Improve Physician Performance Research Articles

Physician Perceptions of Performance Feedback and Impact on Personal Well-Being: A Qualitative Exploration of Patient Satisfaction Feedback in Neurology.

To understand neurologists' experiences and perspectives on patient satisfaction feedback and its impact on personal well-being and behavior. From May to June 2021, the researchers conducted 19 semistructured interviews with neurologists from a large academic medical center. Clinical Performance Feedback Intervention Theory informed a combined inductive and deductive thematic analysis of the qualitative data, which focused on perceptions of current feedback practices, its impact on physician behavior, and recommendations for improvement. Participants tended to be female (n = 12/19, 63.2%), aged 30-39 (n = 8/19, 42.1%), white (n = 9/19, 47.4%), and were 10+ years into clinical practice (n = 18/19, 94.7%). Physicians were receptive to feedback overall, but perceptions varied by feedback type. Physicians preferred informal feedback (delivered unprompted directly by patients), given its tendency toward actionability. They disliked formal feedback (derived from anonymous surveys) due to low actionability, bias and validity issues, lack of contextual considerations, delivery through public reports, and links to financial incentives. Nearly all physicians reported formal feedback programs had the potential to negatively affect well-being and were not beneficial to their practice; a few reported adjusting their clinical practice to improve patient satisfaction performance. Five recommendations to improve patient satisfaction feedback programs emerged: Align on feedback intent, acknowledge survey limitations during program administration, increase actionability of feedback through specificity and control, support direct patient-physician feedback and problem resolution, and support empathetic integration of feedback. Understanding physician perceptions of current approaches to patient satisfaction feedback offers the opportunity to shape subsequent collection and distribution methods to improve physician performance and optimize professional fulfillment.

Artificial intelligence perspective in the future of endocrine diseases.

In recent years, artificial intelligence (AI) shows promising results in the diagnosis, prediction, and management of diseases. The move from handwritten medical notes to electronic health records and a huge number of digital data commenced in the era of big data in medicine. AI can improve physician performance and help better clinical decision making which is called augmented intelligence. The methods applied in the research of AI and endocrinology include machine learning, artificial neural networks, and natural language processing. Current research in AI technology is making major efforts to improve decision support systems for patient use. One of the best-known applications of AI in endocrinology was seen in diabetes management, which includes prediction, diagnosis of diabetes complications (measuring microalbuminuria, retinopathy), and glycemic control. AI-related technologies are being found to assist in the diagnosis of other endocrine diseases such as thyroid cancer and osteoporosis. This review attempts to provide insight for the development of prospective for AI with a focus on endocrinology.

Impact on hospital-wide antipsychotic prescribing practices through physician peer comparison letters.

Peer comparison is a behavioral strategy that provides feedback to individuals on how they compare with others. It is used to improve health care quality, reduce inappropriate prescribing, and improve physician performance. There is very little data on peer comparison and the impact on system-wide prescribing practices, particularly with antipsychotics. To that end, the Maryland statewide pharmacy and therapeutics committee reviews hospital-level antipsychotic data for 5 facilities on a quarterly basis, including high doses and polypharmacy. One facility, Springfield Hospital Center, consistently stood out in 2016 as having higher rates of high doses of haloperidol, olanzapine, and quetiapine as well as patients receiving 3 or more antipsychotics. The pharmacist began to send out individual letters to the psychiatrists detailing their prescribing habits in these areas compared with other psychiatrists and the other state facilities. Over the course of 4 years, the percentage of patients on high doses of 3 antipsychotics substantially decreased. The percentage of patients on polypharmacy in the facility decreased, but not at the same rate as the other hospitals, leaving the facility even higher than the state average at the end of the 4-year period. Pharmacist-initiated physician peer comparison letters were associated with a considerable decrease in the prevalence of high-dose olanzapine, haloperidol, and quetiapine but did not appear to impact antipsychotic polypharmacy. This type of communication may be beneficial for stimulating system-wide changes in prescribing practices for high doses of antipsychotics; however, more individualized interventions are likely needed to reduce antipsychotic polypharmacy.

