RTI International, P. O. Box 12194, Research Triangle Park, Raleigh, NC, 27709-2194, USA.
Schneider Institutes for Health Policy, The Heller School, MS035, Brandeis University, Waltham, MA, USA.
Implement Sci. 2018 Jul 4;13(1):92. doi: 10.1186/s13012-018-0774-1.
Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs).
Building on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes.
At trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191-$16,171).
This study provides experimental evidence supporting P4P as a cost-effective implementation strategy.
NCT01016704 .
绩效薪酬（P4P）已被推荐为改善高质量医疗服务实施的一种有前景的策略。本研究考察了一种绩效薪酬策略的增量成本效益，该策略被发现能非常有效地提高青少年社区强化治疗方法（A-CRA）的实施和效果，A-CRA 是一种针对青少年药物使用障碍（SUD）的循证治疗（EBT）。
在一项耗资 3000 万美元的全国性倡议的基础上，实施 A-CRA 以治疗 SUD，采用 urn 随机化将 29 个组织及其 105 名治疗师和 1173 名患者分配到两种条件之一（实施常规护理（IAU）对照组或 IAU+P4P 实验组）。不可能对组织、治疗师或所有研究人员进行盲法分组。所有治疗组织及其治疗师都接受了多方面的实施策略。除了这些 IAU 策略外，IAU+P4P 条件下的治疗师每月每展示一次治疗提供能力（A-CRA 能力），就获得 50 美元，每治疗一个接受规定数量的治疗程序和治疗次数的患者（与显著改善患者结局相关），就获得 200 美元。增量成本效益比（ICER），表示两种条件下每个治疗组织的平均成本差异除以每个组织相应的平均效果差异，以及质量调整生命年（QALY）是主要结果。
在试验完成时，15 个组织被随机分配到 IAU 条件，14 个组织被随机分配到 IAU+P4P 条件。分析了所有 29 个组织的数据。聚类水平分析表明，与 IAU 对照组相比，P4P 策略导致平均总费用显著增加，但这一平均增加 5%导致治疗提供能力方面治疗师表现出的能力的月数增加了 116%（ICER = $333），接受目标治疗剂量的患者数量增加了 325%（ICER = $453），治疗期间每个患者的禁欲天数增加了 325%（ICER = $8.134）。进一步支持 P4P 作为一种具有成本效益的实施策略，每 QALY 的成本仅为 8681 美元（95%置信区间为 1191 美元至 16171 美元）。
本研究提供了支持 P4P 作为一种具有成本效益的实施策略的实验证据。
NCT01016704。
