nihr school for primary care showcase 2012 - financial incentives

School forPrimary Care

Research

Increasing the

evidence base for

primary care practice

Background

Concludedwork

Non-incentivisedcare

Diabetes

Current work

Effect of Financial Incentives onIncentivised and Non-Incentivised Clinical

ActivitiesUtilising Primary Care Databases to answer clinical,

policy and methodological questions

Evan Kontopantelis Tim Doran David ReevesReilly S, Oiler I, Springate D, Valderas J, Ashcroft D, Sutton M, Ryan R, Morris

R, Planner C, Gask L, Roland M, Campbell S, Salisbury C.

Centre for Primary CareInstitute of Population Health

Faculty of MedicineUniversity of Manchester

NSPCR showcase, 19th October 2012


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

School for Primary Care ResearchPrimary Care Database (PCD) research

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03 Oct 2012

School for Primary

Care Research

Increasing the

evidence base for primary care

practice

The National Institute for Health Research School for Primary Care Research is a partnership between the Universities of Birmingham, Bristol, Keele, Manchester, Nottingham, Oxford, Southampton and UCL. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Other departments

University of Birmingham - Ronan RyanRegional GP datasets and The Health ImprovementNetwork (THIN)Implementing risk models derived from PCD data inpractice (prevention, early detection)

Keele University - Kelvin JordanCPRD and local CiPCAEmphasis on musculoskeletal disorders (burden, longterm course, management)

UCL - Irene Petersen(THIN Database Research Team)Drugs prescribed in pregnancy, missing data methods,cardiovascular diseases in SMI patientsHosts a national primary care database user group andprovides training coursesInternational initiative to develop reporting guidelines forelectronic health records (RECORD)


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Outline

1 Background

2 Concluded workNon-incentivised careDiabetes

3 Current work


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Improving quality of carea (very) juicy carrot...

A pay-for-performance (p4p) program kicked off in April2004 with the introduction of a new GP contract

General practices are rewarded for achieving a set ofquality targets for patients with chronic conditionsThe aim was to increase overall quality of care and toreduce variation in quality between practices

The incentive scheme for payment of GPs was namedthe 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


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Quality and Outcomes Frameworkdetails 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)indicatorsOrganisation of care, with 56 (36) indicatorsAdditional services, with 10 (8) indicatorsPatient experience, with 4 (5) indicators

Implemented simultaneously in all practices (a controlgroup was out of the question)Practices are allowed to exclude patients from theindicators and the payment calculationsInto the 9th year now (01Mar12/31Apr13); cost for thefirst 8 years was well above the estimate at £8 bnapproximately


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Researchpre-PCD

Da

ta

Primary Care Research

Methodological Research

QMAS (QOF)

What about aspects not measured and reported under QMAS?

Investigated GP responses to changes in incentives

How small practices fare within the scheme

Investigated the effect of incentives on inequality

Examined exception reporting and “gaming”

Examined improvement in rates of achievement over time

Simulated

GMSUKBORDERS


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

The Clinical Practice Research DatalinkCPRD

Established in 1987, with only a handful of practicesSince 1994 owned by the Secretary of State for HealthIn July 2012:

644 practices (Vision system only)13,772,992 patients

Access to the whole database is offered and costs≈£130,000 paOffers the ability to extract anything adequatelyrecorded in primary care and construct a usabledataset


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Researchpost-PCD

Da

ta



QMAS (QOF)

The effect of QOF on non-incentivised aspects of care

Patient level care for diabetes, pre- and post-QOF

Investigated GP responses to changes in incentives

How small practices fare within the scheme

Investigated the effect of incentives on inequality

Examined exception reporting and “gaming”

Examined improvement in rates of achievement over time

Simulated

GMSUKBORDERS

CPRD


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Effect of Financial Incentives on Incentivisedand Non-Incentivised Clinical Activities

