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A hospital pay-for-performance program developed in the United States and adopted in Northwest England reduced patient mortality there, according to a report published Nov. 7 in the New England Journal of Medicine.
This result is surprising for three reasons: The American and British health care systems are quite different; to date, there has been very little evidence that any pay-for-performance programs have any effect on any patient outcomes; and this particular program has shown, at best, only "modest and short-term effects" on hospital processes of care in the United States, said Matt Sutton, Ph.D., of the Centre for Health Economics, Institute of Population Health, University of Manchester (England).
The Hospital Quality Incentive Demonstration (HQID), adopted in the United States by the Centers for Medicare and Medicaid Services in 2003, has since shown no effect on patient mortality and only brief, weakly positive effects on other patient outcomes. But a very similar program was adopted at 24 National Health Service hospitals serving a population of 6.8 million people in Northwest England in 2008.
Dr. Sutton and his colleagues assessed the program’s effect on patient mortality by comparing patient-level data from these hospitals against data from all 132 other hospitals in England for the 18 months before and the 18 months after the program was introduced. They focused on acute MI, heart failure, and pneumonia and, as a control condition, assessed six medical disorders not included in the program (acute renal failure, alcoholic liver disease, intracranial injury, paralytic ileus and intestinal obstruction without hernia, pulmonary embolism, and duodenal ulcer).
The final study sample comprised 410,384 patients with pneumonia, 201,003 with heart failure, 1,305 with acute MI, and 241,009 with the control disorders.
Overall, patient mortality was reduced by 1.3 percentage points in the hospitals participating in the pay-for-performance program, compared with the other hospitals. There was no such reduction in patient mortality from the six medical conditions not included in the program.
"This represents a substantial relative reduction rate of 6% and, during the 18-month period that we studied, equates to a reduction of 890 deaths in the total population of 70,644 patients with these conditions in the Northwest region of England," Dr. Sutton and his associates wrote (N. Engl. J. Med. 2012 [doi:10.1056/NEJMsa1114951]).
Further analyses of the data showed a strong correlation between the pay-for-performance program and decreased patient mortality. The final result was unchanged when the data were adjusted to account for baseline patient volume and mortality rates at the hospitals, and it persisted across all types of hospitals.
The finding that a nearly identical program produced different results in the two countries indicates that the details of incentive programs and the context in which they are introduced have an important bearing on their success, the researchers said.
This study was funded by the British National Health Service. No financial conflicts of interest were reported.
The Advancing Quality program was structured so that participating hospitals received reasonable bonuses – 4% of revenue for performing in the top quartile – and no penalties. Bonuses totaling more than $7.5 million were paid during the first 18 months of the program. The CEOs of the participating hospitals agreed in advance that any bonus money would be invested to further improve clinical care, said Dr. Michael J. Pistoria.
Regarding outcomes, Dr. Sutton and his colleagues found that risk-adjusted mortality for all studied conditions decreased during the study period, both in Northwestern England and the entire country, but that reductions were greater in Northwestern England. Conversely, the U.S. pay-for-performance program on which Advancing Quality was based – the Premier Hospital Quality Incentive Demonstration (HQID) – showed no change in 30-day mortality over the course of the 6-year demonstration project.
So why did Advancing Quality work? First, the program was focused geographically and included all the hospitals in its region. This localization may have allowed for greater collaboration and productivity. By contrast, HQID involved 5% of hospitals across the United States.
Second, participating hospitals received a larger bonus in Advancing Quality – 4% compared with 2% in HQID. In addition, a greater proportion of hospitals received the highest bonus – 25% vs. 10% in HQID.
Pay-for-performance programs will continue to impact the U.S. health care system, Dr. Pistoria said. Medicare is introducing pay for performance in the form of its Value-Based Purchasing Program next year. Hospitalists are an essential part of the success of any pay-for-performance program in an individual hospital or health care system. With appropriate incentives – enough to justify the cost of additional person-hours and resources to implement quality improvement measures – this study shows that pay-for-performance programs may positively impact outcomes. We need to continue to advocate nationally for constructive pay-for-performance programs and work locally to ensure their success, he said.
Dr. Pistoria is chief of Hospital Medicine at Coordinated Health, Bethlehem, Pa.
