University of New Brunswick, Department of Sociology, Fredericton, New Brunswick, Canada.
Government of New Brunswick, Department of Health, Fredericton, New Brunswick, Canada.
Can J Diabetes. 2019 Jul;43(5):354-360.e1. doi: 10.1016/j.jcjd.2018.11.006. Epub 2018 Nov 24.
In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs.
We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive.
Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes.
The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.
在加拿大新不伦瑞克省，有 13.6%的 35 岁及以上人群患有 1 型或 2 型糖尿病。为了解决公共卫生和临床方面的挑战，2010 年引入了家庭医生按绩效付费（P4P），以实现全面的糖尿病管理。本研究评估了该 P4P 计划对超额医疗费用的影响。
我们使用了一种准实验研究设计，利用基于人群的行政医师账单、医院出院摘要以及提供者和居民登记数据进行了链接。通过验证的个体与医疗保健系统相互作用的追踪算法，确定了糖尿病患者的前瞻性队列。我们根据患者接受激励措施的医师采用情况，应用倾向评分差异中的差异估计方法，评估了 P4P 对可预防的糖尿病相关住院费用的影响。
激励性护理的覆盖率不到一半（44%），患有糖尿病的成年人倾向于比那些其提供者没有提出激励措施的成年人更年轻，并且往往没有同时存在合并症。P4P 的引入导致新诊断患者的糖尿病住院费用显著降低（-0.083；p<0.01），并且对医师的补偿也得到了改善。在中长期患者或与糖尿病一致的病症住院方面，并未避免成本。
新不伦瑞克省的糖尿病 P4P 效果参差不齐。结果反映了关于 P4P 对以患者为导向和决策者重要的健康结果的影响的证据基础不足。糖尿病患者的多种合并症的高风险以及医师对绩效激励的反应的异质性，可能会阻碍 P4P 改善糖尿病结局的有效性。
