Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: a longitudinal observational study Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007 Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China Patients' perceptions of the quality of care after primary care reform: Family medicine groups in Quebec. A Pilot Test of the Effect of Guided Care on the Quality of Primary Care Experiences for Multimorbid Older Adults Organizational and market influences on physician performance on patient experience measures. The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. The effect of cash and other financial inducements on the response rate of general practitioners in a national postal study. Primary Care Provider Perceptions of the Effectiveness of Two Self-Management Support Programs for Vulnerable Patients with Diabetes Prepayment was superior to postpayment cash incentives in a randomized postal survey among physicians. Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol Designing payment for Collaborative Care for Depression in primary care. A Model-Based Economic Evaluation of Improved Primary Care Management of Patients with Type 2 Diabetes in Australia Trust in insurers and access to physicians: associated enrollee behaviors and changes over time. Pharmacist recommendations to improve the quality of diabetes care: a randomized controlled trial. Effect of Removing Direct Payment for Health Care on Utilisation and Health Outcomes in Ghanaian Children: A Randomised Controlled Trial
Background The UK 's Quality and Outcomes Framework ( QOF ) was introduced in 2004/5 , linking remuneration for general practice s to recorded quality of care for chronic conditions , including diabetes mellitus . We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics . Methods Using the General Practice Research Data base we selected a stratified sample of 148 English general practice s in Engl and , contributing data from 2000/1 to 2006/7 , and obtained a r and om sample of 653 500 patients in which 23 920 diabetes patients identified . We quantified annually recorded quality of care at the patient-level , as measured by the 17  QOF diabetes indicators , in a composite score and analysed it longitudinally using an Interrupted Time Series design . Results Recorded quality of care improved for all subgroups in the pre-incentive period . In the first year of the incentives , composite quality improved over- and -above this pre-incentive trend by 14.2 % ( 13.7–14.6 % ) . By the third year the improvement above trend was smaller , but still statistically significant , at 7.3 % ( 6.7–8.0 % ) . After 3 years of the incentives , recorded levels of care varied significantly for patient gender , age , years of previous care , number of co-morbid conditions and practice diabetes prevalence . Conclusions The introduction of financial incentives was associated with improvements in the recorded quality of diabetes care in the first year . These improvements included some measures of disease control , but most captured only documentation of recommended aspects of clinical assessment , not patient management or outcomes of care . Improvements in subsequent years were more modest . Variation in care between population groups diminished under the incentives , but remained substantial in some cases PURPOSE Major primary care reforms have been introduced in recent years in the United Kingdom , including financial incentives to improve clinical quality and provide more rapid access to care . Little is known about the impact of these changes on patient experience . We examine patient reports of quality of care between 2003 and 2007 , including r and om sample s of patients on practice lists and patients with long-term conditions . METHODS We conducted a cross-sectional design study of family practice s in which  question naires were sent to serial sample s of patients in 42 representative general practice s in Engl and . Question naires sent to sample s of patients with chronic disease ( asthma , angina , and diabetes ) and r and om sample s of adult patients ( excluding patients who reported any long-term condition ) in 2003 , 2005 , and 2007 addressed issues of access , communication , continuity of care , coordination , nursing care , and overall satisfaction . RESULTS There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication , nursing care , coordination , and overall satisfaction . Some aspects of access improved significantly for patients with chronic disease , but not for the r and om sample s of patients . Patients in both sample s reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care . Most scores were significantly higher for the chronic illness sample s than for the r and om sample s of patients in 2003 , even after adjusting for age . CONCLUSIONS There was a modest improvement in access to care for patients with chronic illness , but all patients now find it somewhat harder to obtain continuity of care . This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care . The possibility of unintended effects needs to be considered when introducing pay for performance schemes IMPORTANCE Most evaluations of pay-for-performance ( P4P ) incentives have focused on large-group practice s. Thus , the effect of P4P in small practice s , where many US residents receive care , is largely unknown . Furthermore , whether electronic health records ( EHRs ) with chronic disease management capabilities support small- practice response to P4P has not been studied . OBJECTIVE To assess the effect of P4P incentives on quality in EHR-enabled small