Download - Stephen Gillam presentation WSPCR 2011
The Quality & Outcomes
Framework – triumph or
tragedy?
Steve Gillam
26.10.11
On this day…
„Mr Atlee is a very modest man.
Indeed, he has a lot to be modest about.‟
„I‟m just preparing my impromptu remarks.‟
„If this is a blessing, it is certainly very well
disguised.‟
„A pessimist sees the difficulty in every
opportunity; the optimist sees the opportunity in
every difficulty.‟
Outline
Background
Methods
Main findings
Impact of QoF
Implications
Background
International literature on pay for performance (P4P)
Introduced in 2004 in the UK
>£1billion per annum
22% GP income
Largest natural experiment in P4P in the world
Precursor schemes, e.g. PRICCE
Domains for quality indicators in QOF 2010 Clinical
Secondary prevention of coronary heart disease
Cardiovascular disease: primary prevention
Heart failure
Stroke & TIA
Hypertension
Diabetes mellitus
COPD
Epilepsy
Hypothyroid
Cancer
Palliative care
Mental health
Asthma
Dementia
Depression
Chronic kidney disease
Atrial fibrillation
Obesity
Learning disabilities
Smoking
Organisational
Records and information
Information for patients
Education and training
Practice management
Medicines management
Patient experience
Length of consultations
Patient survey (access)
Additional services
Cervical screening
Child health surveillance
Maternity services
Contraception
QOFability – ideal indicator is
Acceptable
Attributable
Feasible
Reliable
Sensitive to change
Of predictive value
Relevant
Systematic review of all published research till end august 2011
Medline, EMBASE, CINAHL, PsycINFO, Health Business Elite, Health Management Information Consortium, British Nursing Index, Econ Lit
575 research papers identified; 124 selected for review
Methods
Main findings
Health care gains
Population health and equity
Cost effectiveness
Impact on providers and teams
Patients‟ experience
Health care gains
Real but modest gains in some areas, e.g. asthma, DM
(?trendlines)
Better recording in QOF areas but not untargeted areas
No definitive improvement in outcomes, except possibly
epilepsy/DM admissions
Doran et al. N Engl J Med 2009;361:368-78.
Population health and equity
Inequalities related to deprivation slowly narrowing
Reductions in age-related differences for CVD/diabetes
Variable effects for e.g. gender related differences in
CHD
Dixon, Khachatryan & Boyce. The public health impact, In Gillam & Siriwardena (eds) The
Quality and Outcomes Framework, Radcliffe, Oxford 2010.
Lancet 2008;
372: 728–36
High risk individual and population based
strategies for prevention (Rose)
Identify and treat
those beyond a
threshold for risk
factor
Shift the whole
population
distribution of risk
factor
QOF scores nationally (% total points) and
changes in exception reporting rates 2004-2009
Limited evidence of ‘gaming’ but
does ER reduce QOF’s impact on
neediest populations?
Costs and effectiveness
No relationship between pay and health gain
Limitations to modeling, e.g. omit costs of
implementation
Cost effectiveness evidence studied for 12 indicators in
the 2006 revised contract with direct therapeutic effect
(Fleetcroft et al). 3 most cost-effective indicators were:
ACEI/ARB for CKD
Anticoagulants for AF and
Beta-blockers for CHD
Costs and effectiveness
Modest mortality reductions modelled - potential saving of 11 lives per 100,000 people per year across all indicators (Fleetcroft et al).
Average indicator payments ranged from £0.63 to £40.61 per patient; the percentage of eligible patients treated ranged from 63% to 90% (Walker et al).
Improvements in performance required for QOF payments to be cost-effective varied by indicator from less than 1% to 20% (Walker et al).
Impact on providers and teams
Changing structures, roles and staff – nurse-led care
Greater use of information technology
Restratification: „chasers‟ and „chased‟
Emphasis on the biomedical
Commodification of care
Narrative of „no change‟
Checkland & Harrison. Impact of QOF on practice organisation and service delivery. SocSciMed, 2008.
„Every day I come in I check (performance)… I‟m a chaser… You have to chase yourself though. You‟ve no credibility if you don‟t deliver.‟
„Some patients will come to you and they‟ll plead with you: „please don‟t give me any tablets, I‟ll bring my bp down, I‟ll do everything…but we‟re saying to them: „well look, we‟ve checked it three times now and it remains raised, you‟re clinically classed as hypertensive, we follow these guidelines and this is what we should be doing with you.‟
„All I think QOF did was make it a bit more organised and that. I don‟t think it was anything new.‟
Checkland & Harrison. Impact of QOF on practice
organisation and delivery. Soc Sci Med, 2008.
Patients’ experience
Little research on patient related/reported impact
Continuity and relationships affected
Fragmentation of care
Little explanation provided to patients “A slim, active 69-year-old patient attending for influenza vaccine
was faced with questions about diet, smoking, exercise and
alcohol consumption. There was no explanation for why these
questions were asked; they seemed irrelevant to having
a „flu vaccine. Blood pressure and weight had to be recorded and
a cholesterol test organised. A short appointment lasted almost
15 minutes without the patient having the opportunity to ask a
question about any aspect of „flu vaccine.”
Summary - QOF balance sheet
Better data recording and analysis
Modest health benefits for individuals and populations
Narrowing of inequalities in processes of health care
Improved team-working
Opportunity costs unknown, e.g. impact on preventive care
Unintended consequences: on workforce, professionalism
Scientific bureaucratic medicine and the McDonaldisation of care
Re-defined meaning of „quality‟
Implications – ways forward
Limit expansion but expand local discretion
Options
Leave indicators unchanged and anticipate higher achievement each year
Add new indicators or conditions
Select from a larger set of evidence-based measures
Remove measures once agreed level achieved
Rotate measures