Helen Lester presentation WSPCR 2011


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Helen Lester presentation WSPCR 2011

  1. 1. The role of P4P in quality improvement Helen Lester University of Birmingham October 26th 2011
  2. 2. What I‟m going to cover• Where we‟ve come from• Where we are now and why• Where we‟re going…
  3. 3. Defining qualityQuality of care for individual patients• Access - can patients access the heath care they need?• Safe• Effectiveness - is it effective when they get there? • clinical or technical effectiveness • effectiveness of interpersonal careAdditional domains of quality for populations• Equity• Efficiency•  Leading to desired health outcomes
  4. 4. Background: Improving quality in the 1990sMotive:• Recognition of care variation by the medical profession• Recognition of care variation by GovernmentMeans:• Development of methods of measuring quality• Increasing computerisation of practices and electronic data record• Quality improvement initiatives: National Service Frameworks for major chronic diseases Audit• Rise of evidence based medicine
  5. 5. Quality of care in the UK improved between 1998 and 2003 90Overall score (max 100) 85 80 Angina 75 Diabetes 70 Asthma 65 60 55 50 1997 1998 1999 2000 2001 2002 2003 2004 Campbell et al. BMJ 2005; 331: 1121-1123
  6. 6. Background: Improving quality in the 2000s• “We want to be resourced and rewarded for providing high quality care”• In 2001, a BMA ballot found that 86% of GPs would consider resigning if a new contract could not be secured by the BMA• Political will to invest in the NHS underpinned by sustained economic growth
  7. 7. UK expenditure on health care since 1990
  8. 8. USA: P4P• In a national survey in USA, 52% of HMOs (covering 81% of enrollees) report using pay for performance (Rosenthal 2006)• Average of 5 performance measures per scheme• Rewards for reaching fixed threshold dominate; only 23% reward improvement• 5-7% of physician pay
  9. 9. Domains and points from April 2011Domain No. of Indicators Pts % of totalClinical 87 661 66Organisational 34 165.5 17Patient Experience 1 33 3Additional Services 9 44 4QP 11 96.5 10TOTAL 142 1000 100%
  10. 10. Achievement for 50 „stable‟ clinical indicators Median reported achievement: 2004/5 84.9% 2005/6 89.2% 2006/7 91.0% 2007/8 90.9% 2008/9 90.8%
  11. 11. Intended consequences What might the effects be?• Increased computerization• Better organised care - more systematic protocol driven care• Greater job satisfaction• Improved processes of care• May be some improvements in outcomes?
  12. 12. Trends in job satisfaction 7Mean overall satisfaction 6 5.23 4.67 4.62 5.24 5 4.26 3.95 4.6 4 3 2 1 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 Survey year
  13. 13. Estimated GP practice vacancies per 100,000 patients 2005 2006 2007 2008 2009 2010England 3 month 2.6% 1.2% 0.9% 0.3% 0.3% 0.5%GP vacancy rate
  14. 14. Improved care: data from QuIP 1998-2007 Campbell et al NEJM 2007; 357: 181-190 and 2009; 361: 368-378
  15. 15. AsthmaStep change in level (p<0.001)Improvement post 2005 continued at pre-contract rate(p=0.16)
  16. 16. Has P4P improved outcomes?• Data on associations between process performance and outcomes are mixed• Work in press from Tim Doran based on QOF suggests that in absolute terms, improvement in process performance between 2004-8 resulted in improvement in intermediate outcomes performance ofo 1.3% (BP)o 2.0% (CVA)o 2.2% (Diabetes)o 3.6% (CHD)
  17. 17. Impact of P4P on hospital costs and mortality• “The headline finding from this research is that there is an association between achievement of QOF indicators and some measurable reduction in costs for hospital care and mortality outcomes. This association is stronger for some QOF indicators than others and particularly strong for stroke care.”• A single point increase in QOF stroke scores across England was associated with:o 2,385 fewer deaths a yearo Reduction in secondary care costs of £22.15 million a year (Health Foundation report: Do quality improvements in primary care reducesecondary care costs? February 2011)