Effect of financial incentives on incentivised andnon-incentivised clinical activities: longitudinalanalysis of data from the UK Quality and OutcomesFrameworkTim Doran clinical research fellow1, Evangelos Kontopantelis research associate1, Jose M Valderasclinical lecturer 2, Stephen Campbell senior research fellow 1, Martin Roland professor of healthservices research3, Chris Salisbury professor of primary healthcare4, David Reeves senior researchfellow 1

1National Primary Care Research and Development Centre, University of Manchester, Manchester M13 9PL, UK; 2NIHR School for Primary Care

Research, Department of Primary Health Care, University of Oxford, Oxford OX3 7LF; 3General Practice and Primary Care Research Unit, University

of Cambridge, Cambridge CB2 0SR; 4Academic Unit of Primary Health Care, University of Bristol, Bristol BS8 2AA

AbstractObjective To investigate whether the incentive scheme for UK generalpractitioners led them to neglect activities not included in the scheme.

Design Longitudinal analysis of achievement rates for 42 activities (23included in incentive scheme, 19 not included) selected from 428identified indicators of quality of care.

Setting 148 general practices in England (653 500 patients).

Main outcome measures Achievement rates projected from trends inthe pre-incentive period (2000-1 to 2002-3) and actual rates in the firstthree years of the scheme (2004-5 to 2006-7).

Results Achievement rates improved for most indicators in thepre-incentive period. There were significant increases in the rate ofimprovement in the first year of the incentive scheme (2004-5) for 22 ofthe 23 incentivised indicators. Achievement for these indicators reacheda plateau after 2004-5, but quality of care in 2006-7 remained higherthan that predicted by pre-incentive trends for 14 incentivised indicators.There was no overall effect on the rate of improvement fornon-incentivised indicators in the first year of the scheme, but by 2006-7achievement rates were significantly below those predicted bypre-incentive trends.

Conclusions There were substantial improvements in quality for allindicators between 2001 and 2007. Improvements associated withfinancial incentives seem to have been achieved at the expense of smalldetrimental effects on aspects of care that were not incentivised.

IntroductionOver the past two decades funders and policymakers worldwidehave experimented with initiatives to change physicians’behaviour and improve the quality and efficiency of medicalcare.1 Success has been mixed, and attention has recently turnedto payment mechanism reform, in particular offering directfinancial incentives to providers for delivering high qualitycare.2 In 2004 in the UK the Quality and Outcomes Framework(QOF) was introduced—a mechanism intended to improvequality by linking up to 25% of general practitioners’ incometo achievement of publicly reported quality targets for severalchronic conditions.3

Should these incentives succeed, the potential benefits forpatients with the relevant conditions are considerable.4 Incentivesmight also improve general organisation of care, benefitingprocesses and conditions beyond those covered by theincentives.5 Financial incentives have several potentialunintended consequences, however. For example, they mightresult in diminished provider professionalism, neglect of patientsfor whom quality targets are perceived to be more difficult toachieve, and widening of health inequalities.6 7 Doctors mightalso focus on the conditions linked to incentives and neglectother conditions8 or, where certain activities are incentivisedwithin the management of a particular condition, might neglectother activities for patients with that condition.Practices in England generally performed well on incentivisedactivities in the first year of the UK incentive scheme, andoverall performance improved over the next two years.9-11 It is

Corresponding to: Tim Doran [email protected]

Extra material supplied by the author: Methodological appendix (see http://www.bmj.com/content/342/bmj.d3590/suppl/DC1)

Reprints: http://journals.bmj.com/cgi/reprintform Subscribe: http://resources.bmj.com/bmj/subscribers/how-to-subscribe

BMJ 2011;342:d3590 doi: 10.1136/bmj.d3590 Page 1 of 12

Research

RESEARCH


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Incentivised aspects keep improving

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Overall, 48+2 (smoking) indicators

Reported achievementQuality scores for allQOF clinical indicatorshave been improvingOnly a small proportionof all clinical careConcerns that quality fornon-incentivised aspectsmay have beenneglectedHow measureperformance onnon-incentivised care?


