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1.  Pay for perfomance and the quality of diabetes management in individuals with and without co-morbid medical conditions 
To examine the impact of the Quality and Outcomes Framework, a major pay-for-performance incentive introduced in the UK during 2004, on diabetes management in patients with and without co-morbidity.
Cohort study comparing actual achievement of treatment targets in 2004 and 2005 with that predicted by the underlying (pre-intervention) trend in diabetes patients with and without co-morbid conditions.
A total of 422 general practices participating in the General Practice Research Database.
Main outcomes measures
Achievement of diabetes treatment targets for blood pressure (< 140/80 mm Hg), HbA1c (≤ 7.0%) and cholesterol (≤ 5 mmol/L).
The percentage of diabetes patients with co-morbidity reaching blood pressure and cholesterol targets exceeded that predicted by the underlying trend during the first two years of pay for perfomance (by 3.1% [95% CI 1.1–5.1] for BP and 4.1% [95% CI 2.2–6.0] for cholesterol among patients with ≥ 5 co-morbidities in 2005). Similar improvements were evident in patients without co-morbidity, except for cholesterol control in 2004 (−0.2% [95% CI −1.7–1.4]). The percentage of patients meeting the HbA1c target in the first two years of this program was significantly lower than predicted by the underlying trend in all patients, with the greatest shortfall in patients without co-morbidity (3.8% [95% CI 2.6–5.0] lower in 2005). Patients with co-morbidity remained significantly more likely to meet treatment targets for cholesterol and HbA1c than those without after the introduction of pay for perfomance.
Diabetes patients with co-morbid conditions appear to have benefited more from this pay-for-performance program than those without co-morbidity.
PMCID: PMC2738769  PMID: 19734534
2.  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.
Design Interrupted time series.
Setting The Health Improvement Network (THIN) database, United Kingdom.
Participants 470 725 patients with hypertension diagnosed between January 2000 and August 2007.
Intervention 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).
Main outcome measures 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.
PMCID: PMC3026849  PMID: 21266440
3.  Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care 
Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management.
We conducted a retrospective open-cohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154 945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA1c) levels and total cholesterol.
We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA1c level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19).
We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-for-performance programs appear to benefit both large and small practices to a similar extent.
PMCID: PMC3168664  PMID: 21810950
4.  The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators 
Objective To evaluate the effect of financial incentives on four clinical quality indicators common to pay for performance plans in the United Kingdom and at Kaiser Permanente in California.
Design Longitudinal analysis.
Setting 35 medical facilities of Kaiser Permanente Northern California, 1997-2007.
Participants 2 523 659 adult members of Kaiser Permanente Northern California.
Main outcomes measures Yearly assessment of patient level glycaemic control (HbA1c <8%), screening for diabetic retinopathy, control of hypertension (systolic blood pressure <140 mm Hg), and screening for cervical cancer.
Results Incentives for two indicators—screening for diabetic retinopathy and for cervical cancer—were removed during the study period. During the five consecutive years when financial incentives were attached to screening for diabetic retinopathy (1999-2003), the rate rose from 84.9% to 88.1%. This was followed by four years without incentives when the rate fell year on year to 80.5%. During the two initial years when financial incentives were attached to cervical cancer screening (1999-2000), the screening rate rose slightly, from 77.4% to 78.0%. During the next five years when financial incentives were removed, screening rates fell year on year to 74.3%. Incentives were then reattached for two years (2006-7) and screening rates began to increase. Across the 35 facilities, the removal of incentives was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical cancer screening.
Conclusion Policy makers and clinicians should be aware that removing facility directed financial incentives from clinical indicators may mean that performance levels decline.
PMCID: PMC2868163  PMID: 20460330
5.  Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework 
Objectives To investigate the effect of withdrawing incentives on recorded quality of care, in the context of the UK Quality and Outcomes Framework pay for performance scheme.
Design Retrospective longitudinal study.
Setting Data for 644 general practices, from 2004/05 to 2011/12, extracted from the Clinical Practice Research Datalink.
Participants All patients registered with any of the practices over the study period—13 772 992 in total.
Intervention Removal of financial incentives for aspects of care for patients with asthma, coronary heart disease, diabetes, stroke, and psychosis.
Main outcome measures Performance on eight clinical quality indicators withdrawn from a national incentive scheme: influenza immunisation (asthma) and lithium treatment monitoring (psychosis), removed in April 2006; blood pressure monitoring (coronary heart disease, diabetes, stroke), cholesterol concentration monitoring (coronary heart disease, diabetes), and blood glucose monitoring (diabetes), removed in April 2011. Multilevel mixed effects multiple linear regression models were used to quantify the effect of incentive withdrawal.
Results Mean levels of performance were generally stable after the removal of the incentives, in both the short and long term. For the two indicators removed in April 2006, levels in 2011/12 were very close to 2005/06 levels, although a small but statistically significant drop was estimated for influenza immunisation. For five of the six indicators withdrawn from April 2011, no significant effect on performance was seen following removal and differences between predicted and observed scores were small. Performance on related outcome indicators retained in the scheme (such as blood pressure control) was generally unaffected.
