Systematic review: Effects, design choices, and context of pay-for-performance in health care
Systematic review: Effects, design choices, and context of pay-for-performance in health care
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DOI：
10.1186/1472-6963-10-247
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发表时间：
2010-08-23
影响因子：
2.8
通讯作者：
Sermeus, Walter
中科院分区：
文献类型：
--
作者：
Van Herck, Pieter;De Smedt, Delphine;Sermeus, Walter
背景：按绩效付费(P4P)是支持医疗保健服务改革的主要工具之一。在卫生保健中P4P的发展和实施及其效果存在着实质性的异质性。本文总结了1990年1月至2009年7月发表的关于P4P效应的研究证据，以及设计选择和语境中介因素对这些效应影响的证据。影响域包括临床有效性、可获得性和公平性、协调性和连续性、以患者为中心和成本效益。方法：采用电子数据库检索、参考文献筛选、前向引文跟踪和专家咨询等方法进行系统综述。检索了以下数据库：Cochrane图书馆、Econlit、Embase、Medline、Souinfo和Web of Science。包括评估初级保健或急性医院护理医学中P4P效果的研究。涉及其他目标群体或背景、没有实证评估设计或不符合P4P定义的论文被排除在外。根据研究设计，采用了9种有效的质量评价工具和报表。结果：128项评价研究提供了大量关于P4P对临床有效性和医疗公平性的影响的证据--需要谨慎解释。然而，对协调性、连续性、以患者为中心和成本效益的影响的证据较少。根据P4P计划的主要任务：支持最低质量标准和/或促进质量改进，P4P效果可以被判断为令人鼓舞或令人失望。未来的P4P计划应该(1)在基线改进空间的基础上选择和定义P4P目标，(2)利用过程和(中间)结果指标作为目标措施，(3)让利益相关者参与并全面和直接地交流有关计划的信息，(4)在付款人之间实施统一的P4P设计，(5)同时关注质量改进和成果，以及(6)将激励分配到个人和/或团队层面。结论：P4P计划导致对特定目标的可能影响的全谱，从缺失或可忽略到非常有益。根据证据，审查提供了进一步的迹象，说明研究结果可能如何与P4P设计选择和背景相关联。所提供的最佳实践假设应该在未来的研究中得到检验。
Background: Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient centeredness, and cost-effectiveness.Methods: The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.Results: One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution-concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.Conclusions: P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.