This document summarizes a presentation about opening up clinical performance variation and financial incentives in primary care quality of care. It discusses the Quality and Outcomes Framework (QOF), a pay-for-performance program introduced in 2004 as part of a new GP contract in the UK. The QOF rewards general practices for achieving quality targets in chronic disease care. It has expanded over time to include more indicators and domains. While initially estimated to cost £1.8 billion over 3 years, the program has cost over £9 billion after its first 9 years. The presentation examines research on the impact and effectiveness of the QOF program.
Bulent Eren presented information on Turkey's health insurance sector. Some key points:
- Turkey has a population of 76 million with a GDP of $820 billion and per capita GDP of $10,700.
- The insurance sector includes 68 companies, with 61 active including 4 life and 18 pension companies.
- Health expenditures have grown significantly from $5 billion in 1999 to $76 billion in 2012, increasing as a percentage of GDP from 4.8% to 5.4% over that period.
- The Turkish health system includes both public and private providers, with financing from social security, private insurance, and out-of-pocket payments.
- Private health insurance premiums have grown substantially
The document provides an overview of the Analytics Opportunity in Healthcare. It discusses the value of analytics in healthcare, shares examples of best and worst analytics projects, and introduces the Michigan Health Information Network (MiHIN) and how it is adding intelligence to its network. The document contains details about the Institute for Healthcare Business Intelligence (IHBI) at Carnegie Mellon University, including its customers, partners, datasets, and research focus areas like data science and predictive modeling.
This document summarizes key differences between primary care systems in Scotland and England. While both countries implemented a UK-wide GMS contract, Scotland has taken a more integrated approach, with unified health boards and a focus on managed clinical networks, anticipatory care programs, and reducing health inequalities. Scotland also takes a softer approach to monitoring quality targets compared to more rigid monitoring in England. The document discusses opportunities to further improve primary care in both countries, such as increasing public involvement and integrating health and social services.
An old fisherman catches a magical gold fish that offers him a wish in exchange for its freedom. The fisherman wishes for whatever his wife desires. His wife's wishes escalate from a new home, to a palace, to becoming queen, and finally queen of the seas living in the ocean. When the fisherman makes the final wish, the gold fish disappears, leaving the fisherman and his wife back in their poor cottage with nothing. The story teaches that being greedy and asking for too much can result in losing everything.
This document discusses cardiovascular health in the UK. It notes that while improvements have been made, reducing deaths from cardiovascular disease by 36% between 2001-2010, more still needs to be done given an aging population. A strategy from 2013 outlines 10 actions to improve cardiovascular health, but challenges remain in fully implementing them. Early detection of at-risk individuals and better coordinated care across the healthcare system are particular areas that need addressing. The survival rate for heart attacks is high at around 90%, but many do not realize this and confuse it with cardiac arrest which has a much lower survival rate.
This document summarizes a teleconference discussing the cost-effectiveness of various cardiovascular disease therapies. It provides cost-effectiveness ratios for therapies such as statins, clopidogrel, and eplerenone. It also discusses the high costs of post-MI heart failure and the benefits and cost-effectiveness of eplerenone in reducing mortality and hospitalization in MI patients with left ventricular dysfunction.
Each pound invested in cancer-related research by taxpayers and charities in the UK returns around 40 pence annually to the UK economy. This study estimated the economic benefits of public and charitable funding for cancer research in the UK between 1970-2009. It found that this investment of £15 billion produced health benefits valued at £124 billion for UK patients from 1991-2010 through reduced cancer incidence, early detection from screening, and improved survival. Accounting for the average 15 year time lag between investment and health impacts, as well as the proportion of research attributable to the UK, the study estimates cancer research has generated a 10% rate of return. Including indirect economic spillovers, the total estimated annual rate of return is 40%, meaning
John Ribchester: Community integrated health careNuffield Trust
Whitstable Medical Practice has developed a model of community integrated healthcare to address the growing health needs of its aging population. The practice has expanded services to include diagnostics, outpatient clinics, therapies, screening, and minor procedures delivered on site or through partnerships. This has resulted in cost savings up to 63% compared to traditional referrals, shorter wait times, and improved patient experience. The practice has also strengthened partnerships to coordinate long-term condition management, urgent care, and rehabilitation services. While this model has benefits, expanding it would require overcoming obstacles such as practice consolidation, facility upgrades, and gaining support from clinical commissioning groups and other stakeholders.
Bulent Eren presented information on Turkey's health insurance sector. Some key points:
- Turkey has a population of 76 million with a GDP of $820 billion and per capita GDP of $10,700.
- The insurance sector includes 68 companies, with 61 active including 4 life and 18 pension companies.
- Health expenditures have grown significantly from $5 billion in 1999 to $76 billion in 2012, increasing as a percentage of GDP from 4.8% to 5.4% over that period.
- The Turkish health system includes both public and private providers, with financing from social security, private insurance, and out-of-pocket payments.
- Private health insurance premiums have grown substantially
The document provides an overview of the Analytics Opportunity in Healthcare. It discusses the value of analytics in healthcare, shares examples of best and worst analytics projects, and introduces the Michigan Health Information Network (MiHIN) and how it is adding intelligence to its network. The document contains details about the Institute for Healthcare Business Intelligence (IHBI) at Carnegie Mellon University, including its customers, partners, datasets, and research focus areas like data science and predictive modeling.
This document summarizes key differences between primary care systems in Scotland and England. While both countries implemented a UK-wide GMS contract, Scotland has taken a more integrated approach, with unified health boards and a focus on managed clinical networks, anticipatory care programs, and reducing health inequalities. Scotland also takes a softer approach to monitoring quality targets compared to more rigid monitoring in England. The document discusses opportunities to further improve primary care in both countries, such as increasing public involvement and integrating health and social services.
An old fisherman catches a magical gold fish that offers him a wish in exchange for its freedom. The fisherman wishes for whatever his wife desires. His wife's wishes escalate from a new home, to a palace, to becoming queen, and finally queen of the seas living in the ocean. When the fisherman makes the final wish, the gold fish disappears, leaving the fisherman and his wife back in their poor cottage with nothing. The story teaches that being greedy and asking for too much can result in losing everything.
This document discusses cardiovascular health in the UK. It notes that while improvements have been made, reducing deaths from cardiovascular disease by 36% between 2001-2010, more still needs to be done given an aging population. A strategy from 2013 outlines 10 actions to improve cardiovascular health, but challenges remain in fully implementing them. Early detection of at-risk individuals and better coordinated care across the healthcare system are particular areas that need addressing. The survival rate for heart attacks is high at around 90%, but many do not realize this and confuse it with cardiac arrest which has a much lower survival rate.
This document summarizes a teleconference discussing the cost-effectiveness of various cardiovascular disease therapies. It provides cost-effectiveness ratios for therapies such as statins, clopidogrel, and eplerenone. It also discusses the high costs of post-MI heart failure and the benefits and cost-effectiveness of eplerenone in reducing mortality and hospitalization in MI patients with left ventricular dysfunction.
Each pound invested in cancer-related research by taxpayers and charities in the UK returns around 40 pence annually to the UK economy. This study estimated the economic benefits of public and charitable funding for cancer research in the UK between 1970-2009. It found that this investment of £15 billion produced health benefits valued at £124 billion for UK patients from 1991-2010 through reduced cancer incidence, early detection from screening, and improved survival. Accounting for the average 15 year time lag between investment and health impacts, as well as the proportion of research attributable to the UK, the study estimates cancer research has generated a 10% rate of return. Including indirect economic spillovers, the total estimated annual rate of return is 40%, meaning
John Ribchester: Community integrated health careNuffield Trust
Whitstable Medical Practice has developed a model of community integrated healthcare to address the growing health needs of its aging population. The practice has expanded services to include diagnostics, outpatient clinics, therapies, screening, and minor procedures delivered on site or through partnerships. This has resulted in cost savings up to 63% compared to traditional referrals, shorter wait times, and improved patient experience. The practice has also strengthened partnerships to coordinate long-term condition management, urgent care, and rehabilitation services. While this model has benefits, expanding it would require overcoming obstacles such as practice consolidation, facility upgrades, and gaining support from clinical commissioning groups and other stakeholders.
Diabetes care in the time of Covid 19 2021 Prof Vinod PatelVinod0901
The document discusses diabetes care during the COVID-19 pandemic. It begins with the professor declaring interests and conflicts of interest. The rest of the document covers:
- Background on COVID-19 virus and global prevalence data
- Infection control strategies like masks and symptoms
- Risk factors for COVID-19 death like age, diabetes, and comorbidities
- Treatments for COVID-19 including dexamethasone and remdesivir
- Strategies for virtual consultations and protecting communities
- Coping strategies to reduce stress during the pandemic
It aims to inform healthcare professionals about caring for diabetes patients during the COVID-19 crisis.
This document contains a collection of tweets and news articles on various topics:
- A tweet joking about how Andy Burnham would look wearing a balaclava and creeping up on someone.
- Tweets promoting HIV testing and discussing plans to raise funds for the NHS.
- News articles about antibiotic overuse in the UK, a new heart failure drug getting accelerated EU review, one in ten GP practices being high risk, and a study showing relatively lack of access to innovative drugs in the UK.
Presentation to CCG - Capita Health Freakononics v3Mike Thorogood
This document discusses using econometric modeling and statistical analysis to understand factors that influence weight gain and loss. It presents an initial model that links weight to food consumption. The model is then developed to also account for exercise and different activities. The document outlines testing the model by examining the overall fit and significance of individual variables. It also discusses checking for issues like collinearity between variables and establishing causality. Further tests are described to identify patterns in the residuals and improve model specification. Applications of similar modeling for targeted health interventions and estimating cost savings are briefly mentioned.
DR ARYA LUNG CANCER SCREENING 28 TH JAN.pptxdranimesharya
This document summarizes guidelines for managing lung nodules found on CT scans from the British Thoracic Society and Fleischner Society. It discusses key points like who should be screened, thresholds for follow up of solid and subsolid nodules based on size, the definition of nodule growth, and duration of follow up for stable nodules. It also notes that lung cancer prevalence is similar for nodules found on screening vs incidentally. New evidence is presented on outcomes for nodules detected by screening vs incidentally managed pathways.
- The document discusses a support meeting for aspergillosis patients and carers. It includes an agenda with presentations on new NHS structures, changes in commissioning of specialized services like the National Aspergillosis Centre, and a Q&A session.
- Graham Atherton will present on funding streams for treatment which may change between clinical commissioning groups and specialized commissioning.
- Any changes from the patient perspective will be minor, with the main difference being funding approval processes for expensive antifungal drugs.
Getting started at the national level from demonstration to spreadProqualis
This document summarizes a presentation on implementing and scaling patient safety programs nationally in Scotland. It discusses how Scotland implemented a national patient safety program across all hospitals to reduce mortality and adverse events. Key points included establishing clear aims to reduce mortality by 15% and adverse events by 30%, implementing improvement programs in five areas, achieving significant reductions in outcomes like ventilator-associated pneumonia and central line infections, and creating the conditions for large-scale change through establishing aims, priorities, measurement, resources, and testing and spreading new learning.
This document is a manifesto from the Royal College of General Practitioners (Scotland) calling for actions to promote and support general practice ahead of the 2016 Scottish Parliamentary election. It summarizes the challenges facing general practice, including a growing workload amid a shortage of GPs and declining resources that threatens patient care. The manifesto calls on political representatives to commit to increasing the GP workforce through recruitment and retention efforts, replacing the current Quality and Outcomes Framework with a peer-led system of governance, and increasing investment in general practice to 11% of the NHS budget. It provides quotes from GPs and patients to evidence the issues and calls for appropriate actions to address the needs of general practice.
