Kim Sutherland

Lessons from evaluations of purchaser pay-for-performance programs: A review of the evidence

There has been a growing interest in the use of financial incentives to encourage improvements in the quality of health care. Several articles have reviewed past studies of the impact of specific incentive arrangements, but these studies addressed small-scale experiments, making their findings arguably of limited relevance to current improvement efforts. In this article, the authors review evaluations of more recent pay-for-performance initiatives instituted by health plans or by provider organizations in cooperation with health plans. Findings show improvement in selected quality measures in most of these initiatives, but the contribution of financial incentives to that improvement is not clear; the incentives typically were implemented in conjunction with other quality improvement efforts, or there was not a convincing comparison group. However, the literature relating to purchaser pay-for-performance initiatives does underscore several important issues that deserve attention going forward that relate to the design and implementation of pay-for-performance initiatives.

Does certification improve medical standards

The English chief medical officer recently recommended certification of doctors to improve professional regulation. Could a system similar to that used in the United States, which is associated with better care, be the way forward?

Quality of care in the NHS of England

Any progress? Any lessons? The United Kingdoms National Health Service (NHS) was established in post-war Britain (1948) as a social contract between the government and the people, based on explicit values of universality and equity. It is an icon worldwide, both as a social insurance system and as a nationalized health delivery service. The NHS has been remarkably frugal; over four decades the UK has been among the lowest health care spenders of Organisation for Economic Co-operation and Development countries, in absolute terms and as a proportion of gross domestic product (GDP).1 The relatively low expenditure, once feted as a virtue achieved through efficiency, has increasingly been seen as under-investment that has compromised the systems ability to meet the populations health care needs. In 1997-1998, government policy documents acknowledged the magnitude of problems, pledging to place “quality at the heart of the NHS.”2,3 In November 2003, we published an evaluation of the resulting 10-year quality agenda at its midpoint.4 We characterized the quality agenda as being the “most ambitious, comprehensive, systemic and intentionally funded effort to create predictable and sustainable capacity for improving the quality of a nations health care system.” Two research questions were fundamental to our evaluation: whether the policy initiatives for building predictable systemic capacity for quality improvement were coherent and cogent, and what evidence of impact existed to date. #### National Health Service

Influences on clinical practice: the case of glue ear.

A case study of clinical practice in children with glue ear is presented. The case is part of a larger project, funded by the North Thames Research and Development Programme, that sought to explore the part played by clinicians in the implementation of research and development into practice in two areas: adult asthma and glue ear in children. What is striking about this case is the differences found in every area of the analysis. That is, diversity was found in views about diagnosis and treatment of glue ear; the organisation of related services; and in the reported practice of our interviewees, both between particular groupings of clinical staff and within these groupings. The challenge inherent in the case is to go beyond describing the complexity and differences that were found, and look for patterns in the accounts of practice and tease out why such patterns may occur.

The quest for quality in the English NHS: strategic and policy issues.

in other areas of involvement. People taking part in consultations need to be engaged as partners, their expertise acknowledged, objectives need to be explicit, information needs to be shared and communication before, during and after the process needs to be thought through. None of this is difficult, but in the end only if we truly intend to involve people and change what we do as a result will patients and the public have reason to take part. Harry Cayton Director for Patients and the Public Department of Health Richmond House, 79 Whitehall London SW1A 2NS References

Recast the debate about preventable readmissions.

Soong and Bell’s editorial1 questions whether preventable readmissions can be objectively defined and whether such measures represent a valid patient-centred indicator of quality. Our experience of developing and publicly reporting outcomes in New South Wales (NSW), Australia, suggests that the debate about readmissions should be recast away from ascertaining whether or not a particular hospital readmission was preventable, towards assessing all hospital-level variation in readmission patterns. We agree with the assertion that all-cause readmission rates are less specific and include normally occurring events related to disease progression. They are subject to differences in patient case mix and so are strengthened considerably by the use of clearly defined patient cohorts and appropriate adjustment for patient-level factors. Earlier this year, our organisation published a report using a 30-day risk-standardised readmission ratio (RSRR) indicator for five clinical conditions (acute myocardial infarction, ischaemic stroke, congestive heart failure, pneumonia and hip fracture surgery) and a 60-day RSRR for two surgical procedures (total hip replacement and total knee replacement). The report drew on linked data from hospital records and death registries covering 12 years (July 2000–June 2012) and highlighted outlier hospitals in the state.2 In developing our approach to measuring variation in readmissions, we conducted a wide-ranging review of current practices internationally. Our method was informed by …

Is the weekend effect really ubiquitous? A retrospective clinical cohort analyses of 30-day mortality by day of week and time of day using linked population data from New South Wales, Australia

Objective To examine the associations between day of week and time of admission and 30-day mortality for six clinical conditions: ischaemic and haemorrhagic stroke, acute myocardial infarction, pneumonia, chronic obstructive pulmonary disease and congestive heart failure. Design Retrospective population-based cohort analyses. Hospitalisation records were linked to emergency department and deaths data. Random-effect logistic regression models were used, adjusting for casemix and taking into account clustering within hospitals. Setting All hospitals in New South Wales, Australia, from July 2009 to June 2012. Participants Patients admitted to hospital with a primary diagnosis for one of the six clinical conditions examined. Outcome measures Adjusted ORs for all-cause mortality within 30 days of admission, by day of week and time of day. Results A total of 148 722 patients were included in the study, with 17 721 deaths within 30 days of admission. Day of week of admission was not associated with significantly higher likelihood of death for five of the six conditions after adjusting for casemix. There was significant variation in mortality for chronic obstructive pulmonary disease by day of week; however, this was not consistent with a strict weekend effect (Thursday: OR 1.29, 95% CI 1.12 to 1.48; Friday: OR 1.25, 95% CI 1.08 to 1.44; Saturday: OR 1.18, 95% CI 1.02 to 1.37; Sunday OR 1.05, 95% CI 0.90 to 1.22; compared with Monday). There was evidence for a night effect for patients admitted for stroke (ischaemic: OR 1.30, 95% CI 1.17 to 1.45; haemorrhagic: OR 1.58, 95% CI 1.40 to 1.78). Conclusions Mortality outcomes for these conditions, adjusted for casemix, do not vary in accordance with the weekend effect hypothesis. Our findings support a growing body of evidence that questions the ubiquity of the weekend effect.

Disparities in experiences and outcomes of hospital care between Aboriginal and non-Aboriginal patients in New South Wales

17 Aof poor health outcomes among Indigenous people. In Australia, while gaps in health status between Aboriginal and non-Aboriginal people are well documented, until now little was known about the extent of differences in Aboriginal patients’ experiences of care and self-reported outcomes following hospitalisation. In New South Wales, the Bureau of Health Information (BHI) has recently released a report based on survey responses from 2682 Aboriginal and 22 997 non-Aboriginal patients. The report highlights differences between Aboriginal and non-Aboriginal patients’ experiences, particularly in terms of interpersonal aspects of care, coordination and integration, and patient-reported outcomes. Many of the findings have implications for hospital doctors.