Can financial incentives aimed at increasing relational continuity improve the quality of care and outcomes for patients at increased risk of hospitalisation?

Problem

There is worldwide interest in whether improved care in general practice can lead to decreased use of health resources, particularly hospitalisation, for patients with chronic or complex conditions. Financial incentives are one way to encourage service change and have been implemented in a number of countries, including via the Quality and Outcomes Framework in the UK. In Australia general practice is largely funded on a fee-for-service basis. In July 2017 the Royal Australian College of General Practitioners issued a request for proposal ‘Quality in General Practice Trial’ that will provide evidence as to whether financial incentives for longer patient consultations and follow-up leads to better health outcomes. The underlying belief is that relational continuity is a key contributor to quality of care. The aim of the EQuIP-GP trial is to evaluate the impact of a new service model of primary care practice, comprising financial incentives for enrolment with a preferred provider, longer consultations, same day access and structured follow-up after hospitalisation, on the quality of primary care and health service utilisation for patients at increased risk of hospitalisation.

Approach

A randomised trial is being conducted involving practice-based research networks in three states. The trial aims to recruit 36 practices. Patients will include three groups: older patients (over 65 years); patients 18-65 years with chronic and/or complex ambulatory care sensitive conditions; and patients aged < 16 years with increased risk of hospitalisation. The primary outcome is patient-perceived quality of primary care (Primary Care Assessment Tool short form survey). Secondary outcomes are: health-related quality of life (EQ-5D-5L); health service use (hospitalisations, emergency presentations, GP and specialist services in the community, pathology and imaging, medicines); and mortality.

Findings

The incentives system has been developed, ethics approval received and practice recruitment has commenced. The financial incentives encourage ongoing quality improvement relative to current practice: payments are continuous and paid proportionally to the increasing continuity of care and expected health system costs savings from improvement in GP quality of care (reducing potentially unnecessary polypharmacy, diagnostic imaging and pathology), and preventing avoidable hospitalisation.

Consequences

The trial will provide evidence on another approach to incentivising quality of care which can be compared to the pay for performance experience in the UK and the patent-centred medical home work in the United States, as well as the Australian Government ‘Health Care Homes’ trial.