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