Delphine De Smedt

Systematic review: Effects, design choices, and context of pay-for-performance in health care

BackgroundPay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.MethodsThe systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.ResultsOne hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.ConclusionsP4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

Validity and reliability of three commonly used quality of life measures in a large European population of coronary heart disease patients

OBJECTIVE To investigate the validity and reliability of the EuroQol-5D (EQ-5D), the 12-item Short-Form Health Survey (SF-12v2), and the Hospital Anxiety and Depression Scale (HADS) in a stable coronary population. STUDY DESIGN Cross-sectional study EUROASPIRE III. SETTING Quality of life data (QoL) were available on 8745 patients hospitalized for coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI), or myocardial ischemia. They were interviewed and examined at least 6 months after their hospital admission. Reliability and validity of the 3 instruments were tested. Internal consistency, and discriminative, convergent, criterion and construct validity were assessed. RESULTS Cronbachs alpha indicated good internal consistency for all measures (0.73 to 0.87). Discriminative validity analyses confirmed significant QoL differences between known groups: age, gender, educational level. In addition, all hypothesized correlations between QoL constructs (convergent validity) and items (criterion validity) were confirmed with significant correlations. Confirmatory factor analyses indicated good construct validity for HADS and SF-12v2. On country-specific level, results were roughly similar. CONCLUSION The EQ-5D as well as the SF-12v2 and the HADS are reliable and valid instruments for use in a stable coronary population, both on aggregate European level and on country-specific level. However, our results must be generalized with caution, because EUROASPIRE III patients might not be representative for all patients with stable coronary heart disease.

Health related quality of life in coronary patients and its association with their cardiovascular risk profile: Results from the EUROASPIRE III survey

BACKGROUND Cardiovascular patients are likely to have an impaired health-related quality of life (HRQoL) due to functional and psycho-social limitations. The main objective of this study was to assess the distribution of HRQoL scores in coronary heart disease (CHD) patients across 22 European countries and to identify factors associated with the variation between patients. METHODS Data from the EUROASPIRE III survey (European Action on Secondary and Primary Prevention by Intervention to Reduce Events), on 8734 patients, were used. Patients with a diagnosis of CHD (coronary artery bypass graft (CABG), percutaneous coronary intervention (PCI), acute myocardial infarction (AMI) or myocardial ischemia) were interviewed and examined at least 6 months after their acute coronary event. Quality of life of each patient was measured using 2 standardized questionnaires: the EuroQoL-5D (EQ-5D) and the 12-item short-form health survey (SF-12v2). RESULTS HRQoL values differed significantly across countries. Lower HRQoL estimates were found in women, older patients, less educated patients, patients with myocardial infarction or ischemia as recruiting diagnosis, patients with a history of stroke and patients who suffered from a recurring CHD event. In addition, HRQoL was significantly associated with current smoking, central obesity, lack of exercise and inappropriate HbA1c control in patients with diabetes. Furthermore the number of risk factors is inversely associated with HRQoL. CONCLUSION Overall, a large heterogeneity was observed in HRQoL values between countries and patient groups. There seems to be a significant association between quality of life and patient characteristics with lifestyle risk factors as important determinants of HRQoL.

Depression, anxiety, and risk factor control in patients after hospitalization for coronary heart disease: the EUROASPIRE III Study:

Objective: To assess in coronary heart disease (CHD) patients: (1) differences in the prevalence of depression and anxiety between samples selected from 22 countries; (2) the association of depression and anxiety with age, education, diagnostic category, favourable behaviours, use of cardioprotective drugs, and reaching the secondary prevention treatment targets. Design: Cross-sectional study. Methods: The study group consisted of 8580 patients from 22 European countries examined at least 6 months after hospitalization due to CHD. Depression and anxiety were assessed using Hospital Anxiety and Depression Scale (HADS). Results: Prevalence of depression (HADS depression score ≥8) varied from 8.2% to 35.7% in men and from 10.3% to 62.5% in women. Prevalence of anxiety (HADS anxiety score ≥8) varied from 12.0% to 41.8% in men and from 21.5% to 63.7% in women. Older age, female sex, low education, and no history of invasive treatment were associated with more frequent depression and anxiety. Depression and anxiety were associated with less frequent modification of lifestyle. Depression was related with body mass index, waist circumference, fasting glucose, and more frequent self-reported diabetes but not with reaching the treatment targets for blood pressure and lipids. Conclusions: High prevalence of depression and anxiety in CHD patients, and relation with less frequent lifestyle modification, call to integrate methods of identification and minimizing unfavourable effects of depression and anxiety into the cardiac rehabilitation and prevention programmes.

