title: Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007 Identifying predictors of high quality care in English general practice: observational study Cost-effective primary care-based strategies to improve smoking cessation: more value for money. A randomized trial of a pay-for-performance program targeting clinician referral to a state tobacco quitline. Impact of financial incentives on documented immunization rates in the inner city: results of a randomized controlled trial. The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. Paying doctors by salary: a controlled study of general practitioner behaviour in England. Effects of practitioner education, practitioner payment and reimbursement of patients’ drug costs on smoking cessation in primary care: a cluster randomised trial
abstract: PURPOSE Major primary care reforms have been introduced in recent years in the United Kingdom , including financial incentives to improve clinical quality and provide more rapid access to care . Little is known about the impact of these changes on patient experience . We examine patient reports of quality of care between 2003 and 2007 , including r and om sample s of patients on practice lists and patients with long-term conditions . METHODS We conducted a cross-sectional design study of family practice s in which  question naires were sent to serial sample s of patients in 42 representative general practice s in Engl and . Question naires sent to sample s of patients with chronic disease ( asthma , angina , and diabetes ) and r and om sample s of adult patients ( excluding patients who reported any long-term condition ) in 2003 , 2005 , and 2007 addressed issues of access , communication , continuity of care , coordination , nursing care , and overall satisfaction . RESULTS There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication , nursing care , coordination , and overall satisfaction . Some aspects of access improved significantly for patients with chronic disease , but not for the r and om sample s of patients . Patients in both sample s reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care . Most scores were significantly higher for the chronic illness sample s than for the r and om sample s of patients in 2003 , even after adjusting for age . CONCLUSIONS There was a modest improvement in access to care for patients with chronic illness , but all patients now find it somewhat harder to obtain continuity of care . This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care . The possibility of unintended effects needs to be considered when introducing pay for performance schemes Abstract Objectives : To assess variation in the quality of care in general practice and identify factors associated with high quality care . Design : Observational study . Setting : Stratified r and om sample of 60 general practice s in six areas of Engl and . Outcome measures : Quality of management of chronic disease ( angina , asthma in adults , and type 2 diabetes ) and preventive care ( rates of uptake for immunisation and cervical smear ) , access to care , continuity of care , and interpersonal care  ( general practice assessment survey ) . Multiple logistic regression with multilevel modelling was used to relate each of the outcome variables to practice size , routine booking interval for consultations , socioeconomic deprivation , and team climate . Results : Quality of clinical care varied substantially , and access to care , continuity of care , and interpersonal care varied moderately . Scores for asthma , diabetes , and angina were 67 % , 21 % , and 17 % higher in practice s with 10 minute booking intervals for consultations compared with practice s with five minute booking intervals . Diabetes care was better in larger practice s and in practice s where staff reported better team climate . Access to care was better in small practice s. Preventive care was worse in practice s located in socioeconomically deprived areas . Scores for satisfaction , continuity of care , and access to care were higher in practice s where staff reported better team climate . Conclusions : Longer consultation times are essential for providing high quality clinical care . Good teamworking is a key part of providing high quality care across a range of areas and may need specific support if quality of care is to be improved . Additional support is needed to provide preventive care to deprived population s. No single type of practice has a monopoly on high quality care : different types of practice may have different strengths . What is already known on this topic Quality of care varies in virtually all aspects of medicine that have been studied Most studies look at quality of care from a single perspective or for a single condition What this study adds Quality of care varies for both clinical care and assessment s by patients of access and interpersonal care Practice s with longer booking intervals provide better management of chronic disease ; preventive care is less good in practice s in deprived areas No single type of practice has a monopoly on high quality care — small practice s