NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Avenida Padre Cruz, 1600-560, Lisboa, Portugal; Comprehensive Health Research Center (CHRC), Campo Mártires da Pátria, 130 1169-056 Lisboa, Portugal.
NOVA National School of Public Health, Public Health Research Centre, Universidade NOVA de Lisboa, Avenida Padre Cruz, 1600-560, Lisboa, Portugal; Comprehensive Health Research Center (CHRC), Campo Mártires da Pátria, 130 1169-056 Lisboa, Portugal.
Soc Sci Med. 2020 May;252:112908. doi: 10.1016/j.socscimed.2020.112908. Epub 2020 Mar 10.
In 2006 a major primary care reform was initiated in Portugal. The most significant aspect of this reform was the creation of a new organizational model of primary care provision: Family Health Units (FHUs), consisting of small voluntarily constituted multidisciplinary teams that have functional autonomy and are partly financed through capitation and pay-for-performance. The creation of FHUs sought to increase access to care and to chronic disease management by improving the long-term relationship between health professionals and patients. The objectives of this study are to evaluate the impact of the FHUs implementation on population health outcomes, measured by the rate of hospitalizations for ambulatory care sensitive conditions (ACSC), i.e. avoidable hospital inpatient admissions, and to explore the effectiveness of the pay-for-performance in primary care by analysing the subset of disease specific hospitalizations for ACSC related to the financial incentives. Using data from 276 Portuguese municipalities from 2000 to 2015 (n = 4416) and exploiting the gradual introduction of the FHUs over time, we used a difference-in-differences approach contrasting the evolution of the hospitalization rate for ACSC in municipalities that implemented or not the FHUs. We then explored heterogeneous effects by incentivized (diabetes and hypertension) and non-incentivized disease-specific rates of hospitalizations for ACSC. During the period under analysis, 448 FHUs were created in 126 municipalities. No significant impact of the FHUs implementation on the reduction of the hospitalization rate for ACSC was found. This result also held for the incentivized hospitalizations for ACSC. We only found a statistically significant effect of the FHUs implementation in the reduction of one non-incentivized area (the rate of urinary tract infection ACSC). Our results question the capacity of this payment mechanism to achieve better health outcomes, and invites a more careful and evidence-based action toward its wider diffusion.
2006 年，葡萄牙启动了一项重大的初级保健改革。这项改革的最重要方面是创建了新的初级保健提供组织模式：家庭健康单位（FHUs），由小的自愿组成的多学科团队组成，具有功能自主性，并通过人头付费和按绩效付费部分融资。创建 FHUs 的目的是通过改善卫生专业人员和患者之间的长期关系，增加获得护理和慢性病管理的机会。本研究的目的是评估 FHUs 的实施对人口健康结果的影响，这些结果通过门诊保健敏感条件（ACSC）的住院率来衡量，即避免住院的门诊入院，通过分析与财务激励相关的特定疾病的 ACSC 相关住院的子集，探索初级保健中按绩效付费的有效性。本研究使用了 2000 年至 2015 年来自葡萄牙 276 个城市的数据（n=4416），并利用 FHUs 的逐步引入，使用差异中的差异方法对比实施或未实施 FHUs 的城市中 ACSC 住院率的演变。然后，我们通过激励（糖尿病和高血压）和非激励特定疾病的 ACSC 住院率来探索异质效应。在此分析期间，在 126 个城市中创建了 448 个 FHUs。没有发现 FHUs 的实施对降低 ACSC 住院率有显著影响。对于激励性的 ACSC 住院率，这一结果也是如此。我们只发现 FHUs 的实施在降低一个非激励性区域（尿路感染 ACSC 率）方面具有统计学上的显著效果。我们的结果对这种支付机制实现更好的健康结果的能力提出了质疑，并呼吁对其更谨慎和基于证据的行动，以促进其更广泛的传播。
