Impact of Pay for Performance on Ethnic Disparities in Intermediate Outcomes for Diabetes: A Longitudinal Study

Department of Primary Care and Social Medicine, Imperial College Faculty of Medicine, London, UK.
Diabetes care (Impact Factor: 8.42). 02/2009; 32(3):404-9. DOI: 10.2337/dc08-0912
Source: PubMed

ABSTRACT 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.
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.
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.
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.

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Available from: Sonia K Saxena, Sep 28, 2015
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    • "“Pay for performance” (P4P) rewards increased adherence to quality metrics [46] while “hospital acquired condition” penalizes undesirable outcomes. The amount of increased guideline adherence varies across studies [47], , and these programs may either exacerbate [50], [51], [52] or reduce racial disparity [46], [49]. Underserved patients may experience significant out-of-pocket costs so they may delay seeking of care, both for the OA leading to TKA, but also for post-surgical monitoring of emerging complications. "
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    ABSTRACT: The Hospital Acquired Condition Strategy (HACS) denies payment for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The intention is to reduce complications and associated costs, while improving the quality of care by mandating VTE prophylaxis. We applied a system dynamics model to estimate the impact of HACS on VTE rates, and potential unintended consequences such as increased rates of bleeding and infection and decreased access for patients who might benefit from TKA. The system dynamics model uses a series of patient stocks including the number needing TKA, deemed ineligible, receiving TKA, and harmed due to surgical complication. The flow of patients between stocks is determined by a series of causal elements such as rates of exclusion, surgery and complications. The number of patients harmed due to VTE, bleeding or exclusion were modeled by year by comparing patient stocks that results in scenarios with and without HACS. The percentage of TKA patients experiencing VTE decreased approximately 3-fold with HACS. This decrease in VTE was offset by an increased rate of bleeding and infection. Moreover, results from the model suggest HACS could exclude 1.5% or half a million patients who might benefit from knee replacement through 2020. System dynamics modeling indicates HACS will have the intended consequence of reducing VTE rates. However, an unintended consequence of the policy might be increased potential harm resulting from over administration of prophylaxis, as well as exclusion of a large population of patients who might benefit from TKA.
    PLoS ONE 04/2012; 7(4):e30578. DOI:10.1371/journal.pone.0030578 · 3.23 Impact Factor
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    • "In 14 of the 27 studies, the evaluation of equity is an explicit aim (or one of the aims) of the study [29,31-36,38,39,42,46,50-52]. The other studies report results related to equity as additional information or include tables with enough detail to allow the deduction of equity related results. "
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    ABSTRACT: Pay-for-performance systems raise concerns regarding inequity in health care because providers might select patients for whom targets can easily be reached. This paper aims to describe the evolution of pre-existing (in)equity in health care in the period after the introduction of the Quality and Outcomes Framework (QOF) in the UK and to describe (in)equities in exception reporting. In this evaluation, a theory-based framework conceptualising equity in terms of equal access, equal treatment and equal treatment outcomes for people in equal need is used to guide the work. A systematic MEDLINE and Econlit search identified 317 studies. Of these, 290 were excluded because they were not related to the evaluation of QOF, they lacked an equity dimension in the evaluation, their qualitative research focused on experiences or on the nature of the consultation, or unsuitable methodology was used to pronounce upon equity after the introduction of QOF. None of the publications (n = 27) assessed equity in access to health care. Concerning equity in treatment and (intermediate) treatment outcomes, overall quality scores generally improved. For the majority of the observed indicators, all citizens benefit from this improvement, yet the extent to which different patient groups benefit tends to vary and to be highly dependent on the type and complexity of the indicator(s) under study, the observed patient group(s) and the characteristics of the study. In general, the introduction of QOF was favourable for the aged and for males. Total QOF scores did not seem to vary according to ethnicity. For deprivation, small but significant residual differences were observed after the introduction of QOF favouring less deprived groups. These differences are mainly due to differences at the practice level. The variance in exception reporting according to gender and socio-economic position is low. Although QOF seems not to be socially selective at first glance, this does not mean QOF does not contribute to the inverse care law. Introducing different targets for specific patient groups and including appropriate, non-disease specific and patient-centred indicators that grasp the complexity of primary care might refine the equity dimension of the evaluation of QOF. Also, information on the actual uptake of care, information at the patient level and monitoring of individuals' health care utilisation tracks could make large contributions to an in-depth evaluation. Finally, evaluating pay-for-quality initiatives in a broader health systems impact assessment strategy with equity as a full assessment criterion is of utmost importance.
    BMC Health Services Research 08/2011; 11:209. DOI:10.1186/1472-6963-11-209 · 1.71 Impact Factor
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    ABSTRACT: 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. England. 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.
    Journal of the Royal Society of Medicine 04/2009; 102(3):103-7. DOI:10.1258/jrsm.2009.080389 · 2.12 Impact Factor
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