Differences in the quality of primary medical care services by remoteness from urban settlements

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Abstract
To examine if the quality of primary medical care varies with remoteness from urban settlements. Cross-sectional analysis of publicly available data of 18 process and intermediate outcome measures for people with coronary heart disease (CHD), diabetes and stroke. Populations registered with 912 general practices in Scotland grouped into three categories by level of remoteness from urban settlements: not remote, remote and very remote. Mean percentages achieving quality indicators and interquartile range scores. Remote and very remote practices were more likely to have characteristics associated with low Quality and Outcomes Framework (QOF) total points score (smaller, higher capitation income, dispensing practice, and had lower statin prescribing despite higher prevalence of cardiovascular disease and diabetes). However, in contrast with previous research, there was little evidence that quality of care was lower in more remote areas for the 18 process and intermediate outcome measures examined. The exception was significantly lower cholesterol measurement and control in people with CHD, diabetes and stroke attending very remote practices (p<0.01) and beta-blocker prescription in CHD (p = 0.01). Under QOF, there are few differences in the quality of care delivered to patients in practices with different degrees of remoteness. The differences in achievement for cholesterol were consistent with lower rates of statin prescribing relative to disease burden in very remote practices. No differences were found for complex process measures such as retinopathy screening, implying that differences under QOF are more likely to be due to slower adoption of evidence-based practice than access problems. Examining this will require analysis of individual patient data.