Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data

• Published in: BMC medicine 2017-04, Vol.15 (1), p.77-77, Article 77
• Main Authors: Lowrie, Richard, McConnachie, Alex, Williamson, Andrea E, Kontopantelis, Evangelos, Forrest, Marie, Lannigan, Norman, Mercer, Stewart W, Mair, Frances S
• Format: Article
• Language: English
• Subjects: Analysis; Care and treatment; Chronic Disease; Chronic diseases; Chronic illnesses; Confidence intervals; Correlation analysis; Data processing; Delivery contracts; Delivery of Health Care - economics; Delivery of Health Care - methods; Diabetes; Disease control; Disease Management; Disease prevention; Disparities; Family medicine; Female; General practice; Health care; Health care disparities; Health disparities; Health Equity - economics; Health policy; Humans; Hypotheses; Incentives; Inequalities; Longitudinal Studies; Male; Medical screening; Multilevel; Patients; Pay for performance; Population; Primary care; Primary health care; Primary Health Care - economics; Primary Health Care - methods; Quality; Quality Indicators, Health Care - economics; Regression analysis; Reimbursement, Incentive - economics; Retrospective Studies; Scotland - epidemiology; Socioeconomic Factors; Widening
• ISSN: 1741-7015; 1741-7015
• DOI: 10.1186/s12916-017-0833-5

The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p