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Effects of paying physicians based on their relative performance for quality.

ABSTRACT: BACKGROUND: Studies examining the effectiveness of pay-for-performance programs to improve quality of care primarily have been confined to bonus-type arrangements that reward providers for performance above a predetermined threshold. No studies to date have evaluated programs placing providers at financial risk for performance relative to other participants in the program. OBJECTIVE: The objective of the study is to evaluate the impact of an incentive program conferring limited financial risk to primary care physicians. PARTICIPANTS: There were 334 participating primary care physicians in Rochester, New York. DESIGN: The design of the study is a retrospective cohort study using pre/post analysis. MEASUREMENTS: The measurements adhere to 4 diabetes performance measures between 1999 and 2004. RESULTS: While absolute performance levels increased across all measures immediately following implementation, there was no difference between the post- and pre-intervention trends indicating that the overall increase in performance was largely a result of secular trends. However, there was evidence of a modest 1-time improvement in physician adherence for eye examination that appeared attributable to the incentive program. For this measure, physicians improved their adherence rate on average by 7 percentage points in the year after implementation of the program. CONCLUSIONS: This study demonstrates a modest effect in improving provider adherence to quality standards for a single measure of diabetes care during the early phase of a pay-for-performance program that placed physicians under limited financial risk. Further research is needed to determine the most effective incentive structures for achieving substantial gains in quality of care.

SUBMITTER: Young GJ

PROVIDER: S-EPMC2219885 | biostudies-other | 2007 Jun

REPOSITORIES: biostudies-other

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Project description:BackgroundAssessing physicians' clinical performance using statistically sound, evidence-based measures is challenging. Little research has focused on methodological approaches to setting performance standards to which physicians are being held accountable.ObjectiveDetermine if a rigorous approach for setting an objective, credible standard of minimally-acceptable performance could be used for practicing physicians caring for diabetic patients.DesignRetrospective cohort study.ParticipantsNine hundred and fifty-seven physicians from the United States with time-limited certification in internal medicine or a subspecialty.Main measuresThe ABIM Diabetes Practice Improvement Module was used to collect data on ten clinical and two patient experience measures. A panel of eight internists/subspecialists representing essential perspectives of clinical practice applied an adaptation of the Angoff method to judge how physicians who provide minimally-acceptable care would perform on individual measures to establish performance thresholds. Panelists then rated each measure's relative importance and the Dunn-Rankin method was applied to establish scoring weights for the composite measure. Physician characteristics were used to support the standard-setting outcome.Key resultsPhysicians abstracted 20,131 patient charts and 18,974 patient surveys were completed. The panel established reasonable performance thresholds and importance weights, yielding a standard of 48.51 (out of 100 possible points) on the composite measure with high classification accuracy (0.98). The 38 (4%) outlier physicians who did not meet the standard had lower ratings of overall clinical competence and professional behavior/attitude from former residency program directors (p = 0.01 and p = 0.006, respectively), lower Internal Medicine certification and maintenance of certification examination scores (p = 0.005 and p < 0.001, respectively), and primarily worked as solo practitioners (p = 0.02).ConclusionsThe standard-setting method yielded a credible, defensible performance standard for diabetes care based on informed judgment that resulted in a reasonable, reproducible outcome. Our method represents one approach to identifying outlier physicians for intervention to protect patients.

Project description:BackgroundEstimating relative causal effects (i.e., "substitution effects") is a common aim of nutritional research. In observational data, this is usually attempted using 1 of 2 statistical modeling approaches: the leave-one-out model and the energy partition model. Despite their widespread use, there are concerns that neither approach is well understood in practice.ObjectivesWe aimed to explore and illustrate the theory and performance of the leave-one-out and energy partition models for estimating substitution effects in nutritional epidemiology.MethodsMonte Carlo data simulations were used to illustrate the theory and performance of both the leave-one-out model and energy partition model, by considering 3 broad types of causal effect estimands: 1) direct substitutions of the exposure with a single component, 2) inadvertent substitutions of the exposure with several components, and 3) average relative causal effects of the exposure instead of all other dietary sources. Models containing macronutrients, foods measured in calories, and foods measured in grams were all examined.ResultsThe leave-one-out and energy partition models both performed equally well when the target estimand involved substituting a single exposure with a single component, provided all variables were measured in the same units. Bias occurred when the substitution involved >1 substituting component. Leave-one-out models that examined foods in mass while adjusting for total energy intake evaluated obscure estimands.ConclusionsRegardless of the approach, substitution models need to be constructed from clearly defined causal effect estimands. Estimands involving a single exposure and a single substituting component are typically estimated more accurately than estimands involving more complex substitutions. The practice of examining foods measured in grams or portions while adjusting for total energy intake is likely to deliver obscure relative effect estimands with unclear interpretations.

