Association of deprivation, ethnicity, and sex with quality indicators for diabetes: population based survey of 53 000 patients in primary c
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《英国医生杂志》
1 Division of Primary Care, Tower Building, University Park, Nottingham NG2 7RD, 2 The Surgery, Wonersh, Guildford GU5 0PE
Correspondence to: J Hippisley-Cox julia.hippisley-cox@nottingham.ac.uk
Abstract
The national service framework for diabetes set standards for the care of patients with diabetes,1 and the new general medical services contract, implemented in UK general practice on 1 April 2004, specifies specific quality measures. The contract, however, takes no account of deprivation or ethnicity on target levels, and although there has been discussion on this, there is no clinical evidence on the importance of such an omission.
We determined the impact of deprivation and ethnicity on the achievement of indicators for patients with diabetes in a large general practice population. We also determined whether there was any evidence to support the inequalities between the sexes observed in patients with coronary heart disease.2
Methods
The extent of ethnicity and deprivation in an area are important factors in the achievement of quality indicators for patients, as set out in the new general medical services contract. Our findings confirm the inequalities between the sexes reported by patients with diabetes and observed for patients with coronary heart disease.2
What is already known on this topic
The new general medical services contract takes no account of deprivation or ethnicity on target levels
Women are least likely to receive adequate care for coronary heart disease
What this study adds
Practices in areas of high deprivation and high ethnicity will find it harder to meet targets in the new general medical services contract
Women are less likely than men to receive adequate care for diabetes
The association of deprivation and ethnicity with achievement of targets was substantial and was not explained by age, sex, or practice. Of the 17 quality indicators, 10 were adversely associated with deprivation and nine were adversely associated with ethnicity.
We found a large variation between practices in the recording of most of the indicators. Our study design prevented us from determining whether this was due to variation in the quality of care or to differences in the completeness of data entry, although electronic records tend to be more complete than paper records.3 The prevalence of diabetes in our study was higher than that in other studies in primary care.4 This might be because the data are recent and the prevalence of diabetes is increasing. Levels of recording of laboratory investigations were higher than clinical measures such as neuropathy testing. This might be because laboratory test results are now sent electronically to most practices and are automatically uploaded into the patients' clinical records, whereas clinical measurements are entered manually.
These data, reported at the start of the new general medical services contract, will be of interest both to practices as they plan their delivery strategies and to health service planners responsible for monitoring and remuneration. The large variation between practices in levels of outcomes achieved was expected, although the overall values were lower than expected, indicating the huge amount of work needed to provide optimum care for all patients. Practices in areas of high deprivation and high ethnicity will have to work harder to achieve the quality indicators for diabetes, and it is possible that those practices which most need the resources are the ones least likely to get them.
This article was posted on bmj.com on 17 November 2004: http://bmj.com/cgi/doi/10.1136/bmj.38279.588125.7C
We thank David Stables (medical director of EMIS); Mike Pringle for help in creating QRESEARCH; the National Advisory Board for setting and monitoring policy; and the practices for contributing data. The QRESEARCH database is available at www.qresearch.org
Contributors: JH-C initiated and designed the study, obtained ethical approval, and undertook the data extraction, manipulation, and analysis; she is guarantor. SO'H contributed to the design, advised on the general medical services contract queries, and contributed to the paper. CC contributed to the design, advised and checked the statistical analysis, and contributed to the interpretation and the paper.
Funding: Grant from Trent NHS Executive.
Competing interests: QRESEARCH is a non-profit making organisation established to give good access to high quality data for research. JHC is one of the custodians of QRESEARCH; publication of this paper is likely to lead to increased awareness and usage of the database. Practices contributing data are not paid but receive feedback on quality measures. SO'H is a clinical design director for EMIS.
Ethical approval: Trent multicentre ethics committee
References
Department of Health. National service framework for diabetes—the delivery strategy. London: DoH, 2003.
Hippisley-Cox J, Pringle M, Crown N, Meal A, Wynn A. Sex inequalities in ischaemic heart disease in general practice: cross sectional survey. BMJ 2001;322: 832.
Hippisley-Cox J, Pringle M, Cater R, Wynn A, Hammersley V, Coupland C, et al. Electronic record in primary care—regression or progression? Cross sectional survey. BMJ 2003;326: 1439-43.
