Pro Evolution Soccer series logo used from 2007 to 2013. Number for the year is featured on the right side of 'PES'. Stars corresponding to the number of the instalment appear on the upper right.KonamiPlatform(s),21 July 199510 September 2019eFootball Pro Evolution Soccer ( PES) is a series of developed and released annually since 2001. It is being developed and published. It consists of eighteen main instalments and several spin-off style titles and it has seen releases on many different platforms.
It is itself a sister series of Konami's earlier and has been released under different names before the name Pro Evolution Soccer was established worldwide. The series has consistently achieved critical and commercial success.The Pro Evolution Soccer series has also been used in.
(or PES World Finals as it was formerly known) is the official esports world championship held annually since 2010. PES League features both an individual's tournament (1v1) and since the 2018 edition a team's tournament (3v3).In circles, Pro Evolution Soccer has a longstanding rivalry with '. As with the FIFA series, PES allows players to perform their own unique. Listed as, the series has sold over 100 million copies.also created a similar mobile game called PESCM or Pro Evolution Soccer Club Manager.
Polka Dot Chair Free Cricut SVG Files Library: Winning eleven 2002 english version isosorbide; Mobile Menu; Looking for More Patterns, Stencils, Designs? WorldSoccerJikkyouWinningEleven4(Japan)(v1.0)-1.jpg' alt='Winning Eleven 9 Pc' title='Winning Eleven 9 Pc' / Winning Eleven 2002 English IsolFor World Soccer Winning Eleven 2002 on the PlayStation, GameFAQs has 2 FAQs game guides and walkthroughs, 11 cheat codes and secrets, 1 review, 2 save games,. WE2002FE Next Version Winning.
Winning Eleven 2002 English Version Isotonic. The first version appeared in. Eleven papers on differential equations. German-English mathematics dictionary.
Contents.Gameplay The Pro Evolution Soccer series strives to emulate real soccer. As such, gameplay simulates a typical game of association football, with the player controlling either an entire team or a selected player; objectives coincide with the rules of association football.
Various game modes have been featured in the series, allowing for gameplay variety, including the Kick Off, Online and Offline modes. In addition to these modes, there is an editing one where the player can fix (to some extent) the series' greatest problem, poor licensing.Master leagueThe Master League mode, gives the user control of a team of user's selection.
Originally, the players were all generic-fictional players, however this later changed giving the user the option to change the settings and choose to play with default players. These players, such as Brazilian forward Castolo, have become cult figures to many people playing the Master League. The aim is to use these players and gain points by winning matches, cups and leagues. Using acquired points to purchase real players to join the team. Ultimately, one should end up with a team of skilled players.From PES 3 ( Winning Eleven 7), players' growth and decline curves were added, where a player's statistics may improve or decline, depending on training and age. This added a new depth to purchasing players, adding value to an up-and-coming youngster whose abilities rise dramatically and creating a trade-off if the player buys skilled but declining veterans.EditingFans of the series often make 'option files' and 'patches' which modify all player names into those of their real life counterparts, as well as including transfers from the latest transfer window and, occasionally, altered stats of more obscure players whose in-game attributes do not precisely replicate their real life skills.'
PES Stats Database' and 'PES Stats' are examples of websites that are dedicated to creating accurate stats for players. More experienced gamers often use 'patches', editing the actual game code and modifying the graphical content to include accurate kits for unlicensed teams, new stadiums, and footballs from, and, as well as more balls. Most patches also contain licensed referee kits from and the official logos of the various European leagues. These patches are technically a breach of copyright, and are often sold illegally in territories in the. Konami have become less tolerant of this kind of fan editing in recent years, and now the data pertaining to kits and player statistics in each new release. However, fan communities invariably find ways to crack this encryption, and patches still appear once this has been achieved.The gameplay of pes 2019 is far more better than the previous ones.The kits are more lively and you get the feeling of a new football world.Since Pro Evolution Soccer 6 onwards, there has been a separate league with 18 generic teams (Team A, Team B, Team C etc.) present, which can be edited fully.
This is thought to be due to the fact that Konami failed to get the rights to the, and is usually made into the Bundesliga or another league of one's preference by patch makers. However, most people use this to put their edited players into playable teams from the start instead of having to play through Master League to purchase them or alternatively edit the existing non-generic teams.
This feature does not appear in the Wii version of the game (but, as stated above, the non-generic teams can be edited anyway).Goal Storm / ISS Pro series Pro Evolution Soccer series traces its roots to Goal Storm (also known as World Soccer Winning Eleven in Japan). The game was developed by and was released in 1996.
The first Winning Eleven game, without the World Soccer prefix, was which was released only in Japan for the PlayStation in 1995, and featured only the 14 clubs that played in. Main article:Tagline: 'They Will Rock You'Pro Evolution Soccer 2 ( World Soccer: Winning Eleven 6 in Japan and World Soccer: Winning Eleven 6 - International in the United States) is the 2nd instalment and was released in October 2002 and some felt that it was a slight backwards step from the original Pro Evolution Soccer. Others argued that it had improved. The pace of gameplay was much faster than in the game's older sibling, with sharper turns and quicker reactions to tackles. It also included a training session mode. Extra clubs were added, with an extra Master League division. There were two new commentators, and, but this aspect of the game was criticised for the commentators' inaccuracies and tendency to speak over each other.The licensing was much the same, but infamously all Dutch players were called ‘Oranges’, because Konami did not hold the rights from the, for use from Dutch players (in fact, plenty of other football games of the period with FIFPro licences also saw this happen to them (including ), following Netherlands' unsuccessful campaign at the 2002 World Cup qualifiers).
Also, unlike in the original game, the 'unofficial' club names stopped using obvious city names (e.g. Was Manchester, was Madrid etc.), and instead used very ambiguous names (e.g. Manchester United were now Aragon, Liverpool became Europort and West Ham became Lake District). The edit mode included a club editor which offset this problem to some extent, with editable kits and logos as well as club and player names.The game notably included tracks from:.
