The Quality & OutcomesFramework – triumph ortragedy?Steve Gillam26.10.11
On this day… „Mr Atlee is a very modest man. Indeed, he has a lot to be modest about.‟ „I‟m just preparing my impromptu remarks.‟ „If this is a blessing, it is certainly very well disguised.‟ „A pessimist sees the difficulty in every opportunity; the optimist sees the opportunity in every difficulty.‟
Outline Background Methods Main findings Impact of QoF Implications
Background International literature on pay for performance (P4P) Introduced in 2004 in the UK >£1billion per annum 22% GP income Largest natural experiment in P4P in the world Precursor schemes, e.g. PRICCE
Domains for quality indicators in QOF 2010 Clinical Secondary prevention of coronary heart disease Organisational Cardiovascular disease: primary Records and information prevention Information for patients Heart failure Education and training Stroke & TIA Practice management Hypertension Medicines management Diabetes mellitus COPD Epilepsy Hypothyroid Patient experience Cancer Length of consultations Palliative care Patient survey (access) Mental health Asthma Dementia Depression Additional services Chronic kidney disease Cervical screening Atrial fibrillation Child health surveillance Obesity Maternity services Learning disabilities Contraception Smoking
QOFability – ideal indicator is Acceptable Attributable Feasible Reliable Sensitive to change Of predictive value Relevant
Methods Systematic review of all published research till end august 2011 Medline, EMBASE, CINAHL, PsycINFO, Health Business Elite, Health Management Information Consortium, British Nursing Index, Econ Lit 575 research papers identified; 124 selected for review
Main findings Health care gains Population health and equity Cost effectiveness Impact on providers and teams Patients‟ experience
Health care gains Real but modest gains in some areas, e.g. asthma, DM (?trendlines) Better recording in QOF areas but not untargeted areas No definitive improvement in outcomes, except possibly epilepsy/DM admissions Doran et al. N Engl J Med 2009;361:368-78.
Population health and equity Inequalities related to deprivation slowly narrowing Reductions in age-related differences for CVD/diabetes Variable effects for e.g. gender related differences in CHD Lancet 2008; 372: 728–36Dixon, Khachatryan & Boyce. The public health impact, In Gillam & Siriwardena (eds) TheQuality and Outcomes Framework, Radcliffe, Oxford 2010.
High risk individual and population basedstrategies for prevention (Rose) Identify and treat Shift the whole those beyond a population threshold for risk distribution of risk factor factor
QOF scores nationally (% total points) andchanges in exception reporting rates 2004-2009 Limited evidence of ‘gaming’ but does ER reduce QOF’s impact on neediest populations?
Costs and effectiveness No relationship between pay and health gain Limitations to modeling, e.g. omit costs of implementation Cost effectiveness evidence studied for 12 indicators in the 2006 revised contract with direct therapeutic effect (Fleetcroft et al). 3 most cost-effective indicators were: ACEI/ARB for CKD Anticoagulants for AF and Beta-blockers for CHD
Costs and effectiveness Modest mortality reductions modelled - potential saving of 11 lives per 100,000 people per year across all indicators (Fleetcroft et al). Average indicator payments ranged from £0.63 to £40.61 per patient; the percentage of eligible patients treated ranged from 63% to 90% (Walker et al). Improvements in performance required for QOF payments to be cost-effective varied by indicator from less than 1% to 20% (Walker et al).
Impact on providers and teams Changing structures, roles and staff – nurse-led care Greater use of information technology Restratification: „chasers‟ and „chased‟ Emphasis on the biomedical Commodification of care Narrative of „no change‟Checkland & Harrison. Impact of QOF on practice organisation and service delivery. SocSciMed, 2008.
Checkland & Harrison. Impact of QOF on practice organisation and delivery. Soc Sci Med, 2008. „Every day I come in I check (performance)… I‟m a chaser… You have to chase yourself though. You‟ve no credibility if you don‟t deliver.‟ „Some patients will come to you and they‟ll plead with you: „please don‟t give me any tablets, I‟ll bring my bp down, I‟ll do everything…but we‟re saying to them: „well look, we‟ve checked it three times now and it remains raised, you‟re clinically classed as hypertensive, we follow these guidelines and this is what we should be doing with you.‟ „All I think QOF did was make it a bit more organised and that. I don‟t think it was anything new.‟
Patients’ experience Little research on patient related/reported impact Continuity and relationships affected Fragmentation of care Little explanation provided to patients “A slim, active 69-year-old patient attending for influenza vaccine was faced with questions about diet, smoking, exercise and alcohol consumption. There was no explanation for why these questions were asked; they seemed irrelevant to having a „flu vaccine. Blood pressure and weight had to be recorded and a cholesterol test organised. A short appointment lasted almost 15 minutes without the patient having the opportunity to ask a question about any aspect of „flu vaccine.”
Summary - QOF balance sheet Better data recording and analysis Modest health benefits for individuals and populations Narrowing of inequalities in processes of health care Improved team-working Opportunity costs unknown, e.g. impact on preventive care Unintended consequences: on workforce, professionalism Scientific bureaucratic medicine and the McDonaldisation of care Re-defined meaning of „quality‟
Implications – ways forward Limit expansion but expand local discretion Options Leave indicators unchanged and anticipate higher achievement each year Add new indicators or conditions Select from a larger set of evidence-based measures Remove measures once agreed level achieved Rotate measures