Summary of findings 1. Pay for performance (P4P) plus existing payment methods compared with existing payment methods for outpatient healthcare providers.
| P4P plus existing payment methods compared with existing payment methods for outpatient healthcare providers | ||||||
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Patient or population: healthcare providers working in outpatient healthcare settings Settings: Australia, Canada, India, Taiwan, the USA Intervention: P4P plus existing payment methods Comparison: existing payment methods (including capitation, FFS, and salary) | ||||||
| Outcomes | Anticipated absolute effects* (95% CI) | Relative effect (95% CI) | Results in words | No. of participants (studies) | Certainty of the evidence (GRADE) | |
| Risk with existing payment methods | Risk with P4P plus existing payment methods | |||||
| Quantity of service provision (dichotomous) ‐ child immunisation status up‐to‐date | 433 up‐to‐date per 1000 children | 550 up‐to‐date per 1000 children (515 to 588 children) | RR 1.27 (1.19 to 1.36) | P4P added to existing payment methods probably increases the number of children with up‐to‐date immunisation status, compared with an existing payment method. | 3760 children (2 RCTs) | ⊕⊕⊕⊝ MODERATE1 |
| Quantity of service provision (continuous) ‐ immunisation rates for patients aged 65 years or older | The mean immunisation rate with P4P plus existing payment methods was 0.34 per cent points higher (0.2 per cent points lower to 0.87 points higher) compared to existing payment methods. | MD 0.34 (−0.20 to 0.87) | We are uncertain of the effect of P4P added to existing payment methods on immunisation rates for the elderly. | 54 primary care practices (1 RCT) |
⊕⊝⊝⊝ VERY LOW2 | |
| Quantity of service provision (continuous) ‐ number of detailed disease‐related consultation services per 100 prescriptions | The mean number of consultation services with P4P plus existing payment methods was 1.24 per cent higher per 100 prescriptions (0.93 per cent points higher to 1.54 points higher) compared to existing payment methods. | MD 1.24 (0.93 to 1.54) | P4P added to existing payment methods may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist, compared with an existing payment method. | 200 community pharmacies (1 RCT) | ⊕⊕⊝⊝ LOW3 | |
| Quality of service provision ‐ physician prescribing practices | Insufficient data to calculate | RR 1.07 (1.02 to 1.12) | P4P added to existing payment methods may slightly improve providers' prescribing of guideline‐recommended antihypertensive medicines compared with an existing payment method. | 362 people (1 RCT) |
⊕⊕⊝⊝ LOW4 | |
| Patient outcomes ‐ reduction in blood pressure | The mean blood pressure reduction with P4P plus existing payment methods was 0.07 mmHG greater (2.22 less to 2.37 greater) compared to existing payment methods. | MD 0.07 (ranged from −2.22 to 2.37) | We are uncertain of the effect of P4P added to existing payment methods on mean blood pressure reduction compared with an existing payment method. | 181 people (1 RCT) |
⊕⊝⊝⊝ VERY LOW5 |
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| Quality of service provision and patient outcomes ‐ blood pressure management | Insufficient data to calculate | RR 1.13 (1.04 to 1.23) | P4P added to existing payment methods may improve blood pressure control or appropriate responses to patients with uncontrolled blood pressure, compared with an existing payment method. | 362 people (1 RCT) | ⊕⊕⊝⊝ LOW6 | |
| Healthcare provider outcomes (such as work morale or workload) | None of the included studies reported on healthcare provider outcomes. | ‐ | ‐ | |||
| Costs | We are uncertain of the costs of adding P4P to existing payment methods on expenditures for diabetes‐related services due to very low‐certainty evidence. | 1 CBA | ⊕⊝⊝⊝ VERY LOW7 |
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| Unintended or adverse effects | Insufficient data to calculate | RR 0.77 (0.71 to 0.82) | When the P4P intervention ended, there was an important reduction in performance (blood pressure control or appropriate responses to uncontrolled blood pressure) in the intervention group compared with the existing payment method. | 362 people (1 RCT) | ⊕⊕⊝⊝ LOW8 | |
| *The risk in the intervention group (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CBA: controlled before‐after study; FFS: fee‐for‐service; MD: mean difference; P4P: pay for performance; RCT: randomised controlled trial; RR: risk ratio | ||||||
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GRADE Working Group grades of evidence
High certainty: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different** is low.
Moderate certainty: This research provides a good indication of the likely effect. The likelihood that the effect will be substantially different** is moderate.
Low certainty: This research provides some indication of the likely effect. However, the likelihood that it will be substantially different** is high.
Very low certainty: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different** is very high. ** Substantially different = a large enough difference that it might affect a decision | ||||||
1We rated two RCTs as unclear risk of bias (Fairbrother 1999; Fairbrother 2001), downgrading the certainty of the evidence one level because of limitation in study design.
2We rated one RCT as unclear risk of bias (Kouides 1998), downgrading the certainty of the evidence one level for limitation in study design, one level for indirectness (only one study targeting primary care physicians in the USA), and one level for imprecision (limited number of participants, and 95% CI overlaps no effect).
3We rated one RCT as unclear risk of bias (Christensen 2000), downgrading the certainty of the evidence one level for limitation in study design and one level for indirectness (only one study targeting community pharmacies in the USA).
4We rated one RCT as unclear risk of bias (Petersen 2013), downgrading the certainty of the evidence one level for limitation in study design and one level for indirectness (only one study targeting primary care physicians in the USA).
5We rated one RCT as unclear risk of bias (Houle 2016), downgrading the certainty of the evidence one level for limitation in study design, one level for indirectness (only one study targeting pharmacists in pharmacy practice in Canada), and one level for imprecision (study ended prior to enrolment of the full sample size of participants, and 95% CI overlaps no effect).
6We rated one RCT as unclear risk of bias (Petersen 2013), downgrading the certainty of the evidence one level for limitation in study design and one level for indirectness (only one study targeting primary care physicians in the USA).
7We rated one CBA as high risk of bias (Lee 2010). Initial rating of low certainty assigned due to non‐randomised study design and downgraded one level for further limitations in study design and one level for indirectness (only one study targeting pharmacists in community clinics physicians in Taiwan).
8We rated one RCT as unclear risk of bias (Petersen 2013), downgrading the certainty of the evidence one level for limitation in study design and one level for indirectness (only one study targeting primary care physicians in the USA).