Most physicians and hospitals are paid the same regardless of the quality of the health care they provide. This produces no financial incentives and, in some cases, produces disincentives for ...quality. Increasing numbers of programs link payment to performance.
To systematically review studies assessing the effect of explicit financial incentives for improved performance on measures of health care quality.
PubMed search of English-language literature (1 January 1980 to 14 November 2005), and reference lists of retrieved articles.
Empirical studies of the relationship between explicit financial incentives designed to improve health care quality and a quantitative measure of health care quality.
The authors categorized studies according to the level of the incentive (individual physician, provider group, or health care payment system) and the type of quality measure rewarded.
Thirteen of 17 studies examined process-of-care quality measures, most of which were for preventive services. Five of the 6 studies of physician-level financial incentives and 7 of the 9 studies of provider group-level financial incentives found partial or positive effects on measures of quality. One of the 2 studies of incentives at the payment-system level found a positive effect on access to care, and 1 showed evidence of a negative effect on access to care for the sickest patients. In all, 4 studies suggested unintended effects of incentives. The authors found no studies examining the optimal duration of financial incentives for quality or the persistence of their effects after termination. Only 1 study addressed cost-effectiveness.
Few empirical studies of explicit financial incentives for quality were available for review.
Ongoing monitoring of incentive programs is critical to determine the effectiveness of financial incentives and their possible unintended effects on quality of care. Further research is needed to guide implementation of financial incentives and to assess their cost-effectiveness.
Studies have shown gender disparities in cholesterol care in patients with cardiovascular disease (CVD), with women less likely than men to have low-density lipoprotein cholesterol levels <100 mg/dl. ...Whether this is related to a lower evidence-based statin or high-intensity statin use is not known. We used a national cohort of 972,532 patients with CVD (coronary heart disease, peripheral artery disease, and ischemic stroke) receiving care in 130 Veterans Health Administration facilities from October 1, 2010, to September 30, 2011, to identify the proportion of male and female patients with CVD receiving any statin and high-intensity statin. Women with CVD (n = 13,371) were less likely than men to receive statins (57.6% vs 64.8%, p <0.0001) or high-intensity statins (21.1% vs 23.6%, p <0.0001). Mean low-density lipoprotein cholesterol levels (99 vs 85 mg/dl) were higher in women compared with men (p <0.0001). In adjusted models, female gender was independently associated with a lower likelihood of receiving statins (odds ratio 0.68, 95% confidence interval 0.66 to 0.71) or high-intensity statins (odds ratio 0.76, 95% confidence interval 0.73 to 0.80). The median facility-level rate of statin and high-intensity statin use among female patients (57.3% interquartile range = 8.93% for statin, 20% interquartile range = 7.7% for high-intensity statin use) showed significant variation. In conclusion, women with CVD are less likely to receive evidence-based statin and high-intensity statins compared with men, although, their use remains low in both genders. There is a significant facility-level variation in evidence-based statin or high-intensity statin use in female patients with CVD. With the “statin dose-based approach” proposed by the recent cholesterol guidelines, these results highlight areas for quality improvement.
Background: The objectives of the present study are to understand the longitudinal variability in COVID-19 reported cases at the county level and to associate the observed rates of infection with the ...adoption and lifting of stay-home orders.
Materials and Methods: The study uses the trajectory of the pandemic in a county and controls for social and economic risk factors, physical environment, and health behaviors to elucidate the social determinants contributing to the observed rates of infection.
Results and conclusion: Results indicated that counties with higher percentages of young individuals, racial and ethnic minorities and, higher population densities experienced greater difficulty suppressing transmission.Except for Education and the Gini Index, all factors were influential on the rate of COVID-19 spread before and after stay-home orders. However, after lifting the orders, six of the factors were not influential on the rate of spread; these included: African-Americans, Population Density, Single Parent Households, Average Daily PM2.5, HIV Prevalence Rate, and Home Ownership. It was concluded that different factors from the ones controlling the initial spread of COVID-19 are at play after stay-home orders are lifted.
KEY MESSAGES
Observed rates of COVID-19 infection at the County level in the U.S. are not directly associated with adoption and lifting of stay-home orders.
Disadvantages in sociodemographic determinants negatively influence the rate of COVID-19 spread.
Counties with more young individuals, racial and ethnic minorities, and higher population densities have greater difficulty suppressing transmission.