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Clinical indicators

Two aspects to clinical indicators:a disease condition (e.g. diabetes, CHD)a care activity (e.g. influenza vaccination, BP control)

Three indicator classes, in terms of incentivisation:(FI) Condition & process incentivised in QOF (28 ind)(PI) Condition or process incentivised (13 ind)(UI) Neither condition nor process incentivised (7 ind)

Example (Indicators)(FI) DM11: Patients with diabetes in whom the last blood pressure (within15m) is 145/85 or less

(PI) B4: Patients with peripheral arterial disease who have a record of totalcholesterol in the last 15m

(UI) C4: Patients with back pain treated with strong analgesics (co-dydramolupwards) in the last 15m


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Research questionsthe obvious ones at least!

We aimed to compare the three classes on changes inquality from pre-QOF (2000/1 - 2002/3) to post-QOF(2004/5 - 2006/7)Would FI indicators show most improvement?Would PI show some ‘halo’ effects since they involveeither a QOF condition or activity?Has quality for UI indicators declined?


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Issues to tackle

Indicator classes are imbalancedThree different types of activities (x3 classes = 9groups):

clinical processes related to measurement (PM/R)FI:17 PI:9 UI:0

e.g. blood pressure measurementclinical processes related to treatment (PT)

FI:6 PI:4 UI:7e.g. influenza immunisationintermediate outcome measures (I)

FI:5 PI:0 UI:0e.g. control of HbA1c to 7.4 or below

Quality of care was already improving (prior to QOF)The ceiling has been reached for certain ‘easy’indicators


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

The approach

The main analysis used logit-transformed scores, dueto the ceiling effectUntransformed scores were used in a sensitivityanalysisThe six available indicator groups (of a possible nine)were compared, on performance above expectationFE model selected; controlling for RTTM, denominator,patient age and genderAll analyses performed in StataInterrupted Time Series methods employed


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

The approachInterrupted Time Series

With ITS multi-level multiple regression analyses,compared the six indicator groups on two outcomes:

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Pre-trend Observed Uplift in year 1 Uplift in year 3

The difference betweenobserved and expectedachievement, in 2004/5The difference betweenobserved and expectedachievement, in 2006/7


Research

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Concludedwork


Diabetes

Current work

Trends by indicator group

−2.

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2000/01 2001/02 2002/03 2003/04 2004/05 2005/06 2006/07Year

FI−PM/R (17) FI−PT (6) FI−I (5)

PI−PM/R (5) PI−PT (2) UI−PT (2)

using group means of indicator means (by practice)in brackets, the number of indicators in each group

Logit transformed scores

Indicator group performance


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Difference in 2004/5of observed performance compared to expectation

All three fully incentivised indicator groups significantlyincreased in level above expectation post-QOFPartially incentivised treatment indicators significantlydecreased in level below expectation post-QOF

Uplift in

2004/5

Group

Fully

incentivized

measurement

Fully

incentivized

outcome

Fully

incentivized

treatment

Partially

incentivized

measurement

Unincentivized

treatment

Partially

incentivized

treatment

Mean * 14.5% 8.2% 4.2% 0.8% -0.7% -1.5%

95% confidence interval (14.0, 15.0) (7.3, 9.2) (3.2, 5.3) (-0.2, 1.8) (-1.8, 0.5) (-3.0, -0.2)

P value <0.001 <0.001 <0.001 0.128 0.257 0.03

Difference between means** [---------------------------]

* Group means based on logit-transformed data, back-transformed to percentage scores. ** Neuman-Keuls tests. Means connected by a dashed line were not significantly different (p > 0.05).

