University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada.
Eur J Health Econ. 2019 Dec;20(9):1303-1315. doi: 10.1007/s10198-019-01097-4. Epub 2019 Aug 10.
Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems.
Studies were identified by searching ten databases (01/2000-04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs.
We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term-when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts.
Evidence of the effectiveness of P4P depends on whether physicians' incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.
尽管针对糖尿病护理的按效付费（P4P）越来越普遍，但缺乏其改善人群健康和医疗体系可持续性的有效性证据。造成这一信息差距的部分原因是，各国之间的医疗保健融资、涵盖的医疗条件、护理环境以及提供者薪酬安排存在差异。我们系统地回顾了文献，重点关注初级和社区护理中的医生 P4P 是否会导致单一支付者国家健康保险体系中更好的糖尿病结果。
通过搜索十个数据库（2000 年 1 月至 2018 年 4 月）和审查文章及其他全球卫生文献的参考文献列表，确定了研究。我们纳入了评估全民健康覆盖国家中初级保健医生引入糖尿病护理 P4P 的效果的主要研究。感兴趣的结果包括患者发病率、可避免的住院治疗、过早死亡和医疗保健成本。
我们确定了 2218 份报告；经过排除，有 10 篇文章涵盖了 7 个国家的 8 个 P4P 干预措施，符合分析条件。五项研究，共纳入了 717166 名糖尿病患者的记录，被评为 P4P 对健康结果的高质量评估。基于三项高质量研究，当与绩效指标相关联时，P4P 可以降低长期死亡风险。然而，来自其他司法管辖区的研究，其中 P4P 与特定面向患者的目标无关，几乎没有或混合证据表明对健康有积极影响。
P4P 的有效性证据取决于医生的激励性支付是否明确与绩效指标挂钩。然而，用于绩效监测的最合适指标仍存在疑问。需要在不同环境中进行更多具有严格评估的研究。
