Tim Doran

Effect of financial incentives on inequalities in the delivery of primary clinical care in England: analysis of clinical activity indicators for the quality and outcomes framework.

BACKGROUND The quality and outcomes framework is a financial incentive scheme that remunerates general practices in the UK for their performance against a set of quality indicators. Incentive schemes can increase inequalities in the delivery of care if practices in affluent areas are more able to respond to the incentives than are those in deprived areas. We examined the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of this scheme. METHODS We analysed data extracted automatically from clinical computing systems for 7637 general practices in England, data from the UK census, and data for characteristics of practices and patients from the 2006 general medical statistics database. Practices were grouped into equal-sized quintiles on the basis of area deprivation in their locality. We calculated overall levels of achievement, defined as the proportion of patients who were deemed eligible by the practices for whom the targets were achieved, for 48 clinical activity indicators during the first 3 years of the incentive scheme (from 2004-05 to 2006-07). FINDINGS Median overall reported achievement was 85.1% (IQR 79.0-89.1) in year 1, 89.3% (86.0-91.5) in year 2, and 90.8% (88.5-92.6) in year 3. In year 1, area deprivation was associated with lower levels of achievement, with median achievement ranging from 86.8% (82.2-89.6) for quintile 1 (least deprived) to 82.8% (75.2-87.8) for quintile 5 (most deprived). Between years 1 and 3, median achievement increased by 4.4% for quintile 1 and by 7.6% for quintile 5, and the gap in median achievement narrowed from 4.0% to 0.8% during this period. Increase in achievement during this time was inversely associated with practice performance in previous years (p<0.0001), but was not associated with area deprivation (p=0.062). INTERPRETATION Our results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities in the delivery of clinical care related to area deprivation.

Effect of financial incentives on incentivised and non-incentivised clinical activities: longitudinal analysis of data from the UK Quality and Outcomes Framework

Objective To investigate whether the incentive scheme for UK general practitioners led them to neglect activities not included in the scheme. Design Longitudinal analysis of achievement rates for 42 activities (23 included in incentive scheme, 19 not included) selected from 428 identified indicators of quality of care. Setting 148 general practices in England (653 500 patients). Main outcome measures Achievement rates projected from trends in the pre-incentive period (2000-1 to 2002-3) and actual rates in the first three years of the scheme (2004-5 to 2006-7). Results Achievement rates improved for most indicators in the pre-incentive period. There were significant increases in the rate of improvement in the first year of the incentive scheme (2004-5) for 22 of the 23 incentivised indicators. Achievement for these indicators reached a plateau after 2004-5, but quality of care in 2006-7 remained higher than that predicted by pre-incentive trends for 14 incentivised indicators. There was no overall effect on the rate of improvement for non-incentivised indicators in the first year of the scheme, but by 2006-7 achievement rates were significantly below those predicted by pre-incentive trends. Conclusions There were substantial improvements in quality for all indicators between 2001 and 2007. Improvements associated with financial incentives seem to have been achieved at the expense of small detrimental effects on aspects of care that were not incentivised.

Exclusion of Patients from Pay-for-Performance Targets by English Physicians

BACKGROUND In the English pay-for-performance program, physicians use a range of criteria to exclude individual patients from the quality calculations that determine their pay. This process, which is called exception reporting, is intended to safeguard patients against inappropriate treatment by physicians seeking to maximize their income. However, exception reporting may allow physicians to inappropriately exclude patients for whom targets have been missed (a practice known as gaming). METHODS We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England (96% of all practices), data from the U.K. Census, and data on practice characteristics from the U.K. Department of Health. We determined the rate of exception reporting for 65 clinical activities and the association between this rate and the characteristics of patients and medical practices. RESULTS From April 2005 through March 2006, physicians excluded a median of 5.3% of patients (interquartile range, 4.0 to 6.9) from the quality calculations. Physicians were most likely to exclude patients from indicators that were related to providing treatments and achieving target levels of intermediate outcomes; they were least likely to exclude patients from indicators that were related to routine checks and measurements and to offers of treatment. The characteristics of patients and practices explained only 2.7% of the variance in exception reporting. We estimate that exception reporting accounted for approximately 1.5% of the cost of the pay-for-performance program. CONCLUSIONS Exception reporting brings substantial benefits to pay-for-performance programs, providing that the process is used appropriately. In England, rates of exception reporting have generally been low, with little evidence of widespread gaming.