Uplift in

2006/7

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outcome

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measurement

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treatment

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treatment

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incentivized

treatment

Partially

incentivized

measurement

Mean * 3.9% 3.9% 2.4% -1.2% -2.8% -5.1%

95% confidence interval (2.9, 4.8) (3.1, 4.6) (1.4, 3.3) (-2.3, -0.2) (-4.2, -1.5) (-6.2, -3.9)

P value <0.001 <0.001 <0.001 0.024 <0.001 <0.001

Difference between means** [------------------------]



Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Difference in 2006/7of observed performance compared to expectation

All three fully incentivised indicator groups significantlyincreased in level above expectation post-QOFAll partially incentivised and non-incentivised indicatorgroups significantly decreased in level belowexpectation post-QOF

Uplift in

2004/5

Group

Fully

incentivized

measurement

Fully

incentivized

outcome

Fully

incentivized

treatment

Partially

incentivized

measurement

Unincentivized

treatment

Partially

incentivized

treatment

Mean * 14.5% 8.2% 4.2% 0.8% -0.7% -1.5%

95% confidence interval (14.0, 15.0) (7.3, 9.2) (3.2, 5.3) (-0.2, 1.8) (-1.8, 0.5) (-3.0, -0.2)

P value <0.001 <0.001 <0.001 0.128 0.257 0.03

Difference between means** [---------------------------]


Uplift in

2006/7

Group

Fully

incentivized

outcome

Fully

incentivized

measurement

Fully

incentivized

treatment

Unincentivized

treatment

Partially

incentivized

treatment

Partially

incentivized

measurement

Mean * 3.9% 3.9% 2.4% -1.2% -2.8% -5.1%

95% confidence interval (2.9, 4.8) (3.1, 4.6) (1.4, 3.3) (-2.3, -0.2) (-4.2, -1.5) (-6.2, -3.9)

P value <0.001 <0.001 <0.001 0.024 <0.001 <0.001

Difference between means** [------------------------]



Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Conclusions

Short term, on average:The 3 groups of fully incentivised indicators exhibitedperformance above expectationPartially incentivised treatment indicators demonstratedsignificantly lower than expected gains

Long term, on average:Fully incentivised groups continued to have positiveupliftsThe three partially incentivised and non-incentivisedgroups displayed significantly negative uplifts

QOF did not generate positive spill-overs to otheractivities & appears to have had a negative impact onnon-incentivised ones


Research

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Background

Concludedwork


Diabetes

Current work

Quality of primary care for patients withdiabetes in England pre- and post-QOF

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 ispublished online only. Toview this file please visit thejournal online (http://bmjqs.bmj.com)

1Health Sciences PrimaryCare Research Group,University of Manchester,Manchester, UK2Health Services and PolicyResearch Group, NIHRSchool for Primary CareResearch, Department ofPrimary Health Care,University of Oxford,Oxford, UK3European Observatory ofHealth Systems and Policies,London School ofEconomics, London, UK

Correspondence toDr Evangelos Kontopantelis,Health Sciences PrimaryCare Research Group, 5thfloor Williamson Building,Manchester M13 9PL, UK;[email protected]

Accepted 12 July 2012

ABSTRACTBackground: The UK’s Quality and OutcomesFramework (QOF) was introduced in 2004/5,linking remuneration for general practices to recordedquality of care for chronic conditions, includingdiabetes mellitus. We assessed the effect of theincentives on recorded quality of care for diabetespatients and its variation by patient and practicecharacteristics.Methods: Using the General Practice ResearchDatabase we selected a stratified sample of 148 Englishgeneral practices in England, contributing data from2000/1 to 2006/7, and obtained a random sample of653 500 patients in which 23 920 diabetes patientsidentified. We quantified annually recorded quality ofcare at the patient-level, as measured by the 17 QOFdiabetes indicators, in a composite score and analysedit longitudinally using an Interrupted Time Seriesdesign.Results: Recorded quality of care improved for allsubgroups in the pre-incentive period. In the first yearof the incentives, composite quality improved over-and-above this pre-incentive trend by 14.2% (13.7–14.6%).By the third year the improvement above trend wassmaller, but still statistically significant, at 7.3%(6.7–8.0%). After 3 years of the incentives, recordedlevels of care varied significantly for patient gender,age, years of previous care, number of co-morbidconditions and practice diabetes prevalence.Conclusions: The introduction of financial incentiveswas associated with improvements in the recordedquality of diabetes care in the first year. Theseimprovements included some measures of diseasecontrol, but most captured only documentation ofrecommended aspects of clinical assessment, notpatient management or outcomes of care.Improvements in subsequent years were more modest.Variation in care between population groups diminishedunder the incentives, but remained substantial in somecases.

