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International audience; ObjectiveMost studies showed no or little effect of pay-for-performance (P4P) programs on different outcomes. In France, the P4P program IFAQ was generalized to all acute care hospitals in 2016. A pilot study was launched in 2012 to design, implement and assess this program. This article aims to assess the immediate impact of the 2012–14 pilot study.Design and settingFrom nine process quality indicators (QIs), an aggregated score was constructed as the weighted average, taking into account both achievement and improvement. Among 426 eligible volunteer hospitals, 222 were selected to participate. Eligibility depended on documentation of QIs and results of hospital accreditation. Hospitals with scores above the median received a financial reward based on their ranking and budget. Several characteristics known to have an influence on P4P results (patient age, socioeconomic status, hospital activity, casemix and location) were used to adjust the models.InterventionTo assess the effect of the program, comparison between the 185 eligible selected hospitals and the 192 eligible not selected volunteers were done using the difference-in-differences method.ResultsWhereas all hospitals improved from 2012 to 2014, the difference-in-differences effect was positive but not significant both in the crude (2.89, P = 0.29) and adjusted models (4.07, P = 0.12).ConclusionThese results could be explained by several reasons: low level of financial incentives, unattainable goals, too short study period. However, the lack of impact for the first year should not undermine the implementation of other P4P programs. Indeed, the pilot study helped to improve the final model used for generalization.

International audience; PURPOSE:Referrals to the Emergency Department can be distressing to patients with advanced cancer and may be a non-optimizing health care service. We aimed to describe the appropriateness and potential avoidability of Emergency Department referrals in a tertiary cancer care center where only physician referrals are allowed.METHODS:We prospectively reviewed the electronic medical charts of patients consecutively checked into the Emergency Department in August 2015. The appropriateness of referrals was assessed using a nationally validated classification (Classification Clinique des Malades aux Urgences) and local criteria. Potentially avoidable referrals were assessed using international classifications (Institute for Healthcare Improvement State Action on Avoidable Rehospitalizations diagnostic tool according to Kosecoff's criteria) and local criteria.RESULTS:We included 500 referrals related to 423 patients. The mean age was 59 years, and 74% of cancers were progressive. The referrals were appropriate in 61% of cases. They were deemed potentially avoidable "with a high likelihood" in 33.4% (CI95% [29.3-37.5]) of cases, potentially avoidable "with a moderate likelihood" in 14.4% (CI95% [11.3-17.5]) of cases, and "non-avoidable" in 52% (CI95% [47.6-56.4]) of cases. Opportunities to avoid referrals after an index stay involved this hospital stay or discharge process in 66 cases (28%), the follow-up period in 59 cases (25%), or both in 66 cases (28%).CONCLUSIONS:Potentially avoidable ED referrals are common in patients with cancer. These potentially avoidable ED referrals underline the importance of several domains of care coordination.Comment inResponse to "Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center" by Duflos et al. [Support Care Cancer. 2018]Response to the response by Lahbib et al. to "Identification of appropriate and potentially avoidable emergency department referrals in a tertiary cancer care center" by Duflos et al. [Support Care Cancer. 2018]

International audience; Despite a wide implementation of pay-for-performance (P4P) programs, evidence on their impact in hospitals is still limited. Our objective was to assess the implementation of the French P4P pilot program (IFAQ1) across 222 hospitals. The study consisted of a questionnaire among four leaders in each enrolled hospital, combined with a qualitative analysis based on 33 semi-structured interviews conducted with staff in four participating hospitals. For the questionnaire results, descriptive statistics were performed and responses were analyzed by job title. For the interviews, transcripts were analysed using coding techniques. Survey results showed that leaders were mostly positive about the program and reported a good level of awareness, in contrast to the frontline staff, who remained mostly unaware of the program's existence. The main barriers were attributed to lack of clarity in program rules, and to time constraints. Different strategies were then suggested by leaders. The qualitative results added further explanations for low program adoption among hospital staff, so far. Ultimately, although paying for quality is still an intuitive approach; gaps in program awareness within enrolled hospitals may pose an important challenge to P4P efficacy. Implementation evaluations are therefore necessary for policymakers to better understand P4P adoption processes among hospitals.

