An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes.
An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes.
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DOI：
10.1002/14651858.cd009255
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发表时间：
2011-07-06
影响因子：
8.4
通讯作者：
Beyer, Fiona R.
中科院分区：
文献类型：
--
作者：
Flodgren, Gerd;Eccles, Martin P.;Shepperd, Sasha;Scott, Anthony;Parmelli, Elena;Beyer, Fiona R.
人们对提供保健方面的财政奖励措施的有效性很感兴趣。激励措施可用于在医疗保健专业人员中增加循证治疗的使用，或激励医疗保健专业人员改变其在预防、诊断和治疗决策方面的临床行为，或两者兼而有之。财务激励是动机的外在来源，当个人可以期望以特定方式行事为条件的货币转移时，就会存在。由于在医疗保健领域进行了许多审查，描述了各种类型的经济激励措施的效果，因此重要的是要总结这些措施的有效性，以确定哪些措施在改变医疗专业人员的行为和患者结局方面最有效。对系统评价进行概述，评价财务激励对医疗保健专业人员行为和患者结局的影响。我们检索了科克伦系统评价数据库（CDSR）（科克伦图书馆）;有效性评价摘要数据库（DARE）; TRIP; MEDLINE; EMBASE;科学引文索引;社会科学引文索引; NHS EED; HEED; EconLit;和政策决策程序（PPd）（从其成立日期到2010年1月）。我们检索了所有纳入综述的参考文献列表，并对引用综述中所含研究的论文进行了引文检索。我们纳入了科克伦和非科克伦的随机对照试验（RCT）、对照临床试验（CCT）、中断时间序列（ITS）和前后对照研究（CBA）综述，这些研究评价了经济激励对专业实践和患者结局的影响，并报告了纳入的个体研究的数值结果。两位综述作者独立提取数据，并根据AMSTAR标准评估每篇综述的方法学质量。我们纳入了对评估任何类型的经济激励有效性的研究的系统评价。我们将财政奖励分为五组：为特定时间段的工作支付报酬;为每次服务、事件或访问支付报酬;为患者或特定人群提供护理支付报酬;为提供预先指定的水平或提供活动或护理质量变化支付报酬;以及混合或其他系统。我们使用投票计数来总结数据。我们确定了4篇评论，报告了32项研究。两篇评论在AMSTAR标准上得分为7（中等，得分5至7，质量），两篇得分为9（高，得分8至11，质量）。通过各种方法，纳入研究的报告质量为低至中等。在特定时间内工作的报酬通常是无效的，在一项综述中报告的一项研究中，改善了3/11的结果。为每项服务、事件或访问付费通常是有效的，在3项综述中报告的5项研究中，改善了7/10的结果;为患者或特定人群提供护理的付费通常是有效的，在2项综述中报告的13项研究中，改善了48/69的结果;为提供预先规定的水平或提供活动或护理质量的改变而支付的费用通常是有效的，改善了两项审评中报告的10项研究的17/20的报告结果;混合和其他系统的有效性参差不齐，改善了三项审评中报告的7项研究的20/31的报告结果。在研究财政奖励对各类成果的总体影响时，它们对咨询或就诊率的效果参差不齐（两项综述中三项研究的10/17结果得到改善）;在改善护理过程方面总体有效（在三项审查中，改善了19项研究的41/57项结果）;在改善转诊和入院方面普遍有效（4项审查中11项研究的11/16项结局得到改善）;在改善对指南结局的依从性方面通常无效（2项综述中5项研究的5/17结局改善）;在改善处方成本结局方面总体有效（1项综述中10项研究的28/34结局改善）。经济激励措施可能会有效地改变医疗保健专业实践。证据有严重的方法局限性，其完整性和普遍性也非常有限。我们没有发现任何证据，从审查的影响，经济激励对病人的结果。
There is considerable interest in the effectiveness of financial incentives in the delivery of health care. Incentives may be used in an attempt to increase the use of evidence-based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive, diagnostic and treatment decisions, or both. Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way. Since there are numerous reviews performed within the healthcare area describing the effects of various types of financial incentives, it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals’ behaviour and patient outcomes. To conduct an overview of systematic reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes. We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting. We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review). Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.