The Quality and Outcomes Framework (QOF) is a pay-for-performance

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1 Effect of UK Py-for-Performnce Progrm on Ethnic Disprities in Dibetes Outcomes: Interrupted Time Series Anlysis Riydh Alshmsn, MSc John Tyu Lee, MSc Azeem Mjeed, MD Goplkrishnn Netuveli, PhD Christopher Millett, PhD Deprtment of Primry Cre nd Public Helth, Imperil College, London, United Kingdom ABSTRACT PURPOSE We wnted to exmine the long-term effects of the Qulity nd Outcomes Frmework (QOF), mjor py-for-performnce progrm in the United Kingdom, on ethnic disprities in dibetes outcomes. METHODS We undertook n interrupted time series nlysis of electronic medicl record dt of dibetes ptients registered with 29 fmily prctices in South West London, United Kingdom. Min outcome mesures were men hemoglobin A 1c (HbA 1c ), totl cholesterol, nd blood pressure. RESULTS The introduction of QOF ws ssocited with initil ccelerted improvements in systolic blood pressure in white nd blck ptients, but these improvements were sustined only in blck ptients (nnul decrese: 1.68 mm Hg; 95% CI, 2.41 to 0.95 mm Hg). Initil improvements in distolic blood pressure in white ptients ( 1.01 mm Hg; 95% CI, 1.79 to 0.24 mm Hg) nd in cholesterol in white ( 0.13 mmol/l; 95% CI, 0.21 to 0.05 mmol/l) nd blck ( 0.10 mmol/l; 95% CI, 0.20 to 0.01 mmol/l) ptients were not sustined in the period. There ws no beneficil impct of QOF on HbA 1c in ny ethnic group. Existing disprities in risk fctor control remined lrgely intct (for exmple; men HbA 1c : white 7.5%, blck 7.8%, south Asin 7.8%; P <.05) t the end of the study period. CONCLUSION A universl py-for-performnce scheme did not pper to ddress importnt disprities in chronic disese mngement over time. Trgeted qulity improvement strtegies my be required to improve helth cre in vulnerble popultions. Ann Fm Med 2012;10: doi: /fm Confl icts of interest: uthors report none. CORRESPONDING AUTHOR Riydh Alshmsn, MSc Deprtment of Primry Cre nd Public Helth The Reynolds Bldg St Dunstn s Rd W6 8RP London, United Kingdom r105@imperil.c.uk INTRODUCTION The Qulity nd Outcomes Frmework (QOF) is py-for-performnce progrm tht is unique in its scope nd cost. It rewrds fmily prctitioners in the United Kingdom for the chievement of predetermined trgets nd represents pproximtely up to 25% of prctice income. The scheme is divided into domins tht cover clinicl, ptient experience, nd orgniztionl spects of cre through which prctices cn ern up to 1,000 points, with ech point generting on verge pyment of $200 ( 124). Dibetes ccounts for pproximtely 15% of the QOF clinicl domin points (650 points re vilble in the clinicl domin). Currently one-hlf of the points vilble for dibetes cre re directed towrd the chievement of intermedite outcome trgets, such s the control of blood pressure, cholesterol nd hemoglobin A 1c (HbA 1c ). The impct of qulity improvement strtegies, such s py-for-performnce progrms, on disprities in helth cre is n emerging re of reserch inquiry. 1-3 Preliminry studies suggest tht the impct of QOF on disprities in cre hs been mixed. Although there is some evidence tht 228

2 the mngement of chronic conditions in poorer res hs improved more rpidly fter the introduction of QOF, disprities in cre mong ge, sex, nd ethnic groups ppers to hve lrgely persisted nd in some disese res worsened. 4,5 The inverse equity hypothesis proposes tht helth interventions my initilly benefi t people of higher socioeconomic sttus (SES) nd only lter benefi t lower SES groups, thus incresing disprities in the short term. 6 This hypothesis is bsed on fi ndings from child helth studies in Brzil, however, nd remins lrgely untested in popultions with chronic illnesses in developed countries. Exmining whether universl qulity improvement progrms, such s the QOF, ddress disprities in helth cre over time hs importnt implictions for policy mkers nd helth plnners. Reserch fi ndings will inform decisions bout whether dditionl resources re required for trgeted interventions to improve cre in vulnerble popultions. Although the QOF ws not explicitly designed to nrrow disprities, ssocited systemtic improvement nd stndrdiztion in the qulity of cre my be expected to led to reductions in disprities. 