Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: a longitudinal observational study Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol Incentive payments to general practitioners aimed at increasing opportunistic testing of young women for chlamydia: a pilot cluster randomised controlled trial Family doctor responses to changes in incentives for influenza immunization under the U.K. Quality and Outcomes Framework pay-for-performance scheme. Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007 Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation The Cessation in Pregnancy Incentives Trial (CPIT): study protocol for a randomized controlled trial Healthcare providers’ views on the acceptability of financial incentives for breastfeeding: a qualitative study
Background The UK 's Quality and Outcomes Framework ( QOF ) was introduced in 2004/5 , linking remuneration for general practice s to recorded quality of care for chronic conditions , including diabetes mellitus . We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics . Methods Using the General Practice Research Data base we selected a stratified sample of 148 English general practice s in Engl and , contributing data from 2000/1 to 2006/7 , and obtained a r and om sample of 653 500 patients in which 23 920 diabetes patients identified . We quantified annually recorded quality of care at the patient-level , as measured by the 17  QOF diabetes indicators , in a composite score and analysed it longitudinally using an Interrupted Time Series design . Results Recorded quality of care improved for all subgroups in the pre-incentive period . In the first year of the incentives , composite quality improved over- and -above this pre-incentive trend by 14.2 % ( 13.7–14.6 % ) . By the third year the improvement above trend was smaller , but still statistically significant , at 7.3 % ( 6.7–8.0 % ) . After 3 years of the incentives , recorded levels of care varied significantly for patient gender , age , years of previous care , number of co-morbid conditions and practice diabetes prevalence . Conclusions The introduction of financial incentives was associated with improvements in the recorded quality of diabetes care in the first year . These improvements included some measures of disease control , but most captured only documentation of recommended aspects of clinical assessment , not patient management or outcomes of care . Improvements in subsequent years were more modest . Variation in care between population groups diminished under the incentives , but remained substantial in some cases Background Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment , hypertension is controlled in less than one-half of United States citizens . Methods / design This r and omized controlled trial tests whether explicit financial incentives promote the translation of guideline -recommended care for hypertension into clinical practice and improve blood pressure ( BP ) control in the primary care setting . Using constrained r and omization , we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms : physician-level incentive ; group-level incentive ; combination of physician and group incentives ; and no incentives ( control ) . All participants at the hospital ( cluster ) were assigned to the same study arm . We enrolled 83 full-time primary care physicians and 42 non-physician personnel . The intervention consisted of an educational session about guideline -recommended care for hypertension , five audit and feedback reports , and five disbursements of incentive payments . Incentive payments rewarded participants for chart-documented use of guideline -recommended antihypertensive medications , BP control , and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention . To identify potential unintended consequences of the incentives , the study team interviewed study participants , as well as non-participant primary care personnel and leadership at study sites . Chart review s included data collection on quality measures not related to hypertension . To evaluate the persistence of the effect of the incentives , the study design includes a washout period . Discussion We briefly describe the rationale for the interventions being studied , as well as the major design choices . Rigorous research design s such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements . Trial Registration http://www . clinical Background Financial incentives have been used for many years internationally to improve quality of care in general practice . The aim of this pilot study was to determine if offering general practitioners ( GP ) a small incentive payment per test would increase  chlamydia testing in women aged 16 to 24 years , attending general practice . Methods General practice clinics ( n = 12 ) across Victoria , Australia , were cluster r and omized to receive either a $ AUD5 payment per chlamydia test or no payment for testing 16 to 24 year old women for chlamydia . Data were collected on the number of chlamydia tests and patient consultations undertaken by each GP over two time periods : 12 month pre-trial and 6 month trial period . The impact of the intervention was assessed using a mixed effects logistic regression model , accommodating for clustering at GP level . Results Testing increased from 6.2 % ( 95 % CI : 4.2 , 8.4 ) to 8.8 % ( 95 % CI : 4.8 , 13.0 ) ( p = 0.1 ) in the control group and from 11.5 % ( 95 % CI : 4.6 , 18.5 ) to 13.4 % ( 95 % CI : 9.5 , 17.5 ) ( p = 0.4 ) in the intervention group . Overall , the intervention did not result in a significant increase in chlamydia testing in general practice . The odds ratio for an increase in testing in the intervention group compared to the control group was 0.9 ( 95 % CI : 0.6 , 1.2 ) . Major