Abstract
BACKGROUND
Clinical practice guidelines (CPGs) are increasingly used as the basis for pay-for-performance (P4P) programs. It is unclear how support for guidelines varies when treatment efficacy is expressed in varying mathematically equivalent ways.
OBJECTIVES
To assess: (1) how patient and provider compliance with osteoporosis CPGs varies when pharmacotherapy efficacy is presented as relative risk reduction (RRR) versus absolute risk reduction (ARR) and (2) the impact of increasing out-of-pocket drug expenditures on acceptance of guideline concordant therapy.
DESIGN
Cross-sectional survey of patients and physicians.
SUBJECTS AND SETTING
Female patients age >50 years and providers drawn from academic and community outpatient clinics.
MEASUREMENTS
Patient and provider acceptance of pharmacotherapy when treatment efficacy (reduction in hip fractures) was expressed alternatively in relative terms (35% RRR) versus absolute terms (1% ARR); acceptance of pharmacotherapy as patient drug copayment increased from 0% to 100% of the total drug costs.
RESULTS
Compliance with CPGs fell significantly when the expression of treatment benefit was switched from RRR to ARR for both patients (86% vs 57% compliance; P < .001) and physicians (97% vs 56% compliance; P < .001). Increasing drug copayment from 0% to 10% of total drug cost decreased patient compliance with CPGs from 80% to 57% (P < .001) but did not impact physician compliance. With increasing levels of copay, both patient and provider interest in treatment decreased.
LIMITATIONS
Respondents may not have fully understood the risks and benefits associated with osteoporosis and its treatment.
CONCLUSION
Patient and provider interest in CPG-recommended treatment for osteoporosis is reduced when treatment benefit is expressed as ARR rather than RRR. In addition, minimal increases in drug copayment significantly decreased patient, but not provider, interest in osteoporosis treatment. Designers of P4P programs should consider details including expressions of treatment benefit and patients’ out-of-pocket costs when developing measures to assess quality-of-care.
References
Dudley RA. Pay-for-performance research: how to learn what clinicians and policy makers need to know. JAMA. 2005;294:1821–3.
Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA. 2005;294:1788–93.
Levin-Scherz J, DeVita N, Timbie J. Impact of pay-for-performance contracts and network registry on diabetes and asthma HEDIS measures in an integrated delivery network. Med Care Res Rev. 2006;63:14S–28S.
Milgate K, Cheng SB. Pay-for-performance: the MedPAC perspective. Health Aff. 2006;25:413–9.
Bodenheimer T, May JH, Berenson RA, Coughlan J. Can money buy quality? Physician response to pay for performance. Issue Brief Cent Stud Health Syst Change. 2005;(102)1–4.
U.S. Department of Health and Human Services. Bone Health and Osteoporosis: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Office of the Surgeon General; 2004.
Ray NF, Chan JK, Thamer M, Melton LJ. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporosis Foundation. J Bone Miner Res. 1997;12:24–35.
Brown JP, Josse RG, Scientific Advisory Council of the Osteoporosis Society of C. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002;167:S1–34.
U.S. Preventive Services Task Force. Screening for osteoporosis in postmenopausal women: recommendations and rationale. Ann Intern Med. 2002;137:526–28.
American Geriatrics Society Pay for Performance Proposal. Available at: http://www.americangeriatrics.org/policy/2006p4p_proposal.shtml. Accessed December 7, 2007.
CMS Physician Voluntary Reporting Program. Available at: http://www.cms.hhs.gov/apps/media/press/release.asp?Counter=1701. Accessed December 7, 2007.
Hodgson SF, Watts NB, Bilezikian JP, et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the prevention and treatment of postmenopausal osteoporosis: 2001 edition, with selected updates for 2003. Endocr Pract. 2003;9:544–64.
Gigerenzer G, Edwards A. Simple tools for understanding risks: from innumeracy to insight. Bmj. 2003;327:741–4.
Gigerenzer G. Why does framing influence judgment? J Gen Intern Med. 2003;18:960–1.
Malenka DJ, Baron JA, Johansen S, Wahrenberger JW, Ross JM. The framing effect of relative and absolute risk. J Gen Intern Med. 1993;8:543–8.
Nelson HD, Helfand M, Woolf SH, Allan JD. Screening for postmenopausal osteoporosis: a review of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;137:529–41.
Retail Pricing for Alendronate at Drugstore.com. Available at: http://www.drugstore.com/pharmacy/prices/drugprice.asp?ndc=00006093682&trx=1Z5006. Accessed June 14, 2006.
Ancker JS, Kaufman D. Rethinking health numeracy: a multidisciplinary literature review. J Am Med Inform Assoc. 2007;14:713–21.