A version (known as World Soccer: Winning Eleven 2002 in Japan) was also released, which was again a minor update of its predecessor, and was the last Pro Evolution Soccer release for the original PlayStation.Pro Evolution Soccer 3. Main article:First tagline: 'The Season Starts Here' ( Winning Eleven 7/Pro Evolution Soccer 3/Winning Eleven 7: International (US))Second tagline: 'Football is Life' ( Winning Eleven 7: International (JP))Pro Evolution Soccer 3 ( World Soccer: Winning Eleven 7 in Japan and World Soccer: Winning Eleven 7 - International in the United States) is the 3rd instalment in the series and was released in 2003, and featured the Italian referee on the cover (although he is not present as an in-game referee). The most significant update was the overhaul in the graphics engine, with more life like players and much improved likeness. Main article:Tagline: 'The long road to the Final'Pro Evolution Soccer 4 ( World Soccer: Winning Eleven 8 in Japan and World Soccer: Winning Eleven 8 - International in the United States) was the 4th instalment in the series and was released in 2004; featuring referee, and on the cover. This is the first Pro Evolution Soccer game to feature full leagues, namely the English, French, German, Spanish, Italian, and Dutch top divisions, though with full league licences only for the latter three. As a result, clubs in, for example, the English League, an unlicensed league, have ambiguous names like 'West London Blue' and 'Man Red' for and respectively, and their home grounds and are respectively named 'Blue Bridge' and 'Trad Brick Stadium'.The gameplay has improved from Pro Evolution Soccer 3 (though not as much of a significant leap as its predecessor) with improved AI, tweaked play-on advantages and better throughballs.
Dribbling is tighter with the players (though at one-star difficulty, a player receiving the ball on either wing can dribble the ball down the length of the pitch relatively uncontested), plus free-kicks have been changed to allow lay-offs. The gameplay was criticised for its relatively easy scoring opportunities, as players can pass their way through opposing defenses, or hold on to the ball at the edge of the penalty area and simply wait for the opposing defenders to move away and thus give him space to shoot. A new 6-star difficulty was added as an unlockable in the shop, as well as the previous items, while the Master League included enhancements such as player development, so many players over 30 would see certain attributes decline as the game progresses. Conversely, players could improve upon their attributes up to the age of 24-25, though the improvement is most rapid and obvious in players aged 22 and under.The edit mode has been enhanced rapidly, with the options to add text and logos to shirts (essentially sponsors) and pixel logo editing as well as the traditional preset shapes, thus making it easier to replicate a team. The game also includes an 'International Cup' and four regional Cups:. The 'European Cup' is remarkably inclusive, including almost every major European country, as well as smaller countries like Slovenia, Hungary, and Slovakia.
However, countries like Israel and Iceland are not included. The Czech team is simply called 'Czech'. The 'American Championship' is a merger of the and the. It includes most North, Central and South American countries. The 'Asia-Oceania Cup' includes only five Asian countries, Japan, Saudi Arabia, Iran, China, and South Korea, plus Australia. Ironically, in real life, Australia has joined the, and now the defending champion of.
South Korea is simply called 'Korea'. Adidas templates are used in Edit Kit in Edit modePro Evolution Soccer 5. Main article:Tagline: 'Bring it On'Pro Evolution Soccer 5 (known as World Soccer: Winning Eleven 9 in North America and Japan) the 5th instalment in the series, was released in October 2005 and featured and on the cover and alongside on the main menu. The improvements are mainly tweaks to the gameplay engine, while online play finally made it to the version. The game was perceived as much harder by fans, with a very punishing defence AI making it harder to score.
Some players have pointed out inconsistencies in the star difficulty rating, such as 3 star mode being harder to beat than 6 star due to its more defensive nature, but in general scoring is harder. Referees are very fussy over decisions, awarding free kicks for very negligible challenges.There are various new club licences present, including, and a few other European clubs, as well as the full Dutch, Spanish and Italian Leagues.Since crowd animations on the PS2 version slowed down the framerate to an unplayable level in the testing phase, crowds were rendered as flat animated 2D bitmaps which, on certain angles, become unseen, making the stands appear empty; however, fully 3D-rendered crowds are present during cut-scenes. There are however which address this in the PC version, although no official patch was released. Official PlayStation 2 Magazine UK gave it a perfect 10/10 score.Pro Evolution Soccer 5, was released for Xbox, Windows and PS2, all online enabled. A PSP version was released, but with stripped down features, such as no Master League, no commentary, only one stadium and limitations in the editor, due to the limitations to the. The PSP version featured Wi-fi play, and the gameplay was faster and more “pin-ball like” in comparison to its console siblings, but it did not receive the same acclaim as the mainstream console/PC versions.Pro Evolution Soccer 6.
Winning Eleven 2002 English Version Isosorbide 1
Main article:Tagline: 'Express Yourself!' Pro Evolution Soccer 6 ( World Soccer: Winning Eleven 10 in Japan and Winning Eleven: Pro Evolution Soccer 2007 in the United States) is the 6th instalment in the series and was officially released in the on 27 October 2006 for the, and PC platforms and on 9 February 2007 for the. The PC version does not utilise the Xbox 360 engine but is a conversion of the PS2 edition.
The PSP version is similar in many ways to its PS2 brother, while the DS version has graphics and gameplay reminiscent of the older PES series on the original.A criticism of the previous version was that the game was too unforgiving and so suppressed fluid attacking football. Pro Evolution Soccer 6 was issued with more tricks and an overall more attacking mentality, but whether it does make it easier to take on defenders and get forward is debatable.More licences were added, including fully licensed international kits including the nations, and to name a few (as well as the ever-present Japan licence). The French is now included as fully licensed league, as well as the Spanish, Italian and Dutch leagues, plus several other individual clubs. However, the licence from PES5 was removed and, due to a lawsuit, Konami were forced to drop the Bundesliga licence. The only Bundesliga team to appear in the game is.
The game had not updated Arsenal's venue to the Emirates stadium; the defunct Highbury is still present. The same applies for Bayern Munich, who, despite having moved to the, are still represented in the game as playing at.
Also, the recent extensions to are not included, while are still present despite the dissolution of the country in May 2006, this being due to the disestablished state competing at the. All teams which competed at the World Cup featured their 23-man squads from the tournament, including those who retired from international football (e.g. Of the ) and from the game altogether (e.g. Of ), although club teams were fairly up to date.The version features next-generation, hi-definition graphics and more animations, but gameplay similar to the other console versions, according to a recent interview with Seabass. The Xbox 360 version also finally introduces the Pro Evolution series to widescreen gaming, a feature that was sorely missing from the PS2 and versions of the game.
Much of the gameplay and editing options were severely stripped down for the 360 release.Pro Evolution Soccer 2008. Main article:Tagline: 'If football is your life, PES 2008 is your game.' Pro Evolution Soccer 2008 (Known as World Soccer: Winning Eleven 2008) is the 7th instalment in the series. The game was released for, on 26 October 2007 in Europe, 2 November 2007 in Australia, and 31 December 2007 in Japan. The and version were released in November, and the rather different version. Pro Evo Wii was released in March 2008. It was the first game in the series to drop the Winning Eleven name from its title in the United States.The game cover features Portugal and Manchester United player and a local player ( in the UK, in France, in Germany, in Italy and in Australia).
