Quality of care for people with serious mental illness (SMI) following removal of financial incentives.

Problem

People with SMI die 15-20 years younger than the general population, principally from the same preventable conditions such as cardiovascular and respiratory disease. This is known as the mortality gap and is one of the biggest health inequalities of our time. In an effort to address the mortality gap, the Quality and Outcomes Framework (QOF) introduced financial incentives for GP practices to conduct physical health checks on this population with the aim of monitoring their cardiovascular risk. However, in 2014/15 incentives were removed. To date research on the removal of QOF indicators has not focused specifically on people with SMI. This study aimed to examine the effect of removing incentives on the quality of care for patients with SMI.

Approach

Quantitative methods were used to analyse electronic health records data from a UK primary care database, the Clinical Practice Research Datalink (CPRD), linked to other data sources. The study design was a retrospective, longitudinal observational cohort spanning a five year period from 2011/12 to 2015/16. The primary research question stemmed from a natural experiment which arose from the removal of financial incentives in 2014/15 for BMI, cholesterol and glucose, but not for blood pressure. This enabled a difference-in-differences design to be used to examine the effect of removal of incentives on the proportion of eligible SMI patients who received a health check, compared to blood pressure which remained incentivised. Multivariate logistic regression was used to examine the effect key demographic variables such as age, gender, ethnicity, SMI type and deprivation level had on outcomes to predict which demographics affected the likelihood of receiving different types of health check. Data were analysed using Stata version 15.

Findings

Findings from the difference-in-difference analysis demonstrated that removal of financial incentives was followed by an immediate and significant decrease in the proportion of SMI patients who received a health check, compared to the underlying trend controlled for by blood pressure which remained incentivised. BMI had the most substantial decrease in the initial year post-removal of incentives. The multivariate logistic regression analysis indicated nuances and subtle variation between the different types of health checks relating to the likelihood of which patients received a check. Overall age, gender and SMI type had the most significant effect.

Consequences

This study provides new evidence about quality of care for SMI patients in the primary care setting. It demonstrates that removing financial incentives for health checks resulted in a significant reduction in the likelihood of receiving a health check. This raises questions about inequality and unmet need regarding SMI patients, at a time when the mortality gap appears to be widening rather than shrinking. Findings can inform policy about improving quality of care for people with SMI.