Conclusions Following the removal of incentives, levels of performance across a range of clinical activities generally remained stable. This indicates that health benefits from incentive schemes can potentially be increased by periodically replacing existing indicators with new indicators relating to alternative aspects of care. However, all aspects of care investigated remained indirectly or partly incentivised in other indicators, and further work is needed to assess the generalisability of the findings when incentives are fully withdrawn.
PMCID: PMC3903315  PMID: 24468469
6.  Impact of Pay for Performance on Ethnic Disparities in Intermediate Outcomes for Diabetes: A Longitudinal Study  
Diabetes Care  2009;32(3):404-409.
OBJECTIVE—The purpose of this study was to examine the impact of a major pay for performance incentive on trends in the quality of diabetes care in white, black, and South Asian ethnic groups in an urban setting in the U.K.
RESEARCH DESIGN AND METHODS—We developed longitudinal models examining the quality of diabetes care in a cohort of ethnically diverse patients in Southwest London using electronic family practice records. Outcome measures were mean blood pressure and A1C values between 2000 and 2005.
RESULTS—The introduction of pay for performance was associated with reductions in mean systolic and diastolic blood pressure, which were significantly greater than those predicted by the underlying trend in the white (−5.8 and −4.2 mmHg), black (−2.5 and −2.4 mmHg), and South Asian (−5.5 and −3.3 mmHg) groups. Reductions in A1C levels were significantly greater than those predicted by the underlying trend in the white group (−0.5%) but not in the black (−0.3%) or South Asian (−0.4%) groups. Ethnic group disparities in annual measurement of blood pressure and A1C were abolished before the introduction of pay for performance.
CONCLUSIONS—The introduction of a pay for performance incentive in U.K. primary care was associated with improvements in the intermediate outcomes of diabetes care for all ethnic groups. However, the magnitude of improvement appeared to differ between ethnic groups, thus potentially widening existing disparities in care. Policy makers should consider the potential impacts of pay for performance incentives on health disparities when designing and evaluating such programs.
PMCID: PMC2646017  PMID: 19073759
7.  Impact of pay for performance on quality of chronic disease management by social class group in England 
To examine associations between social class and achievement of selected national audit targets for coronary heart disease (CHD), diabetes and hypertension in England before and after the introduction of a major pay for performance programme in 2004.
Secondary analysis of 2003 and 2006 national survey data for respondents with CHD and diabetes and hypertension.
Main outcome measure
Achievement of national audit targets for blood pressure, blood glucose and cholesterol control.
There were no significant differences in achievement of blood pressure targets in individuals from manual and non-manual occupational groups with diabetes (2003: 65.9% v 60.3%, 2006: 67.6% v 69.7%) or hypertension (2003: 66.2% v 66.2%, 2006: 72.8% v 71.9%) before or after the introduction of pay for performance. Achievement of the cholesterol target was also similar in individuals from manual and non-manual groups with diabetes (2003: 52.5% v 46.6%, 2006: 68.7% v 70.5%) or CHD (2003: 54.3% v 53.3%, 2006: 68.6% v 71.3%). Differences in achievement of the blood pressure target in CHD [75.8% v 84.5%; AOR 0.44 (0.21-0.90)] were evident between manual and non-manual occupational groups after the introduction of pay for performance.
The quality of chronic disease management in England was broadly equitable between socioeconomic groups before this major pay for performance programme and remained so after its introduction.
PMCID: PMC2746849  PMID: 19297651
8.  Ethnic Disparities in Coronary Heart Disease Management and Pay for Performance in the UK 
Few pay for performance schemes have been subject to rigorous evaluation, and their impact on disparities in chronic disease management is uncertain.
To examine disparities in coronary heart disease management and intermediate clinical outcomes within a multiethnic population before and after the introduction of a major pay for performance initiative in April 2004.
Comparison of two cross-sectional surveys using electronic general practice records.
Thirty-two family practices in south London, United Kingdom (UK).
Two thousand eight hundred and ninety-one individuals with coronary heart disease registered with participating practices in 2003 and 3,101 in 2005.
Percentage achievement by ethnic group of quality indicators in the management of coronary heart disease
The proportion of patients reaching national treatment targets increased significantly for blood pressure (51.2% to 58.9%) and total cholesterol (65.7% to 73.8%) after the implementation of a major pay for performance initiative in April 2004. Improvements in blood pressure control were greater in the black group compared to whites, with disparities evident at baseline being attenuated (black 54.8% vs. white 58.3% reaching target in 2005). Lower recording of blood pressure in the south Asian group evident in 2003 was attenuated in 2005. Statin prescribing remained significantly lower ( < 0.001) in the black group compared with the south Asian and white groups after the implementation of pay for performance (black 74.8%, south Asian 83.8%, white 80.2% in 2005).
The introduction of pay for performance incentives in UK primary care has been associated with better and more equitable management of coronary heart disease across ethnic groups.