A new adaptive AI system entitled 'Teamvision' was implemented into the game, Teamvision is a sophisticated AI programming that learns and adapts according to an individual's style of play. As such, it will learn new ways to build attacks and to counter specific movements and previous attacking or defensive errors, ensuring games are more in line with the tactical but flowing nature of the real thing. The English commentary was provided by and for the first time. 20 teams are also in the D1 and D2 Leagues, four more than in past editions.The game's 'in-game editor' however was a large downgrade from previous versions, with players unable to add text to unlicensed team shirts or base copy specific players; however, the PC version allows for face pictures to be uploaded or directly photographed through a webcam. On the PS3 the game was a huge disappointment with lots of frame rate issues and strange glitches.Pro Evolution Soccer 2009. Main article:Pro Evolution Soccer 2009 (known as World Soccer: Winning Eleven 2009) is the 8th instalment in the series. Released on the 17th of October in Europe, featuring Argentine star as its cover star (opposite Mexican midfielder from in some versions).While in some respects keeping the same structure of its predecessor, PES 2009 makes a large number of improvements, starting from the graphics, now better suited for image technologies.
Also, the overall pace of the gameplay was slowed down, with a better AI for computer-controlled teammates as well: they will look for better passing spaces and goal routes.A new addition of this game is the Become a Legend mode, which follows the entire career of a single player (as opposed to a whole team, like in the Master League) as he moves to better teams, achieves national team caps and wins MVP awards, like the similar mode called Fantasista in, a special edition only for Japan. This also inspired the Be a Pro mode introduced in.This game has sponsored once in real life (during a match against ), but the team's in-game kit does not feature the PES 2009 sponsorship. This was also the first version to include the licence.Pro Evolution Soccer 2010. Main article:Tagline: 'Where Champions Live!' Pro Evolution Soccer 2010 (known as World Soccer: Winning Eleven 2010) is the 9th instalment in the series.
The cover features players and.The game has gone through a complete overhaul as it tries to compete with the FIFA series. PES 2010 has improved animations and 360-degree control was introduced, available on the PC, PS3, and Xbox 360 versions of the game via the analog sticks on the respective controllers.
PS3 owners benefited from this when using the DualShock's D-Pad, but the Wii D-Pad is limited to eight-directional control and the Xbox 360 D-Pad to sixteen-directional control due to their hardware. Was improved thanks to Teamvision 2.0. The referees were reworked to make better calls during matches.
It also features more licensed teams and players than ever before. In addition to the added licence, the licence was also added, both playable in the Master League.Pro Evolution Soccer 2011. Main article:Pro Evolution Soccer 2013 (known as World Soccer: Winning Eleven 2013) is the 12th instalment of the series. The gameplay improves the AI as well as giving the player the ability to accurately aim passes and shots. Real Madrid player Cristiano Ronaldo is featured for the front cover. For the first time of the series, all 20 teams from the Brazilian National League, Campeonato Brasileiro Serie A, are included in the game series. The UEFA Champions League and the Copa Santander Libertadores is once again appeared in the game.Pro Evolution Soccer 2014.
Promotion at 2013Pro Evolution Soccer 2014, officially abbreviated to PES 2014, also known in Asia as World Soccer: Winning Eleven 2014 is the 13th instalment in the series, developed and published by Konami. The game features a modified version of the new Fox Engine. It was released on 19 September 2013, in Europe, 20 September in United Kingdom, 24 September in North America and on 14 November in Japan. This game also become the last game with PlayStation 2, PlayStation Portable, and Nintendo 3DS.Pro Evolution Soccer 2015. Main article:Tagline: 'Love the Past, Play the Future'Pro Evolution Soccer 2016, officially abbreviated as PES 2016 and also known in Asia as World Soccer: Winning Eleven 2016, is the 15th instalment in the series. It is also the game to be released during the series' 20th anniversary. The cover of the game features and forward player.
It was released on 15 September 2015, in North America, 17 September in Europe, 18 September in United Kingdom, and on 1 October in Japan. Also in April 2016, the special edition of PES 2016 called UEFA Euro 2016 which features and player on the cover. English commentary by is provided for the first time with.Pro Evolution Soccer 2017. Main article:Tagline: 'Control Reality'Pro Evolution Soccer 2017 (officially abbreviated as PES 2017, also known in Japan as Winning Eleven 2017) is the 16th instalment in the series.
On 25 May, Pro Evolution Soccer 2017 was announced and scheduled to be released on PC,. The cover of the game features Barcelona players, including Neymar,. On 26 July 2016, officially announced a premium partnership with Barcelona allowing “extensive” access to the, which will be exclusive to the game for three years. Features includes, among others, improved passing, Real Touch ball control, and improved goal tending technique. Konami has released Pro Evolution Soccer 2017 for mobile phones.
Pro Evolution Soccer 2018. Main article:Tagline: 'Where Legends are Made'Pro Evolution Soccer 2018 (officially abbreviated as PES 2018, also known in Japan as Winning Eleven 2018) is the 17th instalment in the game series. The cover of the game features Barcelona players, including Neymar (who was replaced by after his transfer to before the game's release; due to this as well, the Brazilian edition cover which was to feature him in the Barcelona colors now features playing for the national team),. It was released worldwide in September 2017.Pro Evolution Soccer 2019. Main article:Tagline: 'The Power of Football'Pro Evolution Soccer 2019 (officially abbreviated as PES 2019, also known in Japan as Winning Eleven 2019) is the 18th instalment in the game series.
PES 2019 is the first PES in 10 years not to feature the UEFA Champions League license after Konami lost the rights to EA Sports.eFootball Pro Evolution Soccer series Series overview European titleNorth American titleAsian editionsAsian regionFirst releaseeFootball Pro Evolution Soccer 2020eFootball Winning Eleven 2020Japan10 September 2019Xbox One, PS4WindowsN/AeFootball Pro Evolution Soccer 2020. Main article:eFootball Pro Evolution Soccer 2020 (officially abbreviated as PES 2020, also known in Japan as Winning Eleven 2020) is the 19th instalment in the game series. The Guardian. Retrieved 19 October 2018. Michael, Elvis. PlayStation Lifestyle. Retrieved 18 May 2018.
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LITERATURE FLOWWe reviewed 1,363 titles and abstracts from the electronic search. 509 articles met inclusion criteria. Upon full text review, we excluded 416 articles, for a total of 93 included studies.
We added one additional study recommended by a peer reviewer, for a total of 94 included studies. We identified 47 primary studies for, 41 primary studies meeting inclusion criteria for, and 42 primary studies addressing. Thirty-two studies provided information for more than one key question (see ). Among the included studies, 47 examined the UK's QOF, 10 examined P4P in Taiwan's national health system, and 23 were studies conducted in the United States. A total of 78 studies examined P4P in ambulatory settings, with 11 conducted in hospital settings, of which 5 reported results for CMS P4P demonstrations/programs, and 2 were conducted in VHA settings. KEY QUESTION 1. What are the effects of pay for performance on patient outcomes and processes of care?Forty-seven studies met inclusion criteria for Key Question 1.