This document discusses improving value in healthcare systems through a population health perspective. It provides examples of analyzing clinical pathways and interventions for conditions like COPD, stroke, and diabetes to identify high-value investments based on number of people treated, costs, and quality of life gains. The document emphasizes focusing resources on upstream prevention strategies rather than downstream treatment given evidence that prevention interventions provide much higher value per dollar spent at the population level.
The document summarizes a hospital's venous thromboembolism (VTE) prophylaxis program over 7 years. It shows that the program reduced hospital-acquired deep vein thrombosis and pulmonary embolism by over two-thirds, saving over $6 million in costs. Moving forward, the hospital aims to further improve prophylaxis practices by focusing on areas like daily ambulation and administering prophylaxis in the emergency department and throughout a patient's care. The goal is continuous quality improvement to help more patients and potentially achieve outcomes like preventing all hospital-acquired infections.
Australia Lung Cancer Drugs Market Analysis Sample ReportInsights10
Lung cancer is the fifth most common type of cancer affecting the Australian population, therefore the Australian lung cancer drugs market is projected to grow during the forecast period. The market is segmented by type, treatment, end user, route of administration, and distribution channel. To get a detailed report, contact us at - info@insights10.com
Point of Care Diagnostics: Revenue Growth, New Entrants, InvestmentBruce Carlson
The document discusses point-of-care (POC) testing, which involves diagnostic tests performed near patients outside of centralized laboratories. It estimates the global POC diagnostics market was $17 billion in 2014 and is projected to grow to $18.7 billion by 2016. Key drivers of growth include rapid results to inform immediate treatment decisions, expanded test menus, and advances enabling quantitative lab-quality results. Major diseases addressed by POC solutions discussed are colorectal cancer, cardiovascular disease, and diabetes.
EPRD16 - LIvien Annemans reducing waste and inefficiencies in helathcare Cittadinanzattiva onlus
This document discusses reducing waste and improving efficiencies in healthcare systems to improve quality. It notes that annual growth in healthcare expenditures is a problem in OECD countries. The primary goal of healthcare policy should be to maximize population health within available resources and with principles of equity and solidarity. Improving value for money in healthcare can be achieved through more cost-effective interventions that provide greater health effects for lower costs. Benchmarking cost-effectiveness against thresholds like GDP per capita can help identify good value interventions. Examples show potential cost savings from reducing overuse and investing more in prevention and innovation to reinvest in health. A crucial condition for success is developing a perfect eHealth system.
The size of the prize: doing things differently to prevent heart attacks and ...Innovation Agency
This document discusses cardiovascular disease (CVD) prevention in England. It notes that CVD is a major cause of death and life expectancy gaps. While prevention requires action on wider determinants, the NHS has a key role to play through population-level interventions, supporting behavior change, and optimizing diagnosis and treatment of high-risk conditions like high blood pressure, atrial fibrillation, and high cholesterol. However, diagnosis and treatment of these conditions is often suboptimal. The document presents examples of initiatives that are "doing things differently" through expanded pharmacist roles, community engagement, new technologies, and real-time data to improve CVD prevention outcomes at scale.
Getting to grips with Population Health - 28th Feb 2018James Carter
A set of slides produced by Thames Valley Strategic Clinical Network to support the familiarisation event on Population Health held in Maidenhead on Wednesday 28th February 2018.
With thanks to all colleagues, attendees, chairs and speakers for their involvement on the day.
James Carter - Senior Network Manager TVSCN
james.carter1@nhs.net
The document discusses several medical devices and technologies. It begins by describing a new collaboration between Alder Hey Children's Hospital and Karl Storz to develop minimally invasive surgical technologies for pediatric patients. It then discusses new initiatives by the UK government and health organizations to reduce sepsis, including new guidelines and tools for diagnosis. It concludes by mentioning new monitoring systems installed at Lister Hospital in the UK from Fukuda Denshi.
This document summarizes a presentation about addressing rising health care costs. It discusses how, while health spending is increasing as a share of GDP and government budgets, outcomes have also improved. Non-solutions proposed include shifting costs to consumers, privatizing services, or reducing services. Sensible solutions proposed focus on reorienting the system, improving efficiency without budget cuts, and eliminating waste, such as through benchmarking costs across hospitals and clinical groups.
This document provides an overview and analysis of health spending growth in Australia. It discusses:
- Australia's health spending as a share of GDP and government budgets has been increasing but outcomes have improved.
- Two-thirds of real health spending increases came from factors other than population aging and inflation.
- There are opportunities to improve efficiency through benchmarking costs across hospitals and geographic areas, reducing clinical variation, and task substitution to less specialized healthcare workers without reducing quality.
- Non-solutions like cost-shifting to consumers, privatization, or service reductions are not recommended. Sensible solutions include reorienting the system, eliminating waste, and focusing on efficiency.
This document shares the story of a mesothelioma patient who was initially given a prognosis of 3 months to 2 years to live. After undergoing surgery and chemotherapy, her latest scan showed that her tumor had shrunk, much to the surprise of her oncologist and husband. While she still tires easily, she has been able to enjoy traveling around the UK in a motorhome over the past 4 months and resume activities like walking her dog. Her improved condition has extended her projected lifespan beyond the initial 3 month timeframe. The story highlights the impact of mesothelioma on a previously active individual and some positive outcomes achieved through treatment.
1. Value-based differential pricing, where prices reflect local willingness-to-pay for health and other value elements, is a theoretically robust approach, though many countries currently use therapeutic added value plus price bargaining.
2. Measurement of relative health gain will remain important, but broader definitions of value need further development, moving from listing to measuring to weighting different factors.
3. The UK experience shows measuring broader value factors is possible, but weighting them explicitly makes preferences and social welfare functions clear and may cause backlash without understanding public and patient preferences. A deliberative process combining societal weighting and structured decision-making is needed for fair value assessment.
This document summarizes several large primary care databases in the United Kingdom, including the Clinical Practice Research Datalink (CPRD) and The Health Improvement Network (THIN) database. It provides details on the number of practices and patients covered by each database. The document also discusses the structure of the primary care databases, tools for analyzing the data, and examples of using the data to study conditions like diabetes. Finally, it presents results from studies examining the impact of financial incentives on quality of care indicators in the UK Quality and Outcomes Framework.
Investigating the relationship between quality of primary care and premature ...Evangelos Kontopantelis
This document describes a study investigating the relationship between quality of primary care and premature mortality in England. The study used a longitudinal spatial design to analyze mortality rates and quality of care data at the neighborhood level from 2007-2012. Multiple linear regression analyses found that higher overall quality scores on the UK's Quality and Outcomes Framework for primary care were not significantly associated with lower all-cause premature mortality rates at the neighborhood level after accounting for deprivation, rurality, and disease burden. Higher disease burden was significantly associated with higher mortality rates.
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Diabetes care in the time of Covid 19 2021 Prof Vinod PatelVinod0901
The document discusses diabetes care during the COVID-19 pandemic. It begins with the professor declaring interests and conflicts of interest. The rest of the document covers:
- Background on COVID-19 virus and global prevalence data
- Infection control strategies like masks and symptoms
- Risk factors for COVID-19 death like age, diabetes, and comorbidities
- Treatments for COVID-19 including dexamethasone and remdesivir
- Strategies for virtual consultations and protecting communities
- Coping strategies to reduce stress during the pandemic
It aims to inform healthcare professionals about caring for diabetes patients during the COVID-19 crisis.
This document contains a collection of tweets and news articles on various topics:
- A tweet joking about how Andy Burnham would look wearing a balaclava and creeping up on someone.
- Tweets promoting HIV testing and discussing plans to raise funds for the NHS.
- News articles about antibiotic overuse in the UK, a new heart failure drug getting accelerated EU review, one in ten GP practices being high risk, and a study showing relatively lack of access to innovative drugs in the UK.
Presentation to CCG - Capita Health Freakononics v3Mike Thorogood
This document discusses using econometric modeling and statistical analysis to understand factors that influence weight gain and loss. It presents an initial model that links weight to food consumption. The model is then developed to also account for exercise and different activities. The document outlines testing the model by examining the overall fit and significance of individual variables. It also discusses checking for issues like collinearity between variables and establishing causality. Further tests are described to identify patterns in the residuals and improve model specification. Applications of similar modeling for targeted health interventions and estimating cost savings are briefly mentioned.
DR ARYA LUNG CANCER SCREENING 28 TH JAN.pptxdranimesharya
This document summarizes guidelines for managing lung nodules found on CT scans from the British Thoracic Society and Fleischner Society. It discusses key points like who should be screened, thresholds for follow up of solid and subsolid nodules based on size, the definition of nodule growth, and duration of follow up for stable nodules. It also notes that lung cancer prevalence is similar for nodules found on screening vs incidentally. New evidence is presented on outcomes for nodules detected by screening vs incidentally managed pathways.
- The document discusses a support meeting for aspergillosis patients and carers. It includes an agenda with presentations on new NHS structures, changes in commissioning of specialized services like the National Aspergillosis Centre, and a Q&A session.
- Graham Atherton will present on funding streams for treatment which may change between clinical commissioning groups and specialized commissioning.
- Any changes from the patient perspective will be minor, with the main difference being funding approval processes for expensive antifungal drugs.
Getting started at the national level from demonstration to spreadProqualis
This document summarizes a presentation on implementing and scaling patient safety programs nationally in Scotland. It discusses how Scotland implemented a national patient safety program across all hospitals to reduce mortality and adverse events. Key points included establishing clear aims to reduce mortality by 15% and adverse events by 30%, implementing improvement programs in five areas, achieving significant reductions in outcomes like ventilator-associated pneumonia and central line infections, and creating the conditions for large-scale change through establishing aims, priorities, measurement, resources, and testing and spreading new learning.
This document is a manifesto from the Royal College of General Practitioners (Scotland) calling for actions to promote and support general practice ahead of the 2016 Scottish Parliamentary election. It summarizes the challenges facing general practice, including a growing workload amid a shortage of GPs and declining resources that threatens patient care. The manifesto calls on political representatives to commit to increasing the GP workforce through recruitment and retention efforts, replacing the current Quality and Outcomes Framework with a peer-led system of governance, and increasing investment in general practice to 11% of the NHS budget. It provides quotes from GPs and patients to evidence the issues and calls for appropriate actions to address the needs of general practice.
This document discusses improving value in healthcare systems through a population health perspective. It provides examples of analyzing clinical pathways and interventions for conditions like COPD, stroke, and diabetes to identify high-value investments based on number of people treated, costs, and quality of life gains. The document emphasizes focusing resources on upstream prevention strategies rather than downstream treatment given evidence that prevention interventions provide much higher value per dollar spent at the population level.
The document summarizes a hospital's venous thromboembolism (VTE) prophylaxis program over 7 years. It shows that the program reduced hospital-acquired deep vein thrombosis and pulmonary embolism by over two-thirds, saving over $6 million in costs. Moving forward, the hospital aims to further improve prophylaxis practices by focusing on areas like daily ambulation and administering prophylaxis in the emergency department and throughout a patient's care. The goal is continuous quality improvement to help more patients and potentially achieve outcomes like preventing all hospital-acquired infections.
