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