title: Implementation Processes and Pay for Performance in Healthcare: A Systematic Review.
abstract: BACKGROUND
  Over the last decade, various pay-for-performance (P4P) programs have been implemented to improve quality in health systems, including the VHA. P4P programs are complex, and their effects may vary by design, context, and other implementation processes. We conducted a systematic review and key informant (KI) interviews to better understand the implementation factors that modify the effectiveness of P4P.
  
  
  METHODS
  We searched PubMed, PsycINFO, and CINAHL through April 2014, and reviewed reference lists. We included trials and observational studies of P4P implementation. Two investigators abstracted data and assessed study quality. We interviewed P4P researchers to gain further insight.
  
  
  RESULTS
  Among 1363 titles and abstracts, we selected 509 for full-text review, and included 41 primary studies. Of these 41 studies, 33 examined P4P programs in ambulatory settings, 7 targeted hospitals, and 1 study applied to nursing homes. Related to implementation, 13 studies examined program design, 8 examined implementation processes, 6 the outer setting, 18 the inner setting, and 5 provider characteristics. Results suggest the importance of considering underlying payment models and using statistically stringent methods of composite measure development, and ensuring that high-quality care will be maintained after incentive removal. We found no conclusive evidence that provider or practice characteristics relate to P4P effectiveness. Interviews with 14 KIs supported limited evidence that effective P4P program measures should be aligned with organizational goals, that incentive structures should be carefully considered, and that factors such as a strong infrastructure and public reporting may have a large influence.
  
  
  CONCLUSIONS
  There is limited evidence from which to draw firm conclusions related to P4P implementation. Findings from studies and KI interviews suggest that P4P programs should undergo regular evaluation and should target areas of poor performance. Additionally, measures and incentives should align with organizational priorities, and programs should allow for changes over time in response to data and provider input.
authors.affiliation: Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA. karli.kondo@va.gov.|Oregon Health and Science University, Portland, OR, USA. karli.kondo@va.gov.
authors.forename: Karli K
authors.initials: KK
authors.lastname: Kondo
authors.affiliation: RAND Corporation, Santa Monica, CA, USA.
authors.forename: Cheryl L
authors.initials: CL
authors.lastname: Damberg
authors.affiliation: Oregon Health and Science University, Portland, OR, USA.
authors.forename: Aaron
authors.initials: A
authors.lastname: Mendelson
authors.affiliation: Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.
authors.forename: Makalapua
authors.initials: M
authors.lastname: Motu'apuaka
authors.affiliation: Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.
authors.forename: Michele
authors.initials: M
authors.lastname: Freeman
authors.affiliation: Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.|Oregon Health and Science University, Portland, OR, USA.
authors.forename: Maya
authors.initials: M
authors.lastname: O'Neil
authors.affiliation: Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.
authors.forename: Rose
authors.initials: R
authors.lastname: Relevo
authors.affiliation: Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.
authors.forename: Allison
authors.initials: A
authors.lastname: Low
authors.affiliation: Portland Veterans Affairs Medical Center, Evidence-based Synthesis Program, Mailcode RD71, 3710 SW U.S. Veterans Hospital Road, Portland, OR, 97239, USA.|Oregon Health and Science University, Portland, OR, USA.
authors.forename: Devan
authors.initials: D
authors.lastname: Kansagara
mesh_terms: D000554:Ambulatory Care Facilities / Q000191:economics / Q000592:standards; D002986:Clinical Trials as Topic / Q000191:economics / Q000379:methods; D003695:Delivery of Health Care / Q000191:economics* / Q000592:standards; D006761:Hospitals / Q000592:standards; D006801:Humans; D009735:Nursing Homes / Q000191:economics / Q000592:standards; D064887:Observational Studies as Topic / Q000191:economics / Q000379:methods; D015397:Program Evaluation / Q000191:economics* / Q000592:standards; D011787:Quality of Health Care / Q000191:economics* / Q000592:standards; D012052:Reimbursement, Incentive / Q000191:economics* / Q000592:standards
keywords: financial incentives; implementation; pay for performance; performance metrics; systematic review