Nineteen studies examined processes of care or patient outcomes associated with the QOF. Among the remaining 28 studies, 11 were conducted in the United States, and 8 in Taiwan, with the remaining examining programs in the Netherlands, Canada, Australia, France, and Italy.
Forty-two studies examined processes of care outcomes, with 23 evaluating the effect of P4P on patient outcomes. Outcomes related to programs targeting ambulatory care are presented and discussed separately from those targeting and incentivizing at the hospital level. Forty studies examined P4P programs targeting ambulatory care and incentivizing providers or provider groups, with the remaining 7 focused on hospital P4P programs and providing incentives to the hospitals or hospital administration. In addition to findings from our literature search, we provide a summary of relevant findings from RAND's report.
Summary of RAND's FindingsThe stronger studies as a whole generally showed either no improvements or relatively modest improvements in treatment, screening, and prevention measures ( eg, chronic disease care, cancer screening, and immunizations). For example, a study by Mullen et al of a P4P program sponsored by PacifiCare in California found no improvement on any incentivized measures related to screening (cervical cancer, breast cancer), prevention (childhood immunizations), chronic disease care (HbA1c testing, asthma medication), or appropriate antibiotic usage relative to comparison practices in the Pacific Northwest over a 5-year period. Fagan et al found mixed results on 2-year trends on 5 incentivized measures between 9 physician practices that received incentives from a large national managed care organization and comparison practices. P4P practices had significant improvement compared with non-P4P practices on one measure (influenza vaccine: OR=1.79), had significant reductions on 2 measures (HbA1c testing: OR= 0.44; LDL screening: OR=0.62), and were no different on one measure (eye exam for diabetes). In 2 separate studies of a New York Medicaid P4P plan, Chien et al observed no significant improvement in diabetes process measures over a 5-year period but a statistically significant improvement in immunization rates., A study by Pearson et al of the Massachusetts P4P experiment found P4P was not associated with regular improvements in diabetes scores over a 3-year period among 5 health plans' P4P programs and was also not associated with regular improvements in scores for breast cancer, cervical cancer, or chlamydia screening.
Levin-Scherz et al studied a P4P program within a large integrated delivery system and found that P4P practices experienced significant improvement (2-19% points) compared with non-P4P practices on 4 diabetes measures across a 3-year period. Rosenthal et al in a 4-year cross-sectional comparison, found that P4P practices had significantly better performance on cervical (3.9 percentage points) and breast cancer (2.2 percentage points) screening than non-P4P practices. Summary of Findings from Studies Examining Processes of Care in the UK's Quality and Outcomes FrameworkSeventeen studies examining processes of care associated with the QOF met inclusion criteria. The included studies examined a wide range of processes, such as influenza immunizations, prescribing patterns, and the measurement and/or recording of numerous incentivized indicators such as blood pressure, hypertension, glucose, total cholesterol, smoking status and cessation advice, and body mass index. Reports study details.
Findings indicate modest improvements associated with the QOF, with the largest increases during the program's first and second year, followed by either a plateau or slowing in improvement rates. For example, a study by Doran and others (2011) examined 23 incentivized indicators over a 7-year period beginning 4 years prior to the introduction of the QOF. Results indicate that all 17 process of care indicators improved significantly in the first year, and by the third year of the QOF, achievement for 10 of the 17 indicators remained significantly higher than projected pre-QOF trends; however, between the first and the third year, achievement plateaued, with mean rates increasing by only 1.9% (95% CI 1.4, 2.5).
Summary of Findings from Studies Examining Process of Care Measures in Other Ambulatory P4P ProgramsWe included 19 studies examining processes of care outcomes in other ambulatory P4P programs. Commonly examined outcomes included immunizations ( eg, influenza), screenings ( eg, HbA1c, blood pressure, cholesterol, glucose, eye exams), and prescribing patterns, with other studies examining outcomes related to coordination of care, costs, and training. Provides study details. Similar to the findings reported by Damberg and others, recent studies examining P4P in ambulatory settings report modest to no improvement in process-related measures. For example, 5 studies reported findings related to Taiwan's diabetes mellitus P4P program (DM-P4P). The DM-P4P, which began in 2001, is a voluntary program focused on guideline adherence that allows physicians who had completed a continuing medical education (CME) program to participate.
While P4P was significantly associated with increased screening rates, -, and survival, physicians who had completed the required CME but chose not to participate in the DM-P4P also screened patients at a significantly higher rate than physicians who were program-ineligible. KQ1 Processes of Care Ambulatory P4P Programs Non-QOF.Studies examining other ambulatory programs covered a range of processes of care and found that results varied according to patient population, disease condition, and care process examined., A handful of studies report modest improvements associated with P4P, and findings from short-term and cross-sectional studies report generally positive associations between P4P and screenings and preventive care., However, others, and particularly longer-term studies, report little to no association, or that the effect of P4P fades over time. Summary of RAND's FindingsWe summarize the findings of 6 good-quality studies of hospital P4P programs, 5 of which evaluated the effect of the CMS HQID while one evaluated the Massachusetts Medicaid P4P program which used the same measures ( ie, process of care measures for acute myocardial Infarction (AMI), congestive heart failure (CHF), pneumonia, and surgical infection prevention) and incentive methodology as the HQID.
These studies found modest differential effects between hospitals exposed to P4P and those not exposed that may have been related to the fact that virtually all hospitals were reporting their data to CMS for the purposes of public reporting of results, which in and of itself was a strong motivator for improvement. Two studies evaluated the first 3-year phase of the HQID and found generally positive but modest results., Werner et al found that, over the first 3 years of the HQID, participating hospitals had higher performance on an overall composite measure of AMI, CHF, and pneumonia than non-participating hospitals; however, after 5 years, the scores were virtually identical between HQID participants and non-participants. Ryan and colleagues found that P4P hospitals improved more (a difference of 1 to 2 percentage points) than non-P4P hospitals on the AMI, CHF, and pneumonia care composite measures; P4P hospitals improved less in Phase II than Phase I of HQID, compared with non-P4P hospitals, in large measure because the performance of these hospitals had topped out. The evaluation of the Massachusetts Medicaid hospital P4P program found no effect of P4P for pneumonia or surgical infection prevention in the 2 years after the start of the P4P program. Summary of Findings from Studies Examining Process of Care Measures in Hospital P4P ProgramsSix studies examined processes of care in hospital P4P programs. Among the included studies, 3 studies evaluated P4P in US populations, with one study evaluating the CMS HQID, one evaluating the CMS hospital value-based purchasing (HVBP) program, and one study evaluating a VHA P4P program. Of the remaining studies, one evaluated a program in Italy, and 2 evaluated hospital P4P programs in Taiwan.,provides study details.
