Pay for performance targets do not improve patient health

PA 25/11

Pay for performance targets set for GPs in the UK are failing to improve the health of patients with high blood pressure.

The new 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 UK, Canada and the USA Dr Serumaga’s research focused on patients with hypertension (high blood pressure). The results of his research, which involved nearly half a million patients, are published tonight Tuesday January 25 2011 in the online journal

Around 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 UK, US 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 and part of this programme includes specific targets for GPs to demonstrate high quality care for patients with hypertension and other diseases.

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

Stephen Soumerai, Professor of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute, said: “The study found that good quality of care for hypertension was stable or improving before pay for performance was introduced. 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.”

Dr Serumaga said: “No matter how we looked at the numbers the evidence was unmistakable. To date, there is little evidence of the effectiveness of pay for performance targets.”

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 impact 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 sub-group of patients whose treatment had started close to the first QOF interventions.

Tony Avery, Professor of Primary Care at The University of Nottingham said: “Doctor performance is based on many factors besides money that were not addressed in the QOF programme. 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.”

Professor Stephen Soumerai, from the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute said: “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.

“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.”

Rachel Elliott, Lord Trent Professor of Medicines and Health in the School of Pharmacy at The University of Nottingham said: “These results show clearly the QOF programme hasn’t helped people with hypertension, despite increased prescribing of medicines. 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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