Eyes on Evidence, highlights new research with a focus on possible implications for clinical practice.
QOF drives quality of services in primary care
Overview: About 60 per cent of adults have a long-term or chronic health problem such as coronary heart disease, stroke, hypertension, diabetes, mental disorder or asthma. Chronic diseases have a huge impact on individuals' lives and NHS resources.
Current treatment: The UK's government is keen to tackle chronic disease management to reduce unnecessary admissions to hospital for patients and associated NHS costs. The Quality and Outcomes Framework (QOF), a pay-for-performance scheme funded by NICE, was introduced in 2004 to incentivise effective clinical care, practice organisation and providing a positive patient experience in primary care.
New evidence: The analysis (Campbell SM et al. N Engl J Med 2009;361:368–78) investigated the impact of the initiative on the quality of care provided to people with coronary heart disease, diabetes and asthma using medical records and patient questionnaires. Initial improvements were maintained for heart disease and asthma but reached a plateau a year after introduction. Care for diabetes continued to improve but at the same rate before the scheme was introduced. No changes in access to care or interpersonal aspects of care were seen but continuity of care was reduced. In summary, the scheme accelerated improvements in the quality of care in certain areas but this was not sustained when targets were reached. A recent comprehensive review by the Health Foundation shows that although the evidence is not strong, improvement initiatives can sometimes reduce costs to service providers while simultaneously making care better for patients.This research was carried out at the National Primary Care Research and Development Centre at Manchester University, which is contracted by NICE to support the QOF.
Commentary: "The effectiveness of incentive schemes in improving services is an important question for policy makers, and there are few bigger schemes than the UK's QOF. Can a national scheme making up 25 per cent of GPs' income transform care? The scheme was introduced in the absence of experimental controlled studies and therefore the best evidence we can hope for is provided in well-designed time series studies that report on performance before and after the introduction of the QOF.
"The series of studies by Campbell and colleagues that have tracked performance in the care of patients with asthma, diabetes and coronary heart disease in a sample of practices from 1998 is therefore an important and almost unique source of evidence. In earlier studies they have already shown steep increases in activity in practices in association with the introduction of the QOF. This paper takes a longer view, tracking performance from 1998, well before the QOF, to 2007, three years after the introduction of the QOF. This enabled the authors to compare the rate of improvement in performance before the QOF with the rate after the introduction of the QOF. They found that the scheme accelerated improvements in the short term quality for asthma and diabetes, but not coronary heart disease, but once targets were reached improvement slowed. Quality declined between 2005 and 2007 for some aspects of care not linked to the QOF, and continuity of care declined after the introduction of the QOF.
"These findings have three implications. First, major policy changes need careful evaluation; initial pilot studies would be ideal. Second, incentives schemes can impact on performance, but the impact can run out of steam. Third, incentive schemes have unintended consequences. Since the QOF is being retained, its indicators require remodelling in order to increase efficiency and reduce the negative consequences. In large measure, this task will fall to the National Institute for Health and Clinical Excellence, which will be advising on the selection of indicators in the future." - Richard Baker is Professor of Quality in Health Care and Head of Department for Health Sciences at Leicester University.
QOF influences blood pressure recordings
Overview: High blood pressure (hypertension) increases the risk of heart attacks, strokes and other health problems. In the United Kingdom, high blood pressure (hypertension) affects about half of the population over 65, and about 1 in 4 middle-aged adults.
Current treatment: It is universally recognised that controlling hypertension will reap significant public health benefits. Several different bodies including NICE and the British Society of Hypertension have produced guidance on treating people with hypertension through lifestyle modification and drug therapy. If lifestyle modification alone does not lower blood pressure sufficiently, NICE recommends treatment with an ACE inhibitor for those under 55 years of age and a calcium-channel blocker or thiazide-type drug for those over 55 year or black patients of any age (unless contraindicated). Combination therapy is then recommended if blood pressure remains uncontrolled. However, implementing the guidance presents its own challenges. In 2004 the UK Quality and Outcomes Framework (QOF) introduced a remuneration scheme for GPs achieving clinical targets for hypertension set at 150 mmHg systolic or less.
New evidence: This study (Carey IM et al. J Hum Hypertens 2009;23:764–770) investigated whether rewarding GPs for achieving target blood pressure in their practice had an impact on blood pressure recordings. The group analysed more than 3 million blood pressure readings (taken 2000–2005) from over 235 000 patients with ischaemic heart disease, stroke or hypertension. The percentage of people with systolic blood pressure above the target value fell from 36 per cent to 19 per cent during this period. There was a trend towards recording systolic values just below — rather than just above — the cut-off but this did not adversely affect clinical management. In conclusion, blood pressure levels in UK primary care have continued to fall since the QOF was introduced; QOF targets may have contributed to this through increased treatment.
Commentary: "The authors have compared BP recording and BP treatment in 2000-2001 with 2004-2005. They specifically examine for terminal digit preference. Several findings stand out; SBP levels are falling overall, there is some recording bias but not much – the authors predict that the prevalence of SBP above 150mmHg should be 23 per cent and is 19 per cent; and there has been a rise in prevalence of antihypertensive treatment. While there is some terminal digit preference for figures just below 150mmHg, patients with readings of 148-9 mmHg were also more likely to be on antihypertensive medication.
The authors conclude that QOF has contributed to the reduction in BP levels and that this is a positive finding from a public heath perspective. The paper therefore is reassuring and refutes accusations of 'gaming' i.e. recording of BP at just below target level by GPs. The authors are reassured that patients with levels just below the target are more likely to be receiving antihypertensive medication but from a clinical perspective, I hope this does not represent additional prescribing to reach the QOF target but that we can continue to consider the potential additional burdens for patients in terms of medicine - taking and side effects that may be required to reach an arbitrary cut off figure!" – Norma O'Flynn is a GP and Clinical Director of the National Clinical Guideline Centre
Eyes on Evidence helps contextualise significant new evidence, highlighting areas that could signal a change in clinical practice. It does not constitute formal NICE guidance. The commentaries included are the opinions of contributors and do not necessarily reflect the views of NICE.
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