Australia Lung Cancer Drugs Market Analysis Sample ReportInsights10
Lung cancer is the fifth most common type of cancer affecting the Australian population, therefore the Australian lung cancer drugs market is projected to grow during the forecast period. The market is segmented by type, treatment, end user, route of administration, and distribution channel. To get a detailed report, contact us at - info@insights10.com
Point of Care Diagnostics: Revenue Growth, New Entrants, InvestmentBruce Carlson
The document discusses point-of-care (POC) testing, which involves diagnostic tests performed near patients outside of centralized laboratories. It estimates the global POC diagnostics market was $17 billion in 2014 and is projected to grow to $18.7 billion by 2016. Key drivers of growth include rapid results to inform immediate treatment decisions, expanded test menus, and advances enabling quantitative lab-quality results. Major diseases addressed by POC solutions discussed are colorectal cancer, cardiovascular disease, and diabetes.
EPRD16 - LIvien Annemans reducing waste and inefficiencies in helathcare Cittadinanzattiva onlus
This document discusses reducing waste and improving efficiencies in healthcare systems to improve quality. It notes that annual growth in healthcare expenditures is a problem in OECD countries. The primary goal of healthcare policy should be to maximize population health within available resources and with principles of equity and solidarity. Improving value for money in healthcare can be achieved through more cost-effective interventions that provide greater health effects for lower costs. Benchmarking cost-effectiveness against thresholds like GDP per capita can help identify good value interventions. Examples show potential cost savings from reducing overuse and investing more in prevention and innovation to reinvest in health. A crucial condition for success is developing a perfect eHealth system.
The size of the prize: doing things differently to prevent heart attacks and ...Innovation Agency
This document discusses cardiovascular disease (CVD) prevention in England. It notes that CVD is a major cause of death and life expectancy gaps. While prevention requires action on wider determinants, the NHS has a key role to play through population-level interventions, supporting behavior change, and optimizing diagnosis and treatment of high-risk conditions like high blood pressure, atrial fibrillation, and high cholesterol. However, diagnosis and treatment of these conditions is often suboptimal. The document presents examples of initiatives that are "doing things differently" through expanded pharmacist roles, community engagement, new technologies, and real-time data to improve CVD prevention outcomes at scale.
Getting to grips with Population Health - 28th Feb 2018James Carter
A set of slides produced by Thames Valley Strategic Clinical Network to support the familiarisation event on Population Health held in Maidenhead on Wednesday 28th February 2018.
With thanks to all colleagues, attendees, chairs and speakers for their involvement on the day.
James Carter - Senior Network Manager TVSCN
james.carter1@nhs.net
The document discusses several medical devices and technologies. It begins by describing a new collaboration between Alder Hey Children's Hospital and Karl Storz to develop minimally invasive surgical technologies for pediatric patients. It then discusses new initiatives by the UK government and health organizations to reduce sepsis, including new guidelines and tools for diagnosis. It concludes by mentioning new monitoring systems installed at Lister Hospital in the UK from Fukuda Denshi.
This document summarizes a presentation about addressing rising health care costs. It discusses how, while health spending is increasing as a share of GDP and government budgets, outcomes have also improved. Non-solutions proposed include shifting costs to consumers, privatizing services, or reducing services. Sensible solutions proposed focus on reorienting the system, improving efficiency without budget cuts, and eliminating waste, such as through benchmarking costs across hospitals and clinical groups.
This document provides an overview and analysis of health spending growth in Australia. It discusses:
- Australia's health spending as a share of GDP and government budgets has been increasing but outcomes have improved.
- Two-thirds of real health spending increases came from factors other than population aging and inflation.
- There are opportunities to improve efficiency through benchmarking costs across hospitals and geographic areas, reducing clinical variation, and task substitution to less specialized healthcare workers without reducing quality.
- Non-solutions like cost-shifting to consumers, privatization, or service reductions are not recommended. Sensible solutions include reorienting the system, eliminating waste, and focusing on efficiency.
This document shares the story of a mesothelioma patient who was initially given a prognosis of 3 months to 2 years to live. After undergoing surgery and chemotherapy, her latest scan showed that her tumor had shrunk, much to the surprise of her oncologist and husband. While she still tires easily, she has been able to enjoy traveling around the UK in a motorhome over the past 4 months and resume activities like walking her dog. Her improved condition has extended her projected lifespan beyond the initial 3 month timeframe. The story highlights the impact of mesothelioma on a previously active individual and some positive outcomes achieved through treatment.
1. Value-based differential pricing, where prices reflect local willingness-to-pay for health and other value elements, is a theoretically robust approach, though many countries currently use therapeutic added value plus price bargaining.
2. Measurement of relative health gain will remain important, but broader definitions of value need further development, moving from listing to measuring to weighting different factors.
3. The UK experience shows measuring broader value factors is possible, but weighting them explicitly makes preferences and social welfare functions clear and may cause backlash without understanding public and patient preferences. A deliberative process combining societal weighting and structured decision-making is needed for fair value assessment.
Similar to Faculty showcase 2013 - Opening up clinical performance (20)
This document summarizes several large primary care databases in the United Kingdom, including the Clinical Practice Research Datalink (CPRD) and The Health Improvement Network (THIN) database. It provides details on the number of practices and patients covered by each database. The document also discusses the structure of the primary care databases, tools for analyzing the data, and examples of using the data to study conditions like diabetes. Finally, it presents results from studies examining the impact of financial incentives on quality of care indicators in the UK Quality and Outcomes Framework.
Investigating the relationship between quality of primary care and premature ...Evangelos Kontopantelis
This document describes a study investigating the relationship between quality of primary care and premature mortality in England. The study used a longitudinal spatial design to analyze mortality rates and quality of care data at the neighborhood level from 2007-2012. Multiple linear regression analyses found that higher overall quality scores on the UK's Quality and Outcomes Framework for primary care were not significantly associated with lower all-cause premature mortality rates at the neighborhood level after accounting for deprivation, rurality, and disease burden. Higher disease burden was significantly associated with higher mortality rates.
Re-analysis of the Cochrane Library data and heterogeneity challengesEvangelos Kontopantelis
Heterogeneity issues and a re-analysis of the Cochrane Library data. Presented in the 35th Annual Conference of the International Society for Clinical Biostatistics (ISCB35) in Vienna
The document provides an overview of various UK primary care and population health databases, including Clinical Practice Research Datalink (CPRD), The Health Improvement Network (THIN), QResearch, and ResearchOne. It describes the size and coverage of each database, as well as what types of medical data they contain. Additionally, it outlines other relevant UK data sources like Quality and Outcomes Framework (QOF) datasets, patient satisfaction surveys, census and mortality records, and hospitalization databases that can help provide context when analyzing primary care databases.
This study re-analyzed data from the Cochrane Library to evaluate methods for estimating between-study heterogeneity in meta-analyses. The researchers downloaded RevMan files from over 3,800 Cochrane reviews containing over 57,000 meta-analyses. They evaluated methods for estimating the between-study variance (tau-squared) using simulated and real Cochrane data. Their results showed that the DerSimonian-Laird bootstrap method performed best overall at estimating tau-squared and detecting heterogeneity, especially in small meta-analyses. However, over 50% of small meta-analyses in the Cochrane data failed to detect high between-study heterogeneity. The study highlights limitations in commonly used methods for accounting for heterogeneity in meta-analyses.
This document summarizes a re-analysis of meta-analysis data from the Cochrane Library. It examines the performance of different methods for estimating between-study heterogeneity and explores model selection in published meta-analyses. Simulation studies were conducted to compare heterogeneity estimators. Over 57,000 meta-analyses from the Cochrane Library were also analyzed. Results showed that the DerSimonian-Laird estimator often failed to detect high between-study heterogeneity, particularly in small meta-analyses. Bayesian methods performed well for very small meta-analyses. In the Cochrane data, over 30% of meta-analyses had only 2 studies and the random-effects model was more commonly used with larger numbers of studies.
The document analyzes the relationship between clinical computing systems used by family practices in the UK and their performance under the Quality and Outcomes Framework (QOF) pay-for-performance scheme between 2007-2011. Statistical models found that practices' choice of clinical computing system was a significant predictor of their QOF achievement scores, with some systems associated with better performance than others. Practices using the Vision 3 or Synergy systems tended to score highest overall, while those using the PCS system tended to score the lowest. Performance varied by the type of clinical activities as well.
This document presents a poster on meta-analysis and the ipdforest command in Stata. It discusses meta-analysis approaches including one-stage and two-stage methods. It outlines the use of mixed-effects regression models to combine individual patient data from multiple randomized controlled trials in a one-stage approach. It then presents an example hypothetical study and model to analyze individual patient data using the xtmixed command in Stata, generating results that can be displayed in a forest plot using ipdforest. The poster serves as a practical guide on meta-analysis with individual patient data.
This poster summarizes a document presenting a meta-analysis of individual patient data (IPD) from multiple randomized controlled trials. It discusses three statistical models for conducting a one-stage IPD meta-analysis using mixed effects regression models. The first model includes a fixed common intercept and random treatment effects. The second allows for fixed trial-specific intercepts and baseline effects. The third considers random trial intercepts and treatment effects. The document outlines how to implement each model in Stata software.
Effect of Financial Incentives on Incentivised and Non-Incentivised Clinical Activities: Utilising Primary Care Databases to answer clinical, policy and methodological questions
This poster presents an overview of individual patient data (IPD) meta-analysis and introduces the ipdforest command in Stata. IPD meta-analysis involves pooling raw data from multiple studies and can address issues like inconsistent reporting across studies. The poster outlines three mixed-effects regression models for IPD meta-analysis with varying assumptions about fixed and random effects. It also demonstrates how ipdforest can be used to generate forest plots for one-stage IPD meta-analyses in Stata, overcoming limitations of standard two-stage approaches.
This document summarizes research investigating the effect of provider incentives for influenza immunization through longitudinal studies using two datasets. It finds that reported achievement generally increased over time with the Quality and Outcomes Framework (QOF), but this was partly due to increased exception reporting. Increasing the upper threshold for one indicator led to greater improvements in reported achievement compared to other indicators. Analyzing data prior to QOF allows disentangling the effects of different incentive schemes over time on immunization rates in various patient groups.
The document analyzes the impact of the UK's Quality and Outcomes Framework (QOF), a pay-for-performance scheme for primary care physicians introduced in 2004. It compares changes in quality indicators that were fully incentivized by the QOF, partially incentivized, and non-incentivized. In the short-term (2004/05), fully incentivized indicators showed the largest improvements above expectations, while partially incentivized treatment indicators declined. In the long-term (2006/07), fully incentivized indicators continued improving and non-incentivized/partially incentivized indicators declined below expectations, suggesting the QOF primarily impacted incentivized aspects of care.
This document discusses using electronic patient data from the United Kingdom's General Practice Research Database (GPRD) for primary care research. It provides background on the development of electronic patient records in the UK and the Quality and Outcomes Framework that incentivized general practices to computerize. The GPRD is described as containing longitudinal data from over 500 general practices that can be used to study disease prevalences, clinical quality indicators, and patient comorbidities over time. The document outlines the research team's process of developing code lists to extract relevant data from the GPRD for their studies on the effect of the Quality and Outcomes Framework on clinical quality in primary care.
This document summarizes the results of an analysis of the 2007-08 UK GP Patient Survey data. The analysis used multilevel logistic regression to examine how patient satisfaction and experience relates to patient, practice, and regional characteristics. Key findings include:
- Patient age, employment status, and ethnicity significantly impacted satisfaction levels, with older patients, non-full time workers, and white British individuals most satisfied.
