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Does Performance-Based Remuneration for Individual Health Care Practitioners Affect Patient Care?: A Systematic Review

Sherilyn K.D. Houle, BSP; Finlay A. McAlister, MD, MSc; Cynthia A. Jackevicius, MSc, PharmD; Anderson W. Chuck, PhD, MPH; and Ross T. Tsuyuki, PharmD, MSc
[+] Article, Author, and Disclosure Information

From University of Alberta, University of Alberta Hospital, and Institute of Health Economics, Edmonton, Alberta, Canada, and Western University of Health Sciences, Pomona, California.

Grant Support: Ms. Houle is supported in her PhD studies through the Interdisciplinary Chronic Disease Collaboration (funded by Alberta Innovates Health Solutions), Hypertension Canada, and the Canadian Institutes for Health Research. Dr. McAlister has career salary support from Alberta Innovates Health Solutions and the Capital Health Chair in Cardiovascular Outcomes Research.

Potential Conflicts of Interest: None disclosed. Disclosure forms are available at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M12-1059.

Reproducible Research Statement: Study protocol: Available from Ms. Houle (sherilyn.houle@ualberta.ca). Statistical code: Not applicable. Data set: Available upon agreement with the authors (contact Ms. Houle).

Requests for Single Reprints: Finlay A. McAlister, MD, MSc, 2F1.21 WMC, University of Alberta Hospital, 8440 112 Street, Edmonton, Alberta T6G 2R7, Canada; e-mail, Finlay.McAlister@ualberta.ca.

Current Author Addresses: Ms. Houle and Dr. Tsuyuki: EPICORE Centre, 220 College Plaza, University of Alberta, Edmonton, Alberta T6G 2C8, Canada.

Dr. McAlister: 2F1.21 WMC, University of Alberta Hospital, 8440 112 Street, Edmonton, Alberta T6G 2R7, Canada.

Dr. Jackevicius: College of Pharmacy, Western University of Health Sciences, 309 East Second Street, Pomona, CA 91766.

Dr. Chuck: Institute of Health Economics, Suite 1200, 10405 Jasper Avenue NW, Edmonton, Alberta T5J 3N4, Canada.

Author Contributions: Conception and design: S.K.D. Houle, F.A. McAlister, C.A. Jackevicius, A.W. Chuck, R.T. Tsuyuki.

Analysis and interpretation of the data: S.K.D. Houle, F.A. McAlister, C.A. Jackevicius, R.T. Tsuyuki.

Drafting of the article: S.K.D. Houle, F.A. McAlister.

Critical revision of the article for important intellectual content: S.K.D. Houle, F.A. McAlister, C.A. Jackevicius, A.W. Chuck, R.T. Tsuyuki.

Final approval of the article: S.K.D. Houle, F.A. McAlister, A.W. Chuck, R.T. Tsuyuki.

Administrative, technical, or logistic support: F.A. McAlister.

Collection and assembly of data: S.K.D. Houle, F.A. McAlister, C.A. Jackevicius.

Ann Intern Med. 2012;157(12):889-899. doi:10.7326/0003-4819-157-12-201212180-00009
Text Size: A A A

Background: Pay-for-performance (P4P) is increasingly touted as a means to improve health care quality.

Purpose: To evaluate the effect of P4P remuneration targeting individual health care providers.

Data Sources: MEDLINE, EMBASE, Cochrane Library, OpenSIGLE, Canadian Evaluation Society Unpublished Literature Bank, New York Academy of Medicine Library Grey Literature Collection, and reference lists were searched up until June 2012.

Study Selection: Two reviewers independently identified original research papers (randomized, controlled trials; interrupted time series; uncontrolled and controlled before–after studies; and cohort comparisons).

Data Extraction: Two reviewers independently extracted the data.

Data Synthesis: The literature search identified 4 randomized, controlled trials; 5 interrupted time series; 3 controlled before–after studies; 1 nonrandomized, controlled study; 15 uncontrolled before–after studies; and 2 uncontrolled cohort studies. The variation in study quality, target conditions, and reported outcomes precluded meta-analysis. Uncontrolled studies (15 before–after studies, 2 cohort comparisons) suggested that P4P improves quality of care, but higher-quality studies with contemporaneous controls failed to confirm these findings. Two of the 4 randomized trials were negative, and the 2 statistically significant trials reported small incremental improvements in vaccination rates over usual care (absolute differences, 8.4 and 7.8 percentage points). Of the 5 interrupted time series, 2 did not detect any improvements in processes of care or clinical outcomes after P4P implementation, 1 reported initial statistically significant improvements in guideline adherence that dissipated over time, and 2 reported statistically significant improvements in blood pressure control in patients with diabetes balanced against statistically significant declines in hemoglobin A1c control.

Limitation: Few methodologically robust studies compare P4P with other payment models for individual practitioners; most are small observational studies of variable quality.

Conclusion: The effect of P4P targeting individual practitioners on quality of care and outcomes remains largely uncertain. Implementation of P4P models should be accompanied by robust evaluation plans.

Primary Funding Source: None.


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Summary of evidence search and selection.

* Totals of exclusion characteristics exceed number of studies excluded because of the presence of multiple exclusion criteria within a single study.

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Figure 2.

Risk of bias across all included studies.

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