Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis.
Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis.
复制标题
绩效奖金和巴西家庭卫生团队提供的初级卫生保健质量：差异分析。
DOI：
10.1371/journal.pmed.1004033
复制
发表时间：
2022-07
期刊：
影响因子：
15.8
通讯作者：
中科院分区：
文献类型：
--
作者：
绩效付费（P4P）计划旨在激励医疗服务提供者提高护理质量，已在全球范围内广泛实施。尽管直觉上的吸引力，P4P的有效性的证据是混合的，可能是由于在如何设计方案的差异。我们利用市政府的变化，在巴西的国家计划，提高初级保健的可及性和质量（PMAQ）的设计特点，以研究是否给予家庭健康团队工作人员的绩效奖金与护理质量的变化，以及奖金的大小是否重要。对于这个准实验研究，我们使用了一个差异中的差异与匹配相结合的方法。我们比较了（奖金）城市之间的家庭健康团队提供的医疗质量随时间的变化，这些城市选择使用部分或全部PMAQ资金向团队工作人员提供与绩效相关的奖金，而（非奖金）城市则使用传统的基于投入的预算来投资资金。主要结果是PMAQ评分，这是一个0到100的护理质量指数，基于数百个医疗保健提供指标（范围从598到660）。我们根据基线人口统计和经济特征，对奖金城市和非奖金城市进行了一对一的匹配。在匹配的样本中，我们使用普通最小二乘回归来估计任何奖金和奖金大小与PMAQ分数随时间（2011年11月至2015年10月）变化的关联。我们对家庭卫生团队的当地收入进行了亚组分析。匹配的分析样本包括2 346个城市（1 173个非奖励城市; 1 173个奖励城市），其中包括10 275个从一开始就参加PMAQ的家庭保健小组。与非奖金城市相比，奖金城市的PMAQ得分增加了4.6（95%CI：2.7至6.4; p < 0.001）个百分点。与护理质量的相关性随着奖金的大小而增加：与对照组相比，最大奖金组提高了8.2个百分点（95% CI：6.2至10.2; p < 0.001）。分组分析表明，在最贫穷的五分之二地区，所观察到的业绩改善最为明显。该研究的局限性包括来自未测量的时变混杂的偏倚的可能性，以及PMAQ评分尚未被验证为护理质量的测量的事实。与传统的以投入为基础的预算相比，家庭保健团队工作人员的绩效奖金与护理质量的改善有关。Nasser Fardousi及其同事调查了巴西家庭健康团队提供的绩效奖金与初级卫生保健质量之间的关系。绩效付费（P4P）计划旨在激励医疗服务提供者提高护理质量，已在全球范围内广泛实施。P4P计划在设计方式上差异很大，但这些设计选择是否对护理质量有影响的证据有限。巴西的《改善初级保健机会和质量国家方案》是一项采购换采购计划，赋予市政当局决定如何使用资金的自主权，特别是决定是否可以将付款用于奖励保健工作者。我们使用了差异中的差异的方法来研究是否给予家庭健康团队工作人员的绩效奖金，与传统的基于投入的预算相比，与护理质量的变化，以及奖金的大小是否重要。我们发现，给家庭健康团队工作人员奖金与护理质量的改善有关，并且这种关联随着奖金的大小而增加。在最贫穷的五分之二地区的家庭保健队中，保健质量的改善最为明显。研究结果表明，绩效奖金的家庭保健团队工作人员可能是一个更有效的方式使用PMAQ资金，以提高护理质量比基于投入的预算。家庭保健工作队工作人员的业绩奖金似乎减少了初级保健提供方面的不平等现象。需要进一步的研究，以更好地了解其他设计特征，如谁得到支付和支付的频率，影响P4P计划提高护理质量的程度。
Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil’s National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered. For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care. Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care. Nasser Fardousi and colleagues investigate the association between performance bonuses and the quality of primary health care delivered by family health teams in Brazil. Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. P4P schemes vary considerably in how they are designed, but there is limited evidence on whether these design choices matter for quality of care. The National Programme for Improving Primary Care Access and Quality (PMAQ) in Brazil was a P4P scheme that gave municipalities autonomy to decide how funds could be spent and, specifically, whether payments could be used to reward health workers. We used a difference-in-differences approach to examine whether performance bonuses given to family health team workers, compared with traditional input-based budgets, were associated with changes in the quality of care, and whether the size of bonus mattered. We found that giving bonuses to family health team workers was associated with an improvement in the quality of care, and the association increased with the size of bonus. Improvements in quality of care were most pronounced for family health teams located in the poorest two-fifths of areas. The findings suggest that performance bonuses to family health team workers can potentially be a more effective way of using PMAQ funds to improve quality of care than input-based budgeting. Performance bonuses to family health team workers appeared to reduce inequalities in the delivery of primary health care. Further research is needed to better understand what other design features, such as who gets paid and the frequency of payment, influence the extent to which P4P schemes improve quality of care.
登录
查看更多内容
影响因子：
4.4
作者：
Eijkenaar, Frank
通讯作者：
Eijkenaar, Frank
影响因子：
2.7
作者：
Lannes, Laurence;Meessen, Bruno;Basinga, Paulin
通讯作者：
Basinga, Paulin
DOI：
10.1590/s0102-311x2008001300020
发表时间：
2008-01-01
期刊：
Cadernos de Saúde Pública
影响因子：
--
作者：
Facchini, Luiz Augusto;Piccini, Roberto Xavier;Osório, Alessander
通讯作者：
Osório, Alessander
影响因子：
3.2
作者：
de Walque, Damien;Robyn, Paul Jacob;Steenland, Maria
通讯作者：
Steenland, Maria
影响因子：
4.4
作者：
Kristensen, Soren Rud;Bech, Mickael;Lauridsen, Jorgen T.
通讯作者：
Lauridsen, Jorgen T.