Pay for Quality

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82 Pay for Quality KCE Reports 118 Figure 8: P4Q context: Provider characteristics Provider characteristics Awareness, perception, familiarity, agreement, self-efficacy: High importance of provider awareness (S) Lack of reporting on the other experience dimensions, except some evidence on the importance of involvement (W) Other motivational drivers (intrinsic, professional culture, altruism…): Lack of reporting (N) Medical leadership, role of peers, role of industry: Lack of reporting (N) Existence and implementation of clinical guidelines: Lack of reporting, although this seems one of the mediators of the general quality improvement trend co existing with the introduction of P4Q (see UK example) (N) Level of own control on changes: Lack of reporting (N), but in almost all studies (except smoking cessation studies) controllable measures were targeted. In addition most studies use intermediate instead of long term outcome targets. Target unit (individual, group/organisation, hospital, nursing home, department): Evidence of positive effects on the individual and/or team level (S). Conflicting evidence on the level of an organization (medical group, hospital) and on the level of leadership (C). In case of not-individual, size of unit (# providers): Conflicting evidence on solo vs. group practice performance (C) Positive relationship with the number of providers within a practice (W) No relationship with hospital size (W) Role of the meso level (principal or agent): Lack of reporting (N) Demographics (age, gender, specialty…): Significant effect of provider age, gender, training background, geographical location, and having a second specialty (W) No significant effect of provider experience and rural vs. urban location (W) Organisational resources available: Weak evidence on the influence on P4Q effects, as measured through hospital/medical group/IPA status, age of the group or organization, organization vs. individual ownership, and teaching status of an organization (W) Organisational system change and extra cost/time required: Lack of reporting (N) Number of patients and services per patient: Conflicting evidence (C) Room for improvement: Strong evidence on the influence on P4Q effects (S)
KCE Reports 118 Pay for Quality 83 5.1.9 Patient characteristics The evidence on relationships of patient demographics has been described extensively in the previous section. With regard to age, ethnicity and socio-economical deprivation level positive as well as negative results were found, depending on the disease (W). This will be discussed more extensively in section 5.2.3. Currently there is a lack of research and evidence on the effects of patient educational status and insurance status. There are also no negative findings reported with regard to the use of exception reporting as a P4Q supportive tool in the UK (W). Almost no empirical research has focused upon the patient experience and patient satisfaction with regard to P4Q. The Spanish study as one exception found no significant differences (W). There is no further evidence on how P4Q and patient awareness of P4Q affects the patient provider relationship. Finally, patient behaviour in terms of lifestyle, cooperation and therapeutic compliance might affect P4Q results, as described by the conceptual framework. Again, there is a lack of evidence on this specific topic. However, as part of P4Q target setting and measurement the selection of indicators in the included studies indicates that this issue is taken into account in almost all studies. The structure, process and intermediate outcome measures used have a high degree of provider controllability. There are a few exceptions like the use of long term smoking cessation outcomes, which is in general less controllable and more patient lifestyle related. Figure 9: P4Q context: Patient characteristics Patient characteristics Demographics, Co-morbidities: Closing performance gap with regard to patient age and unclear result with regard to gender, and ethnicity (W) Socio-economics, Insurance status: Unclear results with regard to socio economical deprivation level (W) Lack of reporting on the influence of insurance status (N) Information about price and/or quality: Conflicting evidence on the interaction of P4Q with public reporting (C) Patient behavioural patterns (cultural and consumer patterns, compliance): Lack of reporting (N) 5.2 DISCUSSION AND CONCLUSIONS 5.2.1 Reported effect of Pay for Quality programmes Previous systematic reviews found that the evidence on P4Q effectiveness is mixed, with initial studies finding a lack of impact or incongruent effects which are target specific. They also reported a lack of evidence on the incidence of unintended consequences of P4Q. A high need for further research on these issues was expressed 15 , 16 , 37 , 38 , 40, 46 , 75 , 92 , 231 , 232 , 233 , 234 . The systematic review that was performed in this chapter builds further on a wider search strategy to identify more primary P4Q evaluation studies. In addition, it provides an update of the findings till 2009 as year of publication. Because a lot of studies have been published in 2007 and 2008, this review allowed assessing whether already more evidence is available on P4Q development, implementation and evaluation, how this relates to our conceptual framework and which recommendations can be formulated for research and practice, both within an international and a Belgian scope.
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Pay for Quality

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