RESULTADOS EN EL ÍTEM 4

Although mentioned by some authors ²⁰⁷, in the included studies there has been a lack of attention for the effects of (dis)congruence with professional culture and with internal motivation. Through high involvement and democratically decision making on the implementation of P4Q it seems that these issues can be addressed, as the UK example shows. But it remains unclear what the impact is in terms of P4Q results, as compared to some programmes in other countries where P4Q sometimes was imposed on care providers by the state, employers and/or health plans. The same is true for the influence of leadership support ²⁰⁷. Roski et al (2003) ²⁰¹ question the effect of turnover in senior management without studying this further. One study found no significant association with the nature of the organizational culture, but did find an association with having a patient centred culture ¹⁹² (W). Ashworth et al (2005) ¹⁴⁰ mention the potential influence of existing professional standards and pride.

As mentioned before, some authors suggest that the level of knowledge and awareness of the existence and design of the P4Q programme might influence results ^{193 , 201}. Except for the finding of a relationship with the awareness of a clinical guideline intended as a supportive tool (W), this has not been specifically studied quantitatively

209.

Next to the already discussed room for improvement, the history of engagement with quality improvement activities ¹⁹⁶ has a significant relationship with P4Q results (S).

With regard to the target unit of the P4Q incentive, programmes aimed at the individual provider level report in general positive results (S). The study by Young et al (2007) ¹⁸⁷ is one exception. An absence of effect is found more in programmes targeted at the organization level 74 , 172 , 174 , 183 , 184 , 188. Again, there are also programmes showing positive results at this level, but this seems to require additional efforts (C). Incentives at a team level showed positive results in all three studies (S) 171 , 205 , 206. One study with incentives at the administrator/leadership level found mixed results (S) ²²³. A combination of incentives aimed at different target units is rarely used ¹⁹¹.

Finally, on each of these levels a number of characteristics have been further investigated. The first group concerns individual provider demographics. Provider age was in one study positively related to performance and acceptance (W) ¹⁹⁵. In this study younger physicians made more use of feedback data, while older physicians made more use of cues and stickers. According to the results of Doran et al (2006) ¹⁴⁷ provider age effects are moderate (W). Wang et al (2006) ¹³⁷ found that older providers were less likely to participate in voluntary schemes and performed less due to differences in the organizational domain (structural support), not in the clinical domain (W).

According to one study male providers were more likely to perform better on P4Q programmes ¹⁷⁷. This contrast with the findings by Wang and colleagues (2006) ¹³⁷ who found that male providers were less likely to participate and to perform well. Doran et al (2006) ¹⁴⁷ also found that female physicians performed slightly better (C).

With regard to provider ethnicity one study found a strong relationship indicating that non white physicians were more likely to perform better on P4Q (W) ¹⁹⁵.

The level of provider experience showed no significant effect on P4Q results (W) ¹⁷⁰. There is mixed evidence on the effect of the specialty and/or general practitioner background of the provider (C). Some studies found no significant relationship ¹⁸³. In the study by Rosenthal et al (2008) ⁶⁹ providers meeting P4Q targets were more likely to be specialists than general practitioners. The same is reported in other studies 144, 170 , 173 , 177

. To the contrary other studies found a positive relationship with the percentage of general practitioners ^{202 , 209}. These differences seem to depend on the nature of the targets being studied. According to their content some fall better within a general practitioner’s scope of work and expertise, while others fall within specialists’ areas.

Grady et al (1997) ¹⁹⁵ found a positive relationship with having a second specialty (W).

Grady et al (1997) ¹⁹⁵ reports that not residence trained physicians are more likely to perform better on P4Q (W).

A medical education in the UK is weakly related to better P4Q performance on the QOF ¹⁴⁷. One study in the USA reports that physicians trained abroad perform better

144 (W).

On the level of provider organizations most research has been done concerning general practices, medical groups and independent practice associations. Little results are known on a hospital level.

One collection of studies has reported on the effect of those distinctions: the difference between medical group, Independent Practice Association (IPA), hospital and community based P4Q performance. Medical groups are likely to perform better than IPAs (W) 199 , 202 , 209. Rittenhouse & Robinson (2006) ¹⁸⁶ reported that hospital and community based care performed better than IPA based care (W). The relatively good performance of medical groups or networks of medical groups is also confirmed by Mehrotra et al (2007) ²⁰⁰ (W).

A positive relationship is reported for the age of the group or the age of the organization ^{202 , 208} (W).

In the USA, ownership of the organization by a hospital or health plan is positively related to P4Q performance, as compared to individual provider ownership (W) 198 , 199 , 202 , 207 , 208 , 209. Practice ownership by a provider is associated with incentives to increase services (W) ²¹². Full ownership of groups is associated both with incentives to increase some and to reduce other services. One study found only for preventive care a positive association with an organization being profitable and P4Q results (W) ¹⁸⁶. Bhattacharyya et al (2008) ²¹¹ found no relationship with the size of revenues (W). Some of these authors point to the difference in available resources for investment purposes as part of a possible explanation.

The teaching status of a hospital is positively related to P4Q performance ²¹¹ (W).

Geographical location is sometimes also positively related to P4Q results (W). This is illustrated by two studies finding an association with a location in the Midwestern USA and in California as compared to other USA regions ^{199 , 211}. There is no difference in performance between rural, urban and mixed areas ¹³² (W).

