Commentary: UKs P4P initiative has had ambiguous impact on care
A commentary on the National Quality Measures Clearinghouse website titled “Pay for Performance in U.K. General Practice—The Ambiguous Impact of the Quality and Outcomes Framework,” offers a mixed review of the pay-for-performance (P4P) initiatives of the National Health Services' (NHS) Quality and Outcomes Framework (QOF).
Introduced to the NHS in 2004 for general practice, “the [QOF] is the most comprehensive national primary care P4P program in the world,” wrote Stephen J. Gillam, MD, of the University of Cambridge in England, in the commentary, which appeared March 7.
The P4P program uses financial incentives to promote structured, team-based care in pursuit of evidence-based objectives. Most of these P4P payments link to evidence-based process measures related to the quality of chronic disease management, Gillam wrote. “A sensible verdict regarding the QOF’s effectiveness must balance a nuanced assessment of health and other gains against its costs, many of which are hard to describe, let alone quantify.”
The QOF’s impact is described under the following five headings:
1. Quality of care. “There are early indications that the framework has resulted in better recorded care, enhanced processes, and improved intermediate outcomes (e.g., the control of HbA1c and high blood pressure in people with diabetes). It has helped consolidate evidence-based methods for improving care by increasing the use of computers, decision support, provider prompts, patient reminders and recalls,” he wrote.
2. Population health and inequalities. “While the framework was not designed to reduce health inequalities resulting from socioeconomic disadvantage, inequalities of care between the most and least deprived areas have narrowed. For example, variation in reported achievement decreased at a faster rate for practices in the most deprived areas across all 48 individual indicators during the first three years of the framework. In fact, the QOF does encourage greater consistency of care irrespective of deprivation. Additionally, there are estimates indicating significant population mortality reductions. A modeling study estimated that the potential reduction in mortality from full implementation of the QOF contract was 416 per 100,000 people per year in 2004 to 2005, and 451 in 2006 to 2007. The potential reduction in mortality per 100,000 people per year ranged from 163 in coronary heart disease, to eight in asthma,” Gillam reported.
3. Team structures and ways of working. “The QOF has resulted in positive effects on practice organizations, such as on teamwork (e.g., the development and use of shared protocols) and the diversification of nurse roles (e.g., sub-specializing in different clinical areas)," he reported. "Indeed, the transition to a nurse-led primary care system is accelerating under the QOF in various ways. The QOF has introduced new hierarchies within practice teams and helped stratify medical roles.”
4. Patient views. “Remarkably, little is known of what patients actually make of these changes. Adherence to single, disease-based guidelines can override respect for patient autonomy and ignore the co-morbidities that are today’s norm,” Gillam wrote. “By focusing the clinician's attention on sometimes extraneous targets and the completion of computer templates, the QOF can promote a mechanistic approach to chronic disease management at the expense of personal care.”
5. Cost-effectiveness. A central question is not whether the QOF has had an impact, but rather concerns the QOF’s cost-effectiveness, according to Gillam. “Here, the evidence is sparse.” Indicators in some domains may prove cost-effective; for example, evidence shows that increasing the quality of primary care may reduce hospitalization rates for some conditions. “More sophisticated modelling is required, but the opportunity costs of the QOF are, by any reckoning, considerable.
“The framework is by no means a perfect system for improving quality—it needs improvement and modification based on careful analysis of its effects, both intended and unintended, and the ever-changing evidence that underpins it. Thus far, numerical data suggest some early improvements in quality of care attributable to the QOF, while interview-based data reveal a mixed picture in areas (e.g., professionalism, continuity of care) that are difficult to quantify,” Gillam concluded. “Research needs also to include comparative analyses between health systems as more countries introduce similar [P4P] schemes."
The entire commentary can be seen here.
Introduced to the NHS in 2004 for general practice, “the [QOF] is the most comprehensive national primary care P4P program in the world,” wrote Stephen J. Gillam, MD, of the University of Cambridge in England, in the commentary, which appeared March 7.
The P4P program uses financial incentives to promote structured, team-based care in pursuit of evidence-based objectives. Most of these P4P payments link to evidence-based process measures related to the quality of chronic disease management, Gillam wrote. “A sensible verdict regarding the QOF’s effectiveness must balance a nuanced assessment of health and other gains against its costs, many of which are hard to describe, let alone quantify.”
The QOF’s impact is described under the following five headings:
1. Quality of care. “There are early indications that the framework has resulted in better recorded care, enhanced processes, and improved intermediate outcomes (e.g., the control of HbA1c and high blood pressure in people with diabetes). It has helped consolidate evidence-based methods for improving care by increasing the use of computers, decision support, provider prompts, patient reminders and recalls,” he wrote.
2. Population health and inequalities. “While the framework was not designed to reduce health inequalities resulting from socioeconomic disadvantage, inequalities of care between the most and least deprived areas have narrowed. For example, variation in reported achievement decreased at a faster rate for practices in the most deprived areas across all 48 individual indicators during the first three years of the framework. In fact, the QOF does encourage greater consistency of care irrespective of deprivation. Additionally, there are estimates indicating significant population mortality reductions. A modeling study estimated that the potential reduction in mortality from full implementation of the QOF contract was 416 per 100,000 people per year in 2004 to 2005, and 451 in 2006 to 2007. The potential reduction in mortality per 100,000 people per year ranged from 163 in coronary heart disease, to eight in asthma,” Gillam reported.
3. Team structures and ways of working. “The QOF has resulted in positive effects on practice organizations, such as on teamwork (e.g., the development and use of shared protocols) and the diversification of nurse roles (e.g., sub-specializing in different clinical areas)," he reported. "Indeed, the transition to a nurse-led primary care system is accelerating under the QOF in various ways. The QOF has introduced new hierarchies within practice teams and helped stratify medical roles.”
4. Patient views. “Remarkably, little is known of what patients actually make of these changes. Adherence to single, disease-based guidelines can override respect for patient autonomy and ignore the co-morbidities that are today’s norm,” Gillam wrote. “By focusing the clinician's attention on sometimes extraneous targets and the completion of computer templates, the QOF can promote a mechanistic approach to chronic disease management at the expense of personal care.”
5. Cost-effectiveness. A central question is not whether the QOF has had an impact, but rather concerns the QOF’s cost-effectiveness, according to Gillam. “Here, the evidence is sparse.” Indicators in some domains may prove cost-effective; for example, evidence shows that increasing the quality of primary care may reduce hospitalization rates for some conditions. “More sophisticated modelling is required, but the opportunity costs of the QOF are, by any reckoning, considerable.
“The framework is by no means a perfect system for improving quality—it needs improvement and modification based on careful analysis of its effects, both intended and unintended, and the ever-changing evidence that underpins it. Thus far, numerical data suggest some early improvements in quality of care attributable to the QOF, while interview-based data reveal a mixed picture in areas (e.g., professionalism, continuity of care) that are difficult to quantify,” Gillam concluded. “Research needs also to include comparative analyses between health systems as more countries introduce similar [P4P] schemes."
The entire commentary can be seen here.