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BMJ 2008; 337 doi: (Published 22 July 2008) Cite this as: BMJ 2008;337:a891

English general practitioners play fair with performance related pay

Doctors’ pay is linked increasingly to their performance, as measured by carefully chosen quality indicators. Doctors must reach targets for these indicators, and primary care doctors in the UK can exclude clinically inappropriate patients from target calculations. Exception reporting is meant to minimise overtreatment, but doctors could also exploit it to artificially inflate their targets, a process known as gaming. Researchers found little evidence of gaming in an analysis of data from the second year of a pay for performance programme for primary care doctors in England.

Rates of exception reporting among more than 8000 primary care practices (96% of all practices in England) were low—a median of 5.3% of patients were excluded from the 65 indicators studied. The rate of exclusions from some targets for influenza vaccine varied widely, and higher than average exclusion rates were seen for some cancer and mental health targets. The researchers had no data on the reasons for exclusions, so we don’t know how many, if any, were illegitimate. Low overall rates, however, translated into a generally small increase in doctors’ pay of around £500 (€630; $1000) a year associated with exclusions. No discernible link was seen between the rate of exclusion reporting and the financial rewards available for individual indicators. Widespread abuse of the system does not seem to be happening, say the authors.

Medical records miss adverse events reported by patients

When researchers reviewed the medical records of nearly 1000 patients recently discharged from hospitals in Massachusetts, they found 128 adverse events. When they interviewed the same patients, the number of reported adverse events went up to 304. The record review suggested that about one in 10 patients had had an adverse event (11%, 105/998), whereas the interviews suggested the proportion was closer to one in four (23%, 229/998). Doctors judged that 21 of the events reported by …

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