Millett Christopher, Gray Jeremy, Saxena Sonia, Netuveli Gopalakrishnan, Khunti Kamlesh, Majeed Azeem
Wandsworth Primary Care Research Centre, Wandsworth Primary Care Trust, London, United Kingdom.
PLoS Med. 2007 Jun;4(6):e191. doi: 10.1371/journal.pmed.0040191.
Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004.
We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005.
Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.
按绩效付费是指如果医疗服务提供者成功达到绩效目标，就给予他们更多报酬。英国一项针对全科医生的新合同代表了任何医疗体系中向按绩效付费的最彻底转变。该合同为解决不同种族和社会经济群体在慢性病管理方面的差异提供了一个重要契机。我们研究了2004年4月新合同引入前后，在基层医疗的多民族人群中糖尿病患者管理及中期临床结局方面的差异。
我们利用电子全科医疗记录，在伦敦西南部一个种族多样的地区进行了一项基于人群的纵向调查。结局指标为处方水平和国家治疗目标的达成情况（糖化血红蛋白[HbA1c]≤7.0%；血压[BP]<140/80 mmHg；总胆固醇≤5 mmol/l或≤193 mg/dl）。新合同实施后，达到HbA1c、BP和总胆固醇治疗目标的患者比例显著增加。除加勒比黑人患者组外，这些增加幅度在各民族中大致相同，该组相对于英国白人患者组，HbA1c（调整优势比[AOR]0.75，95%置信区间[CI]0.57 - 0.97）和血压控制（AOR 0.65，95%CI 0.53 - 0.81）的改善明显较低。2003年存在的各民族在处方和治疗目标达成方面的差异在2005年并未减弱。
按绩效付费激励措施并未解决不同民族在糖尿病管理和控制方面的差异。质量改进举措必须更加重视少数族裔社区，以避免心血管疾病及糖尿病其他主要并发症导致的死亡率持续存在差异。
