Money motivates doctors to reduce ethnic differences in heart disease treatments

Financial incentives for doctors can improve the management of coronary heart disease (CHD) and reduce ethnic differences in quality of and access to care, according to Dr. Christopher Millett, Consultant in Public Health at Imperial College Faculty of Medicine in London in the UK, and his colleagues. Their evaluation(1) of the benefits of pay for performance schemes in the UK for the management of coronary heart disease, with a particular focus on ethnic differences, has just been published online in Springer's Journal of General Internal Medicine.

Pay for performance incentive schemes were introduced by the National Health Service in the UK in April 2004, to improve the quality of healthcare for all patients. The new family practitioner contract stated that 25 percent of a doctor's income would depend on performance against targets.

It is well documented that there are marked differences in cardiovascular disease prevalence and subsequent health outcomes between ethnic groups, as well as potential unequal access to high-quality care. The authors looked at whether financial incentives for doctors would address these differences in management of CHD across ethnic groups.

Millett and his team looked at electronic records from 32 family practices in inner city London, before and after the introduction of the new contract in 2004. They identified 2,891 people with CHD in 2003 and 3,101 in 2005 and examined 10 quality indicators for CHD management. There were incentives for recording smoking status, measuring cholesterol and blood pressure, prescribing aspirin, beta-blockers and ACE inhibitors, as well as for controlling cholesterol and blood pressure. There were no incentives for either BMI measurement or prescription of statins.

Millett and his team found that more patients were reaching national treatment targets for both blood pressure and total cholesterol since the implementation of the pay for performance initiative in April 2004. The scheme improved CHD management across both incentivized and non-incentivized indicators. There were also fewer differences in prescribing and clinical outcomes between ethnic groups in 2005 than in 2003. For example, improvements in blood pressure control were greater in the black group than amongst the whites over the two year period, with the treatment gap between the two groups closing between 2003 and 2005. More South Asians also had their blood pressure recorded in 2005 than in 2003. However, black patients were still less likely to be prescribed statins than South Asians or whites in 2005.

The authors conclude that "whilst the management of CHD remains suboptimal in many patients, improvements in the quality of care seen since the new contract are impressive….most patients, including those from ethnic minority groups and living in areas of low socio-economic status, appear to have benefited from the scheme." They add that healthcare planners in other countries may want to consider introducing similar initiatives for their own primary care physicians.

Millett C et al (2008). Ethnic disparities in coronary heart disease management and pay-for-performance in the UK. Journal of General Internal Medicine DOI 10.1007/s11606-008-0832-5

The full-text article is available to journalists as a pdf.