Suicide risk in primary care patients with major physical diseases: a case-control study

CONTEXT Most previous studies have examined suicide risk in relation to a single physical disease. OBJECTIVES To estimate relative risk across a range of physical diseases, to assess the confounding effect of clinical depression and effect modification by sex and age, and to examine physical illness multimorbidity. DESIGN Nested case-control study. SETTING Family practices in England (n = 224) [corrected] registered with the General Practice Research Database from January 1, 2001, through December 31, 2008. The case-control data were drawn from approximately 4.7 [corrected] million complete patient records, with complete linkage to national mortality records. PARTICIPANTS A total of 873 adult suicide cases and 17 460 living controls matched on age and sex were studied. The reference group for relative risk estimation consisted of people without any of the specific physical illnesses examined. MAIN OUTCOME MEASURES Suicide and open verdicts. RESULTS Among all patients, coronary heart disease, stroke, chronic obstructive pulmonary disease, and osteoporosis were linked with elevated suicide risk, and, with the exception of osteoporosis, the increase was explained by clinical depression. The only significantly elevated risk in men was with osteoporosis. Female effect sizes were greater, with 2- or 3-fold higher risk found among women diagnosed as having cancer, coronary heart disease, stroke, chronic obstructive pulmonary disease, and osteoporosis. In women with cancer and coronary heart disease, a significant elevation persisted after adjustment for depression. Overall, heightened risk was confined to physically ill women younger than 50 years and to older women with multiple physical diseases. CONCLUSIONS Our findings indicate that clinical depression is a strong confounder of increased suicide risk among physically ill people. They also demonstrate an independent elevation in risk linked with certain diagnoses, particularly among women. Health care professionals working across all medical specialties should be vigilant for signs of undetected psychological symptoms.

Regression based quasi-experimental approach when randomisation is not an option: interrupted time series analysis

Interrupted time series analysis is a quasi-experimental design that can evaluate an intervention effect, using longitudinal data. The advantages, disadvantages, and underlying assumptions of various modelling approaches are discussed using published examples

Effect of a national primary care pay for performance scheme on emergency hospital admissions for ambulatory care sensitive conditions: controlled longitudinal study

Objective To estimate the impact of a national primary care pay for performance scheme, the Quality and Outcomes Framework in England, on emergency hospital admissions for ambulatory care sensitive conditions (ACSCs). Design Controlled longitudinal study. Setting English National Health Service between 1998/99 and 2010/11. Participants Populations registered with each of 6975 family practices in England. Main outcome measures Year specific differences between trend adjusted emergency hospital admission rates for incentivised ACSCs before and after the introduction of the Quality and Outcomes Framework scheme and two comparators: non-incentivised ACSCs and non-ACSCs. Results Incentivised ACSC admissions showed a relative reduction of 2.7% (95% confidence interval 1.6% to 3.8%) in the first year of the Quality and Outcomes Framework compared with ACSCs that were not incentivised. This increased to a relative reduction of 8.0% (6.9% to 9.1%) in 2010/11. Compared with conditions that are not regarded as being influenced by the quality of ambulatory care (non-ACSCs), incentivised ACSCs also showed a relative reduction in rates of emergency admissions of 2.8% (2.0% to 3.6%) in the first year increasing to 10.9% (10.1% to 11.7%) by 2010/11. Conclusions The introduction of a major national pay for performance scheme for primary care in England was associated with a decrease in emergency admissions for incentivised conditions compared with conditions that were not incentivised. Contemporaneous health service changes seem unlikely to have caused the sharp change in the trajectory of incentivised ACSC admissions immediately after the introduction of the Quality and Outcomes Framework. The decrease seems larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay for performance scheme may have had impacts on quality of care beyond the directly incentivised activities.

Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: a longitudinal observational study

Background The UKs Quality and Outcomes Framework (QOF) was introduced in 2004/5, linking remuneration for general practices to recorded quality of care for chronic conditions, including diabetes mellitus. We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics. Methods Using the General Practice Research Database we selected a stratified sample of 148 English general practices in England, contributing data from 2000/1 to 2006/7, and obtained a random sample of 653 500 patients in which 23 920 diabetes patients identified. We quantified annually recorded quality of care at the patient-level, as measured by the 17 QOF diabetes indicators, in a composite score and analysed it longitudinally using an Interrupted Time Series design. Results Recorded quality of care improved for all subgroups in the pre-incentive period. In the first year of the incentives, composite quality improved over-and-above this pre-incentive trend by 14.2% (13.7–14.6%). By the third year the improvement above trend was smaller, but still statistically significant, at 7.3% (6.7–8.0%). After 3 years of the incentives, recorded levels of care varied significantly for patient gender, age, years of previous care, number of co-morbid conditions and practice diabetes prevalence. Conclusions The introduction of financial incentives was associated with improvements in the recorded quality of diabetes care in the first year. These improvements included some measures of disease control, but most captured only documentation of recommended aspects of clinical assessment, not patient management or outcomes of care. Improvements in subsequent years were more modest. Variation in care between population groups diminished under the incentives, but remained substantial in some cases.