practice s in the context of an established quality improvement initiative . DESIGN , SETTING , AND PARTICIPANTS A cluster-r and omized trial of small ( < 10 clinicians ) primary care clinics in New York City from April 2009 through March 2010 . A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance . INTERVENTIONS Incentivized clinics were paid for each patient whose care met the performance criteria , but they received higher payments for patients with comorbidities , who had Medicaid insurance , or who were uninsured ( maximum payments : $ 200/patient ; $ 100,000/clinic ) . Quality reports were given quarterly to both the intervention and control groups . MAIN OUTCOMES AND MEASURES Comparison of differences in performance improvement , from the beginning to the end of the study , between  control  and  intervention  clinics for  aspirin or antithrombotic prescription , blood pressure control , cholesterol control , and smoking cessation interventions .  Mixed-effects logistic regression was used to account for clustering of patients within clinics , with a treatment by time interaction term assessing the statistical significance of the effect of the intervention . RESULTS Participating clinics ( n = 42 for each group ) had similar baseline characteristics , with a mean of 4592 ( median , 2500 ) patients at the intervention group clinics and 3042 ( median , 2000 ) at the control group clinics . Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription ( 12.0 % vs 6.1 % , difference : 6.0 % [ 95 % CI , 2.2 % to 9.7 % ] , P = .001 for interaction term ) , blood pressure control ( no comorbidities : 9.7 % vs 4.3 % , difference : 5.5 % [ 95 % CI , 1.6 % to 9.3 % ] , P = .01 for interaction term ; with diabetes mellitus : 9.0 % vs 1.2 % , difference : 7.8 % [ 95 % CI , 3.2 % to 12.4 % ] , P = .007 for interaction term ; with diabetes mellitus or ischemic vascular disease : 9.5 % vs 1.7 % , difference : 7.8 % [ 95 % CI , 3.0 % to 12.6 % ] , P = .01 for interaction term ) , and in smoking cessation interventions  ( 12.4 % vs 7.7 % , difference : 4.7 % [ 95 % CI , -0.3 % to 9.6 % ] , P = .02 for interaction term ) . Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control , but no differences were statistically significant . CONCLUSIONS AND RELEVANCE Among small EHR-enabled clinics , a P4P incentive program compared with usual care result ed in modest improvements in cardiovascular care processes and outcomes . Because most proposed P4P programs are intended to remain in place more than a year , further research is needed to determine whether this effect increases or decreases over time . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00884013 Background While integrated health care system has been proved an effective way to help improving patient health and system efficiency , the exact behaviour model and motivation approach are not so clear in poor rural areas where health human re sources and continuous service provision are urgently needed . To gather solid evidence , we initiated a comprehensive intervention project in Qianjiang District , southwest part of rural China in 2012 . And after one-year 's pilot , we developed an intervention package of team service , comprehensive pathway and prospect ive- and performance-based payment system . Methods To testify the potential influence of payment interventions , we use clustered r and omised controlled trial , 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences . Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway . The outcomes are : quality of care , disease burden , supplier cooperative behaviour and patient utilisation behaviour and system efficiency . Repeated multivariate variance analysis will be used to statistically examine the outcome differences . Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care . Though we adopted r and omised controlled trial to gather the highest rank of evidence , still the fully r and omisation was hard to realise in health policy reform experiment . To compensate , the design er should take efforts on control for the potential confounders as much as possible . With this trial , we assume the effects will come from : ( 1 ) improvement on the quality of life through risk factors control and lifestyles change on patient 's behaviours ; ( 2 ) improvement on quality of care through continuous care and coordinated supplier behaviours ; ( 3 ) improvement on the system efficiency through active interaction between suppliers and patients . Conclusion The integrated care system needs collaborative work from different levels of caregivers . So it is extremely important to consider the supplier cooperative behaviour . In this trial , we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles . Also , the multidisciplinary team , the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution OBJECTIVE To evaluate how a primary care reform , which aim ed to promote interprofessional and interorganizational collaborative practice s , affected patients ' experiences of the core dimensions of primary care . DESIGN Before- and -after comparison of patients ' perceptions of care at the beginning of  family medicine group ( FMG ) implementation  ( 15 to 20 months after accreditation ) and 18 months later . SETTING  Five FMGs in the province of Quebec from various setting s and types of practice . PARTICIPANTS A r and om sample of patients was selected in each FMG ; a total of 1046 participants completed both the baseline and follow-up question naires . MAIN OUTCOME MEASURES Patients ' perceptions of relational and informational