  18. 18. Unintended consequences• Transaction costs• Changes to practice nurse and salaried doctor roles• Less holistic approach• Less attention to non incentivised areas of care• Equitable health intervention
  19. 19. Transaction costs• Year 1 (04-05) £76 per point £624,132,687• Year 2 (05-06) £125 per point £1,063,583,954• Year 3 (06-07) £125 per point £1,268,175,404
  20. 20. Overpaid NHS doctors and too few practitioners knocks three years off Britons livesBritons would be far healthier if the NHS paid its doctors less but employedmore of them, a shock international report has concluded.UK health spending is on a par with other prosperous countries - but itspeople are less healthy because too much of the money goes towards GPsand consultants pay packets.At the same time, Britain has fewer doctors per head of population than mostcountries in the Western World - and owns far less hi-tech equipment such ascancer scanners because it cannot afford them.Daily Mail 30th November 2010
  21. 21. What do patients think?• 52 patients on QOF chronic disease registers in 15 practices across England• Interviewed at length Jan-March 2011• Thought the status quo was great and high trust in their GPs• No one had heard of QOF• Almost all thought it strange to reward simple tasks• What has happened to GPs‟ professionalism?
  22. 22. The value of money as a quality improvement tool• The majority thought paying for performance was an inappropriate quality improvement tool: “ Personally I think it’s wrong. I think they should deliver the quality of care because it’s the professional thing to do.” (Male, 54, Hypertension) “They shouldn’t get rewarded for it because it should be part of their everyday job.” (Female, 59, CKD) “ ...you would like to think they were doing it because they thought it was necessary and a part of your care more than possibly, oh, well, if we do him we get extra pay. I don’t like the idea of that.” (Male, 77, Asthma)
  23. 23. Payment for simple tasks• Most were surprised to hear the practice was paid money for doing ‘simple things’ : “Why should you be paid extra for something that is so simple that a nurse could do it? That doesn’t make any sense.” (Male, 77, Asthma) “I certainly didnt realise that you got an extra payment for taking somebodys blood pressure, good heavens.” (Female, 65, Diabetes)• Incentives should be in place for more complex tasks: “I know some of them do minor surgery in there and I think they should have rewards for doing the minor surgery because that saves the hospital a lot of time...” (Female, 59, CKD)
  24. 24. Impact on care received• No patient had heard of the QOF• 75% had not noticed changes in their care: “I don’t think it has changed at all because I’ve been on that medication and I’ve always had a review, had my blood pressure checked every six months.” (Female, 59, CKD) “I haven’t noticed a difference... I don’t get any letters to say...I’m due for a blood test or anything like that.” (Male, 87, Epilepsy)
  25. 25. The importance of baselines: Effect of pay forperformance on blood pressure control and monitoringSerumaga B et al. BMJ 2011;342:bmj.d108
  26. 26. Changes to nurses‟ roles“They (the GPs) forget we’re actually nurses. You’ve notstopped all day because you have had ill patients. Andthen they come in and tell you that you are 1% down ona target.” (practice nurse)“All the three nurses, we agree that we’re doing a lotmore of their work for them (the doctors), and not muchin the way of money recognition.” (practice nurse)McDonald, Lester and Campbell, Soc Sci Med 2009; 68(7);1206-1212
  27. 27. Changes to salaried doctor roles“ “They are feathering their own nests essentially and I do think that it, the other aspect of it is I think they are abusing the younger generation of doctors.” (salaried GP) Lester et al. British Journal of General Practice 2009;59:908-915
  28. 28. Less holistic approach?“The profession has essentially been bribed toimplement a population based disease managementprogram that often conflicts with the individual patientcentered ethos of general practice…it comesdangerously close to medicine by numbers andthreatens the basis of general practice.”Lipman T. Br J Gen Pract 2005; 55: 396.
