investigating the relationship between quality of primary care and premature mortality in england
TRANSCRIPT
-
Investigating the relationship between quality ofprimary care and premature mortality in England
a spatial whole-population study
Evangelos Kontopantelis David Springate Mark AshworthRoger Webb Iain Buchan Tim Doran
Centre for Health Informatics, Institute of Population HealthFaculty of Medicine, University of Manchester
HSCIC public board meeting, 28th January 2015
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 1 / 33
-
Outline
1 Background
2 Methods
3 Findings
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 2 / 33
-
Improving quality of careor quality of recorded care?
A pay-for-performance (p4p) program kicked off in April 2004 withthe introduction of a new GP contract
General practices are rewarded for achieving a set of quality targetsfor patients with chronic conditionsThe aim was to increase overall quality of care and to reducevariation in quality between practices
The incentive scheme for payment of GPs was named the Qualityand Outcomes Framework (QOF)Initial investment estimated at 1.8 bn for 3 years (increasing GPincome by up to 25%)QOF is reviewed at least every two years
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 4 / 33
-
Quality and Outcomes Frameworkdetails for years 1 (2004/5) and 7 (2010/11)
Domains and indicators in year 1 (year 7):Clinical care for 10 (19) chronic diseases, with 76 (80) indicatorsOrganisation of care, with 56 (36) indicatorsAdditional services, with 10 (8) indicatorsPatient experience, with 4 (5) indicators
Implemented simultaneously in all practices (a control group wasout of the question)Into the 11th year now (01Mar14/31Apr15); cost for the first 10years was above the estimate at 10 bn approximately
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 5 / 33
-
Investigated relentlesslyin Manchester and elsewhere
Main driver for complete computerisation in primary careAlthough a voluntary scheme, participation is almost complete andcomputerisation is a prerequisite
Led to improvement in quality more quickly, but the benefitsdiminish over timeReduced inequalities of careLed to some deterioration in unincentivised aspects of careContradictory evidence on its effect on hospital admissions
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 6 / 33
-
But what about harder outcomesnamely, mortality
Aimed to quantify the relationship between performance on theQuality and Outcomes Framework, and:
all cause premature mortalitycause-specific premature mortality linked closely with conditionsincluded in the scheme
No academic access to the practice mortality database
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 7 / 33
-
Design and setting
Design: Longitudinal spatial study, at the Lower Super OutputArea (LSOA) levelSetting: 32482 LSOAs (neighbourhoods of 1500 people onaverage), covering the whole population of England ( 53.5million), from 2007 to 2012Participants: 8647 English general practices participating in theQOF for at least one year of the study period, including over 99%of registered patientsIntervention: National pay-for-performance programmeincentivising performance on over 100 quality-of-care indicators
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 9 / 33
-
Main outcome measures
All-cause mortalityCause-specific mortality rates for six chronic conditions:
diabetesheart failurehypertensionischaemic heart diseasestrokechronic kidney disease
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 10 / 33
-
Generating the outcome variablesusing ONS data
Revised annual LSOA population estimates, 2005-2012:based on 2001 and 2011 census informationbroken down by age and sex
Got annual death counts at the LSOA level, 2005-2012:broken down by age and sex
Calculated annual and 2-year age and sex standardised mortalityrates at the LSOA level:
all-causecause-specific
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 11 / 33
-
Other dataand sources
LSOA levelIndex of Multiple Deprivation, 2007 and 2010 (ONS neighbourhoodstatistics)Rural vs urban (ONS neighbourhood statistics)Lots of collinear 2011 census variables (ONS census)
At the practice level (to be attributed to the LSOA level)QOF performance (HSCIC)QOF disease burden (HSCIC)practice list size (HSCIC)
Spatial shapefile data maps (ONS Geoportal)
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 12 / 33
-
Spatial estimationfirst approach: complete local attendance
32482 English LSOAs with complete census, rurality anddeprivation data 6500 practice-hub LSOAs (at least one practice)QOF achievement and morbidity burden calculated as sum of allnumerators over sum of all practice denominatorsGet longitude-latitude centroid coordinates for all LSOAsQOF achievement and morbidity scores estimated for the LSOAswith no practices as weighted means from the 5 closest hubs (oninverse distance listsize)
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 13 / 33
-
Spatial estimationfirst approach: complete local attendance
Bolton Bury
Manchester
Oldham
Rochdale
Salford
Stockport
Tameside
Trafford
Wigan
(87.0,91.2](84.6,87.0](82.1,84.6][66.2,82.1]No data
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 14 / 33
-
Spatial estimationfirst approach: complete local attendance
001A
001B
001C
001D 001E
002A002B
002C002D
003A
003B
003C
004A
004B
004C004D
005A
005B
005C
005D
006A
006B006C 006D
007A007B
007C 007D007E
007F
008A 008B
008C
008D
009A 009B
009C
009D
010A010B
010C
010D
011A
011B011C
011D
012A
012B
012C012D
012E012F
013A 013B
013C
013D013E
013F
013G 014A
014B
014C
014D
014E014F
015A
015B
015C015D
016A
016B
016C016D016E
016F017A
017B017C
017D
017E
018A
018B
018C
018D019A
019B019C
019D
019E
020A020B
020C020D
020E020F020G
021A