Objective To determine the impact of the Hospital Value-Based Purchasing (HVBP) program—the US pay for performance program introduced by Medicare to incentivize higher quality care—on 30 day mortality for three incentivized conditions: acute myocardial infarction, heart failure, and pneumonia. Design Observational study. Setting 4267 acute care hospitals in the United States: 2919 participated in the HVBP program and 1348 were ineligible and used as controls (44 in general hospitals in Maryland and 1304 critical access hospitals across the United States). Participants 2 430 618 patients admitted to US hospitals from 2008 through 2013. Main outcome measures 30 day risk adjusted mortality for acute myocardial infarction, heart failure, and pneumonia using a patient level linear spline analysis to examine the association between the introduction of the HVBP program and 30 day mortality. Non-incentivized, medical conditions were the comparators. A secondary outcome measure was to determine whether the introduction of the HVBP program was particularly beneficial for a subgroup of hospital—poor performers at baseline—that may benefit the most. Results Mortality rates of incentivized conditions in hospitals participating in the HVBP program declined at −0.13% for each quarter during the preintervention period and −0.03% point difference for each quarter during the post-intervention period. For non-HVBP hospitals, mortality rates declined at −0.14% point difference for each quarter during the preintervention period and −0.01% point difference for each quarter during the post-intervention period. The difference in the mortality trends between the two groups was small and non-significant (difference in difference in trends −0.03% point difference for each quarter, 95% confidence interval −0.08% to 0.13% point difference, P=0.35). In no subgroups of hospitals was HVBP associated with better outcomes, including poor performers at baseline. Conclusions Evidence that HVBP has led to lower mortality rates is lacking. Nations considering similar pay for performance programs may want to consider alternative models to achieve improved patient outcomes.

International audience; The French Ministry of Health and the National Authority for Health launched an experiment of a Financial Incentive to Improve Quality (IFAQ) within 222 acute care hospitals, in June 2012. A working group made of representatives from hospital federations and governmental agencies was created on purpose. The research team COMPAQH (EA7348 Healthcare management Research-EHESP), was in charge of the program design and development. IFAQ was modeled after the Value-Based Purchasing (VBP) program, which was implemented previously, in the US.The objective was to design a model that would rank the participating hospitals according to the results obtained to a set of indicators, and award bonuses to the highest performers.The model was intended to account for both improvement and achievement. It selected quality and safety indicators that were already mandatory to collect, and disclosed publicly, as well as a measure of the level of use of information technologies.Of the 222 hospitals enrolled 93 of them were rewarded. The incentive size was calculated as a portion of their annual budget.Finally, IFAQ diverged from VBP in terms of metric choice, calculation of the score, and incentive structure.; Une expérimentation sur l’Incitation financière à la qualité (IFAQ) a été lancée en France en juin 2012 par le Ministère de la Santé et la Haute Autorité de Santé. Un groupe de travail composé des fédérations hospitalières, des administrations chargées de la santé et de l’assurance maladie a été créé. L’équipe du projet COMPAQH (EA7348-Management des Organisations de Santé, EHESP) a été missionnée pour l’élaboration de la méthode et la conduite de l’expérimentation. La construction du modèle s’est notamment appuyée sur le programme référent en termes de paiement à la performance développé aux Etats-Unis : the Hospital Value Based Pur- chasing (VBP). L’objectif d’IFAQ est de construire un modèle approprié au contexte français permettant de classer les établissements de santé et de rémunérer les meilleurs d’entre eux en fonction de leurs résultats, mais également de leur progression. Le modèle est basé sur l’évaluation de la qualité des établissements de santé à partir d’indicateurs de qualité et de sécurité des soins issus des démarches nationales, de la certification HAS et du niveau de développement de l’informatisation. 222 établissements de santé ont été retenus pour participer à l’expérimentation, 93 ont reçu une rémunération. Le montant de la rémunération dépend du classement et de la valorisation financière de son activité d’hospitalisation en MCO (Médecine Chirurgie Obstétrique) versée par l’assurance maladie. L’expérimentation IFAQ s’est inspirée du modèle VBP mais des différences existent notamment en termes de choix des composantes, du choix de l’expression des résultats des indicateurs, de la prise en compte de l’évolution des résultats et du système d’incitation.