INTRODUCTION

In the last 15 years the National HealthService in the UK has undergone a series ofreforms aimed at improving the quality ofcare for people with chronic conditions.These include the creation of the NationalInstitute for Health and Clinical Excellence,and the introduction of National ServiceFrameworks which set minimum standardsfor the delivery of health services in specifiedclinical areas, including diabetes mellitus.1

The quality of primary care generally, and ofdiabetes care in particular, improved in theearly 2000s,2 partly in response to thesequality improvement initiatives.3 In 2004 newcontractual arrangements for family doctorsallowed them to opt out of out-of-hourscare and linked financial incentives to qualityof care under the Quality and OutcomesFramework (QOF),4 the largest and mostambitious pay-for-performance scheme everattempted in health care.5 6

The QOF initially included 76 clinical indi-cators, covering a range of processes of care(eg, measurement of blood pressure) andintermediate outcomes (eg, glycaemiccontrol). A further 70 indicators coveredaspects of practice organisation and patientexperience of care. Eighteen of the clinicalindicators related to care for patients withdiabetes, reflecting in part the nationalimportance of the disease, the recordedprevalence of which had increased by 75% inthe previous decade.7 By achieving all thediabetes targets, an average practice couldearn over £7500 in the first year of the

BMJ Qual Saf 2012;0:1–12. doi:10.1136/bmjqs-2012-001033 1

Original research

BMJ Quality & Safety Online First, published on 22 August 2012 as 10.1136/bmjqs-2012-001033

Copyright Article author (or their employer) 2012. Produced by BMJ Publishing Group Ltd under licence.

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Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Practice level care for Diabetes keepsimproving but...

Minimumthreshold

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Diabetes 18

Reported achievementQuality of care fordiabetes known toimprove post-QOFDid QOF really have aneffect, if we account forpre-QOF trends?Does quality of care varyacross patientsubgroups?Did the schemepotentially benefit allsubgroups uniformly?


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

The approach

23,920 type I & II diabetes patients identified in 148practices and a sample of 653,500 from CPRDData extracted in yearly ‘bins’, corresponding to QOFyears, from 2000/1 to 2006/7Three time points before and 3 after the interventionFor each time point, annually recorded quality of care atthe patient level was quantified as an aggregate of theapplicable diabetes indicators (of the 17 possible)ITS analysis used again, the best possiblequasi-experimental approach, in lack of a control groupLogistic transformation to deal with ceiling effect


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Analysesthree main analyses

Examined the overall impact of the QOFpay-for-performance scheme in the CPRD diabetespopulationCompared mean QOF scores in the pre- and post-QOFperiods for different patient subgroupsExamined if the intervention impact varied by patientsubgroups (controlled analysis)


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Overall pay-4-performance impactAnalysis 1

Recorded QOF care did not vary significantly by areadeprivation before or after the introduction of theincentivisation scheme. However, the effect of the inter-vention did vary with area deprivation: patients attend-ing practices from the most deprived quartile appear tohave gained less from the intervention compared withpatients in the most affluent quartile of practices, by4.9% in 2004/5 and 3.8% in 2006/7.There was significant variation in recorded QOF care

by practice diabetes prevalence rates, but the differenceswere small and diminished over time. The interventioneffect also varied with practice diabetes prevalence.Compared with practices in the first quartile (lowest dia-betes prevalence), the QOF effect was larger for practicesin the second and third quartiles—by 1.4% and 2.1%respectively in the short term (2004/5) and by 3.2% and4.8% respectively in the long term (2006/7).

