1. Effectiveness of a multiprofessional P4P system in clinical outcomes and organizational alignment A longitudinal study in a primary care organization Tino Martí, Antoni Peris and Alba Brugues

2. Context

3. P4P Worldwide implemented USA to Europe Process to Outcome Primary care Quality improvement Inconclusive evidence

4. ProfessionalsOrganization Contract $ 12%-8% P4P 1.Fix salary 2.Night shifts 3.Career scalator

5. ProfessionalsOrganization Contract $ P4P scheme Team Clinical (40%), Individual Clinical (30%) and Excellence (30%) goals Aligned with system goals P4P scheme Team Clinical (40%), Individual Clinical (30%) and Excellence (30%) goals Aligned with system goals

6. Goals

7. 1.To assess the effectiveness of P4P scheme on quality improvement 2.To analyse the post-goal effect (inertia effect) or what happens once a goal is retrieved. Goals

8. Methods

9. Time span: P4P scheme has been applied in CASAP since 2006. We have selected the last 4 years (2008-2011) for a better consistency of quality indicators. Thus, 2008 is the basal year to measure improvement. 2008200920102011

10. Health professionals: Although all primary care professionals are involved in the P4P scheme, we have selected family doctors and adult-care nurses for this study. Data availability (permanence in the company) during the study period (2008-2011) has been a necessary condition to allow consistent comparisons. Therefore, a group of 11 family doctors and 11 nurses were selected. Methods 11

11. Quality indicators: EQA is a standard set of quality indicators used across Catalonia to assess quality performance in Primary Care Teams. EQA covers major chronic diseases such as DM, heart failure, COPD and cancer. It also includes prevention activities such as blood pressure control, smoking cessation, flu vaccination. A total of 25 quality indicators were monitored during the study period. Methods

12. Preventive activities Primary Secondary Quaternary

13. Results

14. Improvement 08-11: 25.3% Yearly average: 5,8% 22 3 Results

15. Doctors Nurses Percentage represents goal’s weight in the P4P set.

16. Results

18. Doctors Nurses Behaviour of Goal and Non-goal years for goal indicators p < 0.001 p > 0.05

19. PRE 3.1% GOAL 11.9% POST -0.5% Doctors Results

20. PRE 3.7% GOAL 14.6% POST 4.8% Nurses Results

21. PRE GOAL POST MORE INERTIA MORE SENSITIVENESS Doctors Nurses Results

22. Are weights worth?

23. Conclusions 1.P4P works for quality improvement at a 12- 14% improvement rate 2.Nurses are more sensitive to incentives than doctors. 3.After-incentive effect is neutral for doctors and positive for nurses. 4.Doctors are sensitive to weights

24. Thank you