Pay for performance, inequalities, and diabetes care

• Main Author: Alshamsan, Riyadh
• Other Authors: Millett, Christopher ; Majeed, Azeem
• Published: Imperial College London 2012
• Subjects: 361
• Online Access: http://ethos.bl.uk/OrderDetails.do?uin=uk.bl.ethos.544264

Background: The Quality and Outcome Framework (QOF) is a major pay for performance scheme that was introduced in 2004 in the UK. The introduction of QOF is a unique opportunity to evaluate the impact of pay for performance on inequalities and in particular on ethnic inequalities. This thesis examines the impact of QOF on ethnic inequalities and on patients with and without comorbidities in diabetes management. Methods: (1) Interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London for the years 2000 to 2007. (2) Cross-sectional study to examine the association between ethnicity, concordant and discordant comorbidity status and intermediate outcomes (HbA1c, blood pressure, total cholesterol). Results: The quality of diabetes care, as measured by the QOF indicators, has improved substantially throughout the study period, especially for the process aspect of care. The introduction of QOF was associated with initial additional improvements in systolic blood pressure in white and black patients but this was only sustained in black patients. Initial improvements in diastolic blood pressure in white and in cholesterol in black and white patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA1c in any ethnic group. The presence of ≥2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients. Conclusion: The QOF scheme did not appear to address important inequalities in diabetes management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.