• Evangelos Kontopantelis, Tim Doran, Hugh Gravelle, Rosalind Goudie, Luigi Siciliani, and Matt Sutton.
• Health Sciences Primary Care Research Group, University of Manchester, Manchester, UK. e.kontopantelis@manchester.ac.uk
• Health Serv Res. 2012 Jun 1; 47 (3 Pt 1): 1117-36.

ObjectiveTo analyze the effect of setting higher targets, in a primary care pay-for-performance scheme, on rates of influenza immunization and exception reporting.Study SettingThe U.K. Quality and Outcomes Framework links financial rewards for family practices to four separate influenza immunization rates for patients with coronary heart disease (CHD), chronic obstructive pulmonary disease, diabetes, and stroke. There is no additional payment for immunization rates above an upper threshold. Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate.DataPractice-level information on immunizations and exceptions extracted from electronic records of all practices in England 2004/05 to 2009/10 (n=8,212-8,403).Study DesignLongitudinal random effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07.Principal FindingsThe 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients (0.41 percent, CI: 0.25-0.56 percent), and exception was reported (0.26 percent, CI: 0.12-0.40 percent).ConclusionsMaking quality targets more demanding can not only lead to improvement in quality of care but can also have other consequences.© Health Research and Educational Trust.

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