PMCID: PMC2607505  PMID: 18953616
pay for performance; coronary heart disease; primary care; ethnicity
9.  Performance of small general practices under the UK's Quality and Outcomes Framework 
The British Journal of General Practice  2010;60(578):e335-e344.
Small general practices are often perceived to provide worse care than larger practices.
To describe the comparative performance of small practices on the UK's pay-for-performance scheme, the Quality and Outcomes Framework.
Design of study
Longitudinal analysis (2004–2005 to 2006–2007) of quality scores for 48 clinical activities.
Family practices in England (n = 7502).
Comparison of performance of practices by list size, in terms of points scored in the pay-for-performance scheme, reported achievement rates, and population achievement rates (which allow for patients excluded from the scheme).
In the first year of the pay-for-performance scheme, the smallest practices (those with fewer than 2000 patients) had the lowest median reported achievement rates, achieving the clinical targets for 83.8% of eligible patients. Performance generally improved for practices of all sizes over time, but the smallest practices improved at the fastest rate, and by year 3 had the highest median reported achievement rates (91.5%). This improvement was not achieved by additional exception reporting. There was more variation in performance among small practices than larger ones: practices with fewer than 3000 patients (20.1% of all practices in year 3), represented 46.7% of the highest-achieving 5% of practices and 45.1% of the lowest-achieving 5% of practices.
Small practices were represented among both the best and the worst practices in terms of achievement of clinical quality targets. The effect of the pay-for-performance scheme appears to have been to reduce variation in performance, and to reduce the difference between large and small practices.
PMCID: PMC2930243  PMID: 20849683
incentives; quality; primary care
10.  Use of outcomes in monitoring healthcare – how many outcome measures are needed in monitoring diabetes in primary care? 
To investigate the relationship between patient experience assessed through surveys of random samples of practice populations and intermediate outcome targets in those patients with diabetes, collected in the Quality and Outcomes Framework pay-for-performance scheme.
Cross-sectional study.
The East Midlands region of England.
Six hundred and twenty-nine general practices.
Main outcome measures
Logistic regression models were used to assess whether practice-level reports of patient experience of access and consultations were associated with achievement of treatment targets (HbA1c of 7.5% and 10% or lower, BP 145/85 mmHg or lower, and cholesterol 5 mmol/L or lower) in people with diabetes. Survey respondent characteristics (ethnicity, age, sex) and practice size, deprivation, and prevalence of diabetes and obesity were also assessed within the models.
Patient experience of practice populations explained little of the variation in diabetes treatment targets. In the practice survey, the proportion of respondents who had seen a nurse in the last 6 months was associated with increased likelihood of achieving HbA1c of 7.5%, and being involved in decision-making or having tests and treatment explained were associated with achievement of HbA1c of 10% or less, cholesterol of 5 mmol/L or less, and BP of 145/85 or less.
Although patient experience at practice level should be included in monitoring outcomes, it should not replace monitoring clinical outcomes in diabetes. A mix of clinical and patient experience measures will have to be used to monitor outcomes in general practice.
PMCID: PMC3184538  PMID: 21969479
11.  Relationship between quality of care and choice of clinical computing system: retrospective analysis of family practice performance under the UK's quality and outcomes framework 
BMJ Open  2013;3(8):e003190.
To investigate the relationship between performance on the UK Quality and Outcomes Framework pay-for-performance scheme and choice of clinical computer system.
Retrospective longitudinal study.
Data for 2007–2008 to 2010–2011, extracted from the clinical computer systems of general practices in England.
All English practices participating in the pay-for-performance scheme: average 8257 each year, covering over 99% of the English population registered with a general practice.
Main outcome measures
Levels of achievement on 62 quality-of-care indicators, measured as: reported achievement (levels of care after excluding inappropriate patients); population achievement (levels of care for all patients with the relevant condition) and percentage of available quality points attained. Multilevel mixed effects multiple linear regression models were used to identify population, practice and clinical computing system predictors of achievement.
Seven clinical computer systems were consistently active in the study period, collectively holding approximately 99% of the market share. Of all population and practice characteristics assessed, choice of clinical computing system was the strongest predictor of performance across all three outcome measures. Differences between systems were greatest for intermediate outcomes indicators (eg, control of cholesterol levels).
Under the UK's pay-for-performance scheme, differences in practice performance were associated with the choice of clinical computing system. This raises the question of whether particular system characteristics facilitate higher quality of care, better data recording or both. Inconsistencies across systems need to be understood and addressed, and researchers need to be cautious when generalising findings from samples of providers using a single computing system.
PMCID: PMC3733310  PMID: 23913774
General Medicine (see Internal Medicine); Public Health; Primary Care
12.  The Effects of Pay for Performance on Disparities in Stroke, Hypertension, and Coronary Heart Disease Management: Interrupted Time Series Study 
PLoS ONE  2011;6(12):e27236.
The Quality and Outcomes Framework (QOF), a major pay-for-performance programme, was introduced into United Kingdom primary care in April 2004. The impact of this programme on disparities in health care remains unclear. This study examines the following questions: has this pay for performance programme improved the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has this programme reduced disparities in the quality of care between these ethnic groups? Did general practices with different baseline performance respond differently to this programme?