Cost-effectiveness of optimizing prevention in patients with coronary heart disease: the EUROASPIRE III health economics project

AIMS The EUROASPIRE III survey indicated that the guidelines on cardiovascular disease prevention are poorly implemented in patients with established coronary heart disease (CHD). The purpose of this health economic project was to assess the potential clinical effectiveness and cost-effectiveness of optimizing cardiovascular prevention in eight EUROASPIRE III countries (Belgium, Bulgaria, Croatia, Finland, France, Italy, Poland, and the U.K.). METHODS AND RESULTS The individual risk for subsequent cardiovascular events was estimated, based on published Framingham equations. Based on the EUROASPIRE III data, the type of suboptimal prevention, if any, was identified for each individual, and the effects of optimized tailored prevention (smoking cessation, diet and exercise, better management of elevated blood pressure and/or LDL-cholesterol) were estimated. Costs of prevention and savings of avoided events were based on country-specific data. A willingness to pay threshold of €30,000/quality-adjusted life year (QALY) was used. The robustness of the results was validated by sensitivity analyses. Overall, the cost-effectiveness analyses for the eight countries showed mainly favourable results with an average incremental cost-effectiveness ratio (ICER) of €12,484 per QALY. Only in the minority of patients at the lowest risk for recurrent events, intensifying preventive therapy seems not cost-effective. Also, the single impact of intensified cholesterol control seems less cost-effective, possibly because their initial 2-year risk was already fairly low, hence the room for improvement is rather limited. CONCLUSION These results underscore the societal value of optimizing prevention in most patients with established CHD, but also highlight the need for setting priorities towards patients more at risk and the need for more studies comparing intensified prevention with usual care in these patients.

Advantages, disadvantages and feasibility of Pay-for-Quality programs in Belgium

Quality of care, as currently measured, shows unintended and avoidable variability in health care, and the existence of under use, overuse and misuse of health care, as compared to best practice. One possible part of the solution is to introduce Pay- for-Quality (P4Q) by aligning the payment system with quality of care. However, there is a lack of comprehensive conceptual guidance on P4Q use in health care. Reviews of empirical results on P4Q effects concluded that effects are mixed and highly context dependent. The level of acceptance and support by stakeholders in Belgium was unknown. Finally, practical feasibility of P4Q implementation in Belgium was unclear. This study explored the advantages, disadvantages and feasibility of P4Q implementation in Belgium. A consortium of four universities gathered data from literature, international experts and Belgian stakeholders to assess (1) what can be learned from international P4Q models on design, implementation and evaluation; and (2) what conditions are needed to apply international P4Q models in Belgium; i.e., start from scratch, or enlarge the Belgian quality-improvement programs. The focus of this study was restricted to medical care in primary and acute hospital settings.

The association between self‐reported lifestyle changes and health-related quality of life in coronary patients: the EUROASPIRE III survey

Background Patients with coronary heart disease often suffer from an impaired health-related quality of life (HRQoL). A healthier lifestyle not only extends individuals’ lengths of life but might also improve their HRQoL. The aim of this study was to explore the relation between self-reported lifestyle changes and HRQoL in European coronary patients. Methods Data on 8745 coronary patients, from 22 countries, participating in the EUROASPIRE III survey (2006–2007) were used. These patients hospitalized for coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, or myocardial ischaemia were interviewed and examined at least 6 months and no later than 3 years after their hospital admission to gather information on their HRQoL, self-reported lifestyle changes, and risk factors. Results Significantly better HRQoL scores were found in ex-smokers compared to current smokers. Patients who made an attempt to increase their physical activity level had a better HRQoL compared to those who had not made an attempt. Furthermore dietary changes were associated with HRQoL, with better outcomes in patients who tried to reduce fat and salt intake and increase fish, fruit, and vegetable intake. The intention to change behaviour was not associated with HRQoL. Conclusions Better HRQoL scores were found in those coronary patients who adopted a healthier lifestyle. The actual lifestyle changes – smoking cessation, increasing physical activity, and adopting a healthy diet – and not the intention to change are associated with better HRQoL outcomes.