Newnham A, Ryan R, Khunti K, Majeed A. Prevalence of diagnosed diabetes mellitus in general practice in England and Wales. Health Stat Q 2002;14: 5-13.(Julia Hippisley-Cox, read)
Correspondence to: J Hippisley-Cox julia.hippisley-cox@nottingham.ac.uk
Abstract
The national service framework for diabetes set standards for the care of patients with diabetes,1 and the new general medical services contract, implemented in UK general practice on 1 April 2004, specifies specific quality measures. The contract, however, takes no account of deprivation or ethnicity on target levels, and although there has been discussion on this, there is no clinical evidence on the importance of such an omission.
We determined the impact of deprivation and ethnicity on the achievement of indicators for patients with diabetes in a large general practice population. We also determined whether there was any evidence to support the inequalities between the sexes observed in patients with coronary heart disease.2
Methods
The extent of ethnicity and deprivation in an area are important factors in the achievement of quality indicators for patients, as set out in the new general medical services contract. Our findings confirm the inequalities between the sexes reported by patients with diabetes and observed for patients with coronary heart disease.2
What is already known on this topic
The new general medical services contract takes no account of deprivation or ethnicity on target levels
Women are least likely to receive adequate care for coronary heart disease
What this study adds
Practices in areas of high deprivation and high ethnicity will find it harder to meet targets in the new general medical services contract
Women are less likely than men to receive adequate care for diabetes
The association of deprivation and ethnicity with achievement of targets was substantial and was not explained by age, sex, or practice. Of the 17 quality indicators, 10 were adversely associated with deprivation and nine were adversely associated with ethnicity.
We found a large variation between practices in the recording of most of the indicators. Our study design prevented us from determining whether this was due to variation in the quality of care or to differences in the completeness of data entry, although electronic records tend to be more complete than paper records.3 The prevalence of diabetes in our study was higher than that in other studies in primary care.4 This might be because the data are recent and the prevalence of diabetes is increasing. Levels of recording of laboratory investigations were higher than clinical measures such as neuropathy testing. This might be because laboratory test results are now sent electronically to most practices and are automatically uploaded into the patients' clinical records, whereas clinical measurements are entered manually.
These data, reported at the start of the new general medical services contract, will be of interest both to practices as they plan their delivery strategies and to health service planners responsible for monitoring and remuneration. The large variation between practices in levels of outcomes achieved was expected, although the overall values were lower than expected, indicating the huge amount of work needed to provide optimum care for all patients. Practices in areas of high deprivation and high ethnicity will have to work harder to achieve the quality indicators for diabetes, and it is possible that those practices which most need the resources are the ones least likely to get them.
This article was posted on bmj.com on 17 November 2004: http://bmj.com/cgi/doi/10.1136/bmj.38279.588125.7C
We thank David Stables (medical director of EMIS); Mike Pringle for help in creating QRESEARCH; the National Advisory Board for setting and monitoring policy; and the practices for contributing data. The QRESEARCH database is available at www.qresearch.org
Contributors: JH-C initiated and designed the study, obtained ethical approval, and undertook the data extraction, manipulation, and analysis; she is guarantor. SO'H contributed to the design, advised on the general medical services contract queries, and contributed to the paper. CC contributed to the design, advised and checked the statistical analysis, and contributed to the interpretation and the paper.
Funding: Grant from Trent NHS Executive.
Competing interests: QRESEARCH is a non-profit making organisation established to give good access to high quality data for research. JHC is one of the custodians of QRESEARCH; publication of this paper is likely to lead to increased awareness and usage of the database. Practices contributing data are not paid but receive feedback on quality measures. SO'H is a clinical design director for EMIS.
Ethical approval: Trent multicentre ethics committee
References
Department of Health. National service framework for diabetes—the delivery strategy. London: DoH, 2003.
Hippisley-Cox J, Pringle M, Crown N, Meal A, Wynn A. Sex inequalities in ischaemic heart disease in general practice: cross sectional survey. BMJ 2001;322: 832.
Hippisley-Cox J, Pringle M, Cater R, Wynn A, Hammersley V, Coupland C, et al. Electronic record in primary care—regression or progression? Cross sectional survey. BMJ 2003;326: 1439-43.
Newnham A, Ryan R, Khunti K, Majeed A. Prevalence of diagnosed diabetes mellitus in general practice in England and Wales. Health Stat Q 2002;14: 5-13.(Julia Hippisley-Cox, read)