To the Editor: Although it is probably true that population characteristics such as poverty, smoking, and diabetes explain most of the variation in CHD mortality, the availability and quality of primary care are also important.1
Dr Levene and colleagues2 concluded that clinical performance in the English primary health care system does not predict CHD mortality. This may be a consequence of the quality measures that they chose to include in their model. Three of their 6 quality measures used the proportion of Quality and Outcomes Framework points achieved by practices in a region as a proxy for the quality of primary care. For most indicators in the framework, the maximum number of points can be achieved even when targets are missed in a significant proportion of patients. For example, for the hypertension indicator, a practice receives the maximum number of available points if 70% of their patients with hypertension have a blood pressure at or below 150/90 mm Hg.3 Most practices in England achieve virtually all the available points, leaving little variation with which to explore the hypothesis that higher-quality care is associated with improved outcomes.4
Kiran T, Dhalla IA. Population and Primary Health Care Characteristics and Coronary Heart Disease Mortality. JAMA. 2011;305(8):778–779. doi:10.1001/jama.2011.155
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