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Quality of diabetes care is poorer in smaller primary care practices and in deprived areas
- Larger primary care practices provide better overall diabetes care than smaller practices, but differences in quality are generally small
- Smaller practices perform nearly as well as larger ones in achieving national treatment targets for blood pressure, blood glucose and cholesterol control
- Practices working in deprived areas are less likely to achieve national treatment targets for diabetes– this is particularly evident among smaller practices
- These findings come from the largest ever study to examine relationship between volume and outcomes in primary care.
The largest ever study looking at the relationship between primary care practice size and the quality of diabetes care is published in this month’s Journal of the Royal Society of Medicine and shows evidence of an association between quality of care and practice size in primary care. Larger practices achieved the highest quality of care scores for diabetes management, even when deprivation was taken into account.
Many studies have shown an association between higher volume and better outcome in hospital care, but there have been very few studies which looked at the relationship in primary care – even though most long-term, chronic diseases (such as diabetes) are managed in this setting. Volume-outcome relations have a greater public health significance in primary care because of the high number of patients with these conditions being treated. The fact that practices treating a higher number of patients (or a higher number of patients with chronic diseases) provide better care for patients with diabetes, has important implications for the organization of primary care services here and throughout the world.
Christopher Millett, one of the authors of the study, commented, “The fact that smaller practices did almost as well as the larger ones when it came to achieving national treatment targets for blood pressure, blood glucose and cholesterol control is reassuring. However, differences in other quality measures between small and large practices were evident. For example, patients in smaller practices were much less likely to receive an annual eye check than those in larger practices” Reasons for this anomaly were not within the scope of the study but could be to do with better organisation of care and more support staff in larger practices. “It might also be because some larger practices may have a doctor who develops a particular interest in diabetes and runs dedicated clinics for people with the disease.”
The study also found that practices working in deprived areas are less likely to achieve national treatment targets for diabetes than those in affluent areas. The relationship between deprivation and quality of care was particularly evident in smaller practices. “This aspect of our study is worrying and should be looked at more closely. It seems to indicate another example of the inverse care law – where those patients who most need high quality health care are the least likely to receive it.” says Christopher Millett.
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Notes
The study looked at Quality and Outcomes Framework (QOF) data from 8970 general practices in England and Scotland, with a population of 55 522 788 patients. QOF data comes from the national IT system known as QMAS (Quality Management and Analysis System) which is used to calculate disease prevalence and quality achievement in general practice. It measures both process of care and outcomes.
'Diabetes prevalence, process of care and outcomes in relation to practice size, caseload and deprivation: national cross-sectional study in primary care.' is published in the June issue (Vol. 100) of the Journal of the Royal Society of Medicine.
JRSM is the flagship journal of the Royal Society of Medicine. It has been published continuously since 1809. Its Editor is Dr Kamran Abbasi.
Christopher Millettn is available for comment.
