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Pay for performance significantly increased the percentage of patients achieving some diabetes treatment goals in one London primary care trust, but did not improve disparities between white British and ethnic minority patients, according to an observational study.
Researchers from Imperial College London, the University of Leicester, and Wandsworth Primary Care Research Center, London, reviewed electronic general practice records for 4,284 adult type 1 and 2 diabetes patients enrolled in 32 practices in Wandsworth Primary Care Trust before and after the National Health Service implemented a pay-for-performance contract with general practitioners in 2004 (PLoS Med. 2007 June 12 [Epub doi:10. 1371/journal.pmed.0040191]). National treatment targets for diabetes patients included HbA1c less than or equal to 7.0%, blood pressure less than 140/80 mm Hg, and total cholesterol less than or equal to 193 mg/dL.
In terms of cholesterol control, significantly more patients met the treatment target for total cholesterol in 2005, compared with 2003 (70.4% vs. 57.5%, respectively). Improvements were uniform across all ethnic groups except for the Bangladeshi group, which had significantly greater improvement in cholesterol control relative to the white British group after adjusting for age, gender, deprivation, and practice-level clustering. Similarly, there were also large improvements in hypertension control across all ethnic groups except for black Caribbean patients, who had significantly less improvement in blood pressure control, compared with white British patients after adjusting for age, gender, deprivation, and practice-level clustering, the researchers wrote.
The also found no significant difference in the percentage increase of white British or minority patients prescribed angiotensin-converting enzyme inhibitors and lipid-lowering drugs, although black Africans remained significantly behind white British patients in terms of the percentage prescribed the lipid-lowering drugs in 2005 (63.9% vs. 48.8%)
Researchers also found that significantly more patients reached recommended levels of HbA1c in 2005, compared with 2003 (37.4% vs. 35.1%) except for black Caribbean patients, who had significantly less improvement, compared with the white British group. They also found, compared with white British patients in 2005, that black Caribbean, black African, Indian, and Pakistani patients had significantly greater percentages prescribed oral hyperglycemic agents. And, while significantly more patients overall were treated with insulin in 2005, compared with 2003, the increases in insulin prescribing were significantly lower in the black African and south Asian groups, compared with the white British group.
“Although diabetes management improved in all ethnic groups after the introduction of pay-for-performance incentives in UK primary care, disparities in prescribing and intermediate clinical outcomes persisted,” wrote the researchers, led by Christopher Millett, of the Imperial College London's department of primary care and social medicine. “Hence, the main lesson from this study for health-care systems in other countries is that pay-for-performance by itself may not be sufficient to address ethnic disparities in the quality of care.”
The authors acknowledged that they were unable to definitively link changes in diabetes management to the pay-for-performance program, in part because their study design was unable to allow for a control group.
Pay for performance significantly increased the percentage of patients achieving some diabetes treatment goals in one London primary care trust, but did not improve disparities between white British and ethnic minority patients, according to an observational study.
Researchers from Imperial College London, the University of Leicester, and Wandsworth Primary Care Research Center, London, reviewed electronic general practice records for 4,284 adult type 1 and 2 diabetes patients enrolled in 32 practices in Wandsworth Primary Care Trust before and after the National Health Service implemented a pay-for-performance contract with general practitioners in 2004 (PLoS Med. 2007 June 12 [Epub doi:10. 1371/journal.pmed.0040191]). National treatment targets for diabetes patients included HbA1c less than or equal to 7.0%, blood pressure less than 140/80 mm Hg, and total cholesterol less than or equal to 193 mg/dL.
In terms of cholesterol control, significantly more patients met the treatment target for total cholesterol in 2005, compared with 2003 (70.4% vs. 57.5%, respectively). Improvements were uniform across all ethnic groups except for the Bangladeshi group, which had significantly greater improvement in cholesterol control relative to the white British group after adjusting for age, gender, deprivation, and practice-level clustering. Similarly, there were also large improvements in hypertension control across all ethnic groups except for black Caribbean patients, who had significantly less improvement in blood pressure control, compared with white British patients after adjusting for age, gender, deprivation, and practice-level clustering, the researchers wrote.
