Summary Background Introduced in 2004, the UK's Quality and Outcomes Framework (QOF) is the world's largest primary care pay-for-performance programme. We tested whether the QOF was associated with ...reduced population mortality. Methods We used population-level mortality statistics between 1994 and 2010 for the UK and other high-income countries that were not exposed to pay-for-performance. The primary outcome was age-adjusted and sex-adjusted mortality per 100 000 people for a composite outcome of chronic disorders that were targeted by the QOF. Secondary outcomes were age-adjusted and sex-adjusted mortality for ischaemic heart disease, cancer, and a composite of all non-targeted conditions. For each study outcome, we created a so-called synthetic UK as a weighted combination of comparison countries. We then estimated difference-in-differences models to test whether mortality fell more in the UK than in the synthetic UK after the QOF. Findings Introduction of the QOF was not significantly associated with changes in population mortality for the composite outcome (−3·68 per 100 000 population 95% CI −8·16 to 0·80; p=0·107), ischaemic heart disease (−2·21 per 100 000 –6·86 to 2·44; p=0·357), cancer (0·28 per 100 000 –0·99 to 1·55; p=0·679), or all non-targeted conditions (11·60 per 100 000 –3·91 to 27·11; p=0·143). Interpretation Although we noted small mortality reductions for a composite outcome of targeted disorders, the QOF was not associated with significant changes in mortality. Our findings have implications for the probable effects of similar programmes on population health outcomes. The relation between incentives and mortality needs to be assessed in specific disease domains. Funding None.
Summary Background The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive ...schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme. Methods We analysed data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004–05 to 2006–07). Findings Median overall reported achievement was 85·1% (IQR 79·0–89·1) in year 1, 89·3% (86·0–91·5) in year 2, and 90·8% (88·5–92·6) in year 3. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86·8% (82·2–89·6) for quintile 1 (least deprived) to 82·8% (75·2–87·8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4·4% for quintile 1 and by 7·6% for quintile 5, and the gap in median achievement narrowed from 4·0% to 0·8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0·0001), but was not associated with area deprivation (p=0·062). Interpretation Our results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation. Funding None.
Background Gender is a strong predictor of periprocedural major bleeding complications after percutaneous coronary intervention (PCI). The access site represents an important site of such bleeding ...complications, which has driven adoption of the transradial access (TRA) use during PCI, although female gender is an independent predictor of transradial PCI failure. This study sought to define gender differences in access site practice and study associations between access site choice and clinical outcomes for PCI over a 6-year period, through the analysis of the British Cardiovascular Intervention Society observational database. Methods and Results In-hospital major adverse cardiovascular events (a composite of in-hospital mortality and in-hospital myocardial reinfarction and target vessel revascularization), in-hospital bleeding complications, and 30-day mortality were studied based on gender and access site choice (transfemoral access, TRA) in 412,122 patients who underwent PCI between 2007 and 2012 in the United Kingdom. Use of TRA increased in both genders over time, although this lagged behind in women (21% in 2007 to 58% in 2012) compared with men (24% in 2007 to 64% in 2012). In both men and women, TRA was independently associated with a lower in-hospital major adverse cardiovascular event (odds ratio OR 0.82, 95% CI 0.76-0.90; OR 0.75, 95% CI 0.66-0.84), in-hospital major bleeding (OR 0.54, 95% CI 0.44-0.66; OR 0.26, 95% CI 0.20-0.33), and 30-day mortality (OR 0.80, 95% CI 0.73-0.89; OR 0.82, 95% CI 0.71-0.94), respectively. Conclusions Where possible, TRA should be considered as the preferred access site choice for PCI, particularly in women in whom the greatest reductions bleeding end points were observed across all indications.