KQ1 Processes of Care Hospital P4P Programs.In the United States, both the HQID and the HVBP programs used a combination of hospital payment penalties and rewards to incentivize process of care improvements. In both cases, quasi-experimental design studies found no significant change in nearly all the measures examined.,In contrast, a large retrospective cohort study using latent growth modeling found performance bonuses to VHA regional and facility-level senior managers targeted to acute coronary syndrome, heart failure, and pneumonia process measures, were associated with significant improvement on 6 of the 7 measures evaluated. Given the lack of control group, it is impossible to know whether the incentives were directly responsible for, or were coincident with, the change. Baseline performance was already quite high for some of the measures ( eg, diagnostic catheterization for acute myocardial infarction patients, use of ace inhibitors in heart failure patients, and pneumococcal vaccination rates), while the clinical validity of at least one of the measures (timely use of antibiotics in suspected pneumonia) has since been challenged. Internationally, studies evaluating hospital P4P programs report generally positive effects, -, with a slowing of improvements or a plateau over time. Summary of RAND's FindingsOnly a small number of studies have investigated the effect of P4P on measures of clinical outcomes (n=13), and the results are generally insignificant. The studies focused on a relatively small number of outcome measures; 30-day mortality (8 articles) and in-hospital mortality (7 articles) were the most commonly assessed outcomes, while few studies examined complications (2 articles), 30-day readmissions (2 articles), or one-year survival (1 article).
The studies typically used cross-sectional data and examined correlations between individual or composite clinical process measures with one or more outcomes. The studies generally faced important challenges in establishing the link between receipt of process and outcome in an observational study, namely limited power to detect an effect, small expected effect sizes in practice, and potential bias due to unmeasured confounding factors. Given these challenges, the fact that most currently published process-outcome studies could not find an effect is not surprising.A 2011 systematic review summarized the literature on the relationship between performance on clinical processes and outcomes for diabetes: evidence on the relationship between receipt of the clinical processes and patient outcomes was mixed at best. A study by Rosenthal et al found that a P4P program that provided incentives to pregnant members and their prenatal care providers did not result in a reduction of low birth weight deliveries.
A study of a Medicaid plan-sponsored P4P program found that changes in the percentage of patients with LDL control as well as changes in emergency department use and hospitalizations were not significantly different than comparison practices over a 5-year period. A study by Ryan and Doran evaluated the association between improvements in incentivized process and intermediate outcomes in the UK QOF for 5 conditions: diabetes, coronary heart disease, stroke, epilepsy, and hypertension. The study showed that a 10 percentage point increase in the process composite was associated with an increase in performance on intermediate outcome measures of 3.16 percentage points for diabetes, 4.32 percentage points for coronary heart disease, 7.60 percentage points for stroke, 7.24 percentage points for epilepsy, and 7.16 percentage points for hypertension. Summary of Findings from Studies Examining Patient Outcomes in the UK's Quality and Outcomes FrameworkThe 11 included studies examining patient outcomes associated with the UK's QOF evaluated clinical outcomes related to glucose, blood pressure, cholesterol, and hemoglobin levels, as well as the prevalence of COPD, and smoking prevalence. Reports study details. There is no strong evidence that the QOF increased clinical target achievement, as reported results vary by patient outcome, and by study period, as similar to findings related to processes of care; overall, larger improvements were generally observed in the initial year of the QOF, with a subsequent plateau or slowing of improvement for many of the measures, and unlike findings related to processes of care, achievement of certain intermediate targets ( eg, HbA1c), was lower than predicted by pre-QOF trends.
For example, one study examined trends from 1997 to 2005, and found that there was an immediate increase in achievement of blood pressure targets, with an additional increase the following year. There was no immediate improvement in cholesterol target attainment; however, significant improvement was observed in the year after implementation. For HbA1c, there was no immediate improvement, with a non-significant decline in the following year. Another study examining trends between 2000-2007 found that immediately, and in the 3 years following QOF introduction, systolic blood pressure decreased significantly, but there was no effect on diastolic levels. Cholesterol levels decreased significantly as compared with pre-QOF trend predictions, and continued to over the following 3 years; however, HbA1c levels were decreasing prior to the QOF, but increased significantly in the 3 years following QOF implementation.
Summary of Findings from Studies Examining Patient Outcome Measures in Other Ambulatory P4P ProgramsThe 8 included studies evaluated patient outcome measures related to P4P programs in other ambulatory settings, and examined emergency department (ED) and hospital admissions, elective cesarean sections, and clinical outcomes related to diabetes and other chronic illnesses, and provided no strong evidence of an effect of P4P on patient outcomes. Provides study detail. Among these studies, 3 evaluated Taiwan's DM-P4P and reported that despite increases in diabetes-related hospitalizations for non DM-P4P patients, there was no significant difference between P4P and comparison patients. Summary of RAND's FindingsStudies have consistently found either no association or weak associations between better performance on process measures and patient outcomes (some of these studies were done in the context of quality improvement interventions or pay-for-reporting, rather than P4P).
A study by Krumholz et al examined the association between receipt of process measures for AMI, CHF, and pneumonia and 30-day all-cause risk-standardized mortality rates and 30-day, all-cause, risk-standardized readmission rates. No association was observed for AMI or pneumonia, and a negative association was observed between for both outcomes for CHF (r= −0.17, 95% CI). In a study of the surgical infection prevention (SCIP) measures implemented by CMS, Nicholas et al examined their relationship with risk-adjusted postoperative mortality rate, venous thromboembolism, and surgical site infection and found no statistically significant associations.
Werner and Bradlow examined the 10 measures in the Hospital Quality Alliance starter set (pneumonia, CHF, and AMI) and found that hospitals in the 75th percentile of performance had significantly lower inpatient mortality than those in the 25th percentile for each condition's composite measure and most of the individual measures; however, the absolute risk reduction (ARR) was small, ranging from.001 for CHF to.005 for both AMI and pneumonia. Petersen found that a broader set of AMI measures were associated with lower in-hospital mortality among a small group of hospitals participating in the “Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Hospital Association Guideline” (CRUSADE) National Quality Improvement Initiative. The adjusted in-hospital mortality rate for hospitals in the top quartile was 6.31% versus 4.15% for hospitals in the 4th quartile (OR=0.81, p. Summary of Findings from Studies Examining Patient Outcomes in Hospital P4P ProgramsFour studies evaluated the relationship between hospital P4P programs and patient outcomes, of which 2 assessed programs in Taiwan, one evaluated the UK's HQID, and one US study evaluating the HVBP programs. Provides study details. In Taiwan, results from a study examining 5-year breast cancer survival and 5-year breast cancer recurrence, and from another assessing cure rates of tuberculosis, reported higher survival (OR =.167, 95% CI 0.064, 0.432) and lower recurrence rates (OR =.370, 95% CI 0.200, 0.685) in patients enrolled in P4P, and a higher 9-month tuberculosis cure rate (46.9% vs 63%, p.