The gender gap in risk factor control: Effects of age and education on the control of cardiovascular risk factors in male and female coronary patients. The EUROASPIRE IV study by the European Society of Cardiology

OBJECTIVE The aim of this study was to investigate gender related differences in the management and risk factor control of patients with coronary heart disease (CHD), taking into account their age and educational level. METHODS Analyses are based on the EUROASPIRE IV (EUROpean Action on Secondary and Primary Prevention through Intervention to Reduce Events) survey. Males and females between 18 and 80years of age, hospitalized for a first or recurrent coronary event were included in the study. RESULTS Data were available for 7998 patients of which 75.6% were males. Overall, females had a worse risk factor profile compared to males and were more likely to have 3 or more risk factors (29.5% vs. 34.9%; p<0.001) across all age groups. A significant gender by education interaction (p<0.05) and gender by age interaction effect (p<0.05) was found. Furthermore, males were more likely to have a LDL-cholesterol on target (OR=1.50[1.28-1.76]), a HbA1c on target (OR=1.33[1.07-1.64]), to be non-obese (OR=1.45[1.30-1.62]) and perform adequate physical activity (OR=1.71[1.46-2.00]). In contrast males were less likely to be non-smokers (OR=0.71[0.60-0.83]). Furthermore, males were less likely to have made a dietary change (OR=0.78[0.64-0.95]) or a smoking cessation attempt (OR=0.70[0.50-0.96]) and more likely to have received smoking cessation advice if they were smokers (OR=1.52[1.10-2.09]). CONCLUSION Whereas gender differences in CHD treatment are limited, substantial differences were found regarding target achievement. The largest gender difference was seen in less educated and elderly patients. The gender gap declined with decreasing age and higher education.

EQ-5D Versus SF-12 in Coronary Patients: Are They Interchangeable?

OBJECTIVES The aim of this study was to compare EuroQol five-dimensional (EQ-5D) utility scores and six-dimensional health state classification (SF-6D) utility scores (derived from the 12-Item Short-Form Health Survey [SF-12]) by using a large European sample of patients with stable coronary heart disease. Special attention was given to country-specific results. METHODS Data from the EURopean Action on Secondary and Primary Prevention by Intervention to Reduce Events III (EUROASPIRE III) survey were used. Patients hospitalized for a coronary artery bypass graft, percutaneous coronary intervention, acute myocardial infarction, or myocardial ischemia were interviewed and examined at least 6 months after their acute event. Health-related quality of life was assessed by using the EQ-5D and the SF-12. SF-12 outcomes were converted to SF-6D utility values, allowing comparison between both measures. RESULTS Both EQ-5D and SF-6D results were available for 7472 patients with coronary heart disease from 20 European countries. The measures were significantly correlated (intraclass correlation coefficient = 0.536); however, large differences between the two measures remain. A total of 28.8% of the patients reported a ceiling effect on the EQ-5D instrument, whereas only 4.2% of the patients reported full health based on the SF-6D. Especially the mental component does not seem to be completely captured by the EQ-5D instrument. Furthermore, patients with worse EQ-5D outcomes were more likely to have better SF-6D results, whereas patients with better EQ-5D outcomes were more likely to have worse SF-6D results. CONCLUSIONS Both measures are not interchangeable. Whereas the main disadvantage of the EQ-5D questionnaire is its ceiling effect, the potential advantages of SF-12 might disappear when converting the outcomes into an SF-6D utility, because of the small differences between patients.

Educational level and risk profile and risk control in patients with coronary heart disease.

Background The purpose of this study was to ascertain way in which conventional risk factors, readiness to modify behaviour and to comply with recommended medication, and the effect of this medication were associated with education in patients with established coronary heart disease (CHD). Methods The EUROASPIRE IV (EUROpean Action on Secondary Prevention by Intervention to Reduce Events) study was a cross-sectional survey undertaken in 24 European countries to ascertain how recommendations on secondary CHD prevention are being followed in clinical practice. Consecutive patients, men and women ≤80 years of age who had been hospitalized for an acute coronary syndrome or revascularization procedure, were identified retrospectively. Data were collected through an interview with examinations at least six months and no later than three years after hospitalization. Results A total of 7937 patients (1934 (24.37%) women) were evaluated. Patients with primary education were older, with a larger proportion of women. Control of risk factors, as defined by Joint European Societies 4 and 5 guidelines, was significantly better with higher education for current smoking (p = 0.001), overweight and obesity (p = 0.047 and p = 0.029, respectively), low physical activity (p < 0.001) and low high-density lipoprotein (HDL)-cholesterol (p = 0.011) in men, and for obesity (p = 0.005), high blood pressure (p < 0.005 and p < 0.001), low physical activity (p = 0.001), diabetes (p < 0.001) and low HDL-cholesterol (p = 0.023) in women. Patients with primary and secondary education were more often treated with diuretics and antidiabetic drugs. Better control of hypertension was achieved in patients with higher education. Conclusion Particular risk communication and control are needed in secondary CHD prevention for patients with lower educational status.