title: The impact of the Quality and Outcomes Framework (QOF) on the recording of smoking targets in primary care medical records: cross-sectional analyses from The Health Improvement Network (THIN) database.
abstract: BACKGROUND
  Smoking is a UK public health threat but GPs can be effective in helping patients to quit; consequently, the Quality and Outcomes Framework (QOF) incentivises the recording of smoking status and delivery of cessation advice in patients' medical records. This study investigates the association between smoking-related QOF targets and such recording, and the factors which influence these clinical activities.
  
  
  METHODS
  For 2000 to 2008, using medical records in The Health Improvement Network (THIN) database, the annual proportions of i) patients who had a record of smoking status made in the previous 27 months and ii) current smokers recorded as receiving cessation advice in the previous 15 months were calculated. Then, for all patients at selected points before and after the QOF's implementation, data on gender, age, Townsend score, and smoking-related morbidity were extracted. Multivariate logistic regression was used to investigate individual-level characteristics associated with the recording of smoking status and cessation advice.
  
  
  RESULTS
  Rapid increases in recording smoking status and advice occurred around the QOF's introduction in April 2004. Subsequently, compliance to targets has been sustained, although rates of increase have slowed. By 2008 64.5% of patients aged 15+ had smoking status documented in the previous 27 months and 50.5% of current smokers had cessation advice recorded in the last 15 months. Adjusted odds ratios show that, both before and after the introduction of the QOF, those with chronic medical conditions, greater social deprivation and women were more likely to have a recent recording of smoking status or cessation advice. Since the QOF's introduction, the strongest characteristic associated with recording activities was the presence of co-morbidity. An example of this was patients with COPD, who in 2008, were 15.38 (95% CI 13.70-17.27) times and 11.72 (95% CI 10.41-13.21) times more likely to have a record of smoking status and cessation advice, respectively.
  
  
  CONCLUSIONS
  Rates of recording smoking status and cessation advice plateaued after large increases during the QOF's introduction; however, recording remains most strongly associated with the presence of chronic disease as specified by the QOF, and suggests that incentivised targets have a direct effect on clinical behaviour.
authors.affiliation: National School for Primary Care Research and UK Centre for Tobacco Control Studies, Division of Primary Care, University of Nottingham, Medical School, Queen's Medical Centre, Nottingham, NG7 2UH, England. mcxjst@nottingham.ac.uk
authors.forename: Jaspal S
authors.initials: JS
authors.lastname: Taggar
authors.forename: Tim
authors.initials: T
authors.lastname: Coleman
authors.forename: Sarah
authors.initials: S
authors.lastname: Lewis
authors.forename: Lisa
authors.initials: L
authors.lastname: Szatkowski
mesh_terms: D000328:Adult; D000368:Aged; D003376:Counseling / Q000706:statistics & numerical data*; D003430:Cross-Sectional Studies; D016208:Databases, Factual; D004282:Documentation; D005260:Female; D006040:Goals; D006801:Humans; D008297:Male; D008499:Medical Records; D008875:Middle Aged; D010819:Physician's Role; D011320:Primary Health Care; D016540:Smoking Cessation; D006113:United Kingdom