barriers to increased chlamydia testing reported by GPs included a lack of time , difficulty in remembering to offer testing and a lack of patient awareness around testing . Conclusions A small financial incentive alone did not increase chlamydia testing  among young women attending general practice . It is possible small incentive payments in conjunction with reminder and feedback systems may be effective , as may higher financial incentive payments . Further research is required to determine if financial incentives can increase testing in Australian general practice , the type and level of financial scheme required and whether incentives needs to be part of a multi-faceted package . Trial Registration Australian New Zeal and Clinical Trial Registry ACTRN12608000499381 OBJECTIVE To analyze the effect of setting higher targets , in a primary care pay-for-performance scheme , on rates of influenza immunization and exception reporting . STUDY SETTING The U.K. Quality and Outcomes Framework links financial rewards for family practice s to four separate influenza immunization rates for patients with coronary heart disease ( CHD ) , chronic obstructive pulmonary disease , diabetes , and stroke . There is no additional payment for immunization rates above an upper threshold . Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate . DATA Practice -level  information on immunizations and exceptions extracted from electronic records of all practice s in Engl and 2004/05 to 2009/10 ( n=8,212 - 8,403 ) . STUDY DESIGN Longitudinal r and om effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07 . PRINCIPAL FINDINGS The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients ( 0.41 percent , CI : 0.25 - 0.56 percent ) , and exception was reported ( 0.26 percent , CI : 0.12 - 0.40 percent ) . CONCLUSIONS Making quality targets more dem and ing can not only lead to improvement in quality of care but can also have other consequences PURPOSE Major primary care reforms have been introduced in recent years in the United Kingdom , including financial incentives to improve clinical quality and provide more rapid access to care . Little is known about the impact of these changes on patient experience . We examine patient reports of quality of care between 2003 and 2007 , including r and om sample s of patients on practice lists and patients with long-term conditions . METHODS We conducted a cross-sectional design study of family practice s in which  question naires were sent to serial sample s of patients in 42 representative general practice s in Engl and . Question naires sent to sample s of patients with chronic disease ( asthma , angina , and diabetes ) and r and om sample s of adult patients ( excluding patients who reported any long-term condition ) in 2003 , 2005 , and 2007 addressed issues of access , communication , continuity of care , coordination , nursing care , and overall satisfaction . RESULTS There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication , nursing care , coordination , and overall satisfaction . Some aspects of access improved significantly for patients with chronic disease , but not for the r and om sample s of patients . Patients in both sample s reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care . Most scores were significantly higher for the chronic illness sample s than for the r and om sample s of patients in 2003 , even after adjusting for age . CONCLUSIONS There was a modest improvement in access to care for patients with chronic illness , but all patients now find it somewhat harder to obtain continuity of care . This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care . The possibility of unintended effects needs to be considered when introducing pay for performance schemes BACKGROUND Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed . We assessed the effect of performance-based payment of health-care providers ( payment for performance ; P4P ) on use and quality of child and maternal care services in health-care facilities in Rw and a. METHODS 166 facilities were r and omly assigned at the district level either to begin P4P funding between June , 2006 , and October , 2006 ( intervention group ; n=80 ) , or to continue with the traditional input-based funding until 23 months after study baseline ( control group ; n=86 ) . R and omisation was done by coin toss . We surveyed facilities and 2158 households at baseline and after 23 months . The main outcome measures were prenatal care visits and institutional deliveries , quality of prenatal care , and child preventive care visits and immunisation . We isolated the incentive effect from the re source effect by increasing comparison facilities ' input-based budgets by the average P4P payments made to the treatment facilities . We estimated a multivariate regression specification of the difference-in-difference model in which an individual 's outcome is regressed against a dummy variable , indicating whether the facility received P4P that year , a facility-fixed effect , a year indicator , and a series of individual and household characteristics . FINDINGS Our model estimated that facilities in the intervention group had a 23 % increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger ( 56 % ) and aged between 24 months and 59 months ( 132 % ) . No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules . We also estimate an increase of 0·157 st and ard deviations ( 95 % CI 0·026 - 0·289 ) in prenatal quality as measured by compliance with Rw and an prenatal care clinical practice guidelines . INTERPRETATION The P4P scheme in Rw and a had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider . P4P financial performance incentives can improve both the use and quality of maternal and