Primary studies included in this systematic review

loading
22 articles (22 References) loading Revert Studify

Primary study

Unclassified

Ethnic disparities in coronary heart disease management and pay for performance in the UK.

Authors Millett C , Gray J , Wall M , Majeed A
Journal Journal of general internal medicine
Year 2009
Links Pubmed DOI PubMed Central

This article is included in 5 Systematic reviews Systematic reviews (5 references)

Loading references information
BACKGROUND: Few pay for performance schemes have been subject to rigorous evaluation, and their impact on disparities in chronic disease management is uncertain. OBJECTIVE: To examine disparities in coronary heart disease management and intermediate clinical outcomes within a multiethnic population before and after the introduction of a major pay for performance initiative in April 2004. DESIGN: Comparison of two cross-sectional surveys using electronic general practice records. SETTING: Thirty-two family practices in south London, United Kingdom (UK). PATIENTS: Two thousand eight hundred and ninety-one individuals with coronary heart disease registered with participating practices in 2003 and 3,101 in 2005. MEASUREMENTS: Percentage achievement by ethnic group of quality indicators in the management of coronary heart disease RESULTS: The proportion of patients reaching national treatment targets increased significantly for blood pressure (51.2% to 58.9%) and total cholesterol (65.7% to 73.8%) after the implementation of a major pay for performance initiative in April 2004. Improvements in blood pressure control were greater in the black group compared to whites, with disparities evident at baseline being attenuated (black 54.8% vs. white 58.3% reaching target in 2005). Lower recording of blood pressure in the south Asian group evident in 2003 was attenuated in 2005. Statin prescribing remained significantly lower (p < 0.001) in the black group compared with the south Asian and white groups after the implementation of pay for performance (black 74.8%, south Asian 83.8%, white 80.2% in 2005). CONCLUSIONS: The introduction of pay for performance incentives in UK primary care has been associated with better and more equitable management of coronary heart disease across ethnic groups.

Primary study

Unclassified

Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework.

Journal Lancet
Year 2008
Links Pubmed DOI

This article is included in 3 Systematic reviews Systematic reviews (3 references) 1 Broad synthesis Broad syntheses (1 reference)

Loading references information
BACKGROUND: The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme. METHODS: We analysed data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004-05 to 2006-07). FINDINGS: Median overall reported achievement was 85.1% (IQR 79.0-89.1) in year 1, 89.3% (86.0-91.5) in year 2, and 90.8% (88.5-92.6) in year 3. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86.8% (82.2-89.6) for quintile 1 (least deprived) to 82.8% (75.2-87.8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4.4% for quintile 1 and by 7.6% for quintile 5, and the gap in median achievement narrowed from 4.0% to 0.8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0.0001), but was not associated with area deprivation (p=0.062). INTERPRETATION: Our results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation.

Primary study

Unclassified

Potential unintended financial consequences of pay-for-performance on the quality of care for minority patients.

Authors Karve AM , Ou FS , Lytle BL , Peterson ED
Journal American heart journal
Year 2008
Links Pubmed DOI

This article is included in 2 Systematic reviews Systematic reviews (2 references)

Loading references information
OBJECTIVES: The purpose of this study was to determine whether pay-for-performance (PFP) increases existing racial care disparities. BACKGROUND: Medicare's PFP program provides financial rewards to hospitals whose care performance ranks in the highest quintile relative to peers and reduces funding to hospitals that rank in the lowest quintile. Pay-for-performance is designed to improve care but may disproportionately penalize hospitals caring for large minority populations. METHODS: Using Medicare data, 3449 US hospitals were ranked by performance on PFP process measures for acute myocardial infarction (AMI), community-acquired pneumonia (CAP), and heart failure (HF). These rankings were compared with the percentage of African American (AA) patients in a center. We determined the eligibility for financial bonus (highest quintile ranking) or penalty (lowest quintile) among centers treating large AA populations (> or = 20%) versus not after adjusting for hospital facility (catheterization, percutaneous coronary intervention, surgery), academic status, number of hospital beds, location, patient volume, and region. RESULTS: The percentage of AA patients treated by a center was inversely associated with performance for AMI and CAP (P < .01) but not HF (P = .06). Relative to hospitals with < 20% AA, those with > or = 20% AA were less likely eligible for financial bonuses and more likely to face penalties: for AMI, adjusted odds ratio (OR) 0.7 (95% CI 0.5-1.0) and 1.8 (1.4-2.4), respectively; for CAP, OR 0.5 (95% CI 0.3-0.6) and 2.3 (1.8-2.9), respectively; for HF, OR 1.0 (95% CI 0.7-1.2) and 1.2 (0.9-1.5), respectively. CONCLUSIONS: Hospitals with large minority populations may be at financial risk under PFP. Thus, PFP may worsen existing racial care disparities.

