Open Access Research article

Payment for performance (P4P): any future in Italy?

Silvana Castaldi12*, Annalisa Bodina1, Luciana Bevilacqua13, Elena Parravicini3, Michaela Bertuzzi3 and Francesco Auxilia12

Author Affiliations

1 Department of Public Health, Microbiology and Virology, University of Milan, Italy

2 Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy

3 AO Ospedale Niguarda Ca' Granda, Milan, Italy

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BMC Public Health 2011, 11:377  doi:10.1186/1471-2458-11-377

Published: 24 May 2011



Pay for Performance (P4P) programs, based on provision of financial incentives for service quality, have been widely adopted to enhance quality of care and to promote a more efficient use of health care resources whilst improving patient outcomes. In Italy, as in other countries, the growing concern over the quality of health services provided and the scarcity of resources would make P4P programs a useful means of improving their performance. The aim of this paper is to evaluate whether it is possible to implement P4P programs in the Lombardy Region, in Italy, based on the existing data set.


Thirteen quality measures were identified regarding four clinical conditions (acute myocardial infarction (AMI), heart failure (HF), ischemic stroke and hip and knee replacement) on the basis of an international literature review. Data was collected using the database of three institutions, which included hospital discharge records (Scheda di Dimissione ospedaliera-SDO-) and letters of discharge. The study population was identified using both the Principal ICD-9-CM diagnosis codes and the discharge date. A Statistical Analysis System (SAS) program was used for the text analysis.


It was possible to calculate almost all the parameters pertaining to the three hospitals as all the data required was available with the exception of inpatient mortality in two hospitals and smoking cessation advice/counseling in one hospital.


On the ground of this analysis, we believe that it is possible to implement a P4P program in the Lombardy Region. However, for this program to be initiated, all necessary data must be available in electronic format and uniformly collected. Moreover, several other factors must be assessed: which clinical conditions should be included, the threshold for each quality parameter, the amount of financial incentives offered and how they will be provided.

performance; quality; payment; measurement