PURPOSE Primary care practices in the United Kingdom have received substantial fi nancial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This article reviews the growing evidence for the impact of the framework on the quality of primary medical care.
METHODSFive hundred seventy-fi ve articles were identifi ed by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modifi ed Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review.RESULTS Quality of care for incentivized conditions during the fi rst year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients' satisfaction with continuity declined, with little change in other domains of patient experience.
CONCLUSIONSObserved improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefi ts of similar schemes.
INTRODUCTIONS trong primary care is widely accepted to be a prerequisite for effective, effi cient, equitable health systems and to lead to better population health.1 Introduced in 2004, the UK Quality and Outcomes Framework (QOF) is arguably the most comprehensive national primary care pay-for-performance (P4P) scheme in the world.2 The QOF is more than a payment scheme; it is a complex intervention comprising a number of elements (Table 1), including fi nancial incentives and information technology (computerized prompts and decision support), designed to promote structured and team-based care with the aim of achieving evidence -based quality targets.
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IM PAC T O F PAY-F O R-P ER F O R M A NC E IN T HE U Kthat led to a practice-based, rather than practitionerbased, contract and investment to reward quality of care through both fi xed and performance-related funding streams. The fi nancial incentives are substantial, with a maximum of 1,000 points available to practices, and an average payment per practice in...