***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: BACKGROUND A cluster r and omized trial of a pay-for-performance ( P4P ) scheme was implemented in Afghanistan to test whether P4P could improve maternal and child ( MCH ) services . METHODS All 442 primary care facilities in 11 provinces were matched by type of facility and outpatient volume , and r and omly assigned to the P4P or comparison arm . P4P facilities were given bonus payments based on the MCH services provided . An endline household sample survey was conducted in 72 r and omly selected matched pair catchment areas ( 3421 P4P households ; 3427 comparison).The  quality of services was assessed in 81 r and omly sample d matched pairs of facilities . Data collectors and households were blinded to the intervention assignment . MCH outcomes were assessed at the cluster level . RESULTS There were no substantial differences in any of the five MCH coverage indicators ( P4P vs comparison ) : modern contraception(10.7 % vs 11.2 % ( P = 0.90 ) ; antenatal care : 56.2 % vs 55.6 % ( P = 0.94 ) ; skilled birth attendance ( 33.9 % vs 28.5 % , P = 0.17 ) ; postnatal care ( 31.2 % vs 30.3 % , P = 0.98 ) ; and childhood pentavalent3 vaccination ( 49.6 vs 52.3 % , P = 0.41 ) , or in the equity measures . There were substantial increases in the quality of history and physical examinations index ( P = 0.01 ) ; client counselling index ( P = 0.01 ) ; and time spent with patients ( P = 0.05 ) . Health workers reported limited underst and ing about the bonuses . CONCLUSIONS The intervention had minimal effect , possibly due to difficulties communicating with health workers and inattention to dem and -side factors . P4P interventions need to consider management and community dem and issues Effective in 2000 , Medicare 's Outpatient Prospect i ve Payment System ( OPPS ) sets pre-determined reimbursement rates for hospital outpatient services , replacing the prior cost-based methods of reimbursement . Using Florida outpatient discharge data , we study the effect of OPPS on  hospital outpatient volume .  We find that on average Medicare rate cuts either decreased or had no significant effect on Medicare volume , but increased private fee-for-service ( FFS ) volume . We also find that responses vary with the hospital 's " exposure " to Medicare payment changes , where exposure is measured as the baseline Medicare patient share . Compared to less exposed hospitals , highly exposed hospitals responded with larger increases in private FFS volume and with smaller decreases ( in some cases , even increases ) in Medicare volume when payment rates fell . Our results are consistent with provider dem and inducement IMPORTANCE Pay for performance is intended to align incentives to promote high- quality care , but results have been contradictory . OBJECTIVE To test the effect of explicit financial incentives to reward guideline -recommended hypertension care . DESIGN , SETTING , AND PARTICIPANTS Cluster r and omized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel ( eg , nurses , pharmacists ) . INTERVENTIONS Physician-level ( individual ) incentives , practice -level incentives , both , or none . Intervention participants received up to 5 payments every 4 months ; all participants could access feedback reports . MAIN OUTCOMES AND MEASURES Among a r and om sample , number of patients achieving guideline -recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure , number of patients prescribed guideline -recommended medications , and number who developed hypotension . RESULTS Mean ( SD ) total payments over the study were $ 4270 ( $ 459 ) , $ 2672 ( $ 153 ) , and $ 1648 ( $ 248 ) for the combined , individual , and practice -level interventions , respectively . The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75 % to 84 % and 8.84 % ( 95 % CI , 4.20 % to 11.80 % ) for the individual group , 80 % to 85 % and 3.70 % ( 95 % CI , 0.24 % to 7.68 % ) for the practice -level group , 79 % to 88 % and 5.54 % ( 95 % CI , 1.92 % to 9.52 % ) for the combined group , and 86 % to 86 % and 0.47 % ( 95 % CI , -3.12 % to 4.04 % ) for the control group . The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36 % ( 95 % CI , 2.40 % to 13.00 % ; P=.005 ) . The other incentive groups did not show a significant change compared with controls for this outcome . For medications , the unadjusted baseline and final percentages and the adjusted absolute change were 61 % to 73 % and 9.07 % ( 95 % CI , 4.52 % to 13.44 % ) , 56 % to 65 % and 4.98 % ( 95 % CI , 0.64 % to 10.08 % ) , 65 % to 80 % and 7.26 % ( 95 % CI , 2.92 % to 12.48 % ) , and 63 % to 72 % and 4.35 % ( 95 % CI , -0.28 % to 9.28 % ) , respectively . These changes in the use of guideline -recommended medications were not significant in any of the incentive groups compared with controls , nor was the incidence of hypotension . The effect of the incentive was not sustained after a washout . CONCLUSIONS AND RELEVANCE Individual financial incentives , but not practice -level or combined incentives , result ed in greater blood pressure control or appropriate response to uncontrolled blood pressure ; none of the incentives result ed in greater use of guideline -recommended medications or increased incidence of hypotension compared with controls . Further research is needed on the factors that contributed to these findings . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00302718 OBJECTIVE To analyze the effect of setting higher targets , in a primary care pay-for-performance scheme , on rates of influenza immunization and exception reporting . STUDY SETTING The U.K. Quality and Outcomes Framework links financial rewards for family practice s to four separate influenza immunization rates for patients with coronary heart disease ( CHD ) , chronic obstructive pulmonary disease , diabetes , and stroke . There is no additional payment for immunization rates above an upper threshold . Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate . DATA Practice -level  information on immunizations and exceptions extracted from electronic records of all practice s in Engl and 2004/05 to 2009/10 ( n=8,212 - 8,403 ) . STUDY DESIGN Longitudinal r and om effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07 . PRINCIPAL FINDINGS The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients ( 0.41 percent , CI : 0.25 - 0.56 percent ) , and exception was reported ( 0.26 percent , CI : 0.12 - 0.40 percent ) . CONCLUSIONS Making quality targets more dem and ing can not only lead to improvement in quality of care but can also have other consequences Objective . Immunizations and other cost-effective preventive services remain underused by many children , especially those living in poverty . Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns , we design ed and tested an intervention combining these strategies . We studied whether a system of semiannual assessment and feedback , coupled with financial incentives , could improve pediatric preventive care in a Medicaid health maintenance organization ( HMO ) . Methodology . We r and omly assigned primary care sites serving children in a Medicaid HMO to one of three groups : a feedback group ( where physicians received written feedback about compliance scores ) , a feedback and incentive group ( where physicians received feedback and a financial bonus when compliance criteria were met ) , and a control group . We evaluated compliance with pediatric preventive care guidelines  through semiannual chart audits during the years 1993 to 1995 . Results . Compliance with pediatric preventive care improved dramatically in the study period . Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores ( from 56%–73 % ) , as well as scores for immunizations ( from 62%–79 % ) and other preventive care ( from 54%–71 % ) . However , no significant differences were observed between either intervention group and the control group , nor were there any interaction ( group-by-time ) effects . Conclusions . Feedback to physicians , with or without financial incentives , did not improve pediatric preventive care in this Medicaid HMO during a time of rapid , secular improvements in care . Possible explanations include the context and timing of the intervention , the magnitude of the financial incentives , and lack of physician awareness of the intervention BACKGROUND Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed . We assessed the effect of performance-based payment of health-care providers ( payment for performance ; P4P ) on use and quality of child and maternal care services in health-care facilities in Rw and a. METHODS 166 facilities were r and omly assigned at the district level either to begin P4P funding between June , 2006 , and October , 2006 ( intervention group ; n=80 ) , or to continue with the traditional input-based funding until 23 months after study baseline ( control group ; n=86 ) . R and omisation was done by coin toss . We surveyed facilities and 2158 households at baseline and after 23 months . The main outcome measures were prenatal care visits and institutional deliveries , quality of prenatal care , and child preventive care visits and immunisation . We isolated the incentive effect from the re source effect by increasing comparison facilities ' input-based budgets by the average P4P payments made to the treatment facilities . We estimated a multivariate regression specification of the difference-in-difference model in which an individual 's outcome is regressed against a dummy variable , indicating whether the facility received P4P that year , a facility-fixed effect , a year indicator , and a series of individual and household characteristics . FINDINGS Our model estimated that facilities in the intervention group had a 23 % increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger ( 56 % ) and aged between 24 months and 59 months ( 132 % ) . No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules . We also estimate an increase of 0·157 st and ard deviations ( 95 % CI 0·026 - 0·289 ) in prenatal quality as measured by compliance with Rw and an prenatal care clinical practice guidelines . INTERPRETATION The P4P scheme in Rw and a had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider . P4P financial performance incentives can improve both the use and quality of maternal and child health services , and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health . FUNDING World Bank 's Bank-Netherl and s Partnership Program and Spanish Impact Evaluation Fund , the British Economic and Social Research Council , Government of Rw and a , and Global Development Network OBJECTIVE To examine whether decreases in Medicare outpatient payment rates under the  Outpatient Prospect i ve Payment System ( OPPS ) caused outpatient care to shift toward the inpatient setting . DATA SOURCES / STUDY SETTING Hospital inpatient and outpatient discharge files from the Florida Agency for Health Care Administration from 1997 through 2008 . STUDY DESIGN This study focuses on inguinal hernia repair surgery , one of the most commonly performed surgical procedures in the United States . We estimate multivariate regressions of inguinal hernia surgery counts in the outpatient setting and in the inpatient setting . The key explanatory variable is the time-varying Medicare payment rate specific to the procedure and hospital . Control variables include time-varying hospital and county characteristics and hospital and year-fixed effects . PRINCIPAL FINDINGS Outpatient hernia surgeries fell in response to OPPS-induced rate cuts . The volume of inpatient hernia repair surgeries did not increase in response to reductions in the outpatient reimbursement rate . CONCLUSIONS Potential substitution from the outpatient setting to the inpatient setting does not pose a serious threat to Medicare 's efforts to contain hospital outpatient costs IMPORTANCE Most evaluations of pay-for-performance ( P4P ) incentives have focused on large-group practice s. Thus , the effect of P4P in small practice s , where many US residents receive care , is largely unknown . Furthermore , whether electronic health records ( EHRs ) with chronic disease management capabilities support small- 
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Authors ' conclusions Our review found that if policymakers intend to apply P4P incentives to pay health facilities providing outpatient services , this intervention will probably lead to a slight improvement in health professionals ' use of tests or treatments , particularly for chronic diseases .
However , it may lead to little or no improvement in patients ' utilisation of health services or health outcomes .