Family Practice Advance Access originally published online on January 24, 2008
Family Practice 2008 25(1):33-39; doi:10.1093/fampra/cmm073
The effect of the UK incentive-based contract on the management of patients with coronary heart disease in primary care
a Department of General Practice & Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY
b Department of Public Health, School of Medicine, University of Aberdeen, Polwarth Building, Aberdeen AB25 2ZD
c Department of Clinical Pharmacology, Grampian Universities Trust, Foresterhill, Aberdeen AB25 2ZN, UK
Correspondence to Matt P McGovern, Department of General Practice & Primary Care, University of Aberdeen, Foresterhill Health Centre, Westburn Road, Aberdeen AB25 2AY, UK; Email mattmcgovern{at}abdn.ac.uk
Received 1 May 2007; Revised 26 September 2007; Accepted 1 November 2007.
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Abstract |
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Background. The new General Medical Services (nGMS) contract was introduced in April 2004 to improve care of chronic diseases such as coronary heart disease (CHD) and reduce differences in treatment between patient subgroups.
Objective. To determine whether the recording of CHD-related health indicators and prescribing of medicines have increased following the introduction of the nGMS contract and whether differences in the treatment of patients of differing age, gender and deprivation have been affected.
Methods. A serial cross-sectional study carried out with 310 general practices in Scotland. The subjects were patients with CHD as identified by their GP. Main outcome measures were the recording of CHD-related health indicators and prescribing of medicines at pre- and post-contract time points (covariates: gender, age, co-morbidity, deprivation and practice size).
Results. The recording of CHD-related quality indicators and prescribing increased dramatically (mean absolute increase of 17.1%) after the introduction of the nGMS contract. Post-contract, disparities between patient subgroups, continued for certain components of care. Women were less likely to be recorded than men in 9 of 11 components of care, with older patients (7 of 11 components of care) and the most deprived (4 of 11 components of care) also less likely to have a record than the youngest and least deprived, respectively.
Conclusion. The introduction of the new contract was associated with a dramatic rise in the recording of CHD-related quality indicators. However, not all the population benefited equally for certain aspects of care.
Keywords. Chronic disease management, epidemiology, health informatics, health service management, prescribing.
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Introduction |
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On April 1, 2004, the Quality and Outcomes Framework (QOF), an evidence-based new General Medical Services (nGMS) contract, was introduced to UK general practice. This increased the proportion of income GPs are able to earn (approximately 23% of total income) from targeted quality care.1 For example, the contract provides payments to practices with an accurate register of patients who have coronary heart disease (CHD) (a prerequisite for monitoring patients) and for the recording of the smoking habits, blood pressure and cholesterol levels of these patients. Further payments are made for reaching a number of treatment targets, for example, a specific level of blood pressure control and for the prescription of certain medicines.
Previous studies of general practice in the UK have found that women and the elderly with CHD were less likely to receive coronary revascularization than men and younger CHD patients.2 However, no such correlation between deprivation and the delivery of high-quality care has been found.3 Indeed, the prescribing of lipid-lowering therapy has been found to be more prevalent in more deprived regions of England,4 although deprived patients were less likely to be referred for related treatments such as angiography5 and revascularization6 and to be prescribed statins.7 Recent work has found that smaller practice size was associated with relatively poor performance under the nGMS contract.8,9
Although few evaluations of incentive systems have been conducted,10 a recent study of chronic disease care carried out in New York, USA, suggested that financial incentives for primary care physicians lead to improvements in the objective quality of care measures.11 Substantial improvements have also been seen in the quality of care provided by general practices for asthma, CHD and type 2 diabetes as a result of systematic quality improvement initiatives in the UK.12
The recording of quality indicators is intended to be based on the presence of disease rather than the age, gender or deprivation characteristics of the individuals served. In a previous paper, we observed improvements in the recording of stroke-related quality measures after the introduction of the new contract, although the improvements were not enjoyed equally by all parts of the population.13 We have also found that in 55 Scottish practices, the secondary prevention of patients with CHD varied among different subgroups.14 For example, women and younger patients were less likely to receive statins than men and older patients. These patterns were observed over a number of years between 1997 and 2002, with little evidence of improvement over time. We hypothesized that the introduction of a more target-based contract, with strong incentives to provide care among all groups, would improve overall care and diminish gender, age and deprivation differences in patients with CHD.
