Pay for performance and the quality of diabetes management in individuals with and without co-morbid medical conditions

Objective To examine the impact of the Quality and Outcomes Framework, a major pay-for-performance incentive introduced in the UK during 2004, on diabetes management in patients with and without co-morbidity. Design Cohort study comparing actual achievement of treatment targets in 2004 and 2005 with that predicted by the underlying (pre-intervention) trend in diabetes patients with and without co-morbid conditions. Setting A total of 422 general practices participating in the General Practice Research Database. Main outcomes measures Achievement of diabetes treatment targets for blood pressure (< 140/80 mm Hg), HbA1c (<= 70%) and cholesterol (<= 5 mmol/L). Results The percentage of diabetes patients with co-morbidity reaching blood pressure and cholesterol targets exceeded that predicted by the underlying trend during the first two years of pay for performance (by 3.1% [95% Cl 1.1-5.1] for BP and 4.1% [95% Cl 2.2-6.0] for cholesterol among patients with >= 5 co-morbidities in 2005). Similar improvements were evident in patients without co-morbidity, except for cholesterol control in 2004 (-0.2% [95% Cl -1.7-1.4]). The percentage of patients meeting the HbA1c target in the first two years of this program was significantly lower than predicted by the underlying trend in all patients, with the greatest shortfall in patients without co-morbidity (3.8% [95% Cl 2.6-5.0] lower in 2005). Patients with co-morbidity remained significantly more likely to meet treatment targets for cholesterol and HbA1c than those without after the introduction of pay for performance. Conclusions Diabetes patients with co-morbid conditions appear to have benefited more from this pay-for-performance program than those without co-morbidity.