There are wide inequalities in health and life expectancy across the UK; the more disadvantaged a community is, the worse the health of people living there tends to be. For example, people in the most disadvantaged communities live 9 years less than people in the wealthiest communities in England, and have 19 fewer years in good health. This difference is known as ‘the health gap’, and it is widely considered unfair by the public.
NHS organisations that plan and pay for care have a legal duty to reduce health inequalities that result from socio-economic disadvantage. One way they could do this is by providing and paying for services that narrow health gaps. Our project will provide information that will help them to do this.
It is possible to calculate whether a health intervention or policy is likely to narrow or widen health gaps. But this requires information on how common different diseases are in advantaged and disadvantaged communities, and how much access people in these communities have to high quality healthcare. Unfortunately, this information is either unavailable or outdated for many common diseases.
We will therefore use some detailed data from general practices, called CPRD. Focusing on England, we will use the data to assess whether people in disadvantaged communities tend to have more diseases or receive worse care than those in more advantaged communities. Our findings will help NHS organisations know how their existing or planned policies are likely to change the health gap.
Reducing health inequalities in an efficient way depends on prioritising health policies according to their impact on the distribution of health across the entire population, not just on those targeted by the policy. This is because the funds used to support a health policy could have been used on other actions to improve health, potentially in different people.
Distributional cost-effectiveness analysis (DCEA) is a methodology to quantify the costs and benefits of a new health technology or health policy and how they are distributed across different population groups. DCEA helps inform policy-makers about the degree to which different population groups would gain or lose from introducing a new health policy or changing an existing policy. The method can therefore be used to assess their impact on health inequalities.
The Centre for Health Economics at the University of York has been funded by the NIHR Policy Research Programme to explore the health inequality effects of existing health policies, and to inform the design of a new health policy that incentivises the reduction in health inequalities through primary care. This CPRD research project will develop a catalogue of estimates of socioeconomic gradients in disease prevalence and the quality of primary care received under the Quality and Outcome Framework (QOF). These estimates are required to inform the DCEAs.
This study will use CPRD data for a sample of patients registered with English GP practices in two ways. First, direct standardisation against a UK reference population will be used to calculate disease prevalence rates by socio-economic group for 18 common diseases, and combinations. Second, regression analysis adjusting for patients’ socio-economic group membership, age, sex, QOF payments, and practice fixed effects will be used to determine differences in achievement of QOF-incentivised care standards. Patients’ socio-economic circumstances will be approximated using the Index of Multiple Deprivation.
Prevalence of 18 long-term conditions:
Atrial fibrillation
Coronary heart disease
Heart failure
Hypertension
PAD
Stroke and TIA
Asthma
COPD
Obesity
Cancer
Chronic kidney disease
Diabetes Mellitus
Dementia
Depression
Epilepsy
Severe mental illness
Osteoporosis
Rheumatoid arthritis
Achievement of 39 processes of care and intermediate outcomes incentivised under the Quality Outcome Framework (QOF):
AF006. The percentage of patients with atrial fibrillation in whom stroke risk has been assessed using the CHA2DS2-VASc score risk stratification scoring system in the preceding 12 months (excluding those patients with a previous CHADS2 or CHA2DS2-VASc score of 2 or more)
AF007. In those patients with atrial fibrillation with a record of a CHA2DS2-VASc score of 2 or more, the percentage of patients who are currently treated with anti-coagulation drug therapy
CHD005. The percentage of patients with coronary heart disease with a record in the preceding 12 months that aspirin, an alternative anti-platelet therapy, or an anti-coagulant is being taken
CHD007. The percentage of patients with coronary heart disease who have had influenza immunisation in the preceding 1 August to 31 March
CHD008. The percentage of patients aged 79 years or under with coronary heart disease in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less
CHD009. The percentage of patients aged 80 years and over with coronary heart disease in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
HF002. The percentage of patients with a diagnosis of heart failure (diagnosed on or after 1 April 2006) which has been confirmed by an echocardiogram or by specialist assessment 3 months before or 12 months after entering on to the register
HF003. In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction, the percentage of patients who are currently treated with an ACE-I or ARB
HF004. In those patients with a current diagnosis of heart failure due to left ventricular systolic dysfunction who are currently treated with an ACE- I or ARB, the percentage of patients who are additionally currently treated with a beta-blocker licensed for heart failure
HYP003. The percentage of patients aged 79 years or under with hypertension in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less
HYP007. The percentage of patients aged 80 years and over with hypertension in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
STIA007. The percentage of patients with a stroke shown to be non-haemorrhagic, or a history of TIA, who have a record in the preceding 12 months that an anti-platelet agent, or an anti-coagulant is being taken
