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PAY
FOR PERFORMANCE IN NEWBORN INTENSIVE CARE |
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Profit
J, Zupancic JAF, Gould JB, Petersen LA. Implementing
pay-for-performance in the neonatal intensive care unit.
Pediatrics. 2007;119: 975-982.
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may apply for full text articles.) |
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Although
pay for performance approaches have not yet been applied in
newborn intensive care, this arena is a prime target for such
programs because of the high cost of newborn intensive care,
the availability of standardized and well-subscribed databases,
the relative strength of clinical outcome data, the relatively
high degree to which services are utilized by the overall
pediatric population, and the relatively low rate of comorbidities
with respect to adult inpatient populations. The authors,
reporting on an approach to measuring quality and implementing
pay for performance in the NICU, note that provider involvement
in defining and measuring quality is central to pay for performance,
as provider opposition to such programs is often grounded
in concern regarding the basic validity, fairness, and meaningfulness
of assessment methods.
The authors suggest that quality measures in newborn intensive
care be developed as composite indicators derived by expert
opinion based on measures identified in an evidence-based
manner, ie, through the formal interrogation of existing clinical
and research databases. They assert that the design of quality
measures for newborn intensive care should focus on a multidimensional
approach, with emphasis on structure, process, and outcome
measures.18
Further, they outline a strategy to develop new composite
measures, including a 10 step building process designed by
the Organization for Economic Cooperation and Development
(OECD)19
that emphasizes judgments regarding the relative importance
of the individual measures that contribute to a composite.
These steps include, in sequence: the development of a theoretical
framework, measure selection, initial data analysis, imputation
of missing data, normalization, weighting and aggregation,
uncertainty and sensitivity analysis, linkage to other variables,
deconstruction of the composite indicator, and presentation
and dissemination. In describing the advantages of this strategy,
the authors state that the OECD guidelines both ensure transparency
of process, and promote internal and external statistical
and methodological consistency.
In addition, Profit et al outline 3 challenges specific to
newborn intensive care. First, the relative diversity of the
population in terms of gestational age, chronologic age, presence
or absence of congenital anomalies, and need for surgery requires
that measures be developed for patient groups that are commonly
represented (very low birth weight infants, moderately premature
infants, and term infants). Second, quality assessment in
the group of infants at the limit of viability (less than
25 weeks) may require measures focused more on parent education
and satisfaction than clinical outcome. Finally, the authors
note that bias may be introduced by current transport practices,
requiring that tracking across hospital stays at multiple
institutions become more organized.
The incentive design the investigators ultimately promote
involves a combination of competitive/benchmarking and noncompetitive
comparisons, and a payment structure that involves bonus disbursement
of at least 5% of capitation income, at least yearly, to groups
of providers. They assert that an assessment of quality should
incorporate a range of dimensions, with indicators that are
valid, reliable, feasible to collect, and relevant to important
domains of care. Further, they suggest a phased approach to
implementation, whereby well-funded pilot incentive programs
utilizing only a few specific measures are implemented in
select institutions, with the expectation that both measures
and programs are dynamic in nature, and thus open to ongoing
evaluation and revision as clinical outcome data are refined
and the methodology of quality measurement matures.
The IOM has suggested that quality assessment should reflect
health care delivery in the domains of patient safety, effectiveness,
efficiency, patient-centeredness, timeliness, and equity.1
Profit et al assert that the dimensions of the quality of
health care delivered in newborn intensive care may also be
described by physical and organizational composition (structure
of care), by the clinical care interactions between patients/parents
and providers (process of care), and by clinical outcomes – mortality, morbidity, parent/provider satisfaction (outcomes
of care). They conclude that a framework for quality measurement
that includes both the IOM dimensions and structure/process/outcomes
dimensions is best suited to address current weaknesses in
the application of individual provider performance measures,
primarily the temptation by providers to avoid the acceptance
of and/or treatment of our sickest patients. This concept
of provider development of multidimensional measures sets
the stage for both the proactive involvement of newborn intensive
care providers in the process of quality measurement and comparison,
and the development of a process model that could ultimately
be applied across pediatrics. |
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