Abstract
BackgroundIn April 2004, an incentive based contract was introduced to UK primary care. An important element of the new contract is the ability to exclude individuals from quality indicators for a variety of reasons (known as 'exception reporting'). Exception of patients with stroke or TIA from the recording and achievement of quality indicators may have important consequences in terms of stroke recurrence and mortality.MethodsA cross-sectional retrospective analysis of anonymised patient data was performed using 312 Scottish primary care practices.ResultsPatients recorded as unsuitable for inclusion in the contract were more likely to be female (odds ratio (OR) 1.51, 95% confidence interval (CI) 1.36–1.68), older (>75 years:OR 3.15, 95%CI 2.69–3.69), and have dementia (OR 4.40, 95%CI 3.57–5.43) when compared to those patients without such a code. Patients were less likely to be older (>75 years:OR 0.70, 95%CI 0.56–0.87) and were more likely to be from the most deprived areas of Scotland (Quintile 5: OR 2.02, 95%CI 1.50–2.70) if they refused to attend for review or did not reply to letters asking for attendance at primary care clinics. Patients with multiple co-morbidities were more likely to have exclusions for achieving diagnostic clinical targets such as cholesterol control (3 or more co-morbidities: OR 3.37, 95%CI 2.50–4.50).ConclusionScottish practices have appeared to use exception reporting appropriately by excluding patients who are older or have dementia. However, younger or more socio-economically deprived patients were more likely to be recorded as having refused to attend for review or not replying to letters asking for attendance at primary care clinics. It is important for primary care practices to identify and monitor these individuals so that all patients fully benefit from the implementation of an incentive based contract and receive appropriate clinical care to prevent stroke recurrence, further disability and mortality.
Highlights
In April 2004, an incentive based contract was introduced to UK primary care
In April 2004, a new quality-based General Medical Services contract was introduced to UK primary care, which reduced the proportion of income of general practitioners (GP) derived from per capita payments and increased the proportion derived from providing specific aspects of care, such as targets based on quality indicators [1]
Patients may be excepted from all indicators relating to a clinical domain, for example, if individuals with stroke/transient ischaemic attack (TIA) are too frail, refuse to attend for review or do not reply to letters asking for attendance at primary care clinics; known as 'top level' exceptions [5]
Summary
In April 2004, an incentive based contract was introduced to UK primary care. An important element of the new contract is the ability to exclude individuals from quality indicators for a variety of reasons (known as 'exception reporting'). Exception of patients with stroke or TIA from the recording and achievement of quality indicators may have important consequences in terms of stroke recurrence and mortality. In April 2004, a new quality-based General Medical Services (nGMS) contract was introduced to UK primary care, which reduced the proportion of income of general practitioners (GP) derived from per capita payments and increased the proportion (approximately 23%) derived from providing specific aspects of care, such as targets based on quality indicators [1]. Scotland has the highest mortality rate for stroke in Western Europe [3] and it was reassuring that the recording of quality indicators directly relating to stroke or transient ischaemic attack (TIA) care were found to have increased by an average of 40% in the year after the introduction of the contract [4]. There were differences in secondary preventative prescribing between groups of patients such as women, the elderly and the most deprived
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