Pay for Quality

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58 Pay for Quality KCE Reports 118 Key points on the reported effect of Pay for Quality programmes Preventive care results • There is evidence of a positive P4Q effect on influenza immunization and cholesterol screening. An effect ranging from no effect to a positive effect had been reported for cancer preventive screening, children immunization and children preventive screening. For well child visits an effect ranging from a negative effect to a positive effect was reported. Concerning the prevention of sexual transmitted diseased there is evidence of no effect or even a negative effect. For most of the indicators were variability data were reported, a decrease in variability was found. Acute care results • Concerning emergency care there is an effect ranging from no effect to a positive effect on timeliness of care and no effect on hospital admission patient flow. Finally a positive relationship with the smoking cessation referral rate was found. • Regarding myocardial infarction/acute cardiac events, no effect or a positive effect was found on medication use and smoking cessation advice. On the not incentivized control measures, no effect was found. • Concerning coronary artery bypass grafting, an absence of effect was found on almost all long term outcomes. A positive effect was found on the provision of discharge instructions to heart failure patients, no effect or conflicting results were for the other indicators. • Regarding community acquired pneumonia, a positive effect was found for screening, vaccination and the use of blood cultures. For the other indicators conflicting results were found. • There is a mixed effect on targets focusing on replacing inappropriate sinusitis care by evidence based alternatives. • Concerning breastfeeding a shift was found from partial to full breastfeeding. • No data on variability were found for the acute care indicators. Chronic care results • Concerning diabetes four groups can be distinguished. One group of targets showed no effect, another group showed a below 5% effect size, a third group showed a wider range effect, between 0 and 25% and a final group showed a positive effect with a smaller range. Wherever reported most diabetes indicators showed a decrease in variability. • A positive effect was found on heart failure treatment in primary care. • With regard to coronary heart diseases, several targets showed an absence of effect, others showed a below 5% improvement, for still others a larger range of effect size was found, with conflicting evidence for cholesterol recording. • An absence of effect or a positive effect was found for the indicators related to stroke. • Concerning asthma indicators, the effect size ranged between an absence of effect to a below 5% effect, a positive relationship was found with CMP use and no relationship with not incentivized measures. The variability diminished after implementing P4Q programmes. • A positive effect was found on the hypertension care targets. Less variability was reporting after introducing P4Q programmes • With regard to smoking cessation indicators the effect size ranged between no effect and a positive effect. After introducing P4Q programmes, variability showed no difference or a small decrease.
KCE Reports 118 Pay for Quality 59 • Concerning depression/mental illness primary care indicators, osteoarthritis care indicators. Chronic child care indicators, epilepsy indicators and chronic kidney disease, a very limited amount of articles were found, with an effect ranging from an absence of effect to a positive effect. Generic findings • With regard to chronic disease management there is a positive relationship with several targets and an absent or positive relationship with not incentivized targets. • On the overall QOF achievement there is a positive effect. Several QOF targets showed a decrease in variability after implementation of P4Q • There effects with regard to CMP use are mixed. • Regarding patient and provider satisfaction the effect ranged between no effect and a positive effect. Concerning variability a very small decrease was found after implementing P4Q. 4.4 REPORTED COST EFFECTIVENESS AND MODELLING EFFECTS OF P4Q PROGRAMMES 4.4.1 Cost-effectiveness of Pay for Quality Few reports have been identified concerning cost-effectiveness evaluations of Pay for Quality programmes. Only three studies focus on cost-effectiveness of pay for quality programmes, one in the UK 224 and two in the USA 107 , 225 . Mason et al. (2008) 224 focus on the cost-effectiveness of the Quality Outcome Framework implemented in primary care and addressed at general practices. Twelve clinical QOF indicators have been considered that have a direct therapeutic impact (see Table 1). These included preventive, acute and chronic care targets concerning hypertension, heart diseases, heart failure, stroke, diabetes, kidney disease, cervical screening and smoking cessation. The QOF payments are based on point achievement, adjusted for practice size and disease prevalence relative to national average values. The annual per patient payment that is paid by the government, ranged from £0.13 to £87.79 in 2004-2005 and from £0.22 to £73.04 in 2006-2007. For the economic evaluation of this programme a threshold of £20 000 per QALY was assumed. According to this analysis, the most cost-effective indicators are the use of ACE inhibitors or Angiotensin Receptor Blocking (ARB) for chronic kidney disease, anticoagulant therapy for atrial fibrillation, and beta blockers for coronary heart disease. Note that the costeffectiveness varies strongly by baseline uptake. In general, one can state that, when baseline implementation rates are high, larger absolute changes in utilisation are required for indicators to be cost-effective. High baseline utilisation rates imply that many patients already receive the treatment, hence general practitioners receive payments for patients already being treated in a correct way. In 2006, only one indicator was not cost-effective, namely diabetic retinal screening.
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Wettelijk depot : D/2008/10.273/50
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