The Advancing Quality program was structured so that participating hospitals received reasonable bonuses – 4% of revenue for performing in the top quartile – and no penalties. Bonuses totaling more than $7.5 million were paid during the first 18 months of the program. The CEOs of the participating hospitals agreed in advance that any bonus money would be invested to further improve clinical care, said Dr. Michael J. Pistoria.
Regarding outcomes, Dr. Sutton and his colleagues found that risk-adjusted mortality for all studied conditions decreased during the study period, both in Northwestern England and the entire country, but that reductions were greater in Northwestern England. Conversely, the U.S. pay-for-performance program on which Advancing Quality was based – the Premier Hospital Quality Incentive Demonstration (HQID) – showed no change in 30-day mortality over the course of the 6-year demonstration project.
So why did Advancing Quality work? First, the program was focused geographically and included all the hospitals in its region. This localization may have allowed for greater collaboration and productivity. By contrast, HQID involved 5% of hospitals across the United States.
Second, participating hospitals received a larger bonus in Advancing Quality – 4% compared with 2% in HQID. In addition, a greater proportion of hospitals received the highest bonus – 25% vs. 10% in HQID.
Pay-for-performance programs will continue to impact the U.S. health care system, Dr. Pistoria said. Medicare is introducing pay for performance in the form of its Value-Based Purchasing Program next year. Hospitalists are an essential part of the success of any pay-for-performance program in an individual hospital or health care system. With appropriate incentives – enough to justify the cost of additional person-hours and resources to implement quality improvement measures – this study shows that pay-for-performance programs may positively impact outcomes. We need to continue to advocate nationally for constructive pay-for-performance programs and work locally to ensure their success, he said.
Dr. Pistoria is chief of Hospital Medicine at Coordinated Health, Bethlehem, Pa.
The Advancing Quality program was structured so that participating hospitals received reasonable bonuses – 4% of revenue for performing in the top quartile – and no penalties. Bonuses totaling more than $7.5 million were paid during the first 18 months of the program. The CEOs of the participating hospitals agreed in advance that any bonus money would be invested to further improve clinical care, said Dr. Michael J. Pistoria.
Regarding outcomes, Dr. Sutton and his colleagues found that risk-adjusted mortality for all studied conditions decreased during the study period, both in Northwestern England and the entire country, but that reductions were greater in Northwestern England. Conversely, the U.S. pay-for-performance program on which Advancing Quality was based – the Premier Hospital Quality Incentive Demonstration (HQID) – showed no change in 30-day mortality over the course of the 6-year demonstration project.
So why did Advancing Quality work? First, the program was focused geographically and included all the hospitals in its region. This localization may have allowed for greater collaboration and productivity. By contrast, HQID involved 5% of hospitals across the United States.
Second, participating hospitals received a larger bonus in Advancing Quality – 4% compared with 2% in HQID. In addition, a greater proportion of hospitals received the highest bonus – 25% vs. 10% in HQID.
Pay-for-performance programs will continue to impact the U.S. health care system, Dr. Pistoria said. Medicare is introducing pay for performance in the form of its Value-Based Purchasing Program next year. Hospitalists are an essential part of the success of any pay-for-performance program in an individual hospital or health care system. With appropriate incentives – enough to justify the cost of additional person-hours and resources to implement quality improvement measures – this study shows that pay-for-performance programs may positively impact outcomes. We need to continue to advocate nationally for constructive pay-for-performance programs and work locally to ensure their success, he said.
Dr. Pistoria is chief of Hospital Medicine at Coordinated Health, Bethlehem, Pa.
A hospital pay-for-performance program developed in the United States and adopted in Northwest England reduced patient mortality there, according to a report published Nov. 7 in the New England Journal of Medicine.
This result is surprising for three reasons: The American and British health care systems are quite different; to date, there has been very little evidence that any pay-for-performance programs have any effect on any patient outcomes; and this particular program has shown, at best, only "modest and short-term effects" on hospital processes of care in the United States, said Matt Sutton, Ph.D., of the Centre for Health Economics, Institute of Population Health, University of Manchester (England).
The Hospital Quality Incentive Demonstration (HQID), adopted in the United States by the Centers for Medicare and Medicaid Services in 2003, has since shown no effect on patient mortality and only brief, weakly positive effects on other patient outcomes. But a very similar program was adopted at 24 National Health Service hospitals serving a population of 6.8 million people in Northwest England in 2008.
