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Full Title: Strategies To Support Quality-based Purchasing: A Review of the Evidence
View or download Summary/Report
Context: Although evidence of quality problems has been available for years, purchaser interest
in quality-based purchasing (QBP) is a recent phenomenon. Furthermore, employers who
support quality-based purchasing have expressed uncertainty about how to measure quality,
especially outcomes, and what incentives to offer to stimulate performance improvement.
Objectives: The objectives of this project were to develop a conceptual model of how incentives
influence provider behavior, to summarize what is known from randomized controlled trials
about the effectiveness of different QBP strategies, to describe ongoing QBP research, and to
perform simulations to determine whether outcomes reports are too influenced by chance events
to be used in QBP.
Data Sources: We used online databases (e.g., MEDLINE®) and bibliographies of retrieved
articles for the literature search and government and foundation listings to identify ongoing
research. For the simulations, we used data from public reports of myocardial infarction
outcomes in California.
Study Selection: For the literature review, we sought studies in which providers had been
randomized to an incentive group or a control group. We included only projects involving
interventions purchasers could plausibly adopt (payment strategies or public reporting of
performance). Studies of interventions that were beyond purchaser purview (e.g., implementing
clinical guidelines) were excluded.
Data Extraction: We extracted information about the type of incentive used and the clinical and
economic context in which it was applied.
Data Synthesis: We evaluated 5,045 publications. Nine were randomized controlled trials, and
many of these did not report key characteristics of the incentive or the context in which
incentives were applied. Incentives used included additional fee-for-service, quality bonuses, and
public release of performance data. The results were mixed: among the 11 performance
indicators evaluated, 7 showed a statistically significant response to QBP strategies while 4 did
not. We also found 18 ongoing research projects, none randomized. These will yield data about
the approaches to QBP currently in use, provider awareness of and concerns about QBP, and
some preliminary estimates of the potential impact of QBP.
Regarding assessments of outcomes reports, we found that, under reasonable assumptions and
applications, outcomes reports generate meaningful information about provider performance.
Providers with good (expected) performance are unlikely to be labeled as poor quality in any
given period, and very unlikely to be mislabeled more than once in a 3-year period, even if one
allowed approximately 10% of hospitals to be labeled poor performers annually. In addition,
hospitals with superior performance were quite likely to be identified as such at least once in 3
Conclusions: Little is known about the impact of QBP on clinical performance. However, it
does appear that basing incentives on measurements of outcomes is feasible without undue risk
to the reputation or financial status of good hospitals. Ongoing research will only address some
of the gaps in our knowledge about QBP, suggesting that much more additional research is
needed. This should include comparisons of alternative QBP approaches and qualitative
assessment of the barriers to and facilitators of quality improvement in response to QBP
Strategies To Support Quality-based Purchasing: A Review of the Evidence
Evidence-based Practice Center: Stanford-University of California, San Francisco
Topic Nominator: Employer Health Care Alliance Cooperative (The Alliance)
Current as of July 2004