There is conflicting evidence concerning the influence of the size of the organization in terms of number of providers and number of patients (C). Some studies report a positive relationship between the number of patients and P4Q performance (W) ^{95 , 131,}

140 , 153 , 208 , 209 , 211 . Others report no relationship ¹⁸³ or a negative relationship ^{142 , 177} (W).

There is a small negative relationship with the practice population size (W) ¹⁴⁷. Practices with a large patient population are also more likely to exception report more patients (W) ⁸⁴. The size of a hospital is not related to P4Q results (W) ²¹¹.

Group practices perform better on P4Q than single handed practices according to some studies 132 , 177 , 183 and the other way around according to other studies ¹⁹⁵ (C). Mehrotra et al (2007) ²⁰⁰ found a positive relationship with having more than the median number of physicians available. Other studies came to similar results 198 , 199 , 202 , 207 (W). Sutton &

McLean (2006) ¹³⁶ found a similar positive relationship for the size of the team and the non principal proportion of the team (recently trained) (W). Ashworth et al (2005) ¹⁴⁰ found this kind of relationship for the size of staff budgets (W).

A smaller practice size is also related to other factors such as having patients with poorer health, being located in a deprived area, having more patients from minority ethnic groups, etc. ¹³⁷ (W). These interrelationships have to be taken into account when assessing the practice size characteristic and its P4Q effects. The complexity of such relationships is also illustrated by McLean et al (2007) ¹²⁹ who mapped factors related to remoteness of the practice area.

Tahrani et al (2008) ¹⁶⁶ report that the performance gap between large versus small practices which existed before QOF implementation has disappeared afterwards (W).

Figure 8: P4Q context: Provider characteristics Provider characteristics

Awareness, perception, familiarity, agreement, self-efficacy:

High importance of provider awareness (S)

Lack of reporting on the other experience dimensions, except some evidence on the importance of involvement (W)

Other motivational drivers (intrinsic, professional culture, altruism…):

Lack of reporting (N)

Medical leadership, role of peers, role of industry:

Lack of reporting (N)

Existence and implementation of clinical guidelines:

Lack of reporting, although this seems one of the mediators of the general quality improvement trend co existing with the introduction of P4Q (see UK example) (N)

Level of own control on changes:

Lack of reporting (N), but in almost all studies (except smoking cessation studies) controllable measures were targeted. In addition most studies use intermediate instead of long term outcome targets.

Target unit (individual, group/organisation, hospital, nursing home, department):

Evidence of positive effects on the individual and/or team level (S).

Conflicting evidence on the level of an organization (medical group, hospital) and on the level of leadership (C).

In case of not-individual, size of unit (# providers):

Conflicting evidence on solo vs. group practice performance (C) Positive relationship with the number of providers within a practice (W)

No relationship with hospital size (W) Role of the meso level (principal or agent):

Lack of reporting (N)

Demographics (age, gender, specialty…):

Significant effect of provider age, gender, training background, geographical location, and having a second specialty (W)

No significant effect of provider experience and rural vs. urban location (W) Organisational resources available:

Weak evidence on the influence on P4Q effects, as measured through hospital/medical group/IPA status, age of the group or organization, organization vs. individual ownership, and teaching status of an organization (W)

Organisational system change and extra cost/time required:

Lack of reporting (N)

Number of patients and services per patient:

Conflicting evidence (C) Room for improvement:

Strong evidence on the influence on P4Q effects (S)

5.1.9 Patient characteristics

The evidence on relationships of patient demographics has been described extensively in the previous section. With regard to age, ethnicity and socio-economical deprivation level positive as well as negative results were found, depending on the disease (W). This will be discussed more extensively in section 5.2.3.

Currently there is a lack of research and evidence on the effects of patient educational status and insurance status.

There are also no negative findings reported with regard to the use of exception reporting as a P4Q supportive tool in the UK (W).

Almost no empirical research has focused upon the patient experience and patient satisfaction with regard to P4Q. The Spanish study as one exception found no significant differences (W). There is no further evidence on how P4Q and patient awareness of P4Q affects the patient provider relationship.

Finally, patient behaviour in terms of lifestyle, cooperation and therapeutic compliance might affect P4Q results, as described by the conceptual framework. Again, there is a lack of evidence on this specific topic. However, as part of P4Q target setting and measurement the selection of indicators in the included studies indicates that this issue is taken into account in almost all studies. The structure, process and intermediate outcome measures used have a high degree of provider controllability. There are a few exceptions like the use of long term smoking cessation outcomes, which is in general less controllable and more patient lifestyle related.

Figure 9: P4Q context: Patient characteristics Patient characteristics Demographics, Co-morbidities:

Closing performance gap with regard to patient age and unclear result with regard to gender, and ethnicity (W)

Socio-economics, Insurance status:

Unclear results with regard to socio economical deprivation level (W) Lack of reporting on the influence of insurance status (N)

Information about price and/or quality:

Conflicting evidence on the interaction of P4Q with public reporting (C) Patient behavioural patterns (cultural and consumer patterns, compliance):

Lack of reporting (N)

5.2 DISCUSSION AND CONCLUSIONS