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
Worldwide
implemented
USA to Europe
Process to
Outcome
P4P
Primary care
Quality
improvement
Inconclusive
evidence
Organization
$
Contract
1. Fix salary
2. Night shifts
3. Career scalator
12%-8% P4P
Professionals
Organization
$
Professionals
Contract
P4P scheme
Team Clinical (40%),
Individual Clinical (30%)
and Excellence (30%) goals
Aligned with system goals
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.
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
Methods
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.
11
11
Methods
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
Preventive activities
• Primary
• Secondary
• Quaternary
Results
Results
25.3%
Yearly average: 5,8%
22 3
Improvement 08-11:
Results
Doctors
QUALITY INDICATOR
05-Stroke: Antiaggregant treatment
06-Stroke: Lipid control
07-Ischemic heart diseases: Beta-blockers
08-Ischemic heart diseases: Antiaggregant treatment
09-Ischemic heart diseases: Lipid control
10-Dislipemy: Cardiovascular risk (35-74y)
11-Cardiac arrythmia by auricular fibrilation: ASA / OAT
12-Blood pressure: Arterial tension control
13-Blood pressure: Arterial tension control in population at risk
14-Heart failure: ACEI / ARAII treatment
15-Heart failure: Beta-blockers treatment
17-Alcohol: Screening (15-79y)
18-Tabacco: Abstinents in population at risk
19-Tabacco: Cessation in last 12 mo (15-79y)
20-DM2: Foot screening
21-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: Vaccination
34-COPD: Inhalers verifying (>39y)
35-Home care: Integral assessment
36-Homecare: Sore risk
39-Prostate: PSA right use (>74y)
Nurses
Y2008
2,50%
Y2009
5%
Y2010
Y2011
5%
5%
5%
5%
2,50%
5%
5%
2,50%
5%
5%
2,50%
5%
2,50%
10%
2,50%
2,5%
10%
2,50%
10%
2,50%
5%
10%
Percentage represents goal’s weight in the P4P set.
Y2008
Y2009
Y2010
Y2011
5%
5%
6%
10%
10%
6%
6%
5%
10%
5%
10%
6%
6%
6%
6%
5%
10%
2,50%
10%
3%
6%
4%
4%
6%
5%
5%
2,50%
2,50%
2,50%
2,50%
5%
2,50%
2,50%
2,50%
5%
2,50%
4%
4%
4%
4%
4%
4%
2,50%
2,50%
5%
2,50%
5%
5%
5%
5%
Results
Doctor goals
Nurse goals
Common goals
Non-goals
7
9
4
5
QUALITY INDICATOR
05-Stroke: Antiaggregant treatment
06-Stroke: Lipid control
07-Ischemic heart diseases: Beta-blockers
08-Ischemic heart diseases: Antiaggregant treatment
09-Ischemic heart diseases: Lipid control
10-Dislipemy: Cardiovascular risk (35-74y)
11-Cardiac arrythmia by auricular fibrilation: ASA / OAT
12-Blood pressure: Arterial tension control
13-Blood pressure: Arterial tension control in population at risk
14-Heart failure: ACEI / ARAII treatment
15-Heart failure: Beta-blockers treatment
17-Alcohol: Screening (15-79y)
18-Tabacco: Abstinents in population at risk
19-Tabacco: Cessation in last 12 mo (15-79y)
20-DM2: Foot screening
21-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: Vaccination
34-COPD: Inhalers verifying (>39y)
35-Home care: Integral assessment
36-Homecare: Sore risk
39-Prostate: PSA right use (>74y)
DOC NUR COM
2
2
4
3
3
1
4
2
4
4
2
3
3
4
4
3
3
1
4
2
4
4
4
4
2
4
4
4
1
2
2
2
4
3
1
2
2
2
4
4
4
4
4
4
Results
Results
Behaviour of Goal and Non-goal years
for goal indicators
Doctors
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%
p < 0.001
Nurses
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%
p > 0.05
Results
25.0%
20.0%
GOAL
11.9%
15.0%
POST
-0.5%
10.0%
5.0%
PRE
3.1%
0.0%
YEAR 0
YEAR 1
YEAR 2
Doctors
YEAR 3
Results
25.0%
GOAL
14.6%
20.0%
POST
4.8%
15.0%
10.0%
5.0%
PRE
3.7%
0.0%
YEAR 0
YEAR 1
YEAR 2
Nurses
YEAR 3
Results
POST
25.0%
GOAL
20.0%
MORE
INERTIA
15.0%
MORE
SENSITIVENESS
10.0%
5.0%
PRE
0.0%
YEAR 0
YEAR 1
YEAR 2
Doctors
Nurses
YEAR 3
Results
Are weights worth?
Weight
Doctors
Nurses
2,5%
6,9%
26,5%
3,0%
5,8%
10.0%
9.0%
8.0%
7.0%
4,0%
5,0%
21,7%
14,5%
6,0%
10,0%
12,0%
4,0%
15,0%
8,9%
6.0%
5.0%
4.0%
3.0%
2.0%
1.0%
0.0%
0.0%
5.0%
10.0%
Doctors
Nurses
15.0%
20.0%
Linear (Doctors)
25.0%
Linear (Nurses)
30.0%
Conclusions
1. P4P works for quality improvement at a 1214% 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