child health services , and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health . FUNDING World Bank 's Bank-Netherl and s Partnership Program and Spanish Impact Evaluation Fund , the British Economic and Social Research Council , Government of Rw and a , and Global Development Network Background Seventy percent of women in Scotl and have at least one baby , making pregnancy an opportunity to help most young women quit smoking before their own health is irreparably compromised . By quitting during pregnancy their infants will be protected from miscarriage and still birth as well as low birth weight , asthma , attention deficit disorder and adult cardiovascular disease . In the UK , the NICE guidelines : ‘ How to stop smoking in pregnancy and following childbirth ’ ( June 2010 ) highlighted that little evidence exists in the literature to confirm the efficacy of financial incentives to help pregnant smokers to quit . Its first research recommendation was to determine : Within a UK context , are incentives an acceptable , effective and cost-effective way to help pregnant women who smoke to quit ? Design and methods This study is a phase II exploratory individually r and omized controlled trial comparing st and ard care for pregnant smokers with st and ard care plus the additional offer of financial voucher incentives to engage with specialist cessation services and /or to quit smoking during pregnancy .  Participants ( n = 600 ) will be pregnant smokers identified at maternity booking who , when contacted by specialist cessation services , agree to having their details passed to the NHS Smokefree Pregnancy Study Helpline to discuss the trial . The NHS Smokefree Pregnancy Study Helpline will be responsible for telephone consent and follow-up in late pregnancy . The primary outcome will be self reported smoking in late pregnancy verified by cotinine measurement . An economic evaluation will refine cost data collection and assess potential cost-effectiveness while qualitative research interviews with clients and health professionals will assess the level of acceptance of this form of incentive payment . The research questions are : What is the likely therapeutic efficacy ? Are incentives potentially cost-effective ? Is individual r and omization an efficient trial design without introducing outcome bias ? Can incentives be introduced in a way that is feasible and acceptable ? Discussion This phase II trial will establish a workable design to reduce the risks associated with a future definitive phase III multicenter r and omized controlled trial and establish a framework to assess the costs and benefits of financial incentives to help pregnant smokers to quit . Trial registration Current Controlled Trials IS RCT Background Despite a gradual increase in breastfeeding rates , overall in the UK there are wide variations , with a trend towards breastfeeding rates at 6–8 weeks remaining below 40 % in less affluent areas . While financial incentives have been used with varying success to encourage positive health related behaviour change , there is little research on their use in encouraging breastfeeding . In this paper , we report on healthcare providers ’ views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle . This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster r and omised controlled trial . Methods Fifty – three healthcare providers were interviewed about their views on financial incentives for breastfeeding . Participants were purposively sample d to include a wide range of experience and roles associated with supporting mothers with infant feeding . Semi-structured individual and group interviews were conducted . Data were analysed thematically drawing on the principles of Framework Analysis . Results The key theme emerging from healthcare providers ’ views on the acceptability of financial incentives for breastfeeding  was their possible impact on ‘ facilitating or impeding relationships ’ . Within this theme several additional aspects were discussed : the mother ’s relationship with her healthcare provider and services , with her baby and her family , and with the wider community . In addition , a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women . Conclusion Healthcare providers believe that financial incentives could have both positive and negative impacts on a  mother ’s relationship with her family , baby and healthcare provider . When design ing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted , while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low
Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures , but not all .
The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing .
However , there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care .
BACKGROUND The use of blended payment schemes in primary care , including the use of financial incentives to directly reward ' performance ' and ' quality ' is increasing in a number of countries .
There are many examples in the US , and the Quality and Outcomes Framework ( QoF ) for general practitioners ( GPs ) in the UK is an example of a major system-wide reform .
Despite the popularity of these schemes , there is currently little rigorous evidence of their success in improving the quality of primary health care , or of whether such an approach is cost-effective relative to other ways to improve the quality of care .
OBJECTIVES The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians ( PCPs ) and to identify : i ) the different types of financial incentives that have improved quality ; ii ) the characteristics of patient population s for whom quality of care has been improved by financial incentives ; and iii ) the characteristics of PCPs who have responded to financial incentives .