Pay for Quality

80 Pay for Quality KCE Reports 118
5.1.8 Provider characteristics
Although mentioned by some authors 207 , in the included studies there has been a lack
of attention for the effects of (dis)congruence with professional culture and with
internal motivation. Through high involvement and democratically decision making on
the implementation of P4Q it seems that these issues can be addressed, as the UK
example shows. But it remains unclear what the impact is in terms of P4Q results, as
compared to some programmes in other countries where P4Q sometimes was imposed
on care providers by the state, employers and/or health plans. The same is true for the
influence of leadership support 207 . Roski et al (2003) 201 question the effect of turnover
in senior management without studying this further. One study found no significant
association with the nature of the organizational culture, but did find an association with
having a patient centred culture 192 (W). Ashworth et al (2005) 140 mention the potential
influence of existing professional standards and pride.
As mentioned before, some authors suggest that the level of knowledge and awareness
of the existence and design of the P4Q programme might influence results 193 , 201 .
Except for the finding of a relationship with the awareness of a clinical guideline
intended as a supportive tool (W), this has not been specifically studied quantitatively
209
.
Next to the already discussed room for improvement, the history of engagement with
quality improvement activities 196 has a significant relationship with P4Q results (S).
With regard to the target unit of the P4Q incentive, programmes aimed at the individual
provider level report in general positive results (S). The study by Young et al (2007) 187
is one exception. An absence of effect is found more in programmes targeted at the
organization level 74 , 172 , 174 , 183 , 184 , 188 . Again, there are also programmes showing
positive results at this level, but this seems to require additional efforts (C). Incentives
at a team level showed positive results in all three studies (S) 171 , 205 , 206 . One study with
incentives at the administrator/leadership level found mixed results (S) 223 . A
combination of incentives aimed at different target units is rarely used 191 .
Finally, on each of these levels a number of characteristics have been further
investigated. The first group concerns individual provider demographics. Provider age
was in one study positively related to performance and acceptance (W) 195 . In this study
younger physicians made more use of feedback data, while older physicians made more
use of cues and stickers. According to the results of Doran et al (2006) 147 provider age
effects are moderate (W). Wang et al (2006) 137 found that older providers were less
likely to participate in voluntary schemes and performed less due to differences in the
organizational domain (structural support), not in the clinical domain (W).
According to one study male providers were more likely to perform better on P4Q
programmes 177 . This contrast with the findings by Wang and colleagues (2006) 137 who
found that male providers were less likely to participate and to perform well. Doran et
al (2006) 147 also found that female physicians performed slightly better (C).
With regard to provider ethnicity one study found a strong relationship indicating that
non white physicians were more likely to perform better on P4Q (W) 195 .
The level of provider experience showed no significant effect on P4Q results (W) 170 .
There is mixed evidence on the effect of the specialty and/or general practitioner
background of the provider (C). Some studies found no significant relationship 183 . In the
study by Rosenthal et al (2008) 69 providers meeting P4Q targets were more likely to be
specialists than general practitioners. The same is reported in other studies
144, 170 , 173 , 177
. To the contrary other studies found a positive relationship with the percentage of
general practitioners 202 , 209 . These differences seem to depend on the nature of the
targets being studied. According to their content some fall better within a general
practitioner’s scope of work and expertise, while others fall within specialists’ areas.
Grady et al (1997) 195 found a positive relationship with having a second specialty (W).
Grady et al (1997) 195 reports that not residence trained physicians are more likely to
perform better on P4Q (W).