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. 2015 Mar 2:350:h904.
doi: 10.1136/bmj.h904.

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Evangelos Kontopantelis  1 , David A Springate  2 , Mark Ashworth  3 , Roger T Webb  4 , Iain E Buchan  5 , Tim Doran  6
Affiliations

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Evangelos Kontopantelis et al. BMJ. .

Abstract

Objectives: To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.

Design: Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA).

Setting: 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.

Participants: 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.

Intervention: National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.

Main outcome measures: All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.

Results: All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.

Conclusions: Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.

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Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: EK was partly supported by a NIHR School for Primary Care Research fellowship in primary healthcare; TD was supported by a NIHR Career Development Fellowship. The views expressed are those of the authors and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health. No other relationships or activities could appear to have influenced the submitted work.

Figures

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Fig 1 Spatial weighted estimation method summary and example.
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Fig 2 Complete local attendance spatial maps for morbidity load ML9 (red) and population achievement PAoutx (blue) in Greater London for specific conditions and indicators. ML9 is the sum of QOF registers for nine specific intermediate outcome indicators over the practice list size (blood pressure control for coronary heart disease, chronic kidney disease, diabetes, hypertension, and stroke; cholesterol control for coronary heart disease, diabetes, and stroke; and HbA1c control for diabetes). PAoutx is the aggregate QOF population achievement (that is, numerator over the sum of the denominator and exceptions) across the nine intermediate outcome indicators.
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Fig 3 Complete local attendance spatial maps for morbidity load ML9 (red) and population achievement PAoutx (blue) in Greater Manchester for specific conditions and indicators. ML9 is the sum of QOF registers for nine specific intermediate outcome indicators over the practice list size (blood pressure control for coronary heart disease, chronic kidney disease, diabetes, hypertension, and stroke; cholesterol control for coronary heart disease, diabetes, and stroke; and HbA1c control for diabetes). PAoutx is the aggregate QOF population achievement (that is, numerator over the sum of the denominator and exceptions) across the nine intermediate outcome indicators.
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Fig 4 Complete local attendance spatial maps for morbidity load ML9 (red) and population achievement PAoutx (blue) in the West Midlands for specific conditions and indicators. ML9 is the sum of QOF registers for nine specific intermediate outcome indicators over the practice list size (blood pressure control for coronary heart disease, chronic kidney disease, diabetes, hypertension, and stroke; cholesterol control for coronary heart disease, diabetes, and stroke; and HbA1c control for diabetes). PAoutx is the aggregate QOF population achievement (that is, numerator over the sum of the denominator and exceptions) across the nine intermediate outcome indicators.
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