7 For this reson, the UK Deprtment of Helth hs stted tht the QOF is likely to reduce disprities. 8 In ddition, the World Helth Orgniztion commission on socil determinnts of helth hs recommended tht ll new policies be evluted for their impct on helth disprities. 9 We hve previously shown tht the introduction of QOF ws ssocited with n initil widening of disprities in blood pressure control between white nd blck ptients with dibetes. 10 We extend this work by using n interrupted time series nlysis to test the inverse equity hypothesis, ie, tht the QOF will ttenute these disprities over time. METHODS Study Setting The study ws conducted in Wndsworth, in southwest London, where the popultion is younger thn tht of Englnd s whole, with 74% ged less thn 45 yers (compred with ntionl verge of 60%), nd with high proportion of residents from ethnic minority groups: 8.8% re blck nd 4.4% re. All dult ptients (18 yers nd older) with dibetes registered during in 29 of the 34 prctices in the study re were included. Ptients were identifi ed by serching dignostic nd mngement Red codes in the ptient electronic record using n estblished methodology. 11 Red codes re the clinicl clssifi ction system used in primry cre in the United Kingdom. 12 Historicl clinicl dt were extrcted on ech ptient for the yers to from his or her electronic record. Vribles Our outcome mesures were men blood pressure, totl cholesterol, nd HbA 1c bsed on ech ptient s lst recorded mesurement in ech yer. Our min predictor vrible ws ethnicity. Informtion on ethnic bckground is collected from the ptient during consulttion or upon registrtion nd is entered in the ptient s electronic record. Covrites in our nlysis included ge, sex, durtion of dibetes, number of comorbid medicl conditions, nd neighborhood SES. Durtion of dibetes ws clculted in yers using the dte of dibetes dignosis entered in the electronic medicl record. Comorbid conditions included hypertension, stroke, tril fi brilltion, hert filure, coronry hert disese, sthm, chronic obstructive pulmonry disese, chronic kidney disese, nd depression. We used prctice postl codes to ssign neighborhood SES to ech ptient using the Index of Multiple Deprivtion. 13 The index is used to mesure re-level SES in the United Kingdom nd is composed of severl dimensions, such s income, living environment, nd unemployment. Ntionlly, the Index of Multiple Deprivtion scores rnge from 0.37 (lest deprived borough) to (most deprived borough). Anlysis To estimte chnges in risk fctor control ssocited with the QOF while controlling for seculr, we fi tted segmented regression model of our time series for ll the popultion nd for the 3 ethnic groups. 14,15 Ethnic groups included in our nlysis were white, blck, nd. The model estimtes 3 min prmeters. The fi rst prmeter estimtes the chnge in our outcome ssocited with ech yer before QOF ws introduced in April, the second prmeter estimtes the immedite chnge ssocited with QOF, nd the third prmeter estimtes the chnge in our outcome ssocited with ech yer fter QOF hd been introduced. For ech outcome, we treted ptients nd prctices s rndom intercepts in multilevel model to djust for the correltion in error term within both individul level nd prctice level. Further, we estimted overll s in disprities in risk fctor control during the study period by including time s continuous vrible to represent ech yer nd rnging from 1 (for the yer ) to 8 (for the yer ), with ethnicity s predictor vrible nd the white group s the reference group. Additionlly, to exmine the extent of disprities t the end of the study period, we compred ethnic group differences in (the yer before QOF) nd using liner regression model while djusting for ge, sex, SES, number of comorbidities, nd prctice-level clustering. We tested for ttrition bis using Heckmn selection models