Methodology/Principal Findings
Retrospective cohort study of patients registered with family practices in Wandsworth, London during 2007. Segmented regression analysis of interrupted time series was used to take into account the previous time trend. Primary outcome measures were mean systolic and diastolic blood pressure, and cholesterol levels. Our findings suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period.
Pay for performance programmes such as the QOF in the UK should set challenging but achievable targets. Specific targets aimed at reducing ethnic disparities in health care may also be needed.
PMCID: PMC3240616  PMID: 22194781
13.  Ethnic Disparities in Diabetes Management and Pay-for-Performance in the UK: The Wandsworth Prospective Diabetes Study 
PLoS Medicine  2007;4(6):e191.
Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004.
Methods and Findings
We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c ≤ 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol ≤ 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57–0.97) and BP control (AOR 0.65, 95% CI 0.53–0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005.
Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.
Based on a population-based longitudinal survey, Christopher Millett and colleagues concluded that pay-for-performance incentives for UK general practitioners had not addressed disparities in the management and control of diabetes between ethnic groups.
Editors' Summary
When used in health care, the term “pay-for-performance” means rewarding health-care providers by paying them more if they succeed in meeting performance targets set by the government and other commissioners of health care. It is an approach to health service management that is becoming common, particularly in the US and the UK. For example, the UK's general practitioners (family doctors) agreed with the government in 2004 that they would receive increases to their income that would depend on how well they were judged to be performing according to 146 quality indicators that cover clinical care for ten chronic diseases, as well as “organization of care,” and “patient experience.” One of the chronic diseases is diabetes, a condition that has reached epidemic proportions in the UK, as it has also in many other countries.
  Ethnic minorities often suffer more from health problems than the majority population of the country they live in. They are also likely to be served less well by the health services. Diabetes is a case in point; in many countries—including the US and UK—the condition is much more common in minority groups. In addition, their diabetes is usually less well “managed”—i.e., it becomes more severe more rapidly and there are more complications. In the UK, the government recognizes the need to ensure that its health policies are applied to all sectors of the population, including minority ethnic communities. Nevertheless, the advances that have been made in the management of diabetes have not benefited the UK's ethnic minorities to the same extent as they have the majority population. It is hoped that the use of pay-for-performance management by the UK National Health Service will lead to more efficient delivery of health care, and that one consequence will be that different communities will be more equally served.
Why Was This Study Done?
The researchers wanted to find out whether the introduction of pay-for-performance management in general medical practice in the UK was leading to a reduction in the gap in the quality of care provided to people with diabetes who belonged to ethnic minorities and other people with diabetes.
What Did the Researchers Do and Find?
The research was carried out in Wandsworth, an area of southwest London that is considered to be “ethnically diverse.” Over 4,200 people with diabetes are registered with general practitioners in this area. The researchers used the electronic records kept by these doctors and they focused on diabetes “treatment targets” set by the government, according to which the blood pressure and cholesterol levels of people with diabetes should be kept below defined levels. There is also a target level for glycated hemoglobin (HbA1c), which is a substance that can be used to measure the extent to which a patient's diabetes is under control. The researchers calculated the percentage of patients who were meeting these treatment targets. Overall, more patients met their treatment targets after the introduction of pay-for-performance management than were doing so before. All ethnic groups seemed to have benefited, but the black Caribbean group did not benefit as much as the other groups; the number of these patients who met the targets did improve, but the gap between them and patients with diabetes from other ethnic groups remained about the same.
What Do These Findings Mean?
The researchers concluded that, while the introduction of pay-for-performance did seem to have been beneficial, it had not addressed disparities in the management and control of diabetes between ethnic groups. They say that, in all initiatives to improve the quality of health care, special efforts must be made to reduce such gaps. The UK's use of pay-for-performance in general practice is regarded internationally as a very bold step, but, as other countries are also considering moving in this direction, the lessons from the study will be relevant in many other parts of the world.
Additional Information.
Please access these Web sites via the online version of this summary at
Wikipedia has an entry on pay-for-performance in health care (note: Wikipedia is a free online encyclopedia that anyone can edit)
Information about how the NHS works in England
Diabetes UK is the largest organization in the UK working for people with diabetes and its website includes a useful Guide to Diabetes
The London Health Observatory is one of nine health observatories set up by the NHS to monitor health and health care in England. There is a page devoted to “ethnic health intelligence”
Introductory information about diabetes as a medical condition may be found on the MedlinePlus website; there are several MedlinePlus pages on diabetes as well
PMCID: PMC1891316  PMID: 17564486
14.  Trends in utilization of lipid- and blood pressure-lowering agents and goal attainment among the U.S. diabetic population, 1999-2008 
For patients with diabetes, clinical practice guidelines recommend treating to a low-density lipoprotein cholesterol (LDL-C) goal of <2.59 mmol/L (100 mg/dL) and a blood pressure (BP) target of <130/80 mmHg. This analysis assessed recent trends in the utilization of lipid-lowering and BP-lowering agents, as well as LDL-C and BP goal attainment, in the U.S. adult diabetic population.