A Pragmatic Randomized Controlled Trial of an Endoscopist Audit and Feedback Report for Colonoscopy.

Variation in endoscopist performance contributes to poor-quality colonoscopy. Audit and feedback (A/F) can be used to improve physician performance, particularly among lower performing physicians. In this large pragmatic randomized controlled trial, we compared A/F to improve endoscopists' colonoscopy performance to usual practice. Endoscopists practicing in Ontario, Canada, in 2014 were randomly assigned in October 2015 (index date) to receive (intervention group, n = 417) or not receive (control group, n = 416) an A/F report generated centrally using health administrative data. Colonoscopy performance was measured in both groups over two 12-month periods: prereport and postreport (relative to the index date). The primary outcome was polypectomy rate (PR). Secondary outcomes were cecal intubation rate, bowel preparation, and premature repeat after normal colonoscopy. A post hoc analysis used adenoma detection rate as the outcome. Outcomes were compared between groups for all endoscopists and for lower performing endoscopists using Poisson regression analyses under a difference-in-difference framework. Among all endoscopists, PR did not significantly improve from prereport to postreport periods for those receiving the intervention (relative rate [RR], intervention vs control: 1.07 vs 1.05, P = 0.09). Among lower performing endoscopists, PR improved significantly (RR, intervention vs control 1.34 vs 1.11, P = 0.02) in the intervention group compared with controls. In this subgroup, adenoma detection rate also improved but not significantly (RR, intervention vs control 1.12 vs 1.04, P = 0.12). There was no significant improvement in secondary outcomes between the intervention and control groups. A/F reports for colonoscopy improve performance in lower performing endoscopists (ClinicalTrials.gov: NCT02595775).

Regional needs assessment for emergency physician audit and feedback.

Audit and feedback is widely used to improve physician performance. Many data metrics are being provided to physicians, yet most of these are driven by the regulatory environment. We sought to conduct a needs assessment of audit and feedback metrics that were most useful to clinicians within our health care region. We conducted a Web-based survey of five clinical practice sites in our region and asked that physicians rank 49 clinical practice metrics. In addition, we assessed their readiness for audit and feedback and their preferences for data confidentiality. We collected data on duration of training, gender, and site of practice (academic v. community) allowing for comparison between groups. A total of 104 emergency medicine physicians participated in the survey (52.3% response rate). There was a significant readiness for participation in audit and feedback activities. Top ranked metrics were emergency department return rates and colleague's assessment of collegiality and quality of care, which were common across all sites. Small yet significant differences were noted between genders and academic v. community practitioners. This study represents the first regional analysis of physician preferences for audit and feedback activities and implementation. It demonstrates that physicians are interested in audit and feedback activities and provides a roadmap for the development of a regional audit and feedback structure. It will also be used as a guiding document for regional change management.

The Impact of Artificial Intelligence on Quality and Safety

As exponential expansion of computing capacity converges with unsustainable health care spending, a hopeful opportunity has emerged: the use of artificial intelligence to enhance health care quality and safety. These computer-based algorithms can perform the intricate and extremely complex mathematical operations of classification or regression on immense amounts of data to detect intricate and potentially previously unknown patterns in that data, with the end result of creating predictive models that can be utilized in clinical practice. Such models are designed to distinguish relevant from irrelevant data regarding a particular patient; choose appropriate perioperative care, intervention or surgery; predict cost of care and reimbursement; and predict future outcomes on a variety of anchored measures. If and when one is brought to fruition, an artificial intelligence platform could serve as the first legitimate clinical decision-making tool in spine care, delivering on the value equation while serving as a source for improving physician performance and promoting appropriate, efficient care in this era of financial uncertainty in health care.

Real-time Feedback in Pay-for-Performance: Does More Information Lead to Improvement?

