The multiple aims of pay-for-performance and the risk of unintended consequences

Friebel, Rocco; Steventon, Adam

doi:10.1136/bmjqs-2016-005392

Cited by 12 publications

(14 citation statements)

References 23 publications

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“…The validity of emergency readmission rates as a measure for quality of care had been questioned before, mainly due to their sensitivity to changes in patient case-mix, random variation and the poor correlation with other indicators of hospital quality. 54 55 While the limitations of readmission rates as a metric might be a particularly relevant concern for direct provider comparisons, such as in the case of imposing financial penalties for hospitals with high readmission rates and associated fears about unintended consequences, 56 in this study we aimed to assess overall trends in readmission rates for all trusts and across 10 years. This approach helped to deal with random variation and presented longitudinal changes in readmission rates in the English NHS.…”

Section: Discussionmentioning

confidence: 99%

“…While it is common practice in England to adjust for socioeconomic status, however, it is possible that the higher emergency readmission rates observed among patients living in more deprived areas is in part due to lower quality healthcare—a possibility that has been extensively discussed. 56 Another concern relates to omitting variable bias in the risk-adjustment for emergency readmission rates, such as by the lack of information on clinical severity (ie, acuity determined through laboratory test results) that was found to be highly predictive of a readmission. 57 Our study may therefore dilute the true predicted likelihood (ie, upward or downward depending on the severity of disease) of a patient having to return to hospital.…”

Section: Discussionmentioning

confidence: 99%

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National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016

et al. 2018

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ObjectiveTo assess trends in 30-day emergency readmission rates across England over one decade.DesignRetrospective study design.Setting150 non-specialist hospital trusts in England.Participants23 069 134 patients above 18 years of age who were readmitted following an initial admission (n=62 584 297) between April 2006 and February 2016.Primary and secondary outcomesWe examined emergency admissions that occurred within 30 days of discharge from hospital (‘emergency readmissions’) as a measure of healthcare quality. Presented are overall readmission rates, and disaggregated by the nature of the indexed admission, including whether it was elective or emergency, and by clinical health condition recorded. All rates were risk-adjusted for patient age, gender, ethnicity, socioeconomic status, comorbidities and length of stay.ResultsThe average risk-adjusted, 30-day readmission rate increased from 6.56% in 2006/2007 to 6.76% (P<0.01) in 2012/2013, followed by a small decrease to 6.64% (P<0.01) in 2015/2016. Emergency readmissions for patients discharged following elective procedures decreased by 0.13% (P<0.05), whereas those following emergency admission increased by 1.27% (P<0.001). Readmission rates for hip or knee replacements decreased (−1.29%; P<0.001); for acute myocardial infarction (−0.04%; P<0.49), stroke (+0.62%; P<0.05), chronic obstructive pulmonary disease (+0.41%; P<0.05) and heart failure (+0.15%; P<0.05) remained stable; and for pneumonia (+2.72%; P<0.001), diabetes (+7.09%; P<0.001), cholecystectomy (+1.86%; P<0.001) and hysterectomy (+2.54%; P<0.001) increased.ConclusionsOverall, emergency readmission rates in England remained relatively stable across the observation period, with trends of slight increases contained post 2012/2013. However, there were large variations in trends across clinical areas, with some experiencing marked increases in readmission rates. This highlights the need to better understand variations in outcomes across clinical subgroups to allow for targeted interventions that will ensure highest standards of care provided for all patients.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016

et al. 2018

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“…Pay-for-performance can be used within the wider healthcare system to improve quality of care, such as in NHS primary care through the financial incentive to report and perform clinical assessments, and also in secondary care through targeted hospital performance measures like readmission rates 31–33. As with target setting, unintended consequences and perverse outcomes need to be anticipated and closely monitored, presenting big implementation challenges for LMICs 34.…”

Section: Examples Of Strengthening Healthcare Quality In the English mentioning

confidence: 99%

Achieving high-quality universal health coverage: a perspective from the National Health Service in England

et al. 2018

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Governments across low-income and middle-income countries have pledged to achieve universal health coverage by 2030, which comes at a time where healthcare systems are subjected to multiple and persistent pressures, such as poor access to care services and insufficient medical supplies. While the political willingness to provide universal health coverage is a step into the right direction, the benefits of it will depend on the quality of healthcare services provided. In this analysis paper, we ask whether there are any lessons that could be learnt from the English National Health Service, a healthcare system that has been providing comprehensive and high-quality universal health coverage for over 70 years. The key areas identified relate to the development of a coherent strategy to improve quality, to boost public health as a measure to reduce disease burden, to adopt evidence-based priority setting methods that ensure efficient spending of financial resources, to introduce an independent way of inspecting and regulating providers, and to allow for task-shifting, specifically in regions where staff retention is low.

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“…The precision of rankings, that is their reliability, therefore has to be carefully assessed when developing these kinds of approaches to reporting the quality of care. This is particularly the case when payment is linked to performance,9 or when ongoing quality improvement efforts might be undermined by measurement errors.…”

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confidence: 99%

Composite measures of healthcare quality: sensible in theory, problematic in practice

Friebel

Steventon

2018

BMJ Qual Saf

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The multiple aims of pay-for-performance and the risk of unintended consequences

Cited by 12 publications

References 23 publications

National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016

National trends in emergency readmission rates: a longitudinal analysis of administrative data for England between 2006 and 2016

Achieving high-quality universal health coverage: a perspective from the National Health Service in England

Composite measures of healthcare quality: sensible in theory, problematic in practice

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