Dataset Information

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis.

ABSTRACT:

Background

Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke.

Methods

We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in 2012.

Findings

We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference -0.16%/month (95% CI -0.29, -0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality -0.18%, (95% CI -0.34, -0.02).

Interpretation

This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design.

Funding

Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.

SUBMITTER: Grimley RS

PROVIDER: S-EPMC10568297 | biostudies-literature | 2023 Dec

REPOSITORIES: biostudies-literature

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Publications

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis.

Grimley Rohan S RS Collyer Taya A TA Andrew Nadine E NE Dewey Helen M HM Horton Eleanor S ES Cadigan Greg G Cadilhac Dominique A DA

The Lancet regional health. Western Pacific 20231007

<h4>Background</h4>Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within ...[more]

PMID: 37842642

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Project description:ObjectivesTo assess the impact of pay-for-performance financial incentives for improving stroke unit access in Queensland public hospitals on hospital costs and use.Study designPopulation-based longitudinal study; interrupted time series analysis of linked hospital admissions, emergency department, and hospital costs data.Setting, participantsFirst admissions with stroke or myocardial infarction of adult Queensland residents (18 years or older) to public hospitals for more than one day during 1 July 2009 - 31 December 2011 (pre-incentive period), 1 January 2012 - 31 December 2012 (intervention implementation period), and 1 January 2013 - 30 June 2017 (intervention period). Admissions to neurosurgical wards of people with intracerebral haemorrhage were excluded.InterventionQueensland Health pay-for-performance program: Quality Improvement Payments (QIP). Initial three years: payments to hospitals contingent on progressively increasing targets for the proportion of people with stroke admitted to acute stroke units. Subsequent years: 10% loading on Diagnosis Related Group-based payments for the care of patients with primary diagnoses of stroke admitted to stroke units.Main outcome measuresChanges in level and rates of change of outcomes (hospital length of stay, patient-attributed hospital costs, non-elective hospital re-admissions) for admissions of people with stroke or myocardial infarction (as control condition) before and after the introduction of the QIP.ResultsWe analysed data for 23 572 people admitted with stroke and 39 511 admitted with myocardial infarction. The median acute length of stay did not change significantly during the implementation year for either patient group; and pre-intervention downward trends declined to near zero for both groups. The difference between the pre-incentive and implementation periods in median total hospital costs per patient with stroke was not statistically significant (-$1692; interquartile range [IQR], -$4440 to $1056), in contrast to the difference for patients with myocardial infarction (-$4278; IQR, -$5280 to -$3275). The proportion of non-elective hospital re-admissions was consistently larger following myocardial infarction than stroke; both proportions increased from the start of the control period to the end of the intervention period (for stroke: from 5.9%; 95% confidence interval [CI], 4.3-7.4% to 11.3%; 95% CI, 10.1-12.5%).ConclusionsPay-for-performance quality incentives had no impact on hospital length of stay, costs, or re-admissions. By improving quality of care and survival without increasing hospital use or costs, the QIP was associated with improved value for health care expenditure.

Project description:BackgroundDeaths by suicide can increase during infectious disease outbreaks. This study analysed suspected suicide rates in 2020 relative to 2015-19 to assess any early effects of the COVID-19 pandemic in Queensland, Australia.MethodsWe analysed data from the interim Queensland Suicide Register (iQSR), a state-wide real-time suicide surveillance system, using an interrupted time-series design. The data source for the iQSR is the Form 1 police report of a death to a coroner. Two QSR staff independently classed the probability of a death by suicide as possible, probable, or beyond reasonable doubt. The analysis included the probable or beyond reasonable doubt categories as suspected suicides. The primary outcome was the monthly suspected suicide rate. We applied Poisson and negative binomial regressions to assess whether Queensland's Public Health Emergency Declaration on Jan 29, 2020, affected suspected suicides from Feb 1 to Aug 31, 2020. Secondary outcomes included absolute or relative changes in police-reported motives of recent unemployment, financial problems, domestic violence, and relationship breakdown.Findings3793 suspected suicides were recorded with an unadjusted monthly rate of 14·85 deaths per 100 000 people (from Jan 1, 2015, to Jan 31, 2020) before the declaration, and 443 suspected suicides were recorded with an unadjusted monthly rate of 14·07 deaths per 100 000 people (Feb 1, 2020, onwards) after the declaration. An interrupted time-series Poisson regression model unadjusted (rate ratio [RR] 0·94, 95% CI 0·82-1·06) and adjusted for overdispersion, seasonality, and pre-exposure trends (RR 1·02, 95% CI 0·83-1·25) indicated no evidence of a change in suspected suicide rates. We found no absolute or relative increases in the motives for suspected suicides, including recent unemployment, financial problems, relationship breakdown, or domestic violence from February to August, 2020, compared with the pre-exposure period.InterpretationThere does not yet appear to be an overall change in the suspected suicide rate in the 7 months since Queensland declared a public health emergency. Despite this, COVID-19 has contributed to some suspected suicides in Queensland. Ongoing community spread and increasing death rates of COVID-19, and its impact on national economies and mental health, reinforces the need for governments to maintain the monitoring and reporting of suicide mortality in real time.FundingNone.