The also found no significant difference in the percentage increase of white British or minority patients prescribed angiotensin-converting enzyme inhibitors and lipid-lowering drugs, although black Africans remained significantly behind white British patients in terms of the percentage prescribed the lipid-lowering drugs in 2005 (63.9% vs. 48.8%)
Researchers also found that significantly more patients reached recommended levels of HbA1c in 2005, compared with 2003 (37.4% vs. 35.1%) except for black Caribbean patients, who had significantly less improvement, compared with the white British group. They also found, compared with white British patients in 2005, that black Caribbean, black African, Indian, and Pakistani patients had significantly greater percentages prescribed oral hyperglycemic agents. And, while significantly more patients overall were treated with insulin in 2005, compared with 2003, the increases in insulin prescribing were significantly lower in the black African and south Asian groups, compared with the white British group.
“Although diabetes management improved in all ethnic groups after the introduction of pay-for-performance incentives in UK primary care, disparities in prescribing and intermediate clinical outcomes persisted,” wrote the researchers, led by Christopher Millett, of the Imperial College London's department of primary care and social medicine. “Hence, the main lesson from this study for health-care systems in other countries is that pay-for-performance by itself may not be sufficient to address ethnic disparities in the quality of care.”
The authors acknowledged that they were unable to definitively link changes in diabetes management to the pay-for-performance program, in part because their study design was unable to allow for a control group.
Pay for performance significantly increased the percentage of patients achieving some diabetes treatment goals in one London primary care trust, but did not improve disparities between white British and ethnic minority patients, according to an observational study.
Researchers from Imperial College London, the University of Leicester, and Wandsworth Primary Care Research Center, London, reviewed electronic general practice records for 4,284 adult type 1 and 2 diabetes patients enrolled in 32 practices in Wandsworth Primary Care Trust before and after the National Health Service implemented a pay-for-performance contract with general practitioners in 2004 (PLoS Med. 2007 June 12 [Epub doi:10. 1371/journal.pmed.0040191]). National treatment targets for diabetes patients included HbA1c less than or equal to 7.0%, blood pressure less than 140/80 mm Hg, and total cholesterol less than or equal to 193 mg/dL.
In terms of cholesterol control, significantly more patients met the treatment target for total cholesterol in 2005, compared with 2003 (70.4% vs. 57.5%, respectively). Improvements were uniform across all ethnic groups except for the Bangladeshi group, which had significantly greater improvement in cholesterol control relative to the white British group after adjusting for age, gender, deprivation, and practice-level clustering. Similarly, there were also large improvements in hypertension control across all ethnic groups except for black Caribbean patients, who had significantly less improvement in blood pressure control, compared with white British patients after adjusting for age, gender, deprivation, and practice-level clustering, the researchers wrote.
The also found no significant difference in the percentage increase of white British or minority patients prescribed angiotensin-converting enzyme inhibitors and lipid-lowering drugs, although black Africans remained significantly behind white British patients in terms of the percentage prescribed the lipid-lowering drugs in 2005 (63.9% vs. 48.8%)
Researchers also found that significantly more patients reached recommended levels of HbA1c in 2005, compared with 2003 (37.4% vs. 35.1%) except for black Caribbean patients, who had significantly less improvement, compared with the white British group. They also found, compared with white British patients in 2005, that black Caribbean, black African, Indian, and Pakistani patients had significantly greater percentages prescribed oral hyperglycemic agents. And, while significantly more patients overall were treated with insulin in 2005, compared with 2003, the increases in insulin prescribing were significantly lower in the black African and south Asian groups, compared with the white British group.
“Although diabetes management improved in all ethnic groups after the introduction of pay-for-performance incentives in UK primary care, disparities in prescribing and intermediate clinical outcomes persisted,” wrote the researchers, led by Christopher Millett, of the Imperial College London's department of primary care and social medicine. “Hence, the main lesson from this study for health-care systems in other countries is that pay-for-performance by itself may not be sufficient to address ethnic disparities in the quality of care.”
The authors acknowledged that they were unable to definitively link changes in diabetes management to the pay-for-performance program, in part because their study design was unable to allow for a control group.