BMJ: P4P doesn't yield better hypertension outcomes

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A new study published Jan. 26 in the British Medical Journal (BMJ) presents strong evidence that pay-for-performance (P4P) does not offer any benefit to patients with hypertension, despite the enormous administrative costs required to maintain such a system.

Brian Serumaga, formerly of Harvard Medical School in Boston, but now at University of Nottingham Medical School in England, and colleagues studied data from primary care records from 358 U.K. general practices.

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 program includes specific targets for general practitioners to demonstrate high quality care for patients with hypertension and other diseases.

Serumaga and colleagues found there were 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 of 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.

Analysis showed that even after allowing for a number of variations, there was no identifiable impact on the cumulative incidence of stroke, heart attacks, renal failure, heart failure or mortality in both patients who had started treatment before 2001 and patients whose treatment had started close to the implementation of P4P.

The quality of care for hypertension, such as blood pressure monitoring and treatment intensification, was already improving before the QOF began, said the researchers.

"No matter how we looked at the numbers, the evidence was unmistakable; by no measure did pay-for-performance benefit patients with hypertension," said Serumaga.

Researchers said that doctor performance is based on many factors besides money that were not addressed in this program: patient behavior, continuing MD training, shared responsibility and teamwork with pharmacists, nurses and other health professionals. "These are factors that reach far beyond simple monetary incentives."

The U.K. National Health Service committed $2.8 billion in funding to the program.

"Governments and private insurers throughout the world are likely wasting many billions on policies that assume that all you have to do is pay doctors to improve quality of medical care. Based on our study of almost 500,000 patients over seven years, that assumption is questionable at best," said the study's senior author Stephen Soumerai, ScD, a professor in the department of population medicine at Harvard.