- Practice size strongly influenced satisfaction and experience, except for satisfaction with hours - larger practices saw lower ratings.
- The three models examined relationships for all patients, working patients, and interactions between key predictors and found practice size and patient demographics to be major drivers of satisfaction.
hematic appreciation test is a psychological assessment tool used to measure an individual's appreciation and understanding of specific themes or topics. This test helps to evaluate an individual's ability to connect different ideas and concepts within a given theme, as well as their overall comprehension and interpretation skills. The results of the test can provide valuable insights into an individual's cognitive abilities, creativity, and critical thinking skills
Current Ms word generated power point presentation covers major details about the micronuclei test. It's significance and assays to conduct it. It is used to detect the micronuclei formation inside the cells of nearly every multicellular organism. It's formation takes place during chromosomal sepration at metaphase.
Authoring a personal GPT for your research and practice: How we created the Q...Leonel Morgado
Thematic analysis in qualitative research is a time-consuming and systematic task, typically done using teams. Team members must ground their activities on common understandings of the major concepts underlying the thematic analysis, and define criteria for its development. However, conceptual misunderstandings, equivocations, and lack of adherence to criteria are challenges to the quality and speed of this process. Given the distributed and uncertain nature of this process, we wondered if the tasks in thematic analysis could be supported by readily available artificial intelligence chatbots. Our early efforts point to potential benefits: not just saving time in the coding process but better adherence to criteria and grounding, by increasing triangulation between humans and artificial intelligence. This tutorial will provide a description and demonstration of the process we followed, as two academic researchers, to develop a custom ChatGPT to assist with qualitative coding in the thematic data analysis process of immersive learning accounts in a survey of the academic literature: QUAL-E Immersive Learning Thematic Analysis Helper. In the hands-on time, participants will try out QUAL-E and develop their ideas for their own qualitative coding ChatGPT. Participants that have the paid ChatGPT Plus subscription can create a draft of their assistants. The organizers will provide course materials and slide deck that participants will be able to utilize to continue development of their custom GPT. The paid subscription to ChatGPT Plus is not required to participate in this workshop, just for trying out personal GPTs during it.
EWOCS-I: The catalog of X-ray sources in Westerlund 1 from the Extended Weste...Sérgio Sacani
Context. With a mass exceeding several 104 M⊙ and a rich and dense population of massive stars, supermassive young star clusters
represent the most massive star-forming environment that is dominated by the feedback from massive stars and gravitational interactions
among stars.
Aims. In this paper we present the Extended Westerlund 1 and 2 Open Clusters Survey (EWOCS) project, which aims to investigate
the influence of the starburst environment on the formation of stars and planets, and on the evolution of both low and high mass stars.
The primary targets of this project are Westerlund 1 and 2, the closest supermassive star clusters to the Sun.
Methods. The project is based primarily on recent observations conducted with the Chandra and JWST observatories. Specifically,
the Chandra survey of Westerlund 1 consists of 36 new ACIS-I observations, nearly co-pointed, for a total exposure time of 1 Msec.
Additionally, we included 8 archival Chandra/ACIS-S observations. This paper presents the resulting catalog of X-ray sources within
and around Westerlund 1. Sources were detected by combining various existing methods, and photon extraction and source validation
were carried out using the ACIS-Extract software.
Results. The EWOCS X-ray catalog comprises 5963 validated sources out of the 9420 initially provided to ACIS-Extract, reaching a
photon flux threshold of approximately 2 × 10−8 photons cm−2
s
−1
. The X-ray sources exhibit a highly concentrated spatial distribution,
with 1075 sources located within the central 1 arcmin. We have successfully detected X-ray emissions from 126 out of the 166 known
massive stars of the cluster, and we have collected over 71 000 photons from the magnetar CXO J164710.20-455217.
The ability to recreate computational results with minimal effort and actionable metrics provides a solid foundation for scientific research and software development. When people can replicate an analysis at the touch of a button using open-source software, open data, and methods to assess and compare proposals, it significantly eases verification of results, engagement with a diverse range of contributors, and progress. However, we have yet to fully achieve this; there are still many sociotechnical frictions.
Inspired by David Donoho's vision, this talk aims to revisit the three crucial pillars of frictionless reproducibility (data sharing, code sharing, and competitive challenges) with the perspective of deep software variability.
Our observation is that multiple layers — hardware, operating systems, third-party libraries, software versions, input data, compile-time options, and parameters — are subject to variability that exacerbates frictions but is also essential for achieving robust, generalizable results and fostering innovation. I will first review the literature, providing evidence of how the complex variability interactions across these layers affect qualitative and quantitative software properties, thereby complicating the reproduction and replication of scientific studies in various fields.
I will then present some software engineering and AI techniques that can support the strategic exploration of variability spaces. These include the use of abstractions and models (e.g., feature models), sampling strategies (e.g., uniform, random), cost-effective measurements (e.g., incremental build of software configurations), and dimensionality reduction methods (e.g., transfer learning, feature selection, software debloating).
I will finally argue that deep variability is both the problem and solution of frictionless reproducibility, calling the software science community to develop new methods and tools to manage variability and foster reproducibility in software systems.
Exposé invité Journées Nationales du GDR GPL 2024
Remote Sensing and Computational, Evolutionary, Supercomputing, and Intellige...University of Maribor
Slides from talk:
Aleš Zamuda: Remote Sensing and Computational, Evolutionary, Supercomputing, and Intelligent Systems.
11th International Conference on Electrical, Electronics and Computer Engineering (IcETRAN), Niš, 3-6 June 2024
Inter-Society Networking Panel GRSS/MTT-S/CIS Panel Session: Promoting Connection and Cooperation
https://www.etran.rs/2024/en/home-english/
Phenomics assisted breeding in crop improvementIshaGoswami9
As the population is increasing and will reach about 9 billion upto 2050. Also due to climate change, it is difficult to meet the food requirement of such a large population. Facing the challenges presented by resource shortages, climate
change, and increasing global population, crop yield and quality need to be improved in a sustainable way over the coming decades. Genetic improvement by breeding is the best way to increase crop productivity. With the rapid progression of functional
genomics, an increasing number of crop genomes have been sequenced and dozens of genes influencing key agronomic traits have been identified. However, current genome sequence information has not been adequately exploited for understanding
the complex characteristics of multiple gene, owing to a lack of crop phenotypic data. Efficient, automatic, and accurate technologies and platforms that can capture phenotypic data that can
be linked to genomics information for crop improvement at all growth stages have become as important as genotyping. Thus,
high-throughput phenotyping has become the major bottleneck restricting crop breeding. Plant phenomics has been defined as the high-throughput, accurate acquisition and analysis of multi-dimensional phenotypes
during crop growing stages at the organism level, including the cell, tissue, organ, individual plant, plot, and field levels. With the rapid development of novel sensors, imaging technology,
and analysis methods, numerous infrastructure platforms have been developed for phenotyping.
The binding of cosmological structures by massless topological defectsSérgio Sacani
Assuming spherical symmetry and weak field, it is shown that if one solves the Poisson equation or the Einstein field
equations sourced by a topological defect, i.e. a singularity of a very specific form, the result is a localized gravitational
field capable of driving flat rotation (i.e. Keplerian circular orbits at a constant speed for all radii) of test masses on a thin
spherical shell without any underlying mass. Moreover, a large-scale structure which exploits this solution by assembling
concentrically a number of such topological defects can establish a flat stellar or galactic rotation curve, and can also deflect
light in the same manner as an equipotential (isothermal) sphere. Thus, the need for dark matter or modified gravity theory is
mitigated, at least in part.
The debris of the ‘last major merger’ is dynamically youngSérgio Sacani
The Milky Way’s (MW) inner stellar halo contains an [Fe/H]-rich component with highly eccentric orbits, often referred to as the
‘last major merger.’ Hypotheses for the origin of this component include Gaia-Sausage/Enceladus (GSE), where the progenitor
collided with the MW proto-disc 8–11 Gyr ago, and the Virgo Radial Merger (VRM), where the progenitor collided with the
MW disc within the last 3 Gyr. These two scenarios make different predictions about observable structure in local phase space,
because the morphology of debris depends on how long it has had to phase mix. The recently identified phase-space folds in Gaia
DR3 have positive caustic velocities, making them fundamentally different than the phase-mixed chevrons found in simulations
at late times. Roughly 20 per cent of the stars in the prograde local stellar halo are associated with the observed caustics. Based
on a simple phase-mixing model, the observed number of caustics are consistent with a merger that occurred 1–2 Gyr ago.
We also compare the observed phase-space distribution to FIRE-2 Latte simulations of GSE-like mergers, using a quantitative
measurement of phase mixing (2D causticality). The observed local phase-space distribution best matches the simulated data
1–2 Gyr after collision, and certainly not later than 3 Gyr. This is further evidence that the progenitor of the ‘last major merger’
did not collide with the MW proto-disc at early times, as is thought for the GSE, but instead collided with the MW disc within
the last few Gyr, consistent with the body of work surrounding the VRM.
The debris of the ‘last major merger’ is dynamically young
Faculty showcase 2013 - Opening up clinical performance
1. Opening up clinical performance
variation and financial incentives in Primary Care quality of care
Evan (Evangelos) Kontopantelis1
1Institute of Population Health
Faculty Research Series, 25 September 2013
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
2. Outline
1 People
2 The scheme...
3 The research journey
4 Summary
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
3. Collaborative work!
Martin Roland
Tim Doran
David Reeves
Stephen Campbell
Bonnie Sibbald
Matt Sutton
Hugh Gravelle
Jose Valderas
...and others...
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
4. Improving quality of care
a (very) juicy carrot...
A pay-for-performance (p4p) program kicked off in April 2004 with
the introduction of a new GP contract
General 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 GPs was named the Quality
and Outcomes Framework (QOF)
Initial investment estimated at £1.8 bn for 3 years (increasing GP
income by up to 25%)
QOF is reviewed at least every two years
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
5. Quality and Outcomes Framework
details for years 1 (2004/5) and 7 (2010/11)
Domains and indicators in year 1 (year 7):
Clinical care for 10 (19) chronic diseases, with 76 (80) indicators
Organisation of care, with 56 (36) indicators
Additional services, with 10 (8) indicators
Patient experience, with 4 (5) indicators
Implemented simultaneously in all practices (a control group was
out of the question)
Practices are allowed to exclude patients from the indicators and
the payment calculations
Into the 10th year now (01Mar13/31Apr14); cost for the first 9
years was well above the estimate at £9 bn approximately
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
6. Quality and Outcomes Framework
what does it mean?
If you have
Atrial fibrillation, asthma, HT, cancer, CHD,
HF, CKD, COPD, dementia, depression,
diabetes, epilepsy, SMI, osteoporosis, PAD,
stroke, hypothyroidism
but also covers LD, obesity, palliative care,
sexual health, smoking
e.g. for diabetes
measure-control BP, chol, glucose
immunise for influenza
physical exams (retinal screen, foot exam)
...and more... 17 indicators in total
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
7. Quality and Outcomes Framework
2005 reaction
Drugs cut strokes by a third
Doctors get 20%
pay rise just for
doing their jobsDOCTORS are getting 20 per
cent pay rises for doing simple
tasks “they should always have
done,” it was claimed last night.
Health economists, including
Government advisers, say that
under their new contracts GPs
are being paid huge bonuses to
meet “easy” targets that do little
to improve patients’ lives.
Such is the level of concern
over the value for taxpayers that
ministers are already meeting
doctors’ leaders in order to set
tougher goals.