Naylor CD, Chen E, Strauss B. Measured enthusiasm: does the method of reporting trial results alter perceptions of therapeutic effectiveness? Ann Intern Med. 1992;117:916–21.
Hux JE, Naylor CD. Communicating the benefits of chronic preventive therapy: does the format of efficacy data determine patients’ acceptance of treatment? Med Decis Making. 1995;15:152–7.
Halvorsen PA, Selmer, Kristiansen IS. Different ways to describe the benefits of risk-reducing treatments: a randomized trial. Ann Intern Med. 2007;146:848–56.
Forrow L, Taylor WC, Arnold RM. Absolutely relative: how research results are summarized can affect treatment decisions. Am J Med. 1992;92:121–4.
Laupacis A, Sackett DL, Roberts RS. Therapeutic priorities of Canadian internists. CMAJ. 1990;142:329–33.
Krumholz HM. Guideline recommendations and results: the importance of the linkage. Ann Intern Med. 2007;147:342–3.
Acknowledgement
Dr. Cram is supported by a K23 career development award (RR01997201) from the NCRR at the NIH.
Conflict of Interest
None disclosed.
Author information
Authors and Affiliations
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Additional information
Dr. Sinsky presented this work at the 2006 national SGIM meeting in Los Angeles.
Appendix 1: Patient version of survey
Appendix 1: Patient version of survey
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1.
At your annual physical exam your doctor recommends that you have a bone density test to see how strong your bones are, and to see whether you are at risk for a fracture in the future. This is a painless test, for which you do not have to undress, and which takes about 5 min. Insurance covers the cost. Would you choose to have the test done? Yes___ No___
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2.
The test returned showing that you have osteoporosis, or a weakening of the bones, increasing your chances of suffering a hip fracture. You are aware of the consequences of a hip fracture, as your neighbor suffered a hip fracture and was in a nursing home for several months. You have prescription drug insurance coverage. Are you interested in treatment with prescription medication? Yes___ No___
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3.
Your doctor has recommended treatment with a prescription medication which would reduce your risk of fracture by about 35% over 5 years of treatment. The known side effects are minimal. Your insurance pays the entire cost of the medication. Would you be likely to take it? Yes___ No___
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4.
The cost of treatment of osteoporosis for 5 years is $5,000. Would you be likely to take the medication if (please answer for each scenario):
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a.
your insurance covered 10% of the cost, and you paid $4,500. Yes___No___
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b.
your insurance covered 20% of the cost, and you paid $4,000 Yes___No___
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c.
your insurance covered 50% of the cost, and you paid $2,500 Yes___No___
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d.
your insurance covered 90% of the cost, and you paid $500 Yes___No___
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e.
your insurance covered 100% of the cost, and you paid nothing Yes___No___
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a.
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5.
Now consider that your doctor offered you a medication to reduce your chances of a hip fracture by 1%. That is, without treatment we would expect 3 of every 100 women like you to have a hip fracture over 5 years; with the medication 2 of every 100 women like you would have a hip fracture. The side effects are minimal and your insurance pays the entire cost of the medication. Would you take it? Yes___ No___
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6.
The cost of treatment of osteoporosis for 5 years of therapy is $5,000. Your insurance does not pay for medications. You have a 1 in 100 chance that taking the medication will prevent you from having a hip fracture. Would you take the medication? Yes___ No___
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7.
Please indicate the level at which you would consider treatment to prevent a hip fracture? 1 of every _____patients treated for 5 years would personally benefit.
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8.
To make screening for osteoporosis a reasonable procedure, how many patients do you feel would need to be screened and treated to prevent 1 hip fracture?____
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9.
The costs of preventing 1 hip fracture through screening and treatment have been estimated to be approximately $500,000. In light of these costs do you think that this screening and treatment is a reasonable intervention? Yes___ No___
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10.
What do you think is a reasonable cost for screening and treatment to prevent 1 hip fracture? ________
Additional information:
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10.
Age: ___
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10.
Are you currently taking calcium? ___
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10.
Are you currently taking a prescription medication for osteoporosis prevention or treatment? ____
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10.
Where do you receive your medical care? ___
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Sinsky, C.A., Foreman-Hoffman, V. & Cram, P. The Impact of Expressions of Treatment Efficacy and Out-of-pocket Expenses on Patient and Physician Interest in Osteoporosis Treatment: Implications for Pay-for-performance Programs. J GEN INTERN MED 23, 164–168 (2008). https://doi.org/10.1007/s11606-007-0490-z
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DOI: https://doi.org/10.1007/s11606-007-0490-z