Department of Primary Care and Public Health, Faculty of Medicine, Imperial College, London, UK.
Diabet Med. 2011 May;28(5):525-31. doi: 10.1111/j.1464-5491.2011.03251.x.
We examined associations between patient and practice characteristics and exclusions from quality indicators for diabetes during the first 3 years of the Quality and Outcomes Framework, a major pay-for-performance scheme in the UK.
Three cross-sectional analyses, conducted using data from the electronic medical records of all patients with diabetes registered in 23 general practices in Brent, North West London between 2004/2005 and 2006/2007. Patterns of exclusions were examined for three intermediate outcome indicators.
Excluded patients were less likely to achieve treatment targets for HbA(1c) (2004/2005, 2006/2007), blood pressure (2005/2006, 2006/2007) and cholesterol (2005/2006). Black and South Asian patients were more likely to be excluded from the HbA(1c) indicator than White patients [adjusted odds ratio = 1.64 (1.17-2.29) in 2005/2006]. Patients diagnosed with diabetes duration of > 10 years [adjusted odds ratio = 2.01 (1.65-2.45) for HbA(1c) in 2006-2007] and those with co-morbidities (adjusted odds ratio, ≥ 3 co-morbidities compared with no co-morbidity for HbA(1c) adjusted odds ratio = 1.90 (1.24-2.90) in 2004/2005] were more likely to be excluded. Larger practices excluded more patients from the HbA(1c) indicator [adjusted odds ratio, practice ≥ 7000 compared with < 3000, 3.52 (2.35-5.27) in 2005-2006]. More deprived practices consistently excluded more patients from all indicators, whilst in 2007 older patients were excluded to a larger degree [adjusted odds ratio = 2.52 (1.21-5.28) ≥ 75 compared with 18-44 for blood pressure control].
Patients excluded from pay-for-performance programmes may be less likely to achieve treatment goals and disproportionately come from disadvantaged groups. Permitting physicians to exclude patients from pay-for-performance programmes may worsen health disparities.
我们研究了在英国主要的按绩效付费计划（Quality and Outcomes Framework，QOF）实施的头 3 年中，患者和实践特征与糖尿病质量指标排除之间的关联。
使用 2004/2005 年至 2006/2007 年间，伦敦西北部布伦特 23 家普通实践电子病历中所有糖尿病患者的数据，进行了 3 项横断面分析。检查了 3 项中间结局指标的排除模式。
排除的患者实现糖化血红蛋白（HbA1c）[2004/2005 年，2006/2007 年]、血压[2005/2006 年，2006/2007 年]和胆固醇[2005/2006 年]治疗目标的可能性较低。黑人和南亚患者被排除在 HbA1c 指标之外的可能性大于白人患者[2005/2006 年，调整后的比值比为 1.64（1.17-2.29）]。诊断患有糖尿病病程>10 年的患者[HbA1c 调整后的比值比，2006-2007 年，2.01（1.65-2.45）]和伴有合并症的患者（HbA1c 调整后的比值比，与无合并症相比，合并症≥3 种，2004/2005 年，1.90（1.24-2.90）]更有可能被排除在外。更大的实践排除了更多患者的 HbA1c 指标[2005/2006 年，实践人数≥7000 与<3000 相比，调整后的比值比为 3.52（2.35-5.27）]。更贫困的实践始终排除了所有指标的更多患者，而在 2007 年，年龄较大的患者被排除的程度更大[调整后的比值比，2007 年，≥75 岁与 18-44 岁相比，血压控制为 2.52（1.21-5.28）]。
从按绩效付费计划中排除的患者可能不太可能实现治疗目标，并且不成比例地来自弱势群体。允许医生将患者从按绩效付费计划中排除可能会加剧健康差距。
