1. C Wilson, KM Rhodes, RA Payne
Did the UK Quality and Outcomes Framework improve rates of recognition and treatment of cardiovascular risk factors in people with severe mental illness?
C Wilson, KM Rhodes, RA Payne

2. Cardiovascular disease
Severe Mental Illness
e.g. schizophrenia, bipolar affective disorder
Premature morbidity and mortality
Life expectancy 12 years less
Cardiovascular
disease

3. Quality & Outcomes Framework
Introduced 2004
Primary care “payment for performance”
Incentivises annual review
2004 to 2011, unspecified
2011 to 2014, cardiovascular specific

4. Quality & Outcomes Framework
Reduces inequalities in CVD risk factor testing
Unknown
Impact on recognition of CVD risk factors?
Management of CVD risk factors?

5. ?
Have QOF indicators been associated with improvements in identification and management of CV risk factors in people with SMI?

6. Methods
CPRD analysis
UK general practice data
7% of population

7. Study design Retrospective open cohort study 1995 to 2014
Age ≥35 years
Cases with lifetime diagnosis of SMI
Random, unmatched controls (5:1)

8. Outcomes Diagnosis Treatment Diabetes Hypertension Obesity
Elevated cholesterol
Treatment
Lipid-modifying medications
Anti-diabetic medications

9. Interrupted time series analysis
Segmented logistic regression
Adjustment for age, gender, practice
Time periods
, pre-QOF
, introduction of QOF
, change to CV-specific indicators

10. Interrupted time series analysis
Intervention 1 ↓ ↑
Intervention 2
Time

11. Results

12. Population characteristics
SMI cases
Controls
Number
67,239
359,951
Follow-up
5.3 years
7.4 years
Male
46.6%
49.7%
Age (yrs)
1995/6
63.0
56.0
2004/5
57.6
55.6
2013/4
56.8
56.7
Proportion died
20.9%
10.8%

13. Recording elevated cholesterol
84%↑
Compared to non-SMI
p<0.001
OR 1.21
( )
37%↑
Compared to non-SMI
p<0.001
[CLICK] Following the introduction of QOF in 2004, the [CLICK] odds of an SMI patient having elevated cholesterol test results were 1.2-times higher compared to before QOF. [CLICK] This was 37% higher than the change observed in the non-SMI group. The immediate effects appeared to be sustained post The cardiovascular-specific indicator in 2011 resulted in an increase in the odds of detection of high cholesterol which was 84% greater in the SMI group, but this effect was not sustained post-2011.

14. Case detection of risk factors
Elevated cholesterol
Diabetes
37%↑
21%↑
84%↑
Obesity
Hypertension
21%↑
19%↑
Similar to cholesterol, the introduction of the QOF incentives in 2004 was associated with increases in the recording of obesity, diabetes and hypertension in the SMI group compared to the non-SMI group, with these differences maintained. Following the change to the 2011 incentives, the odds of recording obesity increased in the SMI group compared to the non-SMI group, although this effect was not sustained post This was similar to what was observed for cholesterol. However the 2011 incentive did not appear to affect detection of diabetes or hypertension.
39%↑

15. Treatment of risk factors
Anti-diabetic Rx
Lipid-lowering Rx
No association between QOF and changes in prescribing

16. Discussion

17. Improved identification of cardiovascular risk factors
Under-recording of CV risk factors in SMI is known
Impact of cardiovascular-specific indicators uncertain
Possible “catch-up” effect?

18. No impact on treatment of cardiovascular risk factors
At odds with national guidance
Under-treatment of SMI population recognised
e.g. stroke, arthritis
Possible reasons
Patient– e.g. cognitive impairment, adherence
Physician – e.g. stigma, clinical complexity
Service – e.g. care fragmentation, lack of resources

19. Limitations
Can’t distinguish better case-finding from changes in incidence
Age differences and changes in coding practice
Effect of other unknown interventions (e.g. guidelines)
Limited post-2011 data

20. Summary
Incentives for GPs improve detection but not treatment of cardiovascular risk factors in SMI patients
Effect of specifically incentivising treatment?
Broader role of incentives in reducing inequalities and improving care for SMI patients?