title: Association of practice size and pay-for-performance incentives with the quality of diabetes management in primary care.
abstract: BACKGROUND
  Not enough is known about the association between practice size and clinical outcomes in primary care. We examined this association between 1997 and 2005, in addition to the impact of the Quality and Outcomes Framework, a pay-for-performance incentive scheme introduced in the United Kingdom in 2004, on diabetes management.
  
  
  METHODS
  We conducted a retrospective open-cohort study using data from the General Practice Research Database. We enrolled 422 general practices providing care for 154,945 patients with diabetes. Our primary outcome measures were the achievement of national treatment targets for blood pressure, glycated hemoglobin (HbA(1c)) levels and total cholesterol.
  
  
  RESULTS
  We saw improvements in the recording of process of care measures, prescribing and achieving intermediate outcomes in all practice sizes during the study period. We saw improvement in reaching national targets after the introduction of the Quality and Outcomes Framework. These improvements significantly exceeded the underlying trends in all practice sizes for achieving targets for cholesterol level and blood pressure, but not for HbA(1c) level. In 1997 and 2005, there were no significant differences between the smallest and largest practices in achieving targets for blood pressure (1997 odds ratio [OR] 0.98, 95% confidence interval [CI] 0.82 to 1.16; 2005 OR 0.92, 95% CI 0.80 to 1.06 in 2005), cholesterol level (1997 OR 0.94, 95% CI 0.76 to 1.16; 2005 OR 1.1, 95% CI 0.97 to 1.40) and glycated hemoglobin level (1997 OR 0.79, 95% CI 0.55 to 1.14; 2005 OR 1.05, 95% CI 0.93 to 1.19).
  
  
  CONCLUSIONS
  We found no evidence that size of practice is associated with the quality of diabetes management in primary care. Pay-for-performance programs appear to benefit both large and small practices to a similar extent.
authors.affiliation: Department of Primary Care & Public Health, Imperial College, London, UK. e.vamos@imperial.ac.uk
authors.forename: Eszter P
authors.initials: EP
authors.lastname: Vamos
authors.forename: Utz J
authors.initials: UJ
authors.lastname: Pape
authors.forename: Alex
authors.initials: A
authors.lastname: Bottle
authors.forename: Fiona Louise
authors.initials: FL
authors.lastname: Hamilton
authors.forename: Vasa
authors.initials: V
authors.lastname: Curcin
authors.forename: Anthea
authors.initials: A
authors.lastname: Ng
authors.forename: Mariam
authors.initials: M
authors.lastname: Molokhia
authors.forename: Josip
authors.initials: J
authors.lastname: Car
authors.forename: Azeem
authors.initials: A
authors.lastname: Majeed
authors.forename: Christopher
authors.initials: C
authors.lastname: Millett
mesh_terms: D000328:Adult; D000368:Aged; D016009:Chi-Square Distribution; D003920:Diabetes Mellitus / Q000191:economics / Q000628:therapy*; D019468:Disease Management; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000191:economics*; D015995:Prevalence; D011320:Primary Health Care / Q000191:economics / Q000592:standards*; D011787:Quality of Health Care / Q000191:economics*; D012044:Regression Analysis; D012052:Reimbursement, Incentive / Q000191:economics*; D012189:Retrospective Studies; D006113:United Kingdom / Q000453:epidemiology