Pay for Quality
Pay for Quality
Pay for Quality
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KCE Reports 118 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> 89<br />
5.2.3 Reported impact of P4Q on equity<br />
(In)equity in health care is a central point of attention of many health care systems and<br />
tackling this inequity has been an important objective in the development and<br />
reorganization of health services. 63 There is widespread concern that the focus on<br />
quality improving systems driven by financial incentives may lead to a widening of the<br />
existing inequity in health care. Within this report the impact of the introduction of the<br />
<strong>Quality</strong> and Outcome Framework in the UK on equity in treatment and (intermediate)<br />
outcomes was investigated. More specifically with this study we want to target the<br />
following three sub domains: the immediate effect of the implementation of QOF on the<br />
existing inequity in treatment and (intermediate) outcomes, the effects on long term<br />
and the contribution of exception reporting in treatment and (intermediate) outcomes.<br />
Several limitations in the selected studies complicate the <strong>for</strong>mulation of the evidence,<br />
prompting utmost prudence in interpreting and generalizing the results of this study.<br />
In the assessment of equal access to care it is essential to look <strong>for</strong> differences in social<br />
or ethnic background, gender … between the users of health care and the non-users of<br />
health care, both with the same need <strong>for</strong> care. None of the studies addresses this issue:<br />
they do not include in<strong>for</strong>mation on the ratio users/non-users (both in equal need <strong>for</strong><br />
care) and on the variation in the characteristics of the users and the non-users. This<br />
makes it impossible in this study to pronounce upon overall equity in access.<br />
The majority of the studies make no judgments about the appropriateness of the<br />
indicators or the treatment targets <strong>for</strong> both groups. As a result, similar screening or<br />
treatment rates can actually mean under treatment of certain groups, hence inequity<br />
63<br />
.In none of the selected studies normative need, felt need or expressed need is taken<br />
into consideration when observing differences in treatment and/or (intermediate)<br />
treatment outcomes. In the majority of the studies the authors (inexplicitly) adopt a<br />
comparative approach to need: when variations are found between the treatment rates<br />
and outcomes of two groups of patients with the same condition (e.g. low-income<br />
versus high-income diabetic patients), inequity is presumed. Characteristic of a<br />
comparative approach of need is that it makes no judgments about the appropriateness<br />
of the indicators or the treatment targets <strong>for</strong> both groups. E.g. when no differences are<br />
found in the cervical screening rates between population A and B most of the selected<br />
studies would presume equity. However knowing some groups have a higher risk on<br />
cervical cancer related to number of sexual partners, similar screening rates actually<br />
mean under treatment of this second group and so inequity.<br />
As a result utmost prudence is necessary when interpreting the results of the studies:<br />
the absence of social, gender or age differences should not automatically be interpreted<br />
as absence of inequities. 63<br />
Questions can be asked about the relevance and the completeness of the indicators that<br />
are used to measure quality. Although initiatives such as the QOF cover many<br />
important aspects of quality of care, the inherent strength and complexity of the<br />
doctor-patient relationship supports quality at a much deeper level which is not<br />
captured by the QOF indicators. The same reasoning applies to the fact that the<br />
selected publications mainly focus on intermediate outcomes and less on final outcome<br />
measures. To what extent equity in intermediate outcomes or process indicators<br />
predict final outcomes, not to speak to what extent the found (in)equities in health care<br />
predict (in)equities in health?<br />
The selected studies have weak study designs according to the labels presented in<br />
chapter 4. Of the 27 studies studying the pay-<strong>for</strong>-per<strong>for</strong>mance initiative in the UK<br />
• 17 have a cross-sectional design with only one point of measurement;<br />
• 7 studies have a serial cross-sectional design with several points of<br />
measurement in time (of which only 3 with both measurements be<strong>for</strong>e and<br />
after the introduction of the new initiative)<br />
• 3 studies have a longitudinal design with several points of measurement in<br />
time and linking of the data from the same study subject (e.g. patient) over<br />
time