Did the UK Quality and Outcomes Framework improve rates of recognition and treatment of cardiovascular risk factors in people with severe mental illness?

Problem

Severe mental illness (SMI), such as schizophrenia and bipolar affective disorder, is associated with premature morbidity and mortality, principally due to increased cardiovascular disease. In 2004, the Quality and Outcomes Framework (QOF) incentivised the annual review of physical health in people with SMI. Revised indicators in 2011 incentivised cardiovascular-specific review. The aims of the current study were to assess the impact on these indicators on changes in detection of cardiovascular risk factors (hypertension, diabetes mellitus, cholesterol≥5mmol/L, obesity) and treatment with lipid modifying medications and anti-diabetic medications.

Approach

A retrospective cohort study was conducted using routine electronic health record data from the Clinical Practice Research Datalink (CPRD). All available cases from 1996 to 2010 with a lifetime diagnosis of SMI and aged ≥35 years (N=67239) were compared with 359951 individuals without SMI. Segmented logistic regression was used to examine the effect of introducing QOF indicators on detection and treatment of cardiovascular risk factors. A random effect was used to allow for clustering of outcome by GP surgery.

Findings

There was strong evidence (p<0.001) that the 2004 QOF indicator resulted in a greater increase in recording of elevated cholesterol and obesity in the SMI group than it did in the control group (odds ratio 1.30, 95% confidence interval 1.21-1.39; OR 1.26, 1.14-1.39 respectively for difference between SMI and controls). There was a further increase in recording of these factors in the SMI group following the 2011 QOF indicator, but this was not sustained. There was weaker evidence (p<0.05) that the 2004 QOF indicator resulted in a relative increase in first recording of diabetes diagnosis and hypertension in the SMI group compared to the control group (OR 1.20, 1.02-1.41; OR 1.15, 1.03-1.29 respectively ), but recording of these factors did not appear to be affected by the 2011 QOF indicator. There was also no clear evidence that either the 2004 or 2011 QOF indicators affected the prescribing of lipid modifying medications or anti-diabetic medications.

Consequences

There is evidence that incentivising general physical health review for persons with SMI improves identification of cardiovascular risk factors, although specifically incentivising cardiovascular risk factors makes little further difference. Incentives do not appear to affect pharmacological management of these risks, and further work is required to understand the reasons for this.