Research Article: Ethnic Disparities in Diabetes Management and Pay-for-Performance in the UK: The Wandsworth Prospective Diabetes Study

Date Published: June 12, 2007

Publisher: Public Library of Science

Author(s): Christopher Millett, Jeremy Gray, Sonia Saxena, Gopalakrishnan Netuveli, Kamlesh Khunti, Azeem Majeed, Philip Home

Abstract: BackgroundPay-for-performance rewards health-care providers by paying them more if they succeed in meeting performance targets. A new contract for general practitioners in the United Kingdom represents the most radical shift towards pay-for-performance seen in any health-care system. The contract provides an important opportunity to address disparities in chronic disease management between ethnic and socioeconomic groups. We examined disparities in management of people with diabetes and intermediate clinical outcomes within a multiethnic population in primary care before and after the introduction of the new contract in April 2004.Methods and FindingsWe conducted a population-based longitudinal survey, using electronic general practice records, in an ethnically diverse part of southwest London. Outcome measures were prescribing levels and achievement of national treatment targets (HbA1c ≤ 7.0%; blood pressure [BP] < 140/80 mm Hg; total cholesterol ≤ 5 mmol/l or 193 mg/dl). The proportion of patients reaching treatment targets for HbA1c, BP, and total cholesterol increased significantly after the implementation of the new contract. The extents of these increases were broadly uniform across ethnic groups, with the exception of the black Caribbean patient group, which had a significantly lower improvement in HbA1c (adjusted odds ratio [AOR] 0.75, 95% confidence interval [CI] 0.57–0.97) and BP control (AOR 0.65, 95% CI 0.53–0.81) relative to the white British patient group. Variations in prescribing and achievement of treatment targets between ethnic groups present in 2003 were not attenuated in 2005.ConclusionsPay-for-performance incentives have not addressed disparities in the management and control of diabetes between ethnic groups. Quality improvement initiatives must place greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes.

Partial Text: Internationally, there has been a drive to reduce persistent health disparities among minority ethnic populations, particularly in the United Kingdom and the United States [1]. In the UK, the government has recognised the importance of ensuring that new health policies are applied to all sectors of the population, including minority ethnic communities [2]. This consistent application is essential for policies directed at tackling the escalating diabetes epidemic in developed countries such as the UK and US, where diabetes is much more common in minority ethnic groups than in the general population [3,4]. Furthermore, these communities are likely to experience a disproportionate share of the future projected growth in the number of people with diabetes [3,4]. This differential burden in prevalence is exacerbated by higher complication rates and a worse morbidity and mortality profile amongst minority ethnic groups when compared with white patients [5,6]. Because of these disparities, diabetes contributes substantially to the variations in all-cause mortality between ethnic groups [7].

We identified 4,284 adults (aged ≥ 18 y) with diabetes registered with the 32 participating practices in both 2003 and 2005. Included were 2,227 men and 2,057 women. The European age-standardised prevalence of diabetes in 2005 was 42.2 per 1,000 people in all age groups. Ethnicity was recorded in 95.1% of the sample (Table S1). Overall, the four practices that did not participate in the study accounted for less than 6% of the registered population in the study area. Nonparticipating practices were smaller (three of the four had fewer than 3,000 patients) and were located in more deprived areas than the participating practices. Our findings were substantially unchanged when we applied sensitivity analyses to test for the effect of measurement at two time points.



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