Pay-for-performance (P4P) has been used expansively to improve quality of care delivered by physicians. However, to what extent P4P works through the provision of information versus financial incentives is poorly understood. To determine whether an increase in information feedback without changes to financial incentives resulted in improved physician performance within an existing P4P program. Implementation of a new registry enabling real-time feedback to physicians on quality measure performance. Observational, predictive piecewise model at the physician-measure level to examine whether registry introduction associated with performance changes. We used detailed physician quality measure data 3years prior to registry implementation (2010-2012) and 2years after implementation (2014-2015). We also linked physician-level data including age, gender, and board certification; group-level data including registry click rates; and patient panel data including chronic conditions. Four hundred thirty-four physicians continuously affiliated with Advocate from 2010 to 2015. Physician performance on ten quality metrics. We found no consistent pattern of improvement associated with the availability of real-time information across ten measures. Relative to predicted performance without the registry, average performance increased for two measures (childhood immunization status-rotavirus (p < 0.001) and diabetes care-medical attention for nephropathy (p = 0.024)) and decreased for three measures (childhood immunization status-influenza (p < 0.001) and diabetes care-HbA1c testing (p < 0.001) and poor HbA1c control (p < 0.001)). Results were consistent for subgroup analysis on those most able to improve, i.e., physicians in the bottom tertile of performance prior to registry introduction. Physicians who improved most were in groups that accessed the registry more than those who improved least (8.0 vs 10.0 times per week, p = 0.010). More frequent provision of information, provided in real-time, was insufficient to improve physician performance in an existing P4P program with high baseline performance. Results suggest that electronic registries may not themselves drive performance improvement. Future work should consider testing information feedback enhancements with financial incentives.

Erratum: This Article Corrects: "Behind the Curtain: The Nurse's Voice in Assessment of Residents in the Emergency Department".

[This corrects the article on p. 23 in vol. 20, PMID: 30643597.].

Designing a medication timeline for patients and physicians.

Most electronic health records display historical medication information only in a data table or clinician notes. We designed a medication timeline visualization intended to improve ease of use, speed, and accuracy in the ambulatory care of chronic disease. We identified information needs for understanding a patient medication history, then applied human factors and interaction design principles to support that process. After research and analysis of existing medication lists and timelines to guide initial requirements, we hosted design workshops with multidisciplinary stakeholders to expand on our initial concepts. Subsequent core team meetings used an iterative user-centered design approach to refine our prototype. Finally, a small pilot evaluation of the design was conducted with practicing physicians. We propose an open-source online prototype that incorporates user feedback from initial design workshops, and broad multidisciplinary audience feedback. We describe the applicable design principles associated with each of the prototype's key features. A pilot evaluation of the design showed improved physician performance in 5 common medication-related tasks, compared to tabular presentation of the same information. There is industry interest in developing medication timelines based on the example prototype concepts. An open, standards-based technology platform could enable developers to create a medication timeline that could be deployable across any compatible health IT application. The design goal was to improve physician understanding of a patient's complex medication history, using a medication timeline visualization. Such a design could reduce temporal and cognitive load on physicians for improved and safer care.

Behind the Curtain: The Nurse's Voice in Assessment of Residents in the Emergency Department.

IntroductionFeedback provides valuable input for improving physician performance. Conventionally, feedback is obtained from attending physicians; however, residents work in close contact with other members of the care team, especially nurses. Nurses may have more opportunity to directly observe trainees. In addition, they may value different behaviors and provide unique feedback. The objective of this study was to examine the nurse’s perspective of resident performance in the emergency department.MethodsThis was a retrospective, mixed-methods study of nursing assessments of residents using a five-point scale from 1 (unsatisfactory) to 5 (outstanding) and providing comments. Analysis included descriptive statistics of the quantitative assessments and content analysis of the nursing comments by a group of attendings, residents, and nurses.ResultsNurses assessed residents as above expectation or outstanding, especially for the categories of “How would you rate this resident’s attitude?” (65%) and “Is this resident a team player?” (64%). Content analysis of the comments yielded nine themes including being kind, communication with nurses, being a team player, work ethic and efficiency, and respect for other team members. Of the comments made, 50% provided positive feedback, and the majority of comments (80%) were determined to be actionable.ConclusionOur data indicate that nurses provide feedback on residents’ kindness, efficiency and communication. These two aspects of interacting in the healthcare setting may not be highlighted in conventional, attending provider feedback, yet they are clearly noted by the nurse’s voice.

