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Inequalities in chronic disease management have largely persisted after the introduction of the Quality and Outcome Framework. Pay for performance programmes should be designed to reduce inequalities as well as improve the overall quality of care.

PURPOSE We wanted to examine the long-term effects of the Quality and Outcomes Framework (QOF), a major pay-for-performance program in the United Kingdom, on ethnic disparities in diabetes outcomes. METHODSWe undertook an interrupted time series analysis of electronic medical record data of diabetes patients registered with 29 family practices in South West London, United Kingdom. Main outcome measures were mean hemoglobin A 1c (HbA 1c ), total cholesterol, and blood pressure. RESULTSThe introduction of QOF was associated with initial accelerated improvements in systolic blood pressure in white and black patients, but these improvements were sustained only in black patients (annual decrease: -1.68 mm Hg; 95% CI, -2.41 to -0.95 mm Hg). Initial improvements in diastolic blood pressure in white patients (-1.01 mm Hg; 95% CI, -1.79 to -0.24 mm Hg) and in cholesterol in white (-0.13 mmol/L; 95% CI, -0.21 to -0.05 mmol/L) and black (-0.10 mmol/L; 95% CI, -0.20 to -0.01 mmol/L) patients were not sustained in the post-QOF period. There was no benefi cial impact of QOF on HbA 1c in any ethnic group. Existing disparities in risk factor control remained largely intact (for example; mean HbA 1c : white 7.5%, black 7.8%, south Asian 7.8%; P <.05) at the end of the study period.CONCLUSION A universal pay-for-performance scheme did not appear to address important disparities in chronic disease management over time. Targeted quality improvement strategies may be required to improve health care in vulnerable populations.

Patients excluded from pay-for-performance programmes may be less likely to achieve treatment goals and disproportionately come from disadvantaged groups. Permitting physicians to exclude patients from pay-for-performance programmes may worsen health disparities.

OBJECTIVETo examine ethnic disparities in diabetes management among patients with and without comorbid medical conditions after a period of sustained investment in quality improvement in the U.K.RESEARCH DESIGN AND METHODSThis cross-sectional study examined associations between ethnicity, comorbidity, and intermediate outcomes for mean A1C, total cholesterol, and blood pressure levels in 6,690 diabetes patients in South West London.RESULTSThe presence of ≥2 cardiovascular comorbidities was associated with similar blood pressure control among white and South Asian patients when compared with whites without comorbidity but with worse blood pressure control among black patients, with a mean difference in systolic blood pressure of +1.5, +1.4, and +6.2 mmHg, respectively.CONCLUSIONSDespite major reforms to improve quality, disparities in blood pressure management have persisted in the U.K., particularly among patients with cardiovascular comorbidities. Policy makers should consider the potential impacts of quality initiatives on high-risk groups.