Quality variation and its impact on costs and satisfaction: evidence from the QIDS study.
ABSTRACT Improving the quality of inpatient hospital care is increasingly attainable in a variety of settings. However, the relationship between rising quality and costs is unclear; similarly the relationship between varying levels of quality and a patient's satisfaction remains poorly defined.
We use data from the Quality Improvement Demonstration Study (QIDS) based in 30 district hospitals in the Philippines. There were 974 children in the study; these children were cared for by 43 physicians. To measure quality of care, the physicians completed vignettes, a valid and inexpensive measure. Patient exit surveys were given to parents of children on the day of discharge, collecting information on services and hospital charges for the inpatient stay, payment sources for the hospitalization, and the Patient Satisfaction Survey (PSQ-18).
We found a nonlinear relationship between quality and hospital charges: at low levels of quality improvements are linked to lower hospital charges. However, as quality improves further, these changes lead to higher charges. Higher quality also demonstrated a similar nonlinear relationship with patient satisfaction.
The U-shaped association between quality and hospital charges suggests that targeting the lowest quality providers may decrease costs. The similar relationship between patient-reported satisfaction and quality improvement suggests that investments in quality will raise satisfaction, perhaps even when charges are increased.
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ABSTRACT: Variability in treatment is linked to lower quality of care and higher costs. Rheumatoid arthritis (RA) is a chronic inflammatory disease for which care and management may vary considerably among rheumatologists. The extent of this variability and its cost ramifications have not been widely studied. This prospective study evaluated the quality and variability in care and quantified the potential cost implications. We used Clinical Performance and Value® vignettes to measure the quality of RA care among community-based rheumatologists. Three online Clinical Performance and Value® vignettes-representing patients likely seen in practice with mild disease activity (case A), worsening disease activity (case B), and stable disease with a complicating comorbidity (case C)-were administered to each rheumatologist. Responses were scored against evidence-based criteria. Costs were computed using current (2011) Medicare pricing. Data were analyzed using t test and fixed-effects analysis of variance. One hundred eight board-certified rheumatologists (72% were male; mean age, 49.1 years) completed the study. Overall quality scores averaged 61.3%. Those employed by a health system or in a multispecialty practice were more likely to score higher. Highest combined scores for diagnosis and treatment were evident with case A (61.7%) and lowest with case C (46.7%). Up to 79% of rheumatologists ordered at least 1 laboratory test that was considered unnecessary by study protocol criteria, incurring a mean excess cost of $37.85 per physician per case. Up to 26.9% rheumatologists prescribed biologic agents that were not indicated based on American College of Rheumatology treatment guidelines, resulting in additional costs of $2041 per patient per month. In this study, we observed a wide range of reported practice variability by rheumatologists in the management of RA. This included unnecessary testing and use of biologic agents that increased the costs of treatment. Opportunities for quality improvement and cost control exist in the management of RA.Journal of clinical rheumatology: practical reports on rheumatic & musculoskeletal diseases 03/2014; 20(2):79-86. DOI:10.1097/RHU.0000000000000076 · 1.19 Impact Factor
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ABSTRACT: BACKGROUND: A significant minority of patients do not receive all the evidence-based care recommended for their conditions. Health care quality may be improved by reducing this observed variation. Composite measures offer a different patient-centred perspective on quality and are utilized in acute hospitals via the 'care bundle' concept as indicators of the reliability of specific (evidence-based) care delivery tasks and improved outcomes. A care bundle consists of a number of time-specific interventions that should be delivered to every patient every time. We aimed to apply the care bundle concept to selected QOF data to measure the quality of evidence-based care provision. METHODS: Care bundles and components were selected from QOF indicators according to defined criteria. Five clinical conditions were suitable for care bundles: Secondary Prevention of Coronary Heart Disease (CHD), Stroke & Transient Ischaemic Attack (TIA), Chronic Kidney Disease (CKD), Chronic Obstructive Pulmonary Disease (COPD) and Diabetes Mellitus (DM). Each bundle has 3-8 components. A retrospective audit was undertaken in a convenience sample of nine general medical practices in the West of Scotland. Collected data included delivery (or not) of individual bundle components to all patients included on specific disease registers. Practice level and overall compliance with bundles and components were calculated in SPSS and expressed as a percentage. RESULTS: Nine practices (64.3%) with a combined patient population of 56,948 were able to provide data in the format requested. Overall compliance with developed QOF-based care bundles (composite measures) was as follows: CHD 64.0%, range 35.0-71.9%; Stroke/TIA 74.1%, range 51.6-82.8%; CKD 69.0%, range 64.0-81.4%; and COPD 82.0%, range 47.9-95.8%; and DM 58.4%, range 50.3-65.2%. CONCLUSIONS: In this small study compliance with individual QOF-based care bundle components was high, but overall ('all or nothing') compliance was substantially lower. Care bundles may provide a more informed measure of care quality than existing methods. However, the acceptability, feasibility and potential impact on clinical outcomes are unknown.BMC Health Services Research 10/2012; 12(1):351. DOI:10.1186/1472-6963-12-351 · 1.66 Impact FactorThis article is viewable in ResearchGate's enriched formatRG Format enables you to read in context with side-by-side figures, citations, and feedback from experts in your field.
