Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study.
OBJECTIVE
To assess the impact of a pay for performance incentive on quality of care and outcomes among UK patients with hypertension in primary care.


METHODS
Interrupted time series.


METHODS
The Health Improvement Network (THIN) database, United Kingdom.


METHODS
470 725 patients with hypertension diagnosed between January 2000 and August 2007.


METHODS
The UK pay for performance incentive (the Quality and Outcomes Framework), which was implemented in April 2004 and included specific targets for general practitioners to show high quality care for patients with hypertension (and other diseases).


METHODS
Centiles of systolic and diastolic blood pressures over time, rates of blood pressure monitoring, blood pressure control, and treatment intensity at monthly intervals for baseline (48 months) and 36 months after the implementation of pay for performance. Cumulative incidence of major hypertension related outcomes and all cause mortality for subgroups of newly treated (treatment started six months before pay for performance) and treatment experienced (started treatment in year before January 2001) patients to examine different stages of illness.


RESULTS
After accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval -3.04 to 4.74, P=0.669 and trend change -0.01, -0.24 to 0.21, P=0.615), control (-1.19, -2.06 to 1.09, P=0.109 and -0.01, -0.06 to 0.03, P=0.569), or treatment intensity (0.67, -1.27 to 2.81, P=0.412 and 0.02, -0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups.


CONCLUSIONS
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. 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.
Department of Population Medicine, Harvard Medical School, Harvard Pilgrim Health Care Institute, Boston, MA 02215, USA. stephen_soumerai@hms.harvard.edu
Brian
B
Serumaga
Dennis
D
Ross-Degnan
Anthony J
AJ
Avery
Rachel A
RA
Elliott
Sumit R
SR
Majumdar
Fang
F
Zhang
Stephen B
SB
Soumerai
D000328:Adult; D000368:Aged; D000959:Antihypertensive Agents / Q000191:economics / Q000627:therapeutic use*; D001794:Blood Pressure; D001795:Blood Pressure Determination; D003695:Delivery of Health Care / Q000191:economics / Q000592:standards; D005260:Female; D006801:Humans; D006973:Hypertension / Q000188:drug therapy* / Q000191:economics / Q000503:physiopathology; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000191:economics; D019984:Quality Indicators, Health Care / Q000191:economics; D011787:Quality of Health Care; D012052:Reimbursement, Incentive; D006113:United Kingdom
D000959:Antihypertensive Agents
Pharmacoepidemiol Drug Saf. 2007 Apr;16(4):393-401
17066486
Med Care. 2006 Jul;44(7):646-57
16799359
N Engl J Med. 2006 Jul 27;355(4):375-84
16870916
Lancet. 2005 Jan 15-21;365(9455):217-23
15652604
J Gen Intern Med. 2003 Dec;18(12):967-76
14687254
Ann Intern Med. 2010 Feb 16;152(4):225-31
20157137
JAMA. 1990 Feb 9;263(6):831-9
2404151
N Engl J Med. 2009 Jul 23;361(4):368-78
19625717
Inform Prim Care. 2004;12(3):171-7
15606990
BMJ. 2010 Jan 21;340:c88
20093280
BMJ. 2002 Oct 26;325(7370):941
12399345
Health Serv Res. 2003 Apr;38(2):535-52
12785560
J Clin Hypertens (Greenwich). 2002 Nov-Dec;4(6):393-404
12461301
Pharmacoepidemiol Drug Saf. 2009 Sep;18(9):807-14
19551699
N Engl J Med. 2004 Sep 30;351(14):1448-54
15459308
Ann Intern Med. 2006 Aug 15;145(4):265-72
16908917
J Clin Pharm Ther. 2002 Aug;27(4):299-309
12174032
J Hypertens. 2007 Jun;25(6):1105-87
17563527
N Engl J Med. 1991 Oct 10;325(15):1072-7
1891009
BMJ. 2003 Mar 1;326(7387):457-8
12609914
Am J Public Health. 1981 Jan;71(1):38-46
7258429
JAMA. 1990 Jan 26;263(4):549-56
2104640
J Health Polit Policy Law. 2009 Oct;34(5):717-46
19778930
Ann Intern Med. 2007 Jan 16;146(2):96-103
17227933