KEY QUESTION 2. What are the implementation factors that modify the effectiveness of pay for performance?Despite numerous P4P programs in the United States, as a health system the VHA differs greatly from others in the US, which are with a few exceptions multi-payer and heterogeneous in numerous ways, such as size, infrastructure ( eg, use of electronic medical records EMR), practice characteristics, etcetera.
The fundamental differences in the characteristics of US health systems, and thus, the settings in which P4P programs are implemented, present challenges related to generalizability, particularly to a system that differs greatly, such as the VHA. As such, as a P4P program, the QOF may be the model to examine closely, for as a system it similar in many ways to the VHA, being a large (primarily) single-payer system, having the ability to create system-wide changes and enforce or prompt behavior, with shared information through the use of EMRs, the ability to disseminate information in a systematic fashion, and with a commitment to providing integrated care.Forty-one studies met inclusion criteria for Key Question 2, of which 17 examined the QOF. Based on key informant interviews with 14 experienced P4P researchers, we identified 2 main questions related to implementation. Findings from Included StudiesStudies examining implementation factors related to the setting in the UK found that for providers, being a contractor rather than being employed by a practice was associated with greater efficiency and higher quality. Under the QOF, practices improved regardless of list size, with larger practices performing better in the short term, - particularly when examining total QOF points rather than specific patient populations, disease conditions, or indictors. However, when these factors are taken into consideration, few significant differences existed based on practice size., In addition, 2 studies found that group practice and training practice status was associated with a higher quality of care;, however, 2 others found no significant effect of training practice status after controlling for covariates., Studies in the United States and other countries such as the Netherlands, Canada, and Australia differed widely with regard to program structure and system level infrastructure ( eg, technology). Themes from Key Informant InterviewsSimilar to the findings reported in the literature, key informants believed that measures should be evaluated regularly ( eg, yearly), to allow for continued increases in quality.
Once achievement rates are high, those measures should be evaluated, with the possibility of increasing thresholds if relevant, or replacing them with others representing areas in need of quality improvement.Key informants also stressed that, while the optimal number of incentivized measures is unknown, it is likely that a surplus of measures will be burdensome to providers and increase the likelihood “box-ticking/check-listing,” “teaching to the test,” and gaming. Key informants familiar with the QOF pointed out that when the QOF was first introduced in 2004, incentives were linked to 146 indicators. What Implementation Factors are Associated with Changes in Provider Cognitive and/or Behavioral Outcomes?Fourteen of the included studies examined factors associated with changes in provider cognitive and/or behavioral outcomes, of which one examined the QOF ( provides study detail).
In addition, many of our key informants stressed the importance of thoughtful consideration of a balance between intrinsic and extrinsic motivation, as well as designing and implementing programs to maximize positive outcomes and mitigate negative unintended consequences. Themes from Key Informant InterviewsDiscussions of provider characteristics, behavior, and particularly the balance between intrinsic and extrinsic motivation were a common topic in our key informant interviews. Most KIs framed these discussions around increasing intrinsic motivation through the alignment of programs to provider values and provider buy-in, and minimizing the potential unintended consequences that may be associated with too much focus on extrinsic rewards. However, one KI stressed the belief that intrinsic motivation will “trump” extrinsic rewards (in the absence of other accompanying interventions) and cited self-determination theory (SDT) as the primary force that drives provider behavior.
According to SDT, intrinsic motivation is enhanced through communication and feedback, allowing one to make the link between intrinsic motivation, autonomy, and competence. Within the context of P4P, our KI suggested that given the data necessary to support improvement within an environment that is supportive and encouraging, providers will default to what they are intrinsically motivated to do – or the “right thing for patients.” The key, stressed by our key informant, is that reliable data ( eg, their scores as compared with others) are presented to providers in a way that is non-judgmental and within the context of a quality improvement model, and that congruence exists between what they are being asked to do and what they believe is best for their patients. This KI, along with others, also stressed the importance of providing clear, consistent, constructive, and non-judgmental feedback to providers – that providers will respond if they understand how their scores compare with other providers within their organization, and are given the opportunity to vocalize concerns, and are provided with examples of methods used by high-performing providers.Key informants also felt that P4P programs currently place too much emphasis on physicians. Quality of care and patient experience is contingent upon all members of a practice, and P4P programs often increase workloads for nurses and other staff; thus, distributing incentives to both clinical and non-clinical staff will increase professionalism and buy-in. Related to buy-in, KIs also stressed the importance devoting resources to implementation in P4P programs, particularly when new measures are introduced.
One important component is the proper dissemination of the evidence behind, and the rationale for, incentivized measures to enable providers to make the connection between the measures and patient care. They also strongly suggested guidance to providers on how to best meet targets. Transparency and the availability of information was seen as vital, and KIs also felt that programs should have resources devoted to providing support to at the local level ( eg, alleviating concerns and addressing program-related questions), including the designation of a local champion to influence and encourage peers. KIs in the UK pointed to guidance documents for the GMS contract, released yearly, which clearly outline all indicators including the rationale for the targets, and provide easy-to-understand information regarding program changes. In addition, indicators in the UK are managed by NICE through a transparent process that involves policy makers, providers, clinical staff, researchers, and patients. Stakeholders are involved throughout the process, and provide feedback as advisory board members, through open meetings with the public, and through the ability to comment publicly on NICE's website. The importance of stakeholder involvement and provider buy-in was echoed by our key informants.A number of KIs suggested a “bottom-up” approach when developing P4P programs, that is, that providers and other staff, both clinical and non-clinical, be involved in all stages of program development, as part of a panel, or through open forum discussions.
They stressed that starting from the “bottom-up” will help to align intrinsic and extrinsic motivation, and that input from and discussions with clinicians and front line staff throughout the process will also help to alleviate concerns, garner buy-in, and thus greatly contribute to program success.Related to the measures, KIs strongly supported the combination of patient outcomes and processes of care. While incentives should ideally target patient outcomes, key informants also agreed that process of care variables are easier to measure and improve, and may also be valuable in ensuring needed services are available ( eg, translators, case management for low-income patients). They stressed process of care measures should be evidence-based, clear and simple, linked to specific actions rather than complex processes, and clearly connected to a desired outcome.