The move comes just weeks
after the Government boasted
how most GPs had met the tar-
gets for performance-related pay.
But Alan Maynard, professor of
health economics at York Univer-
sity, said yesterday: “It’s quite
ridiculous. The Government’s
CHOLESTEROL -lowering
drugs called statins could pre-
vent heart attacks and strokes in
a third of patients with diseased
arteries, a study shows.
Most doctors consider statin
treatment only when blood cho-
lesterol is above a certain level
but research by British and
Australian scientists shows
many more people with lower
cholesterol could also benefit.
Statins work by blocking the
action of an enzyme that enables
the liver to produce cholesterol.
Research Council scientist Dr
Colin Baigent, who coordinated
By Michael Day
By Geoff Marsh
spent all this money and has
given GPs 20 per cent rises just to
try and get them to do what they
should always have done.
“Now they’re being paid extra
to look out for people with high
blood pressure, which causes
heart attacks and strokes, and to
monitor and treat them – but they
should have been doing that all
along. It’s not rocket science.”
There have already been two
Whitehall meetings after the dis-
closure last month that, on aver-
age, GP practices achieved 91 per
cent of the available perfor-
mance-related bonuses under the
new contract.
After achieving bonuses, aver-
age earnings of a practice surged
by £75,000 while the salary of the
average GP partner rose to
£100,000 a year. The first meeting
to set tougher targets came with-
in a week of the announcement.
The second was held last week.
One BMA negotiator, Leeds GP
Richard Vautrey, said: “We are
looking at making amendments,
but at present we’re not in
the position to say exactly what
these are.
“We would expect the revised
framework to be ready by the end
of the year.”
Apart from blood pressure,
other target areas have been sin-
gled out as too modest. Chris
Ham, professor of health policy
and management at Birmingham
University, said: “My view is that,
in principle, the new GP contract
is a good thing – GPs are being
paid on the basis of how well they
treat patients and not just accord-
ing to how large their list size is.
“But the fact so many of them
met the targets in the first year
suggests they were too easy.”
A BMA spokeswoman denied
the targets were too easy. “They
demonstrate the vast majority of
doctors are already providing
high-quality care for their
patients,” she said.
Simon William, director of pol-
icy at the Patients’ Association,
said, however: “The BMA would
trumpet the GPs’ performance.
It’s a trade union, it’s there to
represent doctors not patients.”
A spokesman for the Depart-
ment of Health said: “These
excellent results show the new
contract is giving GPs a real
incentive to improve the quality
of care.”
the research at Oxford Univer-
sity, said: “This study shows
statin drugs could be beneficial
in a much wider range of
patients than is currently con-
sidered for treatment.
“What matters most is doc-
tors identify all patients at risk
of a heart attack or stroke –
largely ignoring their present
blood cholesterol level – and
then prescribe a statin at a daily
dose that reduces their choles-
terol substantially.
“Lowering the bad (LDL) cho-
lesterol … with a statin should
reduce the risk of a heart attack
or stroke by at least one third.”
The study, published online in
The Lancet, suggests patients
given a statin would also experi-
ence greater benefits if doctors
aimed to achieve larger reduc-
tions in cholesterol levels.
The analysis also provides
information about the safety of
statins. Earlier studies had
raised concerns they could be
linked with an increased risk of
certain cancers or diseases.
British Heart Foundation
Professor Rory Collins, one of
the study authors, said: “This
work shows clearly that statins
are very safe. There is no good
evidence that statins cause can-
cer and nor do they increase the
risk of other diseases. Although
statins can cause muscle pain or
weakness, our study shows seri-
ous cases are extremely rare.”
Study co-author Professor
John Simes, of Sydney Univer-
sity, said: “The benefits of statin
treatment were seen in all pat-
ient groups, including women,
the elderly, individuals with dia-
betes and those with and with-
out prior heart attack or stroke.”
OPINION 12 DIARY 26 LETTERS 38 TV 39 STARS 43 CROSSWORDS 45 CITY 48 SPORT 52
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3 6 5
8 9 3 4
9 4 5 3 6
9 5 7 1 6
1 5
3 9 5 8 7
7 5 1 4 3
5 2 9 8
1 8 6
Fill in all the squares so that each row, each column,
and 3x3 square contain all the digits from 1 to 9.SUDOKU
7 8 6 1 9 3 5 2 4
2 1 9 5 7 4 8 6 3
5 3 4 8 2 6 9 7 1
4 9 7 2 1 5 6 3 8
8 2 5 6 3 7 1 4 9
3 6 1 9 4 8 7 5 2
9 7 2 3 5 1 4 8 6
6 4 3 7 8 9 2 1 5
1 5 8 4 6 2 3 9 7
Yesterday’s solution
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LOTTO NUMBERS
WEDNESDAY LOTTO
September 21
2 23 33 35 40 42 25
Estimated jackpot is £2.8m
Extra: 2 13 18 25 28 47
Estimated jackpot is £8.7m
T-Ball: 5 14 16 18 32 2
DAILY PLAY
Saturday
1 7 8 12 21 23 24
SATURDAY LOTTO
Sept 24
2 11 27 29 36 44 15
Estimated jackpot is £8.4m
Extra: 3 11 16 34 40 45
Jackpot is £9m this week
T-Ball: 6 8 20 26 34 5
EUROMILLIONS
September 23
1 26 31 34 47
Lucky star numbers: 4 9
Amsterdam . . .c 17 63
Athens . . . . . . .f 25 77
Berlin . . . . . . . .sh 16 61
Cape Town . . . .s 16 61
Corfu . . . . . . . .f 25 77
Dublin . . . . . . .c 18 64
Faro . . . . . . . . .s 24 75
Geneva . . . . . .f 20 68
Gibraltar . . . . . .f 23 73
Guernsey . . . . .s 17 63
Los Angeles . . .f 21 70
Madrid . . . . . . .s 22 72
Malaga . . . . . . .f 24 75
Mallorca . . . . . .s 24 75
Malta . . . . . . . .s 25 77
Miami . . . . . . . .f 31 88
Moscow . . . . . .c 14 57
New York . . . . .c 22 72
Nice . . . . . . . . .s 24 75
Paris . . . . . . . . .c 20 68
Rome . . . . . . . .s 23 73
Stockholm . . . .s 20 68
Sydney . . . . . .r 19 66
Tel Aviv . . . . . . .s 34 93
Tenerife . . . . . .s 28 82
Summary: Showers in places.
World yesterday
Europe today
C F A windy day with rain spreading
eastwards across most areas,
but the south and east of England
will have a fine start.
Outlook tomorrow:
North West East Anglia
Breezy with scattered
showers, locally heavy.
A fresh south-westerly wind.
High 18C (64F).
Early rain will clear to leave
sunny spells. A risk of showers
later. Moderate south-westerly
winds. High 20C (68F).
Northern Ireland London/South East
Sunny intervals and
showers. Cool and breezy
with a strong south-westerly
breeze. High 16C (61F).
After a cloudy start with
rain in places, it will soon
become drier with spells
of sunshine. High 21C (70F).
Wales South
Some sunshine at times,
but with scattered showers,
frequent in the west. Fresh
winds. High 18C (64F).
A cloudy start in places,
but turning brighter with
sunny spells. Afternoon
showers. High 20C (68F).
Midlands South West
Sunny spells, but with a
few showers from the west.
Moderate south-westerly
winds. High 20C (68F).
Some sunshine at times,
but with occasional showers.
Moderate westerly winds.
High 19C (66F).
North East/Yorks Channel Isles
A bright day with sunny spells,
but breezy with the chance
of a shower A fresh breeze.
High 18C (64F).
Early rain will soon clear
to leave sunny intervals,
but with a risk of a shower.
High 18C (64F).
Scotland Sea
Gusty at times with frequent,
heavy showers in the west.
Drier and brighter further
east. High 18C (64F).
North Sea: moderate.
Irish Sea: moderate.
Channel: moderate.
Rain 19C/66F
Amsterdam
Fair 19C/66F
Brussels
Fair 22C/72F
Frankfurt
Fair 23C/73F
Geneva
Fair 22C/72F
Paris
Fair 25C/77F
Rome
Warmest: Chivenor 19C (66F).
Coldest: Aboyne 2C (36F).
Wettest: S’th Uist Range 0.55in.
Sunniest: Beccles 5.0hr.
BRITAIN EXTREMES:
(24 hours to 2pm yesterday)
c-cloudy, dr-drizzle, f-fair, fg-fog,
g-gales, h-hail, hz-haze, m-mist,
r-rain, sh-showers, s-sun,
sn-snow, sl-sleet, th-thunder,
Around Britain
HIGH TIDE: London Bridge: 9.03am, 10.00pm
Liverpool: 7.14am, 7.53pm
Greenock: 8.31am, 7.42pm
Dover: 7.04am, 8.01pm
Belfast 0.0 0.13 9 17
Birmingham 2.0 0.00 9 17
Bristol 2.3 0.00 10 19
Cardiff 3.0 0.01 11 20
Edinburgh 2.0 0.04 7 18
Glasgow 0.9 0.94 10 15
Leeds ** ** 9 16
London 3.4 0.00 12 18
Manchester 1.1 0.00 8 17
Newcastle ** 0.00 10 17
Norwich 3.7 0.04 7 16
Oxford 1.5 0.00 7 17
CITIES
Sun Rain Temp
(hr) (in) (min)(max)
Lighting-up times Yesterday
Belfast 7.10pm-7.20am
Birmingham 6.54pm-7.03am
Bristol 6.57pm-7.06am
Glasgow 7.03pm-7.14am
London 6.47pm-6.56am
Manchester 6.55pm-7.05am
Newcastle 6.52pm-7.03am
MOON rises: –, Sets: 5.14pm
SUN rises London: 6.55am, Sets: 6.47pm
Manchester rises: 7.03am, Sets: 6.55pm
Moon, sun and tides
25
30
30
20
15
13
13
16
18
18
18
19
17
1818
20
20
20
21
Weather today
Miami 31C 88F / Moscow 14C 57F
All forecasts and maps provided by PA WeatherCentre
Daily Express Tuesday September 27 20052
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
8. Quality and Outcomes Framework
later reaction
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
9. Key questions
since QOF was parachuted in Primary Care
What were levels of achievement when QOF introduced?
Did they change over time?
What was happening pre-QOF? Was there an increasing trend?
Practice characteristics asssociated with high performance? Size?
Gap between practices in affluent and deprived areas?
Exception reporting rates and evidence for practice ‘gaming’?
What happened to non-incentivised aspects of care?
Did the intervention effect vary by population group?
What about patient satisfaction?
Various computer systems used. Does system choice affect care?
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
14. Performance over time and its variation
All 8000+ English practices
Median overall
achievement was 85.1%,
89.3% and 90.8% in first 3y
Median achievement
increased by 4.4% for
quintile of most affluent and
by 7.6% for most deprived
Gap in median
achievement narrowed from
4.0% to 0.8%
Financial incentive
schemes can contribute to
the reduction of inequalities
Information about practice and patient characteristics
was taken from the 2006 general medical statistics
database, which is maintained by the Department of
Health. Practices were grouped into quintiles of equal
size on the basis of the level of area deprivation in the
census super-output area (a standard, stable unit of
geography used in the UK for statistical analysis; average
population 7200) where they were located, with data from
the Index of Deprivation 2004.20
We calculated the odds of
practices from each quintile being in the top and bottom
performing 5% of practices with respect to achievement
and rates of exclusion by logistic regression. We estimated
the associations of practice-level characteristics with
practice achievement, exclusion of patients, and changes
in these outcomes with multiple linear regressions.
