Objective To assess the impact of a pay for performance incentive on quality of care and outcomes among UK patients with hypertension in primary care. Design Interrupted time series. Setting The Health Improvement Network (THIN) database, United Kingdom. Participants 470 725 patients with hypertension diagnosed between January 2000 and August 2007. Intervention The UK pay for performance incentive (the Quality and Outcomes Framework), which was implemented in April 2004 and included specific targets for general practitioners to show high quality care for patients with hypertension (and other diseases). Main outcome measures Centiles of systolic and diastolic blood pressures over time, rates of blood pressure monitoring, blood pressure control, and treatment intensity at monthly intervals for baseline (48 months) and 36 months after the implementation of pay for performance. Cumulative incidence of major hypertension related outcomes and all cause mortality for subgroups of newly treated (treatment started six months before pay for performance) and treatment experienced (started treatment in year before January 2001) patients to examine different stages of illness. Results After accounting for secular trends, no changes in blood pressure monitoring (level change 0.85, 95% confidence interval −3.04 to 4.74, P=0.669 and trend change −0.01, −0.24 to 0.21, P=0.615), control (−1.19, −2.06 to 1.09, P=0.109 and −0.01, −0.06 to 0.03, P=0.569), or treatment intensity (0.67, −1.27 to 2.81, P=0.412 and 0.02, −0.23 to 0.19, P=0.706) were attributable to pay for performance. Pay for performance had no effect on the cumulative incidence of stroke, myocardial infarction, renal failure, heart failure, or all cause mortality in both treatment experienced and newly treated subgroups. Conclusions Good quality of care for hypertension was stable or improving before pay for performance was introduced. Pay for performance had no discernible effects on processes of care or on hypertension related clinical outcomes. 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.

BackgroundRelatively little is known about prescribing errors in general practice, or the factors associated with error.

BackgroundIn the UK, a process of revalidation is being introduced to allow doctors to demonstrate that they meet current professional standards, are up-to-date, and fit to practise. Given the serious risks to patients from hazardous use of medicines it will be appropriate, as part of the revalidation process, to assess the safety of prescribing by GPs. AimTo identify a set of potential prescribing-safety indicators for the purposes of revalidation of individual GPs in the UK. Design and settingThe RAND Appropriateness Method was used to identify, develop, and obtain agreement on the indicators in UK general practice. MethodTwelve GPs from across the UK with a wide variety of characteristics assessed indicators for appropriateness of use in revalidation. ResultsForty-seven safety indicators were considered appropriate for assessing the prescribing safety of individual GPs for the purposes of revalidation (appropriateness was defined as an overall panel median score of ≥7 (on a 1-9 scale), with no more than three panel members rating the indicator outside the 3-point distribution around the median]. After removing indicators that were variations on the same theme, a final set of 34 indicators was obtained; these cover hazardous prescribing across a range of therapeutic areas, hazardous drugdrug combinations, prescribing with a history of allergy, and inadequate laboratory-test monitoring. ConclusionThis study identified a set of 34 indicators that were considered, by a panel of 12 GPs, to be appropriate for use in assessing the safety of GP prescribing for the purposes of revalidation. Violation of any of the 34 indicators indicates a potential patient-safety problem.

The 2011 United Nations (UN) General Assembly Political Declaration on Prevention and Control of Non-Communicable Diseases (NCDs) brought NCDs to the global health agenda. Essential medicines are central to treating chronic diseases such as hypertension and diabetes. Our study aimed to quantify access to essential medicines for people with chronic conditions in five low- and middle-income countries and to evaluate how household socioeconomic status and perceptions about medicines availability and affordability influence access. We analysed data for 1867 individuals with chronic diseases from national surveys (Ghana, Jordan, Kenya, Philippines and Uganda) conducted in 2007-10 using a standard World Health Organization (WHO) methodology to measure medicines access and use. We defined individuals as having access to medicines if they reported regularly taking medicine for a diagnosed chronic disease and data collectors found a medicine indicated for that disease in their homes. We used logistic regression models accounting for the clustered survey design to investigate determinants of keeping medicines at home and predictors of access to medicines for chronic diseases. Less than half of individuals previously diagnosed with a chronic disease had access to medicines for their condition in every country, from 16% in Uganda to 49% in Jordan. Other than reporting a chronic disease, higher household socioeconomic level was the most significant predictor of having any medicines available at home. The likelihood of having access to medicines for chronic diseases was higher for those with medicines insurance coverage [highest adjusted odds ratio (OR) 3.12 (95% confidence intervals (CI): 1.38, 7.07)] and lower for those with past history of borrowing money to pay for medicines [lowest adjusted OR 0.56 (95% CI: 0.34, 0.92)]. Our study documents poor access to essential medicines for chronic conditions in five resource-constrained settings. It highlights the importance of financial risk protection and consumer education about generic medicines in global efforts towards improving treatment of chronic diseases.

