Ethnic disparities in blood pressure management in patients with hypertension after the introduction of pay for performance

Ethnic differences in multimorbidity after accounting for social-economic factors, findings from The Health Survey for England

BACKGROUND

Social-economic factors and health behaviours may be driving variation in ethnic health inequalities in multimorbidity including among distinct ethnic groups.

METHODS

Using the cross-sectional nationally representative Health Surveys for England 2011-18 (N = 54 438, aged 16+), we performed multivariable logistic regression on the odds of having general multimorbidity (≥2 longstanding conditions) by ethnicity [British White (reference group), White Irish, Other White, Indian, Pakistani, Bangladeshi, Chinese, African, Caribbean, White mixed, Other Mixed], adjusting for age, sex, education, area deprivation, obesity, smoking status and survey year. This was repeated for cardiovascular multimorbidity (N = 37 148, aged 40+: having ≥2 of the following: self-reported diabetes, hypertension, heart attack or stroke) and multiple cardiometabolic risk biomarkers (HbA1c ≥6.5%, raised blood pressure, total cholesterol ≥5mmol/L).

RESULTS

Twenty percent of adults had general multimorbidity. In fully adjusted models, compared with the White British majority, Other White [odds ratio (OR) = 0.63; 95% confidence interval (CI) 0.53-0.74], Chinese (OR = 0.58, 95% CI 0.36-0.93) and African adults (OR = 0.54, 95% CI 0.42-0.69), had lower odds of general multimorbidity. Among adults aged 40+, Pakistani (OR = 1.27, 95% CI 0.97-1.66; P = 0.080) and Bangladeshi (OR = 1.75, 95% CI 1.16-2.65) had increased odds, and African adults had decreased odds (OR = 0.63, 95% CI 0.47-0.83) of general multimorbidity. Risk of cardiovascular multimorbidity was higher among Indian (OR = 3.31, 95% CI 2.56-4.28), Pakistani (OR = 3.48, 95% CI 2.52-4.80), Bangladeshi (OR = 3.67, 95% CI 1.98-6.78), African (OR = 1.61, 95% CI 1.05-2.47), Caribbean (OR = 2.18, 95% CI 1.59-2.99) and White mixed (OR = 1.98, 95% CI 1.14-3.44) adults. Indian adults were also at risk of having multiple cardiometabolic risk biomarkers.

CONCLUSION

Ethnic inequalities in multimorbidity are independent of social-economic factors. Ethnic minority groups are particularly at risk of cardiovascular multimorbidity, which may be exacerbated by poorer management of cardiometabolic risk requiring further investigation.

Ethnic differences in hypertension management, medication use and blood pressure control in UK primary care, 2006-2019: a retrospective cohort study

Background

In the UK, previous work suggests ethnic inequalities in hypertension management. We studied ethnic differences in hypertension management and their contribution to blood pressure (BP) control.

Methods

We conducted a cohort study of antihypertensive-naïve individuals of European, South Asian and African/African Caribbean ethnicity with a new raised BP reading in UK primary care from 2006 to 2019, using the Clinical Practice Research Datalink (CPRD). We studied differences in: BP re-measurement after an initial hypertensive BP, antihypertensive initiation, BP monitoring, antihypertensive intensification, antihypertensive persistence/adherence and BP control one year after antihypertensive initiation. Models adjusted for socio-demographics, BP, comorbidity, healthcare usage and polypharmacy (plus antihypertensive class, BP monitoring, intensification, persistence and adherence for BP control models).

Findings

A total of 731,506 (93.5%), 30,379 (3.9%) and 20,256 (2.6%) people of European, South Asian and African/African Caribbean ethnicity were studied. Hypertension management indicators were similar or more favourable for South Asian than European groups (OR/HR [95% CI] in fully-adjusted models of BP re-measurement: 1.16 [1.09, 1.24]), antihypertensive initiation: 1.49 [1.37, 1.62], BP monitoring: 0.97 [0.94, 1.00] and antihypertensive intensification: 1.10 [1.04, 1.16]). For people of African/African Caribbean ethnicity, BP re-measurement rates were similar to those of European ethnicity (0.98 [0.91, 1.05]), and antihypertensive initiation rates greater (1.48 [1.32, 1.66]), but BP monitoring (0.91 [0.87, 0.95]) and intensification rates lower (0.93 [0.87, 1.00]). Persistence and adherence were lower in South Asian (0.48 [0.45, 0.51] and 0.51 [0.47, 0.56]) and African/African Caribbean (0.38 [0.35, 0.42] and 0.39 [0.36, 0.43]) than European groups. BP control was similar in South Asian and less likely in African/African Caribbean than European groups (0.98 [0.90, 1.06] and 0.81 [0.74, 0.89] in age, gender and BP adjusted models). The latter difference attenuated after adjustment for persistence (0.91 [0.82, 0.99]) or adherence (0.92 [0.83, 1.01]), and was absent for antihypertensive-adherent people (0.99 [0.88, 1.10]).

Interpretation

We demonstrate that antihypertensive initiation does not vary by ethnicity, but subsequent BP control was notably lower among people of African/African Caribbean ethnicity, potentially associated with being less likely to remain on regular treatment. A nationwide strategy to understand and address differences in ongoing management of people on antihypertensives is imperative.

Funding

Diabetes UK.

Health disparities in aging: Improving dementia care for Black women

In the United States, 80% of surveyed Black patients report experiencing barriers to healthcare for Alzheimer's disease and related dementias (ADRD), delaying the time-sensitive treatment of a progressive neurodegenerative disease. According to the National Institute on Aging, Black study participants are 35% less likely to be given a diagnosis of ADRD than white participants, despite being twice as likely to suffer from ADRD than their white counterparts. Prior analysis of prevalence for sex, race, and ethnicity by the Centers for Disease Control indicated the highest incidence of ADRD in Black women. Older (≥65 years) Black women are at a disproportionately high risk for ADRD and yet these patients experience distinct inequities in obtaining clinical diagnosis and treatment for their condition. To that end, this perspective article will review a current understanding of biological and epidemiological factors that underlie the increased risk for ADRD in Black women. We will discuss the specific barriers Black women face in obtaining access to ADRD care, including healthcare prejudice, socioeconomic status, and other societal factors. This perspective also aims to evaluate the performance of intervention programs targeted toward this patient population and offer possible solutions to promote health equity.

Risk Factors Associated With Alzheimer Disease and Related Dementias by Sex and Race and Ethnicity in the US

Importance

Previous estimates suggested that 1 in 3 cases of Alzheimer disease and related dementia (ADRDs) in the US are associated with modifiable risk factors, the most prominent being physical inactivity, depression, and smoking. However, these estimates do not account for changes in risk factor prevalence over the past decade and do not consider potential differences by sex or race and ethnicity.

Objective

To update estimates of the proportion of ADRDs in the US that are associated with modifiable risk factors and to assess for differences by sex and race and ethnicity.