Project description:Feather pecking is a behavior that occurs in order to cope with a constrained environment and is a serious problem in the egg production industry. This longitudinal study was conducted under commercial conditions to investigate whether the application of two repellent mixtures, previously suggested as aversive to wild birds, to the plumage of Prelux-R hybrid egg layers is a viable alternative to beak trimming as a solution to discourage feather pecking among laying hens. A total of 180 untrimmed hybrid layers was reared together in a floor pen. At 18 weeks of age they were allocated randomly to three treatments (repellent P, repellent T, control), each consisting of 6 replicated enriched cages with 10 hens in each cage. Hens were evenly sprayed once every 2 weeks for 54 weeks with solution P (dimethyl anthranilate and methyl phenylacetate), solution T (dimethyl anthranilate and geraniol), or distilled water (control). Body weight, plumage condition, behavior, feed intake, and egg quality measurements were taken at five time periods from 26 to 76 weeks of age. Egg production and mortality were recorded daily. The treatments did not affect feather pecking behavior. Hens treated with repellent T tended to perform less cage pecking than the control hens. The use of the repellents did not reduce feather pecking, the plumage was even more significantly damaged in the hens given the repellents compared to the control hens. This suggests the chemicals in the repellents worsened the plumage. No differences in feed intake and daily egg production between treatments were found. Raw and hard-boiled eggs were highly uniform in odor/flavor/taste and no offensive odor absorption related to the chemicals in the repellents was detected. In conclusion, in the present study we did not find any beneficial effect of dimethyl anthranilate-based repellents on feather pecking frequency and plumage/feather condition. Therefore, we do not encourage their use in wider commercial settings.

Project description:BackgroundBehavioural approaches to knowledge translation inform interventions to improve healthcare. However, such approaches often focus on a single behaviour without considering that health professionals perform multiple behaviours in pursuit of multiple goals in a given clinical context. In resource-limited consultations, performing these other goal-directed behaviours may influence optimal performance of a particular evidence-based behaviour. This study aimed to investigate whether a multiple goal-directed behaviour perspective might inform implementation research beyond single-behaviour approaches.MethodsWe conducted theory-based semi-structured interviews with 12 general medical practitioners (GPs) in Scotland on their views regarding two focal clinical behaviours--providing physical activity (PA) advice and prescribing to reduce blood pressure (BP) to <140/80 mmHg--in consultations with patients with diabetes and persistent hypertension. Theory-based constructs investigated were: intention and control beliefs from the theory of planned behaviour, and perceived interfering and facilitating influence of other goal-directed behaviours performed in a diabetes consultation. We coded interview content into pre-specified theory-based constructs and organised codes into themes within each construct using thematic analysis.ResultsMost GPs reported strong intention to prescribe to reduce BP but expressed reasons why they would not. Intention to provide PA advice was variable. Most GPs reported that time constraints and patient preference detrimentally affected their control over providing PA advice and prescribing to reduce BP, respectively. Most GPs perceived many of their other goal-directed behaviours as interfering with providing PA advice, while fewer GPs reported goal-directed behaviours that interfere with prescribing to reduce BP. Providing PA advice and prescribing to reduce BP were perceived to be facilitated by similar diabetes-related behaviours (e.g., discussing cholesterol). While providing PA advice was perceived to be mainly facilitated by providing other lifestyle-related clinical advice (e.g., talking about weight), BP prescribing was reported as facilitated by pursuing ongoing standard consultation-related goals (e.g., clearly structuring the consultation).ConclusionGPs readily relate their other goal-directed behaviours with having a facilitating and interfering influence on their performance of particular evidence-based behaviours. This may have implications for advancing the theoretical development of behavioural approaches to implementation research beyond single-behaviour models.

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Effects of paying physicians based on their relative performance for quality.

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