Pay-for-performance programs in family practices in the United Kingdom
Pay-for-performance programs in family practices in the United Kingdom
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DOI：
10.1056/nejmsa055505
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发表时间：
2006-07-27
影响因子：
158.5
通讯作者：
Roland, Martin
中科院分区：
文献类型：
--
作者：
Doran, Tim;Fullwood, Catherine;Roland, Martin
背景资料：2004年，在采取了一系列与显著改善护理质量有关的国家举措之后，联合王国国家卫生服务局为家庭医生实行了按业绩计薪合同。该合同根据146项质量指标的表现增加现有收入，这些指标涵盖10种慢性病的临床护理、护理组织和患者体验。方法：我们分析了从临床计算系统中自动提取的数据，这些数据来自英国8105个家庭诊所，在绩效工资计划的第一年（2004年4月至2005年3月），数据来自英国。人口普查和关于个别家庭做法特点的数据。我们检查了符合临床质量指标的患者比例，（报告的成就）和满足质量指标的医疗状况患者总数的比例（人口成就），我们使用多元回归分析，通过将患者分类为不符合质量指标，来确定实践获得高分的程度结果：在新合同的第一年，报告的平均成就为83.4%（四分位数范围，78.2%至87.0%）。患者的社会人口学特征（年龄和社会经济特征）和实践（实践规模，每个从业者的患者数量，从业者的年龄，以及从业者是否在英国接受过医学教育）对性能有中度但显着的影响。实践中的异常报告并不广泛（中位数为6%），但它是成就的最强预测因子：异常报告率增加1%与报告成就增加0.31%相关。例外报告是高的，在少数的做法：1%的做法排除了超过15%的patients.Conclusions：英语家庭的做法达到了高水平的成就，在第一年的新的按业绩计薪合同。少数实践似乎通过例外报告排除了大量患者而获得了高分。需要更多的研究来确定这些做法是出于合理的临床原因还是为了增加收入而将患者排除在外。
Background: In 2004, after a series of national initiatives associated with marked improvements in the quality of care, the National Health Service of the United Kingdom introduced a pay-for-performance contract for family practitioners. This contract increases existing income according to performance with respect to 146 quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience.Methods: We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England in the first year of the pay-for-performance program (April 2004 through March 2005), data from the U.K. Census, and data on characteristics of individual family practices. We examined the proportion of patients deemed eligible for a clinical quality indicator for whom the indicator was met (reported achievement) and the proportion of the total number of patients with a medical condition for whom a quality indicator was met (population achievement), and we used multiple regression analysis to determine the extent to which practices achieved high scores by classifying patients as ineligible for quality indicators (exception reporting).Results: The median reported achievement in the first year of the new contract was 83.4 percent (interquartile range, 78.2 to 87.0 percent). Sociodemographic characteristics of the patients (age and socioeconomic features) and practices (size of practice, number of patients per practitioner, age of practitioner, and whether the practitioner was medically educated in the United Kingdom) had moderate but significant effects on performance. Exception reporting by practices was not extensive (median rate, 6 percent), but it was the strongest predictor of achievement: a 1 percent increase in the rate of exception reporting was associated with a 0.31 percent increase in reported achievement. Exception reporting was high in a small number of practices: 1 percent of practices excluded more than 15 percent of patients.Conclusions: English family practices attained high levels of achievement in the first year of the new pay-for-performance contract. A small number of practices appear to have achieved high scores by excluding large numbers of patients by exception reporting. More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income.