Methods
In April 2000, the Primary Care Clinical Informatics Unit (PCCIU) was created as part of a national primary care initiative. It provides informatics support for the Scottish Programme for Improving Clinical Effectiveness (SPICE), part of a Clinical Effectiveness Programme developed by the Royal College of General Practitioners (Scotland).15 PCCIU's aim is to help GPs understand their clinical information needs through a variety of feedback reports based on data extraction from their practice. As part of the SPICE programme, data entry templates were developed for use by clinicians to systematically record data about a number of chronic conditions including CHD. From 2003 onwards these templates were modified to include all information required for the new contract. Diagnostic criteria are not specified. Instead, clinical diagnoses are those recorded through routine practice, which, for major conditions like CHD, is often after investigation and input from hospital-based specialist colleagues.
Anonymized retrospective data from all 310 of the 850 Scottish practices who use the general practice administrative software system (GPASS) and who participate in SPICE were obtained in November 2005. The completeness and accuracy of morbidity and repeat prescribing data in GPASS practices have been reported previously.16
From the accumulated data, we identified everyone who had a computer record of CHD (G3 to G3401, G342 to G366 and G38 to G3z) on March 31, 2004 (designated ‘pre-contract’ as the nGMS was introduced on April 1, 2004; total population at risk 1 806 266 registered patients) and March 31, 2005 (1 year after the introduction of the new contract; designated ‘post-contract’ 1 775 397 patients).
The key characteristics of each identified person at each time point were determined: gender, age (<64, 65–75 or >75 years), number of CHD-related co-morbidities (0, 1, 2 or 3+) [diabetes (C10 and below), hypertension (G2 ..., G20 and below, G24 to G2z), atrial fibrillation (G573 and below), stroke or transient ischaemic attack (G65 to G654, G656 to G65zz, G61 below, not G617, G66 and below, G63y0-1, G6760, G6w, G6x, G64 and below), heart failure (G58 and below) and peripheral vascular disease (G73 and below)], deprivation status (deprivation quintile 1—most affluent, to 5—most deprived, based on Carstair's DEPCAT postcode categorization which uses as indicators of poverty: household overcrowding, unemployment, social class and proportion of all persons in private households with no car)17 and practice size (five groups based on the number of patients registered with each practice).8
We then determined the time periods of analysis (e.g. 15 months) and the recording of CHD-related quality indicators as defined in the new contract (Appendix) including the following: whether the person's computer records contained details about the CHD diagnosis and care; referral for an exercise test and/or specialist assessment; recording of smoking status and (where appropriate) provision of smoking cessation advice; measurement and (where appropriate) control of cholesterol and blood pressure; GPASS prescribing of antiplatelet (in addition to a coded recording for over-the-counter aspirin), anticoagulant, β-blocker therapy or angiotensin-converting enzyme (ACE) inhibitor (including angiotensin-II receptor antagonist) therapy for patients with a recent myocardial infarction; and provision of influenza vaccination. We determined these quality indicators both preceding (March 2004; defined as pre-contract) and following (March 2005; defined as post-contract) the introduction of the nGMS contract. If more than one entry existed for a particular item, we used the most recent entry.
We excluded from all analyses individuals with an ‘exception code’, which records that the person has refused follow-up or been considered unsuitable to have any of the CHD-related quality indicators measured. Individuals were also excluded from particular analyses if they had an exception code pertaining to a particular quality indicator, e.g. for aspirin treatment, if there was a recorded contraindication or allergy to this medicine.
Statistical analysis
A binary logistic regression model was used to determine the differences between the recording of quality indicators before and after the introduction of the nGMS contract. The covariates (the independent variables) in the logistic model were gender, age, CHD-related co-morbidities, deprivation categories and practice size. The coefficients of the independent variables are presented as odds ratios (ORs) and 95% confidence intervals. Adjustment was made to take into account the clustering of patients within practices. Patients with missing data (e.g. smoking status) were excluded from the analysis of that factor. Where appropriate, chi-square tests were used to compare differences between groups. For clarity, all proportions are presented to one decimal place and ORs to two decimal places. All analyses were performed using SPSS for Windows 14.0 (SPSS Inc, Chicago, IL) and STATA 9.2 (StataCorp, College Station, TX).
