Impact of pay-for-performance on management of diabetes: a systematic review

J Evid Based Med. 2013 Aug;6(3):173-84. doi: 10.1111/jebm.12052.


Objectives: To review and synthesize published evidence of pay-for-performance (P4P) effects on management of diabetes.

Methods: Databases including Ovid MEDLINE, EMbase, PubMed, The Cochrane Library (Issue 3, 2012) were comprehensively searched for the effects of P4P programs in terms of patient outcomes and physician behaviors. Studies covering detailed data were included and synthesized. The quality of the body of evidence for each quality indicator was determined using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

Results: Among 742 identified articles, 12 interrupted time series studies, 7 controlled before-after studies, and 2 cross-sectional studies were included. Additionally, 12 studies were further included for quantitative analysis. Results of meta-analysis showed that P4P produced generally positive effects in most indicators (eg, patients with records of total cholesterol or blood pressure). However, these results were inconsistent. The percentage of patients with HbA1c ≤ 7% or 53 mmol/mol showed a pooled odds ratio of 0.98 in patients, but a pooled mean difference of 19.71% in the physician groups. The odds ratios of receiving tests/reaching an outcome level were also diverse in patients (odds ratios ranged from 0.98 to 3.32). Besides, process indicators had higher rates of improvement than outcome indicators.

Conclusions: P4P programs have variable impacts on patient outcomes of diabetes as well as physician behaviors, with various effects from negligible to strongly beneficial. Considering the low quality of the included studies, this conclusion should be cautiously interpreted.

Keywords: Diabetes; meta‐analysis; pay‐for‐performance (P4P); systematic review.

Publication types

  • Research Support, Non-U.S. Gov't
  • Review
  • Systematic Review

MeSH terms

  • Blood Glucose / analysis
  • Blood Pressure
  • Cholesterol / blood
  • Diabetes Mellitus / therapy*
  • Glycated Hemoglobin A / analysis
  • Humans
  • Hyperlipidemias / blood
  • Hypoglycemic Agents / therapeutic use
  • Motivation*
  • Self Care


  • Blood Glucose
  • Glycated Hemoglobin A
  • Hypoglycemic Agents
  • hemoglobin A1c protein, human
  • Cholesterol