Design, Setting, and Participants

For this cross-sectional study, risk factor prevalence and communality were obtained from the nationally representative US Behavioral Risk Factor Surveillance Survey data from January 2018 to December 2018, and relative risks for each risk factor were extracted from meta-analyses. Data were analyzed from December 2020 to August 2021. Respondents included 378 615 noninstitutionalized adults older than 18 years. The number before exclusion was 402 410. Approximately 23 795 (~6%) had missing values on at least 1 of the variables of interest.

Exposures

Physical inactivity, current smoking, depression, low education, diabetes, midlife obesity, midlife hypertension, and hearing loss.

Main Outcomes and Measures

Individual and combined population-attributable risks (PARs) associated with ADRDs, accounting for nonindependence between risk factors.

Results

Among 378 615 individuals, 171 161 (weighted 48.7%) were male, and 134 693 (weighted 21.1%) were 65 years and older. Race and ethnicity data were self-reported and defined by the US Behavioral Risk Factor Surveillance System Data; 6671 participants (weighted 0.9%) were American Indian and Alaska Native, 8043 (weighted 5.1%) were Asian, 29 956 (weighted 11.7%) were Black, 28 042 (weighted 16.0%) were Hispanic (any race), and 294 394 (weighted 64.3%) were White. Approximately 1 in 3 of ADRD cases (36.9%) in the US were associated with 8 modifiable risk factors, the most prominent of which were midlife obesity (17.7%; 95% CI, 17.5-18.0), physical inactivity (11.8%; 95% CI, 11.7-11.9), and low educational attainment (11.7%; 95% CI, 11.5-12.0). Combined PARs were higher in men (35.9%) than women (30.1%) and differed by race and ethnicity: American Indian and Alaska Native individuals, 39%; Asian individuals, 16%; Black individuals, 40%; Hispanic individuals (any race), 34%; and White individuals, 29%. The most prominent modifiable risk factors regardless of sex were midlife obesity for American Indian and Alaska Native individuals, Black individuals, and White individuals; low education for Hispanic individuals; and physical inactivity for Asian individuals.

Conclusions and Relevance

The findings suggest that risk factors associated with ADRDs have changed over the past decade and differ based on sex and race and ethnicity. Alzheimer risk reduction strategies may be more effective if they target higher-risk groups and consider current risk factor profiles.

Determinants of suboptimal blood pressure control in a multi-ethnic population: The Healthy Life in an Urban Setting (HELIUS) study

Among ethnic minority groups in Europe, blood pressure (BP) control is often suboptimal. We aimed to identify determinants of suboptimal BP control in a multi‐ethnic population. We analyzed cross‐sectional data of the Healthy Life in an Urban Setting (HELIUS) study, including 3571 participants aged 18‐70 with prescribed antihypertensive medication, of various ethnic backgrounds (500 Dutch, 1052 African Surinamese, 656 South‐Asian Surinamese, 637 Ghanaian, 433 Turkish, and 293 Moroccan) living in Amsterdam, the Netherlands. 53.3% of the population had suboptimal BP control, defined as BP ≥140/90 mmHg despite prescribed antihypertensives. Using multivariate logistic regression analysis, female sex (OR 0.50, 95%CI 0.43‐0.59), being married (0.83, 0.72‐0.96), smoking (0.78, 0.65‐0.94), alcohol intake (0.80, 0.66‐0.96), obesity (1.67, 1.35‐2.06), cardiovascular disease (CVD) history (0.56, 0.46‐0.68), non‐adherence to antihypertensives (1.26, 1.00‐1.58), and family history of hypertension (1.19, 1.02‐1.38) were identified to be independently associated with suboptimal BP control in the total population. In the ethnic‐stratified analysis, factors associated with better BP control were female sex (all ethnic groups), smoking (Turks), and CVD history (Dutch, South‐Asian Surinamese, and African Surinamese), whereas factors associated with suboptimal BP control were older age (Turks), obesity (Dutch, African Surinamese, Ghanaian, and Turks), and non‐adherence to antihypertensives (Dutch). In conclusion, our analysis identifies several key determinants that are independently associated with suboptimal BP control in a multi‐ethnic population, with some important variations between ethnic groups. Targeting these determinants may help to improve BP control.

Trends in prevalence of acute stroke impairments: A population-based cohort study using the South London Stroke Register

BACKGROUND

Acute stroke impairments often result in poor long-term outcome for stroke survivors. The aim of this study was to estimate the trends over time in the prevalence of these acute stroke impairments.

METHODS AND FINDINGS

All first-ever stroke patients recorded in the South London Stroke Register (SLSR) between 2001 and 2018 were included in this cohort study. Multivariable Poisson regression models with robust error variance were used to estimate the adjusted prevalence of 8 acute impairments, across six 3-year time cohorts. Prevalence ratios comparing impairments over time were also calculated, stratified by age, sex, ethnicity, and aetiological classification (Trial of Org 10172 in Acute Stroke Treatment [TOAST]). A total of 4,683 patients had a stroke between 2001 and 2018. Mean age was 68.9 years, 48% were female, and 64% were White. After adjustment for demographic factors, pre-stroke risk factors, and stroke subtype, the prevalence of 3 out of the 8 acute impairments declined during the 18-year period, including limb motor deficit (from 77% [95% CI 74%-81%] to 62% [56%-68%], p < 0.001), dysphagia (37% [33%-41%] to 15% [12%-20%], p < 0.001), and urinary incontinence (43% [39%-47%) to 29% [24%-35%], p < 0.001). Declines in limb impairment over time were 2 times greater in men than women (prevalence ratio 0.73 [95% CI 0.64-0.84] and 0.87 [95% CI 0.77-0.98], respectively). Declines also tended to be greater in younger patients. Stratified by TOAST classification, the prevalence of all impairments was high for large artery atherosclerosis (LAA), cardioembolism (CE), and stroke of undetermined aetiology. Conversely, small vessel occlusions (SVOs) had low levels of all impairments except for limb motor impairment and dysarthria. While we have assessed 8 key acute stroke impairments, this study is limited by a focus on physical impairments, although cognitive impairments are equally important to understand. In addition, this is an inner-city cohort, which has unique characteristics compared to other populations.

CONCLUSIONS

In this study, we found that stroke patients in the SLSR had a complexity of acute impairments, of which limb motor deficit, dysphagia, and incontinence have declined between 2001 and 2018. These reductions have not been uniform across all patient groups, with women and the older population, in particular, seeing fewer reductions.

Is the rule of halves still relevant today? A cross-sectional analysis of hypertension detection, treatment and control in an urban community

AIMS

To estimate percentages of patients with undiagnosed hypertension, diagnosed untreated hypertension and diagnosed, treated and uncontrolled hypertension and to identify sociodemographic factors for diagnosed, uncontrolled hypertension and not having a blood pressure (BP) reading recorded.

METHODS

Data from 320 094 patients aged 18 to less than 80 years from general practices in inner London was analysed using both last recorded BP (blood pressure) and mean BP. Logistic regression models identified factors associated with uncontrolled hypertension and no recorded BP.