continuity , organizational and first-contact accessibility , attitude and efficiency of the clinic 's personnel and waiting times ( service responsiveness ) , physician-nurse and primary care physician-specialist coordination , and intra-FMG collaboration were assessed over the telephone , mostly using a modified version of the  Primary Care Assessment Tool . Additional items covered patients ' opinions about consulting nurses , patients ' use of emergency services , and patients ' recall of health promotion and preventive care received . RESULTS A total of 1275 patients were interviewed at the study baseline , and 82 % also completed the follow-up interviews after 18 months ( n = 1046 ) . Overall , perceptions of relational and informational continuity increased significantly ( P < .05 ) , whereas organizational and first-contact accessibility and service responsiveness did not change significantly . Perception of physician-nurse coordination remained unchanged , but perception of primary care physician-specialist coordination decreased significantly ( P < .05 ) . The proportion of participants reporting visits with nurses and reporting use of FMGs ' emergency services increased significantly from baseline to follow-up ( P < .05 ) . CONCLUSION This reorganization of primary care services result ed in considerable changes in care practice s , which led to improvements in patients ' experiences of the continuity of care but not to improvements in their experiences of the accessibility of care Objective Improving health care of multimorbid older adults is a critical public health challenge . The objective of this study is to evaluate the effect of a pilot intervention to enhance the  quality of primary care experiences for chronically ill older persons ( Guided Care ) . Design Nonr and omized prospect i ve clinical trial . Patients / Participants Older , chronically ill , community-dwelling patients ( N = 150 ) of 4 General Internists in 1 urban community practice setting who were members of a capitated health plan and identified as being at high risk of heavy use of health services in the coming year by cl aims -based predictive modeling . Interventions Guided Care , an enhancement to primary care that incorporates the operative principles of chronic care innovations , was delivered by a specially trained , practice -based registered nurse working closely with 2 primary care physicians . Each patient received a geriatric assessment , a comprehensive care plan , evidence -based primary care with proactive follow-up of chronic conditions , coordination of the efforts of health professionals across all health care setting s , and facilitated access to community re sources . Measurements and Main Results Quality of primary care experiences ( physician – patient communication , interpersonal treatment , knowledge of patient , integration of care , and trust in physician ) was assessed using the Primary Care Assessment Survey ( PCAS ) at baseline and 6 months later . At baseline , the patients assigned to receive Guided Care were similar to those assigned to receive usual care in their demographics and disability levels , but they had higher risk scores and were less likely to be married . Thirty-one of the 75 subjects assigned to the Guided Care group received the intervention . At 6 months , intention-to-treat analyses adjusting for age , gender , and risk score suggest that Guided Care may improve the quality of physician – patient communication . In per- protocol analyses , receipt of Guided Care was associated with more favorable change than usual care from baseline to follow-up in all 5 PCAS domains , but only physician – patient communication showed a statistically significant improvement . Conclusions In this pilot study , Guided Care appeared to improve the quality of primary care experiences for high-risk , chronically ill older adults . A larger cluster-r and omized controlled trial of Guided Care is underway OBJECTIVE To examine the extent to which medical group and market factors are related to individual primary care physician ( PCP ) performance on patient experience measures . DATA SOURCES This study employs  Clinician and Group CAHPS survey data ( n=105,663 ) from 2,099 adult PCPs belonging to 34 diverse medical groups across California . Medical group directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the adoption of patient experience improvement strategies . Primary care services area ( PCSA ) data were used to characterize the market environment of physician practice s. STUDY DESIGN We used multilevel models to estimate the relationship between medical group and market factors and physician performance on each Clinician and Group CAHPS measure . Models statistically controlled for respondent characteristics and accounted for the clustering of respondents within physicians , physicians within medical groups , and medical groups within PCSAs using r and om effects . PRINCIPAL FINDINGS Compared with physicians belonging to independent practice associations , physicians belonging to integrated medical groups had better performance on the communication ( p=.007 ) and care coordination ( p=.03 ) measures . Physicians belonging to medical groups with greater numbers of PCPs had better performance on all measures . The use of patient experience improvement strategies was not associated with performance . Greater emphasis on productivity and efficiency criteria in individual physician financial incentive formulae was associated with worse access to care ( p=.04 ) . Physicians located in PCSAs with