The Effect of Pay for Performance in the Emergency Department on Patient Waiting Times and Quality of Care in Ontario, Canada: A Difference-in-Differences Analysis

Study objective: In 2008, a pay-for-performance program was implemented in sequential waves in Ontario emergency departments (EDs), with the aim of reducing length of stay. We seek to evaluate its effects on ED length of stay and quality of care. Methods: This was a retrospective observational study of ED visits in Ontario from April 1, 2007, to March 31, 2011, using multivariable difference-in-differences analysis. Pay-for-performance hospitals and matched control sites were selected for each of 3 waves of the program. The primary outcome was 90th percentile ED length of stay; we also examined quality-of-care indicators. Results: Pay-for-performance hospitals had a modest reduction in overall adjusted 90th percentile ED length of stay in wave 1(-36 minutes; 95% confidence interval [CI] -50 to -21 minutes), but not in wave 2 (-14 minutes; 95% CI -30 to 2 minutes) or wave 3 (-7 minutes; 95% CI -23 to 8 minutes). ED admitted patients had a pronounced reduction in adjusted 90th percentile length of stay in wave 1 (-225 minutes; 95% CI -263 to -188 minutes) and wave 2 (-133 minutes; 95% CI -175 to -91 minutes). Nonadmitted low-acuity patients had reductions in adjusted 90th percentile ED length of stay in wave 1 (-24 minutes; 95% CI -29 to -18 minutes) and wave 3 (-19 minutes; 95% CI -24 to -14 minutes). The program did not negatively affect ED quality-of-care measures, such as 30-day mortality or readmission rates. Conclusion: Pay-for-performance was associated with modest overall benefits for ED length of stay without adversely affecting quality of care.