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Exclusion of patients from pay-for-performance programmes may widen health inequalities

Public reporting of physician and provider performance has become a key component of strategies to improve the quality of health care. Public reporting of performance is also increasingly being linked to provider pay through pay for performance programmes. Many pay for performance schemes permit physicians to exclude selected patients from performance indicators. For example, the Quality and Outcomes Framework (QOF), a major pay for performance scheme introduced into UK primary care in 2004, permits general practitioners to ‘exception report’ patients using set criteria. The criteria include circumstances where a treatment is not clinically appropriate, e.g. achieving tight blood glucose control in a diabetes patient with terminal cancer, or where a patient refuses to attend a review after three clinic invitations.

In a paper published recently in the Journal Diabetic Medicine, Andrew Dalton and colleagues examined associations between patient and practice characteristics and exclusions from quality indicators for diabetes using data from the first three years of the Quality and Outcomes Framework. They carried out three cross-sectional analyses using data from the electronic medical records of all patients with diabetes registered in 23 general practices in Brent, North West London between 2004/2005 and 2006/2007. They found that excluded patients were less likely to achieve treatment targets for HbA1c, blood pressure and cholesterol control. Black and South Asian patients were more likely to be excluded from the HbA1c indicator than White patients. Patients diagnosed with diabetes duration of > 10 years, those patients with co-morbidities and older patients were also more likely to be excluded. Larger practices also excluded more patients from the HbA1c indicator. More deprived practices consistently excluded more patients from all indicators.

The findings of the study suggest that patients excluded from pay-for-performance programmes may be less likely to achieve treatment goals and disproportionately come from disadvantaged groups. One key implication of these findings is that allowing physicians to exclude patients from pay-for-performance programmes may worsen health inequalities.

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