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Med Care. 2012 Mar;50(3):191-9. doi: 10.1097/MLR.0b013e318244e6b5.

The effect of improving processes of care on patient outcomes: evidence from the United Kingdom's quality and outcomes framework.

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Public Health Department, Weill Cornell Medical College, New York, NY, USA.



Despite the extensive use of process of care measures in pay-for-performance programs, little is known about the effect of improving process performance on patient outcomes.


Retrospective longitudinal analysis of data extracted from 7228 family practices in the United Kingdom's Quality and Outcomes Framework pay-for-performance program. We estimated the proportion of the change in outcome performance over time which was attributable to change in process performance for 5 chronic conditions (diabetes, coronary heart disease, stroke, epilepsy, and hypertension). Our analytic strategy accounted for bias resulting from unmeasured processes of care and severity of illness.


The estimated improvement in composite outcomes that was attributable to improved process was 29.6% for diabetes, 25.6% for coronary heart disease, 34.7% for stroke, 29.1% for epilepsy, and 17.7% for hypertension. The relationship between processes and outcomes varied little across patient and practice characteristics.


Improvement in process performance in English family practices led to improvements in patient outcomes. Although the effect was modest at the practice-level, process improvements seem to have led to substantial improvements in population health.

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