Sensitivity analysesThe sensitivity analysis (based on untransformed data)agreed with the main analysis in all respects except forthe relationship between the intervention and patientgender. In the sensitivity analysis both the short- andlong-term impact of the pay-for-performance schemewas significantly larger, though small in scale, for femalepatients (1.2%, p=0.048 and 2.5%, p=0.01 respectively).

DISCUSSION

The main aim of pay-for-performance schemes is toincentivise physicians to provide high quality care andthereby improve patient outcomes. Research to datesuggests that pay-for-performance schemes have limitedimpact when implemented in isolation, but when sup-ported by other quality improvement initiatives canhave a positive effect on quality of care.3 We foundthat recorded quality of primary care in the UK, as

measured by the QOF diabetes indicators, was alreadyimproving prior to the introduction of the scheme in2004, and that it improved at an accelerated rate inthe first years of its implementation, supporting thefindings of previous studies.11 23 However, this acceler-ated improvement did not seem to benefit all popula-tion groups equally.

Strengths and limitations of the studyThe main strength of our study was in the use of datafor individual patients drawn from a nationally represen-tative sample of practices. However, the study is subjectto certain limitations. First, the QOF was introduced uni-versally and was not implemented as part of a rando-mised experiment. The lack of a practice control groupentails that analyses of its effect in quality of care areonly possible using quasi-experimental methods. Resultsobtained with these methods can be method- andassumptions-sensitive; however, the interrupted time-series design is one of the most effective and powerfulof all quasi-experimental designs and is routinely beingused as the best possible approach when such researchscenarios arise.24 Second, we are reliant on the accurateand consistent recording of data by practices; however,usage of clinical computing systems has changed overtime and practices may have exaggerated their perform-ance in response to the financial incentives. This studyhas investigated the quality of recorded diabetes care andthere may be differences with care actually delivered.On the other hand, improved measurement is a neces-sary prerequisite for improved quality of care and onecould argue that it is improved quality of care. Third,most of the measures refer to documentation levels anddo not necessarily lead to the intended improvements inoutcomes if not properly followed-through or the inter-ventions are not offered in an appropriate manner (eg,advising a patient briefly ‘perhaps you should considerquitting smoking’ in order to ‘tick’ the relevant QOFbox is not really a smoking cessation intervention).Fourth, some quality indicators are dependent onothers, for example, indicator DM12 (blood pressurecontrolled) cannot be met unless indicator DM11(blood pressure measured) has also been met. However,we aimed to quantify and assess overall quality of care asmeasured by the whole diabetes domain in the QOFand to be as inclusive as possible. Fifth, the conditionswe modelled to investigate the effect of co-morbiditywere not an exhaustive list and only the presence orabsence was modelled and not the severity of each con-dition. However, the number of chronic co-morbidities isa well-established marker of the overall clinical complex-ity of a patient.25 Sixth, our findings assume that theobserved trends in indicator achievement prior to QOFwould have continued unchanged had the incentive

Figure 2 Aggregate patient level Quality and Outcomes

Framework care and predictions based on the

pre-incentivisation trend.

BMJ Qual Saf 2012;0:1–12. doi:10.1136/bmjqs-2012-001033 9

Original research

group.bmj.com on September 14, 2012 - Published by qualitysafety.bmj.comDownloaded from

In 2004/5 there wasimprovement incomposite recordedQOF careover-and-above thatexpected from thepre-intervention trend, of14.2% (13.7%-14.6%)By the third year(2006/7), the differencewas smaller, at 7.3%(6.7%-8.0%)


Research

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Background

Concludedwork


Diabetes

Current work

Differences in pre- and post-QOF level of careAnalysis 2

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Influenza immunis

Total cholest rec: DM16, record of total cholesterol (15m)Total chol≤5mmol/l: DM17, last measured total cholesterol is ≤5mmol/lInfluenza immunis: DM18, influenza immunisation (6m) performance is not reported for groups with fewer than 20 patients

