Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Objectives: To quantify the relationship between a national primary care pay-for-performance programme, the UK's Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework.

Design: Longitudinal spatial study, at the level of the "lower layer super output area" (LSOA).

Setting: 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012.

Participants: 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care.

Intervention: National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators.

Main outcome measures: All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality.

Results: All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality.

Conclusions: Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.