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84 Pay for Quality KCE Reports 118 The current results are mainly based on a rapid increasing amount of experience in the USA and the UK. Although a number of start up countries were also included, they still are in such a premature phase that the lessons to be learned from their experience are still limited. However, where appropriate we will refer to their choices of P4Q design and implementation. Before discussing the results the following methodological limitations should be taken into account: Although the systematic review was performed using multiple databases and several languages, there exist still other databases and languages which we were unable to check. The tool used for the quality appraisal to eliminate low quality primary studies was based on several existing validated tools, which were combined into a generic tool applicable to P4Q studies. The use of this combined tool is not validated as such. Because observational studies are the main source of information on P4Q, it was decided to report P4Q results comprehensively, without a restriction to randomized designs. A distinction between strong and weak evidence was made. Selection bias can therefore not be excluded. Not all relevant contextual information is available for each of the included studies. For example, leadership as a factor might impact P4Q results, but is rarely reported upon. As has become clear in the previous study description section, for the contextual factors, the P4Q intervention description and the process of implementation and communication, the completeness of reporting is often lacking in P4Q evaluation studies. The limitations in terms of review selection criteria have to be taken into account. A strict P4Q definition was used (e.g. public reporting is not considered to be a form of P4Q). The population does not include studies outside a primary care or general hospital setting (e.g. psychiatric care and nursing homes). The limitations in terms of studies’ selection criteria have to be taken into account. With regard to context, studies are more performed in urban areas than in rural areas. Since a number of studies use a minimal patient panel size per provider or per target for each provider, it is likely that smaller practices are underrepresented. Furthermore, because many studies focus upon a stabile and regular type of patients, results may not be applicable for one time only and quickly physician switching patients. The same is true for patients who are exception reported in the UK system and are excluded from most UK study samples, because their performance data are rarely available. As described in chapter 4 (section 4.2.6), there is a general trend of quality improvement present in some of the countries where P4Q studies took place, like in the UK. Only results based on strong evidence take this trend into account to isolate the P4Q effect from the time trend effect. In addition, P4Q is an intervention that’s typically combined with other interventions. Because of the mix throughout all P4Q studies, it is impossible to separate the P4Q impact from the other concurrent quality improvement initiatives’ impact. The studies discussed here are always based on a ‘bundled’ approach. P4Q is still a very recent phenomenon. For many medical conditions there is no P4Q evidence (urology, intensive care, geriatrics, most of surgical care, etc). Secondly, there are medical conditions for which some first evaluation attempts have been performed, but for which the evidence is still scarce and no conclusions about P4Q effects can be drawn (urinary tract infections, skin infections, gastric infections, depression/mental illness, chronic child care, COPD, epilepsy, hyperthyroidism, chronic cancer care, osteoarthritis). In more generic terms the same can be said for the introduction of new drugs and for P4Q effects on the use of most care management processes when assessed separately. However, this still leaves a large group of target conditions for which evidence is available. The effects on the clinical effectiveness domain are reported firstly.
KCE Reports 118 Pay for Quality 85 What first comes to mind when reviewing the results is that P4Q is no magic bullet. Throughout studies and targets non significant or small size effects are regularly encountered. On the contrary, large effect sizes are also sometimes reported. To come to a comprehensive overview the results are categorized in a systematic way, starting from a negative effect up to large positive effects: For a few targets a small number of studies have identified a lower degree of quality improvement when using P4Q as compared to the degree of improvement when not using P4Q. This was the case for Chlamydia screening with an 11% negative difference in one weak design study, for left ventricular failure (LVF) assessment in heart failure patients with a 2.4% difference in another strong design study and for oxygenation assessment and timely antibiotics administration in pneumonia patients in a third strong design study (1.9 and 3.2% respectively). Finally, for cholesterol recording in coronary heart disease (CHD) patients one weak design study found a 10.8% negative difference. It should be noted that the same LVF assessment, oxygenation assessment and timely antibiotics administration showed a positive P4Q effect up to 5.1%, no significance and a positive 4.3% effect respectively in other strong design studies. For cholesterol recording in CHD patients this even went up to a positive effect of 41.7% in other weak design studies. There are also a number of targets for which only an absence of effect is found. This was the case for most of the long term outcome targets in the one weak design study focusing on coronary artery bypass grafting (CABG). In heart failure patients in hospital care no effect was found on ACE inhibitor use and smoking cessation advice, based on strong evidence. The same was true for one myocardial infarction (MI) indicator, four diabetes care indicators, five CHD indicators, two stroke targets, two asthma indicators, two smoking cessation indicators and three chronic kidney disease indicators. On the following set of indicators P4Q effects show mixed evidence, ranging from no significant effect to a small below five percent effect. This set includes cholesterol screening in adults (3%), well child visits (0-5%), cancer preventive screening (0-4%), most MI indicators (0-4.4%), one pneumonia indicator (blood culture testing, 3.5%), three diabetes indicators, three CHD indicators, and four asthma indicators. There are also indicators showing a much larger range of P4Q effect, according to the specific studies, but still also with no effect in some. Here we identify children immunization (0-25%), children preventive screening (0-29%), the timeliness of emergency care (0-10%), two MI indicators (0-8.5% for prescribing aspirin at discharge and 0-9.9% for ACE inhibitor use). In diabetes indicators, the effects on four testing rate targets varied between zero and 25%. For HbA1c as an intermediate outcome the range was 0-14%. These figures are based on strong evidence. In the included studies, there are a number of targets which show only a positive effect. This includes influenza immunization (6-8%), the provision of discharge instructions to heart failure patients (35.5%), pneumococcal screening and/or vaccination for pneumonia (9.5-44.7%), and three diabetes indicators (cholesterol outcome: up to 23.5%, blood pressure outcome: 1.6-6.3%, foot exam rate: 2.7-45%), based on strong evidence. The same is true for smoking status recording (7.9-24%) and referral rate (6.2%) aimed at smoking cessation patients. Weaker evidence supports a similar finding for reducing inappropriate treatment in acute sinusitis (14-29%), breastfeeding rate (6- 12%), ACE inhibitor use for heart failure in primary care (23.4%), blood pressure recording (0.7-21.5%) and smoking status recording (2.39-26.2%) for CHD patients, eight targets (17-52.1%) for stroke patients, and finally, for hypertension care targets (12%). The overview above shows that a P4Q programme can lead to the full spectrum of clinical effectiveness results, ranging from no effect, a negligible effect, a substantial effect to a high effect, depending on the local programme and the targets selected. The evidence base has become large enough to make these distinctions. The few negative differences that were found in only four studies out of more than hundred are bound to appear in any review of so many targets, when including observational study designs. Further scrutiny of these specific results may provide possible explanations.
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