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Inequalities in chronic disease management have largely persisted after the introduction of the Quality and Outcome Framework. Pay for performance programmes should be designed to reduce inequalities as well as improve the overall quality of care.

PURPOSE We wanted to examine the long-term effects of the Quality and Outcomes Framework (QOF), a major pay-for-performance program in the United Kingdom, on ethnic disparities in diabetes outcomes. METHODSWe undertook an interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London, United Kingdom. Main outcome measures were mean hemoglobin A 1c (HbA 1c ), total cholesterol, and blood pressure. RESULTSThe introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients (annual decrease: -1.68 mm Hg; 95% CI, -2.41 to -0.95 mm Hg). Initial improvements in diastolic blood pressure in white patients (-1.01 mm Hg; 95% CI, -1.79 to -0.24 mm Hg) and in cholesterol in white (-0.13 mmol/L; 95% CI, -0.21 to -0.05 mmol/L) and black (-0.10 mmol/L; 95% CI, -0.20 to -0.01 mmol/L) patients were not sustained in the post-QOF period. There was no benefi cial impact of QOF on HbA 1c in any ethnic group. Existing disparities in risk factor control remained largely intact (for example; mean HbA 1c : white 7.5%, black 7.8%, south Asian 7.8%; P <.05) at the end of the study period.CONCLUSION A universal pay-for-performance scheme did not appear to address important disparities in chronic disease management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.

Patients excluded from pay-for-performance programmes may be less likely to achieve treatment goals and disproportionately come from disadvantaged groups. Permitting physicians to exclude patients from pay-for-performance programmes may worsen health disparities.

OBJECTIVETo examine ethnic disparities in diabetes management among patients with and without comorbid medical conditions after a period of sustained investment in quality improvement in the U.K.RESEARCH DESIGN AND METHODSThis cross-sectional study examined associations between ethnicity, comorbidity, and intermediate outcomes for mean A1C, total cholesterol, and blood pressure levels in 6,690 diabetes patients in South West London.RESULTSThe 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, with a mean difference in systolic blood pressure of +1.5, +1.4, and +6.2 mmHg, respectively.CONCLUSIONSDespite major reforms to improve quality, disparities in blood pressure management have persisted in the U.K., particularly among patients with cardiovascular comorbidities. Policy makers should consider the potential impacts of quality initiatives on high-risk groups.

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Objective To assess and compare health system performance across six middle-income countries that are strengthening their health systems in pursuit of universal health coverage. Design Cross-sectional analysis from the World Health Organization Study on global AGEing and adult health, collected between 2007 and 2010. Setting Six middle-income countries: China, Ghana, India, Mexico, Russia and South Africa. Participants Nationally representative sample of adults aged 50 years and older. Main outcome measures We present achievement against key indicators of health system performance across effectiveness, cost, access, patient-centredness and equity domains. Results We found areas of poor performance in prevention and management of chronic conditions, such as hypertension control and cancer screening coverage. We also found that cost remains a barrier to healthcare access in spite of insurance schemes. Finally, we found evidence of disparities across many indicators, particularly in the effectiveness and patient centredness domains. Conclusions These findings identify important focus areas for action and shared learning as these countries move towards achieving universal health coverage.

Background: Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China. Method: We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain. Findings: Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64). Conclusion: Our findings suggest that urban areas have achieved better prevention and management of noncommunicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities.