Evaluating the impact of financial incentives on inequalities in smoking cessation in primary care

Abstract

Background: Smoking cessation interventions are underprovided in primary care. This thesis examines the impact of financial incentives on the provision of smoking cessation interventions, and inequalities in provision, in primary care. Methods: • Systematic review of financial incentives for smoking cessation in healthcare. • Cross sectional study using general practice data from Wandsworth, London, using logistic regression to examine associations between ethnicity and disease group with ascertainment of smoking status and provision of cessation advice following the introduction of the UK’s Quality and Outcomes Framework (QOF). • Before-and-after studies using general practice data from Hammersmith & Fulham, London, looking at the impact of a local financial incentive scheme (QOF+) on smoking outcomes for patients without smoking-related diseases (primary prevention), and antenatal patients, using logistic regression to examine inequalities. Results: Introduction of financial incentives was associated with increased recording of smoking status and advice to smokers, most evident for patients with smoking-related diseases compared with patients without smoking-related diseases, for whom there were much smaller incentives for recording smoking status and none for offering stop smoking advice. However, when specific incentives were provided for primary prevention large improvements in smoking outcomes were seen. The youngest and oldest groups of patients were less likely to be asked about smoking. White British patients were more likely to smoke than other ethnic groups, except Black Caribbean men with depression, 62% of whom smoked. Smoking advice was provided relatively equitably, but Black Caribbean men with depression were less likely to receive advice than White British men with depression (59% vs 81%). Disparities in smoking outcomes with respect to age and ethnicity persisted after the financial incentives were introduced. Conclusions: Introduction of financial incentives was associated with increases in recording smoking status and largely equitable provision of cessation advice, but variations in smoking outcomes between groups persisted. Extending financial incentives to include recording of ethnicity and rewarding quit rates may further improve smoking outcomes in primary care.