医疗保健中的实施过程与绩效薪酬：系统评价
Implementation Processes and Pay for Performance in Healthcare: A Systematic Review.
作者信息
Kondo Karli K, Damberg Cheryl L, Mendelson Aaron, Motu'apuaka Makalapua, Freeman Michele, O'Neil Maya, Relevo Rose, Low Allison, Kansagara Devan
机构信息
Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.
Oregon Health and Science University, Portland, OR, USA.
出版信息
J Gen Intern Med. 2016 Apr;31 Suppl 1(Suppl 1):61-9. doi: 10.1007/s11606-015-3567-0.
BACKGROUND
Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P.
METHODS
We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight.
RESULTS
Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence.
DISCUSSION
There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input.
背景
在过去十年中，包括美国退伍军人健康管理局（VHA）在内，已实施了各种按绩效付费（P4P）计划以改善卫生系统的质量。P4P计划很复杂，其效果可能因设计、背景和其他实施过程而异。我们进行了一项系统评价和关键 informant（KI）访谈，以更好地了解改变P4P有效性的实施因素。
方法
我们检索了截至2014年4月的PubMed、PsycINFO和CINAHL，并查阅了参考文献列表。我们纳入了P4P实施的试验和观察性研究。两名研究人员提取数据并评估研究质量。我们采访了P4P研究人员以获得进一步的见解。
结果
在1363个标题和摘要中，我们选择了509篇进行全文审查，并纳入了41项主要研究。在这41项研究中，33项研究了门诊环境中的P4P计划，7项针对医院，1项研究适用于疗养院。关于实施，13项研究检查了计划设计，8项研究检查了实施过程，6项研究了外部环境，18项研究了内部环境，5项研究了提供者特征。结果表明，考虑潜在支付模式、使用统计严格的综合测量方法进行开发以及确保在激励措施取消后仍能维持高质量护理的重要性。我们没有确凿证据表明提供者或实践特征与P4P有效性相关。对14名关键 informant 的访谈支持了有限的证据，即有效的P4P计划措施应与组织目标保持一致，激励结构应仔细考虑，强大的基础设施和公开报告等因素可能有很大影响。
讨论
关于P4P实施，从中得出确凿结论的证据有限。研究和关键 informant 访谈的结果表明，P4P计划应定期评估，并应针对表现不佳的领域。此外，措施和激励应与组织优先事项保持一致，并且计划应允许随着时间的推移根据数据和提供者的意见进行更改。
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