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Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h904 (Published 02 March 2015) Cite this as: BMJ 2015;350:h904

Re: Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Although Kontopantelis et al have found no relationship between recorded practice performance under QOF and premature death rates, we are not convinced that it should lead to the conclusion that improvements in healthcare, as measured through QOF, have no impact on population health. We have completed cross-sectional studies of premature CHD mortality with a sample of practices1,2; and two studies at primary care trust level of all-age mortality3,4 for all England, and found that some clinical management variables do explain variations in both premature (i.e. under age 75) and all-age mortality. Furthermore, better detection of hypertension was associated with lower mortality from stroke and coronary heart disease, that is, the more patients on practice hypertension registers, the lower the mortality, drawing attention to the need to provide care for the whole practice population in order to improve population health.

In addition to the points raised by others in their responses to the paper, we would challenge whether the selection and aggregation of QOF indicators by Kontopantelis et al is the most useful approach. Individual QOF indicators and combined scores related to the cause of death have been shown to be related to both all-age and premature mortality1-5. However, the relevance of the combined indicators to the specific causes of disease considered in the paper is not clear, and the consideration of QOF indicators which focus on hypertension management in specific disease groups rather than on the numbers of patients on hypertension registers ignores general practice’s important role in primary prevention. We do not understand why a measure of smoking prevalence was not included.2

Finally, we could not see a clear definition of premature mortality in the paper.

1. Honeyford K, Baker R, Bankart MJG, Jones DR. Modelling factors in primary care quality improvement: a cross-sectional study of premature CHD mortality. BMJ Open2013;3:e003391 doi:10.1136/bmjopen-2013-003391
2. Honeyford K, Baker R, Bankart MJG, Jones DR . Estimating smoking prevalence in general practice using data from the Quality and Outcomes Framework (QOF). BMJ Open2014;4:e005217 doi:10.1136/bmjopen-2014-005217
3. Levene LS, Baker R, Bankart MJG, Khunti K. Association of Features of Primary Health Care with Coronary Heart Disease Mortality. JAMA 2010;304(18):2028-2034.
4. Levene LS, Bankart J, Khunti K, Baker R. Association of Primary Care Characteristics with variations in mortality rates in England: An Observational Study. PLoS ONE 2012. 7(10): e47800. doi:10.1371/journal.pone.0047800
5. Kiran T, Hutchings A, Dhalla IA, et al.. The association between cardiovascular outcomes: a cross-sectional study using data from the UK Quality and Outcomes Framework. J Epidemiol Community Health 2010;64:927–34

Competing interests: No competing interests

13 March 2015
Kate E Honeyford
Research Associate
Dr LS Levene, General Practice Principal, Leicester and Honorary Clinical Fellow, University of Leicester and Professor Richard Baker, University of Leiceser
University of Leicester
Department of Health Sciences, University of Leicester, 22-28 Princess Road West, Leicester, LE1 6TP