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The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A
Jane S Hocking1, Anna Wood1,2, Meredith Temple-Smith2
1Melbourne School of Population and Global Health, University of Melbourne, Parkville, Victoria, Australia.
Insights
Audit/feedback is more effective than financial incentives for maintaining chlamydia testing rates in Australian general practice. Removing audit/feedback significantly reduced testing, while removing incentives had a smaller impact.
Area of Science:
- Public Health
- General Practice
- Health Services Research
Background:
- Financial incentives and audit/feedback are common primary care interventions to improve quality of care.
- Previous observational data suggested declining quality upon intervention removal, but lacked randomized controlled trial (RCT) evaluation.
- This study addresses the gap by evaluating the impact of removing these interventions on chlamydia testing rates.
Purpose of the Study:
- To determine if chlamydia testing rates in Australian general practice are sustained after the removal of financial incentives and/or audit/feedback.
- To compare the effectiveness of audit/feedback versus financial incentives in maintaining testing practices.
- To evaluate the combined and individual effects of removing these interventions.
Main Methods:
- A 2x2 factorial cluster randomized controlled trial (RCT) involving 60 general practices across 4 Australian states.
- Targeted 49,525 patients aged 16-29 years for annual chlamydia testing.
- Practices were randomized into four groups: incentives removed/audit-feedback retained, audit-feedback removed/incentives retained, both removed, or both retained.
Main Results:
- Annual chlamydia testing rates decreased across all groups, with a more pronounced decline when audit/feedback was removed (adjusted difference -2.6%, p=0.0336).
- Removal of financial incentives showed a smaller, non-significant decrease in testing rates (adjusted difference -0.9%, p=0.2267).
- Audit/feedback proved more effective than financial incentives in sustaining GP chlamydia testing practices.
Conclusions:
- Audit/feedback is more effective than financial incentives (AU$5-AU$8 per test) for sustaining general practitioner chlamydia testing.
- The removal of audit/feedback significantly impacts testing rates, highlighting its importance in maintaining quality of care.
- These findings have implications for designing effective quality improvement strategies in primary care settings.
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.
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