intermediate outcome control in people with type 2 diabetes in the uk under comprehensive p4p bruce...
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Intermediate outcome control in people with type 2 diabetes in the UK under comprehensive P4P
Bruce Guthrie
Alistair Emslie-Smith
Andrew Morris
UK General Practice
• Physician owned independent businesses
• Almost all income from state funded National Health Service
• Average size 5400 patients, 3 physicians
• Computerized, multidisciplinary teams
New contract in 2004
• Quality and Outcomes Framework (QOF) is the largest healthcare pay for performance program in the world
• ~ 20% of practice income• ~150 quality indicators• New money• Non-competitive
– Achieve X, receive £Y
Diabetes pay for performance
• 15 indicators (plus smoking)• Foot, eye & renal screening, flu shots etc• Intermediate outcomes
Process in last 15 months OutcomeGlycated hemoglobin ≤10%
≤7.4%
Blood pressure ≤145/85
Cholesterol ≤5mmol/l
Smoking statusSmoking cessation advice
N/A
Population studied
• Regional population register with automatic updating from primary care, hospital and laboratory computers
• Regular external validation• 10,191 patients with type 2 diabetes
registered with 59 general practices with validated data
• Denominator = patient registered on 30th April 2006
Quality measures
Process in last 12 months OutcomeGlycated hemoglobin ≤7.4%
Blood pressure ≤140/80
Cholesterol ≤5mmol/l
Smoking status Not smoking
CompositesSimpleAll-or-nothing
Composites
Process recorded last 12 months
Achieve outcome target
Distribution of quality - age
Indicator Odds ratios (95% CI)Aged<55 vs aged 55-84
All 4 processes 0.73 (0.62 to 0.86)
GHB ≤7.4 0.46 (0.41 to 0.52)
BP ≤140/80 0.77 (0.68 to 0.87)
Cholesterol ≤5 0.47 (0.41 to 0.53)
Not smoking 0.42 (0.37 to 0.48)
All 4 outcomes 0.41 (0.33 to 0.50)
• Hierarchical linear regression (patients within practices)• Process adjusted for gender, SES and duration• Outcome additionally adjusted for body mass index
Distribution of quality• Socio-economic status
– Only difference was for “not smoking”
• Women vs men– Cholesterol control OR 0.63 (0.57 to 0.69)
• Body mass index– Increasing BMI associated with worse GHB & BP
control
• Between practices– Small ICCs (1.2% to 4.3% for outcomes)– No associations with practice characteristics
Conclusions
• Process is reasonably reliable, but intermediate outcome control less so– Blood pressure control stands out
• Most striking variation is by age• SES variation minimal• Can’t examine why patterns exist
– Adjusted for body mass index and duration but not for other patient factors
– Treatment intensity
Implications
• Register, recall, review not enough– Need to focus more on intermediate outcomes
• Particularly applies to younger patients– Growing challenge in face of epidemics
• Need to better define problem– Access or engagement?– Treatment intensity or adherence?
• Uncertain how best to address– Practice vs area based services?
Thank you!
DMARD monitoring
Age (years)
% without minimal monitoring
Adjusted OR (95% CI)
<4040-4950-5960-6970-7980 and over
19%12%10%9%7%7%
3.1 (1.3 to 7.2)1.7 (0.7 to 4.0)1.5 (0.6 to 3.4)1.4 (0.6 to 3.2)1.2 (0.5 to 2.8)Reference
Comparison with HEDIS Medicare
Tayside (aged >65)
HEDIS Medicare mean (90th centile)
GHB recorded 12 months
96% 87% (95%)
GHB>9% 13% 27% (10%)
Lipid screening 24 months
99% 85%
Retinal screening 78% 62%BP<130/80 21% 30%BP<140/90 41% 58%
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