These analyses controlled for missing indicators,
heterogeneity of variance, and clustering of practices,
and we made checks on the robustness of the results to
model specifications (webappendix). All variables were
divided by their standard deviations, thus regression
coefficients show the increase in standard deviations of
the outcome for one standard deviation increase in
predictor variables. All statistical analyses were done with
Stata software (version 9).
Achievement data for 2004–05, 2005–06, and 2006–07
were available for 8277 general practices in England.
Practices were excluded from the study if they had fewer
(164 practices), complete exclusion data were not available
(172 practices), or if the practice population changed in
size by 25% or more (258 practices). Our main results are
drawn from 7637 practices, providing care for more than
49 million patients. We undertook subanalyses for
excluded practices (webappendix).
Role of the funding source
There was no funding source for this study. The
corresponding author had full access to all the data in the
study and had fi nal responsibility for the decision to
submit for publication.
Results
The median overall reported achievement—the propor-
tion of patients who were deemed eligible by the prac-
tices for whom the targets were achieved—was 85·1%
(IQR 79·0–89·1) in year 1, 89·3% (86·0–91·5) in year 2,
and 90·8% (88·5–92·6) in year 3. Increases in
achievement between years were significant (p<0·0001
in all cases). Although average levels of achievement in-
creased over time, variation in achieve ment
diminished.
In year 1, progressively lower levels of achievement
were associated with increased levels of area deprivation
(fi gure 1). Median achievement ranged from 86·8%
(IQR 82·2–89·6) for quintile 1 (least deprived) to 82·8%
Overallreportedachievement(%)
Year 1 (2004–05)
0
20
40
60
80
100
Year 2 (2005–06) Year 3 (2006–07)
Quality and outcome framework year
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
Figure 1: Distribution of scores for overall reported achievement by deprivation quintile for year 1 (2004–05) to year 3 (2006–07)
Central line shows median achievement and box shows interquartile range; whiskers represent range of achievement scores. Circles represent statistical outliers—
ie, individual practices with achievement scores outside the range: first quartile–(1·5×IQR) to third quartile+(1·5×IQR).
most deprived
most affluent
Articles
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
Tim Doran, Catherine Fullwood, Evangelos Kontopantelis, David Reeves
Summary
Background The quality and outcomes framework is a financial incentive scheme that remunerates general practices
in the UK for their performance against a set of quality indicators. Incentive schemes can increase inequalities in the
delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived
areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first
3 years of this scheme.
Methods We analysed data extracted automatically from clinical computing systems for 7637 general practices in
England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical
statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality.
We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the
Lancet 2008; 372: 728–36
Published Online
August 12, 2008
DOI:10.1016/S0140-
6736(08)61123-X
See Comment page 692
National Primary Care Research
and Development Centre,
University of Manchester,
Manchester, UK (T Doran MD,
C Fullwood PhD,
E Kontopantelis PhD,
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
15. Trends of prior achievement and 2006-7 expectations
Representative sample of 42 practices
By 2007 the rate of
improvement had slowed for
all three conditions
Quality of care for
non-incentivised aspects
declined for asthma and CHD
No significant changes on
access to care or on
interpersonal aspects of care
Continuity of care reduced
immediately after the
introduction of the scheme
QOF accelerated short-term
improvements
The new engl and jour nal of medicine
incentives as compared with those that were not.
in the post-introductio
pre-introduction period
ly (P = 0.06). However,
cant when calculated
strapping method (P =
(P = 0.03), and in abso
ity score for aspects of
were not linked to ince
whereas the quality sco
to incentives increased
ate effect of pay for p
between care that wa
linked with incentives
subsequently diverged
vs. pre-introduction pe
duction period vs. intr
with the mean score f
to incentives declining
score for care that wa
creasing. Trends in d
at any time according
linked to incentives.
Communication, Wait
and Continuity of Ca
The percentages of pat
within 48 hours, as w
the physician-commu
significant changes in
declined significantly
pay for performance (
this lower level (Table
Estimated Overall Eff
for Performance
For outcomes in whic
pay for performance a
improvement, we used
rupted time-series ana
of the increase in sco
from the trend in th
(back-transforming th
analysis, with estimat
As compared with the
ment based on the pre-
for-performance schem
22p3
90
Score
85
80
70
65
55
75
60
0
1998 1999 2000 2001 2002 2003 2007200620052004
Coronary
heart disease
Asthma
Diabetes
Year
B
A
AUTHOR:
FIGURE:
JOB:
4-C
H/T
RETAKE
SIZE
ICM
CASE
EMail Line
H/T
Combo
Revised
AUTHOR, PLEASE NOTE:
Figure has been redrawn and type has been reset.
Please check carefully.
REG F
Enon
1st
2nd
3rd
Campbell
1 of 2
xx-xx-09
ARTIST: ts
360xx ISSUE:
100
Score
90
80
60
50
20
70
40
30
0
1998 1999 2000 2001 2002 2003 2007200620052004
Communication
with physicians
Continuity of care
Able to get an appointment
within 48 hr (particular doctor)
Able to get an appointment
within 48 hr (any doctor)
Year
Figure 1. Mean Scores for the Quality of Care at the Practice Level, 1998–2007.
Panel A shows scores for the quality of care provided for coronary heart
disease, asthma, and diabetes. Quality scores range from 0% (no quality
indicator was met for any patient) to 100% (all quality indicators were met
for all patients). Panel B shows scores for patients’ perceptions of commu-
nication with physicians, access to care, and continuity of care. Communi-
cation was assessed by asking seven questions, with the answers scored on
a six-point scale ranging from “very poor” to “excellent”; continuity of care
was assessed with the use of the same six-point scale and a single question:
“How often do you see your usual doctor?” Access to care was scored as
the percentage of patients who reported that they were able to get an ap-
pointment within 48 hours. All scores were rescaled to range from 0 to 100.
special article
The new engl and jour nal of medicine
Effects of Pay for Performance
on the Quality of Primary Care in England
Stephen M. Campbell, Ph.D., David Reeves, Ph.D., Evangelos Kontopantelis, Ph.D.,
Bonnie Sibbald, Ph.D., and Martin Roland, D.M.
From the National Primary Care Research
and Development Centre, University of
Abstr act
Background
A pay-for-performance scheme based on meeting targets for the quality of clinical
care was introduced to family practice in England in 2004.
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
16. Does the size of the practice matter?
All 8000+ English practices
In y1 smallest practices had
the lowest median reported
achievement rates
Performance improved over
time; smallest practices
improved at the fastest rate
Caught up by y3 but displayed
more variation in performance
Small practices represented
among best and worst
QOF reduced variation in
performance and differences
between large and small
practices
e339
proportions over time.
Reported achievement
The median overall reported achievement, the
proportion of patients deemed appropriate by the
practice for whom the targets were achieved, was
85.2% in year 1, 89.3% in year 2, and 90.9% in
year 3. Increases in achievement between years
were statistically significant (P<0.005 in all cases).
Median reported achievement in year 1 varied with
patients, year 1 (2004–2005)
to year 3 (2006–2007).
100
80
60
40
20
0
2004/2005 2005/2006 2006/2007
QOF year
list size 1000–1999
2000–2999
3000–3999
4000–5999
6000–7999
8000–9999
10000–11999
12000 or more
Overallreportedachievement
Figure 2. Distribution of
practice scores for overall
reported achievement by
number of patients, year 1
(2004–2005) to year 3
(2006–2007).
Central white line shows median scores and box shows interquartile range (IQR); whiskers
represent range of scores. Circles represent statistical outliers — that is, individual practices
with points scores outside the range: first quartile — (1.5 × IQR) + (1.5 × IQR).
ABSTRACT
Background
Small general practices are often perceived to provide
worse care than larger practices.
Aim
To describe the comparative performance of small
INTRODUCTION
Small general practices in the UK, particularly those
that are single handed, are often accused of
providing poor-quality care. The 2000 NHS Plan cited
a need to ‘confirm that single-handed (solo)
practices are offering high standards’.1
The Shipman
Inquiry identified advantages and disadvantages
T Doran, S Campbell, C Fullwood, et al
Performance of small general
practices under the UK’s Quality
and Outcomes Framework
Tim Doran, Stephen Campbell, Catherine Fullwood,
Evangelos Kontopantelis and Martin RolandBJGP 2010
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
17. Changes in patient experiences
42 practices, random samples of chronic condition and all patients
No changes in 2003-7
quality of care for
communication, nursing
care, coordination &
overall satisfaction
Aspects of access
improved for chronic
disease patients only
Both samples seeing their
usual GP less & less
satisfied in continuity
Related to incentives to
provide rapid
appointments
ANNALS OF FAMILY MEDICINE ✦
WWW.ANNFAMMED.ORG ✦
VOL. 8, NO. 6 ✦
NOVEMBER/DECEMBER 2010
502
of-access items (P >.05), including ability to see a
particular physician or any physician within 48 hours. Patients Randomly Sampled From
Registered Lists
Results for patients randomly sampled from practice
lists matched those for patients with chronic illness in
all aspects except the speed-of-access items: no signifi-
cant changes over time were observed in any of these
items. The only significant changes from 2003 to 2007
were in regard to continuity of care, with a reduction
in how often patients reported being able to see their
Table 2. Response Rates for Patient Surveys
Patient Group
2003
% (n)
2005
% (n)
2007
% (n)
Chronic illness samples 55 (1,092) 52 (1,040) 50 (922)
Random samples of
registered patients
47 (3,873) 45 (3,601) 37 (3,104)
Table 3. Summary of Practice Mean GPAQ Scale and Individual Item Scores 2003, 2005, and 2007,
for Cross-Sectional Samples of Patients With Chronic Illness and Random Samples of Adult Patients
GPAQ Scale and Item
Samples of Patients
With Chronic Illness
Mean (SD)a
Samples of Randomly
Selected Patients
Mean (SD)a
2003 2005 2007 2003 2005 2007
Communication scale 74.5 (10.1) 74.5 (9.3) 76.0 (8.5) 69.5 (10.0) 68.4 (9.4) 69.9 (8.9)
Coordination scale 72.1 (7.4) 71.0 (5.8) 73.0 (5.9) 67.0 (5.8) 68.6 (5.1) 68.3 (6.1)
Nursing care scale 76.0 (6.1) 76.1 (6.0) 75.3 (8.1) 73.9 (6.2) 73.4 (5.3) 72.9 (7.1)
Overall satisfaction scale 81.6 (8.0) 80.6 (8.6) 81.3 (7.7) 75.2 (9.2) 74.7 (10.6) 75.6 (7.9)
Item: In general, how often do you see your
usual doctor (continuity of care)?
77.2 (8.0) 74.9 (9.4) 70.4 (9.6) 68.2 (13.1) 62.8 (13.5) 62.5 (11.6)
Item: Rating of how often patients get to see
their usual doctor (rating of continuity of care)
71.5 (9.8) 69.1 (9.9) 67.4 (11.5) 64.6 (13.1) 61.0 (12.2) 61.2 (10.4)
Item: Do you get an appointment with a particu-
lar doctor within 48 hours?
36.9 (29.5) 38.7 (26.3) 37.0 (22.6) 33.4 (26.2) 35.9 (25.1) 32.3 (21.0)
Item: Rating of how quickly an appointment
can be made with a particular doctor in the
practice
57.3 (17.7) 58.0 (14.1) 56.6 (15.6) 50.0 (18.6) 52.2 (16.0) 53.0 (13.6)
Item: Do you get an appointment with any doc-
tor within 48 hours?
