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Impact of Pay for Performance on Disparities in Stroke, Hypertension, and Coronary Heart Disease Management


The Quality and Outcomes Framework (QOF), a pay for performance programme, was introduced into United Kingdom (UK) primary care as part of a new General Practitioner (GP) contract in April 2004. Before the introduction of QOF, most British family doctors were earning a large proportion of their income from capitation payments. This system rewarded family doctors for having a large list of registered patients rather than for the quality of care that they provided.

There is limited definitive information about the impact of the QOF on level disparities in health care. In a study published in the journal PLoS One, John Lee and colleagues from Imperial College London investigated the following research questions: has QOF resulted in a step change in the quality of care for coronary heart disease, stroke and hypertension in white, black and south Asian patients? Has QOF reduced disparities in the quality of care for these conditions between these ethnic groups? Did general practices with different baseline performance respond differently to this programme?

The findings of this study suggest that the implementation of QOF resulted in significant short term improvements in blood pressure control. The magnitude of benefit varied between ethnic groups with a statistically significant short term reduction in systolic BP in white and black but not in south Asian patients with hypertension. Disparities in risk factor control were attenuated only on few measures and largely remained intact at the end of the study period.

The authors concluded that the QOF should set more challenging but achievable targets for general practitioners. Specific targets aimed at reducing ethnic disparities in health care may also be needed.

Figure: Trends in mean total cholesterol in patients with CHD and stroke.

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