Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study

doi:10.1136/bmj.b1870

Published 27 May 2009, doi:10.1136/bmj.b1870
Cite this as: BMJ 2009;338:b1870

Research

Effect of the quality and outcomes framework on diabetes care in the United Kingdom: retrospective cohort study

Melanie Calvert, senior lecturer¹, Aparna Shankar, research fellow², Richard J McManus, clinical senior lecturer¹, Helen Lester, professor of primary care³, Nick Freemantle, professor of clinical epidemiology and biostatistics¹

¹ Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham B15 2TT, ² Department of Epidemiology and Public Health, University College London, ³ National Primary Care Research and Development Centre, University of Manchester

Correspondence to: M Calvert m.calvert{at}bham.ac.uk

Objectives To examine the management of diabetes between 2001and 2007 in the United Kingdom and to assess whether changesin the quality of care reflect existing temporal trends or area direct result of the implementation of the quality and outcomesframework.

Design Retrospective cohort study.

Setting 147 general practices (annual list size over 1 million)across the UK.

Patients People with type 1 or type 2 diabetes.

Main outcome measures Annual prevalence of diabetes and attainmentof process and clinical outcomes over the three years beforeand the three years after the introduction of the quality andoutcomes framework.

Results Significant improvements in process and intermediateoutcome measures were observed during the six year period, withconsecutive annual improvements observed before the introductionof incentives. However, the current diagnostic case definitionfor the quality and outcomes framework does not capture up totwo thirds of people with type 1 diabetes and a third of peoplewith type 2 diabetes. After the introduction of the qualityand outcomes framework, existing trends of improvement in glycaemiccontrol, cholesterol levels, and blood pressure were attenuated,particularly in people with diabetes who did not meet the casedefinition of the quality and outcomes framework. The introductionof the quality and outcomes framework did not lead to improvementin the management of patients with type 1 diabetes, nor to areduction in the number of patients with type 2 diabetes whohad HbA_1c levels greater than 10%. Introduction of the qualityand outcomes framework may have increased the number of patientswith type 2 diabetes with HbA_1c levels of $≤$ 7.5%; odds ratio 1.05(95% confidence interval 1.01 to 1.09; P=0.02).

Conclusions The management of people with diabetes has improvedsince the late 1990s, but the impact of the quality and outcomesframework on care is not straightforward; upper thresholds mayneed to be removed or targets made more challenging if peopleare to benefit. Many patients in whom care may be suboptimalmay not be captured in the quality and outcomes framework assessment.

© Calvert et al 2009
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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