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.
Keywords treatment efficacy - out-of-pocket expenses - osteoporosis treatment - pay-for-performance programs
Dr. Sinsky presented this work at the 2006 national SGIM meeting in Los Angeles.