Correspondence

Pay-for-Performance System for English Physicians

N Engl J Med 2008; 359:2176-2177November 13, 2008

Article

To the Editor:

Doran et al. (July 17 issue)1 found low rates of exception reporting among family practices in England and conclude that there is little evidence of gaming in the pay-for-performance system. The authors did not have access to the reasons for exception reporting.

This finding may allay fears of misuse of exceptions while heightening concern that capturing rare events adds an unnecessary data-collection burden. Some incorrectly may assume that all exception data are lost to inquiry.

In fact, exceptions should be captured, categorized, and reported to delineate appropriate and inappropriate variations in care. Exceptions flag important clinical conditions (e.g., allergies) and patient preferences; they permit transparency by accounting for every patient (Table 1Table 1Sample Report for Heart-Failure Performance Measure, with Exceptions Delineated.). In the United States, the Physician Consortium for Performance Improvement includes categories of exceptions and codes for reporting them in its performance measures.3 The Physician Quality Reporting Initiative provides physicians with reports that include rates of categorical exceptions.4 Researchers are exploring exception data in electronic health records.5,6 We are learning how to use these data to improve patient care and encourage continued use of exception reporting.

Bernard M. Rosof, M.D.
North Shore–Long Island Jewish Health System, Great Neck, NY 11021

Carl A. Sirio, M.D.
University of Pittsburgh Medical Center, Pittsburgh, PA 15216

Karen S. Kmetik, Ph.D.
American Medical Association, Chicago, IL 60654
karen.kmetik@ama-assn.org

This letter (10.1056/NEJMc081751) was updated on July 28, 2010, at NEJM.org.

6 References

1. 1

   Doran T, Fullwood C, Reeves D, Gravelle H, Roland M. Exlusion of patients from pay-for-performance targets by English physicians. N Engl J Med 2008;359:274-284[Erratum, N Engl J Med 208;359:546.]
   Full Text | Web of Science | Medline

2. 2

   American College of Cardiology/American Heart Association/Physician Consortium for Performance Improvement: performance measures for heart failure. Chicago: American Medical Association, 2006. (Accessed October 24, 2008, at http://www.physicianconsortium.org.)
   

3. 3

   Physician Consortium for Performance Improvement home page. (Accessed October 24, 2008, at http://www.physicianconsortium.org.)
   

4. 4

   Centers for Medicare & Medicaid Services. Physician quality reporting initiative. (Accessed October 24, 2008, at http://www.cms.hhs.gov/pqri.)
   

5. 5

   Persell SD, Wright JM, Thompson JA, Kmetik KS, Baker DW. Assessing the validity of national quality measures for coronary artery disease using an electronic health record. Arch Intern Med 2006;166:2272-2277
   CrossRef | Web of Science | Medline

6. 6

   Baker DW, Persell SD, Thompson JA, et al. Automated review of electronic health records to assess quality of care for outpatients with heart failure. Ann Intern Med 2007;146:270-277
   Web of Science | Medline

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   Peter J. Fagan, Alyson B. Schuster, Cynthia Boyd, Jill A. Marsteller, Michael Griswold, Shannon M. E. Murphy, Linda Dunbar, Christopher B. Forrest. (2010) Chronic Care Improvement in Primary Care: Evaluation of an Integrated Pay-for-Performance and Practice-Based Care Coordination Program among Elderly Patients with Diabetes. Health Services Research 45:6p1, 1763-1782
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   L. Heinzerling, G. Burbach, P. Van Cauwenberge, P. Papageorgiou, K.-H. Carlsen, K. C. Lødrup Carlsen, T. Zuberbier. (2010) Establishing a standardized quality management system for the European Health Network GA2LEN*. Allergy 65:6, 743-752
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