Email updates

Keep up to date with the latest news and content from BMC Health Services Research and BioMed Central.

Open Access Highly Accessed Research article

Pay-for-performance in disease management: a systematic review of the literature

Simone R de Bruin*, Caroline A Baan and Jeroen N Struijs

BMC Health Services Research 2011, 11:272  doi:10.1186/1472-6963-11-272

PubMed Commons is an experimental system of commenting on PubMed abstracts, introduced in October 2013. Comments are displayed on the abstract page, but during the initial closed pilot, only registered users can read or post comments. Any researcher who is listed as an author of an article indexed by PubMed is entitled to participate in the pilot. If you would like to participate and need an invitation, please email, giving the PubMed ID of an article on which you are an author. For more information, see the PubMed Commons FAQ.

Pay for performance in disease management: a systematic review of the literature.

Lance Turtle   (2012-02-17 14:33)  University of Liverpool

This article by de Bruin et al. (1) addresses a critical research question, that is: do pay for performance (P4P) schemes in healthcare result in the delivery of better care? The stated aims in this review were: (i) to provide an overview of P4P schemes that are currently used to stimulate delivery of chronic care through disease management and (ii) to gain insights into the effects of P4P on healthcare quality and healthcare costs (1).

However, this article has significant shortcomings. It is unfortunate that the UK has been excluded as it is one of the largest schemes to date and represents one of the few examples of the introduction of P4P across a socialised health care system. In 2007 Campbell et al. (2) reported no improvement in clinical outcome with the introduction of pay-for-performance for asthma, diabetes and hypertension in 42 primary care practices in England (though improvement was seen in process outcomes). This study seems to meet all the inclusion criteria of this review; why it was not included is not clear. If the details regarding payment in Campbell et al. were insufficient to justify inclusion, we suggest that the exclusion criteria are too stringent to adequately answer the research question. Several evaluations, articles and news coverage before January 2010 (the cut off date for this review) suggested that the UK P4P scheme was costly, improved monitoring (3), but had unclear benefit on clinical outcomes. Although many of these sources were not within the peer reviewed literature, subsequent peer reviewed publications have still not shown evidence of a benefit on clinical outcomes of the P4P scheme in the UK (4-6).

Given the omission of the UK, the review��s objectives have not been met. Restricting the sources for evaluation to the peer reviewed literature is not adequate to answer this research question. The search should have included grey literature such as published government or health system reports or information from websites about the scheme. This review is incomplete and warrants being repeated in the near future to adequately represent the evidence that is available on P4P schemes.

Nadja van Ginneken MPH MRCGP,
Wellcome Trust Clinical PhD student,
London School of Hygiene and Tropical Medicine, UK

Lance Turtle PhD MRCP,
Wellcome Trust Postdoctoral Clinical Fellow, University of Liverpool, UK


1. De Bruin, S.R.; Baan, C.A.; Struijs, J.N. (2011). Pay for performance in disease management: a systematic review of the literature. BMC Health Services Research, 11:272

2. Campbell, S.; Reeves, D.; Kontopantelis, E.; Middleton, E.; Sibbald, B. and Roland, M. (2007). Quality of primary care in England with the introduction of pay for performance. The New England Journal of Medicine. 357(2) :181-190

3. Ashworth, M., Medina, J. and Morgan, M. (2008). Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework. BMJ (Clinical research ed), 337(2), p.a2030-a2030

4. Fleetcroft, R.; Parekh-Bhurke, S.; Howe, A.; Cookson, R.; Swift, L. and Steel, N. (2010). The UK pay-for-performance programme in primary care: estimation of population mortality reduction. British Journal of General Practice, September :345-352

5. Serumaga, B; Ross-Degnan, D; Avery, A.J.; Elliott, R.A.; Majumdar, S.R.; Zhang, F.; Soumerai, S.B.(2011) Effect of pay for performance on the management and outcomes of hypertension in the United Kingdom: interrupted time series study ;342:d108; doi:10.1136/bmj.d108

6. Shah, S.M.; Carey, I.M.; Harris, T.; DeWilde, S. and Cook, D.G. (2011) Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study. BMJ;342:d912.doi:10.1136

Competing interests

None declared


Post a comment