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Quality of chronic disease care for older people in care homes and the community in a primary care pay for performance system: retrospective study

BMJ 2011; 342 doi: (Published 08 March 2011) Cite this as: BMJ 2011;342:d912
  1. Sunil M Shah, senior lecturer in public health1,
  2. Iain M Carey, research fellow1,
  3. Tess Harris, general practitioner and senior lecturer in primary care1,
  4. Stephen DeWilde, general practitioner and clinical research fellow1,
  5. Derek G Cook, professor of epidemiology1
  1. 1Division of Population Health Sciences and Education, St George’s, University of London, London SW17 0RE, UK
  1. Correspondence to: S M Shah sushah{at}
  • Accepted 29 November 2010


Objective To describe the quality of care for chronic diseases among older people in care homes (nursing and residential) compared with the community in a pay for performance system.

Design Retrospective analysis of The Health Improvement Network (THIN), a large primary care database.

Setting 326 English and Welsh general practices, 2008-9.

Participants 10 387 residents of care homes and 403 259 residents in the community aged 65 to 104 and registered for 90 or more days with their general practitioner.

Main outcome measure 16 process quality indicators for chronic disease management appropriate for vulnerable older people for conditions included in the UK Quality and Outcomes Framework.

Results After adjustment for age, sex, dementia, and length of registration, attainment of quality indicators was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators. The largest differences were for prescribing in heart disease (β blockers in coronary heart disease, relative risk 0.70, 95% confidence interval 0.65 to 0.75) and monitoring of diabetes (retinal screening, 0.75, 0.71 to 0.80). Monitoring hypothyroidism (0.93, 0.90 to 0.95), blood pressure in people with stroke (0.92, 0.90 to 0.95), and electrolytes for those receiving loop diuretics (0.89, 0.87 to 0.92) showed smaller differences. Attainment was lower in nursing homes than in residential homes. Residents of care homes were more likely to be identified by their doctor as unsuitable or non-consenting for all Quality and Outcomes Framework indicators for a condition allowing their exclusion from targets; 33.7% for stroke and 34.5% for diabetes.

Conclusion There is scope for improving the management of chronic diseases in care homes, but high attainment of some indicators shows that pay for performance systems do not invariably disadvantage residents of care homes compared with those living in the community. High use of exception reporting may compromise care for vulnerable patient groups. The Quality and Outcomes Framework, and other pay for performance systems, should monitor attainment and exception reporting in vulnerable populations such as residents of care homes and consider measures that deal with the specific needs of older people.


  • We thank Richard Hubbard, Sarah Lewis, and other colleagues from the Division of Epidemiology and Public Health, University of Nottingham, for their help and advice on the use of THIN data in developing this project.

  • Contributors: SMS conceived the study and led the project. He is guarantor for the paper. IMC undertook the analysis. All authors contributed to the development of the project methodology, interpretation of the results, and drafting of the paper.

  • Funding: This study was funded by a grant from the BUPA Foundation, an independent medical research charity. The funder had no involvement in the study design; collection, analysis, and interpretation of the data; writing of the article; or decision to submit the article for publication.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years; no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved by the South-East Multicentre Research Ethics Committee (reference 08/H1102/33).

  • Data sharing: No additional data available.

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