Primary study

Unclassified

Effect of social deprivation on blood pressure monitoring and control in England: a survey of data from the quality and outcomes framework.

Authors Ashworth M , Medina J , Morgan M
Journal BMJ (Clinical research ed.)
Year 2008
Links Pubmed

This article is included in 3 Systematic reviews Systematic reviews (3 references)

Loading references information
OBJECTIVE: To determine levels of blood pressure monitoring and control in primary care and to determine the effect of social deprivation on these levels. DESIGN: Retrospective longitudinal survey, 2005 to 2007. SETTING: General practices in England. PARTICIPANTS: Data obtained from 8515 practices (99.3% of all practices) in year 1, 8264 (98.3%) in year 2, and 8192 (97.8%) in year 3. MAIN OUTCOME MEASURES: Blood pressure indicators and chronic disease prevalence estimates contained within the UK quality and outcomes framework; social deprivation scores for each practice, ethnicity data obtained from the 2001 national census; general practice characteristics. RESULTS: In 2005, 82.3% of adults (n=52.8m) had an up to date blood pressure recording; by 2007, this proportion had risen to 88.3% (n=53.2m). Initially, there was a 1.7% gap between mean blood pressure recording levels in practices located in the least deprived fifth of communities compared with the most deprived fifth, but, three years later, this gap had narrowed to 0.2%. Achievement of target blood pressure levels in 2005 for practices located in the least deprived communities ranged from 71.0% (95% CI 70.4% to 71.6%) for diabetes to 85.1% (84.7% to 85.6%) for coronary heart disease; practices in the most deprived communities achieved 68.9% (68.4% to 69.5%) and 81.8 % (81.3% to 82.3%) respectively. Three years later, target achievement in the least deprived practices had risen to 78.6% (78.1% to 79.1%) and 89.4% (89.1% to 89.7%) respectively. Target achievement in the most deprived practices rose similarly, to 79.2% (78.8% to 79.6%) and 88.4% (88.2% to 88.7%) respectively. Similar changes were observed for the achievement of blood pressure targets in hypertension, cerebrovascular disease, and chronic kidney disease. CONCLUSIONS: Since the reporting of performance indicators for primary care and the incorporation of pay for performance in 2004, blood pressure monitoring and control have improved substantially. Improvements in achievement have been accompanied by the near disappearance of the achievement gap between least and most deprived areas.

Primary study

Unclassified

The effect of the UK incentive-based contract on the management of patients with coronary heart disease in primary care.

Journal Family practice
Year 2008
Links Pubmed DOI

This article is included in 4 Systematic reviews Systematic reviews (4 references)

Loading references information
BACKGROUND: The new General Medical Services (nGMS) contract was introduced in April 2004 to improve care of chronic diseases such as coronary heart disease (CHD) and reduce differences in treatment between patient subgroups. OBJECTIVE: To determine whether the recording of CHD-related health indicators and prescribing of medicines have increased following the introduction of the nGMS contract and whether differences in the treatment of patients of differing age, gender and deprivation have been affected. METHODS: A serial cross-sectional study carried out with 310 general practices in Scotland. The subjects were patients with CHD as identified by their GP. Main outcome measures were the recording of CHD-related health indicators and prescribing of medicines at pre- and post-contract time points (covariates: gender, age, co-morbidity, deprivation and practice size). RESULTS: The recording of CHD-related quality indicators and prescribing increased dramatically (mean absolute increase of 17.1%) after the introduction of the nGMS contract. Post-contract, disparities between patient subgroups, continued for certain components of care. Women were less likely to be recorded than men in 9 of 11 components of care, with older patients (7 of 11 components of care) and the most deprived (4 of 11 components of care) also less likely to have a record than the youngest and least deprived, respectively. CONCLUSION: The introduction of the new contract was associated with a dramatic rise in the recording of CHD-related quality indicators. However, not all the population benefited equally for certain aspects of care.

