A hospital pay-for-performance program developed in the United States and adopted in Northwest England reduced patient mortality there, according to a report published Nov. 7 in the New England Journal of Medicine.
This result is surprising for three reasons: The American and British health care systems are quite different; to date, there has been very little evidence that any pay-for-performance programs have any effect on any patient outcomes; and this particular program has shown, at best, only "modest and short-term effects" on hospital processes of care in the United States, said Matt Sutton, Ph.D., of the Centre for Health Economics, Institute of Population Health, University of Manchester (England).
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An American-based pay-for-performance program ended up reducing mortality in England.
The Hospital Quality Incentive Demonstration (HQID), adopted in the United States by the Centers for Medicare and Medicaid Services in 2003, has since shown no effect on patient mortality and only brief, weakly positive effects on other patient outcomes. But a very similar program was adopted at 24 National Health Service hospitals serving a population of 6.8 million people in Northwest England in 2008.
Dr. Sutton and his colleagues assessed the program’s effect on patient mortality by comparing patient-level data from these hospitals against data from all 132 other hospitals in England for the 18 months before and the 18 months after the program was introduced. They focused on acute MI, heart failure, and pneumonia and, as a control condition, assessed six medical disorders not included in the program (acute renal failure, alcoholic liver disease, intracranial injury, paralytic ileus and intestinal obstruction without hernia, pulmonary embolism, and duodenal ulcer).
The final study sample comprised 410,384 patients with pneumonia, 201,003 with heart failure, 1,305 with acute MI, and 241,009 with the control disorders.
Matt Sutton, Ph.D.
Overall, patient mortality was reduced by 1.3 percentage points in the hospitals participating in the pay-for-performance program, compared with the other hospitals. There was no such reduction in patient mortality from the six medical conditions not included in the program.
"This represents a substantial relative reduction rate of 6% and, during the 18-month period that we studied, equates to a reduction of 890 deaths in the total population of 70,644 patients with these conditions in the Northwest region of England," Dr. Sutton and his associates wrote (N. Engl. J. Med. 2012 [doi:10.1056/NEJMsa1114951]).
Further analyses of the data showed a strong correlation between the pay-for-performance program and decreased patient mortality. The final result was unchanged when the data were adjusted to account for baseline patient volume and mortality rates at the hospitals, and it persisted across all types of hospitals.
The finding that a nearly identical program produced different results in the two countries indicates that the details of incentive programs and the context in which they are introduced have an important bearing on their success, the researchers said.
This study was funded by the British National Health Service. No financial conflicts of interest were reported.