Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational studyBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2214 (Published 09 May 2016) Cite this as: BMJ 2016;353:i2214
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Re: Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study
This study by Figueroa reaches an eminently sensible set of conclusions. However, the authors were probably unaware of recent research in the UK which demonstrates that in-hospital mortality is simply tracking all-cause mortality in the wider population - with seemingly very little the hospital can do about it [1,2].
Indeed this is part of a far wider issue in that the trends in death appear to be following spatiotemporal patterns consistent with the outbreaks of a novel type of infectious agent [3-4]. In other words, aspects of the trends in death are not at all behaving in the manner that everyone had assumed that they should or ought to behave.
The issues involved in hospital mortality may be far more complex than is appreciated [5-6].
1. Jones R (2015) A ‘fatal’ flaw in hospital mortality models: How spatiotemporal variation in all-cause mortality invalidates hidden assumptions in the models. FGNAMB 1(3): 82-96. doi: 10.15761/FGNAMB.1000116
2. Jones R (2016) Clear the decks of Summary Hospital-level Mortality Indicator. British Journal of Healthcare Management 22(6): 335-338.
3. Jones R (2016) A presumed infectious event in England and Wales during 2014 and 2015 leading to higher deaths in those with neurological and other disorders. Journal of Neuroinfectious Diseases 7(1): 1000213. http://www.omicsonline.com/open-access/a-presumed-infectious-event-in-en...
4. Jones R (2016) Deaths in English Lower Super Output Areas (LSOA) show patterns of very large shifts indicative of a novel recurring infectious event. SMU Medical Journal 3(2): in press
5. Jones R (2016) The unprecedented growth in medical admissions in the UK: the ageing population or a possible infectious/immune aetiology? Epidemiology (Sunnyvale) 6(1): 1000219 http://www.omicsonline.org/open-access/the-unprecedented-growth-in-medic...
6. Jones R (2016) Unusual trends in NHS staff sickness absence. British Journal of Healthcare Management 22(4): 239-240.
Competing interests: No competing interests
The introduction of the HVBP program, as shown recently by Jose F Figueroa et al (1), did not improve 30 day mortality of Medicare beneficiaries admitted to US hospitals for three incentivized conditions. Everybody would agree with the authors’ conclusion that an «appropriate mix of quality metrics and incentives to improve patient outcomes» has yet to be identified.
The VBP program was designed to promote better clinical outcomes for hospital patients, as well as improve their experience of care during hospital stays (2). However, if reducing mortality had been the primary objective, a specific set of indicators should have been selected from relevant practice and organizational guidelines, which was not the case when the program was designed. The absence of impact of HVBP on mortality is therefore not surprising.
In their conclusion Figueroa et al advise «Nations considering similar pay for performance programs … to consider alternative models». This raises a question: should payment depend on achievement of a decrease in mortality rates? The primary objective of P4P programs could remain developing and maintaining continuous quality improvement (CQI) programs based on relevant process indicators assessing critical steps in patients’ management such as, for example, the effective use of check-list in a surgical procedure (3). These process indicators are apt to detect dangerous misconducts, less susceptible to bias and more actionable.
However a problem remains: such CQI programs rely in hospitals on a limited number of persons who repeatedly try to motivate a large number of health professionals insensitive to the benefits of CQI. Instead of diverting the small percentage of budget devoted to P4P programs, it could be more profitable, for patients, to think of a better use for this money.
1 Figueroa JF, Tsugawa Y, Zheng J, Orav EJ, Jha AK. Association between the Value-Based Purchasing pay for performance program and patient mortality in US hospitals: observational study. BMJ 2016; 353:i2214
2 QualityNet. Hospital Value Based Purchasing Overview. QualityNet.org. 2016. www.qualitynet.org/dcs/ContentServer?c=Page&pagename=QnetPublic%2FPage%2...
3 Fourcade A., Blache JL., Grenier C., Bourgain JL, Minvielle E., Barriers to staff adoption of a surgical safety checklist. BMJ Quality and Safety 2012; 21:191-19
Competing interests: No competing interests