9,167 men and nonpregnant women aged ≥20 years were identified from the fasting subsample of the 1999-2008 National Health and Nutritional Examination Survey. Diabetes was identified in 1,214 participants by self report, self-reported use of insulin or oral medications for diabetes, or fasting glucose ≥6.99 mmol/L (126 mg/dL).
The prevalence of diagnosed or undiagnosed diabetes increased significantly over the past decade, from 7.4% in 1999-2000 to 11.9% in 2007-2008 (P = 0.0007). During this period, the use of lipid-lowering agents by participants with diabetes increased from 19.5% to 42.2% (P < 0.0001), and the proportion at LDL-C goal increased from 29.7% to 54.4% (P < 0.0001). Although there was a significant increase in antihypertensive medication use (from 35.4% to 58.9%; P < 0.0001), there was no significant change in the proportion of participants at BP goal (from 47.6% to 55.1%; P = 0.1333) or prevalence of hypertension (from 66.6% to 74.2%; P = 0.3724).
The proportion of diabetic individuals taking lipid- and BP-lowering agents has increased significantly in recent years. However, while there has been a significant improvement in LDL-C goal attainment, nearly one-half of all U.S. adults with diabetes are not at recommended LDL-C or BP treatment goals.
PMCID: PMC3098774  PMID: 21496321
15.  Engaging Physicians in Risk Factor Reduction 
Population Health Management  2010;13(5):255-261.
OptumHealth tested the feasibility of physician-directed population management in 3 primary care practices and with 546 continuously insured patients who exhibited claims markers for coronary artery disease, diabetes, and/or hypertension. During the intervention portion of the study, we asked physicians to improve the following health measurements: blood pressure, body mass index, cholesterol, hemoglobin A1c, and smoking status. We offered a modest pay-for-outcomes incentive for each risk factor improvement achieved. Additionally, on an eligible subset of these patients, we asked physicians to actively refer to population management programs those patients they determined could benefit from nurse or health coach interventions, advising us as to which components of their treatment plan they wished us to address. The 6-month intervention period exhibited a 10-fold improvement in the trend rate of risk factor management success when compared to the prior 6-month period for the same patients. A net of 96 distinct risk factor improvements were achieved by the 546 patients during the intervention period, whereas 9 net risk factor improvements occurred in the comparison period. This difference in improvement trends was statistically significant at P < 0.01. Of the 546 study participants, a subset of 187 members was eligible for participation in OptumHealth care management programs. Physicians identified 80 of these 187 eligible members as appropriate targets for program intervention. Representing ourselves as “calling on behalf” of the physician practices, we established contact with 50 referred members; 43 members (86%) actively enrolled in our programs. This enrollment rate is 2 to 3 times the rate of enrollment through our standard program outreach methods. We conclude that physician-directed population management with aligned incentives offers promise as a method of achieving important health and wellness goals. (Population Health Management 2010;13:255–261)
PMCID: PMC3128448  PMID: 20879906
16.  Experience of contractual change in UK general practice: a qualitative study of salaried GPs 
The British Journal of General Practice  2012;62(597):e282-e287.
General practice in the UK underwent major change in 2004, with the introduction of new contracts and a significant element of pay for performance. Although salaried GPs form an increasing proportion of the general practice workforce, little is known of their experiences.
To explore the views and experiences of salaried GPs working in English general practice.
Design and setting
Qualitative study using semi-structured interviews in 17 practices across England, between July 2007 and September 2009.
Interviews were conducted with 23 salaried GPs. A topic guide included questions on motivations for a career in general practice, descriptions of their daily working environment and duties, practice relationships, and future aspirations.
The new ability to opt out of out-of-hours responsibilities was deemed positive for the profession but not a major driver for choosing medical speciality. Views regarding the impact of the Quality and Outcomes Framework were ambivalent. Differences in pay were regarded as largely reflective of differences in responsibility between salaried GPs and principals. Most participants reported conducting varied work in collaborative practices. Participants held varying career aspirations.
Salaried GPs' working experiences were dependent upon personal aspirations and local context. Most salaried GPs were reportedly content with their current position but many also had aspirations of eventually attaining GP principal status. The current lack of available partnerships threatens to undo recent positive workforce progress and may lead to deep dissatisfaction within the profession and a future workforce crisis. Further large-scale quantitative work is required to assess the satisfaction and future expectations of those in salaried posts.
PMCID: PMC3310035  PMID: 22520916
general practice; primary care; workforce
17.  Long-Term and Recent Progress in Blood Pressure Levels Among U.S. Adults With Diagnosed Diabetes, 1988–2008 
Diabetes Care  2011;34(7):1579-1581.
To examine whether there were long-term (between 1988–1994 and 2001–2008) and recent (between 2001–2004 and 2005–2008) changes in blood pressure (BP) levels among U.S. adults with diagnosed diabetes.
Using data from National Health and Nutrition Examination Surveys (NHANES), we examined changes in BP distributions, mean BPs, and proportion with BP <140/90 mmHg.
