Pay-For-Performance Improves Lipid Levels and Gets More Patients to LDL Targets

August 31, 2013

AMSTERDAM, THE NETHERLANDS — The incentive-driven reimbursement system of the UK results in significantly more patients with dyslipidemia at LDL treatment goal than patients treated in the more budget-conscious German healthcare system, according to an analysis of the Dyslipidemia International Study (DYSIS)[1].

Overall, 80% of UK patients achieved the LDL-cholesterol target of <100 mg/dL compared with just 42% of German patients. The mean LDL-cholesterol level of the 4260 German dyslipidemic patients was 111 mg/dL compared with 82 mg/dL in the 540 UK patients.

Dr Anselm Kai Gitt (Herzzentrum Ludwigshafen, Germany), who presented the results here at the European Society of Cardiology (ESC) 2013 Congress , said that patients in the UK are more likely to be treated with potent statins, and while they didn't specifically ask why physicians prescribed the medications and doses they did, German doctors are typically more concerned with insurance restrictions than UK physicians.

"Lipid targets achieved in clinical practice might be influenced--this is the hypothesis, it's not a proven issue--and be better in pay-for-performance systems and worse in the budget-restrictive system, like in Germany," said Gitt during a morning press conference at the ESC.

Differing Approaches to Healthcare

Speaking with heartwire , Gitt explained that the UK and German healthcare systems differ significantly. In the UK, nearly 100% of physicians participate in the pay-for-performance reimbursement system, whereas German doctors face a limited budget per patient. A German physician who exceeds the budget faces the possibility of being compelled to reimburse the government for the excess costs. In addition, the UK healthcare system makes physicians participate in a clinical audit, and these results are used to assess the quality of care provided. There are no specific quality-improvement strategies in Germany, said Gitt.

Atorvastatin still had a long way to go with its patent.

Not inconsequentially, the German reimbursement for atorvastatin also changed in recent years, and many patients were subsequently switched to the less potent simvastatin.

"To give you an idea, patients used to be on simvastatin because it was the first available statin," said Gitt. "Atorvastatin was then shown to be very effective in reducing LDL cholesterol, and the majority of patients were switched and treated with it. Then, policy decisions by the government introduced a fixed-price system, where all medications within a class were to be priced the same, but atorvastatin still had a long way to go with its patent."

With Pfizer opting out of the German fixed-price system, health insurance, typically, would reimburse patients only if they were prescribed simvastatin and other off-patent statins, such as pravastatin, fluvastatin, and lovastatin, forcing patients to pay out-of-pocket for higher-priced atorvastatin. As a result, simvastatin dominated the market.

The interesting thing now would be to see if better adherence to guidelines might result in a reduction in outcomes.

In the DYSIS analysis of the statin-treated patients, almost 85% of German patients were treated with simvastatin, an average dose of 27 mg/day, compared with just two-thirds of UK patients treated with simvastatin, at an average dose of 37 mg/day. Instead, nearly 25% of UK patients were treated with atorvastatin, average dose 34 mg/day, vs just 4% of Germans who received the high-potency statin.

The study was a one-time snapshot of LDL targets and treatment goals comparing the two healthcare systems. It was not designed to assess the effect of the treatment targets on clinical events. "The interesting thing now would be to see if better adherence to guidelines might result in a reduction in outcomes," said Gitt. "In other words, if we spend a little bit more money now by giving incentives to doctors and paying for higher dosages of statins, it might in the intermediate- and long-term follow-up result in fewer complications, MIs, and hospitalizations. It might even save money long term."

In the UK, based on data presented by Gitt from the Commonwealth Fund, physicians can receive financial incentives for patient care, including achieving high patient satisfaction ratings, achieving clinical targets, managing patients with chronic/complex needs, and providing enhanced preventive care, such as counseling and group visits. In Germany, the opportunity to receive financial incentives for better care is not available, said Gitt.

"Any system has pitfalls, and I'm not saying that money is the final way for these things, but linked to the pay-for-performance is a feedback system," he said. "Doctors can say, 'Oh, only 10% of my patients are at goal. I should do something about this.' This is not happening in Germany."

Treating CAD Patients With Low LDL Levels

An additional study presented during the ESC conference also confirmed the benefit of treating patients even with low LDL-cholesterol levels, such as those with coronary artery disease and LDL-cholesterol levels <70 mg/dL [2].

Presented by Dr Emi Nakano (Saint Marianna University School of Medicine, Kawasaki, Japan), the analysis included 2238 coronary artery disease patients who underwent PCI. Following PCI, 214 patients had very low LDL-cholesterol levels (<70 mg/dL), 669 had low LDL cholesterol levels (71–100 mg/dL), and 1355 had high LDL-cholesterol levels (>101 mg/dL).

Dr Emi Nakano

Statin use, in a multivariate adjusted model, was associated with a 62% lower risk of major adverse cardiovascular events. This benefit extended to all patients, including those with low and very low LDL-cholesterol levels, reported Nakano.

Speaking during the press conference, moderator Dr Terje Pedersen (University of Oslo, Norway) said it might be rare in the US and Europe for patients with coronary artery disease to have such low LDL-cholesterol levels, but this phenotype is more common in Asia.

Gitt reports receiving research/grant support and serving as consultant to and/or receiving speaking-bureau payments from Merck, Sankyo-Daiichi, Novartis, Pfizer, Roche, Sanofi, Servier, Takeda, AstraZeneca, Bristol-Myers Squibb, Eli Lilly, Novo Nordisk, and Regeneron. Pedersen is an advisor/consultant to Merck, AstraZeneca, and Pfizer. Nakano reports no conflicts of interest.


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