In addition, measures should be realistic within the patient population and health system in which they are used, and measure targets should be grounded in clinical significance rather than data improvement. To emphasize this point, one key informant questioned the achievability of, for example, 85% of patients meeting a clinical outcome measure that is reflective of the population mean.Furthermore, key informants emphasized that measures should reflect the priorities of the organization, its providers, and its local population. Incentives should be designed to stimulate different actions depending on the level of the organization at which they are targeted. For example, incentives targeted to leadership or administrative-level incentives are more likely to result in structural improvements such as investment in information technology, while provider-level incentives are aimed at behavior change. Team-level incentives might address the quality of patient-provider interactions, as well as patient experiences with other members of the team.Key informants also discussed the influence of features related to the incentive. With regard to the size of the incentive, key informants agreed that that there is no “magic number,” but that the incentive must be large enough to motivate providers or hospital administrators, and not so large as to encourage gaming – with hypotheses ranging from 5-15% as optimal, but that effects may vary based on the organizational culture, the type of incentivized measures, and numerous other factors.
In addition, consistent across KIs was the belief that incentives should be based on improvements, and that all program participants should have the ability to earn incentives. In the case of competition-based programs, one KI suggested grouping participants by similar characteristics ( eg, patient socioeconomic status SES) with competitions within groups to allow hospitals/providers in areas of lower SES to better compete. KIs stressed that the magnitude of the incentive attached to a specific measure should be relative to organizational priorities, as not only does the presence of an incentive alone suggest prioritization, but the degree of priority is further emphasized by the magnitude of the incentive. Furthermore, one KI suggested that the magnitude of incentives be relative to the degree of clinical improvement. KIs also agreed that when designing incentives, penalties, as compared to rewards, may be more effective at the provider level, and stressed the importance of linking provider-level incentives to the program ( ie, providers must be able to make the connection between their behavior and the reward). Despite decreases over time for the QOF in the percentage of general practitioner (GP) income linked to incentives (from roughly 35% to 15%), incentives remain much higher in the UK than in the US, where incentives have approximated 1 to 2% federally and roughly 5 to 10% in many private programs.
The relatively small incentives in the US present a challenge, in that the more frequent incentive payments ( eg, monthly) recommended by some of our KIs in order to better link behavior and reward for providers would likely be too low to be noticed, and while yearly payments would be larger, they may still be too low in addition to not being frequent enough to reinforce behavior. KIs agreed that in general the lack of consistent effect (both positive and negative) associated with P4P in the United States likely stems from the size of the incentive. KEY QUESTION 3.
What are the positive and negative unintended consequences, including any effect on health disparities, associated with pay for performance?Forty-two studies examining unintended consequences associated with P4P met inclusion criteria for Key Question 3, of which 33 evaluated the QOF. Among these studies, 28 of the 42 evaluated the effect of P4P on health disparities in populations of low socioeconomic status or racial/ethnic minorities, or examined disparities associated with other characteristics such as age, and multiple conditions. Nineteen studies report findings related to other unintended consequences, such as the effect on unincentivized areas of care ( eg, spillover effects), gaming, and cherry-picking/risk selection. Summary of RAND's FindingsThe research regarding negative effects associated with P4P is quite limited, providing insufficient evidence to understand these effects.
The few empirical studies that have been conducted have either no effects or ambiguous effects. Only one relatively weak study found positive effects in lessening gaps in performance.A recent RAND review found insufficient evidence of an association between use of quality measures in hospitals and increased the prevalence of teaching-to-the-test (zero out of 4 fair/good-quality studies demonstrating undesired effects), overtreatment/unnecessary care (0 out of one), or worsening disparities (one out of 4). In nursing homes, there is insufficient evidence regarding teaching-to-the-test (0 out of 2), cherry-picking (0 out of one), and gaming (0 out of one). In the ambulatory setting, the research team could not identify consistent relationships between use of quality measures and cherry-picking (2 out of 3), gaming (one out of 2), teaching-to-the-test (3 out of 8), worsening disparities (one out of 4). There were 3 positive studies suggesting that intermediate outcome measures of ambulatory care for diabetes may have been associated with overtreatment.
The RAND review found limited evidence regarding a relationship between use of performance measures in P4P and public reporting applications and either worsening or reducing disparities. Health DisparitiesMost of the studies examining differential effects of P4P by race/ethnicity, socioeconomic, or other demographic characteristics came from the UK's QOF program. In general, there was no strong consistent evidence that P4P had different effects on different patient subgroups, though there were exceptions as noted below.
Groups with lower baseline care quality tended to experience greater absolute levels of improvement over the short term.In key informant discussions about health disparities, it became clear that differences exist by program, and particularly between the UK's QOF and programs in the United States. A consistent message across our KIs in the UK was that in the first 2 years after its introduction, the QOF successfully decreased health disparities, largely because in general, quality improved in all practices, with lower-performing practices (most often those in areas of high deprivation) demonstrating larger improvements and quickly catching up to practices in more affluent areas.
However, key informants noted that once practices were performing near the upper thresholds, the costs associated with eliminating the small gap that remained were higher in areas with higher deprivation, and that therefore providers in more affluent areas were more likely to receive incentives.In the United States, the relationship between P4P and health disparities has not been well-studied. A number of KIs stressed the lack of formal evaluation of health disparities in US programs, the importance of the collection of cultural variables to allow for an accurate assessment, and the need for consistency across measures to allow for formal evaluation. They felt that targeted measures to assess health disparities are needed, but also recognized the challenges associated with different patient populations by practices/hospitals, thus limiting the ability to conduct meaningful analyses due to limited sample sizes.KI's with knowledge of P4P within the VHA felt that VHA P4P programs have been successful in improving quality in low-income and racial/ethnic minority patients, and that programs have not exacerbated health disparities. Key informants both in the United States and the United Kingdom recommended stratifying providers/hospitals by SES, with one KI suggesting that in the case of competition-based programs, hospitals compete only with others with similar characteristics, and another KI suggesting that providers in low-income areas be awarded a greater number of points. Race/EthnicityOf the 24 studies evaluating the effect of P4P on health disparities (see for study detail), 12 examined disparities in more than one category ( eg, race/ethnicity and SES), and all but 3 studies examined the QOF.
