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

BMJ 2009; 338 doi: (Published 27 May 2009) Cite this as: BMJ 2009;338:b1870

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  1. Melanie Calvert, senior lecturer1,
  2. Aparna Shankar, research fellow2,
  3. Richard J McManus, clinical senior lecturer1,
  4. Helen Lester, professor of primary care3,
  5. Nick Freemantle, professor of clinical epidemiology and biostatistics1
  1. 1Department of Primary Care and General Practice, University of Birmingham, Edgbaston, Birmingham B15 2TT
  2. 2Department of Epidemiology and Public Health, University College London
  3. 3National Primary Care Research and Development Centre, University of Manchester
  1. Correspondence to: M Calvert m.calvert{at}
  • Accepted 28 January 2009


Objectives To examine the management of diabetes between 2001 and 2007 in the United Kingdom and to assess whether changes in the quality of care reflect existing temporal trends or are a direct result of the implementation of the quality and outcomes framework.

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 attainment of process and clinical outcomes over the three years before and the three years after the introduction of the quality and outcomes framework.

Results Significant improvements in process and intermediate outcome measures were observed during the six year period, with consecutive annual improvements observed before the introduction of incentives. However, the current diagnostic case definition for the quality and outcomes framework does not capture up to two thirds of people with type 1 diabetes and a third of people with type 2 diabetes. After the introduction of the quality and outcomes framework, existing trends of improvement in glycaemic control, cholesterol levels, and blood pressure were attenuated, particularly in people with diabetes who did not meet the case definition of the quality and outcomes framework. The introduction of the quality and outcomes framework did not lead to improvement in the management of patients with type 1 diabetes, nor to a reduction in the number of patients with type 2 diabetes who had HbA1c levels greater than 10%. Introduction of the quality and outcomes framework may have increased the number of patients with type 2 diabetes with HbA1c 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 improved since the late 1990s, but the impact of the quality and outcomes framework on care is not straightforward; upper thresholds may need to be removed or targets made more challenging if people are to benefit. Many patients in whom care may be suboptimal may not be captured in the quality and outcomes framework assessment.


  • Contributors: MJC, AS, and NF conceived the study and did the data analyses. HL and RJM contributed to the design and analysis plan. MJC and AS wrote the first draft of the paper. All authors contributed to writing the manuscript and approved the final version. MJC is the guarantor.

  • Funding: This study was sponsored by Pfizer. Analyses and interpretation were done independently of the sponsor. RJM was supported by a national primary care postdoctoral award 2005-7.

  • Competing interests: MJC, AS, RJM, and NF have received funding for research, consulting, and travel from several companies that manufacture therapies for diabetes.

  • Ethical approval: This study went through our formal institutional review process and it was agreed that no further ethical review was required.

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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