This study sought to identify individual-level determinants of COVID-19 vaccine hesitancy based on the Health Belief Model (HBM) and Theory of Planned Behavior (TPB). An online population-based ...survey was distributed in English and Spanish. Data were derived from 1208 U.S. adults (52% female; 38.7% minorities), 43.5% of whom reported vaccine hesitancy. Multivariable analysis revealed that unemployed individuals were more likely (OR = 1.78, 95% CI: 1.16-2.73,
= 0.009) and married (OR = 0.57, 95% CI: 0.39-0.81,
= 0.002) and higher income individuals (OR = 0.52, 95% CI 0.32-0.84,
= 0.008) were less likely to be hesitant. Individuals with greater perceived susceptibility to COVID-19 (OR = 0.82, 95% CI: 0.71-0.94,
= 0.006), who perceived vaccination as being convenient (OR = 0.86, 95% CI: 0.74-1.00,
= 0.047), and who afforded greater importance to cues to action from government (OR = 0.84, 95% CI: 0.74-0.95,
= 0.005), public health (OR = 0.70, 95% CI: 0.59-0.82,
< 0.001), and healthcare experts (OR = 0.59, 95% CI: 0.50-0.69,
< 0.001) were also less likely to be hesitant. Findings suggest that HBM and TPB constructs may be useful in informing strategies to improve COVID-19 vaccine uptake. Specifically, framing appeals based on perceptions of COVID-19 susceptibility, making vaccination convenient, and rebuilding trust through unified cues to action may help to overcome vaccine hesitancy.
IMPORTANCE Pay for performance is intended to align incentives to promote high-quality care, but results
have been contradictory. OBJECTIVE To test the effect of explicit financial incentives to ...reward guideline-recommended hypertension
care. DESIGN, SETTING, AND PARTICIPANTS Cluster randomized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and
a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel (eg,
nurses, pharmacists). INTERVENTIONS Physician-level (individual) incentives, practice-level incentives, both, or none. Intervention
participants received up to 5 payments every 4 months; all participants could access feedback
reports. MAIN OUTCOMES AND MEASURES Among a random sample, number of patients achieving guideline-recommended blood pressure
thresholds or receiving an appropriate response to uncontrolled blood pressure, number of patients
prescribed guideline-recommended medications, and number who developed hypotension. RESULTS Mean (SD) total payments over the study were $4270 ($459), $2672 ($153), and $1648 ($248) for the
combined, individual, and practice-level interventions, respectively. The unadjusted baseline and
final percentages and the adjusted absolute change over the study in patients meeting the combined
blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for
the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group,
79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95%
CI, −3.12% to 4.04%) for the control group. The adjusted absolute estimated difference in the
change between the proportion of patients with blood pressure control/appropriate response for
individual incentive and control groups was 8.36% (95% CI, 2.40% to 13.00%; P=.005). The other
incentive groups did not show a significant change compared with controls for this outcome. For
medications, the unadjusted baseline and final percentages and the adjusted absolute change were 61%
to 73% and 9.07% (95% CI, 4.52% to 13.44%), 56% to 65% and 4.98% (95% CI, 0.64% to 10.08%), 65% to
80% and 7.26% (95% CI, 2.92% to 12.48%), and 63% to 72% and 4.35% (95% CI, −0.28% to 9.28%),
respectively. These changes in the use of guideline-recommended medications were not significant in
any of the incentive groups compared with controls, nor was the incidence of hypotension. The effect
of the incentive was not sustained after a washout. CONCLUSIONS AND RELEVANCE Individual financial incentives, but not practice-level or combined incentives, resulted in
greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the
incentives resulted in greater use of guideline-recommended medications or increased incidence of
hypotension compared with controls. Further research is needed on the factors that contributed to
these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00302718
This study examined the proxy use of patient portals for children in a large Federally Qualified Health Centers (FQHC) network in Texas.
We used de-identified individual-level data of patients, 0-18 ...years, who had 1+ visits between December 2018 and November 2020. Logistic regression was used to examine patient-, clinic-, and geographic-level factors associated with portal usage by an assumed proxy (i.e. parent or guardian).
The proxy portal usage rate increased from 28% in the pre-pandemic months (November 2018-February 2020) to 34% in the pandemic months (March-Nov 2020). Compared to patients 0-5 years, patients aged 6 to 18 years had lower odds of portal usage (6-10 OR: 0.77,
< 0.001; 11-14 OR: 0.62,
< 0.001; 15-18 OR: 0.51,
< 0.001). Minoritized groups had significantly lower odds of portal usage when compared to their non-Hispanic White counterparts (non-Hispanic Black OR: 0.78,
< 0.001; Hispanic OR 0.63,
< 0.001; Asian OR: 0.69,
< 0.001). Having one chronic condition was associated with portal usage (OR: 1.57,
< 0.001); however, there were no significant differences in portal usage between those with none or multiple chronic conditions. Portal usage also varied by service lines, with obstetrics and gynecology (OR: 1.84,
< 0.001) and behavioral health (OR 1.82,
< 0.001) having the highest odds of usage when compared to pediatrics. Having a telemedicine visit was the strongest predictor of portal usage (OR: 2.30,
< 0.001), while residence in zip codes with poor broadband internet access was associated with lower odds of portal usage (OR: 0.97,
< 0.001).
