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Mann O, Bracegirdle T, Shantikumar S. The relationship between Quality and Outcomes Framework scores and socioeconomic deprivation: a longitudinal study. BJGP Open 2023; 7:BJGPO.2023.0024. [PMID: 37562823 PMCID: PMC11176694 DOI: 10.3399/bjgpo.2023.0024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/01/2023] [Accepted: 06/30/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND The Quality Outcomes Framework (QOF) is a pay incentive scheme in England designed to improve and standardise general practice. QOF attainment has been used as a proxy for primary care quality in previous research. AIM To investigate whether there is a relationship between socioeconomic deprivation and QOF attainment in primary care in England. DESIGN & SETTING Retrospective longitudinal study of primary care providers in England. METHOD QOF scores were obtained for individual general practices in England from between 2007-2019 and linked to practice-level Indices of Multiple Deprivation (IMD) scores derived from census data. Beta regression analyses were used to analyse the relationship with either percentage of total QOF attainment or of domain-specific attainment with multivariate analyses, adjusting for additional practice-level demographics. QOF attainment in the most affluent quintile was used as the reference group. RESULTS General practices in less deprived areas have consistently outperformed those in more deprived areas in terms of QOF achievement. Initially, the gap between least and most deprived practices decreased, however since 2015 there has been relatively little change in comparative performance. The magnitude of inequality was reduced after adjusting for demographic factors. Of the independent variables analysed, the proportion of patients aged >65 years ('over 65s') had the strongest relationship with QOF attainment. CONCLUSION There remains an inequality in primary care quality by socioeconomic deprivation in England, even after accounting for demographic differences.
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Affiliation(s)
- Oliver Mann
- Warwick Medical School, University of Warwick, Coventry, UK
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Engelgau MM, Zhang P, Jan S, Mahal A. Economic Dimensions of Health Inequities: The Role of Implementation Research. Ethn Dis 2019; 29:103-112. [PMID: 30906157 DOI: 10.18865/ed.29.s1.103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Health inequities are well-documented, but their economic dimensions have received less attention. In this report, we describe four economic dimensions of health inequities in the United States. First, we describe an economic conceptual framework that connects poverty and health inequities at both individual and population levels and conveys the concept of reverse causality, where poverty worsens health inequities and health inequities worsen poverty. This framework can help us understand the key elements of health inequity and its drivers. Second, we describe economic measurements used for quantifying the economic burden of health inequalities and summarize the empirical findings from studies. Third, we review the evidence on the return-on-investment of economic interventions that are aimed at reducing health inequities. Finally, we highlight the importance of cross disciplinary perspectives from economics and implementation research in effectively delivering interventions that can mitigate health inequities.
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Affiliation(s)
- Michael M Engelgau
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Ping Zhang
- National Center for Chronic Disease and Health Promotion, Centers for Disease Control and Prevention, Atlanta, GA
| | - Stephen Jan
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Ajay Mahal
- Nossal Institute for Global Health, University of Melbourne, VIC, Australia
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Lowrie R, McConnachie A, Williamson AE, Kontopantelis E, Forrest M, Lannigan N, Mercer SW, Mair FS. Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data. BMC Med 2017; 15:77. [PMID: 28395660 PMCID: PMC5387284 DOI: 10.1186/s12916-017-0833-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 03/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. METHODS We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. RESULTS Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices. CONCLUSIONS Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled.
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Affiliation(s)
- Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Andrea E. Williamson
- General Practice and Primary Care, School of Medicine, MVLS, University of Glasgow, Glasgow, Scotland UK
| | - Evangelos Kontopantelis
- The Farr Institute of Health Informatics Research, University of Manchester, Manchester, England UK
| | - Marie Forrest
- East Glasgow Health and Social Care Partnership, Paradise Health Centre, Glasgow, Scotland UK
| | - Norman Lannigan
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Stewart W. Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Frances S. Mair
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
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Tao W, Agerholm J, Burström B. The impact of reimbursement systems on equity in access and quality of primary care: A systematic literature review. BMC Health Serv Res 2016; 16:542. [PMID: 27716250 PMCID: PMC5050924 DOI: 10.1186/s12913-016-1805-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 09/28/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Reimbursement systems provide incentives to health care providers and may drive physician behaviour. This review assesses the impact of reimbursement system on socioeconomic and racial inequalities in access, utilization and quality of primary care. METHODS A systematic search was performed in Web of Science and PubMed for English language studies published between 1980 and 2013, supplemented by reference tracking. Articles were selected based on inclusion criteria, and data extraction and critical appraisal were performed by two authors independently. Data were synthesized in a narrative manner and categorized according to study outcome and reimbursement system. RESULTS Twenty seven articles, mostly from the United States and United Kingdom, were included in the data synthesis. Reimbursement systems seem to have limited effect on socioeconomic and racial inequity in access, utilization and quality of primary care. Capitation might have a more beneficial impact on inequity in access to primary care and number of ambulatory care sensitive admissions than fee-for-service, but did worse in patient satisfaction. Pay-for-performance had little or no impact on socioeconomic and racial inequity in the management of diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, and preventive services. CONCLUSION We found little scientific evidence supporting an association between reimbursement system and socioeconomic or racial inequity in access, utilization and quality of primary care. Overall, few studies addressed this research question, and heterogeneity in context and outcomes complicates comparisons across studies. Further empirical studies are warranted.
