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 Roland.

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




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







BackgroundThe Quality and Outcomes Framework

BackgroundImproving quality of UK primary care in the late 1990s




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


The Quality and Outcomes Framework (QOF)The original framework




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


http://www.qof.ic.nhs.uk/

The quality indicatorsClinical indicators





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





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





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





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




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


Outline







OverviewAchievement of targetsInequalities in quality of care

Quality of care under the UK P4P scheme




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





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%





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%





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







PrevalenceIncentivised processesIncentivised outcomesNon-incentivised activities





Incentivised process DM4: Smoking advice offered in previous 15 months (5 points)

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Incentivised process DM11: Record of blood pressure in previous 15 months (3 points)

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Incentivised intermediate outcomeDM12: Last recorded blood pressure is ≤ 145/85 mmHg (17 points)

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Non-incentivised patient groupRecord of blood pressure in last 15m, all patients aged 25-44

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SummaryIntended outcomes of the QOF


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


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


ConclusionsLessons from the UK’s experiment with pay-for-performance


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


Further readingResources and papers on the UK QOF


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


http://www.dh.gov.uk/en/Healthcare/Primarycare/Primarycarecontracting/QOF/index.htm

http://www.qof.ic.nhs.uk/

Further information: [email protected]

Doran




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 Roland.

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