021B
021C
021D
021E
021F
021G022A
022B
022C
022D
023A023B
023C023D
024A
024B
024C
024D
025A025B025C
025D
026A
026B026C026D
027A
027B
027C
027D
028A 028B
028C028D
029A
029B
029C
029D
029E
029F029G
030A
030B
030C
030D
030E
030F
(87.0,91.2](84.6,87.0](82.1,84.6][66.2,82.1]No data
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 15 / 33
-
Spatial estimationfirst approach: complete local attendance
007B
009C014B014E
020B020G
(87.0,91.2](84.6,87.0](82.1,84.6][66.2,82.1]No data
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 16 / 33
-
Spatial estimationsecond approach: attribution dataset
Complete local attendance assumption difficult to justify for allpatients in all areas, especially urbanHSCIC released information on the attribution of general practicepopulations to LSOAs and vice versaOnly covered 2014 but used it as a blueprint to generate annualattribution datasets from 2011/12 to 2006/7
Poisson and negative binomial regression modelsattributed population over time was adjusted for practice list size inthe respective year
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 17 / 33
-
Analyses
Three sets of multiple linear regressions used to investigate therelationship between QOF quality of care and all-cause andcondition specific mortality:
relationship between QOF scores and 2011-12 SMRsrelationship between changes in QOF scores over a 3 or 5-yearperiod and 2011-12 SMRssensitivity analysis, relationship between QOF quality of care andmortality over time
Following spatial weighted estimation data were complete for all32482 English 2001 LSOAsEach analysis set was applied to both spatial weighted estimationapproaches
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 18 / 33
-
Mortalityby region
North East North West Yorkshire & East MidlandWest MidlanEast EnglandLondon South East South Centr South West EnglandAll-cause death% (2011-12) 1.09 1.05 1.01 0.96 0.98 0.91 0.74 0.93 0.87 0.96 0.94Condition-specific death% (2011-12) 0.39 0.4 0.4 0.39 0.38 0.38 0.24 0.37 0.33 0.4 0.36
0 0.2 0.4 0.6 0.8 1 1.2
North East
North West
Yorkshire & Humber
East Midlands
West Midlands
East England
London
South East
South Central
South West Coast
England
Condition-specific death% (2011-12) All-cause death% (2011-12)
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 20 / 33
-
Standardised mortality ratesby region
North East North West Yorkshire & East MidlandWest MidlanEast EnglandLondon South East South Centr South West EnglandAll-cause SMR (2011-12) 574 580 541 508 528 466 563 456 482 448 513Condition-specific SMR (2011-12) 184 198 194 184 184 167 166 154 155 158 175
0 100 200 300 400 500 600 700
North East
North West
Yorkshire & Humber
East Midlands
West Midlands
East England
London
South East
South Central
South West Coast
England
Condition-specific SMR (2011-12) All-cause SMR (2011-12)
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 21 / 33
-
Overall health burdenGreater London
(1.8,3.9](1.6,1.8](1.4,1.6][0.4,1.4]
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 22 / 33
-
Overall quality of care (PA)Greater London
(83.8,90.9](82.5,83.8](81.1,82.5][68.7,81.1]
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 23 / 33
-
Overall health burdenGreater Manchester
(2.2,2.5](2.0,2.2](1.9,2.0][1.0,1.9]
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 24 / 33
-
Overall quality of care (PA)Greater Manchester
(84.9,89.8](83.6,84.9](82.1,83.6][73.6,82.1]
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 25 / 33
-
Overall health burdenWest Midlands
(2.2,2.7](2.1,2.2](1.9,2.1][0.7,1.9]
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 26 / 33
-
Overall quality of care (PA)West Midlands
(84.4,88.3](83.4,84.4](82.4,83.4][77.5,82.4]
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 27 / 33
-
Spatial analyseson all-cause SMRs
QOF Year 8 (2011/12)* QOF Year 7 (2010/11)* QOF Year 6 (2009/10)* QOF Year 5 (2008/9)* Outcome: all cause SMR; QOF predictors: overall population achievement, overall morbidity load Index of Multiple Deprivation 2010
7.44(7.24,7.65)
-
Spatial analyseson cause-specific SMRs
QOF Year 8 (2011/12)* QOF Year 7 (2010/11)* QOF Year 6 (2009/10)* QOF Year 5 (2008/9)* Outcome: condition specific SMR; QOF predictors: nine indicator outcome population achievement, five domains morbidity load Index of Multiple Deprivation 2010
2.41(2.27,2.55)
-
Spatial analysessummary of results
All-cause and cause-specific mortality rates declined over thestudy periodHigher mortality associated with:
greater area deprivationurban locationproportion of a non-white population
No relationship between practice performance on QOF qualityindicators and all-cause or cause-specific mortality rates in thepractice locality
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 30 / 33
-
Conclusions
Higher reported achievement of activities, incentivised under amajor, nationwide pay-for-performance programme for primarycare, did not appear to result in reduced incidence of prematuredeath in the population
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 31 / 33
-
Future workcomplex methods that need to be re-used to answer more questions
Spatial analysis linking pollution, smoking, BMI, IMD and othercensus variables to:
all deathscancer related deaths
Spatial analysis linking QOF, distance to practice, patientsatisfaction, IMD (except health sub-domain) to:
standardised all hospital admissionsstandardised emergency hospital admissions
Structural equation modelling (SEM) to investigate IMD subscaleson all-cause mortality at the population levelSEM to investigate obesity at the population level
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 32 / 33
-
Heal
th S
cien
ces P
rimar
y Ca
re R
esea
rch
Grou
p
[Poster title]
ABSTRACT TITLE: [Add text here.]