RESULTS

Twenty-nine thousand, seven hundred and nineteen (9.3%) patients had a recorded diagnosis of hypertension. On the basis of analysis of the last BP value, 14.2% (n = 4207) were untreated and 46.3% (n = 13 749) had uncontrolled hypertension; 10.0% (n = 28 274) without a prior hypertension diagnosis had undiagnosed hypertension. Corresponding values based on mean BP analysis were 8.9% (n = 2367) untreated, 51.5% (n = 13 734) uncontrolled; 4.1% (n = 11 446) undiagnosed. 17.5% (n = 55 960) had no recorded BP value.Black ethnicity was a predictor of uncontrolled hypertension: compared with the White British population, the adjusted odds ratio (AOR) for the Black African population was 1.39 (95% CI: 1.25-1.53) and for the Black Caribbean was 1.31 (95% CI: 1.19-1.45). The White Other group were most likely to have no record of BP measurement (AOR: 1.52; 95% CI: 1.47-1.57); conversely, unrecorded BP was less likely in the Black African (AOR: 0.79; CI: 0.74-0.83) and Black Caribbean (AOR: 0.71; CI: 0.66-0.76) groups, relative to the White British population.

CONCLUSION

In an inner-city, multiethnic population, the 'rule of halves' still broadly applies to the diagnosis and control of hypertension, although only a small proportion were untreated.

Impact of a Patient-Centered Behavioral Economics Intervention on Hypertension Control in a Highly Disadvantaged Population: a Randomized Trial

BACKGROUND

Uncontrolled hypertension contributes to disparities in cardiovascular outcomes. Patient intervention strategies informed by behavioral economics and social psychology could improve blood pressure (BP) control in disadvantaged minority populations.

OBJECTIVE

To assess the impact on BP control of an intervention combining short-term financial incentives with promotion of intrinsic motivation among highly disadvantaged patients.

DESIGN

Randomized controlled trial.

PARTICIPANTS

Two hundred seven adults (98% African American or Latino) aged 18 or older with uncontrolled hypertension attending Federally Qualified Health Centers.

INTERVENTION

Six-month intervention, combining financial incentives for measuring home BP, recording medication use, BP improvement, and achieving target BP values with counseling linking hypertension control efforts to participants' personal reasons to stay healthy.

MAIN MEASURES

Primary outcomes: percentage achieving systolic BP (SBP) < 140 mmHg, percentage achieving diastolic BP (DBP) < 90 mmHg, and changes in SBP and DBP, all after 6 months. Priority secondary outcomes were SBP < 140 mmHg, DBP < 90 mmHg, and BP change at 12 months, 6 months after the intervention ended.

KEY RESULTS

After 6 months, rates of achieving target BP values for intervention and control subjects respectively was 57.1% vs. 40.2% for SBP < 140 mmHg (adjusted odds ratio (AOR) 2.53 (1.13-5.70)), 79.8% vs 70.1% for DBP < 90 mmHg (AOR 2.50 (0.84-7.44)), and 53.6% vs 40.2% for achieving both targets (AOR 2.04 (0.92-4.52)). However, at 12 months, the groups did not differ significantly in these 3 measures: 39.5% vs 35.0% for SBP (AOR 1.20 (0.51-2.83)), 68.4% vs 75.0% for DBP (AOR 0.70 (0.24-2.09)), and 35.5% vs 33.8% for both (AOR 1.03 (0.44-2.42)). Change in absolute SBP and DBP did not differ significantly between the groups at 6 or 12 months. Exploratory post hoc analysis revealed intervention benefit only occurred among individuals whose providers intensified their regimens, but not among those with intensification but no intervention.

CONCLUSIONS

The intervention achieved short-term improvement in SBP control in a highly disadvantaged population. Despite attempts to enhance intrinsic motivation, the effect was not sustained after incentives were withdrawn. Future research should evaluate combined patient/provider strategies to enhance such interventions and sustain their benefit.

TRIAL REGISTRATION

NCT01402453; http://clinicaltrials.gov/show/NCT01402453.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

Atherosclerotic Cardiovascular Disease in South Asians in the United States: Epidemiology, Risk Factors, and Treatments: A Scientific Statement From the American Heart Association

South Asians (from Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan, and Sri Lanka) make up one quarter of the world's population and are one of the fastest-growing ethnic groups in the United States. Although native South Asians share genetic and cultural risk factors with South Asians abroad, South Asians in the United States can differ in socioeconomic status, education, healthcare behaviors, attitudes, and health insurance, which can affect their risk and the treatment and outcomes of atherosclerotic cardiovascular disease (ASCVD). South Asians have higher proportional mortality rates from ASCVD compared with other Asian groups and non-Hispanic whites, in contrast to the finding that Asian Americans (Asian Indian, Chinese, Filipino, Japanese, Korean, and Vietnamese) aggregated as a group are at lower risk of ASCVD, largely because of the lower risk observed in East Asian populations. Literature relevant to South Asian populations regarding demographics and risk factors, health behaviors, and interventions, including physical activity, diet, medications, and community strategies, is summarized. The evidence to date is that the biology of ASCVD is complex but is no different in South Asians than in any other racial/ethnic group. A majority of the risk in South Asians can be explained by the increased prevalence of known risk factors, especially those related to insulin resistance, and no unique risk factors in this population have been found. This scientific statement focuses on how ASCVD risk factors affect the South Asian population in order to make recommendations for clinical strategies to reduce disease and for directions for future research to reduce ASCVD in this population.

Do Physicians Change Prescription Practice in Response to Financial Incentives?

We assessed the impact on physician prescription behaviors of an outpatient prescription incentive program providing financial rewards to primary care physicians for saving prescription costs in South Korea. A 10% sample of clinics (N = 1,625) was randomly selected from all clinics in the National Health Insurance claims database for the years 2009-2012, and all claims with the primary diagnosis of peptic ulcer or gastro-esophageal reflux diseases were extracted from those clinics' data. A clinic-level random-effects model was used. After the program, clinics in general medicine showed a lower prescription rate (by 0.8 percentage points), lower number of medicines prescribed (by 0.02), lower prescription duration (by 0.15 days), and lower drug expenditure per claim (by 740 won). Small clinics on the <25th percentile of a regional sum of monthly drug expenditure had shorter prescription duration (by 0.76 days), while large clinics on the ≥75th percentile and clinics in group practice had a higher prescription rate (by 1.5 and 2.5 percentage points, respectively) and a higher number of medicines prescribed (by 0.03 for group practice only) after the program. The outpatient prescription incentive program worked as intended only in certain subgroup clinics for the target medicines.

The Patient-Centered Medical Home: How Is It Related to Quality and Equity Among the General Adult Population?

