The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A cluster randomised controlled trial (ACCEPt-able)

Abstract

Background Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT), to our knowledge. This trial aimed to determine whether chlamydia testing in general practice is sustained when financial incentives and/or audit/feedback are removed. Methods and findings We undertook a 2 × 2 factorial cluster RCT in 60 general practices in 4 Australian states targeting 49,525 patients aged 16–29 years for annual chlamydia testing. Clinics were recruited between July 2014 and September 2015 and were followed for up to 2 years or until 31 December 2016. Clinics were eligible if they were in the intervention group of a previous cluster RCT where general practitioners (GPs) received financial incentives (AU$5–AU$8) for each chlamydia test and quarterly audit/feedback reports of their chlamydia testing rates. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained (group A), audit/feedback removed but incentives retained (group B), both removed (group C), or both retained (group D). The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients, where the numerator was the number who had at least 1 chlamydia test within 12 months and the denominator was the number who had at least 1 consultation during the same 12 months. We undertook a factorial analysis in which we investigated the effects of removal versus retention of incentives (groups A + C versus groups B + D) and the effects of removal versus retention of audit/feedback (group B + C versus groups A + D) separately. Of 60 clinics, 59 were randomised and 55 (91.7%) provided data (group A: 15 clinics, 11,196 patients; group B: 14, 11,944; group C: 13, 11,566; group D: 13, 14,819). Annual testing decreased from 20.2% to 11.7% (difference −8.8%; 95% CI −10.5% to −7.0%) in clinics with incentives removed and decreased from 20.6% to 14.3% (difference −7.1%; 95% CI −9.6% to −4.7%) where incentives were retained. The adjusted absolute difference in treatment effect was −0.9% (95% CI −3.5% to 1.7%; p = 0.2267). Annual testing decreased from 21.0% to 11.6% (difference −9.5%; 95% CI −11.7% to −7.4%) in clinics where audit/feedback was removed and decreased from 19.9% to 14.5% (difference −6.4%; 95% CI −8.6% to −4.2%) where audit/feedback was retained. The adjusted absolute difference in treatment effect was −2.6% (95% CI −5.4% to −0.1%; p = 0.0336). Study limitations included an unexpected reduction in testing across all groups impacting statistical power, loss of 4 clinics after randomisation, and inclusion of rural clinics only. Conclusions Audit/feedback is more effective than financial incentives of AU$5–AU$8 per chlamydia test at sustaining GP chlamydia testing practices over time in Australian general practice. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12614000595617

Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis

“…Several studies have documented declines in quality of care after the withdrawal of financial incentives, 18 19 20 21 22 23 24 often back to levels similar to or worse than before the incentivisation. 18 19 20 22 24 However, other studies have observed no decline in quality of care, 13 14 15 16 17 although for one of these studies, care remained partially incentivised through other indicators for seven of the eight measures examined.…”

“…Several studies have documented declines in quality of care after the withdrawal of financial incentives, 18 19 20 21 22 23 24 often back to levels similar to or worse than before the incentivisation. 18 19 20 22 24 However, other studies have observed no decline in quality of care, 13 14 15 16 17 although for one of these studies, care remained partially incentivised through other indicators for seven of the eight measures examined. 16 Another study that followed-up a trial of incentives for diabetes care did not observe declines in quality when incentives were withdrawn, but the study also did not observe consistent improvements when incentives were introduced, making lack of change after withdrawal hard to interpret.…”

“…Consistent with economic theory that targeting external motivation with incentives may crowd out internal professional motivation to improve care, 8 qualitative research with providers in high income 9 and low income 10 11 countries found that incentive withdrawal is perceived to have negative consequences on motivation and quality. The results of studies examining this association quantitatively have been mixed, with some studies finding no decline in quality 12 13 14 15 16 17 but others observing a worsening of quality after the removal of incentives, 18 19 20 21 22 23 24 often back to similar quality levels before incentivisation or sometimes to lower levels. 18 19 20 22 24 …”

“…The results of studies examining this association quantitatively have been mixed, with some studies finding no decline in quality 12 13 14 15 16 17 but others observing a worsening of quality after the removal of incentives, 18 19 20 21 22 23 24 often back to similar quality levels before incentivisation or sometimes to lower levels. 18 19 20 22 24 …”

Exploring Whether the Electronic Optimization of Routine Health Assessments Can Increase Testing for Sexually Transmitted Infections and Provider Acceptability at an Aboriginal Community Controlled Health Service: Mixed Methods Evaluation

“…Credentialing RNs and AHPs aimed to create opportunities for STI testing in clinical encounters that did not involve a GP, whereas having pathology forms presigned by a GP allowed these tests to receive Medicare funding under the signing GP's provider number. Enhanced data reporting has been shown to be an important component of continuous quality improvement (CQI) systems implemented at ACCHSs [40,41]. These 3 components aimed to increase STI testing outside of the health assessment.…”