BACKGROUND: [Add text here.]
OBJECTIVE: [Add text here.]
METHODS: [Add text here.]
RESULTS: [Add text here.]
CONCLUSIONS: [Add text here.]
BACKGROUND [Add title, if necessary.]
Label One
Label Two
Label Three
Label Four
[Replace the following names and titles with those of the actual contributors: Helge Hoeing, PhD1; Carol Philips, PhD2; Jonathan Haas, RN, BSN, MHA3, and Kimberly B. Zimmerman, MD4 1[Add affiliation for first contributor], 2[Add affiliation for second contributor], 3[Add affiliation for third contributor], 4[Add affiliation for fourth contributor]
OBJECTIVE
[Repeat objective from above.]
METHODS
[Add title, if necessary.]
[Add key point.] [Add description of key point.]
[Add key point.] [Add description of key point.]
[Add key point.] [Add description of key point.]
[Add title, if necessary.]
[Add key point.] [Sub-bullet] [Sub-bullet]
[Add key point.] [Sub-bullet] [Sub-bullet]
[Add title, if necessary.]
[Add key point.] [Sub-bullet] [Sub-bullet]
[Add key point.] [Sub-bullet] [Sub-bullet]
RESULTS
[Add title, if necessary.]
[Add key point.] [Add key point.] [Add key point.] [Add key point.] [Add key point.]
CONCLUSIONS
[Add text as bulleted list or a paragraph.] [Add key point.]
[Add key point.]
[Add key point.]
[Add key point.]
[Add key point.]
[Graphic title]
RESULTS
[Graphic title] [Graphic title]
0% 20% 40% 60% 80% 100%
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
0% 20% 40% 60% 80% 100%
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
0% 20% 40% 60% 80% 100%
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
[Replace, move, resize, or delete graphic, as necessary.]
[Replace, move, resize, or delete graphic, as necessary.]
[Replace, move, resize, or delete graphic, as necessary.] [Replace, move, resize, or delete graphic, as necessary.]
For additional information please contact: [Name] [Department] [Institution or organization] [E-mail address]
Excepteur Sint Lkl
(n=212) Controls
(n=27)
Lorum Wt (kg) 18 (SD 10) 29 (SD 07)
Ipsum (wk) 31 (SD 5) 37 (SD 2)
Irure: B W H HB O
Unknown
79 (373%) 121 (571%)
2 (09%) 0
1 (05%) 9 (42%)
7 (259%) 18 (667%)
0 1 (37%) 1 (37%)
0
Proident F
Lorem
106 (50%) 101 (476%)
5 (24%)
17 (63%) 10 (37%)
Nostrud: N Y
Unknown
172 (811%) 22 (104%) 18 (85%)
26 (963%) 0
1 (37%)
[Add title, if necessary.]
[Add key point.] [Sub-bullet] [Sub-bullet]
[Add key point.] [Sub-bullet] [Sub-bullet]
[Add title, if necessary.]
[Add key point.] [Sub-bullet] [Sub-bullet]
[Add key point.] [Sub-bullet] [Sub-bullet]
Kontopantelis E, Springate DA, Ashworth M, Webb RT, Buchan IE and Doran T.Investigating the relationship between quality of primary care and prematuremortality in England: a spatial whole-population study. BMJ, in print
Comments, suggestions: [email protected]
Kontopantelis (University of Manchester) quality of primary care & mortality 28 Jan 2015 33 / 33
BackgroundMethodsFindingsAppendix