3 The study ws pproved by the Wndsworth Locl Reserch Ethics Committee. We performed ll nlysis using Stt 10.1 (Stt Corp LP). RESULTS We identifi ed 7,434 dibetic ptients registered with the prctices in. The men ge of ptients ws 59.1 yers nd 49.6% were femle. Ethnicity ws coded for 90.0% of ptients: white ptients comprised 47.5% of the smple, 27.1% were blck, nd 24.7% were (Tble 1). HbA 1c The men HbA 1c level ws decresing in ll 3 ethnic groups before introduction of the QOF progrm ( P <.01). In its initil yer, QOF ws ssocited with signifi cnt increse in men HbA 1c mong ptients (0.18%; 95% CI, 0.02% to 0.34%), but not in the other groups. During the next 3 yers, however, HbA 1c levels incresed signifi cntly in ech ethnic group reltive to the pre-qof (Tble 2 nd Figure 1). Cholesterol Men totl cholesterol level ws decresing in ll 3 ethnic groups before introduction of the QOF progrm Tble 1. Ptient Chrcteristics in Chrcteristic All Ptients (N = 7,434) PAY FOR PERFORMANCE AND DISPARITIES IN DIABETES OUTCOMES (n = 3,181) Blck (n = 1,811) ( P <.01). In its initil yer, QOF ws ssocited with significnt dditionl reductions in cholesterol levels in white nd blck ptients, but not in ptients ( 0.07 mmol/l; 95% CI, 0.20 to 0.04 mmol/l). During the next 3 yers, the for men cholesterol levels remined unchnged in blck nd ptients but incresed significntly in the white ptients reltive to the pre-qof (0.04 mmol/l; 95% CI, 0.01 to 0.08 mmol/l) (Tble 3 nd Figure 1). Blood Pressure Men systolic blood pressure ws decresing in white ptients ( 0.50 mm Hg; 95% CI, 0.93 to 0.08 mm Hg) but not in blck (0.31 mm Hg; 95% CI, 0.20 to 0.83 mm Hg) or ptients (0.42 mm Hg; 95% CI, 0.16 to 1.01 mm Hg) before introduction of the QOF progrm. In its initil yer, QOF ws ssocited with dditionl reductions in systolic blood pressure control in white ( 2.12 mm Hg; 95% CI, 3.48 to 0.77 mm Hg) nd blck ( 2.32 mm Hg; 95% CI, 4.03 to 0.61 mm Hg) ptients but not in South Asin ptients ( 1.08 mm Hg; 95% CI, 2.97 to 0.08 mm Hg). During the next 3 yers, there were signifi - cnt dditionl reductions in men systolic blood pressure in blck ( 1.68 mm Hg; 95% CI to 2.41, 0.95 mm Hg) nd ptients ( 1.79 mm Hg; 95% CI, 2.60 to 0.98 mm Hg), but not in white ptients reltive to the pre-qof (Tble 4 nd (n = 1,653) Mle, % Men ge, y Comorbidity: 0, % Comorbidity: 1, % Comorbidity: 2, % Men socioeconomic score Using the Index of Multiple Deprivtion ; the higher the score, the greter the deprivtion. Tble 2. Interrupted Time Series Anlysis for Men Hemoglobin A 1c Levels Prmeter Level chnge HbA 1c, % (95% CI) All Ptients Blck ( 0.23 to 0.18) ( 0.24 to 0.17) ( 0.27 to 0.15) ( 0.26 to 0.15) 0.04 ( 0.04 to 0.12) 0.07 ( 0.04 to 0.18) 0.12 ( 0.29 to 0.04) 0.18 (0.02 to 0.34) b (0.15 to 0.22) (0.16 to 0.26) (0.14 to 0.29) (0.04 to 0.18) HbA 1c = hemoglobin A 1c; QOF = Qulity nd Outcomes Frmework. P <.01. b P <.05. Figure 1). Men distolic blood pressure ws decresing in ll 3 ethnic groups before introduction of the QOF progrm (P <.01). In its initil yer, QOF ws ssocited with dditionl reductions in distolic blood pressure levels in white ptients ( 1.01 mm Hg; 95% CI, 1.79 to 0.24 mm Hg) but not in blck or ptients. During the next 3 yers, men distolic blood pressures remined unchnged in ll ethnic groups reltive to the pre- QOF (Tble 5 nd Figure 1). Findings from our sensitivity nlysis (Supplementl Appendix 1, vilble t were similr to those from our min nlysis nd suggest tht they re robust (Supplementl 230

