Pay for Quality

62 Pay for Quality KCE Reports 118
Fleetcroft et al. (2006) 227 explore the link between financial incentives and the likely
population health gains within the QOF system. In this study only 38 of the 91 clinical
indicators are taken into account. As explained on page 43, the incentives for each
indicator rely on a point system, whereby each quality indicator reflects a number of
points. Points are then allocated to a GP for a certain indicator, with a related payment
that starts above a minimum threshold level of achievement on the indicator. The
clinical domain is 550 points (in 2004) out of 1050. The monetary value of one point is
estimated at £120 for a general practice of average size.
The potential health gain on the 38 QOF indicators was estimated and expressed in
number of lives saved, based on a study by McColl et al. (1998). These authors
subdivided these 38 indicators in 8 interventions. As shown in Table 5, the potential
health gain ranged from 2.8 lives saved per 100 000 people per year to 308 lives saved
per 100 000 people per year. In addition, the potential payments in connection with the
pay for quality programme ranges from no payment to £17 280 per year. In conclusion
there seems to be no obvious relationship between payment and health gain for these 8
interventions. Some indicators could generate a large amount of health gain against a
low payment within the QOF system, others only generate a minimal improvement in
health gain against large payments within the QOF system.
Table 5: Relationship between potential health gains and potential payments
within the QOF system by Fleetcroft et al. (2006)
Quality indicator Maximum lives saved per 100000
people per year (% of total)
ACE in heart failure 308.0 (41%) 2 400 (6%)
Influenza immunization in over 65s 146.0 (20%) 3 600 (10%)
Smoking cessation advice and
nicotine replacement
120.0 (16%)
10 440 (28%)
Screening and treatment of
hypertension
71.0 (10%) 17 280 (46%)
Aspirin in ischemic heart disease 48.0 (6%) 1 320 (4%)
Warfarin in atrial fibrillation 33.0 (4%) 0 (0%)
Statins in ischemic heart disease 13.8 (2%) 2 760 (7%)
Statins in primary prevention 2.8 (0%) 0 (0%)
Maximum payment for a typical
practice per year (% of total)
McElduff et al. (2004) 228 estimated the health gain within cardiovascular patients if a
number of QOF quality measures were to be met. Five interventions were taken into
account, namely the use of aspirin, a cholesterol lowering treatment, a hypertension
management, a treatment with ACE or angiotensin 2 (A2) inhibitors and influenza
immunization. The modelling method used incorporates data on clinical effectiveness
and the baseline rate (current rate) of performance concerning these interventions.
Consequently, the comparator in this study was current treatment. The health gain in
cardiovascular patients is expressed in number of cardiovascular events prevented per
10 000 patients, among which is understood, angina pectoris, myocardial infarction,
death from coronary heart diseases (CHD), stroke, congestive heart failure, peripheral
vascular disease and death from cardiovascular disease. As shown in Table 6, reaching
the cholesterol target (lowering the total cholesterol in patients with values above
5.0mmol/l) will result into a reduction of cardiovascular events among patients with
CHD, stroke and diabetes with respectively 15.5, 7.2 and 6.5 cases per 10 000 over a 5
year period. Reaching the targets concerning hypertension management, will prevent
cardiovascular events with respectively 3.6, 2.9 and 2.9 cases per 10 000 over a 5 year
period for patients with CHD, stroke and diabetes. In addition 15.5 events will be
prevented by meeting these targets in other patients (no stroke, no CHD, no diabetes).
With regard to the targets relating to aspirin, ACE inhibitors/A2 antagonists and
influenza immunization, achieving these targets will only prevent a small number of
events, either due to an already widely spread use of these guidelines (use of aspirin,
ACE inhibitor, A2 antagonist), or due to a low baseline risk of death because of a
currently already high compliance with the indicator (influenza).