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Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review

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Abstract

Background

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.

Methods

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.

Results

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.

Conclusion

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.

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Acknowledgements

The authors wish to thank Barry Cull and Richelle Witherspoon, from the University of New Brunswick’s Harriet Irving Library, for assistance with structuring the literature search and adapting it for the different bibliographic databases. Diabetes Canada and the New Brunswick Health Research Foundation provided financial support for this study. The sponsors had no role in study design, data collection, data analysis, or writing of the paper.

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  1. University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada

    Neeru Gupta & Holly M. Ayles

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  1. Neeru Gupta
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Correspondence to Neeru Gupta.

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Appendix: List of studies excluded due to multiple analyses of a single P4P scheme

Appendix: List of studies excluded due to multiple analyses of a single P4P scheme

Australia

  1. 1.

    Scott A, Schurer S, Jensen PH, Sivey P. The effects of an incentive program on quality of care in diabetes management. Health Econ 2009;18(9):1091–108.

Canada (British Columbia)

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    Hollander MJ, Kadlec H. Incentive-based primary care: cost and utilization analysis. Perm J 2015; 19(4):46–56.

Italy (Emilia Romagna)

  1. 1.

    Lippi Bruni M, Nobilio L, Ugolini C. Economic incentives in general practice: the impact of pay-for-participation and pay-for-compliance programs on diabetes care. Health Policy 2009; 90:140–48.

Taiwan

  1. 1.

    Chen CC, Cheng SH. Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system. Health Policy Plan 2016; 31(1):83–90.

  2. 2.

    Chen YC, Lee CT, Lin BJ, Chang YY, Shi HY. Impact of pay-for-performance on mortality in diabetes patients in Taiwan: a population-based study. Medicine 2016; 95(27):e4197.

  3. 3.

    Chi MJ, Chou KR, Pei D, et al., Effects and factors related to adherence to a diabetes pay-for-performance program: analyses of a national health insurance claims database. J Am Med Dir Assoc 2016; 17(7):613–19.

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    Hsieh HM, Lin TH, Lee IC, et al. The association between participation in a pay-for-performance program and macrovascular complications in patients with type 2 diabetes in Taiwan: a nationwide population-based cohort study. Preventive Medicine 2016; 85:53–59.

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    Hsieh HM, Shin SJ, Tsai SL, Chiu HC. Effectiveness of pay-for-performance incentive designs on diabetes care. Med Care 2016; 54(12):1063–69.

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    Huang YC, Lee MC, Chou YJ, Huang N. Disease-specific pay-for-performance programs: do the P4P effects differ between diabetic patients with and without multiple chronic conditions? Med Care 2016; 54(11):977–83.

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    Lin TY, Chen CY, Huang YT, et al. The effectiveness of a pay for performance program on diabetes care in Taiwan: a nationwide population-based longitudinal study. Health Policy 2016; 120(11):1313–21.

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    Lo HY, Yang SL, Lin HH, Bai KJ, Lee JJ, Lee TI, Chiang CY. Does enhanced diabetes management reduce the risk and improve the outcome of tuberculosis? Int J Tuberc Lung Dis 2016; 20(3):376–82.

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    Yen SM, Kung PT, Sheen YJ, Chiu LT, Xu XC, Tsai WC. Factors related to continuing care and interruption of P4P program participation in patients with diabetes. Am J Manag Care 2016; 22(1):e18–e30.

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    Yu HC, Tsai WC, Kung PT. Does the pay-for-performance programme reduce the emergency department visits for hypoglycemia in type 2 diabetic patients? Health Policy Plan 2014; 29(6):732–41.

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    Yuan SP, Huang CN, Liao HC, et al. Glycemic control outcomes by gender in the pay-for-performance system: a retrospective database analysis in patients with type 2 diabetes mellitus. Int J Endocrinol 2014; 2014:575124.

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    Lai CL, Hou YH. The association of clinical guideline adherence and pay-for-performance among patients with diabetes. J Chin Med Assoc 2013; 76(2):102–7.

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United Kingdom

  1. 1.

    Alshamsan R, Lee JT, Majeed A, et al. Effect of a UK pay-for-performance program on ethnic disparities in diabetes outcomes: interrupted time series analysis. Ann Fam Med 2012;10(3):228–34.

  2. 2.

    Oluwatowoju I, Abu E, Wild SH, Byrne CD. Improvements in glycaemic control and cholesterol concentrations associated with the Quality and Outcomes Framework: a regional 2-year audit of diabetes care in the UK. Diabet Med 2010;27(3):354–59.

  3. 3.

    Campbell SM, Reeves D, Kontopantelis E, et al. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009;361(4):368–78.

  4. 4.

    Crawley D, Ng A, Mainous AG, et al. Impact of pay for performance on quality of chronic disease management by social class group in England. J R Soc Med 2009;102(3):103–7.

  5. 5.

    Millett C, Bottle A, Ng A, et al. Pay for performance and the quality of diabetes management in individuals with and without co-morbid medical conditions. J R Soc Med 2009;102(9):369–77.

  6. 6.

    Millett C, Netuveli G, Saxena S, Majeed A. Impact of pay for performance on ethnic disparities in intermediate outcomes for diabetes: a longitudinal study. Diabetes Care 2009;32(3):404–9.

  7. 7.

    Vaghela P, Ashworth M, Schofield P, Gulliford MC. Population intermediate outcomes of diabetes under pay-for-performance incentives in England from 2004 to 2008. Diabetes Care 2009;32(3):427–29.

  8. 8.

    Millet C, Gray J, Saxena S et al. Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth prospective study. PLoS Med 2007; 4(6):e191.

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Gupta, N., Ayles, H.M. Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review. Eur J Health Econ 20, 1303–1315 (2019). https://doi.org/10.1007/s10198-019-01097-4

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