This study investigates whether patient-reported characteristics of the medical home are associated with improved quality and equity of preventive care, advice on health habits, and emergency department use. We used adjusted risk ratios to examine the association between medical home characteristics and care measures based on the 2010 Medical Expenditure Panel Survey. Medical home characteristics are associated with 6 of the 11 outcome measures, including flu shots, smoking advice, exercise advice, nutrition advice, all advice, and emergency department visits. Educational and income groups benefit relatively equally from medical home characteristics. However, compared with insurance and access to a provider, medical home characteristics have little influence on overall disparities in care. In sum, our findings support that medical home characteristics can improve quality and reduce emergency visits but we find no evidence that medical home characteristics alleviate disparities in care.

Associations Between Prediabetes, by Three Different Diagnostic Criteria, and Incident CVD Differ in South Asians and Europeans

OBJECTIVE

We examined longitudinal associations between prediabetes and cardiovascular disease (CVD) (coronary heart disease [CHD] and stroke) in Europeans and South Asians.

RESEARCH DESIGN AND METHODS

This was a U.K. cohort study of 1,336 Europeans and 1,139 South Asians, aged 40-69 years at baseline (1988-1991). Assessment included blood pressure, blood tests, anthropometry, and questionnaires. Prediabetes was determined by OGTT or HbA1c, using either International Expert Committee (IEC) (HbA1c 6.0-6.5% [42-48 mmol/mol]) or American Diabetes Association (ADA) (HbA1c 5.7-6.5% [39-48 mmol/mol]) cut points. Incident CHD and stroke were established at 20 years from death certification, hospital admission, primary care record review, and participant report.

RESULTS

Compared with normoglycemic individuals, IEC-defined prediabetes was related to both CHD and CVD risk in Europeans but not South Asians (subhazard ratio for CHD 1.68 [95% CI 1.19, 2.38] vs. 1.00 [0.75, 1.33], ethnicity interaction P = 0.008, and for CVD 1.49 [1.08, 2.07] vs. 1.03 [0.78, 1.36], ethnicity interaction P = 0.04). Conversely, IEC-defined prediabetes was associated with stroke risk in South Asians but not Europeans (1.73 [1.03, 2.90] vs. 0.85 [0.44, 1.64], ethnicity interaction P = 0.11). Risks were adjusted for age, sex, smoking, total-to-HDL cholesterol ratio, waist-to-hip ratio, systolic blood pressure, and antihypertensive use. Associations were weaker for OGTT or ADA-defined prediabetes. Conversion from prediabetes to diabetes was greater in South Asians, but accounting for time to conversion did not account for these ethnic differences.

CONCLUSIONS

Associations between prediabetes and CVD differed by prediabetes diagnostic criterion, type of CVD, and ethnicity, with associations being present for overall CVD in Europeans but not South Asians. Substantiation of these findings and investigation of potential explanations are required.

Hypertension: a cross-sectional study of the role of multimorbidity in blood pressure control

BACKGROUND

Hypertension is the most prevalent cardiovascular long-term condition in the UK and is associated with a high rate of multimorbidity (MM). Multimorbidity increases with age, ethnicity and social deprivation. Previous studies have yielded conflicting findings about the relationship between MM and blood pressure (BP) control. Our aim was to investigate the relationship between multimorbidity and systolic blood pressure (SBP) in patients with hypertension.

METHODS

A cross-sectional analysis of anonymised primary care data was performed for a total of 299,180 adult patients of whom 31,676 (10.6 %) had a diagnosis of hypertension. We compared mean SBP in patients with hypertension alone and those with one or more co-morbidities and analysed the effect of type of comorbidity on SBP. We constructed a regression model to identify the determinants of SBP control.

RESULTS

The strongest predictor of mean SBP was the number of comorbidities, β -0.13 (p < 0.05). Other predictors included Afro-Caribbean ethnicity, β 0.05 (p < 0.05), South Asian ethnicity, β -0.03 (p < 0.05), age, β 0.05 (p < 0.05), male gender, β 0.05 (p < 0.05) and number of hypotensive drugs β 0.06 (p < 0.05). SBP was lower by a mean of 2.03 mmHg (-2.22, -1.85) for each additional comorbidity and was lower in MM regardless of the type of morbidity.

CONCLUSION

Hypertensive patients with MM had lower SBP than those with hypertension alone; the greater the number of MM, the lower the SBP. We found no evidence that BP control was related to BP targets, medication category or specific co-morbidity. Further research is needed to determine whether consultation rate, "white-coat hypertension" or medication adherence influence BP control in MM.

Does pay-for-performance benefit patients with multiple chronic conditions? Evidence from a universal coverage health care system

INTRODUCTION

Numerous studies have examined the impact of pay-for-performance (P4P) programmes, yet little is known regarding their effects on continuity of care (COC) and the role of multiple chronic conditions (MCCs). This study aimed to examine the effects of a P4P programme for diabetes care on health care provision, COC and health care outcomes in diabetic patients with and without comorbid hypertension.

METHODS

This study utilized a large-scale natural experiment with a 4-year follow-up period under a compulsory universal health insurance programme in Taiwan. The intervention groups consisted of patients with diabetes who were enrolled in the P4P programme in 2005. The comparison groups were selected via propensity score matching with patients who were seen by the same group of physicians. A difference-in-differences analysis was conducted using generalized estimating equation models to examine the effects of the P4P programme.

RESULTS

Significant impacts were observed after the implementation of the P4P programme for diabetic patients with and without hypertension. The programme increased the number of necessary examinations/tests and improved the COC between patients and their physicians. The programme significantly reduced the likelihood of diabetes-related hospital admissions and emergency department visits [odds ratio (OR): 0.71; 95% confidence interval (CI): 0.63-0.80 for diabetic patients with hypertension; OR: 0.74; 95% CI: 0.64-0.86 for patients without hypertension]. However, the effects of the P4P programme diminished to some extent in the second year after its implementation.

CONCLUSION

This study suggests that a financial incentive programme may improve the provision of necessary health care, COC and health care outcomes for diabetic patients both with and without comorbid hypertension. Health authorities could develop policies to increase participation in P4P programmes and encourage continued improvement in health care outcomes.

Hypertension prevalence, awareness, treatment and control in the over 50s in Ireland: evidence from The Irish Longitudinal Study on Ageing

BACKGROUND

To assess the prevalence, awareness, treatment and control of hypertension among adults in Ireland and to describe the determinants of awareness, treatment and control in order to inform public health policy.

METHODS

A cross-sectional study of a nationally representative sample of community living adults aged 50 years and older using data collected from 2009 to 2011 for the first wave of the Irish Longitudinal Study on Ageing (TILDA) (n = 5857). Hypertension was defined as systolic blood pressure (BP) ≥140 mmHg or diastolic BP ≥90 mmHg and/or currently taking antihypertensive medications.

RESULTS

The prevalence of hypertension was 63.7% [95% confidence interval (CI) 62.3-65.1%]. Among those with hypertension, 54.5% (95% CI 52.6-56.2%) were aware of their hypertensive status and 58.9% (95% CI 57.1-60.4%) were on antihypertensive medication. Among those on treatment, 51.6% (95% CI 49.3-53.9%) had their BP controlled to below 140/90 mmHg. Respondents facing financial barriers to primary care and medication were less likely to be on antihypertensive treatment compared with those without financial barriers.

