To the Editor: A residual concern regarding the use of pay-for-performanceincentives (July 9 issue)1 is that they will not address thecomplex nature of the presentation of chronic disease by olderpeople2; also of concern is the realization that many illnessespreviously thought of as acute actually display the characteristicsof chronic disease.3 It is also troubling that pay-for-performanceincentives diminish the value of important elements of care— such as continuity — that are likely to be veryimportant in the management of complex chronic disease in olderpatients. Not only do these patients belong to the demographicgroup proportionately most likely to need such care, but theyare also the least likely to receive it.4
The useful article by Campbell et al. should prompt the modificationof incentive schemes to incorporate recognition of the complexityof illness presentation in later life. One possibility wouldbe to use an age-attuned schedule to assess the quality of carereceived by older people, as has been proposed for the treatmentof diabetes in later life.5 Another is to look at measures offunctional status or coordination of care that more accuratelyreflect the needs and consider the well-being of older people.
Linda Kearney, M.R.C.P.I. Desmond O'Neill, M.D. Adelaide and Meath Hospital Dublin, Ireland
References
Campbell SM, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009;361:368-378. [Free Full Text]
Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA 2005;294:716-724. [Free Full Text]
O'Neill D, Horgan F, Hickey A, McGee H. Long term outcome of stroke: stroke is a chronic disease with acute events. BMJ 2008;336:461-461. [Free Full Text]
Wenger NS, Solomon DH, Roth CP, et al. The quality of medical care provided to vulnerable community-dwelling older patients. Ann Intern Med 2003;139:740-747. [Free Full Text]
Durso SC. Using clinical guidelines designed for older adults with diabetes mellitus and complex health status. JAMA 2006;295:1935-1940. [Free Full Text]
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