The Public Health Impact score: a new measure of public health effectiveness for general practices in England

Abstract

BackgroundHealth policy in the UK is increasingly focused on the measurement of outcomes rather than structures and processes of health care. AimTo develop a measure of the effectiveness of primary care in terms of population health outcomes. Design and settingA cross-sectional study of general practices in England. MethodTwenty clinical quality of care indicators for which there was evidence of mortality reduction were identified from the national Quality and Outcomes Framework (QOF) payfor-performance scheme. The number of lives saved by 8136 English practices (97.97% of all practices) in 2009/2010 was estimated, based on their performance on these measures, and a public health impact measure, the PHI score, was constructed. Multilevel regression models were used to identify practice and population predictors of PHI scores. ResultsThe mean estimated PHI score was 258.9 (standard deviation [SD] = 73.3) lives saved per 100 000 registered patients, per annum. This represents 75.7% of the maximum potential PHI score of 340.9 (SD = 91.8). PHI and QOF scores were weakly correlated (Pearson r = 0.28). The most powerful predictors of PHI score were the prevalence of the relevant clinical conditions (β = 0.77) and the proportion of patients aged ≥65 years (β = 0.22). General practices that were less successful at achieving their maximum potential PHI score were those with a lower prevalence of relevant conditions (β = 0.29), larger list sizes (β = -0.16), greater area deprivation (β = -0.15), and a larger proportion of patients aged ≥65 years (β = -0.13). ConclusionThe PHI score is a potential alternative metric of practice performance, measuring the estimated mortality reduction in the registered population. Rewards under the QOF pay-forperformance scheme are not closely aligned to the public health impact of practices.

Health Equity Indicators for the English NHS: a longitudinal whole-population study at the small-area level

“…Each indicator was then weighted based on importance in terms of the estimated number of lives saved per 100,000 patients. These weights were derived from Ashworth et al, 85 who identified the highest level of evidence for risk reduction in all-cause mortality and converted risk reduction estimates into estimated mortality reduction rates per 100,000 population per annum (see Table 7 for details).…”

“…202,203 However, in sensitivity analysis we also examined 'reported achievement'. We started with a group of 20 QOF indicators, identified by Ashworth et al, 85 based on available evidence on mortality reduction. We then selected 16 out of the 20 indicators for which data were available throughout our period of analysis in a consistent format.…”

“…85 The resulting measure, termed the 'Public Health Impact' score, was proposed as a measure of primary care quality in terms of population health. We recognise that the QOF only captures Least deprived Most deprived Small-area deprivation rank FIGURE 13 National social gradient in patients per GP in 2011/12: adjusted.…”

“…We selected 16 out of the 20 indicators proposed by Ashworth et al, 85 for which data were available throughout our period of analysis in a consistent format. We define primary care quality as weighted average of clinical process quality from 16 indicators in the QOF, with weights proportional to importance in terms of the estimated number of lives saved per 100,000 patients.…”

“…We define primary care quality as weighted average of clinical process quality from 16 indicators in the QOF, with weights proportional to importance in terms of the estimated number of lives saved per 100,000 patients. 85 For each clinical indicator in QOF, the number of patients deemed appropriate for that indicator is the denominator and the number of patients for whom the indicator was met is the numerator. We use 'population achievement' which puts exception-reported patients back into the population denominator thereby assuming such patients represent poor quality, but as a robustness check we also analysed 'reported achievement' which excludes exception-reported patients from the population denominator.…”