Thirteen studies examined the differential effect of P4P by race/ethnicity. Findings indicate that in the short term, the QOF was associated with a reduction in blood pressure for whites. Socioeconomic StatusSeventeen studies examined the effect of P4P on health disparities in patients of low socioeconomic status, 11 of which evaluated the relationship between SES and the QOF. Provides study detail. Many of the included studies were congruent with the findings from our KI interviews, and report that the QOF increased quality, regardless of SES, - for both process of care measures such as recording of smoking status, hypertension, long-acting injectable reversible contraceptives (LARCs), and blood pressure, as well as patient outcomes such as achievement of blood pressure and cholesterol targets, and that practices with lower SES populations showed greater improvement; thereby, narrowing the gap in performance and quality that existed prior to the QOF. Other studies, however, report poorer performance/quality in low SES patient populations, including lower rates of blood pressure recording, lower rates of immunizations, patient perception of poorer access, lower rates of chronic kidney disease recording, and a smaller magnitude of improvement in the quality of diabetes care as compared to patients residing in affluent areas., Studies differed widely by patient sample ( eg, condition, region) and SES measure ( eg, deprivation index, occupation), with most studies examining outcomes within the first 2 years of the QOF.
Other Health DisparitiesEleven studies reported the differential effects of P4P on health based on other subgroup factors. Provides study detail. Findings indicate that the QOF may be particularly effective for patients with co-morbid conditions, as certain indicators apply to multiple conditions ( eg, recording of blood pressure for both diabetes and coronary heart disease);, however, more complicated patients may be excluded through exception reporting at a higher rate. Conversely, slower improvements were seen in newly diagnosed patients, women, and younger patients., These are groups that had been recognized as experiencing lower levels of care prior to the QOF, and though they experienced some gains after the QOF began, their slower rate of improvement as compared with others resulted in a widening of the gap;, however, findings related to between-group differences were often non-significant, and varied by disease condition and indicator. Conversely, in Taiwan's DM-P4P, which was both optional for providers and allowed providers the choice of which patients to enroll, a study by Chen and others (2011) found that patients enrolled in the DM-P4P were more likely to be female, were younger, and had fewer co-morbid conditions.
Other Unintended ConsequencesNineteen studies examined other unintended consequences, both positive and negative, associated with P4P programs. Provides study detail. Of these studies, 12 evaluated the QOF, 2 evaluated Taiwan's healthcare system, and 2 were set in the United States. Studies examined a variety of unintended consequences, including the positive and negative effect of P4P on unincentivized measures, gaming, risk selection, and others. In addition, much of our discussions with key informants centered on the risk and presence of unintended consequences associated with P4P programs. Both KIs within and outside of the US suggested that both the lack of consistent effects and the general lack of unintended consequences associated with P4P programs in the United States relate directly to the small percentage of provider income linked to incentives.
GamingOnly 3 of the included studies looked for the possibility of gaming. One study found that post-QOF introduction, while there was no evidence of a bias towards recording values just below target thresholds, the proportion of patients who achieved target BP values rose. However, another study found that after systolic target changed to 150, there was an increase of recording of 148-149, and a decrease in recorded values of 151-152. Despite the lack of empirical evidence, consistent across KIs was a clear message that once financial incentives are introduced, gaming will occur, with one KI describing gaming in P4P programs as “rampant.” Related to the QOF, one KI suggested that although the percentage of provider income linked to incentives has dropped, gaming may still occur as a result of factors such as increasingly tougher targets associated with lower financial rewards. KIs stressed that programs must be designed under the assumption that some of those incentivized will game the system, and that design and implementation strategies should be developed in a way to mitigate the potential for harm. KIs suggested that those incentivized must both recognize and buy in to benefits associated with the program that are not financial – and that these benefits must outweigh both the financial incentives and the risks associated with gaming.
In addition, professionalism and compassion should be emphasized. To accomplish this, KIs stressed the importance of measures that are predictable, precise, evidence-based, simple, clear, and realistic, that stakeholders at all levels are involved in program development and dissemination, and that new measures must be implemented in a way that ensures accurate dissemination of the purpose for and evidence related to the measure.
Risk SelectionThe QOF allows for the exclusion of patients meeting certain criteria from indicator calculations through exception reporting. KIs in the UK felt that overall exception reporting was not being abused. However, they did express concern for racial/ethnic minority populations and patients with multiple co-morbidities. In the US, KIs expressed concern about risk selection – in particular with regard to the use of algorithms created by consulting firms to identify higher-risk patients, giving providers the ability to select based on risk and either exclude patients completely or delay procedures until the next reporting period.Eight included studies evaluated programs for risk selection, 6 of which examined exception reporting associated with the QOF (see for study detail). One study by Kontopantelis and others concluded that increases in exception reporting after a target threshold increase were likely due to better documentation. However, a study evaluating the first year of the QOF found that exception reporting was positively related to total QOF score. In addition, a study by Dalton and others found that excluded patients were more likely to have more co-morbid disorders or be of lower SES, that older patients were more likely to excluded from the blood pressure and cholesterol indicators, and those excluded from the HbA1c indicator were more likely to be black or South Asian, with excluded patients less likely to meet targets for HbA1c, blood pressure, and cholesterol.
Another examined the differences between target achievement in non-excluded patients and population achievement, and found lower levels of quality in 31/33 examined indicators, with smaller absolute differences for simple processes ( eg, blood pressure recording), and larger differences for more complex processes ( eg, neuropathy testing) and treatment and immunization indicators. Two studies examining Taiwan's DM-P4P program found that not only did non-enrolled patients have a higher number of co-morbid conditions, they were older, were more likely to have suffered from diabetes-related complications, and have higher diabetes risk scores. Impact on Unincentivized Areas of CareEleven studies evaluated the effect of P4P on unincentivized areas of care. Provides study detail.
Incentivizing certain aspects of care has the potential to affect both unincentivized measures and populations in both positive and negative ways. One such negative way is through “attention shift,” or “teaching to the test,” that is, that providers will focus primarily on those measures on which they are incentivized. Three studies found some evidence of attention shift, with a study by Doran and others (2011) that examined pre-QOF trends for both incentivized and non-incentivized measures and found that while there was no effect on achievement rates for non-incentivized measures in the first year of the QOF, by the third year, rates of achievement were significantly lower than pre-QOF trends.
Additional Unintended ConsequencesKIs also felt that incentivized wait time indicators not only encourage gaming, but are also harmful the provider-patient relationship. In the UK, patients must be seen within 48 hours, which translates in practice to many patients seeing providers other than their primary care provider for visits that are not routine and scheduled far in advance. Relatedly, KIs voiced concern that the degree of documentation required in P4P programs shifts attention away from patient care.
Another area of concern for KIs was the potential for overtreatment, and in particular, environments in which measure attainment is the primary focus, so much so that local reminders and targets may be set incrementally lower or higher to avoid missing a target. Finally, a number of KIs mentioned the QOF implementation of the use of the Patient Health Questionnaire-9 (PHQ-9) to screen for depression severity. Providers felt that the use of the PHQ-9 was akin to “check-boxing” and limited their autonomy/clinical judgment, and stated that it was not uncommon for providers to code patients based on symptomology, rather than diagnose and code them as depressed. The PHQ-9 has recently been retired as an indicator.