Post on 30-Dec-2015
description
Doran
Quality of primary care under the UK pay-for-performance scheme
T Doran, C Fullwood, E Kontopantelis, D Reeves,
J Valderas, S Campbell, M RolandNational Primary Care Research and Development Centre
University of Manchester
CEO Forum Kananaskis, 16 February 2009
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
Outline
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
1. The UK pay-for-performance scheme• Background• The Quality and Outcomes Framework
2. Results from Years 1-4 (2004-05 to 2007-08)• Overview• Achievement of targets• Inequalities in quality of care
3. Quality of care before and after the introduction of P4P• Identification of cases• Achievement of process indicators• Achievement of intermediate outcomes indicators• Quality of care for non-incentivised activities
Outline
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
1. The UK pay-for-performance scheme• Background• The Quality and Outcomes Framework
2. Results from Years 1-4 (2004-05 to 2007-08)• Overview• Achievement of targets• Inequalities in quality of care
3. Quality of care before and after the introduction of P4P• Identification of cases• Achievement of process indicators• Achievement of intermediate outcomes indicators• Quality of care for non-incentivised activities
BackgroundThe Quality and Outcomes Framework
BackgroundImproving quality of UK primary care in the late 1990s
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
o Recognition of the need for quality improvement• Acknowledgement of poor quality care by medical profession • Recognition of health inequalities by Government• Prioritisation of quality improvement initiatives by Department
of Health (DH)
o Additional funding for health services• Government increased funding to NHS
- £69bn (C$130bn) in 2004 £92bn (C$175bn) in 2008• DH determined to address low morale in primary care
o Quality improvement initiatives • National Service Frameworks for major chronic diseases• Audit, inspection and revalidation of doctors• Public release of outcomes data• Computerisation of patient records
BackgroundThe Quality and Outcomes Framework
The Quality and Outcomes Framework (QOF)The original framework
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
o Introduced in April 2004 for all practices in the UKo Family practitioner income increased by ~25% dependent
on performance against 146 quality indicatorso Each indicator allocated between 0.5 and 56 points
(1,050 in total)o Each point earns an average practice £76 (C$144)oMaximum of
• £79,800 (C$151,600) per practice• £25,000 (C$47,500) per physician
o Achievement scores are publicly reported• www.qof.ic.nhs.uk
BackgroundThe Quality and Outcomes Framework
The quality indicatorsClinical indicators
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
BackgroundThe Quality and Outcomes Framework
Disease area Indicators Points
asthma 7 72
cancer 2 12
chronic obstructive pulmonary disease 8 45
coronary heart disease 15 121
diabetes 18 99
epilepsy 4 16
hypertension 5 105
hypothyroidism 2 8
mental health 5 41
stroke 10 31
total 76 550
The quality indicatorsOrganisational indicators
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
BackgroundThe Quality and Outcomes Framework
Activity Indicators Points
Organisation of care 56 184
record keeping 19 85
patient communication 8 8
education and training 9 29
practice management 10 20
medicines management 10 42
Patient experience 4 100
Additional services 10 36
Access --- 50
Overall quality --- 30
Holistic care --- 100
total 70 500
New indicators for Year 3 (2006-07)Clinical indicators
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
BackgroundThe Quality and Outcomes Framework
Disease area Indicators Points
atrial fibrillation 3 30
chronic kidney disease 4 27
dementia 2 20
depression 2 33
learning difficulties 1 4
obesity 1 8
palliative care 2 6
(smoking 2 68)
total 15 128
Achievement thresholdsCHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
BackgroundThe Quality and Outcomes Framework
Minimum threshold
Maximum threshold
•Points: 0 to 19 points
•Income:£0 to £1,444 (C$ 2,744)
•Points: 0 to 19 points
•Income:£0 to £1,444 (C$ 2,744)
Protecting patients against inappropriate treatmentException reporting
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
o Physicians may exclude (‘exception report’) patients for whom targets are inappropriate
o Discretionary exception reporting:• treatment not tolerated• patient terminally ill, exceptionally frail or has
supervening conditiono Non-discretionary exception reporting:
• patient refuses intervention or repeatedly refuses to attend
• patient newly registered or diagnosed• service not available to practice
BackgroundThe Quality and Outcomes Framework
Outline
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
1. The UK pay-for-performance scheme• Background• The Quality and Outcomes Framework
2. Results from Years 1-4 (2004-05 to 2007-08)• Overview• Achievement of targets• Inequalities in quality of care
3. Quality of care before and after the introduction of P4P• Identification of cases• Achievement of process indicators• Achievement of intermediate outcomes indicators• Quality of care for non-incentivised activities
OverviewAchievement of targetsInequalities in quality of care
Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
OverviewAchievement of targetsInequalities in quality of care
NHS Information Centre (www.qof.ic.nhs.uk)
Year % of total points scored
% of clinical points scored
Mean earnings per physician
2004-05 91.3% 92.4% £22,750 (C$ 43,225)
2005-06 96.3% 97.1% £39,490 (C$ 75,030)
2006-07 95.5% 96.3% £37,300 (C$ 70,870)
2007-08 96.8% 97.5% £37,800 (C$ 71,820)
Results for Years 1-4Points scored and remuneration
Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
OverviewAchievement of targetsInequalities in quality of care
Achievement of clinical targetsOverall achievement for 50 ‘stable’ indicators
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Percentage achievement
Mean:Year 1 82.3%Year 2 87.8%Year 3 89.7%Year 4 90.0%
Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
OverviewAchievement of targetsInequalities in quality of care
Exclusion of patientsOverall exception reporting rates for 50 ‘stable’ indicators
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Percentage excluded
Mean:Year 2 7.1%Year 3 7.8%Year 4 7.1%
Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
OverviewAchievement of targetsInequalities in quality of care
Inequality in quality of careAchievement by area deprivation quintile
Doran et al. Lancet 2008; 372: 728-736.