Aged 0−24 25−44 45−64 ≥65

Score higher for patients aged 65+than in patients aged 17-39 by 11%pre- and 11.7% post-QOFQOF care marginally lower forfemales in both time periods, byaround 2%Scores for patients with 3+conditions higher on average by6.3% pre- & 6.1% post-QOFcompared to patients with noco-morbiditiesHighest for patients living withdiabetes for 1-4 yr, lowest for newdiagnoses (4.7% pre & 9.1% post)


Research

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evidence base for


Background

Concludedwork


Diabetes

Current work

Pay-4-performance impact variationAnalysis 3

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7new diagno 44.7 50.4 56.5 65.3 73.4 74.2 74.31-4 years 48.4 53.9 59.4 71.1 80.9 83 83.25-9 years 46.4 51.9 56.8 69.1 78.7 81.4 81.810+ 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 2006/7new diagnoses 44.7 50.4 56.5 65.3 73.4 74.2 74.31-4 years 48.4 53.9 59.4 71.1 80.9 83 83.25-9 years 46.4 51.9 56.8 69.1 78.7 81.4 81.810+ 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

aggr

egat

e re

cord

ed Q

OF

care

scor

e

No significant variationby sex, age, number ofco-morbid conditionsSignificant variation bynumber of years livingwith conditionCompared to newdiagnoses, all othersubgroups morepositively affected bothin 04/5 & 06/07 (≈6-7%)


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Conclusions

Recorded quality of primary care, as measured by theQOF diabetes indicators, was already improving priorto the introduction of the schemeImproved at an accelerated rate in the first years ofimplementation but gains diminished in following yearsQOF may have led to immediate gains in quality of carethan would have eventually been achieved in itsabsence (although it may have taken longer)QOF care tended to be higher for patients with moreco-morbid conditions throughout the entire studyperiod, including pre-QOF yearsNewly diagnosed patients seem to have benefitted lessfrom the QOF


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

ResearchCPRD and/or QOF related

Da

ta



CPRD

QMAS (QOF)

Investigate cancer screening utilisation for patients with type 2 diabetes (NAEDI funded study, in progress)

Investigating the effect of GP clinical system on QOF performance (in progress)

Quality of care for patients with diabetes in England, before and after the QOF (BMJ Quality and safety, 2012)

Exempting dissenting patients for p4p schemes: an analysis of exception reporting in the UK QOF (BMJ, 2012)

Family doctor responses to changes in incentives for influenza immunisation under the QOF (Health Services Research, 2012)

Framework and indicator testing protocol for developing and piloting quality indicators for the UK QOF (BMC Family Practice, 2011)

Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK QOF (BMJ, 2011)

Simulation generation methods (in progress)

Imputation methods for missing data in the GPRD (in progress)

Representative sampling, a greedy algorithm (submitted)

Other Healthcare Research

Investigating the effect of bariatric surgery using GPRD (in progress)

Risk of self harm in physically ill patients (Journal of Psychosomatic Research, 2012)

Suicide risk in primary care patients with major physical diseases: a case-control study (Arch Gen Psychiatry, 2012)

other

other

NSPCR funded

Investigating aspects of the QOF using the GPRD (Evan Kontopantelis)· Indicator removal· Exception reporting and gaming· Diabetes mortality and condition complications

Investigating quality of care for severe mental health patients using the GPRD (Siobhan Reilly & Evan Kontopantelis)· Examine if those with condition develop co-morbidities earlier· Examine BMI, cholesterol, BP and blood glucose and quantify the effect of the QOF· Determine rates of consultations

CANcer DIagnosis Decision rules, CANDID (Paul Little)· Investigate symptoms and examination findings that are predictors of lung or colon cancer

