NIVEL, Netherlands Institute for Health Services Research, Utrecht, The Netherlands.
Scand J Prim Health Care. 2013 Mar;31(1):56-63. doi: 10.3109/02813432.2012.757078. Epub 2013 Jan 21.
Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated.
A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence.
21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs).
Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions.
Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients.
The change in the remuneration system had a limited impact on guideline adherence.
荷兰家庭医生薪酬制度的变化为研究财务激励变化对医疗质量的影响提供了契机。2006 年，公共保险患者（按人头付费）和私人保险患者（按服务收费）的单独薪酬制度被一种针对所有患者的按人头付费和按服务收费相结合的制度所取代。本研究旨在调查这些变化对基于指南的医疗质量的影响。
这是一项 2002 年至 2009 年的纵向研究，数据来自于一般实践中的患者电子病历。采用多水平（患者和实践）方法研究薪酬制度变化对指南依从性的影响。
32 至 52 家普通诊所的 21421 至 39828 名患者（普通医生的动态面板）。
16 项关于急性和慢性疾病的处方和转诊指南依从性指标。
2002 年至 2008 年，（前）公共保险患者的指南依从性提高了 7%，（前）私人保险患者的指南依从性提高了 10%。一般来说，私人保险患者和公共保险患者之间的指南依从性趋势没有显著差异，表明薪酬制度对指南依从性没有影响。在随访接触方面需要更多时间投入的指南的依从性受到薪酬制度变化的影响。对于公共保险患者，与私人保险患者相比，家庭医生在需要更多时间投入随访接触的指南方面表现出更高的依从性趋势。
薪酬制度的变化对指南依从性的影响有限。
