Financial incentives don't improve U.K. doctors' performance for hypertension care

A pay-for-performance initiative in the United Kingdom aimed at managing hypertension had no effect on clinical outcomes, a new study has found.

Researchers performed an interrupted time series study of patients in the United Kingdom who were diagnosed with hypertension between January 2000 and August 2007. In 2004, the U.K. had implemented the Quality and Outcomes Framework, a pay-for-performance program that offered physicians financial incentives, up to 25% of their income, for achieving targets indicating high-quality care for several chronic diseases. The researchers used data from the Health Improvement Network database to examine the effects of the pay-for-performance initiative on processes and outcomes of care for hypertension.

The researchers determined change in systolic and diastolic blood pressures, blood pressure monitoring, blood pressure control, and monthly treatment intensity at baseline and 36 months after the pay-for-performance program was implemented. Other main outcome measures included cumulative incidence of major hypertension-related outcomes and all-cause mortality in newly treated patients (defined as those who began treatment six months before the pay-for-performance began) and treatment-experienced patients (defined as those who started treatment before January 2001). The study results were published online Jan. 25 by BMJ.

Overall, data on 470,725 patients were analyzed. The authors found no change attributable to pay for performance in blood pressure monitoring frequency (level change, 0.85, 95% CI, −3.04 to 4.74, P=0.669; trend change,−0.01, 95% CI, −0.24 to 0.21, P=0.615), rate of blood pressure control (level change, −1.19, 95% CI, −2.06 to 1.09, P=0.109; trend change, −0.01, 95% CI, −0.06 to 0.03, P=0.569), or treatment intensity (level change, 0.67, 95% CI, −1.27 to 2.81, P=0.412; trend change, 0.02, 95% CI, −0.23 to 0.19, P=0.706). Pay for performance did not affect cumulative incidence of myocardial infarction, stroke, renal failure, heart failure, or all-cause mortality in either treatment-experienced or newly treated patients.

The study's limitations included its limited generalizability to other countries and the lack of a comparison group. However, the authors concluded that the pay-for-performance initiative implemented throughout the United Kingdom did not seem to affect processes or outcomes of care for hypertension. Hypertension care before the initiative began was already good and improving, the authors noted, and the performance thresholds may not have been set high enough to make the incentives effective. The results suggest that policymakers may have overestimated the effect of financial incentives on doctors' performance, the authors said. They recommended that resources currently directed toward pay for performance might be better spent on alternative approaches, for example, case management or comanagement.