Download QoF presentation from SAPC Dublin

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
Centre for Academic Primary Care
Severe Mental Illness
• e.g. schizophrenia, bipolar affective disorder
• Premature morbidity and mortality
– Life expectancy 12 years less
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Quality & Outcomes Framework
• Introduced 2004
• Primary care “payment for performance”
• Incentivises annual review
– 2004 to 2011, unspecified
– 2011 to 2014, cardiovascular specific
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Quality & Outcomes Framework
• Reduces inequalities in CVD risk factor testing
• Unknown
– Impact on recognition of CVD risk factors?
– Management of CVD risk factors?
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• Have QOF indicators
been associated with
improvements in
identification and
management of CV risk
factors in people with
SMI?
Centre for Academic Primary Care
Methods
• CPRD analysis
• UK general practice data
• 7% of population
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Study design
•
•
•
•
•
Retrospective open cohort study
1995 to 2014
Age ≥35 years
Cases with lifetime diagnosis of SMI
Random, unmatched controls (5:1)
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Outcomes
• Diagnosis
– Diabetes
– Hypertension
– Obesity
– Elevated
cholesterol
• Treatment
– Lipid-modifying
medications
– Anti-diabetic
medications
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Interrupted time series analysis
• Segmented logistic regression
• Adjustment for age, gender, practice
• Time periods
– 1995-2003, pre-QOF
– 2004-2011, introduction of QOF
– 2011-2014, change to CV-specific indicators
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Interrupted time series analysis
Intervention 1
↓
↑
Intervention 2
Time
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Results
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Population characteristics
Number
Follow-up
Male
Age (yrs)
1995/6
2004/5
2013/4
Proportion died
SMI cases
67,239
5.3 years
46.6%
63.0
57.6
56.8
20.9%
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Controls
359,951
7.4 years
49.7%
56.0
55.6
56.7
10.8%
Recording elevated cholesterol
37%↑
OR 1.21
(1.10-1.33)
Compared to
non-SMI
p<0.001
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84%↑
Compared to
non-SMI
p<0.001
Case detection of risk factors
Elevated cholesterol
Diabetes
21%↑
37%↑
84%↑
Obesity
Hypertension
21%↑
19%↑
39%↑
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Treatment of risk factors
Anti-diabetic Rx
Lipid-lowering Rx
No association between QOF
and changes in prescribing
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Discussion
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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?
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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
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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
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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?
Centre for Academic Primary Care