Impact of pay-for-performance schemes in primary healthcare on avoidable hospital admissions: a systematic review

Abstract

Introduction: Pay-for-performance schemes (P4P) aim to enhance quality of care by financially incentivizing health workers or institutions based on the achievement of pre-specified performance targets. This systematic review main goal was to assess whether P4P implemented in public funded primary healthcare services (pfPHC) may reduce avoidable hospital admission (AHA) rates. Methods: PubMed Central, Cochrane Library, and Web of Science were searched, complemented with citation tracking. Risk of bias was assessed using ROB-2 and ROBINS-I tools. Due to the substantial heterogeneity among the included studies, it was not possible to perform a meta-analysis. A qualitative synthesis is presented. Results: Thirteen observational studies and one cluster-randomized stepped-wedge trial were included. Six studies reported a reduction in AHA following implementation of a P4P in pfPHC, two reported no significant effect, and six reported mixed results. Conclusions: Giving more weight to the clinical trial results and emphasizing those from observational studies with a lower risk of bias, we may conclude that the impact of P4P in AHA depends on aligning targets with governmental support. Moreover, incentives should consider structural reforms, regional needs, patient and physician characteristics, and require standardized evaluation and robust monitoring to ensure sustained quality and equity of care. Fundings: This systematic review has not been funded. Registration: This systematic review protocol was registered in PROSPERO with the register number CRD420250641520.