Correspondence

Pay for Performance and Quality of Care in England

N Engl J Med 2009; 361:1709October 22, 2009

Article

To the Editor:

A residual concern regarding the use of pay-for-performance incentives (July 9 issue)1 is that they will not address the complex nature of the presentation of chronic disease by older people2; also of concern is the realization that many illnesses previously thought of as acute actually display the characteristics of chronic disease.3 It is also troubling that pay-for-performance incentives diminish the value of important elements of care — such as continuity — that are likely to be very important in the management of complex chronic disease in older patients. Not only do these patients belong to the demographic group proportionately most likely to need such care, but they are also the least likely to receive it.4

The useful article by Campbell et al. should prompt the modification of incentive schemes to incorporate recognition of the complexity of illness presentation in later life. One possibility would be to use an age-attuned schedule to assess the quality of care received by older people, as has been proposed for the treatment of diabetes in later life.5 Another is to look at measures of functional status or coordination of care that more accurately reflect the needs and consider the well-being of older people.

Linda Kearney, M.R.C.P.I.
Desmond O'Neill, M.D.
Adelaide and Meath Hospital, Dublin, Ireland

5 References

1. 1

   Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009;361:368-378
   Full Text | Web of Science | Medline

2. 2

   Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005;294:716-724
   CrossRef | Web of Science | Medline

3. 3

   O'Neill D, Horgan F, Hickey A, McGee H. Long term outcome of stroke: stroke is a chronic disease with acute events. BMJ 2008;336:461-461
   CrossRef | Web of Science | Medline

4. 4

   Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med 2003;139:740-747
   Web of Science | Medline

5. 5

   Durso SC. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA 2006;295:1935-1940
   CrossRef | Web of Science | Medline