NAPCRG 2009 - Impact of the QOF on quality of English primary care
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The document summarizes a study that analyzed the impact of the Quality and Outcomes Framework (QOF), a pay-for-performance scheme introduced in 2004 for primary care in the UK. The study used an interrupted time series analysis of clinical quality data from 1998 to 2007 to evaluate whether quality of care improved for conditions like asthma, coronary heart disease, and diabetes after the introduction of QOF. The results showed QOF accelerated short-term quality improvements for asthma and diabetes but had a more mixed impact for coronary heart disease. Post-QOF trends differed between incentivized and non-incentivized quality measures for some conditions. Overall, the study found significant quality improvements over time but a nuanced effect of the Q
NAPCRG 2009 - Impact of the QOF on quality of English primary care
- 1. Background Quality Incentives in Practice (QuIP) study Results Impact of the Quality and Outcomes Framework pay-for-performance scheme on quality of English primary care An interrupted time series analysis Evangelos Kontopantelis Stephen Campbell* David Reeves Martin Roland National Primary Care Research and Development Centre University of Manchester England NAPCRG, 15th November 2009 Kontopantelis The QOF impact
- 2. Background Quality Incentives in Practice (QuIP) study Results Manchester! Kontopantelis The QOF impact
- 3. Background Quality Incentives in Practice (QuIP) study Results Manchester! Kontopantelis The QOF impact
- 4. Background Quality Incentives in Practice (QuIP) study Results Manchester! Kontopantelis The QOF impact
- 5. Background Quality Incentives in Practice (QuIP) study Results Outline 1 Background Change! UK pay-for-performance scheme 2 Quality Incentives in Practice (QuIP) study General information At a glance Method 3 Results Overall clinical scores Incentivised vs non-incentivised Summary Kontopantelis The QOF impact
- 6. Background Quality Incentives in Practice (QuIP) study Results Change! UK pay-for-performance scheme Timeline. 80s: Determinism: Quality cannot be measured. There is no such thing as a bad doctor. Early 90s, a wind of change: Government: improving health care became a priority. Care is too variable but can be expensive to improve. Academics: developed methods for measuring quality. Doctors: cultural shift towards accepting that quality needs to be measured and improved. By 1997, Reversal of perception, guidelines & standards: Quality can be measured. Care is too variable and can improved. Providing high quality care is expensive. Doctors want to be rewarded for providing high quality care. Kontopantelis The QOF impact
- 7. Background Quality Incentives in Practice (QuIP) study Results Change! UK pay-for-performance scheme Improving quality of care. A (very) juicy carrot... A P4P program kicked off in April 2004 with the introduction of a new FP contract. Family practices are rewarded for achieving a set of quality targets for patients with chronic conditions. The aim was to increase overall quality of care and to reduce variation in quality between practices. The incentive scheme for payment of FPs was named Quality and Outcomes Framework (QOF). A continuation of disease specific non-incentivised quality improvement initiatives, introduced in previous years. Kontopantelis The QOF impact
- 8. Background Quality Incentives in Practice (QuIP) study Results Change! UK pay-for-performance scheme Quality and Outcomes Framework. Indicator details relate to Year 1. Estimated cost of $3b, over 3 years (escalated to $4.7b). FP income increased by up to 25%. 146 quality indicators. Clinical care for 10 chronic diseases (76 indicators). Organisation of care (56 indicators). Additional services (10 indicators). Patient experience (4 indicators). Implemented simultaneously in all practices. Some of the (clinical) indicators: % of diabetics with a record of HbA1c measurement, or equivalent, in the previous 15 months (3p). % of diabetics in whom the last HbA1c measurement, was ≤7.4 in the previous 15 months (16p). Kontopantelis The QOF impact
- 9. Background Quality Incentives in Practice (QuIP) study Results Change! UK pay-for-performance scheme More on QOF. QOF is reviewed at least every two years. Not compulsory but over 99% of practices participating. Required a complete computerization, carried out by various contracted companies. In effect, the FP sees a ‘pop-up’ on his/her computer screen with QOF-related advice about the specific patient. At the end of the year (March) performance is measured and a bit later lists of shame appear... Kontopantelis The QOF impact
- 10. Background Quality Incentives in Practice (QuIP) study Results General information At a glance Method Design and the question. Aim: To evaluate the impact of QOF and the ‘new’ 2004 contract for FP on the quality of care provided in family practice. Design: Longitudinal time series with 4 time points: 1998, 2003, 2005 and 2007. Data extracted from medical records of random cross-sectional samples of patients with asthma, CHD or diabetes. Sample of 42 representative English practices. On average, around 12 patients per condition, per practice. Kontopantelis The QOF impact