provide better access but poorer diabetes care Good team climate reported by staff is associated with a range of aspects of high quality BACKGROUND Evidence from cost-effective smoking cessation programs is scarce . This study determined the cost-effectiveness of 3 smoking cessation strategies as provided by general practitioners ( GPs ) in Germany . METHODS In a cluster-r and omized smoking cessation trial , rates and intervention costs for 577 smoking patients of 82 GPs were followed up for 12 months . Three smoking cessation treatments were tested : ( 1 ) GP training plus GP remuneration for each abstinent patient , ( 2 ) GP training plus cost-free nicotine replacement medication and /or bupropion hydrochloride for the patient , and ( 3 ) a combination of both strategies .  Smoking abstinence at 12 months was the primary outcome used to calculate incremental cost-effectiveness ratios and net monetary benefits . RESULTS Intervention 1 was not effective compared with treatment as usual ( TAU ) . Interventions 2 and 3 each proved to be cost-effective compared separately with TAU . When applying a 95 % level of certainty of cost-effectiveness against TAU , euro 9.80 or euro 6.96 , respectively , had to be paid for each additional 1 % of patients abstinent at 12 months ( maximum willingness to pay ) . That means that in intervention 2 , euro 92.12 per patient in the program must be invested to gain 1 additional quitter ( as opposed to euro 39.10 paid per patient during the trial ) . In intervention 2 , the cost was euro 82.82 , as opposed to euro 50.04 . Neither of these 2 cost-effective treatments proved to be superior to the other . The cost-effectiveness of both treatments was stable against TAU in sensitivity analyses . ( The exchange rate from October 1 , 2003 , was used ; euro1 = $ 1.17 . ) CONCLUSIONS Both treatments have a high potential to reduce smoking-related morbidity at a low cost . It is highly recommended that they be implemented as a routine service offered by GPs because in many countries , health insurance plans currently do not fund nicotine replacement therapy BACKGROUND Tobacco quitlines offer clinicians a means to connect their patients with evidence -based treatments . Innovative methods are needed to increase clinician referral . METHODS This is a clinic r and omized trial that compared  usual care ( n = 25 clinics ) vs a pay-for-performance program ( intervention )  offering $ 5000 for 50 quitline referrals ( n = 24 clinics ) .  Pay-for-performance clinics also received monthly up date s on their referral numbers . Patients were eligible for referral if they visited a participating clinic , were 18 years or older , currently smoked cigarettes , and intended to quit within the next 30 days . The primary outcome was the clinic 's rate of quitline referral ( ie , number of referrals vs number of smokers seen in clinic ) . RESULTS Pay-for-performance clinics referred 11.4 % of smokers ( 95 % confidence interval [ CI ] , 8.0%-14.9 % ; total referrals , 1483 ) compared with 4.2 % ( 95 % CI , 1.5%-6.9 % ; total referrals , 441 ) for usual care clinics ( P = .001 ) . Rates of referral were similar in intervention vs usual care clinics ( n = 9 ) with a history of being very engaged with quality improvement activities ( 14.1 % vs 15.1 % , respectively ; P = .85 ) . Rates were substantially higher in intervention vs usual care clinics with a history of being engaged ( n = 22 clinics ; 10.1 % vs 3.0 % ; P = .001 ) or less engaged ( n = 18 clinics ; 10.1 % vs 1.1 % ; P = .02 ) with quality improvement . The rate of patient contact after referral was 60.2 % ( 95 % CI , 49.7%-70.7 % ) . Among those contacted , 49.4 % ( 95 % CI , 42.8%-55.9 % ) enrolled , representing 27.0 % ( 95 % CI , 21.3%-32.8 % ) of all referrals . The marginal cost per additional quitline enrollee was $ 300 . CONCLUSION A pay-for-performance program increases referral to tobacco quitline services , particularly among clinics with a history of less engagement in quality improvement activities OBJECTIVE This study determined the effect of 2 financial incentives --- bonus and enhanced fee-for-service --- on documented immunization rates during a second period of observation . METHODS Incentives were given to 57 r and omly selected inner-city physicians 4 times at 4-month intervals based on the performance of 50 r and omly selected children . Coverage from linked records from all sources was determined for a sub sample of children within physician offices . RESULTS Up-to- date coverage rates documented in the charts increased significantly for children in the bonus group ( 49.7 % to 55.6 % ; P < .05 ) and the enhanced fee-for-service group ( 50.8 % to 58.2 % ; P < .01 ) compared with the control group . The number of immunizations given by these physicians did not change significantly , although the number of immunizations given by others and documented by physicians in the bonus group did increase ( P < .05 ) . Up-to- date coverage for all groups increased from 20 to 40 percentage points when immunizations from physician charts were combined with other sources . CONCLUSIONS Both financial incentives produced a significant increase in coverage levels . Increases were primarily due to better documentation not to better immunizing practice s. The financial incentives appeared to provide motivation to physicians but were not sufficient to overcome entrenched behavior patterns . However , true immunization coverage was substantially higher than that documented in the charts BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition . Patients visiting registry clinics accessed counseling programs statistically significantly more often ( P < 0.001 ) than patients receiving care in the control condition . Other endpoints did not statistically significantly differ between the experimental conditions . CONCLUSIONS The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practice s and patient behaviors was mixed . Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment The study aim was to evaluate the impact of the experimental introduction of salaried contracts  in Engl and on  general practitioner ( GP ) behaviour  and the quality of care . A controlled before- and -after design was implemented involving ten practice s of st and ard contract GPs , paid largely by capitation and fee-for-service , and ten salaried GP practice s. Diaries and routinely available data were used to assess GP workload , and patient assessment s of the quality of care were obtained by postal question naire . GPs in salaried practice s spent less time on practice administration but more working out-of-hours and in direct patient care , allowing more patients to be seen . Total list sizes were smaller in salaried compared with st and ard contract practice s , but lists per GP were higher because of staffing policies . Salaried GPs tended to provide shorter consultations compared with st and ard contract GPs , prescribe in fewer consultations , but referral rates were similar . Quality was rated as higher for seven out of thirteen aspects of care examined in salaried practice s and two in st and ard contract practice s. However , none of these differences were statistically significant . To conclude , salaried contracts did not adversely affect GP productivity and had little impact on other aspects of GP behaviour or the quality of care provided Objective : To evaluate new strategies to enhance the promotion of smoking cessation in general practice . Design : Cluster r and omised trial , 2 × 2 factorial design . Setting : 82 medical practice s in Germany , including 94 general practitioners . Participants : 577 patients who smoked at least 10 cigarettes per day ( irrespective of their intention to stop smoking ) and were aged 36–75 years . Interventions : Provision of a 2-h physician group training in smoking cessation methods and direct physician payments for every participant not smoking 12 months after recruitment ( TI , training+incentive ) ; provision of the same training and direct participant reimbursements for pharmacy costs associated with nicotine replacement therapy or bupropion treatment ( TM , training+medication ) . Main outcome measure : Self-reported smoking abstinence obtained at 12 months follow-up and vali date d by serum cotinine . Results : In intention-to-treat analysis , smoking abstinence at 12 months follow-up was 3 % ( 2/74 ) , 3 % ( 5/144 ) , 12 % ( 17/140 ) and 15 % ( 32/219 ) in the usual care , and interventions TI , TM and TI+TM , respectively . Applying a mixed logistic regression model , no effect was identified for intervention TI ( odds ratio ( OR ) 1.26 , 95 % confidence interval ( CI ) 0.65 to 2.43 ) , but intervention TM strongly increased the odds of cessation ( OR 4.77 , 95 % CI 2.03 to 11.22 ) . Conclusion : Providing cost-free effective drugs to patients along with improved training opportunities for general practitioners could be an effective measure to achieve successful promotion of smoking cessation in general practice
target: Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures , but not all .
  The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing .
  However , there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care .
background: BACKGROUND The use of blended payment schemes in primary care , including the use of financial incentives to directly reward ' performance ' and ' quality ' is increasing in a number of countries .
  There are many examples in the US , and the Quality and Outcomes Framework ( QoF ) for general practitioners ( GPs ) in the UK is an example of a major system-wide reform .
  Despite the popularity of these schemes , there is currently little rigorous evidence of their success in improving the quality of primary health care , or of whether such an approach is cost-effective relative to other ways to improve the quality of care .
  OBJECTIVES The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians ( PCPs ) and to identify : i ) the different types of financial incentives that have improved quality ; ii ) the characteristics of patient population s for whom quality of care has been improved by financial incentives ; and iii ) the characteristics of PCPs who have responded to financial incentives .