چکیده (انگلیسی):

Background:Socioeconomic deprivation is associated with inequalities in health care and outcomes. Despite
concerns that the Quality and Outcomes Framework pay-for-performance scheme in the UK would exacerbate
inequalities in primary care delivery, gaps closed over time. Local schemes were promoted as a means of improving
clinical engagement by addressing local health priorities. We evaluated equity in achievement of target indicators
and practice income for one local scheme.
Methods:We undertook a longitudinal survey over four years of routinely recorded clinical data for all 83 primary
care practices. Sixteen indicators were developed that covered five local clinical and public health priorities: weight
management; alcohol consumption; learning disabilities; osteoporosis; and chlamydia screening. Clinical indicators
were logit transformed from a percentage achievement scale and modelled allowing for clustering of repeated
measures within practices. This enabled our study of target achievements over time with respect to deprivation.
Practice income was also explored.
Results:Higher practice deprivation was associated with poorer performance for five indicators: alcohol use
registration (OR 0.97; 95 % confidence interval 0.96,0.99); recorded chlamydia test result (OR 0.97; 0.94,0.99);
osteoporosis registration (OR 0.98; 0.97,0.99); registration of repeat prednisolone prescription (OR 0.98; 0.96,0.99); and
prednisolone registration with record of dual energy X-ray absorptiometry (DEXA) scan/referral (OR 0.92; 0.86,0.97);
practices in deprived areas performed better for one indicator (registration of osteoporotic fragility fracture (OR 1.26;
1.04,1.51). The deprivation-achievement gap widened for one indicator (registered females aged 65–74 with a fracture
referred for a DEXA scan; OR 0.97; 0.95,0.99). Two other indicators indicated a similar trend over two years before being
withdrawn (registration of fragility fracture and over-75 s with a fragility fracture assessed and treated for osteoporosis
risk). For one indicator the deprivation-achievement gap reduced over time (repeat prednisolone prescription (OR 1.01;
1.01,1.01). Larger practices and those serving more affluent areas earned more income per patient than smaller practices
and those serving more deprived areas (t=−3.99;p=0.0001).
Conclusions:Any gaps in achievement between practices were modest but mostly sustained or widened over the
duration of the scheme. Given that financial rewards may not reflect the amount of work undertaken by practices
serving more deprived patients, future pay-for-performance schemes also need to address fairness of rewards in relation
to workload.