting
    • Higher target quality markers are associated with higher rates of exception reporting
    • Increased exception reporting for complex patients with multiple comorbidities
    • Patients from lower socioeconomic areas are more likely to be exception reported
    • Exception reporting is associated with increased risk of death for patients

Significance to Literature:

Physicians exception reported uncommonly yet more work needs to be done to better understand if and when providers’ decisions to circumvent evidence-based guidelines is appropriate.

 

 

(379) Hackett et al. ‘Just another incentive scheme’: a qualitative interview study of local pay-for-performance scheme for primary care. BMC Fam Pract. 2014 Oct 25;15:168. doi: 10.1186/s12875-014-0168-7.

PMID: 25344735

Summary:

  • Retrospective semi-structured interviews of 46 professionals were conducted to assess whether their experiences differed with development/implementation of local P4P schemes versus United Kingdom national programs such as the Quality and Outcomes Framework
  • Results indicated negligible ownership difference between local and national schemes but a variation in physician motivators between practices serving higher and lower socioeconomic groups

Significance to Literature:

No evidence for differences in experiences with local P4P adaptations versus a national scheme

 

Key Article

(425) Ryan et al. Long-term evidence for the effect of pay-for-performance in primary care on mortality in the UK: a population study. Lancet. 2016 Jul 16;388(10041):268-274. doi: 10.1016/S0140-6736(16)00276-2. Epub 2016 May 17.

PMID: 27207746

Summary:

  • The United Kingdom’s (UK) Quality and Outcomes Framework (QOF), introduced in 2004, is the world’s largest primary care P4P program
  • Population-level mortality statistics from 1994-2010 for the UK and other high-income countries were assessed
    • Primary outcome was mortality per 100,000 population for “a composite outcome of disease areas that were targeted by the QOF from the beginning of the program”
    • Secondary outcomes included mortality for ischemic heart disease, cancer, and a composite of all causes of death not included in the primary outcome
  • No significant association with improved population mortality was found for any assessed disease area, both those targeted and not targeted by the QOF

Significance to Literature:

Results indicates that the viability of P4P to improve population mortality is questionable, and the comparison of the cost-effectiveness of P4P to other health system interventions is necessary

 

(429) Tharby RF, Hex N, Gill P. Pay for performance and the management of hypertension. Journal of Translational Internal Medicine. 2016 Apr; 4(1):14-19. doi: 10.1515/jtim-2016-0004.

Link: http://www.degruyter.com/view/j/jtim.2016.4.issue-1/jtim-2016-0004/jtim-...

Summary:

  • Management of hypertension lends itself to inclusion in P4P programs because there are:
    • National/international guidelines for identification and management
    • Recommended care processes can be translated into measurable statements
    • Effective ways to measure desired outcomes of treatment
  • 17% of the possible financial incentives in the UK’s Quality and Outcomes Framework (QOF) is for management of patients with hypertension
    • Currently there are 13 indicators included in the QOF for hypertension management
  • The impact of P4P on hypertension treatment and management has been mixed and moderate
    • From 2004-2014, the percentage of patients with hypertension who had a blood pressure reading of less than 150/90 mmHg increased from 71.5% to 79.2%
    • No significant changes in the number of patients treated with combination therapy
    • Trends in both categories were observed prior to P4P implementation and have been sustained
    • No evidence of “gaming” to achieve target measures was found, with exception reporting remaining constant
  • Assessment of benefits from modest improvement in hypertension management compared to cost of implementation is necessary to evaluate whether the incentives provide value

Significance to Literature:

Aspects of the management of hypertension appear amenable to P4P programs, but evidence is weak regarding whether or not incentives are necessary or valuable in improving care

 

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