  29. 29. Unintended consequences in GP behaviour • 57 family-practice professionals were interviewed in 24 representative practices across England • Four particular types of unintended consequences were identified: o measure fixation o tunnel vision o misinterpretation o potential gaming Lester, Hannon and Campbell. BMJ Qual Saf doi:10.1136/bmjqs.2010.048371
  30. 30. What happens to non incentivised areas?• Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included)• 148 general practices in England (653 500 patients)• There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends• Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivisedDoran et al. BMJ 2011; 342:d3590 doi: 10.1136/bmj.d3590
  31. 31. Exception reporting by area deprivation quintile 100 80 Quintile 1 Quintile 2Overall mean exception rate Quintile 3 Quintile 4 Quintile 5 60 40 20 0 05/06 06/07 QOF year
  32. 32. Inequality in quality of care Achievement by area deprivation quintile 100 80Overall reported achievement 60 40 Quintile 1 20 Quintile 2 Quintile 3 Quintile 4 Quintile 5 0 04/05 05/06 06/07 QOF year Doran et al. Lancet 2008; 372: 728-736.
  33. 33. What happens when you retire indicators?
  34. 34. Keeping plates spinning• Expectation that work in removed areas will continue since „embedded‟ in primary care• GPs in the UK consistently say that this will not be the case• No UK evidence base to help us answer this question
  35. 35. Kaiser Permanente Northern California Data• Longitudinal analysis• 35 medical facilities of Kaiser Permanente Northern California, 1997-2007• 2 523 659 adult members of KP• Four „shared‟ indicators yearly assessment of patient level glycaemic control (HbA1c <8%) screening for diabetic retinopathy control of hypertension (systolic blood pressure <140 mm Hg) screening for cervical cancer
  36. 36. Hypertension Control (systolic<140), ages 20 and up 100 80 % in conrol 60 40 20 0 2002 2003 2004 2005 2006 2007 year Red dot: incentive off, Green dot: incentive on Lester et al BMJ 2010;340:c1898
  37. 37. Diabetes Glycaemic Control (<8%) ages 18-75 80 60 % in control 40 20 0 1999 2000 2001 2002 2003 2004 2005 2006 2007 yearRed dot: incentive off, Green dot: incentive on
  38. 38. Diabetic Retinopathy Screening, ages 31 and up 100 % screened 80 60 1999 2000 2001 2002 2003 2004 2005 2006 2007 year Red dot: incentive off, Green dot: incentive on
  39. 39. Cervical Cancer ages 21-64 80% screened 60 1999 2000 2001 2002 2003 2004 2005 2006 2007 yearRed dot: incentive off, Green dot: incentive on
  40. 40. 2011 Cochrane reviews• Flodgren at al An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes DOI: 10.1002/14651858.CD009255• “Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability”.• Scott et al. The effect of financial incentives on the quality of health care provided by primary care physicians DOI: 10.1002/14651858.CD008451.pub2• “There is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care. Implementation should proceed with caution and incentive schemes should be carefully designed and evaluated.”
  41. 41. State of play 2011- Yes P4P has a role• Improved care in long term conditions  Achievement for most incentivised activities increased over the first 3 years, but little improvement in Year 4• Reduced variations in quality of care  The poorest performing practices improved the fastest Overall inequalities in quality of care for incentivised activities almost disappeared by Year 3• Some staff are happier  4,000 additional physicians recruited (15% increase)  43% GPs are now salaried  Income of GP principals increased by up to 25%
  42. 42. But…• Too great a cost to the public purse• Changes to the doctor patient relationship• Loss of focus on other areas of care
  43. 43. If this was 2003...• Know the baseline achievement• Consult the public• Pilot all indicators• Attach less money to each measure• Monitor what happens closely• Set up some decent longitudinal research to inform the next Cochrane review
  44. 44. Thank you very much for listening! H.e.lester@bham.ac.uk