Between 1988–1994 and 2001–2008, for adults with diabetes, mean BPs decreased from 135/72 mmHg to 131/69 mmHg (P < 0.01) and the proportion with BP <140/90 mmHg increased from 64 to 69% (P = 0.01). Although hypertension prevalence increased, hypertension awareness, treatment, and control improved. However, there was no evidence of improvement for adults 20–44 years old. Between 2001–2004 and 2005–2008, there were no significant changes in BP levels.
BP levels among adults with diabetes improved between 1988–1994 and 2001–2008, but the progress stalled between 2001–2004 and 2005–2008. The lack of improvement among young adults is concerning.
PMCID: PMC3120172  PMID: 21602427
18.  Impact of a pay-for-performance incentive on support for smoking cessation and on smoking prevalence among people with diabetes 
Many people with diabetes continue to smoke despite being at high risk of cardiovascular disease. We examined the impact of a pay-for-performance incentive in the United Kingdom introduced in 2004 as part of the new general practitioner contract to improve support for smoking cessation and to reduce the prevalence of smoking among people with chronic diseases such as diabetes.
We performed a population-based longitudinal study of the recorded delivery of cessation advice and the prevalence of smoking using electronic records of patients with diabetes obtained from participating general practices. The survey was carried out in an ethnically diverse part of southwest London before (June–October 2003) and after (November 2005–January 2006) the introduction of a pay-for-performance incentive.
Significantly more patients with diabetes had their smoking status ever recorded in 2005 than in 2003 (98.8% v. 90.0%, p <0.001). The proportion of patients with documented smoking cessation advice also increased significantly over this period, from 48.0% to 83.5% (p < 0.001). The prevalence of smoking decreased significantly from 20.0% to 16.2% (p < 0.001). The reduction over the study period was lower among women (adjusted odds ratio 0.71, 95% confidence interval 0.53–0.95) but was not significantly different in the most and least affluent groups. In 2005, smoking rates continued to differ significantly with age (10.6%–25.1%), sex (women, 11.5%; men, 20.6%) and ethnic background (4.9%–24.9%).
The introduction of a pay-for-performance incentive in the United Kingdom increased the provision of support for smoking cessation and was associated with a reduction in smoking prevalence among patients with diabetes in primary health care settings. Health care planners in other countries may wish to consider introducing similar incentive schemes for primary care physicians.
PMCID: PMC1877840  PMID: 17548383
19.  Impact of the pay-for-performance contract and the management of hypertension in Scottish primary care: a 6-year population-based repeated cross-sectional study 
The British Journal of General Practice  2011;61(588):e443-e451.
The 2004 introduction of the pay-for-performance contract has increased the proportion of income that GPs are able to earn by targeting quality care to patients with chronic diseases such as hypertension.
To investigate the impact of pay for performance on the management of patients with hypertension in Scottish primary care.
Design and setting
A population-based repeated cross-sectional study in Scottish primary care practices (n = 315) contributing to the Primary Care Clinical Informatics Unit database.
A dataset was extracted on 826 973 patients aged ≥40 years including, age, sex, socioeconomic deprivation status, hypertension diagnosis, recorded blood pressure measurement, attainment of target blood pressure levels, and provision of hypertension-related prescribing for each year from 2001 until 2006.
Increasing treatment for hypertension (absolute difference [AD] 9.2%; 95% confidence interval [CI] = 9.0 to 9.5) occurred throughout the study period. The majority of increases found in blood pressure measurement (AD 46.8%; 95% CI = 46.5 to 47.1) and recorded hypertension (AD 5.9%; 95% CI = 5.7 to 6.0) occurred prior to 2004. Blood pressure control increased throughout the study period (absolute increase ≤140/90 mmHg; 18.9%; 95% CI = 18.5 to 19.4). After 2004, the oldest female, as well as the male and female patients with the greatest socioeconomic deprivation status, became less likely than their youngest (<40 years) and most affluent counterparts to have a blood pressure measurement recorded (P<0.05). Patients not prescribed therapy were younger and had higher blood pressure levels (P<0.001).
It is likely that the continued efforts of general practice to improve hypertension diagnosis, monitoring, and treatment will reduce future cardiovascular events and mortality in those with hypertension. However, there is a need to follow up patients who are older and more socioeconomically deprived once they are diagnosed, as well as prescribing antihypertensive therapy to younger patients, who are likely to benefit from early intervention.
PMCID: PMC3123508  PMID: 21722469
disease management; epidemiology; hypertension; pay for performance; prescriptions; primary care
20.  Improving Diabetes Care in Practice 
Diabetes Care  2008;31(12):2238-2243.
OBJECTIVE—The purpose of this study was to determine whether implementation of a multicomponent organizational intervention can produce significant change in diabetes care and outcomes in community primary care practices.
RESEARCH DESIGN AND METHODS—This was a group-randomized, controlled clinical trial evaluating the practical effectiveness of a multicomponent intervention (TRANSLATE) in 24 practices. The intervention included implementation of an electronic diabetes registry, visit reminders, and patient-specific physician alerts. A site coordinator facilitated previsit planning and a monthly review of performance with a local physician champion. The principle outcomes were the percentage of patients achieving target values for the composite of systolic blood pressure (SBP) <130 mmHg, LDL cholesterol <100 mg/dl, and A1C <7.0% at baseline and 12 months. Six process measures were also followed.