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Affiliation(s)
- Wenjing Tao
- Centre for Epidemiology and Community Medicine, Stockholm County Council Health Services, Stockholm, Sweden. .,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden.
| | - Janne Agerholm
- Centre for Epidemiology and Community Medicine, Stockholm County Council Health Services, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
| | - Bo Burström
- Centre for Epidemiology and Community Medicine, Stockholm County Council Health Services, Stockholm, Sweden.,Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
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Hamilton FL, Laverty AA, Huckvale K, Car J, Majeed A, Millett C. Financial Incentives and Inequalities in Smoking Cessation Interventions in Primary Care: Before-and-After Study. Nicotine Tob Res 2015; 18:341-50. [PMID: 25995158 DOI: 10.1093/ntr/ntv107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 05/10/2015] [Indexed: 11/14/2022]
Abstract
INTRODUCTION The Quality and Outcomes Framework (QOF) is a financial incentive scheme that rewards UK general practices for providing evidence-based care, including smoking cessation advice mainly as a secondary prevention intervention. We examined the effects on smoking outcomes and inequalities of a local version of QOF (QOF+), which ran from 2008 to 2011 and extended financial incentives to the provision of cessation advice as a primary prevention intervention. METHODS Before-and-after study using data from 28 general practices in Hammersmith & Fulham, London, United Kingdom. We used logistic regression to examine changes in smoking outcomes associated with QOF+ within and between sociodemographic groups. RESULTS Recording of smoking status increased from 55.5% to 64.3% for men (P < .001) and from 67.9% to 75.8% for women (P < .001). All groups benefitted from the increase, but younger patients remained less likely to be asked about smoking than older patients. White patients were less likely to be asked than those from other ethnic groups. Smoking cessation advice increased from 32.7% to 54.0% for men (P < .001) and from 35.4% to 54.1% for women (P < .01) and there was little variation between groups for this outcome. Recorded smoking prevalence reduced from 25.0% to 20.8% for men (P < .001) and from 16.1% to 12.5% for women (P < .001). White patients and those from more deprived areas remained more likely to be smokers than other groups. CONCLUSION The introduction of QOF+ was associated with general improvements in recording of smoking outcomes, but inequalities in ascertainment and smoking prevalence with respect to age, ethnicity, and deprivation persisted.
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Affiliation(s)
- Fiona L Hamilton
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Anthony A Laverty
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Kit Huckvale
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Josip Car
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Azeem Majeed
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
| | - Christopher Millett
- Department of Primary Care and Public Health, School of Public Health, Imperial College London, London, United Kingdom
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Hamilton F, Laverty A, Vamos E, Majeed A, Millett C. Effect of financial incentives on ethnic disparities in smoking cessation interventions in primary care: cross-sectional study. J Public Health (Oxf) 2013; 35:75-84. [DOI: 10.1093/pubmed/fds065] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Abstract
BACKGROUND Previous studies have identified that there is a cohort of frequent attenders to the emergency department (ED). Recent initiatives aim to provide care closer to home and alternatives to ED attendance. This study aims to identify what impact frequent attenders still have on the ED. METHODS A chart review of frequent attenders to the ED was carried out over a 12-month period. Inclusion criterion was 10 or more attendances. Information collected comprised age, sex, postcode, next of kin, number of attendances, day of the week, time, referral source, mode of arrival, triage category, disposal, association with alcohol and drug use, presenting complaint, and diagnosis. RESULTS Forty-four frequent users met the study criterion accounting for 1.9% of departmental activity. Sixty-four percent of frequent attenders were male with an average age of 49 years (range 19-83). The majority lived within 5 miles of the ED. Sixty percent of attendances arrived at the ED through ambulance. Documentation of either concurrent alcohol use or history of alcohol dependence and illicit drug use was reported in 54.6 and 15.9% of patients. The admission rate of this group was 38.5% higher than the total ED admission rate of 22%. CONCLUSION There remains a cohort of frequent attenders that use the ED for their healthcare needs. A significant proportion of these attendances are associated with alcohol use, chronic disease or mental health problems. Reduction of attendances may be achieved by case management strategies and improving access to primary care and drug and alcohol services.
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Alshamsan R, Majeed A, Ashworth M, Car J, Millett C. Impact of pay for performance on inequalities in health care: systematic review. J Health Serv Res Policy 2010; 15:178-84. [PMID: 20555042 DOI: 10.1258/jhsrp.2010.009113] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the impact of pay for performance programmes on inequalities in the quality of health care in relation to age, sex, ethnicity and socioeconomic status. METHODS Systematic search and appraisal of experimental or observational studies that assessed quantitatively the impact of a monetary incentive on health care inequalities. We searched published articles in English identified in the MEDLINE, EMBASE, PsycINFO and Cochrane databases. RESULTS Twenty-two studies were identified, 20 of which were conducted in the United Kingdom and examined the impact of the Quality and Outcomes Framework. Sixteen studies used practice level data rather than patient level data. Socioeconomic status was the most frequently examined inequality; age, sex and ethnic inequalities were less frequently assessed. There was some weak evidence that the use of financial incentives reduced inequalities in chronic disease management between socioeconomic groups. Inequalities in chronic disease management between age, sex and ethnic groups persisted after the use of such incentives. CONCLUSION 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.
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Affiliation(s)
- Riyadh Alshamsan
- Department of Primary Care and Social Medicine, Imperial College, London, UK.
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