The Impact of a Location-Sensing Electronic Health Record on Clinician Efficiency and Accuracy: A Pilot Simulation Study.

Through the Health Information Technology for Economic and Clinical Health Act of 2009, the federal government invested $26 billion in electronic health records (EHRs) to improve physician performance and patient safety; however, these systems have not met expectations. One of the cited issues with EHRs is the human-computer interaction, as exhibited by the excessive number of interactions with the interface, which reduces clinician efficiency. In contrast, real-time location systems (RTLS)-technologies that can track the location of people and objects-have been shown to increase clinician efficiency. RTLS can improve patient flow in part through the optimization of patient verification activities. However, the data collected by RTLS have not been effectively applied to optimize interaction with EHR systems. We conducted a pilot study with the intention of improving the human-computer interaction of EHR systems by incorporating a RTLS. The aim of this study is to determine the impact of RTLS on process metrics (i.e., provider time, number of rooms searched to find a patient, and the number of interactions with the computer interface), and the outcome metric of patient identification accuracy METHODS: A pilot study was conducted in a simulated emergency department using a locally developed camera-based RTLS-equipped EHR that detected the proximity of subjects to simulated patients and displayed patient information when subjects entered the exam rooms. Ten volunteers participated in 10 patient encounters with the RTLS activated (RTLS-A) and then deactivated (RTLS-D). Each volunteer was monitored and actions recorded by trained observers. We sought a 50% improvement in time to locate patients, number of rooms searched to locate patients, and the number of mouse clicks necessary to perform those tasks. The time required to locate patients (RTLS-A = 11.9 ± 2.0 seconds vs. RTLS-D = 36.0 ± 5.7 seconds, p < 0.001), rooms searched to find patient (RTLS-A = 1.0 ± 1.06 vs. RTLS-D = 3.8 ± 0.5, p < 0.001), and number of clicks to access patient data (RTLS-A = 1.0 ± 0.06 vs. RTLS-D = 4.1 ± 0.13, p < 0.001) were significantly reduced with RTLS-A relative to RTLS-D. There was no significant difference between RTLS-A and RTLS-D for patient identification accuracy. This pilot demonstrated in simulation that an EHR equipped with real-time location services improved performance in locating patients and reduced error compared with an EHR without RTLS. Furthermore, RTLS decreased the number of mouse clicks required to access information. This study suggests EHRs equipped with real-time location services that automates patient location and other repetitive tasks may improve physician efficiency, and ultimately, patient safety.

Diagnostic yield of gastrointestinal endoscopy in North West Region Cameroon and trends in diagnosis over time.

IntroductionGastrointestinal endoscopy is an important modality for diagnosis and treatment of gastrointestinal disease, but there are limited data regarding the diagnostic yield of endoscopy in Cameroon and changes in the prevalence of endoscopic findings over time. Our aims were to describe the diagnostic utility of esophagogastroduodenoscopy (EGD) and colonoscopy, the impact of periodic on-site mentorship on cecal intubation rate and changes in the prevalence of common upper gastrointestinal findings when compared to a similar report from our region published in 1990.MethodsRetrospective review of all EGD and colonoscopy procedures performed during 2015 at a regional referral hospital in North West Region, Cameroon, with comparison to EGD findings reported by Dent and colleagues in 1990. During the year 3 endoscopists provided periodic colonoscopy mentorship.ResultsAmong 1,371 EGDs, abnormalities were found in 59.7% and therapeutic interventions (most commonly esophageal stricture dilation or band ligation of varices) were performed in 137 (10%). When compared to 25 years previously, peptic ulcer disease was less common and esophagitis was more common (p < 0.0001; p < 0.0001). The prevalence of malignancy (2.2%) was similar. Among 380 colonoscopies diagnostic findings were seen in 60.5%, including colorectal malignancies in 5.8%. Cecal intubation rate improved from 32% to 89% during the one-year study period.ConclusionEGD and colonoscopy have a diagnostic yield of about 60% in symptomatic patients in North West Region, Cameroon. When compared to 1990 peptic ulcer disease was less common and esophagitis was more common. Periodic on-site mentorship was associated with improved physician performance of colonoscopy.

