The European Journal of Health Economics

, Volume 20, Issue 9, pp 1303–1315 | Cite as

Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review

  • Neeru GuptaEmail author
  • Holly M. Ayles
Original Paper



Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems.


Studies were identified by searching ten databases (01/2000–04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs.


We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term—when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts.


Evidence of the effectiveness of P4P depends on whether physicians’ incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.


Pay-for-performance Systematic review Physician practice Diabetes mellitus National health insurance 

JEL Classification

H51 government expenditures and health I11 analysis of health care markets J33 compensation packages 



The authors wish to thank Barry Cull and Richelle Witherspoon, from the University of New Brunswick’s Harriet Irving Library, for assistance with structuring the literature search and adapting it for the different bibliographic databases. Diabetes Canada and the New Brunswick Health Research Foundation provided financial support for this study. The sponsors had no role in study design, data collection, data analysis, or writing of the paper.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.


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Copyright information

© Springer-Verlag GmbH Germany, part of Springer Nature 2019

Authors and Affiliations

  1. 1.University of New BrunswickFrederictonCanada

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