Pay for Quality

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54 Pay for Quality KCE Reports 118 • A small number of trends and co-interventions have been identified, namely the influence of a period of industrial action, the use of parental incentives, physicians’ training, a stimulation programme and surveillance system and finally a voluntary professional development scheme. 4.3 GENERAL EVIDENCE 4.3.1 Reported effect of Pay for Quality programmes In the following paragraph we summarize the results of the literature study for preventive care, acute care and chronic care. According to study design (see description on page 35) and effect, the following labels are used to grade evidence: • Strong evidence: a strong design (randomized studies; concurrent + historical comparison studies) with a clear effect; • Weak evidence: a weak design (Concurrent comparison studies; Historical comparison studies, multiple time points; Historical comparison studies, before-after time point; cross-sectional studies) with a clear effect; • Conflicting evidence: a significant effect and no significant effect within one design or within a group of weak or strong designs. Below, a summery of the most important evidence is been given. A more detailed description of the result of the literature study, together with the matching evidence table is provided in Appendix 16 A and 16 B. As will become clear most evidence applies for primary care. The following labels will be used to indicate whether the evidence applies to primary care or hospital care: • H= hospital care • P= primary care • H & P= both hospital care and primary care Within this section it must be noted that a lot of the information comes from QOF studies. These studies are not randomized. The introduction of the QOF scheme which was implemented for all GP’s in the whole country at the same time, didn’t allow setting up randomized studies. Nevertheless these studies are of great value. In addition, one could question if randomization is really needed in studies were a universal P4Q scheme is implemented and hence selection problems do not occur. 4.3.1.1 Preventive care There is strong evidence for a positive P4Q effect on influenza immunization, with an effect size of 6 to 8% 177 , 178 (H&P)and weak evidence for a positive P4Q effect on cholesterol screening in adults (P), with an effect size of 3% 188 . For well child visits c there is strong evidence for an effect ranging from a negative effect to a 5% effect, depending on the age-group 172 , 184 (P). For Cancer preventive screening a 4% improvement was found 69 , 74 , 172 , 183 , 195 (H&P). A similar but wider range was found for children immunization (0 - 25%) 181 , 182 , 184 , 206 (P) and for children preventive screening (0 – 29%) 180 , 184 (P). It should be noted that the 29% effect was found in a study with a weaker design. In the prevention of sexually transmitted diseases there was no effect found based on weak evidence and even a negative difference of 11% compared to a matched comparison group based on strong evidence 172 , 185 (P). The latter finding concerns Chlamydia screening. There is almost no evidence on P4Q effects in preventive care on other quality domains than clinical effectiveness. c For your information: the equivalent of well child visits in Belgium are the preventive paediatric consultations organized by Kind & Gezin and ONE.
KCE Reports 118 Pay for Quality 55 4.3.1.2 Acute care Concerning emergency care there is weak evidence of a positive effect on timeliness of care 213 (H). The effect on timeliness had a range of no effect to a 10% effect depending on the urgency of care. There was no effect on emergency department – hospital admission patient flow 213 (H). Finally, there is weak evidence for a positive relationship with the smoking cessation referral rate in the emergency department 220 (H). For myocardial infarction/acute cardiac events there is strong evidence of a lack of effect on the timely administration of thrombolytic agents and of a 5.4% positive effect on timely percutaneous coronary intervention 175 (H). For most other targets P4Q effects ranged between zero and 3% 44 , 174 , 175 , 223 (H). The upper limit of this range was higher for prescribing aspirin at discharge (8.5%) and ACE inhibitor use (9.9%). No effect was found on not incentivized control measures 174 , 223 (H). For coronary artery bypass grafting (CABG) patients there is weak evidence on the absence of effect on various long term outcomes 189 (H). Only a 10% positive effect on the discharge to home ratio was found 189 (H). There is strong evidence of a 25.5% positive effect on the provision of discharge instructions to heart failure patients 175 (H). There is no effect on ACE inhibitor use and smoking cessation advice 44 , 175 (H). For left ventricular failure (LVF) assessment the effect ranges from minus 2.4 to plus 5.1% 44 , 175 , 223 (H). With regard to community acquired pneumonia there is strong evidence of a positive effect on pneumococcal screening and/or vaccination (9.5-44.7%) and for blood culture testing (3.5%) 44 , 175 , 223 (H). For oxygenation assessment and timely antibiotics administration the effect ranged from minus 1.9 and minus 3.2% to zero and plus 4.3% 44 , 175 , 223 (H). There is weak conflicting evidence concerning three targets focusing on replacing inappropriate care by evidence based alternatives in the treatment of acute sinusitis (- 29%- 14%) 171 (P&H). With regard to breastfeeding rate there is weak evidence of a positive effect of P4Q with a range between 6 and 12% 217 (H). This was mainly due to a shift from partial to full breastfeeding and not by a higher patient rate beginning with breastfeeding. 4.3.1.3 Chronic care results Firstly, concerning diabetes for a limited number of targets there is strong evidence of a positive effect, but with a below 5% effect size: weight recording, smoking status recording, and peripheral pulses testing 143 (P) Secondly, another group of targets showed no effect: hypoglycaemic symptoms recording and glycaemia control rate 143, 219 (P). It should be noted that the last target finding is based on weak evidence only. In addition, for blood pressure recording and influenza immunization there is strong evidence of no effect, however some studies with a weaker design came to positive effects 127, 143, 152, 187, 219 (P). Thirdly, a wider effect range, between 0 and 25% is supported by strong evidence for HbA1c testing rate, lipid and cholesterol testing rate, nephropathy testing rate and retinal exam rate 69 , 143, 172 , 187 , 190 , 191 , 222 (H&P). Fourthly, for some targets there is strong evidence of a positive effect with a smaller range: HbA1c intermediate outcomes (0-14%), cholesterol outcome (positive up to 23.5%), blood pressure outcome (1.6-6.3%) and foot exam rate (2.7-45%) 74 , 143, 222 (P). For a number of other targets only weak evidence was available. Finally, there is weak evidence of a positive effect of P4Q on the referral rate for poor glycaemia control (23% effect size) as a care coordination measure 161 (P). There is weak evidence for a positive effect on heart failure treatment in primary care: a 23.4% increase in ACE inhibitor use 205 (P).
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