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Pay for performance Medical Care fails to boost UK hypertension care/outcomes
  February 1, 2011 Sue Hughes
Harvard, MA and Nottingham, UK - The pay-for-performance program used in the UK to encourage family doctors to treat hypertension better has had no impact on quality of care or outcomes, a new study has shown [1].
The study, published online January 26, 2010 in BMJ, was led by Dr Brian Serumaga (Harvard Medical School, Boston, MA and University of Nottingham Medical School, UK).
He explained to heartwire that "pay for performance" was introduced by the UK government in 2004, with the goal of improving care of several chronic diseases by motivating doctors to review their patients more regularly and treat to national targets. Based on the proportion of patients achieving certain quality indicators, general practitioners could receive payments as high as 25% of their total income. But evidence showing that this approach works is lacking.
Targets set too low
The current research suggests the reason that hypertension outcomes had not improved under this program may be because the targets aimed for were not set high enough. Serumaga gave the example that doctors could claim maximum payments if they reviewed 80% of their hypertension patients each year, but they were already reviewing almost that many patients before the scheme was introduced. "So under this program, doctors are being paid a great deal of extra money for what they were doing anyway, without significantly improving the quality of care," he says. "The setting of the indicator thresholds for maximum payment close to prevailing practice may have provided little incentive for further improvement. Thus, pay for performance may have simply supported existing practice for hypertension," the authors write.
"Pay for performance was rushed through with no evidence that it would work, and we have now shown that it probably isn't the best way of improving care," Serumaga said. He noted that the UK government had allocated 1.8 billion to the program for a six-year period, but because of the overwhelming response from GPs, with more than 99% taking up the payments, it has probably cost much more than this. "Some reports estimate that it will have cost twice as much as originally estimated. And if other areas show similarly disappointing effects as we have seen in hypertension, this could be considered a great waste of money," he added.
For the study, Serumaga et al analyzed data from a large database of primary-care medical records in the UK, focusing on 470 725 patients with hypertension diagnosed between 2000 and 2007. They found that after accounting for secular trends, there were no changes in blood-pressure monitoring, control, or treatment intensity after the pay-for-performance scheme came into practice. There was also no effect on the cumulative incidence of stroke, MI, renal failure, heart failure, or all-cause mortality in both treatment-experienced and newly treated subgroups.
They point out that good quality of care for hypertension was stable or improving before pay for performance was introduced, and the new scheme had no discernible effects on processes of care or on hypertension-related clinical outcomes. They conclude: "Generous financial incentives, as designed in the UK pay-for-performance policy, may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.
Quality care needs more than just throwing money at doctors.
"Implementing the broad range of pay-for-performance targets in a series of steps may achieve greater attention to and improvement of specific sets of quality measures," the authors suggest, adding: "To stimulate further improvement in hypertension care in the UK, it may be necessary to implement other evidence-based interventions, such as educational outreach programs, comanagement in mixed professional teams, and engaging patients in their own care."
To heartwire, Serumaga noted that outreach programs, in which experts meet with general practitioners and recommend better ways of managing their patients, have been shown effective in Australia and New Zealand. And mixed professional teams involving pharmacists and nurses can work well, as they can encourage patients to manage their condition better themselves. "Quality care needs more than just throwing money at doctors," he commented.
BMJ (Published 25 January 2011)
Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study
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