1. Intermediate outcome control in people with type 2 diabetes in the UK under comprehensive P4P Bruce Guthrie Alistair Emslie-Smith Andrew Morris

2. UK General Practice Physician owned independent businesses Almost all income from state funded National Health Service Average size 5400 patients, 3 physicians Computerized, multidisciplinary teams

3. New contract in 2004 Quality and Outcomes Framework (QOF) is the largest healthcare pay for performance program in the world ~ 20% of practice income ~150 quality indicators New money Non-competitive –Achieve X, receive £Y

4. Diabetes pay for performance 15 indicators (plus smoking) Foot, eye & renal screening, flu shots etc Intermediate outcomes Process in last 15 monthsOutcome Glycated hemoglobin≤10% ≤7.4% Blood pressure≤145/85 Cholesterol≤5mmol/l Smoking status Smoking cessation advice N/A

5. Population studied Regional population register with automatic updating from primary care, hospital and laboratory computers Regular external validation 10,191 patients with type 2 diabetes registered with 59 general practices with validated data Denominator = patient registered on 30 th April 2006

6. Quality measures Process in last 12 monthsOutcome Glycated hemoglobin≤7.4% Blood pressure≤140/80 Cholesterol≤5mmol/l Smoking statusNot smoking Composites Simple All-or-nothing Composites

7. Process recorded last 12 months

8. Achieve outcome target

9. Distribution of quality - age IndicatorOdds ratios (95% CI) Aged<55 vs aged 55-84 All 4 processes0.73 (0.62 to 0.86) GHB ≤7.40.46 (0.41 to 0.52) BP ≤140/800.77 (0.68 to 0.87) Cholesterol ≤50.47 (0.41 to 0.53) Not smoking0.42 (0.37 to 0.48) All 4 outcomes0.41 (0.33 to 0.50) Hierarchical linear regression (patients within practices) Process adjusted for gender, SES and duration Outcome additionally adjusted for body mass index

10. Distribution of quality Socio-economic status –Only difference was for “not smoking” Women vs men –Cholesterol control OR 0.63 (0.57 to 0.69) Body mass index –Increasing BMI associated with worse GHB & BP control Between practices –Small ICCs (1.2% to 4.3% for outcomes) –No associations with practice characteristics

11. Conclusions Process is reasonably reliable, but intermediate outcome control less so –Blood pressure control stands out Most striking variation is by age SES variation minimal Can’t examine why patterns exist –Adjusted for body mass index and duration but not for other patient factors –Treatment intensity

12. Implications Register, recall, review not enough –Need to focus more on intermediate outcomes Particularly applies to younger patients –Growing challenge in face of epidemics Need to better define problem –Access or engagement? –Treatment intensity or adherence? Uncertain how best to address –Practice vs area based services?

13. Thank you!

14. DMARD monitoring Age (years) % without minimal monitoring Adjusted OR (95% CI) <40 40-49 50-59 60-69 70-79 80 and over 19% 12% 10% 9% 7% 3.1 (1.3 to 7.2) 1.7 (0.7 to 4.0) 1.5 (0.6 to 3.4) 1.4 (0.6 to 3.2) 1.2 (0.5 to 2.8) Reference

15. Comparison with HEDIS Medicare Tayside (aged >65) HEDIS Medicare mean (90 th centile) GHB recorded 12 months 96%87% (95%) GHB>9% 13%27% (10%) Lipid screening 24 months 99% 85% Retinal screening78% 62% BP<130/8021% 30% BP<140/9041% 58%