Pay for performance, inequalities, and diabetes care

Background: The Quality and Outcome Framework (QOF) is a major pay for performance scheme that was introduced in 2004 in the UK. The introduction of QOF is a unique opportunity to evaluate the impact of pay for performance on inequalities and in particular on ethnic inequalities. This thesis examines the impact of QOF on ethnic inequalities and on patients with and without comorbidities in diabetes management. Methods: (1) Interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London for the years 2000 to 2007. (2) Cross-sectional study to examine the association between ethnicity, concordant and discordant comorbidity status and intermediate outcomes (HbA1c, blood pressure, total cholesterol). Results: The quality of diabetes care, as measured by the QOF indicators, has improved substantially throughout the study period, especially for the process aspect of care. The introduction of QOF was associated with initial additional improvements in systolic blood pressure in white and black patients but this was only sustained in black patients. Initial improvements in diastolic blood pressure in white and in cholesterol in black and white patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA1c in any ethnic group. The presence of ≥2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients. Conclusion: The QOF scheme did not appear to address important inequalities in diabetes management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations

Rural and urban differences in health system performance among older Chinese adults : Cross-sectional analysis of a national sample

Background: Despite improvement in health outcomes over the past few decades, China still experiences striking rural-urban health inequalities. There is limited research on the rural-urban differences in health system performance in China. Method: We conducted a cross-sectional analysis to compare health system performance between rural and urban areas in five key domains of the health system: effectiveness, cost, access, patient-centredness and equity, using data from the WHO Study on Global AGEing and adult health (SAGE), China. Multiple logistic and linear regression models were used to assess the first four domains, adjusting for individual characteristics, and a relative index of inequality (RII) was used to measure the equity domain. Findings: Compared to urban areas, rural areas had poorer performance in the management and control of hypertension and diabetes, with more than 50% lower odds of having breast (AOR = 0.44; 95% CI: 0.30, 0.64) and cervical cancer screening (AOR = 0.49; 95% CI: 0.29, 0.83). There was better performance in rural areas in the patient-centredness domain, with more than twice higher odds of getting prompt attention, respect, clarity of the communication with health provider and involvement in decision making of the treatment in inpatient care (AOR = 2.56, 2.15, 2.28, 2.28). Although rural residents incurred relatively less out-of-pocket expenditures (OOPE) for outpatient and inpatient services than urban residents, they were more likely to incur catastrophic expenditures on health (AOR = 1.30; 95% CI 1.16, 1.44). Wealth inequality was found in many indicators related to the effectiveness, costs and access domains in both rural and urban areas. Rural areas had greater inequalities in the management of hypertension and coverage of cervical cancer (RII = 7.45 vs 1.64). Conclusion: Our findings suggest that urban areas have achieved better prevention and management of non-communicable disease than rural areas, but access to healthcare was equivalent. A better understanding of the causes of the observed variations is needed to develop appropriate policy interventions which address these disparities

Pay for performance, inequalities, and diabetes care

Background: The Quality and Outcome Framework (QOF) is a major pay for performance scheme that was introduced in 2004 in the UK. The introduction of QOF is a unique opportunity to evaluate the impact of pay for performance on inequalities and in particular on ethnic inequalities. This thesis examines the impact of QOF on ethnic inequalities and on patients with and without comorbidities in diabetes management. Methods: (1) Interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London for the years 2000 to 2007. (2) Cross-sectional study to examine the association between ethnicity, concordant and discordant comorbidity status and intermediate outcomes (HbA1c, blood pressure, total cholesterol). Results: The quality of diabetes care, as measured by the QOF indicators, has improved substantially throughout the study period, especially for the process aspect of care. The introduction of QOF was associated with initial additional improvements in systolic blood pressure in white and black patients but this was only sustained in black patients. Initial improvements in diastolic blood pressure in white and in cholesterol in black and white patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA1c in any ethnic group. The presence of ≥2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients. Conclusion: The QOF scheme did not appear to address important inequalities in diabetes management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.EThOS - Electronic Theses Online ServiceGBUnited Kingdo