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Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study

BMJ 2011; 342 doi: (Published 25 January 2011) Cite this as: BMJ 2011;342:d108
  1. Brian Serumaga, Harvard Medical School fellow in pharmaceutical policy research12,
  2. Dennis Ross-Degnan, associate professor and director of research1,
  3. Anthony J Avery, professor2,
  4. Rachel A Elliott, professor3,
  5. Sumit R Majumdar, professor4,
  6. Fang Zhang, statistician and instructor1,
  7. Stephen B Soumerai, professor1
  1. 1Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Health Care Institute, 133 Brookline Avenue, Boston, MA 02215, USA
  2. 2Division of Primary Care, University of Nottingham Medical School, UK
  3. 3Division of Social Research in Medicines and Health, University of Nottingham School of Pharmacy, UK
  4. 4Department of Medicine, University of Alberta, Canada
  1. Correspondence to: S B Soumerai stephen_soumerai{at}
  • Accepted 17 November 2010


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.


  • Contributors: BS, SBS, DRD, FZ, AJA, and RAE conceived the study. All authors developed the methods and analysis for the study and contributed to the writing of the manuscript. BS and FZ carried out the analysis. All authors were involved in discussion and interpretation of the analysis. SBS is the guarantor.

  • Funding: This research received no specific grant from any funding agency in the public, commercial, or not for profit sectors.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare: BS is supported by a fellowship in pharmaceutical policy research at Harvard Medical School. DRD, FZ, and SBS are investigators in the HMO Research Network Centre for Education and Research in Therapeutics and are supported by the Agency for Healthcare Research and Quality. SM receives salary support (health scholar) from the Alberta heritage foundation for medical research. All authors have no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years.

  • Ethical approval: This study was approved by the National Health Service North Nottinghamshire and Nottingham 1 research ethics committee.

  • Data sharing: A detailed technical appendix and statistical code are available from the corresponding author at stephen_soumerai{at}

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