Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2023 Oct 7:41:100921.
doi: 10.1016/j.lanwpc.2023.100921. eCollection 2023 Dec.

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis

Rohan S Grimley  1   2   3 , Taya A Collyer  4 , Nadine E Andrew  5   3 , Helen M Dewey  6 , Eleanor S Horton  2   7 , Greg Cadigan  8 , Dominique A Cadilhac  3   9
Affiliations

Impact of pay-for-performance for stroke unit access on mortality in Queensland, Australia: an interrupted time series analysis

Rohan S Grimley et al. Lancet Reg Health West Pac. .

Abstract

Background: Stroke unit care provides substantial benefits for all subgroups of patient with stroke, but consistent access has been difficult to achieve in many healthcare systems. Pay-for-performance incentives have been introduced widely in attempt to improve quality and efficiency in healthcare, but there is limited evidence of positive impact when they are targeted at hospitals. In 2012, a pay-for-performance program targeting stroke unit access was co-designed and implemented within a clinical quality improvement network across public hospitals in Queensland, Australia. We assessed the impact on access to specialist care and mortality following stroke.

Methods: We used interrupted time series analysis on linked hospital and death registry data to compare changes in level (absolute proportions) and trends in outcomes (stroke/coronary care unit admission, 6-month mortality) for stroke, and a control condition of myocardial infarction (MI) without pay-for-performance incentive, from 2009 before, to 2017 after introduction of the pay-for-performance scheme in 2012.

Findings: We included 23,572 patients with stroke and 39,511 with MI. Following pay-for-performance introduction, stroke unit access increased by an absolute 35% (95% CI 29, 41) more than historical trend prediction, with greater impact for regional/rural residents (41% vs major city 24%) where baseline access was lowest (18% vs major city residents 53%). Historical upward 6-month mortality trends following stroke (+0.11%/month) reversed to a downward slope (-0.05%/month) with pay-for-performance; difference -0.16%/month (95% CI -0.29, -0.03). In contrast, access to coronary care and mortality trends for MI controls were unchanged, difference-in-difference for mortality -0.18%, (95% CI -0.34, -0.02).

Interpretation: This clinician led pay-for-performance incentive stimulated significant improvements in stroke unit access, reduced regional disparities; and resulted in a sustained decline in 6-month mortality. As our findings contrast with lack of effect in most hospital directed pay-for-performance programs, differences in design and context provide insights for optimal program design.

Funding: Queensland Advancing Clinical Research Fellowship, National Health and Medical Research Council Senior Research Fellowship.

Keywords: Clinical improvement collaboratives; Mortality; Myocardial infarction; Pay-for-performance; Stroke; Stroke unit.

PubMed Disclaimer

Conflict of interest statement

The authors declare no commercial or financial relationships that could be construed as a potential conflict of interest. RG, NEA, HMD, DAC report membership of governance committees for the Australian Stroke Clinical Registry, DAC is also data custodian. EH is consumer representative for the Queensland Stroke Clinical Network and Australian Stroke Coalition. DAC reports grants from Boehringer Ingelheim (Angel’s Initiative), Moleac and Bristol Myers Squibb paid to her institution unrelated to this project.

Figures

Fig. 1
Fig. 1
Patient selection and exclusions.
Fig. 2
Fig. 2
Impact of pay-for-performance incentives for stroke unit access on proportion of acute stroke and myocardial infarction (MI) patients admitted to designated stroke or coronary care units: Panel A state-wide access; Panels B & C stroke unit access for stroke, and Coronary care unit access for MI in rural/regional vs major city residents.
Fig. 3
Fig. 3
Impact of pay-for-performance incentives for stroke unit access on 6-month mortality following stroke and myocardial infarction (control condition).
See this image and copyright information in PMC

References

    1. Global Burden of Disease Collaborators Global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet Neurol. 2021;20(10):795–820. - PMC - PubMed
    1. Langhorne P., Ramachandra S., Stroke Unit Trialists Collaboration Organised inpatient (stroke unit) care for stroke: network meta-analysis. Cochrane Database Syst Rev. 2020;4 - PMC - PubMed
    1. Langhorne P., Pollock A., Stroke Unit Trialists C. What are the components of effective stroke unit care? Age Ageing. 2002;31(5):365–371. - PubMed
    1. Cadilhac D.A., Purvis T., Reyneke M., Dalli L., Kim J., Kilkenny M.F. 2019. Evaluation of the national stroke audit program: 20-year report. Melbourne.
    1. Stroke Foundation National stroke audit – acute services report 2021. 2021. http://www.informme.org.au/stroke-data