Pay for Quality

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70 Pay for Quality KCE Reports 118 Finally, McLean et al (2006) examined the relation between quality of care and socioeconomic deprivation. Hereto they compared quality indicators based on the care delivered to all patients (delivered quality) and the quality indicators used for payment that allow exclusion of patients (payment quality). This made it possible to assess the quality delivered to patients with an exception report code. They found that little systematic association existed between payment quality and deprivation but for 17/33 indicators examined, delivered quality falls with increasing deprivation. An important finding of this study is that absolute differences in delivered quality are small for most simpler process measures, such as recording of smoking status or blood pressure. Greater inequalities are seen for more complex process measures such as diagnostic procedures, some intermediate outcome measures such as glycaemia control in diabetes and measures of treatment such as influenza vaccination. 230 In Appendix 11 we summarize the findings of the above studies as a tool to answer the first research question (What is the immediate effect of the implementation of the QOF on the existing inequity in treatment and (intermediate) outcomes?). It also clearly shows that there is little information available to answer the research question on the long-term effects of the implementation of the QOF. In addition it must be noted that currently not much evidence can be found on the underlying mechanisms that could explain these results. Exception reporting, the size of the studied group, etc could possibly have had an influence on the reported results Key points on reported impact of P4Q programmes on equity • The existing gap in overall quality of care between deprived areas narrowed during the years following the introduction of the QOF. Practices in the more deprived areas report the greatest increases in quality achievement, this was due to a poorer initial performance and not to being located in a deprived area per se. • Before the implementation of QOF a clear gap in health care for older patients was documented for cerebrovascular related health care, for coronary heart disease care and for diabetes care. After the introduction of QOF for all observed diseases the total number of indicators in which inequity appears diminished. For the existing inequities in health care for women, deprived patients and patients from other than white ethnic backgrounds, the results are not as clear as for the elderly patients. For women the total number of indicators in which inequity appears decreased for health care related to cerebrovascular disease. And increased for CHD and diabetes after the introduction of QOF. Considering socio-economic groups the relatively small gap for cerebrovascular disease care and CHD care increased after the implementation of QOF, whether for diabetes care the gap got smaller. Finally the small existing gap in CHD care for ethnic minorities disappeared after the introduction of QOF. • Concerning exception reporting some mixed results were found with regard to the relationship between exception reporting and deprivation. However the most recent study reports that patients’ characteristics explain only a very limited percentage of the variance in exception reporting.
KCE Reports 118 Pay for Quality 71 5 REVISING THE CONCEPTUAL FRAMEWORK BASED ON EVIDENCE 5.1 INTRODUCTION After presenting the results focusing on P4Q effects on quality domains, this section will clarify the evidence on the mediating effects of the components and contextual characteristics which were identified in the conceptual framework (see Chapter 3). The end result will be an updated conceptual framework with identified evidence for the role of each item, to the extent that evidence is available. To accomplish this we make use of the systematic review results in two ways. Firstly, the relationships between framework items and P4Q effect, identified as significant versus not significant in primary P4Q evaluation studies, are presented and their direction of effect clarified. Secondly, by assessing each item’s influence through all included studies in a descriptive way i.e. detecting whether there is a prominent difference between studies with positive effects versus studies with absent or negative effects. The results of both approaches are presented within the framework structure. The following labels are used to grade evidence: • Strong evidence (S): a strong design (randomized studies; concurrent + historical comparison studies) with a clear effect; • Weak evidence (W): a weak design (Concurrent comparison studies; Historical comparison studies, multiple time points; Historical comparison studies, before-after time point; cross-sectional studies) with a clear effect; • Conflicting evidence (C): a significant effect and no significant effect within one design or within a group of weak or strong designs. • No evidence (N): an absence of evidence 5.1.1 Quality goals and targets As became clear in the previous section, only two quality domains are mainly focused upon in P4Q evaluation studies: clinical effectiveness (S) and equity of care (W). The results for effectiveness can be summarized as showing a positive effect or showing no effect. The studies focussing on equity rather positive results and will be discussed extensively in section 5.2.3. The few studies that focused on care continuity and integration 161 , 220 showed positive effects within their study design restrictions (W). In addition to the domains identified in the conceptual framework, two other main goals can be reported. The first goal is the use of care management processes, which can have one or more of the quality domains as a target (e.g. reminder use to improve effectiveness, equity and coordination). With regard to use of these tools a similar positive effect or absence of effect was reported (W). The second goal is to assess the effect of P4Q on patient experience and on provider work experience. This dimension is not identified in the framework. Here again a positive effect or an absence of effect were found in the included quantitative studies, but the low number of studies should be taken into account (W). Current P4Q studies make use of process and intermediate outcome indicators. Structural indicators are used to a lesser extent (e.g. the organizational domain in the QOF). Long term outcome indicators are used very rarely (see for example Casale et al (2007) 189 and Downing et al (2007) 149 ) and often only as a not incentivized control measure. The results illustrate that this target choice has a substantial influence on the effect of P4Q for such indicators, as predicted by the framework. Whereas structural and process targets show in general a more positive effect of P4Q, this is more difficult to reach for intermediate outcome targets such as HbA1c < 7.4% in diabetes patients (S).
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