A reporting framework for describing and a typology for categorizing and analyzing the designs of health care pay for performance schemes.

BACKGROUND: Pay for Performance (P4P) has increasingly being adopted in different countries as a provider payment mechanism to improve health system performance. Evaluations of pay for performance (P4P) schemes across several countries show significant variation in effectiveness, which may be explained by differences in design. There is however no reliable framework to structure the reporting of the design or a typology to help analyse and interpret results of P4P schemes. This paper reports the development of a reporting framework and a typology of P4P schemes. METHODS: P4P design features were identified from literature and then explored using relevant theories from behavioural and economic science. These design features were then combined with the help of multidimensional tables to produce a reporting framework and a typology which was tested using 74 P4P studies. The inter-rater reliability of the typology was assessed using Fleiss' Kappa. RESULTS: A Healthcare Incentive Scheme Reporting Framework (HISReF) was developed consisting of nine design features. This was collapsed into a typology consisting of 4 items/design features. There was good inter-rater reliability on all the four items on the typology (kappa > 0.7). CONCLUSION: The HISReF provides an important first step towards establishing a common language in which intervention designers can clearly specify the content of P4P designs. Our typology may be used to aid evidence synthesis and interpretation of results of P4P schemes.

Women in medicine: historical perspectives and recent trends.

INTRODUCTION: Women now outnumber men in British medical schools. This paper charts the history of women in medicine and provides current demographic trends. SOURCES OF DATA: A historical literature review and routinely collected data from Department of Health and the Health and Social Care Information Centre. AREAS OF AGREEMENT: Clear gender differences are apparent in working practices, including greater likelihood of working part time and specializing in certain areas of medicine. AREAS OF CONTROVERSY: The increasing need to increase activity among the existing medical workforce is timely amidst a changing workforce demographic. GROWING POINTS: Workforce planners, policymakers and Royal Colleges should continue to develop interventions that may reduce disparities in career choices, as well as considering ways to increase participation and activity. AREAS TIMELY FOR DEVELOPING RESEARCH: Further research is needed to explore the cost-effectiveness of existing and future interventions in this field.

Early appraisal of China's huge and complex health-care reforms.

China's 3 year, CN¥850 billion (US$125 billion) reform plan, launched in 2009, marked the first phase towards achieving comprehensive universal health coverage by 2020. The government's undertaking of systemic reform and its affirmation of its role in financing health care together with priorities for prevention, primary care, and redistribution of finance and human resources to poor regions are positive developments. Accomplishing nearly universal insurance coverage in such a short time is commendable. However, transformation of money and insurance coverage into cost-effective services is difficult when delivery of health care is hindered by waste, inefficiencies, poor quality of services, and scarcity and maldistribution of the qualified workforce. China must reform its incentive structures for providers, improve governance of public hospitals, and institute a stronger regulatory system, but these changes have been slowed by opposition from stakeholders and lack of implementation capacity. The pace of reform should be moderated to allow service providers to develop absorptive capacity. Independent, outcome-based monitoring and evaluation by a third-party are essential for mid-course correction of the plans and to make officials and providers accountable.

Health care rationing: doing it better in public and private health care systems.

All public and private health care systems ration patient access to care. The private sector rations access to consumers who are willing and able to pay. The poor and disadvantaged have limited access to care and inadequate income protection. In public health systems, care is provided on the basis of "need," that is, the comparative cost-effectiveness of competing treatments. This results in patients being deprived of care if treatments are clinically effective but not cost-effective. Rationing health care is ubiquitous. In both types of systems physicians have discretion to deviate from these rationing principles. This has created inefficient variations in clinical practice. These are difficult to resolve because of the lack of transparency of costs and patient outcomes and perverse incentives. The failure to remove universal inefficiency in a period of economic austerity sharpens awareness of rationing. Hopes of greater efficiency are largely faith based. Competing ideologues from the left and the right continue to offer evidence for free solutions to long-established problems. Inefficiency is unethical, as it deprives potential patients of care from which they could benefit. Reducing inefficiency is essential but difficult. The universal challenge is to decide who shall live when all will die in a world of scarce resources.

Using evidence to meet population healthcare needs: A UK perspective.

For over 30 years, researchers have questioned the standard practice of planning the health workforce, with relatively little effect on policy. The authors of this commentary find it extremely refreshing and thoroughly heartening to see their Canadian colleagues making new attempts to change the way that the health workforce is planned and structured. In this commentary, the authors discuss what is meant by healthcare "needs" and the traditionally poor use of data in healthcare planning, and they support Tomblin Murphy and MacKenzie's call for proper evaluation of healthcare resources interventions.

Roundtable. Will the penny drop for clinical managers?

Increasing clinical engagement is an NHS priority. Some medical staff have been reluctant to get involved in management. Giving clinicians more data about what their interventions are costing and how this compares with their peers could help get them more involved.

Gender and variation in activity rates of hospital consultants.

OBJECTIVE: To explore whether or not gender predicts consultant activity rates. DESIGN: Using data from the Hospital Episode Statistics for England 2004/2005, we explored inpatient activity rates of male and female hospital consultants, with and without adjustment for case-mix differences. As a sensitivity analysis we also explored outpatient attendances for male and female hospital consultants. SETTING: Data from the Hospital Episode Statistics for England. MAIN OUTCOME MEASURES: Finished consultant episodes per year, with and without adjustment for case-mix differences, age and gender of consultant, contract held, hospital trust, specialty of practice, and clinical excellence awards, discretionary points and distinction awards. RESULTS: Including only consultants on full-time or maximum part-time contracts, men have significantly higher activity rates than women, after accounting for age, specialty and hospital trust. CONCLUSIONS: The reasons for the different activity rates of male and female consultants are unclear, but the implications of these results for the planning of the medical workforce are important.

Hospital Surgical Volumes and Mortality after Coronary Artery Bypass Grafting: Using International Comparisons to Determine a Safe Threshold.

OBJECTIVE: To estimate a safe minimum hospital volume for hospitals performing coronary artery bypass graft (CABG) surgery. DATA SOURCE: Hospital data on all publicly funded CABG in five European countries, 2007-2009 (106,149 patients). DESIGN: Hierarchical logistic regression models to estimate the relationship between hospital volume and mortality, allowing for case mix. Segmented regression analysis to estimate a threshold. FINDINGS: The 30-day in-hospital mortality rate was 3.0 percent overall, 5.2 percent (95 percent CI: 4.0-6.4) in low-volume hospitals, and 2.1 percent (95 percent CI: 1.8-2.3) in high-volume hospitals. There is a significant curvilinear relationship between volume and mortality, flatter above 415 cases per hospital per year. CONCLUSIONS: There is a clear relationship between hospital CABG volume and mortality in Europe, implying a "safe" threshold volume of 415 cases per year.

Nurse staffing and healthcare outcomes: a systematic review of the international research evidence.

The relationship between quality of care and the cost of the nursing workforce is of concern to policymakers. This study assesses the evidence for a relationship between the nursing workforce and patient outcomes in the acute sector through a systematic review of international research produced since 1990 involving acute hospitals and adjusting for case mix. Twenty-two large studies of variable quality were included. They strongly suggest that higher nurse staffing and richer skill mix (especially of registered nurses) are associated with improved patient outcomes, although the effect size cannot be estimated reliably. The association appears to show diminishing marginal returns.