The RBF scheme, which paid incentives for verified results, steadily improved the CMS's performance over 1 year, particularly for supply and distribution planning. Key apparent success factors:1) The CMS had full discretion over how to spend the funds. 2) Payment was shared with and dependent on all staff, which encouraged teamwork. 3) Performance indicators were challenging yet achievable. 4) The quarterly payment cycle was frequent enough to be motivating. Recommendations for future programs: focus on both quality and quantity indicators; strengthen results verification processes; and work toward institutionalizing the approach.ABSTRACT Background: Public health commodity supply chains are typically weak in low-income countries, partly because they have many disparate yet interdependent functions and components. Approaches to strengthening supply chains in such settings have often fallen short-they address technical weaknesses, but not the incentives that motivate staff to perform better. Methods:We reviewed the first year of a results-based financing (RBF) program in Mozambique, which began in January 2013. The program aimed to improve the performance of the central medical store-Central de Medicamentos e Artigos Medicos (CMAM)-by realigning incentives. We completed in-depth interviews and focus group discussions with 33 key informants, including representatives from CMAM and donor agencies, and collected quantitative data on performance measures and use of funds. Implementation:The RBF agreement linked CMAM performance payments to quarterly results on 5 performance indicators related to supply planning, distribution planning, and warehouse management. RBF is predicated on the theory that a combination of carrot and stick-i.e., shared financial incentives, plus increased accountability for results-will spur changes in behavior. Important design elements: (1) indicators were measured against quarterly targets, and payments were made only for indicators that met those targets; (2) targets were set based on documented performance, at levels that could be reasonably attained, yet pushed for improvement; (3) payment was shared with and dependent on all staff, encouraging teamwork and collaboration; (4) results were validated by verifiable data sources; and (5) CMAM had discretion over how to use the funds. Findings:We found that CMAM's performance continually improved over baseline and that CMAM achieved many of its performance targets, for example, timely submission of quarterly supply and distribution planning reports. Warehouse indicators, such as inventory management and order fulfillment, proved more challenging but were nonetheless positive. By linking payments to periodic verified results, and giving CMAM discretion over how to spend the funds, the RBF agreement motivated the workforce; focused attention on results; strengthened data collection; encouraged teamwork and innovation; and ultimately strengthened the central supply chain.Conclusion: Policy makers and program managers can use performance incentiv...

Lack of standardization related to compounded drug preparations, especially in the transition of care situations, threatens patient safety by facilitating medication error. This paper outlines progress to-date from the United States Pharmacopeia (USP) Expert Panel on the Exchange of Compounded Drug Preparation Information in Health IT Systems. The work plan developed for the group is focused on proposing a set of encoding rules that would govern how compounded nonsterile drug preparations (CNSPs) are digitized and exchanged, including patient electronic health records (EHR), pharmacy systems, e-prescribing (eRx), and other Health IT (HIT) systems to ensure a seamless compounding process tailored to the needs of an individual patient. Included in this work are identifying authorized compounding monographs, surveying provider and end-user groups for information about data specificity during e-prescribing, and generating guidelines for the development of a compatible data model for clinical formulation identifiers (CF-IDs). This paper will also discuss how evolving nomenclature standards for CNSPs within HIT systems are part of a quality assurance system for comprehensive medication management (CMM) in children, thereby minimizing medication errors across the continuum of care. Finally, a network approach for the design of medication management systems for children and their families/caregivers is proposed.

This article is a summary and update for prescribing clinicians and primary care managers who are interested in medication error in general practice. It summarizes the state of primary care prescribing in the UK and reviews areas in which there is potential for error. Practical solutions and methods to mitigate the impact of error are presented alongside potential prescribing problems throughout the article.

In this series we present a number of prescribing safety indicators developed as part of an RCGP project.1 The evidence base behind each of the indicators is given along with information to illustrate their clinical significance. We provide a ‘real‐life’ audit based on the indicator to show how practices could begin to analyse their own prescribing data. Copyright © 2011 Wiley Interface Ltd