In England, type 2 diabetes is a major cause of disability and death, and it accounts for approximately 10% of the country's health expenditure. As such, there is demand for interventions that can prevent both the disease and disease complications. The Quality and Outcomes Framework (QOF) was introduced in 2004, aiming to enhance the quality of various aspects of primary care, including diabetes management, through financial incentives provided to general practitioners (GPs) based on performance against pre-defined targets. English diabetes primary care management is also subject to regular assessment via the National Diabetes Audit, which reports on the achievement of eight care processes that GPs are expected to provide to individuals with diabetes annually. There is some evidence that QOF has had small positive impacts on achievement of some aspects of diabetes care. However, it is not clear that achievement of the particular clinical targets incentivised through QOF, or the care processes reviewed in the National Diabetes Audit, leads to improvements in key outcomes such as emergency hospital admissions and mortality, which carry high human and financial cost. We therefore aim to determine whether achievement of the QOF clinical targets is associated with improvements in these key outcomes.
Objective: To determine whether achievement of primary care diabetes targets is associated with improved emergency hospital admission or mortality outcomes for people with type 2 diabetes, accounting for potential confounding by sociodemographic indices and baseline comorbidity, and potential interactions with age, duration of disease, and presence/absence of complications.
Methods: Historical closed cohort study. Participants >18 years with record of a type 2 diabetes diagnosis before April 2010 will be eligible for inclusion. Exposure status will be based on individual-level achievement of diabetes Quality and Outcomes Framework clinical targets and National Diabetes Audit care process measures, in the 2010-2011 year. Outcomes (diabetes-related, cardiovascular, and all-cause emergency hospital admissions and mortality) will be observed over the 2011-2016 period.
Data analysis: We will describe baseline characteristics, for those with each exposure status, among the full cohort. Applying propensity score matching to account for patient characteristics, we will use Poisson regression analyses to estimate the rate ratios denoting the differential incidence of hospital admissions, among the exposed versus unexposed groups, for each admission outcome. We will use Cox proportional hazards models to estimate survival, and the hazard ratios denoting the differential hazard of each mortality outcome, among the exposed versus unexposed groups.
Diabetes-related emergency hospital admission
- Diabetes-related mortality
- Cardiovascular disease-related emergency hospital admission
- Cardiovascular mortality
- Any emergency hospital admission
- All-cause mortality
Azeem Majeed - Chief Investigator - Imperial College London
Ailsa McKay - Corresponding Applicant - Imperial College London
Ailsa McKay - Collaborator - Imperial College London
Eszter P Vamos - Collaborator - Imperial College London
Laura Gunn - Collaborator - Imperial College London
Manjula Nugawela - Collaborator - University College London ( UCL )
Pasha Normahani - Collaborator - Imperial College London
Sathish Thirunavukkarasu - Collaborator - McMaster University
Sobha Sivaprasad - Collaborator - University College London ( UCL )
HES Admitted Patient Care;ONS Death Registration Data;Patient Level Index of Multiple Deprivation;Practice Level Index of Multiple Deprivation