The Quality and Outcomes Framework (QOF) is a scheme which financially rewards general practices for providing high quality care to their patients. General practices receive payments based on their performance against a list of clinical indicators included in the QOF. For example, there is a clinical indicator assessing the proportion of patients with coronary heart disease (CHD) whose blood pressure is controlled within the recommended limits.
The QOF was first introduced in 2004 and has undergone a number of changes over time. Each year the scheme is reviewed and the list of indicators included in the programme changes. In 2014 approximately one third of the clinical indicators were retired from the QOF, meaning that financial incentives were no longer provided for performance against those indicators. It is important to understand what happens to the quality of care provided to patients when general practices are no longer incentivised to deliver these activities.
Previous studies have examined the direct effect of removing these indicators on the patients or activities targeted. However, the wider consequences for other patient groups or activities have not been considered. We will use CPRD data to examine whether the removal of financial incentives from the QOF had wider impacts on the quality of care for patient groups and activities not directly targeted by this removal. These wider effects could be positive or negative. It is important to understand the full impact of the changes to determine the overall impact on care quality for patients.
The Quality and Outcomes Framework (QOF) links financial incentives to the quality of care provided by general practices. Practices are rewarded for their performance against a list of indicators. The QOF underwent a major revision in 2014, when 40 of the 121 indicators were removed. It is important to understand what happens to the quality of care provided to patients when general practices are no longer incentivised to deliver these activities.
Previous studies have examined the direct effect of removing these indicators on the patients or activities targeted. However, the wider consequences for other patient groups or activities have not been considered. For example, doctors may now divert their efforts away from patients or activities that no longer attract financial incentives towards patients and activities that are still linked to incentives. We will use CPRD to examine whether the removal of financial incentives from the QOF resulted in wider spillover effects beyond the patient groups and activities directly targeted by this removal. We will use programme evaluation techniques (including interrupted time series) to test for wider spillover effects onto a) patients not targeted by the incentive removal, and b) activities not targeted by the incentive removal.
We will examine the achievement over time for the patient-task pairs denoted in Table 1 as direct effects (DE) of indicator removal, within-paitent spillovers (WPS) and between-patient spillovers (BPS).
We will examine three types of patient-task pairs: those that were incentivised before the 2014 revision of the QOF but from which incentives were subsequently removed, those that remained incentivised, and those which were never incentivised by the QOF but are clinically recommended based on the NICE guidelines.
A full list of QOF indicators that we will examine is provided in Appendix 1. More specifically, the seven conditions and associated QOF indicators are:
1. Chronic kidney disease (CKD) CKD002, CKD004, SMOK002
2. Coronary heart disease (CHD) CHD003, CHD007, SMOK002
3. Hypertension (HYP) SMOK002
4. Diabetes (DM) DM002, DM003, DM004, DM005, DM018, SMOK002
5. Stroke and transient ischaemic attack (STIA) STIA009, SMOK002
6. Chronic obstructive pulmonary disease (COPD) COPD007, SMOK002
7. Atrial fibrillation (AF) AF005
The seven tasks are:
1. Body Mass Index (BMI) recording (BMI) DM002
2. Albumin:creatinine ratio test recorded (UP/C) DM005, CKD004
3. Cholesterol management (CH) CHD003, STIA005, DM004
4. Blood pressure management (BP) CKD002, DM003
5. Smoking status recording (SMK) SMOK002
6. Influenza immunisation (IIV) DM018, CHD007, COPD007, STIA009
7. Alcohol consumption recording (AC) MH007
Matt Sutton - Chief Investigator - University of Manchester
Shaolin Wang - Corresponding Applicant - University of Manchester
Rachel Meacock - Collaborator - University of Manchester
Soren Kristensen - Collaborator - Imperial College London