higher area-level deprivation had worse performance on the access to care ( p=.04 ) and care coordination ( p<.001 ) measures . CONCLUSIONS Physicians from integrated medical groups and groups with greater numbers of PCPs performed better on several patient experience measures , suggesting that organized care processes adopted by these groups may enhance patients ' experiences . Physicians practicing in markets with high concentrations of vulnerable population s may be disadvantaged by constraints that affect performance . Future studies should clarify the extent to which performance deficits associated with area-level deprivation are modifiable BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition . Patients visiting registry clinics accessed counseling programs statistically significantly more often ( P < 0.001 ) than patients receiving care in the control condition . Other endpoints did not statistically significantly differ between the experimental conditions . CONCLUSIONS The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practice s and patient behaviors was mixed . Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment BACKGROUND Low response rates are acknowledged as a potential source of bias in survey results . Response rates are a particular problem in surveys of GPs . Thus , the methods used to encourage response to mailed surveys and the influence of inducements in maximizing response rates are fundamental issues to be examined when addressing the problem of response bias . AIM To increase the overall response rate to a national study of GPs and to explore the effects of financial and non-financial inducements on response rates . METHODS Two mailing waves of a postal question naire to a 20 % r and om sample of all GPs in Engl and and Wales had achieved a 33 % response rate . For the third mailing wave , the non-responding GPs were then divided into a control group , a group who were offered a donation to charity to complete the question naire and a group who were offered cash . The charity and cash groups were further subdivided into 5 pounds and 10 pounds groups to assess the effect of the size of the inducement offered . For the control group , a fourth wave was sent the offer of a 5 pounds or 10 pounds incentive . RESULTS Response was positively affected by the offer of an inducement . Cash , however , had a more substantial effect than the offer of a donation to charity .  Older GPs were less likely to participate overall , whereas male GPs were more likely to respond to a cash inducement . Doctors who had seen more patients were less likely to reply earlier and were more likely to respond to the offer of cash . CONCLUSIONS Primary care is going through many changes , some of which have increased the workload of the GP . It may now be that , to achieve the response rates needed to vali date policy-related research , the offer of inducements will become a necessary part of the research process Background : Primary care providers ( PCPs ) in safety net setting s face barriers to optimizing care for patients with diabetes . We conducted this study to assess PCPs ' perspectives on the effectiveness of two language -concordant diabetes self-management support programs . Methods : One year postintervention , we surveyed PCPs whose patients with diabetes participated in a three-arm multiclinic r and omized controlled trial comparing usual care ( UC ) , weekly automated telephone self-management ( ATSM ) support with nurse care management  ,  and monthly group medical visits ( GMVs ) . We compared PCP perspectives on patient activation to create and achieve goals , quality of care , and barriers to care using regression models accounting for within-PCP clustering . Results : Of 113 eligible PCPs caring for 330 enrolled patients , 87 PCPs ( 77 % ) responded to surveys about 245 ( 74 % ) enrolled patients . Intervention patients were more likely to be perceived by PCPs as activated to create and achieve goals for chronic care when compared with UC patients ( st and ardized effect size , ATSM vs UC , + 0.41 , p = 0.01 ; GMV vs UC , + 0.31 , p = 0.05 ) . Primary care providers rated quality of care as higher for patients exposed to ATSM compared to UC ( odds ratio 3.6 , p < 0.01 ) . Compared with GMV patients , ATSM patients were more likely to be perceived by PCPs as overcoming barriers related to limited English proficiency ( 82 % ATSM vs 44 % GMV , p = 0.01 ) and managing medications ( 80 % ATSM vs 53 % GMV , p = 0.01 ) . Conclusions : Primary care providers perceived that patients receiving ATSM support had overcome barriers , participated more actively , and received higher quality diabetes care . These views of clinician stakeholders lend additional evidence for the potential to upscale ATSM more broadly to support PCPs in their care of diverse , multi-linguistic population OBJECTIVE Improving response rates , particularly among physicians , is important to minimize nonresponder bias and increase the effective sample size in epidemiologic research . We conducted a r and omized trial to examine the impact of prepayment vs. postpayment incentives on response rates . STUDY DESIGN AND SETTING Self-completion postal question naires were mailed to 949 physicians who were respondents to an earlier survey and representative of the general physician population in Hong Kong . These physicians were r and omly allocated to receive a HK dollar 20 cash prepayment incentive that accompanied the survey ( n=474 ) or a postpayment reward of the same amount on receipt of the completed question naire ( n=475 ) . RESULTS