RESULTS—Over 24 months, 69,965 visits from 8,405 adult patients with type 2 diabetes were recorded from 238 health care providers in 24 practices from 17 health systems. Diabetes process measures increased significantly more in intervention than in control practices, giving net increases as follows: foot examinations 35.0% (P < 0.0.001); annual eye examinations 25.9% (P < 0.001); renal testing 28.5% (P < 0.001); A1C testing 8.1%(P < 0.001); blood pressure monitoring 3.5% (P = 0.05); and LDL testing 8.6% (P < 0.001). Mean A1C adjusted for age, sex, and comorbidity decreased significantly in intervention practices (P < 0.02). At 12 months, intervention practices had significantly greater improvement in achieving recommended clinical values for SBP, A1C, and LDL than control clinics (P = 0.002).
CONCLUSIONS—Introduction of a multicomponent organizational intervention in the primary care setting significantly increases the percentage of type 2 diabetic patients achieving recommended clinical outcomes.
PMCID: PMC2584171  PMID: 18809622
21.  Observed Changes in Risk during Naturopathic Treatment of Hypertension 
Few outcome assessments are published from complementary and alternative medicine (CAM) practices. We aimed to describe patient and practice characteristics of ND care for hypertension (HTN), quantify changes in blood pressure (BP), and evaluate the proportion achieving control of HTN during care. A retrospective, observational study of ND practice in HTN was performed in an outpatient clinic in WA State. Eighty-five charts were abstracted for the final analysis. At initiation of care, the mean patient age was 61 years, with 51% having stage 2 HTN, despite common use of anti-hypertensive medications (47%). Patients with both stage 1 and stage 2 HTN appeared to improve during care, with stage 2 patients achieving mean reductions of −26 mmHg (P < .0001) and −11 mmHg (P < .0001) in systolic BP (SBP) and diastolic BP (DBP), respectively. The proportion of patients achieving control (<140/90 mmHg) in both SBP and DBP was increased significantly from 14 to 44% (P < .033), although the statistical significance was not maintained upon correction for multiple comparisons. BP appears to improve during ND care for HTN, in a high-risk population. Randomized trials are warranted.
PMCID: PMC3137652  PMID: 21799695
22.  Patients' views of pay for performance in primary care: a qualitative study 
The British Journal of General Practice  2012;62(598):e322-e328.
Many countries use pay-for-performance schemes to reward family practices financially for achieving quality indicators. The views of patients on pay for performance remain largely unexplored.
To gain the views of family practice patients on the United Kingdom pay-for-performance Quality and Outcomes Framework (QOF).
Design and setting
Interviews with 52 patients were conducted in 15 family practices across England. All patients had at least one long-term condition that had been diagnosed before the introduction of the QOF in 2004.
Semi-structured interviews analysed using open explorative thematic coding.
Few patients had heard of the QOF or had noticed changes to the structure or process of their care. However, where they were noted, changes to consultations such as increased use of computers and health checks initiated by the GP or practice nurse were seen as good practice. The majority of patients were surprised to hear their practice received bonuses for doing ‘simple things’. Some patients also raised concerns over potential unintended consequences of pay-for-performance frameworks, such as a reduced focus on non-incentivised areas.
This study adds a unique patient perspective to the debate around the impact of pay-for-performance schemes and consequences on patient care. Patients' views, experiences, and concerns about pay for performance mostly chime with previously described opinions of primary care staff. Patient surprise and concern around incentivising basic processes of care shows how patient views are vital when monitoring and evaluating a scheme that is designed to improve patient care.
PMCID: PMC3338053  PMID: 22546591
patients; pay for performance; qualitative research
23.  Implementation and evaluation of the SPRINT protocol for tight glycaemic control in critically ill patients: a clinical practice change 
Critical Care  2008;12(2):R49.
Stress-induced hyperglycaemia is prevalent in critical care. Control of blood glucose levels to within a 4.4 to 6.1 mmol/L range or below 7.75 mmol/L can reduce mortality and improve clinical outcomes. The Specialised Relative Insulin Nutrition Tables (SPRINT) protocol is a simple wheel-based system that modulates insulin and nutritional inputs for tight glycaemic control.
SPRINT was implemented as a clinical practice change in a general intensive care unit (ICU). The objective of this study was to measure the effect of the SPRINT protocol on glycaemic control and mortality compared with previous ICU control methods. Glycaemic control and mortality outcomes for 371 SPRINT patients with a median Acute Physiology And Chronic Health Evaluation (APACHE) II score of 18 (interquartile range [IQR] 15 to 24) are compared with a 413-patient retrospective cohort with a median APACHE II score of 18 (IQR 15 to 23).
