Effect of a UK Pay-for-Performance Program on Ethnic Disparities in Diabetes Outcomes: Interrupted Time Series Analysis

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Abstract
We wanted to examine the long-term effects of the Quality and Outcomes Framework (QOF), a major pay-for-performance program in the United Kingdom, on ethnic disparities in diabetes outcomes. We undertook an interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London, United Kingdom. Main outcome measures were mean hemoglobin A(1c) (HbA(1c)), total cholesterol, and blood pressure. The introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients (annual decrease: -1.68 mm Hg; 95% CI, -2.41 to -0.95 mm Hg). Initial improvements in diastolic blood pressure in white patients (-1.01 mm Hg; 95% CI, -1.79 to -0.24 mm Hg) and in cholesterol in white (-0.13 mmol/L; 95% CI, -0.21 to -0.05 mmol/L) and black (-0.10 mmol/L; 95% CI, -0.20 to -0.01 mmol/L) patients were not sustained in the post-QOF period. There was no beneficial impact of QOF on HbA(1c) in any ethnic group. Existing disparities in risk factor control remained largely intact (for example; mean HbA(1c): white 7.5%, black 7.8%, south Asian 7.8%; P <.05) at the end of the study period. A universal pay-for-performance scheme did not appear to address important disparities in chronic disease management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.

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