Changes in the UK during the 1990s
PAY FOR PERFORMANCE:
THE UK EXPERIENCE
The impact of the Quality and Outcomes
Framework P4P scheme on general practice clinical
quality in the UK
Stephen Campbell, NPCRDC, University of
Manchester, UK
Academy Health, Orlando
5 June 2007
Government
• Improving health care became
political priority: Care too variable.
Academics
• Developed methods of measuring
quality: Quality can be measured
Doctors
• Cultural shift: Quality needs to be
measured and improved + opportunity
for increased income
National Strategy Æ 1997
• Guidelines/standards: National Service Frameworks / NICE: i.e. CHD
• Quality improvement - clinical governance in PCTs ie. CHD, audit
• Performance monitoring / inspection: CHI / Healthcare Commission
1980s
• Quality can’t be measured
• There’s no such thing as a bad doctor
2000s
• Care is too variable
• Quality can be measured
• Care can be improved
NB: Quality improvement initiatives before QOF
NB: Quality was improving before QOF…
New GMS contract: 2004
Pay for performance scheme “Quality and
Outcomes Framework”
25% of GPs’ income relates to a complex
set of 146 quality indicators in years 1 and 2
– Chronic disease management (ten conditions): 65
clinical targets
– Practice organisation (five areas)
– Patient experience
$3.2 billion additional funding
1998-2003: pre QOF
• Quality was
improving already
• Data extracted from
medical records in
42 practices:
necessary aspects of
care
• How will the new
contract affect
quality of care…?
80
70
60
50
40
30
20
10
0
76
59
Coronary heart
disease
P<0.01
70
70
62
60
Diabetes
Asthma
P<0.01
P<0.01
1998
2003
Quality of care in 42 representative English practices.
Campbell et al. BMJ 2005; 331: 1121-1123.
Study 1
QuIP:
Quality in Practice
Aim: Evaluate the impact of the 2004 Quality
and Outcomes Framework on clinical quality of
care
1998-2007
Focus today on asthma, CHD, diabetes….
1
QuIP
Data collection points
Data measured at two points before (1998 and 2003) and
again after (2005 and 2007) the introduction of the new
contract / QOF.
PRE-QOF
POST-QOF
NGMS/
QOF
1998
2003
2005
2007
Sample: 42 nationally representative practices
Method: Data extracted from medical records of random
cross-sectional samples of patients with asthma, CHD
and diabetes in each year
Patient sample: 2300 patients in 1998, 1495 in 2003, and
1882 in 2005.
Analyses: Performance in 2005 was compared to that
predicted by a logit model, based on observed trends
between 1998 and 2003.
Longitudinal time-series design
(4 cross sectional samples)
1998-2005
• Quality is still improving
• Is the rate of improvement significantly more than what
was expected from previous trends?
• In other words: is there a QOF effect?
90
80
70
60
50
40
30
20
10
0
81
85
76
59
Coronary heart
disease
QOF effect? Better than expected?
Mean practice achievement scores 2005
Angina
Diabetes
Asthma
Actual score
85
81.4
84.3
Predicted on logit model
80.7
73.2
72.3
0.066
0.002
<0.001
84
70
70
62
60
(based on 1998-2003 trend)
Diabetes
1998
2003
Asthma
Significance of difference
2005
Study 2
QOF-A
Aim: Evaluate the performance of all practices in
England- all targets in QOF
2004 –
Doran T, Fullwood C, Gravelle H et al. Family practice performance in the first
year of the UK’s new pay for performance scheme: good clinical practice or
‘gaming’? New England Journal of Medicine 2006; 355: 375-384.
QOF-A
Sample: All practices in England submitting data on
QOF. 7935 practices – where data from both years are
available
Method: Data extracted automatically from clinical
computing systems for practices in the first (2004/05)
and second years (2005/06) of the scheme.
Analyses: Reported achievement on targets: % of
patients deemed eligible for whom a quality indicator
was met (population achievement)
Focus today: 10 disease areas: 65 clinical targets
2
Practice performance in Years 1 and 2
1000
• Overall weighted reported achievement across all 10
conditions (65 targets)
• High levels of achievement: even higher in year 2
• Year 1: Higher than expected by government
2005-6
Median
Overall
83.4%
87.1%
CHD
85.7%
88.7%
Diabetes
80.1%
83.7%
Asthma
80.5%
83.6%
0
200
400
600
Frequency
800
2004-5
Median
0
20
40
60
80
100
Types of indicator: Achievement for
level of control etc (diabetes)
90
85
94
80
overall
BMI
smoking
BP
HBA1c
2005-06
76
Study 1: QuIP: The pay-for-performance scheme was
associated with accelerated quality improvement for asthma
and diabetes but not heart disease.
71
59
overall
84
96
96
96
Conclusion
80
72
98
97
94
Study 2 -QOF-A: Very high levels of achievement across
all chronic conditions in years 1 and 2 higher than that
predicted by the government.
84
80
100
95
90
85
80
75
70
65
60
55
50
2004-05
Percentage achievement
100
95
90
85
80
75
70
65
60
55
50
Types of indicator: Achievement for
recording of…(diabetes)
Chol <5
2004-05
61
HBA1c <7.4
BP <140/85
2005-06
Against a background of already improving quality of care
in the UK for these chronic conditions, pay-forperformance may be a useful means of augmenting other
approaches to quality improvement.
Thank you for listening...
Questions / comments ?
stephen.campbell@manchester.ac.uk
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