Pay for Quality
Pay for Quality
Pay for Quality
You also want an ePaper? Increase the reach of your titles
YUMPU automatically turns print PDFs into web optimized ePapers that Google loves.
66 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
4.5 EVIDENCE RELATED TO EQUITY<br />
The initial aim of this paragraph was to assess the impact of P4Q initiatives on equity in<br />
access, treatment and outcomes. An important first step was to assess how equity is<br />
conceptualized in the selected studies (to what extent did the selected papers address<br />
the three domains of equity and did they conceptualize equity as vertical or horizontal<br />
or both?). Since the selected publications do not include in<strong>for</strong>mation on access, the<br />
following paragraph will mainly focus on equity in treatment and treatment outcomes.<br />
Out of the 32 selected publications, 27 address the relatively new <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong><br />
initiative in the UK. Sixteen of them use the QOF database to do this. The other ten<br />
studies make use of alternative databases. This relatively large number of studies on the<br />
UK initiative should make it possible to get a broad and deep insight on its impact on<br />
equity. Since the 5 other publications each cover another P4Q initiative, we do not get<br />
enough in-depth insight in these initiatives to make conclusions on their impact on<br />
equity. There<strong>for</strong>e the focus of this paragraph will be on QOF.<br />
Inequity in health care occurs when systematically differences are found in access,<br />
treatment or outcomes <strong>for</strong> people from certain subgroups in society. The assessment of<br />
equity <strong>for</strong> socioeconomic groups receives by far-out most attention in the selected<br />
studies (in 22 of the 26 selected studies on pay-<strong>for</strong>-per<strong>for</strong>mance in the UK).<br />
Socioeconomic status is hereby defined using the area-level Index of Multiple<br />
Deprivation or the DEPCAT score (supra). A smaller number of studies (11) also<br />
address equity in health care <strong>for</strong> patients with a different ethnic background. Finally, a<br />
few studies also look at gender differences (6 studies) or differences in age groups (7<br />
studies).<br />
4.5.1 Reported evidence on equity<br />
In this part of the chapter we summarize the available evidence on the effect of the<br />
introduction of the QOF in the UK on equity in treatment and (intermediate) treatment<br />
outcomes. We first summarize the available evidence on the total QOF score, followed<br />
by the available evidence per condition (cardiovascular diseases and diabetes), the<br />
evidence on the measuring of blood pressure independent from a specific condition and<br />
finally the evidence on exception reporting. According to the labels used on page 54, all<br />
equity related publications were graded as “weak evidence”.<br />
4.5.1.1 Total QOF-score<br />
Two cross-sectional studies 142 , 148 provide in<strong>for</strong>mation on the evolution of the total<br />
QOF score after the introduction of the QOF. In their analyses Doran et al (2008)<br />
adjusted <strong>for</strong> area characteristics (deprivation, population density), patient characteristics<br />
(% >or= 15 years of age, >or= 65 years of age, % of women, % of ethnic minority),<br />
practice characteristics (size of practice population, number of GPs per 10 000 patients,<br />
primary medical services contract), GP characteristics (age, gender, % medically<br />
educated in the UK) and exclusion rate. 148 Ashworth et al. (2007) analyzed the raw<br />
QOF data and where possible adjusted <strong>for</strong> exception reporting. 142<br />
Both studies showed that the existing (but small) gap in overall quality of care between<br />
deprived areas (the more deprived, the lower the overall quality) after the introduction<br />
142 , 148<br />
of the QOF, narrowed during the years following the introduction of the QOF.<br />
According to Doran et al. (2008) the gap in median achievement between year 1 after<br />
the introduction of QOF and year 3 narrowed from 4.0% to 0.8%. Practices in areas<br />
with initial low quality achievement (i.e. the more deprived areas) report the greatest<br />
increases during the following years. This more rapid improvement in achievement of<br />
overall quality in practices located in more deprived area quintiles was there<strong>for</strong>e<br />
attributable to poorer initial per<strong>for</strong>mance and not to being located in a deprived area<br />
per se. 148