Study Highlights Lack of Resources Needed to Participate Successfully in U.S. P4P Initiatives

The heavy investment in a primary care infrastructure in the United Kingdom may have better prepared physician practices there to achieve pay-for-performance, or P4P, quality measures than their U.S. counterparts. That's one of the conclusions of a recent study (subscription required) in the Sept. 11 issue of Family Practice.

The study compared the quality of chronic illness care among 60 family physician practices in the United Kingdom and 55 practices in the United States to assess their readiness to participate in P4P programs. Researchers found that family physician practices in the United Kingdom were likely to be in a much better position to participate in P4P programs based on a higher level of care coordination, greater standardization of care and documentation, and more widespread use of electronic health records, or EHRs.

The authors attributed the preparation of the U.K. practices to investments made by the U.K. government in a primary care infrastructure that focuses on improving quality and access to care. The government also made investments in care teams and provided support for linkages between clinical practices and community resources, including clinical infrastructures and financial backing for EHR systems.

In addition, much of the U.K. evaluation efforts focused on documenting and improving processes of care, thus encouraging less variation in U.K. practice patterns, according to the study.

The study analyzed documentation levels and recommended care processes for two chronic disease states -- diabetes and coronary artery disease, or CAD -- from family physician practices in New Jersey and Pennsylvania from April 2003 through December 2004 and from family physician practices in the United Kingdom from February 2003 through August 2003. Researchers also looked at intermediate patient outcomes for the two groups. In the U.S. analysis, researchers looked at the records of about 20 patients from each practice; in the United Kingdom, they looked at the records of about 12 patients from each practice.

The study found much less variation in care among the U.K. practices compared with the U.S. practices, and a much higher degree of processes of care delivery documented among the U.K. practices.

In the United Kingdom, for example, the likelihood of patients with diabetes receiving most recommended services was more than eight times that of patients in the U.S. practices. Similarly, the chance of patients with CAD in the United Kingdom receiving recommended services was nine times that of patients in the U.S. practices.

In addition, the likelihood that smoking status would be recorded for a patient with either diabetes or CAD in a U.K. practice was more than 11 times greater than that for a patient in U.S. practices, a finding that has implications for patient health and care coordination, according to the study.

"In the (United States), gaps in documentation of process of care, especially related to recording of smoking status among patients at elevated cardiovascular disease risk, represent significant missed public health opportunities," said study researchers.

Jesse Crosson, Ph.D., lead author of the study and a visiting scholar at the AAFP's Robert Graham Center, pointed out that the smoking status of many of the patients in most of the U.S. practices in the study was never recorded.

"If you want to help people to stop smoking, you need to a keep a record of whether they are smoking," said Crosson, an assistant professor of family medicine at the University of Medicine & Dentistry of New Jersey-Robert Wood Johnson Medical School in Newark. "It helps you to communicate with other people on the team about where this person is and what needs to be done."

It is not clear whether the lack of documentation means that primary care in the United States is not as good as the care delivered in the United Kingdom, Crosson said. "It is hard to know if the care is not as good, but the documentation of care would indicate that it isn't," said Crosson.

Notably, the U.S. practice sample did not include patients without insurance or a usual source of care. Patients in the U.S. practices did a better job of meeting intermediate diabetes outcome targets than patients in the U.K. practices, prompting researchers to issue two distinct recommendations.

"U.S. policymakers should focus on reducing variation in care documentation to ensure the effectiveness of pay-for-performance efforts," the study said. At the same time, policymakers in the United Kingdom "should focus on moving from process documentation to better patient outcomes."

Researchers also noted that all of the 60 family physician practices in the United Kingdom had EHR systems, but only nine of the 55 family physician practices in the United States used EHRs. In addition, more than half of U.S. practices were using EHRs in combination with some type of paper record system. The lack of EHRs among family physician practices in the United States may put the practices at a distinct disadvantage when trying to meet the documentation and reporting requirements for participation in P4P initiatives, according to Crosson.

The report urges policymakers in the United States to invest in or provide incentives for the development of key quality improvement and documentation capacities for primary care practices. "Without such a commitment to realigning the priorities of the U.S. health care delivery system, pay-for-performance is likely to lead to results that are not significantly different from the poor ones already achieved," the report said.

The report validated widely held beliefs that health care in the United States is fragmented and uncoordinated, especially when compared with that in the United Kingdom, said Crosson. This is partly a result of the different roles played by family physicians in the two countries.

In the United Kingdom, for example, family physicians take care of a defined patient population and serve as gatekeepers. In this role, they decide whether to refer patients to subspecialists. "That is how family physicians in England described their own role," said Crosson. "Gatekeeper is sort of a dirty word (in the United States), but in England, it is not."

According to Crosson, in the United Kingdom, family physicians are responsible for overseeing and managing patient care for a defined patient population, leading to higher levels of care coordination. In the United States, however, patients are able to bypass their primary care physician to seek care from subspecialists, which can lead to more fragmented care.

"No one has a defined responsibility for any one patient's care in the typical practice setting in the United States," said Crosson.

The report also assailed the current fee-for-service payment system in the United States as another impediment to P4P, saying that such payment mechanisms have been found to be associated with poorer adherence to recommended processes of care. Fee-for-service payments also may lead to relatively poor documentation of unreimbursed services, the report said.

"I think we need to get away from fee-for-service to something that pays for the quality of care itself, something like pay-for-performance," said Crosson.