CONCLUSIONS

A high prevalence of hypertension was identified in this cohort, with low levels of awareness, treatment and control. Population and primary care interventions are required to reduce prevalence and to improve awareness, detection and management of hypertension.

Change in prevalence of chronic kidney disease in England over time: comparison of nationally representative cross-sectional surveys from 2003 to 2010

OBJECTIVES

To determine whether the prevalence of chronic kidney disease (CKD) in England has changed over time.

DESIGN

Cross-sectional analysis of nationally representative Health Survey for England (HSE) random samples.

SETTING

England 2003 and 2009/2010.

SURVEY PARTICIPANTS

13,896 adults aged 16+ participating in HSE, adjusted for sampling and non-response, 2009/2010 surveys combined.

MAIN OUTCOME MEASURE

Change in prevalence of estimated glomerular filtration rate (eGFR)<60 mL/min/1.73 m2 (as proxy for stage 3-5 CKD), from 2003 to 2009/2010 based on a single serum creatinine measure using an isotope dilution mass spectrometry traceable enzymatic assay in a single laboratory; eGFR derived using Modified Diet in Renal Disease (MDRD) and Chronic Kidney Disease Epidemiology Collaboration (CKDEPI) eGFR formulae.

ANALYSIS

Multivariate logistic regression modelling to adjust time changes for sociodemographic and clinical factors (body mass index, hypertension, diabetes, lipids). A correction factor was applied to the 2003 HSE serum creatinine to account for a storage effect.

RESULTS

National prevalence of low eGFR (<60) decreased within each age and gender group for both formulae except in men aged 65-74. Prevalence of obesity and diabetes increased in this period, while there was a decrease in hypertension. Adjustment for demographic and clinical factors led to a significant decrease in CKD between the surveyed periods. The fully adjusted OR for eGFR<60 mL/min/1.73 m2 was 0.75 (0.61 to 0.92) comparing 2009/2010 with 2003 using the MDRD equation, and was similar using the CKDEPI equation 0.73 (0.57 to 0.93).

CONCLUSIONS

The prevalence of a low eGFR indicative of CKD in England appeared to decrease over this 7-year period, despite the rising prevalence of obesity and diabetes, two key causes of CKD. Hypertension prevalence declined and blood pressure control improved but this did not appear to explain the fall. Periodic assessment of eGFR and albuminuria in future HSEs is needed to evaluate trends in CKD.

Impact of ethnic-specific guidelines for anti-hypertensive prescribing in primary care in England: a longitudinal study

Background

In England, the National Institute for Health and Care Excellence (NICE) produces guidelines for the management of hypertension. In 2006, the NICE guidelines introduced an ethnic-age group algorithm based on the 2004 British Hypertension Society guidelines to guide antihypertensive drug prescription.

Methods

A longitudinal retrospective study with 15933 hypertensive patients aged 18 years or over and registered with 28 general practices in Wandsworth, London in 2007 was conducted to assess variations in antihypertensive prescribing. Logistic models were used to measure variations in the odds of being prescribed the 2006 NICE first line recommended monotherapy among NICE patient groups over the period.

Results

From 2000 to 2007, the percentage of patients prescribed the recommended monotherapy increased from 54.2% to 61.4% (p < 0.0001 for annual trend). Over the study period, black patients were more likely to be prescribed the recommended monotherapy than younger non-black patients (OR 0.16, 95% CI 0.12 – 0.21) and older non-black patients (OR 0.49, 95% CI 0.37 – 0.65). After the introduction of the NICE guidelines there was an increase in the NICE recommended monotherapy (OR 1.44, 95% CI 1.19 – 1.75) compared with the underlying trend. Compared to black patients, an increase in the use of recommended monotherapy was observed in younger non-black patients (OR 1.49, 95% CI 1.17 – 1.91) but not in older non-black patients (OR 0.58, 95% CI 0.46 – 0.74).

Conclusion

The introduction of the 2006 NICE guideline had the greatest impact on prescribing for younger non-black patients. Lower associated increases among black patients may be due to their higher levels of recommended prescribing at baseline. The analysis suggests that guidelines did not impact equally on all patient groups.

Impact of universal health insurance coverage on hypertension management: a cross-national study in the United States and England

Background

The Patient Protection and Affordable Care Act (ACA) galvanised debate in the United States (US) over universal health coverage. Comparison with countries providing universal coverage may illustrate whether the ACA can improve health outcomes and reduce disparities. We aimed to compare quality and disparities in hypertension management by socio-economic position in the US and England, the latter of which has universal health care.

Method

We used data from the Health and Retirement Survey in the US, and the English Longitudinal Study for Aging from England, including non-Hispanic White respondents aged 50–64 years (US market-based v NHS) and >65 years (US-Medicare v NHS) with diagnosed hypertension. We compared blood pressure control to clinical guideline (140/90 mmHg) and audit (150/90 mmHg) targets; mean systolic and diastolic blood pressure and antihypertensive prescribing, and disparities in each by educational attainment, income and wealth, using regression models.

Results

There were no significant differences in aggregate achievement of clinical targets aged 50 to 65 years (US market-based vs. NHS- 62.3% vs. 61.3% [p = 0.835]). There was, however, greater control in the US in patients aged 65 years and over (US Medicare vs. NHS- 53.5% vs. 58.2% [p = 0.043]). England had no significant socioeconomic disparity in blood pressure control (60.9% vs. 63.5% [p = 0.588], high and low wealth aged ≥65 years). The US had socioeconomic differences in the 50–64 years group (71.7% vs. 55.2% [p = 0.003], high and low wealth); these were attenuated but not abolished in Medicare beneficiaries.

Conclusion

Moves towards universal health coverage in the US may reduce disparities in hypertension management. The current situation, providing universal coverage for residents aged 65 years and over, may not be sufficient for equality in care.

Changes in cardiovascular risk factors in relation to increasing ethnic inequalities in cardiovascular mortality: comparison of cross-sectional data in the Health Surveys for England 1999 and 2004

OBJECTIVES

Reducing disease inequalities requires risk factors to decline quickest in the most disadvantaged populations. Our objective was to assess whether this happened across the UK's ethnic groups.

DESIGN

Secondary analysis of repeated but independent cross-sectional studies focusing on Health Surveys for England 1999 and 2004.

SETTING

Community-based population level surveys in England.

PARTICIPANTS

Seven populations from the major ethnic groups in England (2004 sample sizes): predominantly White general (6704), Irish (1153), Chinese (723), Indian (1184), Pakistani (941), Bangladeshi (899) and Black Caribbean (1067) populations. The numbers were smaller for specific variables, especially blood tests.

OUTCOME MEASURES

Data on 10 established cardiovascular risk factors were extracted from published reports. Differences between 1999 and 2004 were defined a priori as occurring when the 95% CI excluded 0 (for prevalence differences), or 1 (for risk ratios) or when there was a 5% or more change (independent of CIs).