4 Figure 1. Trends in men hemoglobin A 1c, totl cholesterol, nd blood pressure levels. 9.0 Blck 5.4 Blck HbA 1c, % Cholesterol, mmol/l Yer Yer 150 Blck 84 Blck Systolic BP, mmhg Distolic BP, mmhg Yer Yer BP = blood pressure; HbA1c = hemoglobin A1c; QOF = Qulity nd Outcomes Frmework. Note: spnned -, QOF introduced in, spnned -. Tbles 1 nd 2, vilble t Overll Disprities Trend in Risk Fctor Control Throughout the study period blck ptients hd higher men HbA 1c levels nd systolic nd distolic blood pressure when compred with the white group. Blck ptients continued to hve signifi cntly higher HbA 1c levels, nd systolic nd distolic blood pressure before nd fter QOF compred with white ptients. Similrly, throughout the study period ptients hd higher HbA 1c levels but lower systolic nd distolic blood pressures when compred with the white group. At the end of study ptients continued to hve higher levels of HbA 1c when compred with white ptients. Both blck nd South Asin ptients hd lower cholesterol levels when compred with the white group. Tble 3. Interrupted Time Series Anlysis for Men Cholesterol Levels Prmeter Level chnge QOF = Qulity nd Outcomes Frmework. P <.01. b P <.05. Cholesterol, mmol/l (95% CI) All Ptients Blck ( 0.15 to 0.11) ( 0.17 to 0.12) ( 0.14 to 0.08) ( 0.17 to 0.08) ( 0.18 to -0.06) ( 0.21 to 0.05) ( 0.20 to 0.01) b ( 0.20 to 0.04) (0.01 to 0.05) b (0.01 to 0.08) b ( 0.01 to 0.07) 0.02 ( 0.03 to 0.07) 231

5 DISCUSSION As in previous reserch on the qulity of cre delivered to dibetes ptients in the United Kingdom before the introduction of QOF, 17 our nlysis indictes n underlying of generl improvements in HbA 1c, cholesterol, nd blood pressure control predting QOF. The introduction of this py-for-performnce scheme ppered to hve only modest impct on some intermedite outcomes; it ws ssocited with initil ccelerted improvements in systolic blood pressure in white nd blck ptients, but these improvements were sustined only in blck ptients. Initil improvements in distolic blood pressure in white ptients nd in cholesterol level in blck nd white ptients were not sustined in the period. There ws no benefi cil impct of QOF on HbA 1c levels in ny ethnic group. Existing disprities in risk fctor control remined lrgely intct t the end of the study period. Our fi ndings tht QOF hd no signifi cnt effect on men HbA 1c levels (they ctully incresed slightly during the yers) is in keeping with previous fi nd ing s. 18 Cmpbell et l, 19 found signifi cnt chnge in the level of performnce for dibetes cre ssocited with QOF introduction; however, it is diffi cult to compre it with our fi ndings, s they performed their nlysis using summry indictor rther thn individul indictors. Furthermore, their nlysis used prctice-level dt nd did not djust for vrious ptient-level covrites. Clvert et l found smll improvement in the HbA 1c trget level of 7.5% nd no improvement ws evident for trget level of 10%. The uthors, however, did not use segmented time series nlysis. 20 Few studies hve evluted the impct of py-for-performnce progrms on ethnic group disprities in helth cre. We hve previously shown tht the introduction of QOF ws ssocited PAY FOR PERFORMANCE AND DISPARITIES IN DIABETES OUTCOMES with incresed disprities in risk fctor control. 10 The present study dds to this reserch by exmining the longer term impct of this py-for-performnce progrm on the qulity of dibetes mngement using segmented time series methodology. Our study hs number of strengths nd limittions. The QOF ws implemented ntionlly, which ment we did not hve control over the introduction of the intervention, nd s such, we could not use rndomized controlled tril to evlute its impct. Nevertheless, the interrupted time series used is robust qusi-experimentl method tht cn withstnd mny bises nd is superior to before-fter study designs tht do not tke underlying s into ccount. 21 Further, s QOF ws the only mjor qulity improvement inititive introduced in primry cre during, it is Tble 4. Interrupted Time Series Anlysis for Men Systolic nd Distolic Blood Pressure Prmeter Systolic Level chnge Distolic Level chnge Blood Pressure, mm Hg (95% CI) All Ptients Blck 0.03 ( 0.31 to 0.25) 0.50 ( 0.93 to 0.08) 0.31 ( 0.20 to 0.83) 0.42 ( 0.16 to 1.01) ( 2.87 to 1.02) b ( 3.48 to 0.77) b ( 4.03 to 0.61) b ( 2.97 to 0.08) ( 1.42 to -0.64) b ( 0.80 to 0.37) ( 2.41 to 0.95) b ( 2.60 to 0.98) b ( 1.00 to 0.67) b ( 0.93 to 0.44) b ( 1.14 to 0.54) b ( 1.41 to 0.72) b 0.51 ( 1.05 to 0.01) 0.19 ( 0.03 to 0.41) QOF = Qulity nd Outcomes Frmework. P <.05 b P < ( 1.79 to 0.24) ( 1.32 to 0.65) 0.10 ( 0.23 to 0.43) 0.12 ( 0.30 to 0.54) Tble 5. Ethnic Differences in Men Risk Fctor Levels Before nd After QOF nd Pooled 8-Yer Differences From to HbA 1c % (95% CI) 0.20 ( 0.90 to 1.30) 0.40 ( 0.07 to 0.87) Cholesterol mmol/l (95% CI) Ethnic Group Difference Difference ( 0.15 to 0.06) ( 0.54 to 0.39) Blck ( 0.35 to -0.02) ( 0.32 to -0.02) HbA1c = hemoglobin A1c; QOF = Qulity nd Outcomes Frmework ( 0.47 to 0.29) ( 0.58 to 0.35) Indictes significnt differences to white group t 5% level fter djusting for ge, sex, socioeconomic sttus, number of comorbidities, nd prctice-level clustering. 232

