Pay for Quality

130 Pay for Quality KCE Reports 118
In addition, initiatives on a national or regional level (care itineraries, preventive module,
breast cancer screening) predefine the targets with no attention for local room for
improvement.
The level of cost effectiveness as a target selection criterion in existing initiatives lacks
evidence and is rarely explicitly focused upon. A P4Q initiative will therefore require
additional attention for the degree of health gain per unit of expense as part of the
target selection process.
A strength of many initiatives is their dynamical approach. Care itineraries, clinical
pathways, the quality and patient safety in hospitals initiative, hospital accreditation, use
of the EPA tool, hospital benchmarking, etc. are all meant to evolve and change over
time, both regarding targets as regarding the quality improvement process itself.
Quality measurement
Current quality improvement initiatives in Belgian primary and hospital care show that
quality is measured based on different methods of data collection. Some initiatives make
use of secondary data analysis based on existing administrative data (capitation
revaluation, reference payments for hospitals, prescription feedback) or clinical data
(breast cancer screening). Others use a sampled approach based on health care records
(clinical pathways, EPA tool). Automatic data extraction is planned for more recent
initiatives like care itineraries. Finally, a number of initiatives are based on a combined
approach of data collection methods (quality and patient safety in hospitals, hospital
accreditation, hospital benchmarking). The validity of data is subject to the limitations of
all methods used. Probably a combined approach offers most security. A strength and
P4Q opportunity is that quality data are being collected broadly throughout initiatives.
Data validity deserves specific attention, but both international and national examples
show that a valid data foundation is possible when addressed profoundly.
A strength of current initiatives is the attention for case mix adjustment for outcome
measures (care itineraries, clinical pathways, hospital benchmarking). This can be based
on separate subgroup analyses and comparisons or on a more integrated risk
adjustment modelling approach. This experience can be considered a P4Q opportunity.
Currently quality improvement initiatives do not use exception reporting as a way to
preserve intended or uncontrollable variability of care. However, the clinical pathway
initiative makes use of a similar approach by using analysis of variation. This means that
deviations of expected care are recorded continuously as part of daily practice
(integrated in the health record system) and are used as a source of information to
improve the quality of care systematically. This method does not predefine exception
reporting criteria as in the UK QOF framework, but can be used as a starting point to
explore exception reporting possibilities.
A weakness of existing quality initiatives in Belgium is the general lack of monitoring for
unintended consequences. Differences in equity of care (based on gender, age, ethnicity,
socio economical status, presence of co morbidities, etc.) and potential neglecting
effects toward other quality priority areas are not exclusively related to the ‘pay’
component in P4Q. Unintended consequences may be present or arise in quality
improvement initiatives in general. Irrespective of P4Q implementation, this issue
deserves specific attention in Belgian healthcare.