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