Effectiveness of a multiprofessional P4P system in clinical outcomes and

organizational alignment

A longitudinal study in a primary care organization

Tino Martí, Antoni Peris and Alba Brugues

Context

P4PWorldwide

implementedUSA to Europe

Process to Outcome

Primary care

Quality improvemen

tInconclusive

evidence

ProfessionalsOrganizationContract

$

12%-8% P4P

1. Fix salary2. Night shifts3. Career scalator

ProfessionalsOrganizationContract

$

P4P schemeTeam Clinical (40%),

Individual Clinical (30%) and Excellence (30%) goals

Aligned with system goals

Goals

1. To assess the effectiveness of P4P scheme on quality improvement

2. To analyse the post-goal effect (inertia effect) or what happens once a goal is retrieved.

Goals

Methods

Methods

Time span:• P4P scheme has been applied in CASAP since

2006. • We have selected the last 4 years (2008-2011)

for a better consistency of quality indicators. • Thus, 2008 is the basal year to measure

improvement.

2008 2009 2010 2011

Health professionals:

• Although all primary care professionals are involved in the P4P scheme, we have selected family doctors and adult-care nurses for this study.

• Data availability (permanence in the company) during the study period (2008-2011) has been a necessary condition to allow consistent comparisons.

• Therefore, a group of 11 family doctors and 11 nurses were selected.

Methods

11 11

Quality indicators:

• EQA is a standard set of quality indicators used across Catalonia to assess quality performance in Primary Care Teams.

• EQA covers major chronic diseases such as DM, heart failure, COPD and cancer.

• It also includes prevention activities such as blood pressure control, smoking cessation, flu vaccination.

• A total of 25 quality indicators were monitored during the study period.

Methods

Methods

Preventive activities• Primary• Secondary• Quaternary

Results

Improvement 08-11: 25.3%

Yearly average: 5,8%22 3

Results

Results

QUALITY INDICATOR Y2008 Y2009 Y2010 Y2011 Y2008 Y2009 Y2010 Y201105-Stroke: Antiaggregant treatment 2,50% 5%06-Stroke: Lipid control07-Ischemic heart diseases: Beta-blockers 5% 5% 5% 5%08-Ischemic heart diseases: Antiaggregant treatment 5% 2,50% 2,50%09-Ischemic heart diseases: Lipid control 5% 5% 5%10-Dislipemy: Cardiovascular risk (35-74y) 5% 5% 5% 6%11-Cardiac arrythmia by auricular fibrilation: ASA / OAT 2,50% 2,50% 2,50% 2,50%12-Blood pressure: Arterial tension control 10% 10% 10% 10% 6% 6%13-Blood pressure: Arterial tension control in population at risk 2,50% 2,50% 2,50% 2,50%14-Heart failure: ACEI / ARAII treatment 2,5% 5% 5% 5%15-Heart failure: Beta-blockers treatment17-Alcohol: Screening (15-79y) 5% 5% 5% 5% 6% 6%18-Tabacco: Abstinents in population at risk 10% 10% 6% 6%19-Tabacco: Cessation in last 12 mo (15-79y)20-DM2: Foot screening 5% 2,50% 3% 4%21-DM2: HBA1C control (15-79y) 10% 10% 5% 10% 10% 6% 4%22-DM2: retinopathy screening (15-79y) 6%29-Flu: Vaccination (>59y) 5% 2,50%30-Flu: Vaccination populatino at risc (15-59y) 5% 2,50%31- Pneumococcic disease: Vaccination (>59y) 2,50% 2,50%32-Tetanus: Vaccination34-COPD: Inhalers verifying (>39y) 5% 2,50% 4% 4%35-Home care: Integral assessment 2,50% 5% 4% 4%36-Homecare: Sore risk 2,50% 2,50% 4% 4%39-Prostate: PSA right use (>74y)

Doctors Nurses

Percentage represents goal’s weight in the P4P set.

QUALITY INDICATOR05-Stroke: Antiaggregant treatment06-Stroke: Lipid control07-Ischemic heart diseases: Beta-blockers08-Ischemic heart diseases: Antiaggregant treatment 09-Ischemic heart diseases: Lipid control10-Dislipemy: Cardiovascular risk (35-74y)11-Cardiac arrythmia by auricular fibrilation: ASA / OAT12-Blood pressure: Arterial tension control13-Blood pressure: Arterial tension control in population at risk14-Heart failure: ACEI / ARAII treatment15-Heart failure: Beta-blockers treatment17-Alcohol: Screening (15-79y)18-Tabacco: Abstinents in population at risk19-Tabacco: Cessation in last 12 mo (15-79y)20-DM2: Foot screening21-DM2: HBA1C control (15-79y)22-DM2: retinopathy screening (15-79y)29-Flu: Vaccination (>59y)30-Flu: Vaccination populatino at risc (15-59y)31- Pneumococcic disease: Vaccination (>59y)32-Tetanus: Vaccination34-COPD: Inhalers verifying (>39y)35-Home care: Integral assessment36-Homecare: Sore risk39-Prostate: PSA right use (>74y)

DOC NUR COM2 2

4 43 33 31 3 14 42 4 24 44 4

2 4 24 4

4 43 4 3

1 12 22 22 2

4 44 44 4

Results

Doctor goals 7Nurse goals 9Common goals 4Non-goals 5

Results

Results

Doctors

Nurses

Y2009 Y2010 Y2011 AVG

GOAL YEAR 23,7% 2,3% 7,0% 11,9%

NON-GOAL YEAR 3,1% -3,8% 1,5% 0,2%

TOTAL 20,0% 0,6% 4,5% 8,4%

Y2009 Y2010 Y2011 AVG

GOAL YEAR 18,5% 20,2% 3,7% 14,6%

NON-GOAL YEAR 5,7% -11,5% 20,3% 4,6%

TOTAL 17,5% 10,4% 8,8% 12,3%

Behaviour of Goal and Non-goal years for goal indicators

p < 0.001

p > 0.05

YEAR 0 YEAR 1 YEAR 2 YEAR 30.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Chart Title

PRE 3.1%

GOAL 11.9%

POST-0.5%

Doctors

Results

YEAR 0 YEAR 1 YEAR 2 YEAR 30.0%

5.0%

10.0%

15.0%

20.0%

25.0%

Chart Title

PRE 3.7%

GOAL 14.6%

POST4.8%

Nurses

Results

YEAR 0 YEAR 1 YEAR 2 YEAR 30.0%

5.0%

10.0%

15.0%

20.0%

25.0%

PRE

GOAL

POST

MORE INERTIA

MORE SENSITIVENESS

DoctorsNurses

Results

0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 30.0%0.0%

1.0%

2.0%

3.0%

4.0%

5.0%

6.0%

7.0%

8.0%

9.0%

10.0%

Doctors Linear (Doctors) Nurses

Weight Doctors Nurses

2,5% 6,9% 26,5%

3,0% 5,8%

4,0% 21,7%

5,0% 14,5% 12,0%

6,0% 4,0%

10,0% 15,0% 8,9%

ResultsAre weights worth?

Conclusions

1. P4P works for quality improvement at a 12-14% improvement rate

2. Nurses are more sensitive to incentives than doctors.

3. After-incentive effect is neutral for doctors and positive for nurses.

4. Doctors are sensitive to weights

Thank you