Even though a significant improvement is evident in the care of patients with diabetes over the last ten years, they are not considered as a direct result of the quality and outcomes framework, considered as the method that rewards UK general practices to ensure quality care.
In an article published today on bmj.com, researchers mention that the present reward scheme may even lead to reduced levels of care for some particular patients.
The quality and outcomes framework established in 2004 is solely to improve standards of quality care based in rewarding financial incentives linked to performance indicators for all general practitioners in the UK. These payments are staged and are subject to minimum and maximum thresholds, which include targets for controlling blood pressure, as well as cholesterol and blood glucose levels.
Since its introduction in 2004, several studies do confirm an improvement in the care management of diabetes patients in primary care, but others suggest that it is still uncertain if these improvements are due to the direct effect of the scheme, or basically because of other existing tendencies in response to further quality enhancement approaches.
An interesting investigation, including 147 general practices covering over one million patients across the UK carried out by researchers from the Universities of Birmingham and Manchester, was evaluated between 2001 and 2007 (three years before and after the introduction of the scheme).
As a result, they concluded constant significant progress in all the diabetes targets over the entire six year period, but with a more notable improvement in the years prior to the introduction of the incentives. Surprisingly, the improvements in care reached a plateau after the introduction of the framework.
The authors conclude that these results can be caused by the increasing complexity of target accomplishment in poorly controlled patients, as well as the lack of additional incentive after achieving the superior fee thresholds (ceiling effect).
In this case, they recommend the removal of those upper thresholds or the making of more challenging targets.
Another significant point the researchers mention in their finding was that up to two thirds of patients with type 1 diabetes and a third with type 2 diabetes were not included n the framework evaluation. This is of concern in order to reduce health inequalities.
“Our work and that of others highlights the potential unintended consequences of the scheme and raises concerns that the quality and outcomes framework may not have been as efficient in reducing inequalities in health in diabetes as was hoped”, say the authors.
Since the late 1990s, the management of patients with diabetes has progressed, the effect of the pay-for-performance scheme on care is not clear-cut, they conclude.
“Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study”
Melanie Calvert, senior lecturer, Aparna Shankar, research fellow, Richard J McManus, clinical senior lecturer, Helen Lester, professor of primary care, Nick Freemantle, professor of clinical epidemiology and biostatistics
Written by Stephanie Brunner (B.A.)