LETTER TO THE EDITORPay-for-performance Versus a Budget-Restrictive System for the Managementof Dyslipidemia. Should this Approach also be Applied in Hypertension?

The results of the Dyslipidemia International Study (DYSIS) were reported yesterday in the European Society of Cardiology (ESC) congress held at Amsterdam, Netherlands [1]. DYSIS compared low density lipoprotein cholesterol (LDL-C) target achievement in two West European Countries, UK, with an incentive-driven reimbursement system and Germany, with a budget-restrictive healthcare system. Overall, 80% of UK patients achieved the LDL-C target of <100 mg/dL (mean levels 82 mg/dL), compared with just 42% of patients in Germany (mean levels 111 mg/dL), despite the higher use of ezetimibe in the German population than in the UK population (11 vs. 3%). Dyslipidemic patients in the UK were more likely to be treated with potent statins whereas German doctors were more concerned with insurance restrictions than UK physicians [1]. Thus, it seems that lipid targets are more likely to be achieved in clinical practice in pay-for-performance than in budget-restrictive systems, like in Germany [1]. 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. Interestingly, the German reimbursement for atorvastatin changed in recent years, and many patients were subsequently switched to the less potent simvastatin [1]. A total of 85% of German patients were treated with simvastatin (average dose 27 mg/d) compared with just 66% of UK patients (average simvastatin dose 37 mg/d), while nearly 25% of UK patients were treated with atorvastatin (average dose 34 mg/d) vs. just