Real-time endoscopic image orientation correction system using an accelerometer and gyrosensor.

The discrepancy between spatial orientations of an endoscopic image and a physician’s working environment can make it difficult to interpret endoscopic images. In this study, we developed and evaluated a device that corrects the endoscopic image orientation using an accelerometer and gyrosensor. The acceleration of gravity and angular velocity were retrieved from the accelerometer and gyrosensor attached to the handle of the endoscope. The rotational angle of the endoscope handle was calculated using a Kalman filter with transmission delay compensation. Technical evaluation of the orientation correction system was performed using a camera by comparing the optical rotational angle from the captured image with the rotational angle calculated from the sensor outputs. For the clinical utility test, fifteen anesthesiology residents performed a video endoscopic examination of an airway model with and without using the orientation correction system. The participants reported numbers written on papers placed at the left main, right main, and right upper bronchi of the airway model. The correctness and the total time it took participants to report the numbers were recorded. During the technical evaluation, errors in the calculated rotational angle were less than 5 degrees. In the clinical utility test, there was a significant time reduction when using the orientation correction system compared with not using the system (median, 52 vs. 76 seconds; P = .012). In this study, we developed a real-time endoscopic image orientation correction system, which significantly improved physician performance during a video endoscopic exam.

Interdisciplinary Obstetric Simulation for Common Obstetric Emergencies

BACKGROUND: Duty hour restrictions limit trainee exposure to obstetric emergencies. Additionally, nursing turnover creates an area of need for increased education for preparation for these emergencies. Simulation has been used to improve physician performance, communication, and medical documentation; however, whether these benefits extend to all providers is understudied. METHODS: We conducted a quasi-randomized prospective educational trial targeted toward L&amp;D nurses with less than 2 years' experience and junior obstetric residents. Participants were exposed to a pretest examining their knowledge (multiple choice, yes/no, free text responses) and comfort level (measured utilizing the Likert scale) with three common obstetric emergencies: shoulder dystocia, emergency cesarean delivery, and eclampsia. Participants underwent a simulation of one of the scenarios, watched their video-taped performance, participated in a debrief and educational session, and then repeated the simulation. Participants were administered a posttest following the simulation. RESULTS: Eighteen L&amp;D nurses and 17 obstetric residents participated. Examination of the pre- and posttest results revealed improvements in the comfort level with shoulder dystocia maneuvers (P=.0178), communication during a shoulder dystocia (P=.0339), medical management of an eclamptic seizure (P=.0190), and knowledge of how to appropriately administer magnesium to an eclamptic patient without an IV (P=.0047). DISCUSSION: Interdisciplinary collaboration through the use of obstetric simulation can be utilized to improve knowledge and comfort necessary for the management of obstetric emergencies for both obstetric residents and L&amp;D nurses.

The Role of Electronic Feedback Loops in the Continuous Quality Improvement of Thyroid Nodule and Thyroid Cancer Care

