Pay for Quality

52 Pay for Quality KCE Reports 118
• Changes in staffing policy: the introduction of ‘health visitors’ and local
132
immunization coordinators , a higher recruitment of nursing and
administrative staff to support primary care delivery, and a higher number of
general practitioners 148 .
• Changes in IT support: the introduction of an immunization recall system to
the provider 132 , the use of clinical prompts 163 . A system of uniform
electronic patient records with automatic data extraction was introduced as a
relevant factor in all QOF evaluation studies 148 .
• Together with the QOF came the introduction of two billion pounds of
additional funding 148 . This budget enlargement has to be taken into account.
• A final category consists of care management processes used as tools to
support quality improvement. Here we identify educational strategies 132 and
feedback and public reporting 148 , 163 . In the UK, feedback and peer
comparison of performance is considered part of the P4Q intervention.
Public reporting is also applicable for all QOF evaluation studies.
The interrelationship between P4Q as intervention, these other concurrent factors and
the reported quality performance effects is not further reported upon in most UK
studies. Some trends and co interventions were already in effect before P4Q
implementation, others are introduced simultaneously. This obscures the direction of
effects. Another related issue concerns the improvement in documentation 128, 165 . It
might be that P4Q has led to better documentation of care instead of real quality
improvement. It might also be that both better documentation and quality improvement
occurred, with mutual reinforcement. This distinction is often unclear, because quality
measurement makes use of available documentation in patient records.
4.2.6.2 United States of America
Because of the diversity in the USA, trends and co interventions are more difficult to
generalize towards the USA as a whole. In the American P4Q studies, general trends in
standard medical practice and the adoption of new scientific evidence into practice is
less identified. One example, similar to the UK, is the introduction of an extended
schedule of public influenza immunization clinics 178 . In addition, some broader quality
improvement initiatives are described within the context of P4Q studies, such as the
vaccines for children programmes 181 , 184 . Authors also point out the influence of
extensive media campaigns 178 and of general publicity attending P4Q 172 .
Structural changes in terms of settings/infrastructure and staffing policy are less
described than in UK studies. However, changes in IT support are often reported. An
example is the use of patient registries 144 , 191 , 222 , which can be part of a fully electronic
health record 193 and be centralized 201 . In another study, implementable best practices
are integrated in IT 189 . New supportive IT can be applied for coordination and follow
up 223 .
The use of reminders is a related co intervention 178 , 190 , 193 , 195 . In one USA study a
significant inverse relationship was found with the use of reminder postcards: lower
achievers on performance measurement sent more cards 177 . Another study found no
significant relationship with reminder system use (phone, postcard, flowchart in record)
178
.
Finally, the growth in the use of electronic patient records is identified as a relevant
factor 172 .
One study reported the introduction of gate keeping with prior authorization as a
relevant change on the market/payer level 173 .
On the level of the provider a very diverse set of care management processes are
reported as tools co supporting quality improvement in many P4Q studies.
Firstly, there are similar processes as in the UK: educational strategies, feedback and
public reporting. The use of new educational approaches is often reported as a co
intervention 171 , 174 , 183 , 190 , 195 , 222 , 223 .