64.5 (23.9) 68.0 (22.6) 67.2 (19.9) 61.5 (24.2) 63.4 (21.0) 63.8 (22.4)
Item: Rating of how quickly an appointment can
be made with any doctor in the practice
65.2 (15.2) 64.5 (13.8) 65.5 (14.5) 59.2 (17.2) 61.2 (14.2) 62.4 (13.1)
Item: If you need an urgent appointment can you
get one on the same day?
81.8 (17.7) 81.2 (15.5) 82.2 (16.8) 79.6 (17.1) 78.2 (17.5) 79.4 (18.8)
GPAQ=General Practice Assessment Questionnaire.
Note: See the Appendix for a description of how the scales were scored.
a
Figures relate to raw practice-level scores (mean and standard deviation of practice means).
13/09/2013 Changes in Patient Experiences of PrimaryCare During Health Service Reforms
+
The Annals of Family Medicine
www.annfammed.org
doi: 10.1370/afm.1145
Ann Fam Med November 1, 2010 vol. 8 no. 6 499-506
Changes in Patient Experiences of
Primary Care During Health Service
Reforms in England Between 2003 and
2007
Stephen M. Campbell, PhD1, Evangelos Kontopantelis, PhD1,
David Reeves, PhD1, Jose M. Valderas, PhD1, Ella Gaehl, MPhil1,
Nicola Small, MPhil1 and Martin O. Roland, DM2
Author Affiliations
CORRESPONDING AUTHOR: Stephen Campbell, PhD, National Primary Care
Research and Development Centre, University of Manchester, Williamson Bldg,
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
18. Patient satisfaction
2007-8 GP Access Survey, all English practices
Young, Asian, working FT, with
long commuting times: lowest
levels of satisfaction and
experience of access
Ability to take time off to visit
GP eliminated the
disadvantage in access
Patients in small practices
more positive for all aspects of
access; except opening hours
Positive access to care
associated with higher QOF
scores and slightly lower rates
of emergency admission
0
20
40
60
80
100
%ofpositiveresponses
<1
1−2
2−3
3−4
4−6
6−88−1010−12>=12
Phone access
0
20
40
60
80
100
%ofpositiveresponses
<1
1−2
2−3
3−4
4−6
6−88−1010−12>=12
Appointment within 2 days
0
20
40
60
80
100
%ofpositiveresponses
<1
1−2
2−3
3−4
4−6
6−88−1010−12>=12
Advance appointment (>2 days)
0
20
40
60
80
100
%ofpositiveresponses
<1
1−2
2−3
3−4
4−6
6−88−1010−12>=12
Appointment with a particular GP
Practice size in 1,000s of patients
by practice list size
Satisfaction & positive experience
RESEARCH ARTICLE Open Access
Patient experience of access to primary care:
identification of predictors in a national patient
survey
Evangelos Kontopantelis1*
, Martin Roland2
, David Reeves1
Abstract
Background: The 2007/8 GP Access Survey in England measured experience with five dimensions of access:
getting through on the phone to a practice, getting an early appointment, getting an advance appointment,
Kontopantelis et al. BMC Family Practice 2010, 11:61
http://www.biomedcentral.com/1471-2296/11/61
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
19. Advising NICE on removing indicators
All English practices, 2004/5 to 2009/10
Indicators should be removed on
statistical criteria and the economics
of incentives
Replaced with other indicators to
drive improvement in other areas
It is unknown what will happen to
the withdrawn indicators
BMJ | 24 APRIL 2010 | VOLUME 340 899
ANALYSIS
Increasing numbers of countries are using indi-
cators to evaluate the quality of clinical care,
with some linking payment to achievement.1
For performance frameworks to remain effective
the indicators need to be regularly reviewed. The
frameworks cannot cover all clinical areas, and
achievement on chosen indicators will even-
tually reach a ceiling beyond which further
improvement is not feasible.2 3
However, there
has been little work on how to select indictors for
replacement. The Department of Health decided
in 2008 that it would regularly replace indicators
in the national primary care pay for performance
scheme, the Quality and Outcomes Framework,4
making a rigorous approach to removal a prior-
ity. We draw on our previous work on pay for
performance5 6
and our current work advising
the National Institute for Health and Clinical
Excellence (NICE) on the Quality and Outcomes
Framework to suggest what should be consid-
ered when planning to remove indicators from
a clinical performance framework.
First UK decisions
The Quality and Outcomes Framework cur-
rently includes 134 indicators for which gen-
eral practices can earn up to a total of 1000
points. Negotiations between the Department
of Health and the BMA’s General Practitioners
Committee last autumn led to an agreement to
remove eight clinical indicators worth 28 points
in April 2011 (table 1). The eight indicators are
all process measures and reward actions such as
taking blood pressure or taking blood to measure
cholesterol, glucose, or creatinine concentra-
tions for people with relevant chronic diseases.
The framework rewards the action itself rather
than a clinically informed response to results or
intermediate outcomes such as better control of
blood pressure or cholesterol levels. It is there-
fore not surprising that achievement of these
process indicators is high (median >95% and
interquartile range <4.5%) with little change in
rates or variation across practices since 2005-6,
the second year of the Quality and Outcomes
Framework.
In many schemes, including the Quality and
Outcomes Framework, providers can “except”
certain patients from inclusion in the denomi-
nator figures for an indicator on grounds such as
extreme frailty or contraindications to a specified
drug. Exception reporting rates are also low for
these eight indicators (median <5% and inter-
quartile range <3%).
How to identify when a performance
indicator has run its course
In April 2011 eight clinical indicators will be removed from the UK Quality and Outcomes
Framework. David Reeves and colleagues explain why they were chosen and suggest
a rationale for future decisions
National achievement and exception rates for indicators that are to be removed from the Quality and Outcomes Frameworkin 20117
Indicator (measurement of ) Condition
Median (interquartile range) achievement (%) Median (interquartile range) rate of exceptions (%) Paired
indicator*2005-6 2006-7 2007-8 2005-6 2006-7 2007-8
Bloodpressure Coronaryheartdisease 98.2 (96.7-99.3) 98.5 (97.2-99.5) 98.4(97.1-99.4) 0.8 (0-1.8) 0.8 (0-1.7) 0.7 (0-1.6) Yes
Haemoglobin A1c
Diabetes 97.4 (95.1-98.8) 97.8 (95.9-99.0) 97.7 (96.0-98.9) 2.7 (1.4-4.4) 2.5 (1.3-4.2) 2.4 (1.2-3.9) Yes
Bloodpressure Diabetes 98.8 (97.6-99.7) 99.0 (98.0-100) 98.9 (97.9-99.6) 1.1 (0.3-2.2) 1.0 (0.3-2.1) 1.0 (0.3-2.1) Yes
Serum creatinine Diabetes 96.7 (94.1-98.3) 97.4 (95.3-98.7) 97.4 (95.6-98.7) 1.9 (0.9-3.4) 1.7 (0.8-3.2) 1.6 (0.7-3.1) No
Totalcholesterol Diabetes 96.4 (93.8-98.1) 96.9 (94.8-98.3) 96.8 (94.8-98.2) 2.2 (1.1-3.9) 2.1 (1.0-3.8) 2.0 (0.9-3.6) Yes
Serum creatinine andthyroid
stimulating hormone
Mentalhealth (lithium) 100 (100-100) 100 (100-100) 100 (100-100) 0 (0-0) 0 (0-0) 0 (0-0) No
Bloodpressure Stroke 97.4 (95.1-100) 97.7 (95.8-100) 97.6 (95.8-99.5) 1.3 (0-3.3) 1.2 (0-2.9) 1.1 (0-2.7) Yes
Thyroidfunction Hypothyroidism 96.8 (94.5-98.7) 96.7 (94.5-98.5) 96.5 (94.3-98.3) 0 (0-0.9) 0 (0-0.9) 0 (0-0.8) No
*Paired indicators relate to control of the relevant measure—for example, the indicator that focuses on recording blood pressure in patients with coronary heart disease, is paired with another
indicator that rewards on the basis of the proportion of patients whose last blood pressure reading was ≤150/90 mm Hg.
BMJ | 24 april 2010 | Volume 340 899
tually reach a ceiling beyond which further
improvement is not feasible.2 3
However, there
has been little work on how to select indictors for
replacement. The Department of Health decided
in 2008 that it would regularly replace indicators
in the national primary care pay for performance
scheme, the Quality and Outcomes Framework,4
making a rigorous approach to removal a prior-
ity. We draw on our previous work on pay for
performance5 6
and our current work advising
the National Institute for Health and Clinical
Excellence (NICE) on the Quality and Outcomes
Framework to suggest what should be consid-
ered when planning to remove indicators from
a clinical performance framework.
First UK decisions
The Quality and Outcomes Framework cur-
rently includes 134 indicators for which gen-
eral practices can earn up to a total of 1000
points. Negotiations between the Department
of Health and the BMA’s General Practitioners
Committee last autumn led to an agreement to
remove eight clinical indicators worth 28 points
in April 2011 (table 1). The eight indicators are
all process measures and reward actions such as
taking blood pressure or taking blood to measure
cholesterol, glucose, or creatinine concentra-
tions for people with relevant chronic diseases.
The framework rewards the action itself rather
than a clinically informed response to results or
intermediate outcomes such as better control of
blood pressure or cholesterol levels. It is there-
fore not surprising that achievement of these
process indicators is high (median >95% and
interquartile range <4.5%) with little change in
rates or variation across practices since 2005-6,
the second year of the Quality and Outcomes
Framework.
In many schemes, including the Quality and
Outcomes Framework, providers can “except”
certain patients from inclusion in the denomi-
nator figures for an indicator on grounds such as
extreme frailty or contraindications to a specified
drug. Exception reporting rates are also low for
these eight indicators (median <5% and inter-
quartile range <3%).
National achievement and exception rates for indicators that are to be removed from the Quality and Outcomes Frameworkin 20117
Indicator (measurement of ) Condition
Median (interquartile range) achievement (%) Median (interquartile range) rate of exceptions (%) Paired
indicator*2005-6 2006-7 2007-8 2005-6 2006-7 2007-8
Bloodpressure Coronaryheartdisease 98.2 (96.7-99.3) 98.5 (97.2-99.5) 98.4(97.1-99.4) 0.8 (0-1.8) 0.8 (0-1.7) 0.7 (0-1.6) Yes
Haemoglobin A1c
Diabetes 97.4 (95.1-98.8) 97.8 (95.9-99.0) 97.7 (96.0-98.9) 2.7 (1.4-4.4) 2.5 (1.3-4.2) 2.4 (1.2-3.9) Yes
Bloodpressure Diabetes 98.8 (97.6-99.7) 99.0 (98.0-100) 98.9 (97.9-99.6) 1.1 (0.3-2.2) 1.0 (0.3-2.1) 1.0 (0.3-2.1) Yes
Serum creatinine Diabetes 96.7 (94.1-98.3) 97.4 (95.3-98.7) 97.4 (95.6-98.7) 1.9 (0.9-3.4) 1.7 (0.8-3.2) 1.6 (0.7-3.1) No
Totalcholesterol Diabetes 96.4 (93.8-98.1) 96.9 (94.8-98.3) 96.8 (94.8-98.2) 2.2 (1.1-3.9) 2.1 (1.0-3.8) 2.0 (0.9-3.6) Yes
Serum creatinine andthyroid
stimulating hormone
Mentalhealth (lithium) 100 (100-100) 100 (100-100) 100 (100-100) 0 (0-0) 0 (0-0) 0 (0-0) No
Bloodpressure Stroke 97.4 (95.1-100) 97.7 (95.8-100) 97.6 (95.8-99.5) 1.3 (0-3.3) 1.2 (0-2.9) 1.1 (0-2.7) Yes
Thyroidfunction Hypothyroidism 96.8 (94.5-98.7) 96.7 (94.5-98.5) 96.5 (94.3-98.3) 0 (0-0.9) 0 (0-0.9) 0 (0-0.8) No
*Paired indicators relate to control of the relevant measure—for example, the indicator that focuses on recording blood pressure in patients with coronary heart disease, is paired with another
indicator that rewards on the basis of the proportion of patients whose last blood pressure reading was ≤150/90 mm Hg.
