Pay for Quality

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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.
KCE Reports 118 Pay for Quality 131 Figure 11 : P4Q concepts: Quality Quality Strength Weakness Effectiveness focus, often combined with other domains Growing attention for integration and coordination High level of local adaptation No clear focus in all initiatives Some initiatives with an exclusive efficiency focus Limited attention for Equity Quality targets Strength Weakness Primary care + hospital care initiatives Preventive + Acute + Chronic care initiatives Medical condition specific + generic initiatives Availability of different target types (structure, process, intermediate outcome, long term outcome High number of target definitions available Attention for both appropriate and inappropriate care Attention for SMART target definition Use of a dynamical approach in most initiatives High level of local adaptation No measured quality targets in all initiatives Lack of evidence base selection requirements Lack of room for improvement selection requirements Lack of cost effectiveness selection requirements Quality measurement Strength Weakness Different types of data collection available A combined approach is used in some initiatives Attention for case mix adjustment in various initiatives Limited experience with exception reporting Lack of monitoring of unintended consequences Existing databases can be leveraged for hospital care, and more limited for primary care
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37. HTA Magnetische Resonantie Beel
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