Physicians strive to achieve and society demands that the delivery of health care undergo continuous quality improvement. In 2001, the Institute of Medicine's report, Crossing the Quality Chasm: A New Health System for the 21st Century, underscored the importance of improving the standards of care of our health care system and emphasized the goal of delivering personalized care for each patient ( 1. Insitute of Medicine Committee on Quality of Health Care in America Crossing the quality chasm: a new health system for the 21st century. National Academies Press, Washington, DC2001 Google Scholar ). In response to this report, the National Learning Consortium (NLC) was established as a “virtual and evolving body of knowledge and resources designed to support health care providers and IT professionals collaborating to achieving this end” ( 2. Continuous quality improvement (CQI) strategies to optimize your practice. National Learning Consortium; 2013. Google Scholar ). The NLC's strategy focused on “continuous quality improvement” (CQI), which emphasized the need to improve patient-specific quality of care through enhanced efficiency of data sharing between involved physicians as well as via electronic feedback loops as a mechanism to encourage continual self-assessment ( 2. Continuous quality improvement (CQI) strategies to optimize your practice. National Learning Consortium; 2013. Google Scholar ). Vital to this initiative was the adoption and use of electronic health record (EHR) systems, designed to efficiently record health data and facilitate the sharing of this health-related information between individual clinicians and their patients ( 2. Continuous quality improvement (CQI) strategies to optimize your practice. National Learning Consortium; 2013. Google Scholar ). While the concept of CQI can be broadly applied to health care, this model can also be employed to improve the quality of care of specific disease processes. Not only does enhancing quality of care lead to an improvement in patient outcomes, it also enhances patient safety and facilitates cost-effective utilization of precious health care resources. By establishing a culture as well as a mechanism for self-assessment, the development of feedback loops of patient information is vital to improve physician performance through continuous self-monitored modification and fine-tuning of diagnostic and therapeutic interventions. Ultimately, the goal of this initiative is to eliminate the current clinical silos of specialties that serve as barriers to clinical information sharing.

Identification of educational gaps among oncologists who treat patients with pancreatic cancer.

431 Background: Pancreatic ductal adenocarcinoma (PDA) is the fourth-most common cause of cancer-related death in the United States, with only 7.7% of patients surviving beyond 5 years. Given the poor outcomes associated with PDA, it is imperative that patients with PDA receive optimal care. Continuing medical education (CME) offers an effective means to improve physician performance, and CME programs are most effective when they address areas of greatest need. This study was conducted to identify and quantify the educational gaps in PDA management that can potentially be addressed with CME. Methods: A case-vignette survey instrument was developed to assess physicians’ practices related to PDA. Case vignettes are a validated means of assessing healthcare provider practice patterns. The survey instrument included three patient cases: 1) A 50 year-old man with resectable PDA; 2) a 75 year-old man with locally advanced, unresectable PDA; and 3) a 55 year-old woman with metastatic PDA. Each case was followed by a series of questions designed to assess medical decision-making, physician/patient communication, and barriers to optimal practice. Results: Survey responses were collected from 150 US oncologists in July 2016 (19% at academic centers). Several key educational gaps were identified. For Case 1, 44% of oncologists did not select an evidence-based adjuvant chemotherapy regimen from a list of options. For Case 2, in which the patient had developed metastases and neuropathy after first-line therapy, 57% of respondents did not select an evidence-based second-line option, and 35% selected a regimen with oxaliplatin. For Case 3, only 18% of oncologists recommended an initial diagnostic evaluation that included a biopsy, chest imaging, and liver function tests. Finally, for all 3 cases, little emphasis was placed on enrolling patients in clinical trials. Conclusions: This study identified appreciable discrepancies between respondents’ recommendations and standard evidence-based guidelines for treating all stages of PDA. Well-designed CME programs may help bridge the educational gaps among practicing oncologists and ultimately improve adherence to national guidelines.

Do Emergency Medicine Residents Prefer Resident-initiated or Attending-initiated Feedback?