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
20. Non-incentivised aspects of care
Sample of 148 representative practices from the CPRD
Achievement rates improved
for most indicators in the
pre-incentive period
Significant initial gains in
incentivised indicators but no
gains in later years
No overall effect on the rate of
improvement for non
incentivised indicators in
2004-5
But by 2006-7 achievement
rates significantly below those
predicted by pre-incentive
trends
Figure
Mean achievement rate of 148 general practices for qua
grouped by activity and whether they were incentivised
mean rate is the mean of the adjusted means for the in
Effect of financial incentives on incentivised and
non-incentivised clinical activities: longitudinal
analysis of data from the UK Quality and Outcomes
Framework
Tim Doran clinical research fellow1
, Evangelos Kontopantelis research associate1
, Jose M Valderas
clinical lecturer 2
, Stephen Campbell senior research fellow 1
, Martin Roland professor of health
services research3
, Chris Salisbury professor of primary healthcare4
, David Reeves senior research
fellow 1
1
National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL, UK; 2
NIHR School for Primary Care
Research, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF; 3
General Practice and Primary Care Research Unit, University
of Cambridge, Cambridge CB2 0SR; 4
Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA
Abstract
Objective To investigate whether the incentive scheme for UK general
practitioners led them to neglect activities not included in the scheme.
Design Longitudinal analysis of achievement rates for 42 activities (23
included in incentive scheme, 19 not included) selected from 428
identified indicators of quality of care.
Setting 148 general practices in England (653 500 patients).
Main outcome measures Achievement rates projected from trends in
the pre-incentive period (2000-1 to 2002-3) and actual rates in the first
Introduction
Over the past two decades funders and policy makers worldwide
have experimented with initiatives to change physicians’
behaviour and improve the quality and efficiency of medical
care.1
Success has been mixed, and attention has recently turned
to payment mechanism reform, in particular offering direct
financial incentives to providers for delivering high quality
care.2
In 2004 in the UK the Quality and Outcomes Framework
(QOF) was introduced—a mechanism intended to improve
BMJ 2011;342:d3590 doi: 10.1136/bmj.d3590 Page 1 of 12
Research
RESEARCH
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
21. Reasons for exception reporting patients
All English practices in 2008-9
Median exception rate was 2.7% (IQR 1.9-3.9%) overall and
0.44% (0.14-1.1%) for informed dissent
Common reasons logistical (40.6%), clinical contraindication
(18.7%), patient informed dissent (30.1%)
Higher rates associated with: larger practices, higher deprivation,
failure to secure maximum remuneration in previous year
Cost of the provision relatively low at £0.58 per patient (£31m)
Relatively few patients excluded for informed dissent, suggesting
that the incentivised activities were broadly acceptable to patientsFigures
Fig 1 Proportion of patients exception reported by indicator and reason, 2008-9. For 37 indicators for which reasons for
exception reporting were ascribable (see table 1). Indicators ordered by type of activity (measurement or outcome) and by
rate of exception reporting attributable to informed dissent
BMJ 2012;344:e2405 doi: 10.1136/bmj.e2405 (Published 17 April 2012) Page 11 of 11
RESEARCH
Exempting dissenting patients from pay for
performance schemes: retrospective analysis of
exception reporting in the UK Quality and Outcomes
Framework
OPEN ACCESS
Tim Doran clinical research fellow
1
, Evangelos Kontopantelis research fellow
1
, Catherine Fullwood
research associate
2
, Helen Lester professor of primary care
3
, Jose M Valderas clinical lecturer
4
,
Stephen Campbell senior research fellow
1
1
Health Sciences Research Group-Primary Care, University of Manchester, Manchester M13 9PL, UK; 2
Manchester Academic Health Science
Centre, Central Manchester University Hospitals NHS Foundation Trust, University of Manchester; 3
School of Health and Population Sciences,
University of Birmingham, Birmingham, UK; 4
NIHR School for Primary Care Research, Health Services and Policy Research Group, Department
of Primary Care Health Sciences, University of Oxford, Oxford, UK
Abstract
Objective To examine the reasons why practices exempt patients from
the UK Quality and Outcomes Framework pay for performance scheme
(exception reporting) and to identify the characteristics of general
Conclusions The provision to exception report enables practices to
exempt dissenting patients without being financially penalised. Relatively
few patients were excluded for informed dissent, however, suggesting
that the incentivised activities were broadly acceptable to patients.
BMJ 2012;344:e2405 doi: 10.1136/bmj.e2405 (Published 17 April 2012) Page 1 of 11
Research
RESEARCH
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
23. Patient level diabetes care
Sample of 148 representative practices from the CPRD
In 2004-5 quality improved
over-and-above this
pre-incentive trend by 14.2%
By 2006-7 the improvement
above trend was smaller at 7.3
Levels of care varied
significantly for sex, age, years
of previous care, number of
co-morbid conditions
Recorded quality of primary care for
patients with diabetes in England
before and after the introduction
of a financial incentive scheme:
a longitudinal observational study
Evangelos Kontopantelis,1
David Reeves,1
Jose M Valderas,2,3
Stephen Campbell,1
Tim Doran1
▸ An additional data is
published online only. To view
this file please visit the journal
online (http://bmjqs.bmj.com)
1
Health Sciences Primary Care
Research Group, University of
ABSTRACT
Background The UK’s Quality and Outcomes
Framework (QOF) was introduced in 2004/5,
linking remuneration for general practices to
recorded quality of care for chronic conditions,
years were more modest. Variation in care
between population groups diminished under
the incentives, but remained substantial in some
cases.
ORIGINAL RESEARCH
group.bmj.comon September 13, 2013 - Published byqualitysafety.bmj.comDownloaded from
Recorded QOF care did not vary significantly by area
deprivation before or after the introduction of the
incentivisation scheme. However, the effect of the inter-
vention did vary with area deprivation: patients attend-
ing practices from the most deprived quartile appear to
have gained less from the intervention compared with
patients in the most affluent quartile of practices, by
4.9% in 2004/5 and 3.8% in 2006/7.
There was significant variation in recorded QOF care
by practice diabetes prevalence rates, but the differences
Figure 2 Aggregate patient level Quality and Outcomes
Framework care and predictions based on the
pre-incentivisation trend.
on Sequalitysafety.bmj.comDownloaded from
2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7
new diagno 44.7 50.4 56.5 65.3 73.4 74.2 74.3
1-4 years 48.4 53.9 59.4 71.1 80.9 83 83.2
5-9 years 46.4 51.9 56.8 69.1 78.7 81.4 81.8
10+ years 45.4 50 55.1 66.7 77.6 79.3 80.4
2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7
new diagnoses 44.7 50.4 56.5 65.3 73.4 74.2 74.3
1-4 years 48.4 53.9 59.4 71.1 80.9 83 83.2
5-9 years 46.4 51.9 56.8 69.1 78.7 81.4 81.8
10+ years 45.4 50 55.1 66.7 77.6 79.3 80.4
40
45
50
55
60
65
70
75
80
85
90
aggregaterecordedQOFcarescore
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
24. Clinical computer systems
All English practices, 2007-8 to 2010-11
Seven clinical computer
systems consistently active
collectively holding ≈ 99% of
the market share
System choice strongest
predictor of performance on
62 stable care indicators
Differences greatest for
intermediate outcome
indicators
Particular system
characteristics facilitate higher
quality of care, better data
recording or both?
North East
North West
London
West Midlands
Yorkshire & the Humber
South West
East Midlands
East of England
South Central
South East Coast
(85.4,85.7]
(85.1,85.4]
(84.8,85.1]
(84.5,84.8]
(84.2,84.5]
[83.9,84.2]
LV
Vision 3
ProdSysOneX
PCS
Synergy
Practice Manager
Premiere
NOTE: Chart size proportional to number of practices in area
Average practice scores by Strategic Health Authority, 2010−11
Overall population achievement (62 indicators)
and GP systems products
Relationship between quality of care
and choice of clinical computing
system: retrospective analysis of family
practice performance under the UK’s
quality and outcomes framework
Evangelos Kontopantelis,1,2
Iain Buchan,3
David Reeves,1,2
Kath Checkland,1
Tim Doran4
To cite: Kontopantelis E,
Buchan I, Reeves D, et al.
Relationship between quality
of care and choice of clinical
computing system:
retrospective analysis of
family practice performance
under the UK’s quality and
outcomes framework. BMJ
ABSTRACT
Objectives: To investigate the relationship between
performance on the UK Quality and Outcomes
Framework pay-for-performance scheme and choice of
clinical computer system.
Design: Retrospective longitudinal study.
Setting: Data for 2007–2008 to 2010–2011, extracted
from the clinical computer systems of general practices
ARTICLE SUMMARY
Article focus
▪ Practice and patient-level characteristics are
known predictors of quality of care, as measured
by the Quality and Outcomes Framework (QOF)
indicators.
▪ Various general practitioner (GP) clinical com-
Open Access Research
group.bmj.comon September 13, 2013 - Published bybmjopen.bmj.comDownloaded from
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
25. Getting there...
Very high levels of initial
achievent leading to
overpayment
Still confusion about whether
the aim is to reward high
quality of care or to drive
improvement
It appears that the same levels
of care would have been met
eventually; QOF just took us
there quicker
050010001500
Numberofpractices
0 20 40 60 80 100
Percentage of patients
08/09 07/08 06/07 05/06 04/05
Overall, 48+2 (smoking) indicators
Reported achievement
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
26. Getting there...
Reduced inequalities but negatively affected continuity and
aspects of non incentivised care
QOF led to bigger, better organised practices but patients do not
seem to like that
Exception reporting a cheap provision to ensure no patient
discrimination
Small changes in the scheme details can have big effects on
quality of care
The intervention effect varied by patient groups
Strongest predictor of achievement was clinical system
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
27. What’s to be done with it?
good on paper but massive cost
Limit incentives to intermediate
outcome indicators only?
Remove the upper thresholds for
indicators, thereby reducing the
cost and driving improvement?
Re-negotiate the payment
platform for the same reason?
Bigger range of indicators and
only a random set assessed each
year?
Drop the whole scheme and
re-invest in other ventures?
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
28. More questions
What happens when the incentive for an indicator is removed?
What is the effect of the incentivisation on harder outcomes?
mortality
complications (e.g. for diabetes)
What really happens with exceptions and is there any gaming?
Kontopantelis (IPH) Variation and financial incentives 25 September 2013
29. Thank you for listening!
Comments and questions: e.kontopantelis@manchester.ac.uk
Kontopantelis (IPH) Variation and financial incentives 25 September 2013