QOF year
Ove
rall
repo
rted
achi
evem
ent
04/05 05/06 06/07
020
4060
8010
0
Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5
2004-05 2005-06 2006-07
Outline
Doran Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
1. The UK pay-for-performance scheme• Background• The Quality and Outcomes Framework
2. Results from Years 1-4 (2004-05 to 2007-08)• Overview• Achievement of targets• Inequalities in quality of care
3. Quality of care before and after the introduction of P4P• Identification of cases• Achievement of process indicators• Achievement of intermediate outcomes indicators• Quality of care for non-incentivised activities
PrevalenceIncentivised processesIncentivised outcomesNon-incentivised activities
Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
PrevalenceIncentivised processesIncentivised outcomesNon-incentivised activities
Incentivised process DM4: Smoking advice offered in previous 15 months (5 points)
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Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
PrevalenceIncentivised processesIncentivised outcomesNon-incentivised activities
Incentivised process DM11: Record of blood pressure in previous 15 months (3 points)
Doran
Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
PrevalenceIncentivised processesIncentivised outcomesNon-incentivised activities
Incentivised intermediate outcomeDM12: Last recorded blood pressure is ≤ 145/85 mmHg (17 points)
Doran
Quality of care under the UK P4P scheme
UK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF
PrevalenceIncentivised processesIncentivised outcomesNon-incentivised activities
Non-incentivised patient groupRecord of blood pressure in last 15m, all patients aged 25-44
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SummaryIntended outcomes of the QOF
Doran Quality of care under the UK P4P scheme
Summary
o Improving quality of care• Achievement for most incentivised activities increased over the first 3
years, but there was little improvement in Year 4• Improvement over underlying trend for processes with low baseline • Marginal improvement over trend for outcomes activities
o Reducing variations in quality of care• The poorest performing practices improved at the fastest rate• Overall inequalities in quality of care for incentivised activities almost
disappeared by Year 3
o Keeping physicians happy• Over 4,000 additional physicians recruited (15% increase) • Income of principals increased by 58% (£41,600/ C$79,000)• Income of salaried physicians increased by 3% (£2,200/ C$4,200)
Intended outcomesUnintended outcomesConclusions
SummaryUnintended outcomes of the QOF
Doran Quality of care under the UK P4P scheme
Summary
o Reducing quality of care• Quality of care for non-incentivised activities may have declined after
the introduction of the QOF
o Excluding patients• Practices in deprived areas excluded marginally more patients• Some practices struggling to hit maximum achievement thresholds
inappropriately excluded patients in order to maximise income• Some practices removed patients from chronic disease registers • Patients have had little input to the QOF to date
o Reducing staff morale• Pressure on staff to hit QOF targets has caused some dissatisfaction• Rewards from QOF have not been equitably distributed
Intended outcomesUnintended outcomesConclusions
ConclusionsLessons from the UK’s experiment with pay-for-performance
Doran Quality of care under the UK P4P scheme
Summary
o Put the necessary infrastructure in place• Installation of computing systems subsidised by Government• Several years of audit and quality improvement preceded the QOF
o Get physicians on-side• Indicators based on evidence (or at least expert opinion)• Generous remuneration for achieving targets
o Establish a baseline• Quality of care was already improving when QOF introduced• Most practices were already achieving above the maximum thresholds
o Regularly review the framework and the indicators• QOF reviewed and indicators updated every 1-2 years• In future the cost-effectiveness of indicators will be assessed by the
National Institute for Health and Clinical Excellence (NICE)• Potential new indicators will be piloted• Local QOFs will be introduced to address local priorities
Intended outcomesUnintended outcomesConclusions
Further readingResources and papers on the UK QOF
Doran Quality of care under the UK P4P scheme
o Resources• Department of Health. The Quality and Outcomes Framework. Available from:
http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/index.htm • The NHS Information Centre. Online GP Practice Results Database. Available from: http://www.qof.ic.nhs.uk/
o Published research• Ashworth M, Seed P, Armstrong D, Durbaba S, Jones R. The relationship between social deprivation and the quality of
primary care: a national survey using indicators from the UK Quality and Outcomes Framework. British Journal of General Practice 2007: 57: 441-448.
• Campbell S, Reeves D, Kontopantelis E, et al. Quality of primary care in England with the introduction of pay for performance. New England Journal of Medicine 2007; 351: 181-190.
• Doran T, Fullwood C, Gravelle H, et al. Pay for performance programs in family practices in the United Kingdom. New England Journal of Medicine 2006; 355: 375-384.
• Doran T, Fullwood C, Reeves D, et al. Exclusion of patients from pay-for-performance targets by English physicians. New England Journal of Medicine 2008; 359: 274-284.
• Doran T, Fullwood C, Kontopantelis E, Reeves D. Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework. Lancet 2008; 372: 728-736.
• Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: further evidence from the quality and outcomes framework. CHE Research Paper 32. York: Centre for Health Economics, 2008.
• Gray J, Millett C, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnicity and quality of diabetes care in a health system with universal coverage: population-based cross sectional survey in primary care. J Gen Intern Med. 2007; 22(9): 1317-1320.
• Guthrie B, McLean G, Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. British Journal of General Practice. 2006; 56: 836-841.
• McDonald R, Harrison S, Checkland K, Campbell S, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. British Medical Journal 2007; 334: 1357-1362.
• Roland M. Linking physicians’ pay to the quality of care – a major experiment in the United Kingdom. New England Journal of Medicine. 2004; 351: 1448-1454.
Further readingUK pay-for-performance schemeResults for 2004-05 to 2007-08
Quality pre- and post- QOF