Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study

Abstract

Objectives To examine the management of diabetes between 2001 and 2007 in the United Kingdom and to assess whether changes in the quality of care reflect existing temporal trends or are a direct result of the implementation of the quality and outcomes framework.Design Retrospective cohort study.Setting 147 general practices (annual list size over 1 million) across the UK.Patients People with type 1 or type 2 diabetes.Main outcome measures Annual prevalence of diabetes and attainment of process and clinical outcomes over the three years before and the three years after the introduction of the quality and outcomes framework.Results Significant improvements in process and intermediate outcome measures were observed during the six year period, with consecutive annual improvements observed before the introduction of incentives. However, the current diagnostic case definition for the quality and outcomes framework does not capture up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes. After the introduction of the quality and outcomes framework, existing trends of improvement in glycaemic control, cholesterol levels, and blood pressure were attenuated, particularly in people with diabetes who did not meet the case definition of the quality and outcomes framework. The introduction of the quality and outcomes framework did not lead to improvement in the management of patients with type 1 diabetes, nor to a reduction in the number of patients with type 2 diabetes who had HbA1c levels greater than 10%. Introduction of the quality and outcomes framework may have increased the number of patients with type 2 diabetes with HbA1c levels of ≤7.5%; odds ratio 1.05 (95% confidence interval 1.01 to 1.09; P=0.02).Conclusions The management of people with diabetes has improved since the late 1990s, but the impact of the quality and outcomes framework on care is not straightforward; upper thresholds may need to be removed or targets made more challenging if people are to benefit. Many patients in whom care may be suboptimal may not be captured in the quality and outcomes framework assessment.

The Quality of Primary Care in a Country with Universal Health Care Coverage

“…The high overall level of care we found may be related to universal coverage or to the specific setting. Indeed, quality of care might have been lower if we had included community-based PCP offices outside of university primary care settings, like in the US 14 or UK 25,26 studies.…”

“…In the UK, the systematic performance monitoring known as QOF 3 was introduced in 2004. Current published data were limited to patients with cardiovascular diseases 26 or diabetes, 25 which may not be applicable to the general population. In over a million patients with diabetes followed in 147 clinics, Calvert et al 25 found higher rates of HbA1c testing (89.3% vs 71.9% in our study), annual eye examination (75.0% vs 55.8%) or screening for nephropathy (74.1% vs 65.1%), but a lower rate of cholesterol testing (89.7% vs 97.6%).…”

Structured personal care of type 2 diabetes: a 19 year follow-up of the study Diabetes Care in General Practice (DCGP)

“…Although assessments of the quality of diabetes care continue to show suboptimal management [7,8], the benefit of pursuing intensive glucose control in all patients to reduce cardiovascular disease has been questioned [9][10][11][12]. In response to this, the European Association for the Study of Diabetes (EASD) and the ADA, in a joint position statement, have recommended individualising both treatment goals and choice of pharmacological intervention in the management of hyperglycaemia [13].…”

A cluster randomized trial on the effect of a multifaceted intervention improved the technical quality of diabetes care by primary care physicians: The Japan Diabetes Outcome Intervention Trial‐2 (J‐DOIT2)

“…In connection with an initiative to improve chronic disease care and outcomes, the UK government introduced a pay‐for‐performance model called the Quality Outcomes Framework (QOF) as part of the general practitioner contract in 2004. The evidence suggests that in the UK, incentive models have spurred some improvements in process outcomes 28, 29. However, these improvements do not appear to have been uniform across all patients groups 30.…”