Department of Family Medicine, Ghent University, Belgium.
BMC Health Serv Res. 2011 Aug 31;11:209. doi: 10.1186/1472-6963-11-209.
Pay-for-performance systems raise concerns regarding inequity in health care because providers might select patients for whom targets can easily be reached. This paper aims to describe the evolution of pre-existing (in)equity in health care in the period after the introduction of the Quality and Outcomes Framework (QOF) in the UK and to describe (in)equities in exception reporting. In this evaluation, a theory-based framework conceptualising equity in terms of equal access, equal treatment and equal treatment outcomes for people in equal need is used to guide the work.
A systematic MEDLINE and Econlit search identified 317 studies. Of these, 290 were excluded because they were not related to the evaluation of QOF, they lacked an equity dimension in the evaluation, their qualitative research focused on experiences or on the nature of the consultation, or unsuitable methodology was used to pronounce upon equity after the introduction of QOF.
None of the publications (n = 27) assessed equity in access to health care. Concerning equity in treatment and (intermediate) treatment outcomes, overall quality scores generally improved. For the majority of the observed indicators, all citizens benefit from this improvement, yet the extent to which different patient groups benefit tends to vary and to be highly dependent on the type and complexity of the indicator(s) under study, the observed patient group(s) and the characteristics of the study. In general, the introduction of QOF was favourable for the aged and for males. Total QOF scores did not seem to vary according to ethnicity. For deprivation, small but significant residual differences were observed after the introduction of QOF favouring less deprived groups. These differences are mainly due to differences at the practice level. The variance in exception reporting according to gender and socio-economic position is low.
Although QOF seems not to be socially selective at first glance, this does not mean QOF does not contribute to the inverse care law. Introducing different targets for specific patient groups and including appropriate, non-disease specific and patient-centred indicators that grasp the complexity of primary care might refine the equity dimension of the evaluation of QOF. Also, information on the actual uptake of care, information at the patient level and monitoring of individuals' health care utilisation tracks could make large contributions to an in-depth evaluation. Finally, evaluating pay-for-quality initiatives in a broader health systems impact assessment strategy with equity as a full assessment criterion is of utmost importance.
绩效薪酬制度引起了人们对医疗保健公平性的担忧，因为提供者可能会选择那些容易达到目标的患者。本文旨在描述英国引入质量和结果框架（QOF）后预先存在的（不）公平性的演变，并描述异常报告中的（不）公平性。在这项评估中，使用了一个基于理论的框架，从平等获得、平等对待和同等需求人群的平等治疗结果的角度来理解公平性，以指导工作。
系统地在 MEDLINE 和 Econlit 上进行搜索，确定了 317 项研究。其中，290 项被排除在外，因为它们与 QOF 的评估无关，评估中缺乏公平性维度，其定性研究侧重于经验或咨询的性质，或者在引入 QOF 后使用不合适的方法来判断公平性。
没有一项出版物（n=27）评估了获得医疗保健的公平性。关于治疗和（中间）治疗结果的公平性，整体质量评分普遍提高。对于大多数观察到的指标，所有公民都受益于这一改善，但不同患者群体受益的程度往往有所不同，并且高度依赖于所研究的指标类型和复杂性、观察到的患者群体以及研究的特征。总的来说，QOF 的引入对老年人和男性有利。QOF 总分似乎与种族无关。关于贫困，在引入 QOF 后，观察到有利于贫困程度较低群体的小但显著的剩余差异。这些差异主要是由于实践层面的差异造成的。根据性别和社会经济地位报告异常的方差很低。
尽管 QOF 乍一看似乎没有社会选择性，但这并不意味着 QOF 不会导致反向护理法。为特定患者群体引入不同的目标，并纳入适当的、非疾病特异性和以患者为中心的指标，以掌握初级保健的复杂性，可能会完善 QOF 评估的公平性维度。此外，关于实际护理利用率的信息、患者层面的信息以及监测个人的医疗保健利用率轨迹，都可以为深入评估做出巨大贡献。最后，将支付质量的举措纳入更广泛的卫生系统影响评估策略，并将公平性作为全面评估标准，是至关重要的。