- 11. Background Quality Incentives in Practice (QuIP) study Results General information At a glance Method 1998-2003. Life before the QOF. Quality was already improving. How will the new contract affect quality of care... No change? Change in level but not slope? Change in level & slope? Change: quality fall? Kontopantelis The QOF impact
- 12. Background Quality Incentives in Practice (QuIP) study Results General information At a glance Method 1998-2007. QOF in the middle. Quality was higher in 2005 and 2007, compared to 1998 and 2003. Is the improvement observed in 2005 above what was expected from the pre-QOF trend? Is the post-QOF trend different to the pre-QOF one? Is the improvement limited to monetary incentivised indicators within QOF? 55 60 65 70 75 80 85 90 % 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 year Coronary heart disease Asthma Diabetes 40, 42 and 42 practices respectively in total Clinical performance Kontopantelis The QOF impact
- 13. Background Quality Incentives in Practice (QuIP) study Results General information At a glance Method The approach. Interrupted Time Series analysis on logit transformed scores. ITS multivariate regressions, allowed us to estimate: The level difference between the observed and the estimated* score in 2005. The change in slope from the pre- to the post-QOF trend. Due to the ceiling effect we applied the method to logit-transformed scores. 20 30 40 50 60 70 80 90 100 Performance(%) 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 Years Observations Regression line, pre−QOF Regression line, post−QOF pre−QOF line extended level change Kontopantelis The QOF impact
- 14. Background Quality Incentives in Practice (QuIP) study Results Overall clinical scores Incentivised vs non-incentivised Summary Coronary Heart Disease. Quality had been improving for CHD prior to QOF (3.5% per year on average). In 2005, scores on quality rose slightly (but not significantly) higher than expected. The post-qof rate of improvement dropped. Kontopantelis The QOF impact
- 15. Background Quality Incentives in Practice (QuIP) study Results Overall clinical scores Incentivised vs non-incentivised Summary Asthma. Quality had been improving for Asthma prior to QOF (2.0% per year on average). In 2005, scores on quality rose significantly higher than expected. The post-qof rate of improvement did not change significantly. Kontopantelis The QOF impact
- 16. Background Quality Incentives in Practice (QuIP) study Results Overall clinical scores Incentivised vs non-incentivised Summary Diabetes. Quality had been improving for Diabetes prior to QOF (1.8% per year on average). In 2005, scores on quality rose significantly higher than expected. The post-qof rate of improvement did not change significantly. Kontopantelis The QOF impact
- 17. Background Quality Incentives in Practice (QuIP) study Results Overall clinical scores Incentivised vs non-incentivised Summary Comparing incentivised and non-incentivised indicators. Mean quality scores for incentivised aspects of care were higher. CHD: 2005 ‘jump’ was greater for incentivised aspects*. Post-QOF slope changes did not differ significantly* Asthma: post-QOF trends for the two groups diverged. DM: no differences. 30 40 50 60 70 80 90 100 % 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 year CHD incentivised CHD non−incentivised Asthma incentivised Asthma non−incentivised Diabetes incentivised Diabetes non−incentivised 40, 42 and 42 practices respectively in total Clinical performance Kontopantelis The QOF impact
- 18. Background Quality Incentives in Practice (QuIP) study Results Overall clinical scores Incentivised vs non-incentivised Summary Conclusions. For the three investigated major chronic diseases, there were significant improvements in measurable aspects of clinical performance between 1998 and 2007. The P4P scheme accelerated improvements in quality for asthma and diabetes in the short term between 2003 and 2005. Post-QOF rate of improvement dropped only for asthma (but 2003 to 2005 gains were very small for DM and CHD). The only clear difference that emerged from the inc vs non-inc comparison was for the asthma post-QOF trends. Kontopantelis The QOF impact
- 19. Appendix Thank you! UK P4P references Comments, suggestions: [email protected] Kontopantelis The QOF impact
- 20. Appendix Thank you! UK P4P references Relevant references. Just in care you are interested... Campbell S, Reeves D, Kontopantelis E, Middleton E, Sibbald B, Roland M. Quality of Primary Care in England with the Introduction of Pay for Performance. N Engl J Med, 357:181-90, July 12, 2007 Special Report. Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland M. Effects of Pay for Performance on the Quality of Primary Care in England. N Engl J Med, 361:368-78, July 23, 2009 Special Report. Kontopantelis The QOF impact