From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom.
N Engl J Med. 2018 Sep 6;379(10):948-957. doi: 10.1056/NEJMsa1801495.
The benefits of pay-for-performance schemes in improving the quality of care remain uncertain. There is little information on the effect of removing incentives from existing pay-for-performance schemes.
We conducted interrupted time-series analyses of electronic medical record (EMR) data from 2010 to 2017 for 12 quality-of-care indicators in the United Kingdom's Quality and Outcomes Framework for which financial incentives were removed in 2014 and 6 indicators for which incentives were maintained. We estimated the effects of removing incentives on changes in performance on quality-of-care measures.
Complete longitudinal data were available for 2819 English primary care practices with more than 20 million registered patients. There were immediate reductions in documented quality of care for all 12 indicators in the first year after the removal of financial incentives. Reductions were greatest for indicators related to health advice, with a reduction of 62.3 percentage points (95% confidence interval [CI], -65.6 to -59.0) in EMR documentation of lifestyle counseling for patients with hypertension. Changes were smaller for indicators involving clinical actions that automatically update the EMR, such as laboratory testing, with a reduction of 10.7 percentage points (95% CI, -13.6 to -7.8) in control of cholesterol in patients with coronary heart disease and 12.1 percentage points (95% CI, -13.6 to -10.6) for thyroid-function testing in patients with hypothyroidism. There was little change in performance on the 6 quality measures for which incentives were maintained.
Removal of financial incentives was associated with an immediate decline in performance on quality measures. In part, the decline probably reflected changes in EMR documentation, but declines on measures involving laboratory testing suggest that incentive removal also changed the care delivered.
绩效薪酬计划在提高护理质量方面的益处仍不确定。关于取消现有绩效薪酬计划中的激励措施的效果，信息甚少。
我们对 2010 年至 2017 年英国质量和结果框架中的 12 项质量护理指标的电子病历（EMR）数据进行了中断时间序列分析，这些指标中的财务激励措施在 2014 年被取消，而另外 6 项指标中的激励措施则得以保留。我们估计了取消激励措施对护理质量措施绩效变化的影响。
对于 2819 家拥有超过 2000 万注册患者的英国初级保健诊所，我们获得了完整的纵向数据。在取消财政激励措施的第一年，所有 12 项指标的护理质量记录都立即下降。与健康建议相关的指标下降幅度最大，高血压患者生活方式咨询的 EMR 记录减少了 62.3 个百分点（95%置信区间[CI]，-65.6 至-59.0）。涉及自动更新 EMR 的临床操作的指标变化较小，例如实验室检测，冠心病患者的胆固醇控制减少了 10.7 个百分点（95%CI，-13.6 至-7.8），甲状腺功能减退症患者的甲状腺功能检测减少了 12.1 个百分点（95%CI，-13.6 至-10.6）。对于激励措施得以保留的 6 项质量指标，其绩效变化不大。
取消财政激励措施与质量措施绩效的立即下降有关。部分下降可能反映了 EMR 记录的变化，但实验室检测指标的下降表明，激励措施的取消也改变了提供的护理。
