Is chlamydia testing in general practice sustainable when financial incentives and external audit plus feedback are removed? ACCEPt-able: a cluster randomised controlled trial
Financial incentives (FI) and audit plus feedback (A+F) are often used by governments to motivate and improve general practitioner (GP) performance. Removing or reducing incentive payments is often undertaken with insufficient evidence of the impact on GP clinical practice.
The Australian Chlamydia Control Evaluation Pilot (ACCEPt), in a cluster-randomised controlled trial (RCT), evaluated an intervention to increase chlamydia testing among 16-29 year old patients attending general practices in four Australian States. As part of a complex multi-faceted intervention, GPs in the intervention group received a FI of $5-$8 per chlamydia test and a quarterly A+F report of their chlamydia testing rates, discussed with GPs by researchers in face-to-face meetings. The objective of this current study, ACCEPt-able, was to examine the effects of removal of these measures on chlamydia testing.
At the end of the ACCEPt trial, we designed ACCEPt-able, a new 2x2 factorial cluster-RCT. ACCEPt intervention general practices were re-randomised to four groups: remove A+F and retain FI, remove FI and retain A+F, remove both A+F and FI, or retain both FI and A+F. The main comparisons were: removal versus retention of FI and removal versus retention of A+F. The primary outcome was the absolute difference in chlamydia testing rates (proportion with 95% confidence intervals, CI, of 16-29 year old patients tested for chlamydia within a 12-month period) at year 2 compared with baseline, estimated using mixed-effect logistic regression models accounting for clustering at the clinical level.
A total of 55 general practices were re-randomised. Chlamydia testing decreased in all general practices across the four groups. In groups where FI was removed, testing decreased from 20.0% to 11.7% and where FI was retained, from 20.1% to 14.4%. There was no evidence of a treatment effect between the groups (difference = 2.6% 95% CI: - 0.1, 5.7). In groups where A+F was removed, chlamydia testing rates decreased from 20.8% to 11.5% and where A+F was retained, from 19.7% to 14.8%. There was a larger reduction in chlamydia testing when A+F was removed than when it was retained (difference = 4.4%, 95% CI: 1.1, 7.8).
Chlamydia testing rates fell in all general practices after the end of the ACCEPt intervention, but when A+F was removed, chlamydia testing decreased more than when FI was removed. Providing feedback and discussing performance might therefore be more important than modest incentive payments. These results suggest the removal of interventions aimed to modify GP performance can have a negative impact on subsequent performance and thus patient outcomes. These results highlight the challenges for policy makers and require consideration in their decision making.