The impact of the Quality and Outcomes Framework on general practice consultation rates for patients with diabetes mellitus: a longitudinal observational study.

Problem

General practices in England report considerable workload pressure, and the increasing prevalence of long-term conditions is a challenge for primary care services. However, there is currently no standardised national reporting of practice activity or unified national dataset. The Quality and Outcomes Framework (QOF) is an innovative, pay-for-performance scheme introduced in 2004 and is the first time such a scheme has been introduced in general practice at a national level. Previous research has not specifically analysed the impact of the QOF on consultation rates for patients with long-term conditions. This study aimed to investigate this for patients with diabetes mellitus.

Approach

A longitudinal interrupted time series analysis with segmented regression was used to assess annual trends in GP clinical consultation rates (face-to-face, telephone and home visits) before and after the introduction of QOF (April 2000 - March 2015) and quarterly trends in GP and nurse clinical consultation rates. The sample consisted of 37,065 patients with diabetes mellitus from 125 practices drawn from the Clinical Practice Research Datalink, one of the largest longitudinal primary care databases in the world.Consultations were calculated as total consultations per total active patient per year (for annual trends) and per day (for quarterly trends). Consultations for patients that move in or out of the practice or those nearing the end of their life were included, as these comprise an important part of GP workload. Change in national prevalence of diabetes mellitus was used to predict the impact of the QOF at a practice level.

Findings

Average GP consultation rates for patients with diabetes were having 8.2 per year in 2000/01 and fell by 0.445 consultations (95% CI 0.22, 0.67, p=0.001) per year prior to QOF. After the introduction of QOF, the magnitude of the underlying trend increased by 0.463 (95% CI 0.23, 0.69, p=0.001). For a practice of average size and diabetes prevalence, since the introduction of QOF these trends combined with increasing diabetes prevalence equate to an increase of 95.8% GP consultations for patients with diabetes (from 30.7 per week in 2004/05 to 60.2 per week in 2014/15). Combined nurse and GP consultation rates have been relatively static over time with peaks in October - December for nurses (p<0.001) and January - March for GPs (p<0.001).

Consequences

Introduction of QOF was associated with a statistically significant change in GP consultation rates for patients with diabetes mellitus from a previous decreasing trend. Recorded prevalence of diabetes also increased, resulting in a substantial increase in workload for practices. QOF is under review and has been abandoned in Scotland. From the findings in this study it is recommended alternatives to QOF are monitored closely in terms of impact on GP workload and clinical care for patients.