University of Alberta, University of Alberta Hospital, and Institute of Health Economics, Edmonton, Alberta, Canada.
Ann Intern Med. 2012 Dec 18;157(12):889-99. doi: 10.7326/0003-4819-157-12-201212180-00009.
Pay-for-performance (P4P) is increasingly touted as a means to improve health care quality.
To evaluate the effect of P4P remuneration targeting individual health care providers.
MEDLINE, EMBASE, Cochrane Library, OpenSIGLE, Canadian Evaluation Society Unpublished Literature Bank, New York Academy of Medicine Library Grey Literature Collection, and reference lists were searched up until June 2012.
Two reviewers independently identified original research papers (randomized, controlled trials; interrupted time series; uncontrolled and controlled before-after studies; and cohort comparisons).
Two reviewers independently extracted the data.
The literature search identified 4 randomized, controlled trials; 5 interrupted time series; 3 controlled before-after studies; 1 nonrandomized, controlled study; 15 uncontrolled before-after studies; and 2 uncontrolled cohort studies. The variation in study quality, target conditions, and reported outcomes precluded meta-analysis. Uncontrolled studies (15 before-after studies, 2 cohort comparisons) suggested that P4P improves quality of care, but higher-quality studies with contemporaneous controls failed to confirm these findings. Two of the 4 randomized trials were negative, and the 2 statistically significant trials reported small incremental improvements in vaccination rates over usual care (absolute differences, 8.4 and 7.8 percentage points). Of the 5 interrupted time series, 2 did not detect any improvements in processes of care or clinical outcomes after P4P implementation, 1 reported initial statistically significant improvements in guideline adherence that dissipated over time, and 2 reported statistically significant improvements in blood pressure control in patients with diabetes balanced against statistically significant declines in hemoglobin A1c control.
Few methodologically robust studies compare P4P with other payment models for individual practitioners; most are small observational studies of variable quality.
The effect of P4P targeting individual practitioners on quality of care and outcomes remains largely uncertain. Implementation of P4P models should be accompanied by robust evaluation plans.
None.
绩效薪酬制（P4P）越来越被吹捧为改善医疗质量的一种手段。
评估针对个人医疗保健提供者的 P4P 薪酬激励的效果。
MEDLINE、EMBASE、Cochrane 图书馆、OpenSIGLE、加拿大评估学会未发表文献库、纽约科学院图书馆灰色文献集以及参考文献列表，检索时间截至 2012 年 6 月。
两位评审员独立确定了原始研究论文（随机对照试验、间断时间序列、无对照和对照前后研究、队列比较）。
两位评审员独立提取数据。
文献检索确定了 4 项随机对照试验、5 项间断时间序列、3 项对照前后研究、1 项非随机对照研究、15 项对照前后研究和 2 项对照队列研究。研究质量、目标条件和报告结果的差异排除了荟萃分析。非对照研究（15 项对照前后研究，2 项对照队列研究）表明 P4P 提高了医疗质量，但具有同期对照的高质量研究未能证实这些发现。4 项随机试验中有 2 项为阴性，2 项具有统计学意义的试验报告称，疫苗接种率相对于常规护理有所提高（绝对差异为 8.4 和 7.8 个百分点）。在 5 项间断时间序列中，有 2 项在实施 P4P 后没有发现任何改善护理过程或临床结果的迹象，有 1 项报告最初在遵医嘱方面有统计学意义的改善，但随着时间的推移逐渐消失，还有 2 项报告在糖尿病患者的血压控制方面有统计学意义的改善，但血红蛋白 A1c 控制方面的统计学意义下降。
很少有方法学上稳健的研究将 P4P 与其他针对个体从业者的支付模式进行比较；大多数是质量参差不齐的小型观察性研究。
针对个体从业者的 P4P 对护理质量和结果的影响仍在很大程度上不确定。实施 P4P 模式应伴随强有力的评估计划。
无。