While others have reported portal usage rates as high as 64% in pediatric settings, our analysis suggests proxy portal usage rates of 30% in pediatric FQHC settings, with race/ethnicity, age group, and chronic disease status being significant drivers of portal non-usage. These findings highlight the need for appropriate and responsive health information technology approaches for vulnerable populations receiving care in low-resource settings.
Over the past 20 years, there has been an increased focus on quality improvement (QI) in health care, which is critical in achieving care that is patient-centered, safer, timelier, and more ...effective, efficient, and equitable. At the center of this movement is QI education, which is known to lead to learning, behavior change, and improved outcomes. However, there is a need for the development and provision of long-duration, interactive, interprofessional training in QI, to allow for in-depth learning and application of learned skills. To this end, we designed a curriculum for an established interprofessional, interactive, web-based QI fellowship for doctorally prepared clinicians. Curricular content is delivered virtually to geographically dispersed learners over a 2-year time span. The didactic curriculum and experiential learning opportunities provide learners with the foundational knowledge and practical skills to engage in—and eventually, lead—QI initiatives around the country. Evaluation of learner satisfaction and cognitive, affective, and skills-based learning has found that this model is an effective method to train geographically distributed learners. A hybrid training structure is used, where learners interact with the material through 3 distinct delivery modes: (1) virtual instruction in QI topics; (2) face-to-face training, mentorship, and the opportunity for practical application of applied knowledge and skills through the completion of QI projects; and (3) opportunities for other types of training, tailored to each learner’s Individual Development Plan. This training program model holds value for QI learning in various health care settings, which are interprofessional by nature. These foundational concepts of hybrid learning to distributed learners—wherein an instructor delivers curriculum in small, face-to-face batches, interprofessional learning is supplemented in a virtual, longitudinal manner, and learners are allowed the opportunity to put skills into action for real-world problems in interdisciplinary clinical teams—can be applied in a multitude of settings, with comparatively lower time and cost expenditure than traditional training programs.
ABSTRACT
Background
The recent cholesterol guideline recommends high‐intensity statins in cardiovascular disease (CVD) patients. High‐intensity statins are associated with more frequent side effects. ...Therefore, it may be of concern that these recommendations might reduce statin adherence.
Hypothesis
High‐intensity statins are associated with lower adherence compared with low‐ to moderate‐intensity statins.
Methods
In a national database of 972 532 CVD patients from the Veterans Health Administration, we identified patients receiving statins between October 1, 2010, and September 30, 2011. We assessed statin adherence by calculating proportion of days covered (PDC) and determined whether high‐intensity statin therapy was independently associated with a lower PDC.
Results
Statins were prescribed in 629 005 (64.7%). Of those, 229 437 (36.5%) received high‐intensity statins. Mean PDC (0.87 vs 0.86, P < 0.0001) and patients with PDC ≥0.80 (76.3% vs 74.2%, P < 0.0001) were slightly higher for those receiving low‐ to moderate‐intensity compared with high‐intensity statins. In adjusted analyses, high‐intensity statin use was associated with a significant but modest PDC reduction compared with low‐ to moderate‐intensity statin use, whether PDC was assessed as a continuous (β‐coefficient: −0.008, P < 0.0001) or categorical (PDC ≥0.80 odds ratio: 0.94, 95% confidence interval: 0.93‐0.96) measure of statin adherence.
Conclusions
An approach of high‐intensity statin therapy will lead to a significant practice change, as the majority of CVD patients are not on high‐intensity therapy. However, this change may be associated with a very modest reduction in statin adherence compared with low‐ to moderate‐intensity therapy that is unlikely to be of clinical significance.
Objective
Evaluate the effect of a pay‐for‐performance intervention on the quality of hypertension care provided to black patients and determine whether it produced risk selection.
Data Source/Study ...Setting
Primary data collected between 2007 and 2009 from Veterans Affairs physicians and their primary care panels.
Study Design
Nested study within a cluster randomized controlled trial of three types of financial incentives and no incentives (control). We compared the proportion of physicians’ black patients meeting hypertension performance measures for baseline and final performance periods. We measured risk selection by comparing the proportion of patients who switched providers, patient visit frequency, and panel turnover. Due to limited power, we prespecified in the analysis plan combining the three incentive groups and oversampling black patients.
Data Collection/Extraction Method
Data collected electronically and by chart review.
Principal Findings
The proportion of black patients who achieved blood pressure control or received an appropriate response to uncontrolled blood pressure in the final period was 6.3 percent (95 percent confidence interval, 0.8–11.7 percent) greater for physicians who received an incentive than for controls. There was no difference between intervention and controls in the proportion of patients who switched providers, visit frequency, or panel turnover.
Conclusions and Relevance
A pay‐for‐performance intervention improved blood pressure control or appropriate response to uncontrolled blood pressure in black patients and did not produce risk selection.
PDF
