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%