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Pay-for-performance program shows modest benefits for emergency department wait times


Ontario hospitals that participated in a pay-for-performance program to reduce emergency department wait times showed a reduction in overall length of stay without compromising quality of care, according to a study by the Institute for Clinical Evaluative Sciences (ICES).

The study, now published online in the journal Annals of Emergency Medicine, examined hospital and patient records in Ontario during the period 2008 – 2011 when the province of Ontario introduced in consecutive waves a pay-for-performance program as part of its Emergency Department Wait Time Strategy.

Analyzing visit types by levels of acuity, the researchers reviewed wait times and patient outcomes at hospitals that received financial incentives under the program, comparing them to matched hospitals that had not.

“Overall, we saw modest improvements in emergency department wait times in the first year after the introduction of a pay-for-performance program, without negative effects on quality of care,” says Marian Vermeulen, the ICES researcher who led the study.

The researchers note that the improvements to wait times primarily impacted patients with longer wait times, particularly those who were admitted to hospital, as well as hospitals that had the poorest performance in wait times at the start of the program. However, for the majority of patients, reductions in wait time were not as pronounced.

In 2008, the Ontario Ministry of Health and Long-Term Care launched the Emergency Department Wait Times Strategy to address emergency department crowding and reduce length of stay. As part of the strategy, the Pay for Results Program provided up-front financial incentives to hospitals for improved performance on emergency department length-of-stay targets: a maximum of 8 hours for emergency or acute care, and 4 hours for non-admitted low-acuity patients. Incentives were allocated internally within each hospital, and could not be used to supplement physician income. Funds were not restricted to the emergency department and could be used to improve flow in inpatient areas as well. Failure to attain specified targets meant potential repayment of these funds.

The study notes that there were many attributes of the program design that could have led to the improvement in wait times, such as the up-front payment of incentives that hospitals could use to improve patient flow. However, the uncertainty of this annual payment may have made hospital administrators more reluctant to commit to longer-term investments. “Future research and policy design should consider the sustainability, incentive design, and healthcare context that are all factors in driving the effectiveness of pay-for-performance schemes,” says Vermeulen.

“The Effect of Pay for Performance in the Emergency Department on Patient Waiting Times and the Quality of Care in Ontario, Canada” was published today in the journal Annals of Emergency Medicine.

Author block: Marian J. Vermeulen, Therese A. Stukel, Andrew S. Boozary, Astrid Guttmann, Michael J. Schull

ICES is an independent, non-profit organization that uses population-based health information to produce knowledge on a broad range of healthcare issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting healthcare needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy.

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Tara Maher
Communications Officer, ICES
[email protected]
(o) 416-480-4055 ext. 3859

Read the Journal Article