Socioeconomic inequalities in the quality of primary care under Brazil's national pay-for-performance programme: a longitudinal study of family health teams.
Socioeconomic inequalities in the quality of primary care under Brazil's national pay-for-performance programme: a longitudinal study of family health teams.
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DOI：
10.1016/s2214-109x(20)30480-0
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发表时间：
2021-03
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影响因子：
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通讯作者：
Powell-Jackson T
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作者：
Kovacs R;Maia Barreto JO;da Silva EN;Borghi J;Kristensen SR;Costa DRT;Bezerra Gomes L;Gurgel GD Junior;Sampaio J;Powell-Jackson T
许多政府实行了按绩效付费方案，以激励卫生服务提供者提高护理质量。关于这些规划是减少还是加剧了卫生保健方面的差距的证据很少。在本研究中，我们旨在评估巴西国家改善初级保健可及性和质量方案（PMAQ）下家庭保健团队绩效中的社会经济不平等。在这项纵向研究中，我们分析了参与PMAQ的家庭卫生团队在三轮实施中提供的护理质量数据：第一轮（2011年11月至2013年3月），第二轮（2013年4月至2015年9月）和第三轮（2015年10月至2019年12月）。主要结果是基于数百个（从598到914）保健服务指标，家庭保健小组可获得的最高绩效分数（PMAQ分数）的百分比。利用地方居民家庭收入普查数据，对PMAQ得分进行收入分类检验。我们使用普通最小二乘回归来检验PMAQ分数与每个地区在实施回合中的收入之间的关系，并进行方差分析来评估PMAQ分数的地理差异。在40361个登记参与PMAQ的家庭卫生团队中，我们在分析中纳入了13934个参加过三轮PMAQ的团队。这些工作队分布在11 472个人口普查地区，为大约4 800万人提供服务。第1轮的平均PMAQ评分为61.0%（中位数为61.8，IQR为55.3 - 67.9），第2轮为55.3%（中位数为56.0，IQR为47.6 - 63.4），第3轮为61.6%（中位数为62.7，IQR为54.4 - 69.9）。在第一轮中，我们观察到一个正的社会经济梯度，平均PMAQ得分从最贫穷组的56.6%到最富裕组的64.1 %不等。在第1轮和第3轮之间，最贫穷组的平均PMAQ绩效提高了7.1个百分点，最富裕组的平均PMAQ绩效下降了0.8个百分点（p< 0.0001），最富裕和最贫穷组之间的差距在同一时期（-1·6到0.8）从7.5个百分点（95% CI 6.5到8.5）缩小到- 0.4个百分点。在三轮PMAQ中，在提供初级卫生保健方面存在的收入不平等现象被消除了，这可能是由于PMAQ的设计特点调整了针对社会经济不平等的财政支付。然而，巴西仍然有一个重要的政策议程来解决卫生方面的巨大不平等现象。英国医学研究理事会、牛顿基金和CONFAP（国家咨询委员会Fundações Estaduais de Amparo <e:1> Pesquisa）。
Many governments have introduced pay-for-performance programmes to incentivise health providers to improve quality of care. Evidence on whether these programmes reduce or exacerbate disparities in health care is scarce. In this study, we aimed to assess socioeconomic inequalities in the performance of family health teams under Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ). For this longitudinal study, we analysed data on the quality of care delivered by family health teams participating in PMAQ over three rounds of implementation: round 1 (November, 2011, to March, 2013), round 2 (April, 2013, to September, 2015), and round 3 (October, 2015, to December, 2019). The primary outcome was the percentage of the maximum performance score obtainable by family health teams (the PMAQ score), based on several hundred (ranging from 598 to 914) indicators of health-care delivery. Using census data on household income of local areas, we examined the PMAQ score by income ventile. We used ordinary least squares regressions to examine the association between PMAQ scores and the income of each local area across implementation rounds, and we did an analysis of variance to assess geographical variation in PMAQ score. Of the 40 361 family health teams that were registered as ever participating in PMAQ, we included 13 934 teams that participated in the three rounds of PMAQ in our analysis. These teams were located in 11 472 census areas and served approximately 48 million people. The mean PMAQ score was 61·0% (median 61·8, IQR 55·3–67·9) in round 1, 55·3% (median 56·0, IQR 47·6–63·4) in round 2, and 61·6% (median 62·7, IQR 54·4–69·9) in round 3. In round 1, we observed a positive socioeconomic gradient, with the mean PMAQ score ranging from 56·6% in the poorest group to 64·1% in the richest group. Between rounds 1 and 3, mean PMAQ performance increased by 7·1 percentage points for the poorest group and decreased by 0·8 percentage points for the richest group (p<0·0001), with the gap between richest and poorest narrowing from 7·5 percentage points (95% CI 6·5 to 8·5) to –0·4 percentage points over the same period (–1·6 to 0·8). Existing income inequalities in the delivery of primary health care were eliminated during the three rounds of PMAQ, plausibly due to a design feature of PMAQ that adjusted financial payments for socioeconomic inequalities. However, there remains an important policy agenda in Brazil to address the large inequities in health. UK Medical Research Council, Newton Fund, and CONFAP (Conselho Nacional das Fundações Estaduais de Amparo à Pesquisa).