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