Investigating the relationship between quality of primary care and premature mortality in England: a spatial whole-population study

Objectives To quantify the relationship between a national primary care pay-for-performance programme, the UK’s Quality and Outcomes Framework (QOF), and all-cause and cause-specific premature mortality linked closely with conditions included in the framework. Design Longitudinal spatial study, at the level of the “lower layer super output area” (LSOA). Setting 32482 LSOAs (neighbourhoods of 1500 people on average), covering the whole population of England (approximately 53.5 million), from 2007 to 2012. Participants 8647 English general practices participating in the QOF for at least one year of the study period, including over 99% of patients registered with primary care. Intervention National pay-for-performance programme incentivising performance on over 100 quality-of-care indicators. Main outcome measures All-cause and cause-specific mortality rates for six chronic conditions: diabetes, heart failure, hypertension, ischaemic heart disease, stroke, and chronic kidney disease. We used multiple linear regressions to investigate the relationship between spatially estimated recorded quality of care and mortality. Results All-cause and cause-specific mortality rates declined over the study period. Higher mortality was associated with greater area deprivation, urban location, and higher proportion of a non-white population. In general, there was no significant relationship between practice performance on quality indicators included in the QOF and all-cause or cause-specific mortality rates in the practice locality. Conclusions Higher reported achievement of activities incentivised under a major, nationwide pay-for-performance programme did not seem to result in reduced incidence of premature death in the population.

Withdrawing performance indicators: retrospective analysis of general practice performance under UK Quality and Outcomes Framework

Objectives To investigate the effect of withdrawing incentives on recorded quality of care, in the context of the UK Quality and Outcomes Framework pay for performance scheme. Design Retrospective longitudinal study. Setting Data for 644 general practices, from 2004/05 to 2011/12, extracted from the Clinical Practice Research Datalink. Participants All patients registered with any of the practices over the study period—13 772 992 in total. Intervention Removal of financial incentives for aspects of care for patients with asthma, coronary heart disease, diabetes, stroke, and psychosis. Main outcome measures Performance on eight clinical quality indicators withdrawn from a national incentive scheme: influenza immunisation (asthma) and lithium treatment monitoring (psychosis), removed in April 2006; blood pressure monitoring (coronary heart disease, diabetes, stroke), cholesterol concentration monitoring (coronary heart disease, diabetes), and blood glucose monitoring (diabetes), removed in April 2011. Multilevel mixed effects multiple linear regression models were used to quantify the effect of incentive withdrawal. Results Mean levels of performance were generally stable after the removal of the incentives, in both the short and long term. For the two indicators removed in April 2006, levels in 2011/12 were very close to 2005/06 levels, although a small but statistically significant drop was estimated for influenza immunisation. For five of the six indicators withdrawn from April 2011, no significant effect on performance was seen following removal and differences between predicted and observed scores were small. Performance on related outcome indicators retained in the scheme (such as blood pressure control) was generally unaffected. Conclusions Following the removal of incentives, levels of performance across a range of clinical activities generally remained stable. This indicates that health benefits from incentive schemes can potentially be increased by periodically replacing existing indicators with new indicators relating to alternative aspects of care. However, all aspects of care investigated remained indirectly or partly incentivised in other indicators, and further work is needed to assess the generalisability of the findings when incentives are fully withdrawn.

The effect of improving processes of care on patient outcomes: Evidence from the United Kingdom's quality and outcomes framework

Background:Despite the extensive use of process of care measures in pay-for-performance programs, little is known about the effect of improving process performance on patient outcomes. Methods:Retrospective longitudinal analysis of data extracted from 7228 family practices in the United Kingdom’s Quality and Outcomes Framework pay-for-performance program. We estimated the proportion of the change in outcome performance over time which was attributable to change in process performance for 5 chronic conditions (diabetes, coronary heart disease, stroke, epilepsy, and hypertension). Our analytic strategy accounted for bias resulting from unmeasured processes of care and severity of illness. Results:The estimated improvement in composite outcomes that was attributable to improved process was 29.6% for diabetes, 25.6% for coronary heart disease, 34.7% for stroke, 29.1% for epilepsy, and 17.7% for hypertension. The relationship between processes and outcomes varied little across patient and practice characteristics. Conclusions:Improvement in process performance in English family practices led to improvements in patient outcomes. Although the effect was modest at the practice-level, process improvements seem to have led to substantial improvements in population health.