Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study

Abstract

BackgroundReports of higher quality care by higher-volume secondary care providers have fuelled a shift of services from smaller provider units to larger hospitals and units. In the United Kingdom, most patients are managed in primary care. Hence if larger practices provide better quality of care; this would have important implications for the future organization of primary care services. We examined the association between quality of primary care for cardiovascular disease achieved by general practices in England and Scotland by general practice caseload, practice size and area based deprivation measures, using data from the New General Practitioner (GP) Contract.MethodsWe analyzed data from 8,970 general practices with a total registered population of 55,522,778 patients in England and Scotland. We measured practice performance against 26 cardiovascular disease (coronary heart disease, left ventricular disease, and stroke) Quality and Outcomes Framework (QOF) indicators for patients on cardiovascular disease registers and linked this with data on practice characteristics and census data.ResultsDespite wide variations in practice list sizes and deprivation, the prevalence of was remarkably consistent, (coronary heart disease, left ventricular dysfunction, hypertension and cerebrovascular disease was 3.7%; 0.45%; 11.4% and 1.5% respectively). Achievement in quality of care for cardiovascular disease, as measured by QOF, was consistently high regardless of caseload or size with a few notable exceptions: practices with larger list sizes, higher cardiovascular disease caseloads and those in affluent areas had higher achievement of indicators requiring referral for further investigation. For example, small practices achieved lower scores 71.4% than large practices 88.6% (P < 0.0001) for referral for exercise testing and specialist assessment of patients with newly diagnosed angina.ConclusionThe volume-outcome relationship found in hospital settings is not seen between practices in the UK in management of cardiovascular disorders in primary care. Further work is warranted to explain apparently poorer quality achievement in some aspects of cardiovascular management relating to initial diagnosis and management among practices in deprived areas, smaller practices and those with a smaller caseload.

Deprivation, demography, and the distribution of general practice:

“…[22][23][24][25] This is not to deny that deprived populations may face particular disadvantages in gaining access to high quality primary care. Several studies suggest that general practices located in areas of socioeconomic deprivation provide a lower quality of care as judged by QOF scores [26][27][28][29][30] (although it should be acknowledged that other studies find little evidence of socioeconomic inequality 31,32 ). There may also be plausible reasons why, relative to underlying morbidity, deprived groups need greater access to primary care.…”

Does practice size matter? Review of effects on quality of care in primary care

“…23 Also, larger practices may be more likely to incorporate guidelines for the diagnosis and treatment of ADHD, as solo practices may have poorer access to mental health services, limited insurance coverage, and other potential system barriers to the delivery of ADHD care. 29 The association of larger practices with better diabetes management also suggests that there may be positive effects of having a multidisciplinary team, 15,16 that shared care with nurses allowed for certain processes to be effectively performed by nurses, 32 or that larger practices simply have better information technologies to facilitate execution of clinical processes. 10 The mixed results regarding the effects of larger practice sizes on preventive services could be due to methodological limitations, different settings, and varying independent variables and process measures across the studies.…”

Impact of pay for performance on quality of chronic disease management by social class group in England

“…6 Several studies have compared quality of care in deprived and affluent areas after the introduction of QOF. [7][8][9] These studies have generally found marginally lower achievement of quality indicators in deprived areas, with evidence of near attenuation of these differences in the second and third year of the contract. 10,11 However, the data used for these studies are derived from the financial administration system for QOF which has a number of limitations.…”