Overall, 53.9% of all measurements were in the 4.4 to 6.1 mmol/L band. Blood glucose concentrations were found to be log-normal and thus log-normal statistics are used throughout to describe the data. The average log-normal glycaemia was 6.0 mmol/L (standard deviation 1.5 mmol/L). Only 9.0% of all measurements were below 4.4 mmol/L, with 3.8% below 4 mmol/L and 0.1% of measurements below 2.2 mmol/L. On SPRINT, 80% more measurements were in the 4.4 to 6.1 mmol/L band and standard deviation of blood glucose was 38% lower compared with the retrospective control. The range and peak of blood glucose were not correlated with mortality for SPRINT patients (P >0.30). For ICU length of stay (LoS) of greater than or equal to 3 days, hospital mortality was reduced from 34.1% to 25.4% (-26%) (P = 0.05). For ICU LoS of greater than or equal to 4 days, hospital mortality was reduced from 34.3% to 23.5% (-32%) (P = 0.02). For ICU LoS of greater than or equal to 5 days, hospital mortality was reduced from 31.9% to 20.6% (-35%) (P = 0.02). ICU mortality was also reduced but the P value was less than 0.13 for ICU LoS of greater than or equal to 4 and 5 days.
SPRINT achieved a high level of glycaemic control on a severely ill critical cohort population. Reductions in mortality were observed compared with a retrospective hyperglycaemic cohort. Range and peak blood glucose metrics were no longer correlated with mortality outcome under SPRINT.
PMCID: PMC2447603  PMID: 18412978
24.  Patient Complexity and Diabetes Quality of Care in Rural Settings 
Even though pay-for-performance programs are being rapidly implemented, little is known about how patient complexity affects practice-level performance assessment in rural settings. We sought to determine the association between patient complexity and practice-level performance in the rural United States.
Basic procedures
Using baseline data from a trial aimed at improving diabetes care, we determined factors associated with a practice’s proportion of patients having controlled diabetes (hemoglobin A1c ≤7%): patient socioeconomic factors, clinical factors, difficulty with self-testing of blood glucose, and difficulty with keeping appointments. We used linear regression to adjust the practice-level proportion with A1c controlled for these factors. We compared practice rankings using observed and expected performance and classified practices into hypothetical pay-for-performance categories.
Main Findings
Rural primary care practices (n = 135) in 11 southeastern states provided information for 1641 patients with diabetes. For practices in the best quartile of observed control, 76.1% of patients had controlled diabetes vs 19.3% of patients in the worst quartile. After controlling for other variables, proportions of diabetes control were 10% lower in those practices whose patients had the greatest difficulty with either self testing or appointment keeping (p < .05 for both). Practice rankings based on observed and expected proportion of A1c control showed only moderate agreement in pay-for-performance categories (κ = 0.47; 95% confidence interval, 0.32–0.56; p < .001).
Principal Conclusions
Basing public reporting and resource allocation on quality assessment that does not account for patient characteristics may further harm this vulnerable group of patients and physicians.
PMCID: PMC3156053  PMID: 21671526
diabetes; quality of care; primary care
25.  Long term virological, immunological and mortality outcomes in a cohort of HIV-infected female sex workers treated with highly active antiretroviral therapy in Africa 
BMC Public Health  2011;11:700.
Concerns have been raised that marginalised populations may not achieve adequate compliance to antiretroviral therapy. Our objective was to describe the long-term virological, immunological and mortality outcomes of providing highly active antiretroviral therapy (HAART) with strong adherence support to HIV-infected female sex workers (FSWs) in Burkina Faso and contrast outcomes with those obtained in a cohort of regular HIV-infected women.
Prospective study of FSWs and non-FSWs initiated on HAART between August 2004 and October 2007. Patients were followed monthly for drug adherence (interview and pill count), and at 6-monthly intervals for monitoring CD4 counts and HIV-1 plasma viral loads (PVLs) and clinical events.
95 women, including 47 FSWs, were followed for a median of 32 months (interquartile range [IQR], 20-41). At HAART initiation, the median CD4 count was 147 cells/μl (IQR, 79-183) and 144 cells/μl (100-197), and the mean PVLs were 4.94 log10copies/ml (95% confidence interval [CI], 4.70-5.18) and 5.15 log10 copies/ml (4.97-5.33), in FSWs and non-FSWs, respectively. Four FSWs died during follow-up (mortality rate: 1.7 per 100 person-years) and none among other women. At 36 months, the median CD4 count increase was 230 cells/μl (IQR, 90-400) in FSWs vs. 284 cells/μl (193-420) in non-FSWs; PVL was undetectable in 81.8% (95% CI, 59.7-94.8) of FSWs vs. 100% (83.9-100) of non-FSWs; and high adherence to HAART (> 95% pills taken) was reported by 83.3% (95% CI, 67.2-93.6), 92.1% (95% CI, 78.6-98.3), and 100% (95% CI, 54.1-100) of FSWs at 6, 12, and 36 months after HAART initiation, respectively, with no statistical difference compared to the pattern observed among non-FSWs.
Clinical and biological benefits of HAART can be maintained over the long term among FSWs in Africa and could also lead to important public health benefits.
PMCID: PMC3191514  PMID: 21917177

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