The final prepayment response rate was 82.9 % , compared with 72.5 % in the postpayment arm ( P < .001 ) . Of the eight alternative incentive and follow-up strategies evaluated , three lie on the efficiency frontier ( i.e. , not dominated ) , including postpayment with three mailings at HK dollar 42.7 , prepayment with three mailings at HK dollar 66.5 and prepayment with three mailings and telephone follow-up at HK dollar 112.1 per responder recruited ( US dollar 1=HK dollar 7.8 ) . CONCLUSION The findings demonstrate that prepayment cash incentives are superior to postpayment of the equivalent amount in improving response rates among a representative sample of Hong Kong physicians . Further research should concentrate on confirming the generalizability of these findings in other health care occupation groups and setting Background Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment , hypertension is controlled in less than one-half of United States citizens . Methods / design This r and omized controlled trial tests whether explicit financial incentives promote the translation of guideline -recommended care for hypertension into clinical practice and improve blood pressure ( BP ) control in the primary care setting . Using constrained r and omization , we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms : physician-level incentive ; group-level incentive ; combination of physician and group incentives ; and no incentives ( control ) . All participants at the hospital ( cluster ) were assigned to the same study arm . We enrolled 83 full-time primary care physicians and 42 non-physician personnel . The intervention consisted of an educational session about guideline -recommended care for hypertension , five audit and feedback reports , and five disbursements of incentive payments . Incentive payments rewarded participants for chart-documented use of guideline -recommended antihypertensive medications , BP control , and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention . To identify potential unintended consequences of the incentives , the study team interviewed study participants , as well as non-participant primary care personnel and leadership at study sites . Chart review s included data collection on quality measures not related to hypertension . To evaluate the persistence of the effect of the incentives , the study design includes a washout period . Discussion We briefly describe the rationale for the interventions being studied , as well as the major design choices . Rigorous research design s such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements . Trial Registration http://www . clinical OBJECTIVE To design a bundled case rate for Collaborative Care for Depression ( CCD ) that aligns incentives with evidence -based depression care in primary care . DATA SOURCES A clinical information system used by all care managers in a r and omized controlled trial of CCD for older primary care patients . STUDY DESIGN We conducted an empirical investigation of factors accounting for variation in CCD re source use over time and across patients . CCD re source use at the patient-episode and patient-month levels was measured by number of care manager contacts and direct patient contact time and analyzed with count data ( Poisson or negative binomial ) models . PRINCIPAL FINDINGS Episode-level re source use varies substantially with patient 's time in the program . Monthly use declines sharply in the first 6 months regardless of treatment response or remission status , but it remains stable afterwards . An adjusted episode or monthly case rate design better matches payment with variation in re source use compared with a fixed design . CONCLUSIONS Our findings lend support to an episode payment adjusted by number of months receiving CCD and a monthly payment adjusted by the ordinal month . Nonpayment tools including program certification and performance evaluation and reward systems are needed to fully align incentives Background There are few studies investigating the economic value of the Australian practice nurse workforce on the management of chronic conditions . This is particularly important in Australia , where the government needs evidence to inform decisions on whether to maintain or redirect current financial incentives that encourage practice s to recruit practice nurses . Objective The objective of this study was to estimate the lifetime costs and quality -adjusted life-years ( QALYs ) associated with two models of  practice nurse involvement in clinical -based activities ( high and low level ) in the management of type 2 diabetes within the primary care setting . Methods A previously vali date d state transition model ( the United Kingdom Prospect i ve Diabetes Study Outcomes Model ) was adapted , which uses baseline prognostic factors ( e.g. gender , haemoglobin A1c [ HbA1c ] ) to predict the risk of occurrence of diabetes-related complications ( e.g. stroke ) . The model was populated by data from Australian and UK observational studies . Costs and utility values associated with complications were summed over patients ’ lifetimes to estimate costs and QALY gains from the perspective of the health care system . All costs were expressed in 2011 Australian dollars ( AU$ ) . The base-case analysis assumed a 40-year time horizon with an annual discount rate of 5 % . Results Relative to low-level involvement of practice nurses in the provision of clinical -based activities , the high-level model was associated with lower mean lifetime costs of management of complications ( −AU$8,738 ; 95 % confidence interval [ CI ] −AU$12,522 to −AU$4,954 ) , and a greater average gain in QALYs ( 0.3 ; 95 % CI 0.2–0.4 ) . A range of sensitivity analyses were performed , in which the high-level model was dominant in all cases . Conclusion Our results suggest that the high-level model is a dominant management strategy over the low-level model in all modelled scenarios . These findings indicate the need for effective primary care-based incentives to encourage general practice s not only to employ practice nurses , but to better integrate them into the provision of clinical services OBJECTIVE Most studies of trust in the medical arena have focused on trust in physicians rather than trust in health insurers , and have been cross-sectional rather than longitudinal studies . This study examined associations among trust in a managed care insurer , trust in one 's primary physician , and subsequent enrollee behaviors relating to source of care . The study also documents changes in trust in the study population following the disclosure of physician incentives . STUDY SETTING A medium-sized ( 300,000 member ) HMO , located in the southeastern United States . DATA COLLECTION One to two years after baseline , we r and omly resurveyed a quarter ( n = 558 ) of the initial study population of a large intervention study design ed to measure the impact of disclosing HMO financial incentives on patient trust . This follow-up study was also design ed to measure the effects of trust on source of care . ANALYSES Multivariate regression analyses of survey data examined associations between baseline levels of trust and subsequent enrollee behaviors such as using a non-PCP physician without a PCP referral , as well as changes in trust since baseline . RESULTS High baseline insurer trust was associated with a lower probability of a patient seeking care from a non-PCP physician ( OR = 0.55 , 95 percent CI : 0.33 , 0.91 ) . No long-term effects of prior disclosure of financial incentives were observed . Overall , there was a slight increase in overall trust in the insurer ( 1.8 percent , p < .05 ) but no change in trust in one 's primary physician . The increase in insurer trust was primarily restricted to 23 percent of the enrollees who had changed their PCPs following the baseline survey ( 6.6 percent , p < .01 ) . In multivariate analyses , changing physicians was the most significant predictor of increased insurer trust ( OR = 2.17 , 95 percent CI : 1.37 , 3.43 ) . CONCLUSIONS . Trust in one 's insurer seems to change over time more than trust in one 's primary physician , and is predictive of enrollee behaviors such as seeking care from other physicians . The ability to change physicians seems to increase trust in the insurer BACKGROUND Diabetes mellitus continues to result in substantial morbidity and mortality despite receiving much attention from health care providers . Automated clinician reminder systems have been developed to improve adherence to diabetes care guidelines , but these reminder systems do not always provide actionable information and may be unable to detect relevant , subjective patient information that affects clinical decision making . Face-to-face visits with pharmacists , who have knowledge of care guidelines and medication management strategies , may assist in improving diabetes care . It is unknown if the combination of pharmacist chart review and clinician reminders could improve diabetes care without requiring face-to-face visits . OBJECTIVE To assess the effects of a comprehensive , pharmacistdelivered , primary care , physician-focused intervention in a large hospital based primary care practice to improve the quality of care for patients with diabetes including rates of semiannual hemoglobin A1c testing and other biomarker and process measures . METHODS This was a prospect i ve , r and omized , controlled study conducted in a hospital-based , primary care practice , composed of 37 faculty primary care physicians ( PCPs ) and 95 internal medicine residents . The initial sample included 346 patients with diabetes and 72 PCPs caring for them . PCPs were r and omized to receive either a personalized letter from a practicing pharmacist containing treatment recommendations for patients with upcoming primary care visits ( intervention , n = 33 ) or to usual care without the letters ( control , n = 39 ) . The letter included patient-specific recommendations regarding overdue testing as well as drug therapy to achieve diabetes-related treatment targets . The intervention included addition of the letter to the electronic medical record ( EMR ) and presentation of the letter to the PCP at the time of the index primary care visit that occurred between November 2003 and August 2004 . Follow-up chart review was performed after the primary care visit to determine changes in 5 process and 3 biomarker outcome measures of diabetes care within 30 days of the index visit . The primary study outcome was a process measure , change in rates of semiannual A1c testing from baseline to 30-day follow-up . Baseline differences were tested for statistical significance using Pearson chisquare . The statistical significance of the intervention 's effect was tested using logistic regression models predicting achievement of each study outcome , with r and omization status ( intervention vs. control ) as the predictor variable of interest , controlling for baseline performance for each measure . RESULTS 171 patients were in the 4 medical clinic suites with 33 PCPs who received the intervention , and 175 patients were in the 4 suites with 39 PCPs in usual care . 