Exclusion of patients from pay-for-performance targets by english physicians
Exclusion of patients from pay-for-performance targets by english physicians
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DOI：
10.1056/nejmsa0800310
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发表时间：
2008-07-17
影响因子：
158.5
通讯作者：
Roland, Martin
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文献类型：
--
作者：
Doran, Tim;Fullwood, Catherine;Roland, Martin
背景：在英国的按绩效付费计划中，医生使用一系列标准将个别患者排除在决定其薪酬的质量计算之外。这一过程称为异常报告，旨在保护患者免受寻求最大化收入的医生的不当治疗。然而，异常报告可能允许医生不适当地排除错过目标的患者（这种做法称为游戏）。 方法：我们分析了从英格兰 8105 个家庭诊所（占所有诊所的 96%）的临床计算系统自动提取的数据、来自英国人口普查的数据以及来自英国卫生部的有关诊所特征的数据。我们确定了 65 项临床活动的异常报告率以及该比率与患者特征和医疗实践之间的关联。结果：从 2005 年 4 月到 2006 年 3 月，医生从质量计算中排除了中位数 5.3% 的患者（四分位数范围，4.0 至 6.9）。医生最有可能将患者排除在与提供治疗和实现中间结果目标水平相关的指标之外；他们最不可能将患者排除在与常规检查和测量以及提供治疗相关的指标之外。患者和实践的特征仅解释了异常报告中 2.7% 的差异。我们估计，异常报告约占绩效工资计划成本的 1.5%。 结论： 异常报告可以为绩效工资计划带来巨大的好处，前提是该流程使用得当。在英格兰，异常报告率普遍较低，几乎没有证据表明游戏广泛存在。
Background: In the English pay-for-performance program, physicians use a range of criteria to exclude individual patients from the quality calculations that determine their pay. This process, which is called exception reporting, is intended to safeguard patients against inappropriate treatment by physicians seeking to maximize their income. However, exception reporting may allow physicians to inappropriately exclude patients for whom targets have been missed (a practice known as gaming).Methods: We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England (96% of all practices), data from the U.K. Census, and data on practice characteristics from the U.K. Department of Health. We determined the rate of exception reporting for 65 clinical activities and the association between this rate and the characteristics of patients and medical practices.Results: From April 2005 through March 2006, physicians excluded a median of 5.3% of patients (interquartile range, 4.0 to 6.9) from the quality calculations. Physicians were most likely to exclude patients from indicators that were related to providing treatments and achieving target levels of intermediate outcomes; they were least likely to exclude patients from indicators that were related to routine checks and measurements and to offers of treatment. The characteristics of patients and practices explained only 2.7% of the variance in exception reporting. We estimate that exception reporting accounted for approximately 1.5% of the cost of the pay-for-performance program.Conclusions: Exception reporting brings substantial benefits to pay-for-performance programs, providing that the process is used appropriately. In England, rates of exception reporting have generally been low, with little evidence of widespread gaming.