BackgroundPay-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 FindingsWe 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 ≤ 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol ≤ 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.ConclusionsPay-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.
Objective To establish current practice in the use of Read codes for diabetes. Design Cross sectional study. Setting 17 practices in the Battersea primary care group in southwest London. Data sources Computerised medical records.Main outcome measures Number of codes in use in all practices; variation in the use of codes between practices; and prevalence of Read code use in diabetic patients. Results At least 9 separate Read code groupings and 25 individual diabetes codes were in use in the 17 general practices. Only one Read code (C10, diabetes mellitus) and its subcodes was being used in all 17 practices, but its use varied from 14% to 98% of patients with diabetes. The use of other key Read codes for monitoring the care of patients with diabetes also varied widely between practices; for example, < 20% of practices used the code for the location of care. Less than half of patients (45%) with diabetes had their type of diabetes coded, and even fewer (21%) had measures such as the examination of the retina coded. Conclusions The use of Read codes for diabetes needs to be standardised and coding levels improved if valid diabetic registers are to be constructed and the quality of care is to be monitored effectively. Until all patients with diabetes have the C10 Read code recorded, clinicians will have to use a wide range of Read codes and prescribing data to ensure that diabetes registers are complete.
Most patients with coronary heart disease in primary care were being treated with aspirin but less than half with statins or beta-blockers. More men than women were treated with aspirin and statins, even though women had higher cholesterol levels than men. Men were also more likely to have a confirmed diagnosis and to have undergone a coronary revascularization procedure. There is considerable scope for improving the secondary prevention of coronary heart disease and addressing gender inequalities in primary care.
PURPOSE Little is known about the impact of pay-for-performance incentives on health care disparities. We examined ethnic disparities in the management of hypertension among patients with and without cardiovascular comorbidities after the implementation of a major pay-for-performance incentive scheme in UK primary care. METHODSWe undertook a population-based, cross-sectional survey of medication prescriptions and blood pressure control among patients with hypertension using electronic medical records from 16 family practices in southwest London. RESULTSBlack patients with hypertension were signifi cantly less likely to achieve an established treatment target for blood pressure control than white or South Asian patients (adjusted odds ratio, 0.86; 95% confi dence interval, 0.74-0.99). The prevalence of cardiovascular comorbidities was higher among South Asian patients with hypertension than among their white or black counterparts (41.3% vs 28.5% vs 28.8%). The presence of 2 or more cardiovascular comorbidities was associated with signifi cantly improved blood pressure control among white patients but not among black or South Asian patients (mean systolic blood pressure, −9.4 mm Hg, −0.6 mm Hg, and −1.8 mm Hg, respectively). South Asian patients with poorly controlled hypertension were prescribed fewer antihypertensive medications than their black or white peers (adjusted odds ratio, 0.66; 95% confi dence interval, 0.46-0.96).CONCLUSIONS Ethnic disparities in the management of hypertension have persisted in the United Kingdom despite major investment in quality improvement initiatives, including pay for performance. These disparities are particularly marked among patients with multiple cardiovascular conditions. Ann Fam Med 2008;6:490-496. DOI: 10.1370/afm.907. INTRODUCTIONH ypertension is an important determinant of ethnic disparities in health. The prevalence of hypertension is considerably higher among black African and Caribbean individuals than among white individuals, 1,2 and the hypertension-associated risk of cardiovascular disease may be accentuated in South Asian individuals.3 High-quality management of hypertension is especially important in black and South Asian groups as they are more likely than their white counterparts to have coexisting cardiovascular comorbidities, such as diabetes. 4,5 Over the past decade, the UK government has implemented an ambitious quality improvement agenda, a key objective of which is to reduce disparities in the quality of chronic disease management. 6 This agenda includes a series of National Service Frameworks for chronic conditions such as coronary heart disease, stroke, and diabetes, and the implementation of the Quality and Outcomes Framework as part of a new family Christopher Millett, PhD, FFPH 1,2 Jeremy Gray, MBBS E T HNIC DISPA R I T IES IN BLO OD PR ES SUR E M A NAG EMEN Tpractitioner contract in 2004. Described as the boldest attempt to link pay to performance in any health care system, 7 the framework places considerable emphasis on improving the q...
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