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Results |
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Pre-contract (as at March 31, 2004), 3.7% of patients over the age 16 years (58 406 of the 1 578 902 registered individuals) had a computer record of CHD. Forty-eight patients had a computer record of an exception code. Post-contract (as at March 31, 2005), 4.9% of patients over the age 16 years (75 495 of the 1 533 802 registered individuals) had a computer record of CHD. A total of 3083 patients had a computer record of an exception code.
Characteristics of the patients
There were a greater proportion of male, younger and more deprived patients with CHD post-contract compared with pre-contract (Table 1). CHD patients pre- and post-contract were more likely to be registered with larger practices and in the post-contract dataset were also more likely to have co-morbidity recorded. Men, the oldest and the most deprived patients, were more likely to have three or more co-morbidities recorded than women, the youngest and the least deprived patients (men: n = 2621, 16.1%; women: n = 2159, 13.4%), (>75 years: n = 2647, 17.6%; <65 years: n = 634, 8.0%) (deprivation quintile 5: n = 749, 16.0%; deprivation quintile 1: n = 850, 13.3%).
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In the post-contract dataset, men were more likely to have a CHD-related co-morbidity of atrial fibrillation, diabetes, heart failure or peripheral vascular disease, but less likely to have hypertension, than women (Table 2). In the post-contract dataset, the oldest patients were more likely than the youngest patients to have a recorded diagnosis of all the co-morbidities analysed, except diabetes. The most deprived patients were more likely than least deprived individuals to have diabetes, heart failure, peripheral vascular disease or stroke.
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Recording of quality indicators
Overall, the recording of quality indicators in patients with a history of CHD increased after the introduction of the nGMS contract. The quality indicators with the largest increases were the recording of cholesterol (absolute increase 41.7%) smoking status (26.2%), and the prescribing of β-blockers (27.4%) and antiplatelet or anticoagulant therapy (24.5%) (Table 3).
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Gender differences
Post-contract, women with a history of CHD were less likely than men to be referred for an exercise test and/or specialist assessment after angina is first diagnosed, have blood pressure recorded and controlled, have cholesterol recorded and controlled, be prescribed an anticoagulant, β-blocker or ACE inhibitor therapy or receive an influenza vaccination (even after adjustment for age, number of CHD-related co-morbidities and deprivation, Table 4). However, women who smoke were more likely to receive smoking cessation advice.
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Age differences
Post-contract, the oldest patients (75+) were less likely than the youngest patients (under 65) to have a referral for an exercise test and/or specialist assessment after a new diagnosis of angina, receive smoking cessation advice, have a record of β-blocker or ACE inhibitor therapy and have a record of blood pressure or cholesterol measurement. The oldest group of patients were also less likely to have achieved blood pressure control. However, these patients were more likely to have their cholesterol levels controlled and to receive an influenza vaccination.
Deprivation differences
Post-contract, the most deprived patients were more likely to receive antiplatelet/anticoagulant or ACE inhibitor therapy than the least deprived. However, the most deprived patients were less likely to have smoking status recorded. The most deprived were also less likely to have their blood pressure measured, receive β-blocker therapy or an influenza vaccination.
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Discussion |
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After the implementation of the new contract, there was a large increase in the number of patients recorded with a diagnosis of CHD. Although details of the criteria used to make the diagnosis were not specifically recorded, this increase was probably the result of financial incentives for primary care practices to have accurate disease registers. Also, opportunities were introduced for practices wishing to code patients who are contraindicated treatment or who are too frail or refuse to have clinical examinations, and this resulted in a substantial increase in the number of patients with these exception codes, although it is unclear as to why any of these contract specific exception codes were utilized pre-contract.
We found that the recording of data relating to the care of patients with CHD increased substantially in Scottish practices after the introduction of the nGMS contract. The most dramatic increase was observed in the measurement of cholesterol levels in all patients with CHD, although this indicator was the most poorly recorded (non-prescription) item pre-contract. However, despite these increases, we found that gender and age disparities for certain components remained post-contract. Previous analyses found no association between socio-economic deprivation and quality of care for CHD patients3; however, we found that the most deprived patients were less likely than the most affluent to have aspects of care such as blood pressure measured and more likely to receive certain secondary preventative therapies.
