英国的按效付费：质量和结果框架的影响：系统评价。
Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review.
机构信息
Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, England, UK.
出版信息
Ann Fam Med. 2012 Sep-Oct;10(5):461-8. doi: 10.1370/afm.1377.
PURPOSE
Primary care practices in the United Kingdom have received substantial financial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This article reviews the growing evidence for the impact of the framework on the quality of primary medical care.
METHODS
Five hundred seventy-five articles were identified by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modified Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review.
RESULTS
Quality of care for incentivized conditions during the first year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients' satisfaction with continuity declined, with little change in other domains of patient experience.
CONCLUSIONS
Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefits of similar schemes.
目的
自 2004 年 4 月以来，英国的初级保健实践因达到质量和结果框架中规定的标准而获得了大量财政奖励。本文综述了该框架对初级医疗保健质量的影响不断增加的证据。
方法
通过搜索 MEDLINE、EMBASE 和 PsycINFO 数据库以及已发表的综述和文章的参考文献列表，共确定了 575 篇文章。使用改良的 Downs 和 Black 评分量表对 110 项观察性研究和 14 项定性研究的 Critical Appraisal Skills Programme 评分量表对 124 篇相关文章进行了评估。有 94 项研究被纳入综述。
结果
在框架的第一年，激励条件下的医疗质量改善速度快于干预前的趋势，随后又恢复到之前的改善速度。在某些领域，死亡率和住院率有适度的成本效益降低。与非贫困地区相比，贫困地区的绩效差距缩小。框架之外的条件的达标率最初较低，并且自成立以来相对恶化。一些医生报告说数据记录和团队合作有所改善，护士提高了专业技能。两组人员都认为咨询的以患者为中心和连续性受到了负面影响。患者对连续性的满意度下降，而其他患者体验领域几乎没有变化。
结论
框架中慢性病的医疗质量观察到的改善是适度的，对成本、专业行为和患者体验的影响仍不确定。需要进一步研究如何在不同领域提高质量，同时尽量降低按绩效付费计划的成本和任何意外的不利影响。医疗保健组织应谨慎对待类似计划的好处。
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