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Does paying for performance in primary care save lives?

Probably not, according to state of the art evidence from the UK, published in The BMJ this week.

The researchers say the impact of the incentive scheme “has fallen short of previous estimates and indicators will need to be reconsidered and better aligned with evidence.”

The Quality and Outcomes Framework (QOF) is a UK pay-for-performance programme that has cost approximately £1bn per annum since 2004. It links up to 25% of family practitioners’ income to performance on over 100 publicly reported quality indicators.

No studies to date have examined the relationships between recorded practice performance under the QOF and death rates for conditions included in the programme.

So Dr Evan Kontopantelis at the University of Manchester and colleagues decided to assess whether QOF performance at the practice level was associated with either all-cause mortality or with premature mortality attributed to incentivised conditions, such as diabetes, hypertension, ischaemic heart disease, stroke, and chronic kidney disease.

They used complex spatial analysis to link QOF scores in 8,000 English general practices to mortality data from over 30,000 statistical regions, each of which corresponds to populations of between 1,500 and 3,000 individuals.

Their work hinges on the assumption that practice performance on the QOF should, in theory, be reflected in the health of communities served by those practices.

The results show that, despite a reduction in mortality for the incentivised conditions in the study period, there was no relationship between practice QOF scores and standardised all-cause and specific-cause mortality rates of the incentivised conditions in corresponding regions.

This lack of a relationship held for both 2011-12 standardised mortality rates and for trends in mortality rates between 2007 and 2012.

There were, however, clear and sadly predictable associations between mortality and social deprivation, rurality, and the proportions of non-white people within populations.

The study helps clarify the population health impact of the world’s largest pay for performance scheme.

An accompanying editorial says Kontopantelis and colleagues’ paper “provides the best evidence we have as to its lack of impact on population health.”


Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study, Evangelos Kontopantelis, senior research fellow, David A Springate, Mark Ashworth, Roger T Webb, Iain E Buchan, Tim Doran, The BMJ, doi: 10.1136/bmj.h904, published 2 March 2015.