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ABSTRACT: There is a growing interest in paying for performance as a means to align the incentives of health workers and health providers with public health goals. However, there is currently a lack of rigorous evidence on the effectiveness of these strategies in improving health care and health, particularly in low- and middle-income countries. Moreover, paying for performance is a complex intervention with uncertain benefits and potential harms. A review of evidence on effectiveness is therefore timely, especially as this is an area of growing interest for funders and governments. To assess the current evidence for the effects of paying for performance on the provision of health care and health outcomes in low- and middle-income countries. We searched more than 15 databases in 2009, including the Cochrane Effective Practice and Organisation of Care Group Specialised Register (searched 3 March 2009), CENTRAL (2009, Issue 1) (searched 3 March 2009), MEDLINE, Ovid (1948 to present) (searched 24 June 2011), EMBASE, Ovid (1980 to 2009 Week 09) (searched 2 March 2009), EconLit, Ovid (1969 to February 2009) (searched 5 March 2009), as well as the Social Sciences Citation Index, ISI Web of Science (1975 to present) (searched 8 September 2010). We also searched the websites and online resources of numerous international agencies, organisations and universities to find relevant grey literature and contacted experts in the field. We carried out an updated search on the Results-Based Financing website in April 2011, and re-ran the MEDLINE search in June 2011. Pay for performance refers to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. To be included, a study had to report at least one of the following outcomes: changes in targeted measures of provider performance, such as the delivery or utilisation of healthcare services, or patient outcomes, unintended effects and/or changes in resource use. Studies also needed to use one of the following study designs: randomised trial, non-randomised trial, controlled before-after study or interrupted time series study, and had to have been conducted in low- or middle-income countries (as defined by the World Bank). We aimed to present a meta-analysis of results. However, due to the limited number of studies in each category, the diversity of intervention designs and study methods, as well as important contextual differences, we present a narrative synthesis with separate results from each study. Nine studies were included in the review: one randomised trial, six controlled before-after studies and two interrupted time series studies (or studies which could be re-analysed as such). The interventions were varied: one used target payments linked to quality of care (in the Philippines). Two used target payments linked to coverage indicators (in Tanzania and Zambia). Three used conditional cash transfers, modified by quality measurements (in Rwanda, Burundi and the Democratic Republic of Congo). Two used conditional cash transfers without quality measures (in Rwanda and Vietnam). One used a mix of conditional cash transfers and target payments (China). Targeted services also varied. Most of the interventions used a wide range of targets covering inpatient, outpatient and preventive care, including a strong emphasis on services for women and children. However, one focused specifically on tuberculosis (the main outcome measure was cases detected); one on hospital revenues; and one on improved treatment of common illnesses in under-sixes. Participants were in most cases in a mix of public and faith-based facilities (dispensaries, health posts, health centres and hospitals), though districts were also involved and in one case payments were made direct to individual private practitioners.One study was considered to have low risk of bias and one a moderate risk of bias. The other seven studies had a high risk of bias. Only one study included any patient health indicators. Of the four outcome measures, two showed significant improvement for the intervention group (wasting and self reported health by parents of the under-fives), while two showed no significant difference (being C-reactive protein (CRP)-negative and not anaemic). The two more robust studies both found mixed results - gains for some indicators but no improvement for others. Almost all dimensions of potential impact remain under-studied, including intended and unintended impact on health outcomes, equity, organisational change, user payments and satisfaction, resource use and staff satisfaction. The current evidence base is too weak to draw general conclusions; more robust and also comprehensive studies are needed. Performance-based funding is not a uniform intervention, but rather a range of approaches. Its effects depend on the interaction of several variables, including the design of the intervention (e.g. who receives payments, the magnitude of the incentives, the targets and how they are measured), the amount of additional funding, other ancillary components such as technical support, and contextual factors, including the organisational context in which it is implemented.Cochrane database of systematic reviews (Online) 01/2012; 2:CD007899. DOI:10.1002/14651858.CD007899.pub2 · 5.94 Impact Factor