Background: The Quality and Outcome Framework (QOF) is a major pay for
performance scheme that was introduced in 2004 in the UK. The introduction of
QOF is a unique opportunity to evaluate the impact of pay for performance on
inequalities and in particular on ethnic inequalities. This thesis examines the
impact of QOF on ethnic inequalities and on patients with and without
comorbidities in diabetes management.
Methods: (1) Interrupted time series analysis of electronic medical record data of
diabetes patients registered with 29 family practices in South West London for
the years 2000 to 2007. (2) Cross-sectional study to examine the association
between ethnicity, concordant and discordant comorbidity status and
intermediate outcomes (HbA1c, blood pressure, total cholesterol).
Results: The quality of diabetes care, as measured by the QOF indicators, has
improved substantially throughout the study period, especially for the process
aspect of care. The introduction of QOF was associated with initial additional
improvements in systolic blood pressure in white and black patients but this was
only sustained in black patients. Initial improvements in diastolic blood pressure
in white and in cholesterol in black and white patients were not sustained in the
post-QOF period. There was no beneficial impact of QOF on HbA1c in any
ethnic group. 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.
Conclusion: The QOF scheme did not appear to address important inequalities
in diabetes management over time. Targeted quality improvement strategies
may be required to improve health care in vulnerable populations.