title: Impact of 'stretch' targets for cardiovascular disease management within a local pay-for-performance programme.
abstract: Pay-for-performance programs are often aimed to improve the management of chronic diseases. We evaluate the impact of a local pay for performance programme (QOF+), which rewarded financially more ambitious quality targets ('stretch targets') than those used nationally in the Quality and Outcomes Framework (QOF). We focus on targets for intermediate outcomes in patients with cardiovascular disease and diabetes. A difference-in-difference approach is used to compare practice level achievements before and after the introduction of the local pay for performance program. In addition, we analysed patient-level data on exception reporting and intermediate outcomes utilizing an interrupted time series analysis. The local pay for performance program led to significantly higher target achievements (hypertension: p-value <0.001, coronary heart disease: p-values <0.001, diabetes: p-values <0.061, stroke: p-values <0.003). However, the increase was driven by higher rates of exception reporting (hypertension: p-value <0.001, coronary heart disease: p-values <0.03, diabetes: p-values <0.05) in patients with all conditions except for stroke. Exception reporting allows practitioners to exclude patients from target calculations if certain criteria are met, e.g. informed dissent of the patient for treatment. There were no statistically significant improvements in mean blood pressure, cholesterol or HbA1c levels. Thus, achievement of higher payment thresholds in the local pay for performance scheme was mainly attributed to increased exception reporting by practices with no discernable improvements in overall clinical quality. Hence, active monitoring of exception reporting should be considered when setting more ambitious quality targets. More generally, the study suggests a trade-off between additional incentive for better care and monitoring costs.
authors: Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.
authors: Utz J
authors: UJ
authors: Pape
authors: Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.
authors: Kit
authors: K
authors: Huckvale
authors: Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.
authors: Josip
authors: J
authors: Car
authors: Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.
authors: Azeem
authors: A
authors: Majeed
authors: Department of Primary Care and Public Health, Imperial College London, London, United Kingdom.
authors: Christopher
authors: C
authors: Millett
mesh_terms: D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000453:epidemiology* / Q000628:therapy; D015897:Comorbidity; D019468:Disease Management; D005006:Ethnicity; D005260:Female; D006801:Humans; D008131:London / Q000453:epidemiology / Q000208:ethnology; D008297:Male; D017063:Outcome Assessment, Health Care; D010816:Physician Incentive Plans; D011320:Primary Health Care; D019984:Quality Indicators, Health Care; D011787:Quality of Health Care