Grimley Rohan S, Collyer Taya A, Andrew Nadine E, Dewey Helen M, Horton Eleanor S, Cadigan Greg, Cadilhac Dominique A
School of Medicine and Dentistry, Griffith University, Birtinya, Queensland 4575, Australia.
State-Wide Stroke Clinical Network, Clinical Excellence Queensland, Queensland Department of Health, Brisbane, Queensland 4001, Australia.
Lancet Reg Health West Pac. 2023 Oct 7;41:100921. doi: 10.1016/j.lanwpc.2023.100921. eCollection 2023 Dec.
Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke.
We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in 2012.
We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference -0.16%/month (95% CI -0.29, -0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality -0.18%, (95% CI -0.34, -0.02).
This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design.
Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.
卒中单元护理对所有卒中患者亚组均有显著益处，但在许多医疗系统中，持续获得该护理服务却难以实现。为提高医疗质量和效率，绩效薪酬激励措施已被广泛采用，但针对医院实施时，其产生积极影响的证据有限。2012年，澳大利亚昆士兰州的公立医院临床质量改进网络共同设计并实施了一项针对卒中单元服务可及性的绩效薪酬计划。我们评估了该计划对卒中后获得专科护理服务及死亡率的影响。
我们对关联的医院和死亡登记数据进行中断时间序列分析，以比较2009年（绩效薪酬计划实施前）至2017年（2012年引入绩效薪酬计划后）卒中患者在服务水平（绝对比例）上的变化以及结局（卒中/冠心病监护病房入院、6个月死亡率）的趋势，同时以无绩效薪酬激励措施的心肌梗死（MI）作为对照情况。
我们纳入了23,572例卒中患者和39,511例MI患者。引入绩效薪酬计划后，卒中单元服务可及性比历史趋势预测值绝对增加了35%（95%置信区间29, 41），对基线服务可及性最低的地区/农村居民影响更大（41%对大城市居民的24%）（18%对大城市居民的53%）。卒中后6个月死亡率的历史上升趋势（每月+0.11%）在实施绩效薪酬计划后转变为下降趋势（每月-0.05%）；差异为每月-0.16%（95%置信区间-0.29, -0.03）。相比之下，MI对照组的冠心病监护病房服务可及性和死亡率趋势未变，死亡率的差异为-0.18%，（95%置信区间-0.34, -0.02）。
这项由临床医生主导的绩效薪酬激励措施显著改善了卒中单元服务可及性，减少了地区差异，并使6个月死亡率持续下降。由于我们的研究结果与大多数医院导向的绩效薪酬计划缺乏效果形成对比，设计和背景方面的差异为优化计划设计提供了见解。
昆士兰推进临床研究奖学金、国家卫生与医学研究委员会高级研究奖学金。
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