LETTER TO THE EDITOR
Pay-for-performance Versus a Budget-Restrictive System for the Management
of Dyslipidemia. Should this Approach also be Applied in Hypertension?
Authors: Doumas Michael , Tziomalos Konstantinos , Athyros Vasilios G. 
Published: November 2013

The results of the Dyslipidemia International Study
(DYSIS) were reported yesterday in the European Society of
Cardiology (ESC) congress held at Amsterdam, Netherlands
[1]. DYSIS compared low density lipoprotein cholesterol
(LDL-C) target achievement in two West European Countries,
UK, with an incentive-driven reimbursement system
and Germany, with a budget-restrictive healthcare system.
Overall, 80% of UK patients achieved the LDL-C target of
<100 mg/dL (mean levels 82 mg/dL), compared with just
42% of patients in Germany (mean levels 111 mg/dL), despite
the higher use of ezetimibe in the German population
than in the UK population (11 vs. 3%). Dyslipidemic patients
in the UK were more likely to be treated with potent statins
whereas German doctors were more concerned with insurance
restrictions than UK physicians [1]. Thus, it seems that
lipid targets are more likely to be achieved in clinical practice
in pay-for-performance than in budget-restrictive systems,
like in Germany [1]. The UK healthcare system makes
physicians participate in a clinical audit, and these results are
used to assess the quality of care provided. There are no specific
quality-improvement strategies in Germany. Interestingly,
the German reimbursement for atorvastatin changed in
recent years, and many patients were subsequently switched
to the less potent simvastatin [1]. A total of 85% of German
patients were treated with simvastatin (average dose 27
mg/d) compared with just 66% of UK patients (average simvastatin
dose 37 mg/d), while nearly 25% of UK patients
were treated with atorvastatin (average dose 34 mg/d) vs. just 4% of Germans who received this higher-potency statin [1].
These despite the fact that the German population had a
higher baseline incidence of cerebrovascular disease, peripheral
arterial disease and diabetes mellitus; more secondary
prevention patients that should achieve even lower LDL-C
targets. Since 2005 there is abundant data suggesting a close
relation of LDL-C levels with cardiovascular disease (CVD)
events, even between two groups on active statin treatment
[2]. The Treating to New Targets study showed a significant
22% further reduction in CVD events achieved with 80 mg/d
of atorvastatin (mean LDL-C level 77 mg/dL) compared
with 10 mg/d of atorvastatin (mean LDL-C level 100 mg/dL)
in high risk patients [2]. This was confirmed in the Pravastatin
or Atorvastatin Evaluation and Infection (PROVE-IT)
Thrombolysis In Myocardial Infarction (PROVE IT)-TIMI-
22 study in patients with acute coronary syndromes [3]. This
was also verified in March 2013 (in the ACC Congress) by
the results of the Ibaraki Cardiovascular Assessment Study
(ICAS) in CVD patients with initially low LDL-C [4]. These
findings suggest that if you save money today from prescribing
a cheaper (and less potent) statin you will pay tomorrow
twice as much in costs from CVD fatal and non-fatal events.
This was confirmed in The Health Improvement Network
(THIN) registry [5,6]. Switching from atorvastatin to simvastatin
was significantly associated with increased risk for all
CVD events [hazards ratio (HR) 1.30, 95% confidence interval
(CI) 1.02-1.64], major CVD events (HR 1.43, 95% CI
1.10-1.87), and stroke (HR 2.14, 95% CI 1.21-3.81). Interestingly,
these increased risks were partly attributed to differences
in lipid levels and partly to the pleitropic effects of
statins [5, 6].

Arterial hypertension (AH) is a major risk factor for
CVD, accounting globally for 51% of stroke and 45% of ischemic heart disease deaths [7]. The important question is
whether treatment results are similar in antihypertensive
treatment as in hypolipidaemic treatment if the pay-forperformance
approach is used. In UK, the inclusion of renalspecific
indicators in a primary care pay for performance
(P4P) system has promoted identification and better management
of risk factors related to chronic kidney disease
(CKD) since April 2006 [8]. The P4P framework, also
known as the Quality and Outcomes Framework (QOF),
aims at control of CVD risk factors; one of its key targets is
AH. It is clear that AH is a major risk factor for CKD, and
consequently CVD [8]. Thus, achieving better blood pressure
(BP) control is likely to have a positive impact on both CKD
and CVD [9]. BP control was improved since the introduction
of P4P and this improvement has been sustained [9].
This was associated with a significant increase in the use of
antihypertensive medication, resulting in increased prescription
cost (€25/month) [9]. Longer-term follow-up will establish
whether or not this translates into improved outcomes in
terms of progression of CKD and CVD events [9].

