Are different groups of patients with stroke more likely to be excluded from the new UK general medical services contract? A cross-sectional retrospective analysis of a large primary care population

Background: In April 2004, an incentive based contract was introduced to UK primary care. An important element of the new contract is the ability to exclude individuals from quality indicators for a variety of reasons (known as 'exception reporting'). Exception of patients with stroke or TIA from the recording and achievement of quality indicators may have important consequences in terms of stroke recurrence and mortality. Methods: A cross-sectional retrospective analysis of anonymised patient data was performed using 312 Scottish primary care practices. Results: Patients recorded as unsuitable for inclusion in the contract were more likely to be female (odds ratio (OR) 1.51, 95% confidence interval (Cl) 1.36-1.68), older (>75 years: OR 3.15, 95% Cl 2.69-3.69), and have dementia (OR 4.40, 95% Cl 3.57-5.43) when compared to those patients without such a code. Patients were less likely to be older (> 75 years:OR 0.70, 95% Cl 0.56-0.87) and were more likely to be from the most deprived areas of Scotland (Quintile 5: OR 2.02, 95% Cl 1.50-2.70) if they refused to attend for review or did not reply to letters asking for attendance at primary care clinics. Patients with multiple co-morbiditieswere more likely to have exclusions for achieving diagnostic clinical targets such as cholesterol control (3 or more co-morbidities: OR 3.37, 95% Cl 2.50-4.50). Conclusion: Scottish practices have appeared to use exception reporting appropriately by excluding patients who are older or have dementia. However, younger or more socio-economically deprived patients were more likely to be recorded as having refused to attend for review or not replying to letters asking for attendance at primary care clinics. It is important for primary care practices to identify and monitor these individuals so that all patients fully benefit from the implementation of an incentive based contract and receive appropriate clinical care to prevent stroke recurrence, further disability and mortality.