The quality of chronic disease care under the GP pay for performance system is poorer for residents of care homes than those living in the community, according to a study published in the British Medical Journal today.
The Quality and Outcomes Framework (QOF) for general practice is a voluntary system of financial incentives, which has been in place since 2004. Part of the programme includes specific targets for GPs to demonstrate high quality care for patients with chronic diseases.
The study found that, although pay for performance systems do not invariably disadvantage residents of care homes, GPs are much more likely to exclude them from quality targets, which may compromise their care.
The authors, led by Dr Sunil Shah from St George's, University of London, say that pay for performance systems should include measures relevant to care home residents to improve chronic disease care in this often vulnerable group.
Dr Shah and his team studied data from The Health Improvement Network (THIN), a large database of primary care records from 326 UK general practices, to assess the quality of chronic disease care for care home and community residents.
They identified 10,387 care home and 403,259 community residents aged 65 to 104 years who were registered for 90 or more days with their general practitioner.
Even after adjusting for age, sex and dementia diagnosis, they found that attainment of quality targets was significantly lower for residents of care homes than for those in the community for 14 of 16 indicators suitable for older people in care homes.
The largest differences were for prescribing in heart disease and monitoring of diabetes. Smaller differences were seen for use of antiplatelet therapy and monitoring of blood pressure.
Residents of care homes were also more likely to be excluded from all QOF targets for a condition. For example, 34% of patients with stroke in care homes were excluded compared with 17% in the community, and 35% compared with 9% for diabetes.
This difference persisted even after taking account of patients with dementia or with limited life expectancy.
This is the first study to examine quality of care for residents in care home since the introduction of pay for performance in the primary care contract and shows a need to improve care for chronic diseases among older people in care homes, say the authors.
They acknowledge that, for some interventions, lower attainment of quality indicators may be appropriate, but argue that "high disease wide exceptions suggest a less individualised approach and may act as a disincentive to good disease management."
They conclude: "Our current findings support enhancement of pay for performance systems to include measures that are particularly relevant to residents of care homes and vulnerable older people in the community, such as pain management, falls and continence care."
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