BMJ: P4P improves blood pressure monitoring, reduced health inequalities

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Pay-for-performance (P4P) has substantially improved blood pressure monitoring and control in England, and the difference in monitoring levels between the most and least deprived areas has all but disappeared, according to research published Oct. 28 in the British Medical Journal.

This study adds to the evidence that the Quality of Outcomes Framework (QOF) is a “truly equitable public health intervention,” wrote Helen Lester, MD, from the National Primary Care Research and Development Center in Manchester, England, in an accompanying editorial.

High blood pressure is the single most important risk factor for developing heart disease and adds significantly to the gap in life expectancy between deprived and affluent areas. Studies have shown that successful blood pressure control could prevent 43,000 strokes and 83,000 cases of heart disease in the U.K. each year, but this is less likely to be achieved in socially deprived areas, according to the authors.

The QOF was introduced in 2004 to improve standards of primary care by linking financial incentives to 135 performance indicators for all general practitioners in the U.K. It includes the target of blood pressure monitoring of all primary-care patients older than 45 years annually, and meeting blood pressure control targets in patients with chronic diseases, such as hypertension and diabetes.

In the first year of the program’s implementation, practices in socially deprived areas reported lower achievement scores (6.1 percent of the total QOF score), and therefore less financial reward than the more affluent areas, but by year two the gap had reduced to 2.9 percent, the researchers reported.

Mark Ashworth, MD, and colleagues from Kings College London, reported on the data from the first three years of the QOF’s implementation, including more than 97 percent of practices (8,515) in England involving 53 million people. They examined the effect of social deprivation on the achievement of blood pressure targets between general practices in deprived and less deprived communities in England.

The authors found that blood pressure recording increased from 52.8 million of adults in 2005 to 53.2 million in 2007, and that the gap between median blood pressure recording levels narrowed from 1.7 to 0.2 percent between practices in the most deprived and least deprived areas.

Over the past decade, data have shown that steady improvements in population blood pressure control, but the findings of this study show a rapid improvement in the last three years.

In addition, the achievement of blood pressure targets for the five chronic diseases improved substantially, particularly in diabetics in the most deprived practices, which improved by more than 10 percent, with more than 79 percent achieving target blood pressure levels by 2007.

The study shows that performance indicators linked to financial incentives result in improved achievement of targets, which at the same time narrows health inequalities, the authors concluded.

"Perhaps the greatest contribution that the QOF has made to changing practice will therefore be the largely unintended consequence of generating more equitable healthcare,” Lester wrote.

Lester said that this study and other evidence suggest that P4P schemes should be designed with health inequalities in mind.