RESULTS

Generally, there were reductions in smoking and blood pressure and increases in the waist-hip ratio, body mass index and diabetes. Changes between 1999 and 2004 indicated inconsistent progress and increasing inequalities. For example, total cholesterol increased in Pakistani (0.3 mmol/L) and Bangladeshi men (0.3 mmol/L), and in Pakistani (0.3 mmol/L), Bangladeshi (0.4 mmol/L) and Black Caribbean women (0.3 mmol/L). Increases in absolute risk factor levels were common, for example, in Pakistani (five risk factors), Bangladeshi (four factors) and general population women (four factors). For men, Black Caribbeans had the most (five factor) increases. The changes relative to the general population were also adverse for three risk factors in Pakistani and Black Caribbean men, four in Bangladeshi women and three in Pakistani women.

CONCLUSIONS

Changes in populations with the most cardiovascular disease and diabetes did not decline the quickest. Cardiovascular screening programmes need more targeting.

Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework

OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.

Impact of the GP contract on inequalities associated with influenza immunisation: a retrospective population-database analysis

BACKGROUND

Influenza immunisation is recommended for all people aged ≥65 years and younger people with particular chronic diseases. The Quality and Outcomes Framework (QOF) has provided new financial incentives for influenza immunisation since 2004.

AIM

To determine the impact of the 2004 UK General Medical Services contract on the overall uptake of, and socioeconomic inequalities associated with, influenza immunisation.

DESIGN AND SETTING

Retrospective general-practice population database analysis in 15 general practices in Scotland, UK.

METHOD

Changes in influenza-immunisation uptake for those in at-risk groups between 2003-2004 and 2006-2007 were measured, and variation in uptake examined using multilevel modelling.

RESULTS

Uptake rose from 67.9% in 2003-2004 to 71.4% in 2006-2007. The largest increases were seen in those aged <65 years with chronic disease, with uptake rising from 49.6% to 58.4%, but rates remained considerably lower than in those aged ≥65 years. Differences between practices narrowed (median odds ratio [OR] for two patients randomly selected from different practices: 2.13 (95% confidence interval [CI] = 2.00 to 2.26) in 2003-2004 versus 1.44 (95% CI = 1.40 to 1.49) in 2006-2007. However, inequalities in uptake by patient socioeconomic status did not change: adjusted OR for most deprived versus most affluent was 0.75 (95% CI = 0.70 to 0.80) in 2003-2004 versus 0.72 (95% CI = 0.68 to 0.76) in 2006-2007.

CONCLUSION

Overall uptake rose significantly and differences between practices narrowed considerably. However, socioeconomic and age inequalities in influenza immunisation persisted in the first 3 years of the QOF. This contrasts with other ecological analyses, which have concluded that the QOF has reduced inequalities. The impact of financial incentives on inequalities is likely to vary, and some kinds of care may require more targeted improvement activity and support.

System dynamics to model the unintended consequences of denying payment for venous thromboembolism after total knee arthroplasty

BACKGROUND

The Hospital Acquired Condition Strategy (HACS) denies payment for venous thromboembolism (VTE) after total knee arthroplasty (TKA). The intention is to reduce complications and associated costs, while improving the quality of care by mandating VTE prophylaxis. We applied a system dynamics model to estimate the impact of HACS on VTE rates, and potential unintended consequences such as increased rates of bleeding and infection and decreased access for patients who might benefit from TKA.

METHODS AND FINDINGS

The system dynamics model uses a series of patient stocks including the number needing TKA, deemed ineligible, receiving TKA, and harmed due to surgical complication. The flow of patients between stocks is determined by a series of causal elements such as rates of exclusion, surgery and complications. The number of patients harmed due to VTE, bleeding or exclusion were modeled by year by comparing patient stocks that results in scenarios with and without HACS. The percentage of TKA patients experiencing VTE decreased approximately 3-fold with HACS. This decrease in VTE was offset by an increased rate of bleeding and infection. Moreover, results from the model suggest HACS could exclude 1.5% or half a million patients who might benefit from knee replacement through 2020.

CONCLUSION

System dynamics modeling indicates HACS will have the intended consequence of reducing VTE rates. However, an unintended consequence of the policy might be increased potential harm resulting from over administration of prophylaxis, as well as exclusion of a large population of patients who might benefit from TKA.

The effects of pay for performance on disparities in stroke, hypertension, and coronary heart disease management: interrupted time series study

BACKGROUND

The Quality and Outcomes Framework (QOF), a major pay-for-performance programme, was introduced into United Kingdom primary care in April 2004. The impact of this programme on disparities in health care remains unclear. This study examines the following questions: has this pay for performance programme improved the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has this programme reduced disparities in the quality of care between these ethnic groups? Did general practices with different baseline performance respond differently to this programme?

METHODOLOGY/PRINCIPAL FINDINGS

Retrospective cohort study of patients registered with family practices in Wandsworth, London during 2007. Segmented regression analysis of interrupted time series was used to take into account the previous time trend. Primary outcome measures were mean systolic and diastolic blood pressure, and cholesterol levels. Our findings suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period.

CONCLUSIONS/SIGNIFICANCE

Pay for performance programmes such as the QOF in the UK should set challenging but achievable targets. Specific targets aimed at reducing ethnic disparities in health care may also be needed.

Both patient and facility contribute to achieving the Centers for Medicare and Medicaid Services' pay-for-performance target for dialysis adequacy

The Centers for Medicare and Medicaid Services (CMS) designated the achieved urea reduction ratio (URR) as a pay-for-performance measure, but to what extent this measure reflects patient characteristics and adherence instead of its intent to reflect facility performance is unknown. Here, we quantified the contributions of patient case-mix and adherence to the variability in achieving URR targets across dialysis facilities. We found that 92% of 10,069 hemodialysis patients treated at 173 facilities during the last quarter of 2004 achieved the target URR ≥65%. Mixed-effect models with random intercept for dialysis facility revealed a significant facility effect: 11.5% of the variation in achievement of target URR was attributable to the facility level. Adjusting for patient case-mix reduced the proportion of variation attributable to the facility level to 6.7%. Patient gender, body surface area, dialysis access, and adherence with treatment strongly associated with achievement of the URR target. We could not identify specific facility characteristics that explained the remaining variation between facilities. These data suggest that if adherence is not a modifiable patient characteristic, providers could be unfairly penalized for caring for these patients under current CMS policy. These penalties may have unintended consequences.

Cardiovascular multimorbidity: the effect of ethnicity on prevalence and risk factor management

BACKGROUND

Multimorbidity is common in primary care populations. Within cardiovascular disease, important differences in disease prevalence and risk factor management by ethnicity are recognised.

AIM

To examine the population burden of cardiovascular multimorbidity and the management of modifiable risk factors by ethnicity.

DESIGN AND SETTING

Cross-sectional study of general practices (148/151) in the east London primary care trusts of Tower Hamlets, City and Hackney, and Newham, with a total population size of 843 720.