Simulated

Investigating the validity of Primary Care Databases (David Reeves)· Aims to identify,

further develop and test methods for addressing validity issues in PCDs

NSPCRfunded

GMSUKBORDERS


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Validity of evaluations of effectiveness basedon PCDsReeves, Kontopantelis, Doran, Ashcroft, Ryan, Morris

Recommend methods by which the internal andexternal validity of evaluations of effectiveness basedon PCDs can be assessed and maximised


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Exploring physical health and primary caremanagement of SMI patients using the CPRDReilly, Kontopantelis, Doran, Reeves, Ashcroft, Gask, Planner

Patients with SMI (schizophrenia, schizophrenia-likepsychosis, bipolar affective disorder or other psychosis)are at greater risk of developing chronic physicalillnesses than the general populationThis is a result of both the primary illnesses and theirtreatmentThis higher incidence of chronic disease iscompounded by generally poorer health outcomes inpatients with SMIThis despite frequent contact with health careprofessionals


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Exploring physical health and primary caremanagement of SMI patients using the CPRDReilly, Kontopantelis, Doran, Reeves, Ashcroft, Gask, Planner

By examining 2000-2011 CPRD data aims to:Determine frequency of primary care usage and ofprimary preventative activities for patients with SMIcompared to patients withoutCompare the number and pattern of comorbidities inpatients with SMI compared with those without SMIExamine whether patients with SMI developcomorbidities at a younger age than those without SMIAssess quality of care for all mental health relatedactivities incentivised under the QOF scheme, andwhether this changed following the introduction of QOF


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

An investigation of the Quality and OutcomesFramework (QOF) using the CPRDKontopantelis, Doran, Reeves, Campbell, Sutton, Valderas, Ashcroft

Three different projects which aim to investigateaspects of the UK primary care pay-for-performancescheme with the use of CPRDThese projects, albeit different in scope, share acommon background and require the same or a verysimilar extraction procedure

Indicator removalException reportingDiabetes management on survival and diabetes-relatedcomplications

Therefore, combined in a single programme of work


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

An investigation of the Quality and OutcomesFramework (QOF) using the CPRDProject 1 - indicator removal

Performance of GPs under the p4p scheme has beenquantified using indicators that express the percentageof the patients for which the appropriate treatment, test,examination etc was performedConsidering resources are fixed, in order to maximisethe benefit from the scheme, indicators would need tobe routinely replacedHowever, we do not know what the effect of removal willbe on levels of performanceThree indicators were removed in 2006/7 and we willinvestigate their performance over time


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

An investigation of the Quality and OutcomesFramework (QOF) using the CPRDProject 2 - Exception reporting

To protect patients from being discriminated against,the scheme allows for practices to exclude patientsfrom the payment calculations for a variety of reasonsHowever, the true levels of this provision are unknownsince patients that have been excluded and for whichthe respective clinical indicator has been ‘met’ areincluded in the payment calculationsUsing the CPRD we will

estimate the actual levels of exception reportinginvestigate the profile of excluded patientsuse the timing of exceptions to assess whether theyhave been used appropriately


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

An investigation of the Quality and OutcomesFramework (QOF) using the CPRDProject 3 - Diabetes complications and survival

Diabetes is one of the conditions incentivised under theQOF, through 17 clinical indicatorsSome of these indicators are based on findings fromthe UKPDS study which established the positive effectsof blood pressure, HbA1c and total cholesterol controlHowever, in that study only patients aged 25-65 wereenrolled, while various other patient exclusion criteriawere appliedUsing the CPRD we will determine the effects for allsubgroups and would be able to control the analysesfor other important factors, such as co-morbiditiesWe will also investigate the effect of all the indicators onsurvival and diabetes complications


Research

Increasing the

evidence base for


Background

Concludedwork


Diabetes

Current work

Something goes around something but that's as far as I've got...

Comments and questions:[email protected]

nihr school for primary care showcase 2012 - financial incentives

Health & Medicine

clinical care

primary care databases

primary care esearch

overall quality of care

health research school

evidence base

practice prevention

keele university undergraduate