Pay for Quality

KCE Reports 118 Pay for Quality 71
5 REVISING THE CONCEPTUAL FRAMEWORK
BASED ON EVIDENCE
5.1 INTRODUCTION
After presenting the results focusing on P4Q effects on quality domains, this section will
clarify the evidence on the mediating effects of the components and contextual
characteristics which were identified in the conceptual framework (see Chapter 3). The
end result will be an updated conceptual framework with identified evidence
for the role of each item, to the extent that evidence is available. To
accomplish this we make use of the systematic review results in two ways.
Firstly, the relationships between framework items and P4Q effect, identified as
significant versus not significant in primary P4Q evaluation studies, are presented and
their direction of effect clarified.
Secondly, by assessing each item’s influence through all included studies in a descriptive
way i.e. detecting whether there is a prominent difference between studies with positive
effects versus studies with absent or negative effects. The results of both approaches
are presented within the framework structure. The following labels are used to grade
evidence:
• Strong evidence (S): a strong design (randomized studies; concurrent +
historical comparison studies) with a clear effect;
• Weak evidence (W): 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 (C): a significant effect and no significant effect within
one design or within a group of weak or strong designs.
• No evidence (N): an absence of evidence
5.1.1 Quality goals and targets
As became clear in the previous section, only two quality domains are mainly focused
upon in P4Q evaluation studies: clinical effectiveness (S) and equity of care (W). The
results for effectiveness can be summarized as showing a positive effect or showing no
effect. The studies focussing on equity rather positive results and will be discussed
extensively in section 5.2.3. The few studies that focused on care continuity and
integration 161 , 220 showed positive effects within their study design restrictions (W).
In addition to the domains identified in the conceptual framework, two other main goals
can be reported. The first goal is the use of care management processes, which can
have one or more of the quality domains as a target (e.g. reminder use to improve
effectiveness, equity and coordination). With regard to use of these tools a similar
positive effect or absence of effect was reported (W). The second goal is to assess the
effect of P4Q on patient experience and on provider work experience. This dimension
is not identified in the framework. Here again a positive effect or an absence of effect
were found in the included quantitative studies, but the low number of studies should
be taken into account (W).
Current P4Q studies make use of process and intermediate outcome indicators.
Structural indicators are used to a lesser extent (e.g. the organizational domain in the
QOF). Long term outcome indicators are used very rarely (see for example Casale et al
(2007) 189 and Downing et al (2007) 149 ) and often only as a not incentivized control
measure. The results illustrate that this target choice has a substantial influence on the
effect of P4Q for such indicators, as predicted by the framework.
Whereas structural and process targets show in general a more positive effect of P4Q,
this is more difficult to reach for intermediate outcome targets such as HbA1c < 7.4% in
diabetes patients (S).