Do the smoking status recording and cessation advice indicators in the Quality and Outcomes framework (QOF) mask inequalities in care for patients with serious mental illness?

Talk Code: 
Rachel Foskett-Tharby
Dr Yongzhong Sun, Dr Ronan Ryan, Ms Andrea Roalfe, Dr Paramjit Gill
Author institutions: 
Institute of Applied Health Research, University of Birmingham


Since 2006, QOF indicators for smoking status recording and cessation advice in patients diagnosed with coronary heart disease, stroke or transient ischaemic attack, hypertension, diabetes mellitus, chronic obstructive pulmonary disease and asthma were combined into two measures in which the indicator denominators are the sum of patients diagnosed with one or more specified long-term conditions. Patients with chronic kidney disease, serious mental illness (SMI) and peripheral arterial disease have since been added to this denominator. Whilst overall achievement against these indicators has been consistently high this may mask variations in care experienced by patients with the different long term conditions. This may be particularly problematic for patients with a serious mental illness as they are more likely to smoke. We examined differences in recording rates in smoking status and cessation advice between patients with long term conditions incentivised through the QOF and then to quantify any differences based upon a diagnosis of i) SMI only, ii) physical long term condition only and iii) co-morbid physical condition and SMI.


We extracted data relating to smoking status and cessation advice from The Health Improvement Network database (THIN) for all patients with a diagnosis of a long-term condition included in the QOF from 2000-2015. We calculated the crude proportions of patients with smoking status recorded and cessation advice given by individual condition and then grouped as above. We undertook a multivariable analysis of the 2015 data to quantify differences in care between these groups.


Rates of recording of smoking status and cessation advice increased for all conditions during the study period. At all time points the lowest proportions of smoking status recording and cessation advice were observed in patients with psychosis only. Patients with physical health conditions only were 30% more likely to have a record of smoking status compared to patients with a psychosis only (OR 1•30, 95%CI 1•25–1•36) and 78% more likely to receive cessation advice (OR1•78, 95%CI 1•67–1•9). Those with a comorbid psychosis and physical condition were 91% more likely to have smoking status recorded compared to those with psychosis only (OR 1•91, 95%CI 1•76–2•07) and more than twice as likely to receive cessation advice (OR 2•28, 95%CI 2•00–2•60).


Pay for performance indicators which combine groups of patients in the denominator can mask variations in care; potentially exacerbating health inequalities. This has implications for the design, utilisation and reporting of quality measures.

Submitted by: 
Rachel Foskett-Tharby
Funding acknowledgement: 
This work was funded by the National Institute for Health and Care Excellence (NICE) as part of their work on indicator development