Dr. Sutton and his colleagues assessed the program’s effect on patient mortality by comparing patient-level data from these hospitals against data from all 132 other hospitals in England for the 18 months before and the 18 months after the program was introduced. They focused on acute MI, heart failure, and pneumonia and, as a control condition, assessed six medical disorders not included in the program (acute renal failure, alcoholic liver disease, intracranial injury, paralytic ileus and intestinal obstruction without hernia, pulmonary embolism, and duodenal ulcer).
The final study sample comprised 410,384 patients with pneumonia, 201,003 with heart failure, 1,305 with acute MI, and 241,009 with the control disorders.
Overall, patient mortality was reduced by 1.3 percentage points in the hospitals participating in the pay-for-performance program, compared with the other hospitals. There was no such reduction in patient mortality from the six medical conditions not included in the program.
"This represents a substantial relative reduction rate of 6% and, during the 18-month period that we studied, equates to a reduction of 890 deaths in the total population of 70,644 patients with these conditions in the Northwest region of England," Dr. Sutton and his associates wrote (N. Engl. J. Med. 2012 [doi:10.1056/NEJMsa1114951]).
Further analyses of the data showed a strong correlation between the pay-for-performance program and decreased patient mortality. The final result was unchanged when the data were adjusted to account for baseline patient volume and mortality rates at the hospitals, and it persisted across all types of hospitals.
The finding that a nearly identical program produced different results in the two countries indicates that the details of incentive programs and the context in which they are introduced have an important bearing on their success, the researchers said.
This study was funded by the British National Health Service. No financial conflicts of interest were reported.
A hospital pay-for-performance program developed in the United States and adopted in Northwest England reduced patient mortality there, according to a report published Nov. 7 in the New England Journal of Medicine.
This result is surprising for three reasons: The American and British health care systems are quite different; to date, there has been very little evidence that any pay-for-performance programs have any effect on any patient outcomes; and this particular program has shown, at best, only "modest and short-term effects" on hospital processes of care in the United States, said Matt Sutton, Ph.D., of the Centre for Health Economics, Institute of Population Health, University of Manchester (England).
The Hospital Quality Incentive Demonstration (HQID), adopted in the United States by the Centers for Medicare and Medicaid Services in 2003, has since shown no effect on patient mortality and only brief, weakly positive effects on other patient outcomes. But a very similar program was adopted at 24 National Health Service hospitals serving a population of 6.8 million people in Northwest England in 2008.
Dr. Sutton and his colleagues assessed the program’s effect on patient mortality by comparing patient-level data from these hospitals against data from all 132 other hospitals in England for the 18 months before and the 18 months after the program was introduced. They focused on acute MI, heart failure, and pneumonia and, as a control condition, assessed six medical disorders not included in the program (acute renal failure, alcoholic liver disease, intracranial injury, paralytic ileus and intestinal obstruction without hernia, pulmonary embolism, and duodenal ulcer).
The final study sample comprised 410,384 patients with pneumonia, 201,003 with heart failure, 1,305 with acute MI, and 241,009 with the control disorders.
Overall, patient mortality was reduced by 1.3 percentage points in the hospitals participating in the pay-for-performance program, compared with the other hospitals. There was no such reduction in patient mortality from the six medical conditions not included in the program.
"This represents a substantial relative reduction rate of 6% and, during the 18-month period that we studied, equates to a reduction of 890 deaths in the total population of 70,644 patients with these conditions in the Northwest region of England," Dr. Sutton and his associates wrote (N. Engl. J. Med. 2012 [doi:10.1056/NEJMsa1114951]).
Further analyses of the data showed a strong correlation between the pay-for-performance program and decreased patient mortality. The final result was unchanged when the data were adjusted to account for baseline patient volume and mortality rates at the hospitals, and it persisted across all types of hospitals.
The finding that a nearly identical program produced different results in the two countries indicates that the details of incentive programs and the context in which they are introduced have an important bearing on their success, the researchers said.
This study was funded by the British National Health Service. No financial conflicts of interest were reported.
FROM THE NEW ENGLAND JOURNAL OF MEDICINE
Major Finding: Patient mortality was 1.3 percentage points lower in U.K. hospitals that adopted an American-designed pay-for-performance program than in hospitals that did not, which translates into 890 fewer patient deaths in the participating hospitals.
Data Source: Data are from a study comparing mortality rates between U.K. hospitals that adopted the American pay-for-performance program and similar hospitals that did not.
Disclosures: This study was funded by the British National Health Service. No financial conflicts of interest were reported.
