Ethnic Disparities in Coronary Heart Disease Management and Pay for Performance in the UK

  • Christopher Millett
  • Jeremy Gray
  • Martin Wall
  • Azeem Majeed
Original Article



Few pay for performance schemes have been subject to rigorous evaluation, and their impact on disparities in chronic disease management is uncertain.


To examine disparities in coronary heart disease management and intermediate clinical outcomes within a multiethnic population before and after the introduction of a major pay for performance initiative in April 2004.


Comparison of two cross-sectional surveys using electronic general practice records.


Thirty-two family practices in south London, United Kingdom (UK).


Two thousand eight hundred and ninety-one individuals with coronary heart disease registered with participating practices in 2003 and 3,101 in 2005.


Percentage achievement by ethnic group of quality indicators in the management of coronary heart disease


The proportion of patients reaching national treatment targets increased significantly for blood pressure (51.2% to 58.9%) and total cholesterol (65.7% to 73.8%) after the implementation of a major pay for performance initiative in April 2004. Improvements in blood pressure control were greater in the black group compared to whites, with disparities evident at baseline being attenuated (black 54.8% vs. white 58.3% reaching target in 2005). Lower recording of blood pressure in the south Asian group evident in 2003 was attenuated in 2005. Statin prescribing remained significantly lower (p < 0.001) in the black group compared with the south Asian and white groups after the implementation of pay for performance (black 74.8%, south Asian 83.8%, white 80.2% in 2005).


The introduction of pay for performance incentives in UK primary care has been associated with better and more equitable management of coronary heart disease across ethnic groups.


pay for performance coronary heart disease primary care ethnicity 



We wish to thank practices who participated in the study. Christopher Millett is supported by a grant from the National Institute for Health Research Service Delivery and Organisation Programme. The Wandsworth Primary Care Research Centre has received funding from the Department of Health and also received support from the Medical Research Council through the VOTES (Virtual Organisation of Trials and Epidemiological Studies) project. The Department of Primary Care & Social Medicine at Imperial College is grateful for support from the National Institute for Health Research Biomedical Research Centre Scheme and the National Institutes of Health Collaboration for Leadership in Applied Health Research and Care program.


JG, CM and AM conceived the study. MW performed the statistical analyses. All authors contributed to the data interpretation. CM wrote the first draft of the manuscript and all authors contributed to the revision and approved the final version. CM is the guarantor for the study.

Conflict of Interest

None disclosed.