The 310 SPICE practices used for this study were self-selected. However, the patients registered with these practices have previously been shown to be representative of the Scottish population.18 Although, the long-term nature of the database and its clinical focus help to ensure that initially uncertain events are confirmed or refuted over time, no direct validation of CHD diagnoses and data were undertaken as part of this study. However, with the introduction of the QOF, it was important that high-quality disease registers with accurate data were maintained. In addition, while it was recognized that these may not be 100% accurate, any variation between expected and reported disease prevalence by practices were likely to be assessed by Health Board quality assurance and appraisal teams.19 It is possible that the exclusion of patients with exception codes who are likely to be one particular patient group, e.g. the elderly, might have impacted on our analyses; however, a further analyses, which included these patients, showed little change from existing results. We were unable to control directly for disease severity, although we could allow for differences between groups in a number of other confounders such as age, sex, deprivation, practice size and number of co-morbidities.
The data presented in this study were derived from the electronic recording of quality indicators on general practice computer systems. An unknown amount of the increase in the recording of quality indicators will have occurred because of the transfer of data from paper to electronic patient records (rather than from the provision of additional care), although it seems unlikely that practitioners would have systematically improved their computerized documentation of CHD-related care for only certain groups of patients (e.g. patients over 75). Routine use of the electronic prescribing utility by Scottish practices using GPASS ensured that the recording and reporting of repeat prescribing was both accurate and complete in the period prior to the introduction of the nGMS contract.16 It is therefore likely that any observed increases in the levels of secondary preventative prescribing recorded using the GPASS prescribing utility were likely to be real (with the exception of over-the-counter drugs which are likely to be bought by younger and less deprived patients who are not exempt from prescription charges).
The non-experimental design of the study means that we cannot directly attribute the changes observed to the new contract. Other developments may have also contributed, such as an increased incidence of CHD, although the strong relationship between reaching targets and payment to practices suggests that the new contract was a major driver for the changes.
The rational for the use of the time periods of analysis (e.g. 15 months) was determined by the nGMS contract, when it was introduced and when it had been in place for 12 months. Some overlap in data between the two time periods may have occurred; however, the use of the most recent recording of each quality measure prior to the cut-off date would minimize any overlap. The likely consequence of any overlap would be to underestimate changes in recording of events between the two time periods.
The post-contract prevalence of CHD among the SPICE practices of 4.9% of adults is somewhat lower than the 7.3% estimate (adults over 16 years of age) made by the 2003 Scottish Health Survey.20 However, this was similar to the 4.5% rate found in all Scottish practices participating in the nGMS contract.21 We found similar increases in aspects of care of chronic disease, including improvements in the recording of symptoms, advice and test ordering, which were observed in 41 practices based in six areas of England in 2003.12
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Conclusions |
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Few studies have compared the level of care received by patients with CHD before and after the introduction of the nGMS contract.11 A substantial increase in the use of exception reporting was found; further work should focus on this group of patients. The introduction of the nGMS contract was associated with a dramatic rise in the recording of CHD-related quality indicators. Not all patients with CHD, however, benefited equally from these changes. This has important implications for CHD recurrence and mortality. Strategies are needed at both a national and individual practice level to further improve the care for women, older and more deprived patients with CHD to reduce the burden imposed by this disease on the Scottish community.
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Declaration |
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Funding: Scottish Executive Health Department, University of Aberdeen.
Ethical approval: Ethical approval was not required for this study.
Conflicts of interest: None.
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Appendix |
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Quality indicators for CHD as defined by the nGMS contract
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The contract requires that only patients who smoke are offered smoking cessation advice or referral to a specialist service.
a Each point is worth £124.60 to the practice.
b Points are awarded for attainment of thresholds within this range.
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Notes |
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McGovern MP, Boroujerdi MA, Taylor MW, Williams DJ, Hannaford PC, Lefevre KE and Simpson CR. The effect of the UK incentive based contract on the management of patients with coronary heart disease in primary care. Family Practice 2008; 25: 33–39.