30-day outcomes were analyzed for 301 patients ( 87.0 % ) who attended their scheduled index primary care visit . Of these 301 patients , 44.5 % were black , 65.8 % were female , and the mean age was 63 years . At baseline , there were no significant differences between the intervention group ( n = 150 ) and the usual care ( control ) group ( n = 151 ) in the 3 biomarker measures ( proportion with A1c less than 7 % , proportion with low-density lipoprotein cholesterol [ LDL-C ] less than 100 milligrams per deciliter [ mg per dL ] , or blood pressure less than 130/80 millimeters mercury [ mm Hg ] ) . There were no significant baseline differences in 4 of the 5 process measures ; however , the rate of annual LDL-C testing was significantly higher for the intervention than for the control group at baseline ( 86.0 % vs. 74.8 % , respectively , P = 0.015 ) . In logistic regression analysis , rates of semiannual A1c testing were not significantly different between the intervention and control groups , increasing from baseline to follow-up by 16 % in the intervention group and 9 % in the control group ( P = 0.146 ) . The proportion of patients with A1c less than 7 % at follow-up was 43.3 % in the intervention group versus 37.7 % in the control group ( intervention effect P = 0.099 ) . The only statistically significant difference between the 2 groups in the 8 outcome measures was a higher proportion with an annual eye exam at follow-up in the intervention group ( 60.0 % ) versus the usual care group ( 50.3 % , intervention effect P = 0.017 ) . CONCLUSIONS Pharmacist-generated recommendations delivered by letter to PCPs in an academic medical practice were not associated with statistically significant improvements in most quality measures for diabetes care assessed at 30 days following the intervention . Further research is needed with more patients and a longer follow-up time to determine how best to improve the quality of care of patients with diabetes using focused recommendations for therapy changes and reminder notices to clinicians Background Delays in accessing care for malaria and other diseases can lead to disease progression , and user fees are a known barrier to accessing health care . Governments are introducing free health care to improve health outcomes . Free health care affects treatment seeking , and it is therefore assumed to lead to improved health outcomes , but there is no direct trial evidence of the impact of removing out-of-pocket payments on health outcomes in developing countries . This trial was design ed to test the impact of free health care on health outcomes directly . Methods and Findings 2,194 households containing 2,592 Ghanaian children under 5 y old were r and omised into a prepayment scheme allowing free primary care including drugs , or to a control group whose families paid user fees for health care ( normal practice ) ; 165 children whose families had previously paid to enrol in the prepayment scheme formed an observational arm . The primary outcome was moderate anaemia ( haemoglobin [ Hb ] < 8 g/dl ) ; major secondary outcomes were health care utilisation , severe anaemia , and mortality . At baseline the r and omised groups were similar . Introducing free primary health care altered the health care seeking behaviour of households ; those r and omised to the intervention arm used formal health care more and nonformal care less than the control group . Introducing free primary health care did not lead to any measurable difference in any health outcome . The primary outcome of moderate anaemia was detected in 37 ( 3.1 % ) children in the control and 36 children ( 3.2 % ) in the intervention arm ( adjusted odds ratio 1.05 , 95 % confidence interval 0.66–1.67 ) . There were four deaths in the control and five in the intervention group . Mean Hb concentration , severe anaemia , parasite prevalence , and anthropometric measurements were similar in each group . Families who previously self-enrolled in the prepayment scheme were significantly less poor , had better health measures , and used services more frequently than those in the r and omised group . Conclusions In the study setting , removing out-of-pocket payments for health care had an impact on health care-seeking behaviour but not on the health outcomes measured . Trial registration : Clinical Trials.gov ( # NCT00146692 )
Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures , but not all .
The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing .
However , there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care .
BACKGROUND The use of blended payment schemes in primary care , including the use of financial incentives to directly reward ' performance ' and ' quality ' is increasing in a number of countries .
There are many examples in the US , and the Quality and Outcomes Framework ( QoF ) for general practitioners ( GPs ) in the UK is an example of a major system-wide reform .
Despite the popularity of these schemes , there is currently little rigorous evidence of their success in improving the quality of primary health care , or of whether such an approach is cost-effective relative to other ways to improve the quality of care .
OBJECTIVES The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians ( PCPs ) and to identify : i ) the different types of financial incentives that have improved quality ; ii ) the characteristics of patient population s for whom quality of care has been improved by financial incentives ; and iii ) the characteristics of PCPs who have responded to financial incentives .