6 resonble to ttribute ny dditionl improvements in dibetes mngement seen to this policy. Chnges in our popultion during the study period could hve ffected our estimte, but such bis would be limited becuse we used individul-level, longitudinl dt on ptients. Our study is bsed on retrospective dt from ptients registered with prctices in, which mens tht we do not hve informtion on ptients who died or chnged their prctice during the study period. Our sensitivity nlyses, which ccounted for the possibility of ttrition bis, yielded results substntiting the robustness of fi ndings from our min nlysis. Becuse there were only few ptients in some of the ethnic groups, we hd to combine ptients into 3 min groups. We ccept tht such grouping might msk differences in dibetes mngement. 22 We were not ble to distinguish between ptients with type 1 nd type 2 dibetes. Our fi ndings were derived from one primry cre orgniztion in the United Kingdom nd my not refl ect the impct of QOF in other prts of the country or be trnsferble to py-for-performnce progrms in other helth systems. Finlly, we used prctice-bsed postl codes to ssign deprivtion scores to ptients, which my not present true estimtion of their individul socioeconomic position. Our fi ndings suggest tht this mjor py-forperformnce progrm hs not ddressed importnt disprities in chronic disese mngement in its fi rst 3 yers; tht is, the fi ndings re thus fr not consistent with the inverse equity hypothesis tht disprities will be reduced over time. Our fi ndings do provide support for the view tht trgeted qulity improvement strtegies my be required to ddress disprities in chronic disese mngement. Designers of py for performnce should weigh the effect of such schemes on minority ptients nd consider incorporting trgeted incentives to ddress the persistence of such disprities. Locl efforts in the United Kingdom to reduce disprities by Systolic Blood Pressure mm Hg (95% CI) Distolic Blood Pressure mm Hg (95% CI) Difference Difference ( 6.5 to 4.3) ( 7.8 to 4.9) ( 6.8 to 3.6) ( 3.2 to 1.9) ( 3.5 to 1.8) ( 3.8 to 1.9) using fi nncil incentives to improve cre in minority groups nd monitor progress through better recording of ethnicity nd fi rst lnguge my represent promising step forwrd. 23 To red or post commentries in response to this rticle, see it online t Key words: py for performnce; disprities; dibetes Submitted Mrch 18, 2011; submitted, revised, August 3, 2011; ccepted September 6, Author contributions: Riydh Alshmsn hd full ccess to ll of the dt in the study nd tkes responsibility for the integrity of the dt nd the ccurcy of the dt nlysis. Funding support: This study represents independent reserch commissioned by the Ntionl Institute for Helth Reserch (NIHR) Service Delivery & Orgniztion progrm (08/1716/209). The Wndsworth Primry Cre Reserch Centre hs received funding from the Deprtment of Helth. Deprtment of Primry Cre & Public Helth t Imperil College London received support from the NIHR Biomedicl Reserch Centre scheme; the NIHR Collbortion for Ledership in Applied Helth Reserch & Cre scheme, nd the Imperil Centre for Ptient Sfety nd Service Qulity. Dr Netuveli is supported by ESRC Interntionl Centre for Life Course Studies in Society nd Helth (RES ). Disclimer: The views expressed in this publiction re those of the uthors nd not necessrily those of the Ntionl Helth Service, the Ntionl Institute for Helth Reserch, or the Deprtment of Helth. References 1. Millett C, Gry J, Sxen S, Netuveli G, Khunti