Abstract Purpose The purpose of this study was to examine the association between the prevalence of both diabetes-concordant and diabetes-discordant conditions and the quality of diabetes care at the ...family practice level in England. We hypothesized that the prevalence of concordant (or discordant) conditions would be associated with better (or worse) quality of diabetes care. Methods We conducted a cross-sectional study using practice-level data (7,884 practices). We estimated the practice-level prevalence of diabetes and 15 other chronic conditions, which were classified as diabetes concordant (ie, with the same pathophysiologic risk profile and therefore more likely to be part of the same management plan) or diabetes discordant (ie, not directly related in either their pathogenesis or management). We measured quality of diabetes care with diabetes-specific indicators (8 processes and 3 intermediate outcomes of care). We used linear regression models to quantify the effect of the prevalence of the conditions on aggregate achievement rate for quality of diabetes care. Results Consistent with the proposed model, the prevalence rates of 4 of 7 concordant conditions (obesity, chronic kidney disease, atrial fibrillation, heart failure) were positively associated with quality of diabetes care. Similarly, negative associations were observed as predicted for 2 of the 8 discordant conditions (epilepsy, mental health). Observations for other concordant and discordant conditions did not match predictions in the hypothesized model. Conclusions The quality of diabetes care provided in English family practices is associated with the prevalence of other major chronic conditions at the practice level. The nature and direction of the observed associations cannot be fully explained by the concordant-discordant model.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Abstract Purpose Major primary care reforms have been introduced in recent years in the United Kingdom, including financial incentives to improve clinical quality and provide more rapid access to ...care. Little is known about the impact of these changes on patient experience. We examine patient reports of quality of care between 2003 and 2007, including random samples of patients on practice lists and patients with long-term conditions. Methods We conducted a cross-sectional design study of family practices in which questionnaires were sent to serial samples of patients in 42 representative general practices in England. Questionnaires sent to samples of patients with chronic disease (asthma, angina, and diabetes) and random samples of adult patients (excluding patients who reported any long-term condition) in 2003, 2005, and 2007 addressed issues of access, communication, continuity of care, coordination, nursing care, and overall satisfaction. Results There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication, nursing care, coordination, and overall satisfaction. Some aspects of access improved significantly for patients with chronic disease, but not for the random samples of patients. Patients in both samples reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care. Most scores were significantly higher for the chronic illness samples than for the random samples of patients in 2003, even after adjusting for age. Conclusions There was a modest improvement in access to care for patients with chronic illness, but all patients now find it somewhat harder to obtain continuity of care. This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care. The possibility of unintended effects needs to be considered when introducing pay for performance schemes.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Abstract Objectives This study used a large national cohort to examine patterns of thrombectomy use in ST-segment elevation myocardial infarction (STEMI) and the relationship to mortality. Background ...The impact of coronary thrombectomy on mortality in STEMI has not been definitively established. Published trial data have been insufficiently powered to address this. Methods The U.K. national registry was used to study 98,176 patients treated with primary percutaneous coronary intervention (PCI), between January 1, 2006, and December 31, 2013. Patients were grouped on the basis of whether they received thrombectomy or not; subgroups of simple (manual aspiration) and complex (mechanical) thrombectomy were also evaluated. The primary endpoint was 30-day mortality. The principal adjusted analysis used propensity score matching (PSM). A sensitivity analysis was performed using logistic regression controlled for the propensity score. Results Thrombectomy use markedly increased in the United Kingdom between 2008 and 2010 but plateaued thereafter at slightly below 50% of all primary PCI cases. No significant mortality difference was seen, in adjusted analyses, between the overall thrombectomy group and the no thrombectomy group, at 30 days or 1 year (at 30 days, PSM average treatment effect ATE coefficient 0.0028, 95% confidence interval: −0.0048 to 0.0104; p = 0.47). Likewise, no difference was seen between the simple (manual) thrombectomy versus no thrombectomy, at either time point (at 30 days, PSM ATE coefficient 0.0007, 95% confidence interval: −0.0049 to 0.0063; p = 0.80). By contrast, the complex (mechanical) thrombectomy group demonstrated a significantly higher mortality than the no thrombectomy group at 1-year follow-up (PSM ATE coefficient 0.0434, 95% confidence interval: 0.0081 to 0.0786; p = 0.017). Conclusions Coronary thrombectomy was not associated with lower mortality in primary PCI for STEMI when used in our large all-comer cohort in a selective manner on the basis of physician judgment. These findings are consistent with other negative clinical outcomes in recent large randomized controlled trials studying routine manual thrombectomy in primary PCI.
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