Pay-for-performance programs are designed to improve patients’ quality of care and outcomes. Although short-term improvements are related to financial incentives, the long-term effects are uncertain. The Advancing Quality program, an initiative based on the Premier Hospital Quality Incentive Demonstration, significantly reduced 30-day in-hospital mortality during the first 18 months. The present analysis was undertaken to evaluate the policy’s effects for an additional 24 months.
Starting in 2008, all 24 hospitals providing emergency care in the northwest region of England participated in the Advancing Quality program. Measures of quality of care related to clinical conditions focused on acute myocardial infarction (AMI), heart failure, and pneumonia, conditions for which patients are hospitalized on an emergency basis. In the first year, hospitals with appropriate scores on quality metrics linked to incentives received bonus payments. For the next 6 months, financial incentives were awarded on the basis of additional criteria. No penalties were assessed, nor was reimbursement withheld for poor performance. After the first 18-month period, instead of bonuses, a fixed proportion of the hospital’s expected income was withheld and paid out only if required performance thresholds were reached. Data were obtained for all patients admitted as emergency cases along with equivalent data for patients admitted as emergencies for diagnoses unrelated to the incentives program. Data were divided into the 18 months before the program’s introduction, the first 18 months of its operation (“short-term”), and months 19 to 42 (“long-term”). The final sample included 390,652 patients with AMI, 338,921 with heart failure, 761,954 with pneumonia, and 333,991 with conditions unrelated to incentives. In-hospital mortality during the first 30 days after admission was determined. Statistical analyses were based on between-region difference-in-differences that compared changes in mortality over time between the northwest region and the rest of England for conditions that were or were not linked to financial incentives.
The mean performance improved in the first 18 months and the next 24 months, especially for heart failure and pneumonia. Rates of improvement slowed over time and some reached plateaus. The between-region difference-in-differences analysis confirmed that the initiative had a significant overall effect on mortality in the short term (−0.9 percentage points; 95% confidence interval [CI], −1.3 to −0.4), with a significant reduction in mortality among patients with pneumonia (−1.5 percentage points; 95% CI, −2.3 to −0.7) and nonsignificant reductions among patients with AMI (−0.1 percentage points; 95% CI, −0.9 to 0.6) and heart failure (−0.2 percentage points; 95% CI, −1.1 to 0.7). Triple-difference analysis showed an overall short-term effect of −1.5 percentage points (95% CI, −2.6 to −0.5), with a significant reduction in mortality for pneumonia (−2.2 percentage points; 95% CI, −3.4 to −1.0) and nonsignificant reductions for AMI and heart failure. Between the short- and long-term periods, the risk-adjusted mortality for conditions linked to incentives fell by 1.6 and 2.3 percentage points in the northwest region and the rest of England, respectively. The greater mortality reduction in the rest of England reflected the reduction in mortality among patients with pneumonia (1.1 percentage points; 95% CI, 0.4 to 1.8). Triple-difference analyses showed a larger reduction in mortality (1.9 percentage points; 95% CI, 1.0 to 2.8) in areas outside the northwest region than in the northwest region between the short- and long-term periods. The change in mortality from before the initiative to the end of the long-term period was not significant in either the between-region difference-in-difference analysis (−0.1 percentage points; 95% CI, −0.6 to 0.3) or the triple-difference analysis (0.4 percentage points; 95% CI, −0.6 to 1.3).
Although short-term improvements in the measures for conditions related to incentives were sustained in the long-term, incentives had no long-term effect on 30-day mortality. Possible explanations are that the effects of paying for performance were temporal, early effects on outcomes were easier to achieve, the nature of the incentive was changed from bonuses to withholding some reimbursement, and spillover effects reached into other geographic and clinical areas.