激励计费代码对基层医疗机构心力衰竭管理的影响:一项基于人群的研究

Shijie Zhou, Douglas S. Lee, Francis Nguyen, Harsukh Benipal, Richard Perez, Peter C. Austin, Husam Abdel-Qadir, Jacob A. Udell, Catherine Demers
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摘要

背景:为了支持家庭医生(FPs)管理心力衰竭(HF)患者,加拿大安大略省卫生部于2008年实施了Q050计费代码,这是对基于指南的HF护理的绩效付费(P4P)激励措施。我们研究了该激励措施是否与护理流程措施(尤其是高血压药物处方)的变化有关:我们确定了安大略省所有年龄在 65 岁以上的高血压患者,这些患者在 2008 年至 2021 年期间由申请 Q050 激励的家庭医生管理。我们统计了为这些患者申请 Q050 账单代码前后三个月内处方肾素-血管紧张素系统抑制剂 (RASi)、β-受体阻滞剂 (BB)、矿物质皮质激素受体拮抗剂 (MRA) 和利尿剂的患者人数。在适用的情况下,我们按照是否为加拿大心血管协会 (CCS) 推荐的指导性药物对每一类药物进行了分类。结果:研究共纳入了 39425 名高血压患者。中位年龄为 80(IQR 73-85)岁;49% 为女性。半数患者在确诊心房颤动前的六个月内接受过内科医生或心脏病专家的评估。与 Q050 前相比,激励后 RASi 处方从 42.5% 增加到 45.8%,BB 从 51.9% 增加到 54.4%,MRA 从 9.2% 增加到 11.7%,利尿剂从 63.2% 增加到 65.7%(p<0.05)。未服用任何高血压药物的患者从 27.5% 降至 24.9%(p<0.001)。新诊断为高血压并及时接受家庭医生随访的患者服用高血压药物的比例增幅最大,但临床增幅不大。结论:据我们所知,这是首次对初级保健高血压管理中与绩效薪酬项目相关的护理流程措施进行评估。Q050 激励措施导致心房颤动药物处方量的增长微乎其微;改变病情药物的使用不足。要了解绩效工资计划为何对医生的处方行为没有影响,还需要进一步的研究。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
The effect of an incentive billing code on heart failure management in primary care: a population-based study
Background: To support family physicians (FPs) in managing patients with heart failure (HF), the Ministry of Health in Ontario, Canada, implemented the Q050 billing code in 2008, a pay-for-performance (P4P) incentive for guideline-based HF care. We studied whether the incentive was associated with any change in process-of-care measure, particularly the prescriptions of HF medications. Methods: We identified all patients with HF in Ontario of age>65, who were managed by FPs claiming the Q050 incentive between 2008 and 2021. We counted the number of patients who were prescribed renin-angiotensin system inhibitors (RASi), beta-blockers (BB), mineralocorticoid receptor antagonists (MRA), and diuretics three months before and after the Q050 billing code was claimed for these patients. Where applicable, we classified the agents within each class by whether they are guideline-directed as recommended by the Canadian Cardiovascular Society (CCS). Results: We included 39,425 HF patients in the study. The median age was 80 (IQR 73-85) years; 49% were female. Half were assessed by an internist or cardiologist during the six months before their HF diagnosis. Compared to pre-Q050, there was an increase in RASi prescriptions from 42.5% to 45.8%, BB from 51.9% to 54.4%, MRA from 9.2% to 11.7%, and diuretics from 63.2% to 65.7% after the incentive (p<0.05). There was a decrease in those not on any HF medications from 27.5% to 24.9% (p<0.001). Those with newly diagnosed HF and prompt follow-up with FPs experienced the largest but clinically modest increase in HF medications. Conclusions: To our knowledge, this is the first evaluation of process-of-care measures related to a pay-for-performance program in primary care HF management. The Q050 incentive led to a minimal increase in the prescription of HF medications; there is underutilization of disease-modifying agents. Further research is needed to understand why pay-for-performance programs had no effect on physician prescribing behaviours.
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