  1. 1.
    Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA. 2005;294:1788–93.PubMedCrossRefGoogle Scholar
  2. 2.
    Epstein AM. Paying for performance in the United States and abroad. N Engl J Med. 2006;355:406–8.PubMedCrossRefGoogle Scholar
  3. 3.
    Roland M. Linking physicians’ pay to the quality of care — a major experiment in the United Kingdom. NEJM. 2004;351:1448–54.PubMedCrossRefGoogle Scholar
  4. 4.
    Department of Health. (June 2004) NHS Improvement plan: Putting people at the heart of public services. London. Available at: Accessed 01 October 2008.
  5. 5.
    British Medical Association (June 2005) Improving health - general practice. Available at: Accessed 01 October 2008
  6. 6.
    Casalino LP, Elster A. Will pay-for-performance and quality reporting affect health care disparities? Health Aff. 2007;26(3):w405–14.CrossRefGoogle Scholar
  7. 7.
    Chien AT, Chin MH, Davis AM, Casalino LP. Pay for performance, public reporting, and racial disparities in health care: how are programs being designed? Med Care Res Rev. 2007;64(5 Suppl):283S–304S. Review, Oct.PubMedCrossRefGoogle Scholar
  8. 8.
    Peterson L, Woodard L, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med. 2006;145:265–72.Google Scholar
  9. 9.
    Health and Social Care Information Centre. National quality and outcomes framework statistics for England 2004/05. Statistical Bulletin [4], 23. 2005. Available at: Accessed 01 October 2008
  10. 10.
    Doran T, Fullwood C, Gravelle H, et al. Pay-for-performance programs in family practices in the United Kingdom. NEJM. 2006;355(4):375–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Sheth T, Nair C, Nargundkar M, Anand S, Yusuf S. Cardiovascular and cancer mortality among Canadians of European, south Asian and Chinese origin from 1979 to 1993. CMAJ. 1999;161(2):132–8.PubMedGoogle Scholar
  12. 12.
    Forouhi N, Sattar N, Tillin T, McKeigue P, Chaturvedi N. Do known risk factors explain the higher coronary heart disease mortality in South Asian compared with European men? Prospective follow-up of the Southall and Brent studies, UK. Diabetologia. 2006;49(11):2580–8. Nov.PubMedCrossRefGoogle Scholar
  13. 13.
    Mensah G, Mokdad A, Ford E, Greenlund K, Croft J. State of disparities in cardiovascular health in the United States. Circulation. 2005;111(10):1233–41. Mar 15.PubMedCrossRefGoogle Scholar
  14. 14.
    Balarajan R. Ethnic differences in mortality from ischaemic heart disease and cerebrovascular disease in England and Wales. BMJ. 1991;3026776560–4. Mar 9.PubMedCrossRefGoogle Scholar
  15. 15.
    Fiscella K, Franks P, Gold MR, Clancy CM. Inequality in quality: addressing socioeconomic, racial, and ethnic disparities in health care. JAMA. 2000;283(19):2579–84. May 17.PubMedCrossRefGoogle Scholar
  16. 16.
    Institute of Medicine. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: National Academy Press; 2002. = 16740 Accessed 01 October 2008.Google Scholar
  17. 17.
    Feder G, Crook A, Magee P, Banerjee S, Timmis A, Hemingway H. Ethnic differences in invasive management of coronary disease: prospective cohort study if patients undergoing angiography. BMJ. 2002;324:511–6.PubMedCrossRefGoogle Scholar
  18. 18.
    Britton A, Shipley M, Marmot M, Hemingway H. Does access to cardiac investigation and treatment contribute to social and ethnic differences in coronary heart disease? Whitehall II prospective cohort study. BMJ. 2004;329:318–23.PubMedCrossRefGoogle Scholar
  19. 19.
    British Medical Association. General medical services contract. Available at: Accessed 01 October 2008
  20. 20.
    Gray J, Majeed A, Kerry S, Rowlands G. Identifying patients with ischaemic heart disease in general practice: cross sectional study of paper and computerised medical records. BMJ. 2000;321:548–50.PubMedCrossRefGoogle Scholar
  21. 21.
    UK 2001 Census Available at: Accessed 01 October 2008
  22. 22.
    Department of Communities and Local Government. Index of Multiple Deprivation 2004. Available at: Accessed 01 October 2008
  23. 23.
    Froot KA. Consistent covariance matrix estimation with cross-sectional dependence and heteroskedasticity in financial data. J Financ Quant Anal. 1989;24:333–355.CrossRefGoogle Scholar
  24. 24.
    Gill P, Quirke T, Mant J, Allan T. The use of lipid-lowering drugs across ethnic groups in the secondary prevention of ischaemic heart disease: analysis of cross-sectional surveys in England. BJGP. 2004;54:442–3.Google Scholar
  25. 25.
    Ferdinand K. Coronary heart disease and lipid-modifying treatment in african american patients. Heart. 2004;147(5):774–82.CrossRefGoogle Scholar
  26. 26.
    Millett C, Gray J, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnic Disparities in Diabetes Management and Pay-for-Performance in the UK: The Wandsworth Prospective Diabetes Study. PLoS Medicine. 2007;4(6):e191. doi: 10.1371/journal.pmed.0040191.PubMedCrossRefGoogle Scholar
  27. 27.
    Chaturvedi N, McKeigue P, Marmot M. Resting and ambulatory blood pressure differences in Afro-Caribbeans and Europeans. Hypertension. 1993;22:90–96.PubMedGoogle Scholar
  28. 28.
    Wolfe C, Smeeton N, Coshall C, Tilling K, Rudd A. Survival differences after stroke in a multiethnic population: follow-up study with the south London stroke register. BMJ. 2005;331(7514):431. Aug 20.PubMedCrossRefGoogle Scholar
  29. 29.
    Mensah G, Mokdad A, Ford E, Greenlund K, Croft J. State of disparities in cardiovascular health in the United States. Circulation. 2005;111(10):1233–41. Mar 15.PubMedCrossRefGoogle Scholar
  30. 30.
    Campbell S, Roland M, Middleton E, Reeves D. Improvements in quality of clinical care in English general practice 1998–2003: longitudinal observational study. BMJ. 2005;331:1121–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. N Engl J Med. 2007;357:181.PubMedCrossRefGoogle Scholar
  32. 32.
    Nazroo J. The health of Britain’s ethnic minorities. London: Policy Studies Institute; 1997.Google Scholar
  33. 33.
    Bhopal R, Unwin N, White M, et al. Heterogeneity of coronary heart disease risk factors in Indian, Pakistani, Bangladeshi and European origin populations: cross sectional study. BMJ. 1999;319:215–20.PubMedGoogle Scholar
  34. 34.
    Majeed A. Sources, uses, strengths and limitations of data collected in primary care in England. Health Stat Q. 2004;21:5–14.PubMedGoogle Scholar
  35. 35.
    Hippisley-Cox J, Pringle M, Crown N, Meal A, Wynn A. Sex inequalities in ischaemic heart disease in general practice: cross sectional survey. BMJ. 2001;322:832–8.PubMedCrossRefGoogle Scholar
  36. 36.
    Ramsay S, Morris R, Papacosta O, et al. Secondary prevention of coronary heart disease in older British men: extent of inequalities before and after implementation of the National Service Framework. Am J Publ Health. 2005;27(4):338–43.CrossRefGoogle Scholar
  37. 37.
    Hippisley-Cox J, Pringle M, Cater R, Coupland C, Meal A. Coronary heart disease prevention and age inequalities: the first year of the National Service Framework for CHD. BJGP. 2005;55:369–75.Google Scholar
  38. 38.
    Department of Health. Tackling health inequalities. A programme for action. London: Department of Health; 2003 Available at: Accessed 01 October 2008.Google Scholar

Copyright information

© Society of General Internal Medicine 2008

Authors and Affiliations

  • Christopher Millett
    • 1
    • 2
  • Jeremy Gray
    • 2
  • Martin Wall
    • 3
  • Azeem Majeed
    • 1
  1. 1.Department of Primary Care & Social MedicineImperial College Faculty of MedicineLondonEngland
  2. 2.Wandsworth Primary Care Research CentreWandsworth PCTLondonEngland
  3. 3.Institute of Health & Human DevelopmentUniversity of East LondonLondonEngland

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