Primary study

Unclassified

Diabetes prevalence, process of care and outcomes in relation to practice size, caseload and deprivation: national cross-sectional study in primary care.

Journal Journal of the Royal Society of Medicine
Year 2007
Links Pubmed DOI

This article is included in 3 Systematic reviews Systematic reviews (3 references)

Loading references information
OBJECTIVE: To examine the association between practice list size, deprivation and the quality of care of patients with diabetes. DESIGN: Population-based cross-sectional study using Quality and Outcomes Framework data. SETTING: England and Scotland. PARTICIPANTS: 55,522,778 patients and 8970 general practices with 1,852,762 people with diabetes. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Seventeen process and surrogate outcome measures of diabetes care. RESULTS: The prevalence of diabetes was 3.3%. Prevalence differed with practice list size and deprivation: smaller and more deprived practices had a higher mean prevalence than larger and more affluent practices (3.8% versus 2.8%). Practices with large patient list sizes had the highest quality of care scores, even after stratifying for deprivation. However, with the exception of retinal screening, peripheral pulses and neuropathy testing, differences in achievement between small and large practices were modest (<5%). Small practices performed nearly as well as the largest practices in achievement of intermediate outcome targets for HbA1c, blood pressure and cholesterol (smallest versus largest practices: 57.4% versus 58.7%; 70.7% versus 70.7%; and 69.5% versus 72.7%, respectively). Deprivation had a negative effect on the achieved scores and this was more pronounced for smaller practices. CONCLUSION: Our study provides some evidence of a volume-outcome association in the management of diabetes in primary care; this appears most pronounced in deprived areas.

Primary study

Unclassified

Social deprivation and statin prescribing: a cross-sectional analysis using data from the new UK general practitioner 'Quality and Outcomes Framework'.

Journal Journal of public health (Oxford, England)
Year 2007
Links Pubmed DOI

This article is included in 3 Systematic reviews Systematic reviews (3 references)

Loading references information
We aimed to study the relationship between the prescribing of lipid-lowering medication, social deprivation and other general practice characteristics. We conducted a cross-sectional survey of all general practices in England, 2004-05. For each practice, the following variables were obtained: standardized cost and volume data for lipid-lowering medication, descriptors of general practices, Index of Multiple Deprivation, 2004, ethnicity data from the 2001 Census and Quality and Outcomes Framework data. A regression model was constructed which explained 34.5% of the variation in statin prescribing by general practitioners. The most powerful predictors were higher social deprivation, higher prevalence of coronary heart disease and achievement of cholesterol targets for diabetics. Negative regression coefficients were demonstrated for the proportion of elderly patients in the practice and, to a lesser extent, for the proportion of south Asian and Afro-Caribbean patients. In conclusion, contrary to previous local studies, we found that statin prescribing was higher in more deprived communities, even after adjustment for increased disease prevalence and practice variables associated with deprivation. Statin prescribing was also independently associated with success at achieving cholesterol targets in established disease (secondary prevention). However, our findings suggest under-prescribing of statins to the elderly and possibly also to ethnic minorities.

Primary study

Unclassified

The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework.