Real-time feedback is crucial to improving physician performance. Emerging theory suggests that learner-initiated feedback may be more effective in changing performance than attending-initiated feedback, but little is known about how residents perceive resident- versus attending-initiated feedback. The primary aim was to determine whether residents' satisfaction varied by learner-versus attending-initiated feedback encounters. We hypothesized that residents would be more satisfied with resident-initiated feedback. This was a multicenter study of five emergency medicine residency programs. We developed a milestones-based, real-time feedback intervention that provided behavioral anchors for ED subcompetencies and prompted a feedback discussion. The intervention was implemented at all sites for a 3-month period from March to November 2014. Residents were asked to initiate one card per shift; attendings were also invited to initiate encounters and, in either instance, asked to provide one specific suggestion for improvement. Residents confidentially rated their satisfaction with feedback on a 10-point scale. Reported satisfaction was categorized as "very satisfied" (score of 10) versus "less than very satisfied" (score<10). Logistic regression was used to assess the difference in satisfaction between resident- versus attending-initiated feedback, and random effects were used to account for the clustering of repeated ratings within resident and by site. A total of 785 cards was collected from five sites. Participation varied by site (range= 21-487 cards per site). Of the 587 cards with both feedback initiator and satisfaction data, 67% (396/587) were resident-initiated, and median satisfaction score was 10 (range= 4-10). There was no difference in the odds of being "very satisfied" by resident- vesus attending-initiated encounters (odds ratio= 1.08, 95% confidence interval= 0.41 to 2.83). Our results suggest that residents are likely to be as satisfied with self-initiated feedback as attending-initiated feedback. Further research is needed to determine whether resident-initiated feedback is more likely to be incorporated into practice and result in objective performance improvements.

ПРИМЕНЕНИЕ КОНСТРУКТОРА ТЕКСТОВЫХ ГРАФ ДЛЯ ИНФОРМАТИЗАЦИИ ИНСТРУМЕНТАЛЬНЫХ ОБСЛЕДОВАНИЙ

To work effectively with text data of instrumental examinations the original menu designer proposed. For the analysis of textual data of instrumental examinations, a mechanism of automatic alignment of nominations offered. Using the proposed approach can significantly reduce the time and improve physician performance and analysis of large data sets.

Abstract #235: T2D Management: Can Case-Based CME Improve Physician Performance?

Abstract #235: T2D Management: Can Case-Based CME Improve Physician Performance?

Evaluating a Pay-for-Performance Program for Medicaid Children in an Accountable Care Organization

Pay for performance (P4P) is a mechanism by which purchasers of health care offer greater financial rewards to physicians for improving processes or outcomes of care. To our knowledge, P4P has not been studied within the context of a pediatric accountable care organization (ACO). To determine whether P4P promotes pediatric performance improvement in primary care physicians. This retrospective cohort study was conducted from January 1, 2010, to December 31, 2013. A differences-in-differences design was used to test whether P4P improved physician performance in an ACO serving Medicaid children. Data were obtained from 2966 physicians and 323,812 patients. Three groups of physicians were identified: (1) community physicians who received the P4P incentives, (2) nonincentivized community physicians, and (3) nonincentivized physicians employed at a hospital. Pay for performance. Healthcare Effectiveness Data Information Set measure rates for preventive care, chronic care, and acute care primary care services. We examined 21 quality measures, 14 of which were subject to P4P incentives. There were 203 incentivized physicians, 2590 nonincentivized physicians, and 173 nonincentivized hospital physicians. Among them, the incentivized community physicians had greater improvements in performance than the nonincentivized community physicians on 2 of 2 well visits (largest difference was for adolescent well care: odds ratio, 1.05; 99.88% CI, 1.02-1.08), 3 of 10 immunization-incentivized measures (largest difference was for inactivated polio vaccine: odds ratio, 1.14; 99.88% CI, 1.07-1.21), and 2 nonincentivized measures (largest difference was for rotavirus: odds ratio, 1.11; 99.88% CI, 1.04-1.18). The employed physician group at the hospital had greater improvements in performance than the incentivized community physicians on 8 of 14 incentivized measures and 1 of 7 nonincentivized measures (largest difference was for hepatitis A vaccine: odds ratio, 0.34; 99.88% CI, 0.31-0.37). Pay for performance resulted in modest changes in physician performance in a pediatric ACO, but other interventions at the disposal of the ACO may have been even more effective. Further research is required to find methods to enhance quality improvements across large distributed pediatric health systems.