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References |
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1 The NHS Confederation. Investing in General Practice: The New General Medical Services Contract. http://www.bma.org.uk/ap.nsf/content/NewGMSContract. (accessed on October 5, 2005).
2 Shaw M, Maxwell R, Rees K, et al. Gender and age inequity in the provision of coronary revascularisation in England in the 1990s: is it getting better? Soc Sci Med (2004) 59:2499–2507.[CrossRef][Web of Science][Medline]
3 Strong M, Maheswaran R, Radford J. Socioeconomic deprivation, coronary heart disease prevalence and quality of care: a practice-level analysis in Rotherham using data from the new UK general practitioner Quality and Outcomes Framework. J Public Health (2006) 28:39–42.[CrossRef]
4 Ashworth M, Lloyd D, Smith RS, Wagner A, Rowlands G. Social deprivation and statin prescribing: a cross-sectional analysis using data from the new UK general practitioner "Quality and Outcomes Framework". J Public Health (2007) 29:40–47.[CrossRef]
5 MacLeod MCM, Finlayson AR, Pell JP, Findlay IN. Geographic, demographic and socicoeconomic variations in the investigation and management of coronary heart disease in Scotland. Heart (1999) 81:252–256.
6 Hippisley-Cox J, Pringle M. Inequalities in access to coronary angiography and revascularisation: the association of deprivation and location of primary care services. Br J Gen Pract (2000) 50:449–454.[Web of Science][Medline]
7 Ward PR, Noyce PR, St Leger AS. Are GP practice prescribing rates for coronary heart disease drugs equitable? A cross sectional analysis in four primary care trusts in England. J Epidemiol Community Health (2004) 58:89–96.
8 Saxena S, Car J, Eldred D, Soljak M, Majeed A. Practice size, caseload, deprivation and quality of care of patients with coronary heart disease, hypertension and stroke in primary care: national cross-sectional study. BMC Health Serv Res (2007) 7:96.[CrossRef][Medline]
9 Wang Y, O'Donnell CA, Mackay DF, Watt GDM. Practice size and quality attainment under the new GMS contract. Br J Gen Pract (2006) 56:830–835.[Web of Science][Medline]
10 Rosenthal M, Fernandopulle H, Song R, Landon B. Paying for quality: providers incentives for quality improvement. Health Aff (2005) 23:127–141.[CrossRef]
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12 Campbell SM, Roland MO, Middleton E, Reeves D. Improvements in quality of clinical care in English general practice 1998–2003: longitudinal observational study. BMJ (2005) 331:1121–1123.
13 Simpson CR, Hannaford P, Lefevre K, Williams D. Effect of the UK incentive-based contract on the management of patients with stroke in Scottish primary care. Stroke (2006) 37:2354.
14 Simpson CR, Hannaford P, Williams D. Evidence for inequalities in the management of coronary heart disease in Scotland. Heart (2005) 91:630–634.
15 Scottish Clinical Information Management in Primary Care Group. Making IT Work for You. http://www.scimp.scot.nhs.uk/gpg/doc_page65.shtml. (accessed on October 7, 2005).
16 Whitelaw FG, Taylor RJ, Nevin SL, Taylor MW, Milne RM, Watt AH. Completeness and accuracy of morbidity and repeat prescribing records held on general practice computers in Scotland. Br J Gen Pract (1996) 46:181–186.[Web of Science][Medline]
17 Carstairs V, Morris R. Deprivation and Health in Scotland (1991) Aberdeen, UK: Aberdeen University Press.
18 Helms PJ, Ekins-Daukes S, Taylor MW, Simpson CR, McLay JS. Utility of routinely acquired primary care data for paediatric disease epidemiology and pharmacoepidemiology. Br J Clin Pharmacol (2005) 59:331–341.
19 The British Medical Association. The Quality and Outcomes Framework Guidance. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4088693.pdf. (accessed on August 14, 2007).
20 Bromley C, Sproston K, Shelton N. (2005) The Scottish Health Survey. (2003) Volume 1. Edinburgh: HMSO.
21 Information Services Division Scotland. Quality and Outcomes Framework. ISDScotland http://www.isdscotland.org/isd/4897.html. (accessed on January 11, 2007).
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