International audience; In the past decade, pay-for-performance (P4P) programs in the health care sector have been implemented throughout the world. These programs differ in their design, as they have different targets (hospitals or physicians) and different performance sectors incentivised. P4P has also been introduced to Chinese hospitals recently. This article reviews major P4P initiatives (programs of the U.K., U.S., France, etc.) and collects common design factors for analysis (targets, quality measures, incentive schemes, performance benchmarks, etc.). The pros and cons of each design factor are discussed, and some inevitable empirical pitfalls are also reviewed. It is anticipated that such international experiences can provide possible future reference for the Chinese hospital remuneration reform.

International audience; Objectives: The aim of this study was to assess the impact of financial incentives on hospitals based on the perspectives of professionals working in the hospitals. Pay-for-performance (P4P) programs have been used extensively in modern health systems but there is little evidence that these programs may improve quality of care. Methods: The study was conducted using a qualitative approach based on data derived from four distinct hospitals involved in IFAQ, the first P4P program for hospitals in France, which started in July 2012 and will end in June 2014. The study looked at 222 voluntary acute care hospitals and its aim was to test the impact of a financial incentive on quality improvement. The four hospitals were selected according to the size, the status (profit, non-profit), the ownership (public, private), the university affiliation, and the location, to ensure adequate representation. The analysis consisted of 30 semi-structured interviews with the hospital staff (directors, heads of department, and the frontline staff including physicians, nurses and assistants), conducted between April and September 2013. The interview guide was shaped by a literature review and validated by experts in the field. The main parts consisted of:1. participants awareness and understanding of the experiment,2. the perceived validity and feasibility of the program,3. the Organisational culture of their Organisation,4. their opinion on the financial incentive (size, distribution),5. the corrective actions to be taken. Interviews lasted about one hour each and were then recorded, transcribed and Analysed by classifying data into categories, and reviewing internal documents for external validity. Results: The study explored the different views of participants within the enrolled hospitals. The findings indicated that major gaps existed in participants’ attitudes, mainly due to the lack of information given to them. Knowledge about the P4P experiment was limited to the administrative level and therefore did not percolate within the Organisation. A typology of the different perceptions was constructed to Analyse how the experiment was apprehended within the hospital. First, top-management believed quality-based payments were critical in the present context and wanted their hospitals to be pioneers. They also perceived P4P as an opportunity to advocate the importance of quality within the hospital, and the experiment as a way to better engage practitioners in quality improvement programs. In contrast, frontline staff, including physicians, nurses, and assistants were mostly unaware that money was tied to the results of a set of quality indicators. During the interviews, physicians were mostly neutral about the experiment, mainly because they thought IFAQ would not impact the Organisation of their work. On the other hand, nurses and assistants, whose work can be affected by this financial incentive because of the selection of process indicators, which must be documented on a daily basis, were uninformed about this program. In addition, the frontline staff expressed concern of becoming overburdened by administrative tasks. Finally, very few actions were undertaken during the first year of the experiment. The fact that the model was still under construction at that time was one of the main explanations provided. Conclusion: Today, minor changes could be observed among enrolled hospitals. Since adherence of professionals is needed to maximize the program effectiveness, a questionnaire-based study (222 hospitals, June 2014), based on these results, will be conducted to better understand how they perceived IFAQ to adjust the program, if needed.