METHOD

Using MIQUEST, patient data were extracted from five cardiovascular registers. Logistic regression analysis was used to examine the risk of being multimorbid by ethnic group, and the control of risk factors by ethnicity and burden of cardiovascular multimorbidity.

RESULTS

The crude prevalence of cardiovascular multimorbidity among patients with at least one cardiovascular condition was 34%. People of non-white ethnicity are more likely to be multimorbid than groups of white ethnicity, with adjusted odds ratios of 2.04 (95% confidence interval [CI] = 1.94 to 2.15) for South Asians and 1.23 (95% CI = 1.18 to 1.29) for groups of black ethnicity. Achievement of targets for blood pressure, cholesterol, and glycated haemoglobin (HbA(1c)) was higher for patients who were multimorbid than unimorbid. For cholesterol and blood pressure, South Asian patients achieved better control than those of white and black ethnicity. For HbA(1c) levels, patients of white ethnicity had an advantage over other groups as the morbidity burden increased.

CONCLUSION

The burden of multiple disease varies by ethnicity. Risk factor management improves with increasing levels of cardiovascular multimorbidity, but clinically important differences by ethnicity remain and contribute to health inequalities.

The relationship of ethnicity to the prevalence and management of hypertension and associated chronic kidney disease

BACKGROUND

The effect of ethnicity on the prevalence and management of hypertension and associated chronic kidney (CKD) disease in the UK is unknown.

METHODS

We performed a cross sectional study of 49,203 adults with hypertension to establish the prevalence and management of hypertension and associated CKD by ethnicity. Routinely collected data from general practice hypertension registers in 148 practices in London between 1/1/07 and 31/3/08 were analysed.

RESULTS

The crude prevalence of hypertension was 9.5%, and by ethnicity was 8.2% for White, 11.3% for South Asian and 11.1% for Black groups. The prevalence of CKD stages 3-5 among those with hypertension was 22%. Stage 3 CKD was less prevalent in South Asian groups (OR 0.77, 95% CI 0.67 - 0.88) compared to Whites (reference population) with Black groups having similar rates to Whites. The prevalence of severe CKD (stages 4-5) was higher in the South Asian group (OR 1.53, 95% CI 1.17 - 2.0) compared to Whites, but did not differ between Black and White groups. In the whole hypertension cohort, achievement of target blood pressure (< 140/90 mmHg) was better in South Asian (OR 1.43, 95% CI 1.28 - 1.60) and worse in Black groups (OR 0.79, 95% CI 0.74 - 0.84) compared to White patients. Hypertensive medication was prescribed unequally among ethnic groups for any degree of blood pressure control.

CONCLUSIONS

Significant variations exist in the prevalence of hypertension and associated CKD and its management between the major ethnic groups. Among those with CKD less than 50% were treated to a target BP of ≤ 130/80 mmHg. Rates of ACE-I/ARB prescribing for those with CKD were less than optimal, with the lowest rates (58.5%) among Black groups.

The equity dimension in evaluations of the quality and outcomes framework: a systematic review

BACKGROUND

Pay-for-performance systems raise concerns regarding inequity in health care because providers might select patients for whom targets can easily be reached. This paper aims to describe the evolution of pre-existing (in)equity in health care in the period after the introduction of the Quality and Outcomes Framework (QOF) in the UK and to describe (in)equities in exception reporting. In this evaluation, a theory-based framework conceptualising equity in terms of equal access, equal treatment and equal treatment outcomes for people in equal need is used to guide the work.

METHODS

A systematic MEDLINE and Econlit search identified 317 studies. Of these, 290 were excluded because they were not related to the evaluation of QOF, they lacked an equity dimension in the evaluation, their qualitative research focused on experiences or on the nature of the consultation, or unsuitable methodology was used to pronounce upon equity after the introduction of QOF.

RESULTS

None of the publications (n = 27) assessed equity in access to health care. Concerning equity in treatment and (intermediate) treatment outcomes, overall quality scores generally improved. For the majority of the observed indicators, all citizens benefit from this improvement, yet the extent to which different patient groups benefit tends to vary and to be highly dependent on the type and complexity of the indicator(s) under study, the observed patient group(s) and the characteristics of the study. In general, the introduction of QOF was favourable for the aged and for males. Total QOF scores did not seem to vary according to ethnicity. For deprivation, small but significant residual differences were observed after the introduction of QOF favouring less deprived groups. These differences are mainly due to differences at the practice level. The variance in exception reporting according to gender and socio-economic position is low.

CONCLUSIONS

Although QOF seems not to be socially selective at first glance, this does not mean QOF does not contribute to the inverse care law. Introducing different targets for specific patient groups and including appropriate, non-disease specific and patient-centred indicators that grasp the complexity of primary care might refine the equity dimension of the evaluation of QOF. Also, information on the actual uptake of care, information at the patient level and monitoring of individuals' health care utilisation tracks could make large contributions to an in-depth evaluation. Finally, evaluating pay-for-quality initiatives in a broader health systems impact assessment strategy with equity as a full assessment criterion is of utmost importance.

Ethnic differences in blood pressure monitoring and control in south east London

BACKGROUND

High blood pressure is the single most important risk factor worldwide for the development of cardiovascular disease, and has been shown to affect some ethnic minority groups disproportionately.

AIM

To explore ethnic inequalities in blood pressure monitoring and control.

METHOD

Data from Lambeth DataNet was used, based on case records from GP practices in one inner-city London borough. Blood pressure monitoring and control was compared using Quality and Outcomes Framework (QOF) targets for patients with: diabetes, coronary heart disease, stroke, hypertension, and chronic kidney disease. The study controlled for age, sex, social deprivation, and clustering within GP practices.

RESULTS

A total of 16 613 patients met the study criteria, with 5962 categorised as black/black British. Blood pressure monitoring was similar across ethnic groups and as good, if not better, for black patients compared to white. However, marked ethnic inequalities in blood pressure control were found, with black patients significantly less likely to achieve QOF targets than their white counterparts (odds ratio [OR] 0.73; 95% confidence interval [CI] = 0.64 to 0.82). Further inequalities were revealed in blood pressure control within disease groups and ethnic subgroups. In particular, blood pressure control was poor in African patients with diabetes (OR 0.63; 95% CI = 0.50 to 0.79) and Caribbean patients with coronary heart disease (OR 0.53; 95% CI = 0.37 to 0.77) when compared with white patients.

DISCUSSION

While black patients with chronic conditions are equally likely to have their blood pressure monitored, their blood pressure control is consistently poorer than that of their white counterparts. This may have important implications for cardiovascular risk management in black patients.

Ethnic differences in diabetes management in patients with and without comorbid medical conditions: a cross-sectional study

OBJECTIVE

To 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 METHODS

This 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.

RESULTS

The 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.

CONCLUSIONS

Despite 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.

