title: Associations between exemption and survival outcomes in the UK's primary care pay-for-performance programme: a retrospective cohort study.
abstract: The UK's Quality and Outcomes Framework permits practices to exempt patients from financially-incentivised performance targets. To better understand the determinants and consequences of being exempted from the framework, we investigated the associations between exception reporting, patient characteristics and mortality. We also quantified the proportion of exempted patients that met quality targets for a tracer condition (diabetes).
  
  
  
  Retrospective longitudinal study, using individual patient data from the Clinical Practice Research Datalink.
  
  
  
  644 general practices, 2006/7 to 2011/12.
  
  
  
  Patients registered with study practices for at least one year over the study period, with at least one condition of interest (2 460 341 in total).
  
  
  
  Exception reporting rates by reason (clinical contraindication, patient dissent); all-cause mortality in year following exemption. Analyses with logistic and Cox proportional-hazards regressions, respectively.
  
  
  
  The odds of being exempted increased with age, deprivation and multimorbidity. Men were more likely to be exempted but this was largely attributable to higher prevalence of conditions with high exemption rates. Modest associations remained, with women more likely to be exempted due to clinical contraindication (OR 0.90, 99% CI 0.88 to 0.92) and men more likely to be exempted due to informed dissent (OR 1.08, 99% CI 1.06 to 1.10). More deprived areas (both for practice location and patient residence) were non-linearly associated with higher exception rates, after controlling for comorbidities and other covariates, with stronger associations for clinical contraindication. Compared with patients with a single condition, odds ratios for patients with two, three, or four or more conditions were respectively 4.28 (99% CI 4.18 to 4.38), 16.32 (99% CI 15.82 to 16.83) and 68.69 (99% CI 66.12 to 71.37) for contraindication, and 2.68 (99% CI 2.63 to 2.74), 4.02 (99% CI 3.91 to 4.13) and 5.17 (99% CI 5.00 to 5.35) for informed dissent. Exempted patients had a higher adjusted risk of death in the following year than non-exempted patients, regardless of whether this exemption was for contraindication (hazard ratio 1.37, 99% CI 1.33 to 1.40) or for informed dissent (1.20, 99% CI 1.17 to 1.24). On average, quality standards were met for 48% of exempted patients in the diabetes domain, but there was wide variation across indicators (ranging from 8 to 80%).
  
  
  
  Older, multimorbid and more deprived patients are more likely to be exempted from the scheme. Exception reported patients are more likely to die in the following year, whether they are exempted by the practice for a contraindication or by themselves through informed dissent. Further research is needed to understand the relationship between exception reporting and patient outcomes.
authors.affiliation: NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Kontopantelis
authors.affiliation: NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: David A
authors.initials: DA
authors.lastname: Springate
authors.affiliation: Centre for Pharmacoepidemiology and Drug Safety, Manchester Pharmacy School, University of Manchester, Manchester, Uk.
authors.forename: Darren M
authors.initials: DM
authors.lastname: Ashcroft
authors.affiliation: Patient Centred Care, APEx Collaboration for Academic Primary Care, Medical School, University of Exeter, Exeter, UK.
authors.forename: Jose M
authors.initials: JM
authors.lastname: Valderas
authors.affiliation: Centre for Health Informatics, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Sabine N
authors.initials: SN
authors.lastname: van der Veer
authors.affiliation: NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: David
authors.initials: D
authors.lastname: Reeves
authors.affiliation: Population Health Sciences Division, Medical Research Institute, University of Dundee, Dundee, Uk.
authors.forename: Bruce
authors.initials: B
authors.lastname: Guthrie
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: Tim
authors.initials: T
authors.lastname: Doran
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D005194:Family Practice; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011320:Primary Health Care; D019984:Quality Indicators, Health Care; D012052:Reimbursement, Incentive; D012189:Retrospective Studies; D016019:Survival Analysis; D006113:United Kingdom
keywords: Diabetes mellitus; Financial incentives; General practice; Health services research; Pay for performance