Pay for Quality

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