STIA009. The percentage of patients with stroke or TIA who have had influenza immunisation in the preceding 1 August to 31 March
STIA010. The percentage of patients aged 79 years or less with a history of stroke or TIA in whom the last blood pressure reading (measured in the preceding 12 months) is 140/90 mmHg or less
STIA011. The percentage of patients aged 80 years and over with a history of stroke or TIA in whom the last blood pressure reading (measured in the preceding 12 months) is 150/90 mmHg or less
DM006. The percentage of patients with diabetes, on the register, with a diagnosis of nephropathy (clinical proteinuria) or micro-albuminuria who are currently treated with an ACE-I (or ARBs)
DM012. The percentage of patients with diabetes, on the register, with a record of a foot examination and risk classification: 1) low risk (normal sensation, palpable pulses), 2) increased risk (neuropathy or absent pulses), 3) high risk (neuropathy or absent pulses plus deformity or skin changes in previous ulcer) or 4) ulcerated foot within the preceding 12 months
DM014. The percentage of patients newly diagnosed with diabetes, on the register, in the preceding 1 April to 31 March who have a record of being referred to a structured education programme within 9 months after entry on to the diabetes register
DM018. The percentage of patients with diabetes, on the register, who have had influenza immunisation in the preceding 1 August to 31 March
DM019. The percentage of patients with diabetes, on the register, without moderate or severe frailty in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less
DM020. The percentage of patients with diabetes, on the register, without moderate or severe frailty in whom the last IFCC-HbA1c is 58 mmol/mol or less in the preceding 12 months
DM021. The percentage of patients with diabetes, on the register, with moderate or severe frailty in whom the last IFCC-HbA1c is 75 mmol/mol or less in the preceding 12 months
DM022. The percentage of patients with diabetes aged 40 years and over, with no history of cardiovascular disease and without moderate or severe frailty, who are currently treated with a statin (excluding patients with type 2 diabetes and a CVD risk score of <10% recorded in the preceding 3 years)
DM023. The percentage of patients with diabetes and a history of cardiovascular disease (excluding haemorrhagic stroke) who are currently treated with a statin
AST002. The percentage of patients aged 8 or over with asthma (diagnosed on or after 1 April 2006), on the register, with measures of variability or reversibility recorded between 3 months before or any time after diagnosis
AST003. The percentage of patients with asthma, on the register, who have had an asthma review in the preceding 12 months that includes an assessment of asthma control using the 3 RCP questions
AST004. The percentage of patients with asthma aged 14 or over and who have not attained the age of 20, on the register, in whom there is a record of smoking status in the preceding 12 months
COPD002. The percentage of patients with COPD (diagnosed on or after 1 April 2011) in whom the diagnosis has been confirmed by post bronchodilator spirometry between 3 months before and 12 months after entering on to the register
COPD003. The percentage of patients with COPD who have had a review, undertaken by a healthcare professional, including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months
COPD007. The percentage of patients with COPD who have had influenza immunisation in the preceding 1 August to 31 March
COPD008. The percentage of patients with COPD and Medical Research Council (MRC) dyspnoea scale ≥3 at any time in the preceding 12 months, with a subsequent record of an offer of referral to a pulmonary rehabilitation programme (excluding those who have previously attended a pulmonary rehabilitation programme)
DEM004. The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months
DEP003.The percentage of patients aged 18 or over with a new diagnosis of depression in the preceding 1 April to 31 March, who have been reviewed not earlier than 10 days after and not later than 56 days after the date of diagnosis
MH002. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive care plan documented in the record, in the preceding 12 months, agreed between individuals, their family and/or carers as appropriate
MH003. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of blood pressure in the preceding 12 months
MH006. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of BMI in the preceding 12 months
CAN003. The percentage of patients with cancer, diagnosed within the preceding 15 months, who have a patient review recorded as occurring within 6 months of the date of diagnosis
RA002. The percentage of patients with rheumatoid arthritis, on the register, who have had a face-to-face review in the preceding 12 months
CVD-PP001. In those patients with a new diagnosis of hypertension aged 30 or over and who have not attained the age of 75, recorded between the preceding 1 April to 31 March (excluding those with pre-existing CHD, diabetes, stroke and/or TIA), who have a recorded CVD risk assessment score (using an assessment tool agreed with NHS CB) of ≥20% in the preceding 12 months: the percentage who are currently treated with statins
Nils Gutacker - Chief Investigator - University of York
Nils Gutacker - Corresponding Applicant - University of York
Anne Mason - Collaborator - University of York
David Glynn - Collaborator - University of York
Luigi Siciliani - Collaborator - University of York
Mark Wilson - Collaborator - University of York
NI GAO - Collaborator - University of York
Simon Walker - Collaborator - University of York
Susan Griffin - Collaborator - University of York
Tim Doran - Collaborator - University of York
Luis Fernandes - Collaborator - University of York
Patient Level Index of Multiple Deprivation;Practice Level Index of Multiple Deprivation