K, Mjeed A. Ethnic disprities in dibetes mngement nd py-for-performnce in the UK: the Wndsworth Prospective Dibetes Study. PLoS Med. ;4(6):e Chien AT, Chin MH, Dvis AM, Cslino LP. Py for performnce, public reporting, nd rcil disprities in helth cre: how re progrms being designed? Med Cre Res Rev. ;64(5)(Suppl): 283S-304S. 3. Werner RM, Asch DA, Polsky D. Rcil profiling: the unintended consequences of coronry rtery bypss grft report crds. Circultion. ;111(10): Alshmsn R, Mjeed A, Ashworth M, Cr J, Millett C. Impct of py for performnce on inequlities in helth cre: systemtic review. J Helth Serv Res Policy. 2010;15(3): Vn Herck P, De Smedt D, Annemns L, Remmen R, Rosenthl MB, Sermeus W. Systemtic review: Effects, design choices, nd context of py-for-performnce in helth cre. BMC Helth Serv Res. 2010;(Aug): Victor CG, Vughn JP, Brros FC, Silv AC, Tomsi E. Explining s in inequities: evidence from Brzilin child helth studies. Lncet. ;356(9235): Ho K, Moy E, Clncy CM. Cn incentives to improve qulity reduce disprities? Helth Serv Res. 2010;45(1): Deprtment of Helth. The NHS Improvement Pln: Putting People t the Hert of Public Services. London: Deprtment of Helth;. 9. World Helth Orgniztion. Closing the Gp in Genertion: Helth Equity through Action on the Socil Determinnts of Helth. Finl Report of the Commission on Socil Determinnts of Helth. Switzerlnd, Genev: World Helth Orgniztion;

7 10. Millett C, Netuveli G, Sxen S, Mjeed A. Impct of py for performnce on ethnic disprities in intermedite outcomes for dibetes: longitudinl study. Dibetes Cre. 2009;32(3): Gry J, Orr D, Mjeed A. Use of Red codes in dibetes mngement in south London primry cre group: implictions for estblishing disese registers. BMJ. ;326(7399): Mjeed A. Sources, uses, strengths nd limittions of dt collected in primry cre in Englnd. Helth Stt Q. ;(21): Deprtment of Communities nd Locl Government. Indices of Deprivtion. deprivtion07/. Accessed Dec 12, Eccles M, Grimshw J, Cmpbell M, Rmsy C. Reserch designs for studies evluting the effectiveness of chnge nd improvement strtegies. Qul Sf Helth Cre. ;12(1): Wgner AK, Soumeri SB, Zhng F, Ross-Degnn D. Segmented regression nlysis of interrupted time series studies in mediction use reserch. J Clin Phrm Ther. ;27(4): Heckmn JJ. Smple Selection Bis s Specifiction Error. Econometric. 1979;47(1): Lusignn S, Sismnidis C, Crey IM, DeWilde S, Richrds N, Cook DG. Trends in the prevlence nd mngement of dignosed type 2 dibetes in Englnd nd Wles. BMC Fm Prct. ; 6(1): Millett C, Bottle A, Ng A, et l. Py for perfomnce nd the qulity of dibetes mngement in individuls with nd without co-morbid medicl conditions. J R Soc Med. 2009;102(9): Cmpbell SM, Reeves D, Kontopntelis E, Sibbld B, Rolnd M. Effects of py for performnce on the qulity of primry cre in Englnd. N Engl J Med. 2009;361(4): Clvert M, Shnkr A, McMnus RJ, Lester H, Freemntle N. Effect of the qulity nd outcomes frmework on dibetes cre in the United Kingdom: retrospective cohort study. BMJ. 2009;338:b Bigln A, Ary D, Wgenr AC. The vlue of interrupted time-series experiments for community intervention reserch. Prev Sci Mr. ;1(1): Bhopl R, Unwin N, M, et l. Heterogeneity of coronry hert disese risk fctors in Indin, Pkistni, Bngldeshi, nd Europen origin popultions: cross sectionl study. BMJ. 1999;319 (7204): Millett C, Mjeed A, Huckvle C, Cr J. Going locl: devolving ntionl py for performnce progrmmes. BMJ. 2011;342:c7085. CHANGE-OF-ADDRESS FORM Plese complete this form nd mil to the following ddress or fx to Annls Circultion t : Annls of Fmily Medicine, Circultion Deprtment, Tomhwk Creek Pkwy, Lewood, KS Check if member of sponsoring orgniztion: AAFP ABFM STFM ADFM AFMRD NAPCRG CFPC ID number from lbel on your journl cover OLD Informtion (Plese print.) NEW Informtion (Plese print.) Nme Nme Compny (if pplicble) Compny (if pplicble) Address (Street plus Apt or Ste) Address (Street plus Apt or Ste) City Stte City Stte Country Postl Code (9-digit ZIP for US) Country Postl Code (9-digit ZIP for US) Telephone Fx Telephone Fx E-Mil E-Mil 234