Effect of a UK Pay-for-Performance Program on Ethnic Disparities in Diabetes Outcomes: Interrupted Time Series Analysis | Annals of Family Medicine

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Figure 1
Trends in mean hemoglobin A_1c, total cholesterol, and blood pressure levels.

BP=blood pressure; HbA_1c = hemoglobin A_1c; QOF = Quality and Outcomes Framework.

Note: Pre-QOF spanned 2000–2003, QOF introduced in 2004, post-QOF spanned 2005–2007.

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Table 1

Patient Characteristics in 2007

Characteristic	All Patients (N=7,434)	White (n=3,181)	Black (n=1,811)	South Asian (n=1,653)
Male, %	50.4	52.5	54.1	53.4
Mean age, y	59.1	59.7	60.4	58.1
Comorbidity: 0, %	31.8	29.6	28.6	34.7
Comorbidity: 1, %	36.6	35.2	45.0	32.8
Comorbidity: ≥2, %	31.4	35.1	26.3	32.4
Mean socioeconomic score^a	20.7	20.9	21.3	19.7

↵a Using the Index of Multiple Deprivation 2007; the higher the score, the greater the deprivation.

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Table 2

Interrupted Time Series Analysis for Mean Hemoglobin A_1c Levels

	HbA_1c, % (95% CI)

Parameter	All Patients	White	Black	South Asian
Pre-QOF trend	−0.21 (−0.23 to −0.18)^a	−0.20 (−0.24 to −0.17)^a	−0.21 (−0.27 to −0.15)^a	−0.20 (−0.26 to −0.15)^a
Level change post-QOF	0.04 (−0.04 to 0.12)	0.07 (−0.04 to 0.18)	−0.12 (−0.29 to 0.04)	0.18 (0.02 to 0.34)^b
Post-QOF trend	0.19 (0.15 to 0.22)^a	0.21 (0.16 to 0.26)^a	0.21 (0.14 to 0.29)^a	0.11 (0.04 to 0.18)^a

HbA_1c=hemoglobin A_1c; QOF = Quality and Outcomes Framework.
↵a P <.01.
↵b P <.05.

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Table 3

Interrupted Time Series Analysis for Mean Cholesterol Levels

	Cholesterol, mmol/L (95% CI)

Parameter	All Patients	White	Black	South Asian
Pre-QOF trend	−0.13 (−0.15 to −0.11)^a	−0.15 (−0.17 to −0.12)^a	−0.11 (−0.14 to −0.08)^a	−0.13 (−0.17 to −0.08)^a
Level change post-QOF	−0.12 (−0.18 to −0.06)^a	−0.13 (−0.21 to −0.05)^a	−0.10 (−0.20 to −0.01)^b	−0.07 (−0.20 to 0.04)
Post-QOF trend	0.03 (0.01 to 0.05)^b	0.04 (0.01 to 0.08)^b	0.03 (−0.01 to 0.07)	0.02 (−0.03 to 0.07)

QOF = Quality and Outcomes Framework.
↵a P <.01.
↵b P <.05.

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Table 4

Interrupted Time Series Analysis for Mean Systolic and Diastolic Blood Pressure

	Blood Pressure, mm Hg (95% CI)

Parameter	All Patients	White	Black	South Asian
Systolic
Pre-QOF trend	−0.03 (−0.31 to 0.25)	−0.50 (−0.93 to −0.08)^a	0.31 (−0.20 to 0.83)	0.42 (−0.16 to 1.01)
Level change post-QOF	−1.95 (−2.87 to −1.02)^b	−2.12 (−3.48 to −0.77)^b	−2.32 (−4.03 to −0.61)^b	−1.08 (−2.97 to 0.08)
Post-QOF trend	−1.04 (−1.42 to −0.64)^b	−0.21 (−0.80 to 0.37)	−1.68 (−2.41 to −0.95)^b	−1.79 (−2.60 to −0.98)^b
Diastolic
Pre-QOF trend	−0.84 (−1.00 to −0.67)^b	−0.69 (−0.93 to −0.44)^b	−0.84 (−1.14 to −0.54)^b	−1.06 (−1.41 to −0.72)^b
Level change post-QOF	−0.51 (−1.05 to 0.01)	−1.01 (−1.79 to −0.24)^a	−0.33 (−1.32 to 0.65)	0.20 (−0.90 to 1.30)
Post-QOF trend	0.19 (−0.03 to 0.41)	0.10 (−0.23 to 0.43)	0.12 (−0.30 to 0.54)	0.40 (−0.07 to 0.87)

QOF = Quality and Outcomes Framework.
↵a P <.05
↵b P <.01

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Table 5

Ethnic Differences in Mean Risk Factor Levels Before and After QOF and Pooled 8-Year Differences From 2000 to 2007

	HbA_1c % (95% CI)			Cholesterol mmol/L (95% CI)			Systolic Blood Pressure mm Hg (95% CI)			Diastolic Blood Pressure mm Hg (95% CI)

Ethnic Group	2003	2007	Difference	2003	2007	Difference	2003	2007	Difference	2003	2007	Difference
White	7.5	7.5	−0.04 (−0.15 to 0.06)	4.9	4.4	−0.47 (−0.54 to −0.39)	138.3	132.9	−5. (−6.5 to −4.3)	78.6	76.0	−2.5 (−3.2 to −1.9)
Black	8.0^a	7.8^a	−0.18 (−0.35 to −0.02)	4.8^a	4.4	−0.38 (−0.47 to −0.29)	141.4^a	135.1^a	−6.3 (−7.8 to −4.9)	80.4^a	77.7^a	−2. (−3.5 to −1.8)
South Asian	7.9^a	7.8^a	−0.17 (−0.32 to −0.02)	4.7^a	4.2^a	−0.47 (−0.58 to −0.35)	136.3	131.0^a	−5.2 (−6.8 to −3.6)	78.5	75.6	−2.9 (−3.8 to −1.9)

HbA_1c=hemoglobin A_1c; QOF = Quality and Outcomes Framework.
↵a Indicates significant differences to white group at 5% level after adjusting for age, sex, socioeconomic status, number of comorbidities, and practice-level clustering.

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Supplemental Appendix & Tables

Supplemental Appendix 1. Sensitivity Analysis; Supplemental Table 1. Results of the Sensitivity Analysis for Blood Pressure; Supplemental Table 2. Results of the Sensitivity Analysis for Hemoglobin A1c and Cholesterol

Files in this Data Supplement:

Adobe PDF - Alshamsan_Supp_App.pdf
Supplemental data: Tables 1 & 2 - PDF file, 1 page, 172 KB
The Article in Brief

Riyadh Alshamsan, and colleagues

Background The Quality and Outcomes Framework (QOF) is a UK pay-for-performance program that rewards general practitioners for achieving preset targets. This study examines the QOF's impact over time on ethnic disparities in diabetes outcomes.

What This Study Found When the QOF was introduced, there were initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients. Initial improvements in diastolic blood pressure in white patients and in cholesterol levels in black and white patients were not sustained after QOF was introduced. There was no beneficial impact of QOF on hemoglobin A1c levels in any ethnic group, and existing disparities in risk factor control remained largely intact at the end of the study period.

Implications

Targeted quality improvement strategies may be required to address disparities in chronic disease management.

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