The UK pay-for-performance programme in primary care: estimation of population mortality reduction

Abstract

BackgroundGeneral practices in the UK contract with the government to receive additional payments for highquality primary care. Little is known about the resulting impact on population health. AimTo estimate the potential reduction in population mortality from implementation of the pay-forperformance contract in England. Design of studyCross-sectional and modelling study. SettingPrimary care in England. MethodTwenty-five clinical quality indicators in the contract had controlled trial evidence of mortality benefit. This was combined with condition prevalence, and the differences in performance before and after contract implementation, to estimate the potential mortality reduction per indicator. Improvement was adjusted for pre-existing trends where data were available. ResultsThe 2004 contract potentially reduced mortality by 11 lives per 100 000 people (lower-upper estimates 7-16) over 1 year, as performance improved from baseline to the target for full incentive payment. If all eligible patients were treated, over and above the target, 56 (29-81) lives per 100 000 might have been saved. For the 2006 contract, mortality reduction was effectively zero, because new baseline performance for a typical practice had already exceeded the target performance for full payment. ConclusionThe contract may have delivered substantial health gain, but potential health gain was limited by performance targets for full payment being set lower than typical baseline performance. Information on both baseline performance and population health gain should inform decisions about future selection of indicators for pay-for-performance schemes, and the level of performance at which full payment is triggered. Keywordsphysician incentive plans; primary health care; quality indicators; quality of health care.

The epidemiology of teaching and training General Practices in England

“…35 We have used practices' QOF scores as a proxy for quality of care, as the best available measure. While there is evidence that mortality has decreased since the introduction of the QOF in 2004 36 , individual practices' performance do not appear to be associated with mortality, rather deprivation was seen to be the greatest predictor. 37 We have adjusted for deprivation in this analysis.…”

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

“…These were based on 25 QOF indicators identified by Fleetcroft et al, which, with subsequent changes in the QOF, have now been subsumed into 19 QOF indicators. 11,12 Estimates of mortality reduction for each of these indicators are displayed in Table 1. QOF indicators not included in Fleetcroft's original analysis were re-examined, and it was considered that there was sufficient evidence to include one further indicator, the cervical screening indicator (Table 1).…”

“…Estimates of mortality reduction were obtained, derived from the available literature, identifying the highest level of evidence for risk reduction in all-cause mortality. [11][12][13] Risk reduction estimates, defined as absolute risk reduction (ARR), relative risk reduction (RRR), or as odds ratios (ORs), were converted into estimated mortality reduction rates per 100 000 population, per annum (Table 1).…”

“…11,12 The remaining indicators excluded from the sensitivity analysis were derived from non-RCT studies.…”

Quality and Outcomes Framework: time to take stock

“…9 QOF was born in an era of plenty, but since the credit crunch in 2007, global recession in 2008, and tax rises planned for 2010, it is clear that we now need to adapt to an era of public sector austerity. It is timely therefore to consider the article by Fleetcroft et al 10 QOF has started to evolve into a value-for-money scheme. Not only should indicators be effective, they should also be cost-effective.…”