But why to restrict this policy only in hypertensive patients
with CKD? AH is a prevalent CVD risk factor with
rather disappointing control results. A recent systematic review
evaluated data regarding AH control from 35 countries
[10]. AH control was achieved in about third of treated patients.
In particular, AH control rates were higher in women
than in men (36.8% versus 31.9%), and in developed countries
compared to developing countries (33.3% versus 29.6%
for men, and 38.4 versus 34.0% for women, respectively)
[10]. However, when the awareness and treatment of hypertension
were taken into account, the true hypertension control
rates were substantially lower (16.9% for women versus
10.5% for men) and rather similar in developed and developing
countries (17.3% versus 16.2% for men, and 10.8% versus
9.8% for women, respectively) [10]. These incredibly
disappointing AH control rates were verified in the Copenhagen
City Heart Study, a prospective longitudinal study.
During the 25-year follow up period AH control increased
from 21% to 26% [11]. Once again however, when control
rates were adjusted for AH awareness and treatment, the true
AH control rates were improved but remained unacceptably
low (4.7% vs. 1.4%). It is therefore of no surprise that 7.6
million premature deaths (about 13.5% of the global total)
are attributed to high BP [12].

A study evaluated an intensive protocol-based strategy
for achieving BP control in family practice in the Centre for
Studies in Primary Care, Queen's University, Kingston, Ontario
[13]. There was an improvement between baseline and
12-month follow-up. BP control was significantly better for
the intervention group as assessed with both systolic and
diastolic mean BP on 24-hour ambulatory BP monitoring
[13]. This suggests that an intensive, protocol-based approach
to achieve BP control in hypertensive patients in family
practice is effective and works even when there is flexibility
built into the algorithm to allow family physicians to
use their judgment in individual patients [13].

Moreover, data from the REACH Registry, Austrian
Chapter, determined the extent of lost therapeutic benefit
(LTB) in hypertensive patients, and investigated the relationship
between the presence of LTB and clinical outcomes [14]. Presence of heart failure, previous myocardial infarction
and being male decreased the likelihood of LTB, while
presence of diabetes, age > 65 and ankle brachial index <
0.90 increased the risk of LTB. Patients with LTB in the age
category 55-64 had higher incidence of vascular events compared
to those with non-LTB [14].

The pay-for-performance system was introduced in the
new General Medical Services contract in the United Kingdom
since April 2004, and general practitioners are awarded
for the achievement of various clinical targets, including
hypertension control [15]. Some reports questioned the effectiveness
of the pay-for-performance system on blood
pressure control [16,17], however several lines of evidence
point towards a beneficial effect of the P4P system on blood
pressure management. A large longitudinal survey in over
8,500 general practices in England demonstrated that both
blood pressure monitoring and blood pressure control have
improved substantially after the implementation of the P4P
system [18]. In particular, a mean increased of 6% to 8% in
blood pressure control rates was observed in hypertensive
patients with or without coronary artery disease, cerebrovascular
disease, and diabetes [18]. Another recent study evaluated
the effects of pay-for-performance system in Wandswort,
London at 2007 [19]. This interrupted time series
study showed that both systolic and diastolic blood pressure
were constantly decreasing after the implementation of the
pay-for-performance system, for a mean reduction of 5.8
mmHg for systolic and 2.9 mmHg for diastolic between
2003 and 2007 [19]. More importantly, robust epidemiological
data confirm the improvements in hypertension control
rates in England. The results of the 2006 Health Survey in
England revealed that hypertension control rates increased
from 22% at 2003 to 28% at 2006, especially in women
(from 23% to 32%) [20]. Although several factors might
have contributed to this improvement in control rates, it
seems very likely that the pay-for-performance system might
have exerted beneficial effects.

The pay-for-performance system might also affect the
inequalities in primary care delivery. The quality of health
services is usually compromised in deprived areas. It has
been shown that the financial incentives of the pay-forperformance
system have substantially reduced the inequalities
in clinical care delivery due to area deprivation, narrowing
the gap between the least deprived and the most deprived
areas from 4.0% to 0.8% [21]. Similar beneficial effects of
the pay-for-performance system might also apply for the
ethnic disparities in hypertension management. Although
some older studies reported the persistence of ethnic disparities
in the management of hypertension [22], more recent
studies demonstrate attenuation of ethnic disparities in blood
pressure control [19].

In contrast, the removal of financial incentives carries the
risk of worsening performance levels. Indeed, a study from
the Kaiser Permanente Insurance System in Northern California
reveals that when financial incentives for some conditions
were removed from some facilities, the level of performance
for the detection and control of these conditions
declined significantly by about 3% per year [23], while the
reattachment of financial incentives was associated with significant
improvements.

To conclude, it appears that pay-for-performance, especially
based on treatment protocols, may substantially increase
BP control with considerable clinical benefits and in a
cost-effective way.