Family Doctor Responses to Changes in Incentives for Influenza Immunization under the U.K. Quality and Outcomes Framework Pay-for-Performance Scheme


Address correspondence to Evangelos Kontopantelis, Ph.D., Health Sciences Primary Care Research Group, 5th Floor Williamson Building, University of Manchester, M13 9PL, UK; e-mail:



To analyze the effect of setting higher targets, in a primary care pay-for-performance scheme, on rates of influenza immunization and exception reporting.

Study Setting

The U.K. Quality and Outcomes Framework links financial rewards for family practices to four separate influenza immunization rates for patients with coronary heart disease (CHD), chronic obstructive pulmonary disease, diabetes, and stroke. There is no additional payment for immunization rates above an upper threshold. Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate.


Practice-level information on immunizations and exceptions extracted from electronic records of all practices in England 2004/05 to 2009/10 (n = 8,212–8,403).

Study Design

Longitudinal random effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07.

Principal Findings

The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients (0.41 percent, CI: 0.25–0.56 percent), and exception was reported (0.26 percent, CI: 0.12–0.40 percent).


Making quality targets more demanding can not only lead to improvement in quality of care but can also have other consequences.