Pay for Quality

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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).
Clinical domain (disease) KCE Reports 118 Pay for Quality 63 Table 6: Potential health gain per indicator within the QOF system by McElduff et al. (2004) Quality intervention Clinical domain (disease) Number of CVD events Cholesterol lowering treatment Blood pressure lowering treatment CHD 15.5 Stroke 7.2 Diabetes 6.5 CHD 3.6 Stroke 2.9 Diabetes 2.9 Hypertension 15.5 Aspirin CHD 1.1 Stroke 0.4 ACE inhibitor /A2 antagonist CHD and HF 1.2 Influenza vaccination CVD 0.003 prevented over 5 year period Fleetcroft et al. (2008) 226 , estimate the potential population health gain of the full implementation of the 8 clinical interventions in both the original and the revised QOF contract. The population health gain is represented by number of lives saved per 100 000 people per year. This research identified evidence for lives saved on 22 indicators in the original contract and 19 indicators in the revised one. The potential of lives saved in the original contract was 415.77 lives per 100 000 in one year. For the revised contract this number raised with 35.73 lives to a potential number of 451.5. In addition, it is important to point out that the comparator in this study was “doing nothing”, whereas there was already a significant baseline activity in primary care before the implementation of the QOF contract. Hence, it should be emphasized that the resulting figures represent a maximum potential. As shown in the table below, influenza immunization (in contrast with the study by McElduff et al (2004) 228 ) and primary prevention for hypertension carry the greatest potential for lives saved. It must be noted that influenza immunization was already incentivised before the QOF was introduced, therefore the room for improvement is rather small. Table 7 : Potential health gain per QOF indicator by Fleetcroft et al. (2008) Quality indicator Potential lives saved per 100000 population per year (2003) Potential lives saved per 100000 populations per year by clinical domain Potential lives saved per 100000 population per year (2006) Potential lives saved per 100000 populations per year by clinical domain Atrial fibrillation AF3: anticoagulant - - 21.4 21.4 Asthma Asthma5: smoking cessation advice/referral 8.8 8.8 See smoking2 - Hypertension BP3: smoking cessation advice/referral 5.4 53.6 See smoking2 48.2 BP5: hypertension, BP, 150/90 in past 9 months 48.2 48.2 Coronary CHD4: smoking cessation 2.4 163.2 See smoking2 160.9 heart disease advice/referral CHD6: BP
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