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GP incentives ‘have no effect on hypertension management’



By Lilian Anekwe

GP leaders have been forced to defend the QOF after an analysis showed it had ‘no discernible effect’ on the management of patients with hypertension or their outcomes.

The BMJ analysis found ‘pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes’, and suggested the management of hypertension was already improving before the introduction of the QOF.

Researchers conducted a time series analysis of the primary care records of 470,000 patients with hypertension in The Health Improvement Network, a primary care database from 358 UK general practices, between January 2000 and August 2007, to observe the impact of five clinical indicators on, rates of blood pressure monitoring, blood pressure control, and treatment intensity.

The international team from the UK, USA and Canada also calculated the impact of the QOF on the cumulative major hypertension related outcomes – incidence of stroke, myocardial infarction, renal failure, heart failure or all-cause mortality.

After the QOF had been implemented, the rate of controlled blood pressure did not differ significantly, neither did changes in the frequency of blood pressure measurement.

There was an increase in the proportion of patients receiving combination therapy with either two or more drugs during the baseline period, but after the introduction of the QOF was not associated with any changes in these trends in prescribing.

Hypertension related outcomes showed a steady increasing trend before the QOF began, and the researchers found ‘the level and trend for adverse outcomes did not change significantly after the start of pay for performance.’

‘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, the researchers concluded.

Professor Stephen Soumeri, professor of population medicines at Harvard Medical School in the US, argued in the BMJ: ‘Effective alternative approaches to improving quality of primary care for hypertension exist, such as case management or co-management of hypertension and other chronic conditions with allied health professional such as nurses and pharmacists.’

Professor Tony Avery, professor of primary care at the University of Nottingham and a GP in the city, co-authored the study and told Pulse: ‘Treatment intensity has gone up over time and the number of people on more than one drug for hypertension has gone up, but you don’t see any discernible benefit from the introduction of the QOF.

‘There has been a move toward quality improvement over the last ten years but GPs were already raising their game. So in some ways it’s not surprising that there was no big jump when QOF came in. We were already aware of what we were doing.

‘GPs were already fairly close to the levels at which we would get maximum points. If targets had been set a little bit tougher GPs might have tried a little bit harder. I think quality of care has improved.’

But GP leaders defended the QOF. GPC chair Dr Laurence Buckman said the QOF was more than ‘simply an incentive scheme’.

‘There is a mistaken belief that the Quality and Outcomes Framework is simply an incentive scheme, but it’s much more than that. It was designed to fund work by GPs that previously wasn’t being funded, to ensure that patients received uniform high-quality care no matter where they lived in the country and improve public health over the long term and help reduce health inequalities.

‘The QOF is still relatively new. We expect the true gains will be seen in the long term as more evidence becomes available.’

The introduction of the QOF did not changes rates of hypertension treatment