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.