Pay for Quality

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8 Pay for Quality KCE Reports 118 Because of these reasons and because of the high number of retrieved publications in peer reviewed scientific literature as an input in the study, grey literature is excluded from the systematic review. After completion of the report, an additional search from January 2009 to July 2009 was performed, to identify more recent relevant studies, which could be of value to our report. The results of this additional search are described in appendix 16C. 2.1.1.2 Relevance screening The following inclusion criteria were defined: • Participants included health care providers in general primary and/or hospital care, being a provider organization, team of providers or an individual provider. • The intervention is defined as policies, including laws, rules, financial or administrative orders, made by governments, non-governmental organizations (health funds, provider organizations,…), public or private insurers, that specifically and directly intend to affect the quality of care, by means of financial incentives. The intervention can be combined with other interventions, conform the McKinley model 15 . It can comprise a financial incentive directed at a person’s income or directed at further investment in quality improvement. The financial incentive can be either positive or negative. Target payments, paying the practice of professionals only if they provide a minimum level of care, are considered a form of P4Q. Even if these targets imply a volume or quantity (e.g. the % of patients vaccinated), these indicators are still based on evidence based guidelines, intended to maximize quality of care, making it distinct from an uncontrolled fee for service approach not based on evidence based standards. • Comparison is standard practice, i.e. without the presence of the above described intervention. • At least one objective process or (intermediate) outcome measure must be reported on clinical effectiveness of care, interpersonal aspects of care, patient safety, access and equity of care, continuity and/or coordination of care or cost-effectiveness of care. The following exclusion criteria were applied: • Studies situated in mental health or behavioural health are excluded. • Financial incentives aimed at patients do not comply with the P4Q concept. This is a whole other array of research, mainly within the field of prevention and changing lifestyle behaviour 15 , 16 . • Papers only treating implicit financial incentives, which might influence quality of care, but are not specifically intended as such to promote explicitly quality in the first place, are excluded. Examples are studies on Fee For Service, capitation, salary use, etc. As noted by Kane et al (2004): “Any provider fee or reimbursement system within healthcare is by definition an economic incentive” 15 . • Subjective outcomes (qualitative research results, patient satisfaction, etc.) are not included, unless they were measured using standardized validated instruments. • Papers only focusing on improving cost containment or productivity using financial incentives, without a primary quality objective, do not pass the PICOD requirements and are therefore excluded (see Lewandowski et al (2006) as an example 17 ). Appendix 3 and 4 list the reasons for excluding publications during full text review.
KCE Reports 118 Pay for Quality 9 2.1.1.3 Quality appraisal Quality appraisal of systematic reviews was based on the criteria of the Dutch Cochrane Center (Form Va). 18 Validity rating by use of this Cochrane tool was based on 7 items (namely research question, search strategy, relevance selection, quality appraisal included studies, data extraction, study description, heterogeneity and pooling). If more than three items were assessed as unclear or insufficient, a publication was excluded. However, for the majority of excluded reviews the reason was the narrative nature of the review or the lack of specification of methods used (Appendix 5). Quality appraisal of primary studies was performed using a specifically constructed tool, based on a combination of existing tools 19 , 20 , 21 , 22 , 23 , 24 , 25 , 26 , 27 , 28 , 29 , 30 . The tool consists of ten generic items (namely research question, patient population and setting, intervention, comparison, outcome, design, sample size, statistics, generalisability, confounders addressed) and four design specific items (randomization, blinding, clustering effect, number of data points) (Appendix 6). For each primary study, a score has been given to each of the 14 items, ranging from -1 to +1. A score of +1 on a certain item corresponds with ‘a good result’, a score of -1 corresponds with ‘a bad result’, and a score of 0 corresponds with ‘this item has not been discussed in the article’. To pass the quality appraisal, an article has to gain a score of minimum 8 out of 14. An article can be excluded on the basis of an ‘overrule’ argument when a certain criteria was not met, hence the overall validity has to be questioned (for example no significance testing, too small sample size etc…). Quality appraisal of the studies reporting cost-effectiveness and modelling effects of P4Q programmes, was also performed by using two specifically constructed tools (See appendix 7). The quality appraisal tool for the modelling studies is based on the modelling guidelines from the KCE and on the ISPOR guidelines by Weinstein et al. It consists of the following items: model design (transparent and as simple as possible); assumptions and data input tested in extensive sensitivity analysis; original data set provided; sources used presented and described in detail; scenarios (for models that extrapolate to longer time periods); calibration (results should be logically consistent with real-life observations and data); face validity (the results of the model should be intuitively correct) and cross-validation (transparent enough to allow an explanation of the differences with other models for the same intervention). The tool used for the cost-effectiveness studies is based on the pharmaco-economic guidelines from the KCE 31 . It consists of the following items: literature review; perspective of the evaluation; target population; comparator; analytic technique; study design; calculation of costs; valuation of outcomes; data sources; incremental cost-effectiveness; time horizon; modelling; handling uncertainty; discount rate. For each item one of the following scores have been assigned: +, +/-, -. A ‘+’ score on given item corresponds with a good result, a ‘-‘ score corresponds with a bad result, a ‘+/-‘ score corresponds with an in between result. Given the limited amount of modelling and cost-effectiveness studies, the quality appraisal is only performed to inform the reader about the quality of the studies, but was not used to exclude any study. Overall the quality of the modelling and cost-effectiveness studies was acceptable. Comparison between reviewers (DDS and PVH) identified seven non corresponding review publications out of 5480 potentially relevant reviews (Cohen’s Kappa 99.9% interrater reliability) and 18 non corresponding primary publications out of 5517 potentially relevant primary publications (Cohen’s Kappa 99.7% interrater reliability). Appendix 8 and 9 list the citations that were included in full text analysis. As a result 103 primary P4Q evaluation articles, 5 modelling articles and 3 costeffectiveness articles, resulting from the primary publication search (phase 2) and from the review search (phase 1), are included in this review. 31, 32
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