Aaron Mendelson, BA; Karli Kondo, PhD; Cheryl Damberg, PhD; Allison Low, BA; Makalapua Motúapuaka, BA; Michele Freeman, MPH; Maya O'Neil, PhD; Rose Relevo, MLIS, MS; Devan Kansagara, MD, MCR
Disclaimer: The views and conclusions expressed in this article are those of the authors, who are responsible for its content, and do not necessarily represent the views of the U.S. Department of Veterans Affairs or the U.S. government. Therefore, no statement in this article should be construed as an official position of the U.S. Department of Veterans Affairs.
Financial Support: By the U.S. Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, Quality Enhancement Research Initiative, Evidence-based Synthesis Program (project 05-225).
Disclosures: Authors have disclosed no conflicts of interest. Forms can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M16-1881.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that she has no financial relationships or interests to disclose. Darren B. Taichman, MD, PhD, Executive Deputy Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interest to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Catharine B. Stack, PhD, MS, Deputy Editor for Statistics, reports that she has stock holdings in Pfizer and Johnson & Johnson.
Reproducible Research Statement:Study protocol and data set: See the Supplement. Statistical code: Not applicable.
Requests for Single Reprints: Devan Kansagara, MD, MCR, VA Portland Health Care System, Mail Code R&D 71, 3710 SW US Veterans Hospital Road, Portland, OR 97239-2999; e-mail, email@example.com.
Current Author Addresses: Mr. Mendelson: Oregon Health & Science University, Mail Code MDYCHSE, 3181 SW Sam Jackson Park Road, Portland, OR 97239.
Drs. Kondo, O'Neil, and Kansagara; Ms. Low; Ms. Motúapuaka; Ms. Freeman; and Ms. Relevo: VA Portland Health Care System, Mail Code R&D 71, 3710 SW US Veterans Hospital Road, Portland, OR 97239-2999.
Dr. Damberg: RAND (Health), 1776 Main Street, Santa Monica, CA 90407-2138.
Author Contributions: Conception and design: K. Kondo, M. Motúapuaka, M. O'Neil, R. Relevo, D. Kansagara.
Analysis and interpretation of the data: A. Mendelson, K. Kondo, C. Damberg, A. Low, M. Motúapuaka, M. Freeman, M. O'Neil, D. Kansagara.
Drafting of the article: A. Mendelson, K. Kondo, C. Damberg, M. Motúapuaka, M. O'Neil, D. Kansagara.
Critical revision of the article for important intellectual content: A. Mendelson, K. Kondo, A. Low, M. Motúapuaka, D. Kansagara.
Final approval of the article: A. Mendelson, K. Kondo, C. Damberg, A. Low, M. Motúapuaka, M. Freeman, M. O'Neil, R. Relevo, D. Kansagara.
Obtaining of funding: D. Kansagara.
Administrative, technical, or logistic support: A. Low, M. Motúapuaka, M. Freeman.
Collection and assembly of data: A. Mendelson, K. Kondo, C. Damberg, A. Low, M. Motúapuaka, M. Freeman, M. O'Neil, R. Relevo, D. Kansagara.
The benefits of pay-for-performance (P4P) programs are uncertain.
To update and expand a prior review examining the effects of P4P programs targeted at the physician, group, managerial, or institutional level on process-of-care and patient outcomes in ambulatory and inpatient settings.
PubMed from June 2007 to October 2016; MEDLINE, PsycINFO, CINAHL, Business Economics and Theory, Business Source Elite, Scopus, Faculty of 1000, and Gartner Research from June 2007 to February 2016.
Trials and observational studies in ambulatory and inpatient settings reporting process-of-care, health, or utilization outcomes.
Two investigators extracted data, assessed study quality, and graded the strength of the evidence.
Among 69 studies, 58 were in ambulatory settings, 52 reported process-of-care outcomes, and 38 reported patient outcomes. Low-strength evidence suggested that P4P programs in ambulatory settings may improve process-of-care outcomes over the short term (2 to 3 years), whereas data on longer-term effects were limited. Many of the positive studies were conducted in the United Kingdom, where incentives were larger than in the United States. The largest improvements were seen in areas where baseline performance was poor. There was no consistent effect of P4P on intermediate health outcomes (low-strength evidence) and insufficient evidence to characterize any effect on patient health outcomes. In the hospital setting, there was low-strength evidence that P4P had little or no effect on patient health outcomes and a positive effect on reducing hospital readmissions.
Few methodologically rigorous studies; heterogeneous population and program characteristics and incentive targets.
Pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but consistently positive associations with improved health outcomes have not been demonstrated in any setting.
U.S. Department of Veterans Affairs.
Literature flow diagram.
P4P = pay-for-performance.
* The current systematic review updates and expands on the review by Damberg and colleagues (7).
Table 1. Findings From Studies of Ambulatory-Based Pay-for-Performance Programs
Table 2. Findings From Studies of Hospital-Based Pay-for-Performance Programs
Table 3. Strength of the Evidence
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Mendelson A, Kondo K, Damberg C, Low A, Motúapuaka M, Freeman M, et al. The Effects of Pay-for-Performance Programs on Health, Health Care Use, and Processes of Care: A Systematic Review. Ann Intern Med. [Epub ahead of print 10 January 2017]166:341–353. doi: 10.7326/M16-1881
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Published: Ann Intern Med. 2017;166(5):341-353.
Published at www.annals.org on 10 January 2017
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