Journal The British journal of general practice : the journal of the Royal College of General Practitioners
Year 2007
Links Pubmed

This article is included in 3 Systematic reviews Systematic reviews (3 references)

Loading references information
BACKGROUND: The existence of health inequalities between least and most socially deprived areas is now well established. AIM: To use Quality and Outcomes Framework (QOF) indicators to explore the characteristics of primary care in deprived communities. DESIGN OF STUDY: Two-year study. SETTING: Primary care in England. METHOD: QOF data were obtained for each practice in England in 2004-2005 and 2005-2006 and linked with census derived social deprivation data (Index of Multiple Deprivation scores 2004), national urbanicity scores and a database of practice characteristics. Data were available for 8480 practices in 2004-2005 and 8264 practices in 2005-2006. Comparisons were made between practices in the least and most deprived quintiles. RESULTS: The difference in mean total QOF score between practices in least and most deprived quintiles was 64.5 points in 2004-2005 (mean score, all practices, 959.9) and 30.4 in 2005-2006 (mean, 1012.6). In 2005-2006, the QOF indicators displaying the largest differences between least and most deprived quintiles were: recall of patients not attending appointments for injectable neuroleptics (79 versus 58%, respectively), practices opening > or =45 hours/week (90 versus 74%), practices conducting > or = 12 significant event audits in previous 3 years (93 versus 81%), proportion of epileptics who were seizure free > or = 12 months (77 versus 65%) and proportion of patients taking lithium with serum lithium within therapeutic range (90 versus 78%). Geographical differences were less in group and training practices. CONCLUSIONS: Overall differences between primary care quality indicators in deprived and prosperous communities were small. However, shortfalls in specific indicators, both clinical and non-clinical, suggest that focused interventions could be applied to improve the quality of primary care in deprived areas.

Primary study

Unclassified

Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study.

Authors Saxena S , Car J , Eldred D , Soljak M , Majeed A
Journal BMC health services research
Year 2007
Links Pubmed DOI PubMed Central

This article is included in 3 Systematic reviews Systematic reviews (3 references)

Loading references information
BACKGROUND: Reports of higher quality care by higher-volume secondary care providers have fuelled a shift of services from smaller provider units to larger hospitals and units. In the United Kingdom, most patients are managed in primary care. Hence if larger practices provide better quality of care; this would have important implications for the future organization of primary care services. We examined the association between quality of primary care for cardiovascular disease achieved by general practices in England and Scotland by general practice caseload, practice size and area based deprivation measures, using data from the New General Practitioner (GP) Contract. METHODS: We analyzed data from 8,970 general practices with a total registered population of 55,522,778 patients in England and Scotland. We measured practice performance against 26 cardiovascular disease (coronary heart disease, left ventricular disease, and stroke) Quality and Outcomes Framework (QOF) indicators for patients on cardiovascular disease registers and linked this with data on practice characteristics and census data. RESULTS: Despite wide variations in practice list sizes and deprivation, the prevalence of was remarkably consistent, (coronary heart disease, left ventricular dysfunction, hypertension and cerebrovascular disease was 3.7%; 0.45%; 11.4% and 1.5% respectively). Achievement in quality of care for cardiovascular disease, as measured by QOF, was consistently high regardless of caseload or size with a few notable exceptions: practices with larger list sizes, higher cardiovascular disease caseloads and those in affluent areas had higher achievement of indicators requiring referral for further investigation. For example, small practices achieved lower scores 71.4% than large practices 88.6% (P < 0.0001) for referral for exercise testing and specialist assessment of patients with newly diagnosed angina. CONCLUSION: The volume-outcome relationship found in hospital settings is not seen between practices in the UK in management of cardiovascular disorders in primary care. Further work is warranted to explain apparently poorer quality achievement in some aspects of cardiovascular management relating to initial diagnosis and management among practices in deprived areas, smaller practices and those with a smaller caseload.

Primary study

Unclassified

Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth Prospective Diabetes Study.

Journal PLoS medicine
Year 2007
Links Pubmed DOI PubMed Central

This article is included in 5 Systematic reviews Systematic reviews (5 references)

Loading references information
BACKGROUND: Pay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004. METHODS AND FINDINGS: We conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c < or = 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol < or = 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57-0.97) and BP control (AOR 0.65, 95% CI 0.53-0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005. CONCLUSIONS: Pay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.