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University of Nottingham

Health Care

Pay-for-Performance Targets Do Not Improve Patient Health

Study of hypertension patients shows no change in metrics

Published: Tuesday, February 1, 2011 - 06:00

Pay-for-performance targets set for general practitioners in the United Kingdom are failing to improve the health of patients with high blood pressure, according to a joint study funded by U.K., U.S., and Canadian research organizations.

The study, which presents the strongest evidence yet that pay for performance does not offer any benefit, was carried out by Dr. Brian Serumaga, a Harvard Medical School fellow in pharmaceutical policy research in the Division of Primary Care and School of Pharmacy at The University of Nottingham.

Working with a team of experts from the United Kingdom, Canada, and the United States, Serumaga focused on patients with hypertension (high blood pressure). The results of his research, which involved nearly half a million patients, have been published in the online journal bmj.com.

About half of people aged over 50 have hypertension, which is one of the most treatable, but undertreated, cardiovascular risk factors. Hypertension is the most common reason for a visit to the doctors in the United Kingdom, the United States, and Canada.

The Quality and Outcomes Framework (QOF) for general practice is a voluntary system of financial incentives, which has been in place since 2004; part of this program includes specific targets for general practitioners (GPs) to demonstrate high-quality care for patients with hypertension and other diseases.

Working in collaboration with experts from Harvard Medical School, Harvard Pilgrim Health Care Institute, and the University of Alberta, Serumaga set out to assess the effect of the targets on quality of care and outcomes among UK patients with hypertension.

“The study found that good quality of care for hypertension was stable or improving before pay for performance was introduced,” says Stephen Soumerai, professor of population medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. “Pay for performance had no discernible effects on processes of care or on hypertension-related clinical outcomes, and the system may not be sufficient to improve quality of care and outcomes for hypertension and other common chronic conditions.”

Serumaga concurs. “No matter how we looked at the numbers the evidence was unmistakable,” he says. “To date, there is little evidence of the effectiveness of pay-for-performance targets.”

This study was funded by the Harvard Medical School Fellowship in Pharmaceutical Policy Research, the U.S. Agency for Healthcare Research and Quality, HMO Research Network’s Centre for Education and Research in Therapeutics, and the Alberta Heritage Foundation.

The team studied data from The Health Improvement Network (THIN), a large database of primary-care records from 358 UK general practices. They found 470,725 patients diagnosed with hypertension between January 2000 and August 2007.

They looked at various measures, including blood pressures over time, rates of blood pressure monitoring, blood pressure control and treatment intensity at monthly intervals three years before and four years after the introduction of the targets, and hypertension outcomes as well as illnesses.

Analysis showed that even after allowing for secular trends, there was no change in blood pressure monitoring, blood pressure control, or treatment intensity that could be attributed to the QOF targets.

There was a decline in the proportion of patients receiving no medicines or only a single medicine, at the same time as a rise in numbers of patients receiving combination therapy with two or three-plus medications.

The researchers found, however, that the QOF targets were not associated with any change to these trends in medication prescribing.

Similarly, there was no identifiable effect from the targets on the cumulative incidence of stroke, heart attacks, renal failure, heart failure, or mortality in both patients who had started treatment before 2001 and another subgroup of patients whose treatment had started close to the first QOF interventions.

“Doctor performance is based on many factors besides money that were not addressed in the QOF program,” says Tony Avery, professor of primary care at The University of Nottingham. “Patient behavior, continuing GP training, shared responsibility, and teamwork with pharmacists, nurses, and other health professionals are factors that reach far beyond simple monetary incentives.”

The study points to the need to reevaluate current funding policies. “Governments and private insurers throughout the world are likely wasting many billions of dollars on policies that assume that all you have to do is pay doctors to improve quality of medical care,” Avery says. “By no measure does pay for performance benefit patients with hypertension. Based on our study of almost 500,000 patients over seven years, that assumption is questionable at best.”

Meanwhile patients’ hypertension continues. “These results show clearly the QOF program hasn’t helped people with hypertension, despite increased prescribing of medicines,” says Rachel Elliott, Lord Trent Professor of Medicines and Health in the School of Pharmacy at The University of Nottingham. “In a time of constrained budgets, policymakers need to consult evidence so they don’t introduce new initiatives that cost huge amounts of public money and don’t work.”


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University of Nottingham

The University of Nottingham has award-winning campuses in the United Kingdom, China, and Malaysia. The university is committed to providing a truly international education for its 39,000 students, producing world-leading research and benefiting the communities around its campuses in the United Kingdom and Asia. The University’s vision is to be recognized around the world for its signature contributions, especially in global food security, energy and sustainability, and health.