Pay for Quality

76 Pay for Quality KCE Reports 118
Studies in the USA finding an absence of effect of P4Q on many measures focused
relatively more on programmes using voluntary P4Q schemes 174 , 175 , 195 , 206 , although
this cannot be generalized (the QOF in the UK is also a voluntary scheme) (C). One
study specifically studied the hypothesis that voluntary schemes will lead to a selection
bias of overly representation of already high performers, which might reinforce a lesser
room for improvement 206 . These authors found that in each of the tested periods there
was such a selection bias for only one or two of the tested eleven indicators (S).
Communication and participant awareness of the programme is identified in this review
as an important factor of influence affecting P4Q results (S). A number of studies finding
no P4Q effects clearly relate this to an absent or insufficient awareness of the existence
and the elements of a P4Q programme 183 , 184 . Especially in preventive care this might
have limited P4Q effects. For preventive targets it also was not always clear who was
responsible for providing care (e.g. vaccinating by GPs versus by other public preventive
services involved).
When looking at different communication strategies we observe that the studies that
made use of more extensive and more direct communication to the involved providers
in general found more positive P4Q effects (S). A similar observation can be made in
terms of the importance of the involvement of all stakeholders, in the first place the
providers themselves, when developing the P4Q programme. However, here again it
has to be noted that findings for studies with high involvement remain mixed (C).
As illustrated both in the UK and the USA, P4Q programmes are often a part of a larger
quality improvement initiative and therefore combined with other interventions such as
feedback, education, public reporting, etc. In the UK this seems to have reinforced the
P4Q effect (S). In the USA the combination effects are more mixed (C). Reiter et al
(2006) 221 found a significant influence of interventions to support structure and process
change (W). A few supportive elements are almost indispensable when implementing
P4Q: the presence of a quality measurement system and the use of feedback. These are
already interventions as such. A few USA programmes treat these aspects as the
responsibility of the providers themselves, but in the majority of programmes these
elements are bundled into one package of interventions. At the moment the added
value of adding staffing support, education, public reporting, guideline distribution,
patient engagement, etc. remains unclear. Many studies with positive results make use of
one or more of these supportive means in combination with P4Q, but the contribution
of each element as such to the combined effect cannot be isolated. Concerning IT
138 , 186 , 194 , 198 , 199 ,
support multiple studies report a positive significant relationship (W)
202 , 207 .
5.1.5 Evaluation of the programme
With regard to sustainability of change there is strong evidence that target performance
does not regress while being incentivized (S). The evolution of target performance after
it has been dropped from a P4Q indicator set is at present unknown (N). In addition,
while being incentivized, there seems to be an upper limit in terms of how far any target
can improve (S). This corresponds with the concept of ‘room for improvement’. After a
target has reached a plateau of performance the goal could shift from improving
towards sustaining the level of quality of care.
Evaluation is used to assess P4Q programme performance (S). However, this review can
only report this for programmes reported in peer reviewed literature. This is likely
distorted by publication bias.
In terms of reviewing and revising the process currently there is no evidence of a
widespread iterative and cyclical approach of quality improvement (N). This may be due
to the still early stage of P4Q dissemination.