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