Blood pressure monitoring and control by cardiovascular disease status in UK primary care: 10 year retrospective cohort study 1998-2007

BACKGROUND

Strategies to reduce the burden of cardiovascular disease (CVD) in the UK have emphasized improved management of high-risk individuals rather than population-based approaches.

METHODS

This 10-year retrospective cohort study examined blood pressure (BP) monitoring and control among patients with and without CVD in general practices in Wandsworth, London between 1998 and 2007. Logistic regression was used to assess associations among age, gender, ethnicity, deprivation and BP control.

RESULTS

The percentage of patients with elevated BP (>140/90 mm Hg) decreased at a slower rate in patients without CVD (31.0-25.3%) compared with those with CVD (56.8-36.0%) (P < 0.001). Mean systolic BP decreased from 146.1 to 136.4 mm Hg in patients with CVD and from 133.7 to 130.1 in patients without CVD. Mean diastolic BP decreased from 84.2 to 78.4 mm Hg in patients with CVD and from 80.5 to 79.0 in patients without CVD. Inequalities in BP control decreased among age, ethnic and deprivation groups but increased between men and women without CVD.

CONCLUSIONS

Measurement and control of BP among those with CVD has improved much more rapidly compared with those without CVD. Inequalities in BP control appeared to increase between men and women without CVD, but decreased among age, ethnicity and deprivation groups.

Systematic review: Effects, design choices, and context of pay-for-performance in health care

BACKGROUND

Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.

METHODS

The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.

RESULTS

One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.

CONCLUSIONS

P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

Reductions in risk factors for secondary prevention of coronary heart disease by ethnic group in south-west London: 10-year longitudinal study (1998-2007)

OBJECTIVES

To explore trends by ethnicity in clinical risk factor recording and control among patients with coronary heart disease (CHD), during a period of major investment in quality improvement initiatives in general practice in England.

DESIGN

Longitudinal study from 1998 to 2007, using general practice data extracted from electronic patient records of all adult patients (n=177,412) registered in 2007.

SETTING

Twenty-nine general practices in Wandsworth south-west London.

SUBJECTS

Three thousand two hundred registered patients with a recorded diagnosis of CHD, in 2007.

MAIN OUTCOME MEASURES

Mean systolic and diastolic blood pressure and mean cholesterol of patients with CHD, for each calendar year.

RESULTS

From 1998 to 2007, the proportion of patients with CHD who had their blood pressure recorded rose from 33.2% to 93.9% and cholesterol from 21.7% to 83.5%. Over this period, mean blood pressure decreased from 140/80 to 133/74 mmHg (P<0.001). There was a reduction in mean cholesterol from 5.2 to 4.3 mmol/l (P<0.001). Reductions in mean blood pressure and cholesterol occurred across all ethnic groups.

CONCLUSIONS

From 1998 to 2007, risk factor control among patients with CHD improved, with reductions in their mean blood pressure and cholesterol across all ethnic groups. Widespread policy change has helped to improve the quality and equity of primary care for heart disease patients. Health improvements predated implementation of the Quality and Outcomes Framework and have since continued. Our findings illustrate how a national health care system with universal coverage can significantly reduce inequalities and improve chronic disease care for all ethnic groups.

Technical and compliance considerations for mobile health self-monitoring of glucose and blood pressure for patients with diabetes

Self-monitoring of blood glucose is an integral part of diabetes care which may be extended to other biometrics. Cellular and short range communication technologies will be important for the routine usage of these systems. However, the issues of follow-up and patient compliance with these emerging systems have not been yet studied evaluated but could be critical to the adoption of these technologies. We evaluated the impact of mobile telemonitoring on the intensification of care on blood pressure control and exposure to hyperglycaemia in patients with diabetes. We randomised 137 patients with diabetes to either mobile telemonitoring (n = 72) or usual care patients (n = 65) for 9 months. In this paper we present some of the clinical results with focus on blood pressure control hypertension and highlight some of the technical and compliance issues that were encountered.

Pay for perfomance and the quality of diabetes management in individuals with and without co-morbid medical conditions

OBJECTIVE

To examine the impact of the Quality and Outcomes Framework, a major pay-for-performance incentive introduced in the UK during 2004, on diabetes management in patients with and without co-morbidity.

DESIGN

Cohort study comparing actual achievement of treatment targets in 2004 and 2005 with that predicted by the underlying (pre-intervention) trend in diabetes patients with and without co-morbid conditions.

SETTING

A total of 422 general practices participating in the General Practice Research Database.

MAIN OUTCOMES MEASURES

Achievement of diabetes treatment targets for blood pressure (< 140/80 mm Hg), HbA1c (<or= 7.0%) and cholesterol (<or= 5 mmol/L).

RESULTS

The percentage of diabetes patients with co-morbidity reaching blood pressure and cholesterol targets exceeded that predicted by the underlying trend during the first two years of pay for perfomance (by 3.1% [95% CI 1.1-5.1] for BP and 4.1% [95% CI 2.2-6.0] for cholesterol among patients with >or= 5 co-morbidities in 2005). Similar improvements were evident in patients without co-morbidity, except for cholesterol control in 2004 (-0.2% [95% CI -1.7-1.4]). The percentage of patients meeting the HbA1c target in the first two years of this program was significantly lower than predicted by the underlying trend in all patients, with the greatest shortfall in patients without co-morbidity (3.8% [95% CI 2.6-5.0] lower in 2005). Patients with co-morbidity remained significantly more likely to meet treatment targets for cholesterol and HbA1c than those without after the introduction of pay for perfomance.

CONCLUSIONS

Diabetes patients with co-morbid conditions appear to have benefited more from this pay-for-performance program than those without co-morbidity.

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

OBJECTIVE

To examine associations between social class and achievement of selected national audit targets for coronary heart disease (CHD), diabetes and hypertension in England before and after the introduction of a major pay for performance programme in 2004.

DESIGN

Secondary analysis of 2003 and 2006 national survey data for respondents with CHD and diabetes and hypertension.

SETTING

England.

MAIN OUTCOME MEASURE

Achievement of national audit targets for blood pressure, blood glucose and cholesterol control.

RESULTS

There were no significant differences in achievement of blood pressure targets in individuals from manual and non-manual occupational groups with diabetes (2003: 65.9% v 60.3%, 2006: 67.6% v 69.7%) or hypertension (2003: 66.2% v 66.2%, 2006: 72.8% v 71.9%) before or after the introduction of pay for performance. Achievement of the cholesterol target was also similar in individuals from manual and non-manual groups with diabetes (2003: 52.5% v 46.6%, 2006: 68.7% v 70.5%) or CHD (2003: 54.3% v 53.3%, 2006: 68.6% v 71.3%). Differences in achievement of the blood pressure target in CHD [75.8% v 84.5%; AOR 0.44 (0.21-0.90)] were evident between manual and non-manual occupational groups after the introduction of pay for performance.

CONCLUSION

The quality of chronic disease management in England was broadly equitable between socioeconomic groups before this major pay for performance programme and remained so after its introduction.