Project description:ObjectivesA male is less adaptable to biological stressors than a female fetus with consequent higher morbidity and mortality. Adverse birth outcomes increase and male livebirths decrease after environmental disasters, economic crises, and terrorist events. We hypothesized the ratio of male to female livebirths would decrease in areas affected by severe tropical cyclones (TCs) in Queensland, Australia. Additionally, in male livebirths, there would be an increase in preterm and low birthweight births. Lastly, we hypothesized that the pregnancy stage at which exposure occurred would modify the association between TC exposure and observed outcomes.MethodsInterrupted time series analysis was used to analyze Queensland administrative birth records from July 2007 to June 2018 for significant changes in the sex ratio at birth, measured as the proportion of male livebirths. Adjusted generalized linear models were fitted to births in areas affected by two category five TCs: cyclones Yasi (February 2011) and Marcia (February 2015). To explore male mortality and morbidity risk, additional analysis was conducted on the proportion of male stillborn, low birthweight, and preterm births. The association between estimated pregnancy stage during the TC and the proportion of male births was also analyzed.ResultsContrary to our hypothesis, increases in the proportion of male livebirths were observed following early-pregnancy exposure to cyclone Yasi and mid-pregnancy exposure to Marcia, although the latter was not statistically significant. No significant changes were observed in proportions of male stillborn, low birthweight, and preterm births.ConclusionsThis study found a significant association between severe TCs and sex ratio at birth. The stage of pregnancy at which maternal stressors were experienced modified this association. Among people exposed in early to mid-pregnancy, the proportion of male births was higher. This may be because of differential loss of females in utero. Studying sex differences in birth outcomes provides insight into in utero vulnerabilities associated with environmental stressors. Climate change is increasing the intensity and frequency of natural disasters. Understanding fetal vulnerability to environmental stressors will provide crucial information supporting early life health interventions that mitigate the immediate and long-term effects.

Project description:ObjectiveTo assess the impact of a pay for performance incentive on quality of care and outcomes among UK patients with hypertension in primary care.DesignInterrupted time series.SettingThe Health Improvement Network (THIN) database, United Kingdom.Participants470 725 patients with hypertension diagnosed between January 2000 and August 2007.InterventionThe UK pay for performance incentive (the Quality and Outcomes Framework), which was implemented in April 2004 and included specific targets for general practitioners to show high quality care for patients with hypertension (and other diseases).Main outcome measuresCentiles of systolic and diastolic blood pressures over time, rates of blood pressure monitoring, blood pressure control, and treatment intensity at monthly intervals for baseline (48 months) and 36 months after the implementation of pay for performance. Cumulative incidence of major hypertension related outcomes and all cause mortality for subgroups of newly treated (treatment started six months before pay for performance) and treatment experienced (started treatment in year before January 2001) patients to examine different stages of illness.ResultsAfter accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval -3.04 to 4.74, P=0.669 and trend change -0.01, -0.24 to 0.21, P=0.615), control (-1.19, -2.06 to 1.09, P=0.109 and -0.01, -0.06 to 0.03, P=0.569), or treatment intensity (0.67, -1.27 to 2.81, P=0.412 and 0.02, -0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups.ConclusionsGood quality of care for hypertension was stable or improving before pay for performance was introduced. Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes. Generous financial incentives, as designed in the UK pay for performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.

Project description:BackgroundThe prevalence of smoking in Central Queensland (CQ), Australia was higher than the state and national averages. A regional smoking cessation initiative ("10,000 Lives") was launched to promote available interventions (e.g., Quitline). We investigated the impact of "10,000 Lives" on referral to and use of Quitline services.MethodsWe conducted an interrupted time series analysis using a segmented Poisson regression model to measure the impact of "10,000 Lives" on monthly referrals to, and use of Quitline services (counselling sessions and nicotine replacement therapy (NRT) dispatched by Quitline), in CQ compared to other areas in the state (control population). The control population included all regional areas in Queensland with a comparable smoking prevalence to CQ and similar access to Quitline's Intensive Quit Support Program. We calculated the changes in level and trend of outcomes in CQ relative to the change in the control area during the post-launch period of "10,000 Lives". The models were checked for autocorrelation and seasonality and adjusted accordingly.FindingsAfter the introduction of "10,000 Lives", the mean monthly rate per 1,000 smoking population increased in the intervention area for each outcome; e.g., from 3.3 to 10.8 for referrals to Quitline, from 1.6 to 4.4 for initial counselling session completed. These results were validated by the controlled interrupted time series analysis which showed relative increases for each of these outcomes (238•5% for monthly rate of referral to Quitline per 1,000 smoking population and 248•6% for monthly rate of initial counselling sessions completed per 1,000 smoking population).InterpretationOur study demonstrates a locally coordinated health promotion initiative can promote and boost the referral to, and use of Quitline smoking cessation services.FundingThe research is funded by a collaborative research grant between School of Public Health at University of Queensland and Central Queensland Public Health Unit which is awarded by the Central Queensland Hospital and Health Service (CQHHS93907). The lead author (AK) is supported by a University of Queensland Research Training Scholarship and a Research Higher Degree Top-up Scholarship.

Dataset Information

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis.

Background

Methods

Findings

Interpretation

Funding

Publications

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis.

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