Pay for performance of Estonian family doctors and impact of different practice- and patient-related characteristics on a good outcome: A quantitative assessment.

BACKGROUND AND OBJECTIVE: Several practice- and patient-related characteristics are reported to have an influence on a good quality outcome. Estonia started the pay-for-performance (P4P) system for family doctors (FDs) in 2006. Every year the number of FDs participating in P4P has increased, but only half of the FDs achieved good outcome. The aim of this study was to find out which practice- and patient-related characteristics could have an impact on a good outcome. MATERIALS AND METHODS: The study was conducted using the database from the Estonian Health Insurance Fund. All working FDs were divided into two groups (with "good" and "poor" outcomes) according their achievements in P4P. We chose characteristics which described structure (practice list size, number of doctors, composition of FDs list: age, number of chronically ill patients) during the observation period 2006-2012. RESULTS: During the observation period 2006-2012, the number of FDs with a good outcome in P4P increased from 6% (2006) to 53% (2012). The high number of FDs in primary care teams, longer experience of participation in P4P and the smaller number of patients on FDs' lists all have an impact on a good outcome. The number of chronically ill patients in FDs lists has no significant effect on an outcome, but P4P increases the number of disease-diagnosed patients. CONCLUSIONS: Different practice and patient-related characteristics have an impact on a good outcome. As workload increases, smaller lists of FDs patients or increased staff levels are needed in order to maintain a good outcome.

The influence of performance-based payment on childhood immunisation coverage.

BACKGROUND: Pay-for-performance, also called the quality system (QS) in Estonia, was implemented in 2006 and one indicator for achievement is the childhood immunisation coverage rate. The WHO vaccination coverage in Europe for diphtheria, tetanus and pertussis, and measles in children aged around one year old should meet or exceed 90 per cent. METHODS: The study was conducted using a database from the Estonian Health Insurance Fund. The study compared childhood immunisation coverage rates of all Estonian family physicians in two groups, joined and not joined to the quality system during the observation period 2006-2012. Immunisation coverage was calculated as the percentage of persons in the target age group who received a vaccine dose by a given age. The target level of immunisations in Estonia is set at 90 per cent and higher. RESULTS: Immunisation coverage rates of family doctors (FD) in Estonia showed significant differences between two groups of doctors: joined to the quality system and not joined. Doctors joined to the quality system met the 90 per cent vaccination criterion more frequently compared to doctors not joined to the quality system. Doctors not joined to the quality system were below the 90 per cent vaccination criterion in all vaccinations listed in the Estonian State Immunisation Schedule. CONCLUSION: Pay-for-performance as a financial incentive encourages higher levels of childhood immunisations.

The effect of continuous monitoring of hypertension and type 2 diabetes mellitus on the number of visits to medical specialists and hospitalization: a retrospective study.

OBJECTIVE: The aim of the study was to determine whether the implementation of the quality system (QS) in primary healthcare made the care of chronically ill patients in family practice more consistent and reduced the load in specialized medical care. MATERIAL AND METHODS: A quantitative retrospective cohort study using the database of the Estonian Health Insurance Fund was provided. Patients with diagnosed essential hypertension (HYP) and/or type 2 diabetes mellitus (DM2) formed the study group. If the family physician met the criteria for the monitoring of patients with DM2 and HYP set in the QS, the result was defined as positive. The number of disease-specific hospitalizations, the length of hospital stay, and the number of visits to family physicians and medical specialists due to HYP or DM2 in 2005-2008 were evaluated. RESULTS: Chronically ill patients (DM2 and HYP) in the lists of family physicians with a positive QS result were 1.26 times more likely (95% CI, 1.25-1.28) to be continuously monitored than those in the lists of family physicians with a negative QS result. The 2 coexisting chronic diseases (DM2 and HYP) increased the chance of being continuously monitored and increased the number of visits. The chance of being monitored by a medical specialist alone was reduced if the family physician participated in the QS (OR, 0.66; 95% CI, 0.64-0.69) and had a rural practice (OR, 0.53; 95% CI, 0.51-0.55) and if the patient was a woman and older and had a diagnosis of HYP alone. The participation of family physicians in the QS reduced the hospitalization risk (OR, 0.9; 95% CI, 0.88-0.94) as well as the number of hospitalizations for the patients with HYP (OR, 0.93; 95% CI, 0.87-0.99). CONCLUSIONS: The implementation of the QS in primary healthcare reduces the load in specialized medical care. A more detailed analysis of the effect of the QS on the workload and the organization of family practice as well as on the patients' morbidity and satisfaction could be done in the near future.